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Health and Health Care Delivery in Canada [3 ed.]
 9781771721691

Table of contents :
Title page
Table of Contents
Copyright
Dedication
Preface
Content
Learning Features
Acknowledgements
Reviewers
Special Features
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
Chapter 10
1: The History of Health Care in Canada
Evolution of health care: an overview
The introduction of health insurance
Significant events leading up to the canada health act
The canada health act (1984)
After the canada health act: commissioned reports and accords
Summary
Review questions
2: The Role of the Federal Government in Health Care
Health canada: objectives and responsibilities
Health canada organization and structure
Organizational structure of health canada
Agencies of health canada
Global organizations collaborating with health canada
Summary
Review questions
3: The Role of Provincial and Territorial Governments in Health Care
Provincial and territorial health care plans
Regionalization initiatives across canada
Who pays for health care? Provincial/territorial roles
Private and public health insurance
Drug Plans
Summary
Review questions
4: The Dollars and “Sense” of Health Care Funding
Funding versus the delivery of health care
Levels of health care funding
Expenditures for hospitals
Continuing care in canada
Continuing care: options
The rising cost of drugs
Health human resources
Other health care cost drivers
Conclusion
Summary
Review questions
5: Practitioners and Workplace Settings
Categories of health care providers
Regulation of health care professions
Mainstream health care providers
Practice settings
Primary health care: issues and trends
Summary
Review questions
6: Essentials of Population Health in Canada
Population health
Introduction of population health to canada
Determinants of health
The population health approach: the key elements
Population health promotion model
Population health in canada and abroad
Summary
Review questions
7: Health and the Individual
Health, wellness, and illness: key concepts
Health models
Changing perceptions of health and wellness
The psychology of health behaviour
The health–illness continuum
The health of canadians today
Summary
Review questions
8: The Law and Health Care
Laws used in health care legislation
The law, the division of power, and the jurisdictional framework
Health care as a right
The legality of private services in canada
Informed consent to treatment
The health record
Health care professions and the law
Other legal issues in health care
Summary
Review questions
9: Ethics and Health Care
What Is Ethics?
Ethical Theories: The Basics
Ethical Principles and the Health Care Profession
Patients’ Rights in Health Care
Ethics at work
End-of-life issues
Allocation of resources
Other Ethical Issues in Health Care
Summary
Review Questions
10: Current Issues and Future Trends in Health Care in Canada
Mental health and addiction
Caring for an aging population
Home and continuing care
Drug coverage
Indigenous health care
Information technology and electronic health records
The financial sustainability of health care in canada
Summary
Review Questions
Appendix: Declaration of Alma-Ata
Declaration
Glossary
Index

Citation preview

Health and Health Care Delivery in Canada THIRD EDITION

Valerie D. Thompson, RN, PHC, NP Former Professor, School of Health & Life Sciences and Community Services Professor/Coordinator, Health Office Administration Programme, School of Business and Hospitality, Conestoga Institute of Technology and Advanced Learning

Table of Contents Cover image Title page Copyright Dedication Preface Content Learning Features Acknowledgements Reviewers Special Features Chapter 1 Chapter 2 Chapter 3 Chapter 4

Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 9 Chapter 10 1: The History of Health Care in Canada Evolution of health care: an overview The introduction of health insurance Significant events leading up to the canada health act The canada health act (1984) After the canada health act: commissioned reports and accords Summary Review questions 2: The Role of the Federal Government in Health Care Health canada: objectives and responsibilities Health canada organization and structure Organizational structure of health canada Agencies of health canada

Global organizations collaborating with health canada Summary Review questions 3: The Role of Provincial and Territorial Governments in Health Care Provincial and territorial health care plans Regionalization initiatives across canada Who pays for health care? Provincial/territorial roles Private and public health insurance Drug Plans Summary Review questions 4: The Dollars and “Sense” of Health Care Funding Funding versus the delivery of health care Levels of health care funding Expenditures for hospitals Continuing care in canada Continuing care: options The rising cost of drugs Health human resources

Other health care cost drivers Conclusion Summary Review questions 5: Practitioners and Workplace Settings Categories of health care providers Regulation of health care professions Mainstream health care providers Practice settings Primary health care: issues and trends Summary Review questions 6: Essentials of Population Health in Canada Population health Introduction of population health to canada Determinants of health The population health approach: the key elements Population health promotion model Population health in canada and abroad

Summary Review questions 7: Health and the Individual Health, wellness, and illness: key concepts Health models Changing perceptions of health and wellness The psychology of health behaviour The health–illness continuum The health of canadians today Summary Review questions 8: The Law and Health Care Laws used in health care legislation The law, the division of power, and the jurisdictional framework Health care as a right The legality of private services in canada Informed consent to treatment The health record Health care professions and the law

Other legal issues in health care Summary Review questions 9: Ethics and Health Care What Is Ethics? Ethical Theories: The Basics Ethical Principles and the Health Care Profession Patients’ Rights in Health Care Ethics at work End-of-life issues Allocation of resources Other Ethical Issues in Health Care Summary Review Questions 10: Current Issues and Future Trends in Health Care in Canada Mental health and addiction Caring for an aging population Home and continuing care Drug coverage

Indigenous health care Information technology and electronic health records The financial sustainability of health care in canada Summary Review Questions Appendix: Declaration of Alma-Ata Declaration Glossary Index

Copyright ELSEVIER Health and Health Care Delivery in Canada, Third Edition ISBN: 978-1-77172-169-1 (Softcover) Copyright © 2020 Elsevier Inc. All Rights Reserved. Previous editions copyrighted 2010, 2016, Elsevier Canada, a division of Reed Elsevier Canada, Ltd. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher. Reproducing passages from this book without such written permission is an infringement of copyright law. Requests for permission to make copies of any part of the work should be mailed to: College Licensing Officer, access ©, 1 Yonge Street, Suite 1900, Toronto, ON, M5E 1E5. Fax: (416) 868-1621. All other inquiries should be directed to the publisher. www.elsevier.com/permissions Every reasonable effort has been made to acquire permission for copyright material used in this text and to acknowledge all such indebtedness accurately. Any errors and omissions called to the publisher’s attention will be corrected in future printings. The book and the individual contributions made to it are protected under copyright by the Publisher (other than as may be noted herein).

  Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors, or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence, or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. ISBN: 978-1-77172-169-1 VP Education Content: Kevonne Holloway Content Strategist (Acquisitions): Roberta A. Spinosa-Millman Director, Content Development: Laurie Gower Content Development Specialist: Sandy Matos Publishing Services Manager: Deepthi Unni Project Manager: Radjan Lourde Selvanadin Last digit is the print number:    9    8    7    6    5    4    3    2    1

Dedication To the memory of my beloved son, Spencer, who passed away in April 2017 and to his wife, Leigh, and their two little boys, Gregory and Severin

Preface Valerie D. Thompson Individuals working in any facet of health care should understand the components of health and wellness and how health care is delivered in Canada. This unique text will provide a valuable overview of and foundation for understanding these important and challenging concepts. This book will also benefit individuals wanting to better understand the essentials of health care delivery in Canada. While by no means exhaustive, Health and Health Care Delivery in Canada, Third Edition, discusses many components of health and health care delivery. The chapters in this edition have been updated and rearranged beginning with the history of health care in Canada. The proceeding chapters discuss the responsibilities of the various levels of government, the cost of health and illness, the current state of health human resources and the impact of population health initiatives from the perspective of the determinants of health. The concepts of health and illness follow which leads to an examination of the legal and ethical aspects of health care. The last chapter takes a critical look at current issues in health care as well as future trends. The book’s content has been carefully selected in order to highlight essential material. The chapter relate to and expand on content in the previous chapter. Common threads such as the determinants of health (in particular the effects of the social determinants of health) are carried throughout the book and material flows in an orderly and understandable manner. Throughout this edition more emphasis on the health care challenges and needs of Indigenous people of Canada. It is important to note that this book provides a general overview, a snapshot of health and health care delivery in Canada, recognizing also that each jurisdiction delivers health care differently, and that changes are ongoing, thus currency in some areas is relative.

By the end of this book, students will be able to say, “I understand health care issues in Canada and how different levels of government operate in terms of health care delivery. I understand how our health care system is funded and the future issues facing health and health care in Canada,” and, most important, “I understand the system that I am choosing to work in.” Intended to accompany postsecondary introductory courses in Canadian health care delivery, this book offers students a foundation with which they can easily move forward to other, more specifically focused courses.

Content Chapter 1 (The History of Health Care in Canada) provides the reader with the highlights in the history of our health care system. These include the events leading up to the implementation of the Canada Health Act, which is the foundation of the health care system in Canada. Students are encouraged to examine the principles of this Act in terms of their relevance in the twenty-first century. New to this chapter is an expanded section discussing the history of the health and healing practices of Indigenous Peoples in Canada from the “precontact” era to present day. Chapter 2 (The Role of Health Canada and Other Federal and International Health Agencies) and Chapter 3 (The Role of Provincial and Territorial Governments in Health Care) focus on the division of powers and the implementation of health care from federal and provincial or territorial levels. Chapter 2 explores recent changes in the organizational structure of Health Canada such as the newly created Opioid Response Branch and the Cannabis Legalization and Regulation branch. Chapter 3 follows three families—two of whom are new to Canada addressing the challenges and barriers they face settling in a new country and understanding a new healthcare system. Most students are likely to have had some exposure either direct or indirect to individuals seeking a new life in Canada and will be better able to relate to and appreciate the challenges involved with such things as finding a physician, navigating the healthcare system, and understanding what is covered under their provincial/territorial plan. This chapter highlights some variations in the provincial and territorial health care plans how health care is delivered, and how these differences affect the families. For example, in 2 019 the government of Ontario changed the structure and functional aspects of how health care is delivered. Educators are encouraged to expand on health care delivery in their own jurisdictions while comparing it with those of other jurisdictions. Chapter 4 (The Dollars and “Sense” of Health Care Funding) looks at current financial issues, where the money for health care comes

from where it goes, and also examines what “strings” the federal government attaches to its funding for the provinces and territories. This chapter includes a discussion about the targeted funding for mental health and home care services designated by the federal government in the 2017 budget, and the specific funding arrangements made by each jurisdiction. The major cost drivers regarding prescription drugs and the current status of a proposed national pharmacare program are also addressed. Chapter 4 examines the sobering fact that real-life health care decisions are sometimes made based on who qualifies for treatment under a provincial or territorial plan and who does not—and who will opt to pay for services out-of-pocket. Chapter 5 (Practitioners and Workplace Settings) provides the student with a clear picture of the current state of our health human resources—who delivers the care, in what setting, and under what circumstances. It examines how the delivery of primary healthcare has changed across Canada in terms of primary health care teams which operate under numerous delivery models and the expanding roles and responsibilities of various health care providers. Chapter 6 (The Essentials of Population Health in Canada) explains how the government and other health care stakeholders evaluate the health of Canadians, identify risk factors, implement strategies to deal with current health problems, and predict problems that are likely to arise in the future. Population health initiatives are discussed from the perspective of the determinants of health, particularly the social determinants and their sometimesdevastating effects on vulnerable population groups. Chapter 7 (Health and the Individual) provides the student with an understanding of the key concepts of health, wellness, illness, disease, and disability. In this edition, spiritual and emotional wellness are emphasized along with holistic interventions and models of wellness. The concept of the Indigenous “wholistic” theory framework which incorporates the medicine wheel along with the w/holistic concept of understanding the nature of balance, harmony, and living a good life. Among other things, students are encouraged to examine their own health beliefs and health

behaviours and to consider how these contribute to maintaining health. Chapter 8 (The Law and Health Care) analyzes legal issues, clarifying provincial, territorial, and federal boundaries in terms of legislation and the law. Considerable discussion is devoted to current laws regarding confidentiality and consent to treatment. Included in this chapter is a discussion surrounding the legal aspects of medical assistance in dying and the use of both medical and recreational cannabis. Chapter 9 (Ethics and Health Care) highlights ethical principles and points out that health care professionals are held to a higher level of ethical accountability than are those in many other professions. This chapter also discusses the fine line that sometimes divides ethics and health-related legal issues such as medical assistance in dying and the use of cannabis. The student will learn why this boundary is so fragile and how to practise in a moral and ethical manner. Legal implications retarding the current opioid crisis in Canada are also discussed Chapter 10 (Current Issues and Future Trends in Health Care in Canada) discusses important challenges currently facing Canada’s health care system, such as the state of mental health services, managing care for Canada’s aging population, the shortage of human health resources, and the increasing need for home care services. This chapter also contains an expanded discussion on the health of Indigenous People of Canada, disparities that affect their health and well-being, current challenges many Indigenous population groups face, and health care services available. Additionally, this chapter explores other issues that will impact the future of health care in Canada. This includes the risks and benefits involving the safety/security of electronic health information and the impact of social media on health care. How can Canada maintain adequate health care services in the face of complex medical problems, increasingly expensive drugs, advancing and costly technology, and less funding? Will electronic medical records and electronic health records be implemented at a national level, and how and when will this implementation take place? Although no concrete answers exist, the student will be

prepared to look ahead, aware of the significant obstacles that we as a nation must overcome if we are indeed to salvage publicly funded health care for all.

Learning Features Each chapter contains several unique features meant to stimulate student interest. Learning outcomes outline the objectives for the chapter. Key terms define challenging concepts. Chapter summaries and review questions underscore key elements. Additional features include general interest, “Thinking It Through,” “Did You Know?,” and “Case Example” boxes. These features encourage the student to think through facts, points of interest, and actual situations and to answer questions that promote exploration of personal views, general discussion, and, in some cases, further investigation. Additional Evolve® online resources to accompany the text can be found at http://evolve.elsevier.com/Canada/Thompson/health.

Acknowledgements Writing a book of this nature cannot possibly occur in isolation. I owe a great deal to so many people, including those working with the Canadian Institute for Health Information and Health Canada. Thanks also to Judith Surridge, BScN Woman’s College Hospital, and Dr. James McArthur for sharing his knowledge and expertise regarding treatments and supports available for those misusing opioids and other drugs. I owe a debt of gratitude to Lynda Cranston, substantive editor, for her meticulous review, organizing and editing of numerous chapters, and to Ellen Hawman for her assistance in researching and citing resources throughout the book. I’d also like to acknowledge Lyle Grant for his detailed and expert legal review of Chapter 8. Special thanks to the Elsevier team that have been supportive throughout all editions of the textbook. A very special thank you to Sandy Matos, Development Editor, for her patience, knowledge, and support throughout the writing and preparation of the third edition. I would like also to acknowledge and thank Elsevier’s reviewers, who provided helpful comments, constructive criticism, and suggestions for improvements during various stages of the manuscript. I am grateful for the advice and recommendations provided to me, much of which was used to prepare this third edition.

Reviewers Sharon Demers, RN BN, CAE Instructor, Practical Nursing Qualification Recognition Program, Assiniboine Community College, Winnipeg, MB Tracy Hoot, RN, BScN, MSN, DHEd Associate Dean, School of Nursing, Thompson Rivers University, Kamloops, BC Laureen Larson, MHRD, PMP, BVTEd, BScN, RN Occupational Health Nursing Academic Chair – Addictions Counselling, Health Information Management, Occupational Health Nursing, and Psychiatric Nursing Programs; Indigenous Nursing and Inter-Professional Education Services School of Nursing, Saskatchewan Polytechnic, Saskatoon, SK Tammie McParland, RN, PhD, CCNE Director and Assistant Professor, Faculty of Education & Professional Studies, School of Nursing, Nipissing University, Nipissing, ON Kathlyn Palafox, BSN, BCPID Academic Instructor, West Coast College of Massage Therapy, New Westminster, BC Andria Phillips, RN MScN CCNE Sessional Lecturer, School of Nursing, Faculty of Health, York University, Toronto, ON Professor Kari Rivest, MRT (R), BSc Medical Radiation Technology Program, School of Health Sciences and Emergency Services, Cambrian College, Sudbury, ON Beverley Robinson, MA Social Work Lecturer, School of Continuing Studies, McGill University, Montreal, QC Isabelle Wallace, RN, BScN, MScN Director, Dialogue NB, Moncton, NB

Lead Analyst, Indigenous Policy and Research, New Brunswick Health Council - Conseil de la santé du Nouveau-Brunswick, Moncton, NB Chris Watkins, RPN, Dip PN, BScPN, MN Assistant Professor, Psychiatric Nursing Program, MacEwan University, Edmonton, AB

Special Features

Chapter 1 Did You Know? (p. 5) Box 1.1 Residential Schools (p. 6) Thinking It Through (p. 6) Box 1.2 Innovation in Newfoundland: The Cottage Hospital System (p. 7) Did You Know? (p. 9) Thinking It Through (p. 9) Thinking It Through (p. 14) Thinking It Through (p. 14) Box 1.3 Legislation Leading up to the Canada Health Act (p. 15) Box 1.4 Eligibility for Health Care under the Canada Health Act (p. 16) Box 1.5 The Primary Objective of Canadian Health Care Policy (p. 16) Box 1.6 The Canada Health Act: Criteria and Conditions (p. 17) Case Example 1.1 (p. 17) Case Example 1.2 (p. 18) Case Example 1.3 (p. 19) Case Example 1.4 (p. 19) Case Example 1.5 (p. 19) Case Example 1.6 (p. 19) Thinking It Through (p. 20) Case Example 1.7 (p. 21) Box 1.7 Alternative Health Care Strategies (p. 22) Table 1.1 The Goals of Primary Care Reform (p. 23) Box 1.8 Three Major Reports on the Status of Health Care in Canada (p. 24) Thinking It Through (p. 27) Did You Know? (p. 29)

Chapter 2 Thinking It Through (p. 38) Did You Know? Jordan’s Principle (p. 40) Box 2.1 The First Ever Food Guide for First Nations, Inuit, and Métis (p. 42) Did You Know? (p. 42) Did You Know? Health Canada Gives Permission for New Product (p. 44) Thinking It Through (p. 44) Box 2.2 Canadian Institutes of Health Research (CIHR) Institutes Across Canada (p. 46) Thinking It Through (p. 48) Did You Know? (p. 48) Box 2.3 The World Health Organization: The Six-Point Agenda (p. 49) Thinking It Through Ethical Use of Vaccines (p. 54)

Chapter 3 Case Example 3.1 (p. 57) Case Example 3.2 (p. 58) Case Example 3.3 (p. 58) Box 3.1 The Constitution Act: A Clarification (p. 58) Case Example 3.4 Levels of Care (p. 61) Box 3.2 Regional Health Authorities: A Definition (p. 61) Thinking It Through (p. 68) Case Example 3.5 (p. 70) Case Example 3.6 (p. 70) Case Example 3.7 (p. 71) Box 3.3 Reciprocal Agreement (p. 71) Thinking It Through The Arrival of a Syrian Family (p. 71) Did You Know? (p. 72) Box 3.4 Private Clinics: Concerns (p. 75) Box 3.5 Uninsured (Chargeable) Versus Insured Physician Services (p. 77) Thinking It Through (p. 77) Case Example 3.8 (p. 78) Case Example 3.9 (p. 78) Case Example 3.10 (p. 81) Thinking It Through (p. 82)

Chapter 4 Box 4.1 Equalization Payments Embedded in the Canadian Constitution (p. 88) Table 4.1 Provincial and Territorial Health Spending per Capita: 2017 (Estimated) (p. 89) Thinking It Through (p. 90) Thinking It Through (p. 93) Table 4.2 National Average Cost of Procedures and Conditions for Inpatients of All Age Groups, Based on the Average Total Length of Stay, 2014–2015 (p. 95) Case Example 4.1 (p. 96) Case Example 4.2 (p. 101) Case Example 4.3 (p. 102) Case Example 4.4 (p. 105)

Chapter 5 Table 5.1 Some of Canada’s Health Care Providers (p. 115) Thinking It Through (p. 116) Table 5.2 Regulated Health Care Professions in Each Province and Territory (p. 118) Box 5.1 Regulated Professions: Common Elements (p. 120) Thinking It Through (p. 121) Case Example 5.1 (p. 122) Case Example 5.2 (p. 123) Case Example 5.3 (p. 123) Case Example 5.4 (p. 126) Case Example 5.5 (p. 128) Did You Know? (p. 132) Thinking It Through (p. 133) Case Example 5.6 (p. 138) Case Example 5.7 (p. 138) Thinking It Through (p. 139) Did You Know? (p. 140) Case Example 5.8 (p. 142) Case Example 5.9 (p. 145) Thinking It Through (p. 146) Case Example 5.10 (p. 146) Case Example 5.11 (p. 147)

Chapter 6 Box 6.1 Population Health Versus Public Health (p. 152) Did You Know? (p. 152) Box 6.2 Alma-Ata Definition of Primary Health Care (p. 154) Thinking It Through (p. 154) Thinking It Through (p. 154) Case Example 6.1 (p. 155) Box 6.3 Socioeconomic Status Explained (p. 156) Box 6.4 Strategies for Improving the Health of Canadians (p. 157) Thinking It Through (p. 158) Did You Know? (p. 159) Case Example 6.2 (p. 160) Case Example 6.3 (p. 160) Thinking It Through (p. 160) Did You Know? (p. 161) Thinking It Through (p. 162) Thinking It Through (p. 163) Did You Know? (p. 164) Did You Know? (p. 165) Did You Know? (p. 166) Thinking It Through (p. 168) Thinking It Through (p. 168) Box 6.5 An Aging Population: An Example of Population-Based Surveillance (p. 170)

Chapter 7 Box 7.1 Health: An Evolving Definition (p. 181) Thinking It Through (p. 184) Thinking It Through (p. 185) Box 7.2 People With Disabilities: Rights Are Formally Recognized (p. 186) Did You Know? Terry Fox: A Continuing Legacy (p. 186) Thinking It Through (p. 188) Thinking It Through (p. 191) Case Example 7.1 (p. 191) Case Example 7.2 (p. 194) Case Example 7.3 (p. 195) Did You Know? Medical Assistance in Dying in Canada (p. 195) Case Example 7.4 (p. 196) Case Example 7.5 (p. 197) Thinking It Through (p. 198) Box 7.3 Stages of Illness (p. 198) Table 7.1 Life Expectancy at Birth, 2014–2016 (p. 200) Did You Know? Calculating Infant Mortality (p. 200)

Chapter 8 Box 8.1 Equality of Care for Hearing Impaired People (p. 210) Case Example 8.1 (p. 211) Box 8.2 Strategies for Avoiding Legal Problems (p. 212) Case Example 8.2 (p. 213) Did You Know? (p. 216) Case Example 8.3 (p. 216) Thinking It Through (p. 216) Did You Know? (p. 218) Thinking It Through (p. 218) Thinking It Through (p. 222) Thinking It Through (p. 224) Case Example 8.4 (p. 225) Thinking It Through (p. 225) Case Example 8.5 (p. 228) Did You Know? (p. 230) Box 8.3 Confidentiality: An Age-Old Concept (p. 234) Case Example 8.6 (p. 235) Case Example 8.7 (p. 240)

Chapter 9 Case Example 9.1 (p. 247) Case Example 9.2 (p. 248) Thinking It Through (p. 248) Case Example 9.3 (p. 249) Thinking It Through (p. 250) Thinking It Through (p. 251) Case Example 9.4 (p. 252) Did You Know? (p. 253) Box 9.1 A Modern Version of the Hippocratic Oath (p. 255) Thinking It Through (p. 256) Case Example 9.5 (p. 256) Thinking It Through (p. 259) Did You Know? (p. 261) Did You Know? Medical Assistance in Dying (p. 261) Case Example 9.6 The Latimer Tragedy (p. 262) Thinking It Through (p. 262) Thinking It Through (p. 264) Case Example 9.7 (p. 265) Case Example 9.8 (p. 267) Thinking It Through (p. 268) Case Example 9.9 (p. 268) Thinking It Through (p. 268) Thinking It Through (p. 271) Thinking It Through (p. 271)

Chapter 10 Thinking It Through (p. 280) Thinking It Through (p. 285) Case Example 10.1 (p. 288) Did You Know? (p. 289) Thinking It Through (p. 289) Did You Know? (p. 290) Thinking It Through (p. 291) Did You Know? (p. 293) Box 10.1 The Sioux Lookout Meno Ya Win Health Centre (p. 297) Did You Know? (p. 297) Thinking It Through (p. 300) Case Example 10.2 (p. 303)

1

The History of Health Care in Canada I came to believe that health services ought not to have a price tag on them, and that people should be able to get whatever health services they required irrespective of their individual capacity to pay. Tommy Douglas

LEARNING OUTCOMES 1.1 Summarize the early evolution of health care in Canada. 1.2 Explain the effects of colonization on Indigenous peoples’ health practices and ceremonies. 1.3 Discuss the introduction of public health insurance. 1.4 Describe significant events and legislation shaping health care from 1960 until the introduction of the Canada Health Act (CHA) in 1984. 1.5 Understand and discuss the terms and conditions of the Canada Health Act. 1.6 Explain the events that have occurred since the implementation of the Canada Health Act, including commissioned reports and accords. 1.7 Summarize agreements, accords, and other health legislation enacted since the year 2000.

KEY TERMS Aseptic technique Block transfer Canada Health Act Catastrophic drug costs Delisted Eligible Extra billing First ministers Health accord Medically necessary Medicare Palliative care Prepaid health care Primary health care reform Quarantine Refugee claimants Royal assent Social movements User charges Tommy Douglas (1904–1986) was considered by many to be the father of medicare in Canada. One can’t help but wonder what advice he would have for Canadians today regarding the sustainability of medicare, how to manage it, and how to ensure that our publicly funded system can continue to equitably meet the needs of all Canadians. This chapter will look at the evolution of the Canadian health care system as it existed before Confederation, how it has evolved into

what it is today, and what challenges the system is faced with to remain viable for the future. The chapter will address the nature of health care for the Indigenous population, the traditions and ceremonies they practised, and the devastating effects colonization had on their health care system. The effects of social, economic, and technological growth has dramatically transformed health care in Canada over the past century. Every decade has brought changes to where and how people live, their views of and responses to illness, in addition to the kind of treatment they both need and expect. This includes adapting to meet the needs of new Canadians in a knowledgeable and culturally sensitive manner. According to the United Nations High Commission for Refugees (UNHCR) Canada welcomed over 46,000 refugees in 2016, compared to 24,070 in 2014 and 32,115 in 2016 (UNHCR, 2017). This surge in immigration required volunteers, health care providers, community agencies, and other stakeholders to work together to help these refugees adapt to life in Canada, which included meeting their health care needs. Immigrants came from different countries such as Eritrea, Iraq, Congo, and Afghanistan. The largest number of refugees came from Syria with over 33,000 new Canadians. As you read this chapter, note continuing parallels between the needs of the population and the adaptation and growth of health care services, including primary care in your own jurisdiction. Do the majority of Canadians in your region have a family physician or a nurse practitioner? Are you part of a primary health care multidisciplinary team? Are primary care services, home care, and community care services adequate? When you reach the end, think about the terms and conditions of the Canada Health Act in particular, and ask yourself if the Act still meets the needs of Canadians. Is our health care universal? Is health care accessible to all? Is it provided to all Canadians on uniform terms? Is it delivered in a timely fashion to all? Continued debate about the quality and availability of health care has generated repeated demands for system improvements and for increases in dedicated funds. Does the Canada Health Act need to be changed, or do the expectations and attitudes of Canadians need to be adjusted? Write down your thoughts about these questions

before you continue reading, and then compare your thoughts with those shared in this chapter.

Evolution of health care: an overview With the passage of the British North America Act in 1867 (renamed the Constitution Act in 1982), Confederation became a reality. The Dominion of Canada consisted of Ontario and Quebec (formerly Upper and Lower Canada, respectively), New Brunswick, and Nova Scotia, and Sir John A. Macdonald was the Dominion’s prime minister. Each province had its own representation in government, its own law-making body (which evolved into a provincial government), and its own Lieutenant Governor to represent the Crown. The British North America Act also established a federal government comprising the House of Commons and the Senate—the same structure in place today. The first census for the new Dominion in 1871, showed a population of 3 689 257—a large enough number to warrant closer attention to people’s health care needs. Legislation regarding responsibilities for health care was vague at best, but even at this early stage responsibilities were divided between the federal and provincial governments.

Division of Responsibilities for Health Health matters received little attention in the British North America Act. The federal government was charged with responsibilities for the establishment and maintenance of marine hospitals, the care of Indigenous populations, and the management of quarantine. Relatively common, quarantines were imposed to prevent outbreaks of such diseases as cholera, diphtheria, typhoid fever, tuberculosis (TB), and influenza, and this remains the case today in the face of current infectious outbreaks discussed in Chapter 6. Provinces were responsible for establishing and managing hospitals, asylums, charities, and charitable institutions. Many of the provincial responsibilities regarding health care—including social welfare, which, broadly speaking, encompassed health and public health matters—were assumed by default since they were not clearly outlined in the Act as federal responsibilities.

Today the federal government retains responsibility for health care for most Indigenous communities (on reserves), some members of the RCMP, the armed forces, people detained by Correctional Services, and veterans. As of April 2013, regular members of the RCMP have been covered for basic health benefits by the province or territory in which they live (see Chapter 3). Under the Interim Federal Health Program (IFHP), the federal government also pays for temporary health insurance for selected refugee claimants, discussed in more detail in Chapter 7. In 1919, the federal government created the Department of Health, largely to assume its health-care-related responsibilities, which included working collaboratively with the provinces and territories in health care matters and promoting new health care initiatives. (From 1867 to 1919, federal health concerns were managed by the Department of Agriculture.) Early projects undertaken by this new department reflected the issues faced by Canadians at that time— specifically, the increase in sexually transmitted infections (STIs) and the recognition of the importance of keeping children healthy and safe. In response, venereal disease clinics were established across the country, and campaigns promoting child welfare were launched. In 1928, the Department of Health became known as the Department of Pensions and National Health. The name changed again in 1944 to the Department of National Health and Welfare, and federal responsibilities expanded to include food and drug control, the development of public health programs, health care for members of the civil service, and the operation of the Laboratory of Hygiene (a precursor to Canada’s current Laboratory Centre for Disease Control). In 1993 the department was renamed Health Canada. The federal government also retains responsibility for health coverage for certain population groups (discussed in Chapter 2).

The Origins of Medical Care in Canada The first doctors in Canada, a combination of civilian and military physicians, came with the arrival of European settlers (primarily from England and France). These doctors cared for the sick at home and then in hospitals once they were built. In the eighteenth century

and early nineteenth century, only the wealthier settlers were able to afford medical attention from a doctor and to seek care in a hospital when required. The less fortunate received care through religious and other charitable organizations, or from family and friends, who provided in-home care using botanical remedies and other natural medicines shared with them by Indigenous peoples. Canada’s first medical school was established in Montreal in 1825. By the time of Confederation, the country had a steadily increasing number of doctors, hospitals, and medical schools, resulting in medical and hospital care that was more accessible to all sectors of the population.

The History of Healing Practices of Indigenous Canadians Health and healing ceremonies practised by Canada’s Indigenous population date back centuries. The information surrounding these rituals, ceremonies, and practices has been passed down from one generation to another both orally and through ‘hands on’ experiences (e.g., from one healer to another). Very little information was actually documented, resulting in few written resources. Many of the healers and elders with knowledge about cultural and healing practices died during epidemics and from diseases introduced by non-Indigenous people. The large numbers of deaths and ultimately the collapse of many population groups nearly eradicated the Indigenous health care system. Most cultural practices were rooted in holistic and spiritual beliefs along with an integral relationship with nature and “Mother Earth.” Indigenous healers went by many names including the “Medicine Man” and the “Shaman.” There were also midwives (also known as life-givers, typically women), spiritual and herbal healers. The role of healer was not exclusive to men; in fact in many Indigenous cultures, women had long been recognized as powerful healers. History indicates that prior to contact with Europeans (sometimes referred to as the precontact era) Indigenous people were very healthy. They led an active lifestyle and ate a healthy diet—sources of food were from the land: hunting, fishing, and harvesting local

vegetation (most bands moved to maximize seasonal food sources). The few illnesses Indigenous people had were sometimes attributed to evil spirits, or an imbalance or disharmony between such entities as the body, mind, community, and nature. For example, oral history indicates that Indigenous people had arthritis and jaw abscesses. Like many traditions, an understanding of healing and the use of herbal medicines was passed down through generations via oral teachings and observances. A variety of rituals, ceremonies, and spiritual practices were used to treat some of these disorders, whereas other disorders were treated with a variety of plants, herbs, roots, and fungi. For example, Indigenous healers used the bark of the willow tree—which contains the same active ingredient in aspirin—to treat headaches. Parts of the dandelion were used for skin ailments such as boils, abscesses, rashes, and inflamed joints. Even gooseberries helped with constipation. Today many traditional medicines have been incorporated into contemporary Western medicinal practices. Traditional rituals and spiritual ceremonies include the sweat lodge, healing circle, smudging ceremonies, and the Medicine Wheel —many are still used today. Each of the rituals is described below to explain the holistic and spiritual nature of traditional healing practices. Please note that elements of these ceremonies differ from one group to another. The sweat lodge was one of the most valued methods of traditional healing and it is still used by many communities today. It is a cleansing and healing ceremony. In preparation for the ceremony the person or persons being treated must fast (up to 4 days) thus depriving the physical self of food and water. This is thought to weaken the (powerful) physical self and rendering the person vulnerable thus more receptive to advice and teachings from the spirit world. The sweat lodge itself is dome shaped, specially constructed, and the ceremonies are complex. The desired outcome is to have those who are participating in the ceremony pushed to their limit both physically and emotionally. This occurs when they endure long periods in the extreme heat generated within the sweat lodge. This enabled the person’s spiritual self to receive messages from the spirit world (or the creator) and complete the ceremony

with a renewed sense of self and life’s direction. It must be noted that although the ceremony was most often associated with cleansing and healing, ceremonial leaders could assign a different purpose to each ceremony; for example, to work out any family issues and in more recent years, deal with addictions (e.g., alcohol/drug). The configuration of the healing circle was structured to promote open communication. Participants include individuals who were dealing with difficulties and problems in their everyday lives. This ceremony sometimes began with smudging—the burning of medicine such as sage or sweetgrass. Smudging requires that participants sweep the smoke towards their faces (eyes, ears, mouth) and all over their bodies. The smoke is supposed to help participants to see, hear, and understand things in a positive manner; speak wisely, carefully, and truthfully; and create a loving environment. Often individual prayers are followed by a group prayer that is said to be carried to the creator by the smoke. Then a facilitator makes group introductions and explains the rules and how the session will be conducted. For some ceremonies the facilitator passes out an eagle feather or a stick. The person who has possession of the feather or stick is allowed to speak. Everyone is offered the chance to speak. The healing circle is very similar to a therapy session. There must be a skilled facilitator who leads the session, carefully monitoring what is being said, and leading the discussion. The exact structure of the medicine wheel varies. Basically, the wheel represents four parts of a person—spiritual, physical, cognitive, and emotional. The person must acknowledge responsibility for themselves in all categories to regain total health. The circle represents continuous movement and connectivity.

  Did You Know? The Eagle Feather has significant spiritual significance in First Nations culture. The eagle is considered sacred as it flies higher than other birds, thus closer to the creator. The feather has been adopted by courts in several jurisdictions as an alternative to using the bible

when Indigenous people are testifying under oath in court-related occurrences (affirmation or oath swearing). The move is to make the legal process more culturally acceptable for Indigenous people. In October 2017, the RCMP in Nova Scotia adopted this practice at the detachment level (a first in Canada for the RCMP). Sources: Rice, W. (January 18, 2016). Eagle feathers now on hand for oaths at Ottawa courthouse. Retrieved from http://www.cbc.ca/news/canada/ottawa/eagle-feathers-now-onhand-for-oaths-at-ottawa-courthouse-1.3409212; Royal Canadian Mounted Police. (October 27, 2017). Media Advisory: Nova Scotia RCMP to unveil eagle feather initiative. Retrieved from www.grc.gc.ca/en/news/2017/media-advisory-nova-scotia-unveileagle-feather-initiative; Thatcher, A. (October 3, 2017). Eagle feather flies into Nova Scotia detachments. Gazette (Vol. 79, No. 4). Retrieved from www.rcmp-grc.gc.ca/en/gazette/eagle-feather-flies-novascotia-detachments.

Contact With Outsiders Some of the earliest contacts were in the 1700s with Russian, French, Spanish, and British traders, explorers, as well as settlers. Contact in the interior was primarily with traders who worked for the Hudson’s Bay Company. They brought with them numerous diseases previously unknown to this part of the world. Indigenous people had no natural immunity to these diseases, let alone any traditional treatments. Such illnesses included smallpox, tuberculosis, influenza, whooping cough, and measles. The effect on the Indigenous population was disastrous, resulting in the death of thousands. Traditional rituals and practices remained largely ineffective in treating these conditions. The smallpox vaccine discovered at the turn of the century was rarely available to the Indigenous population. The British North American Act (1867) and the India Act (1876) set the stage for the assimilation of Indigenous people, applying numerous restrictions to their practices and way of life. The inability of Indigenous healers to successfully treat the newly introduced diseases allowed non-Indigenous people to discredit traditional

healing ceremonies and the legitimacy of traditional healers. Subsequent amendments to the Indian Act legally banned most Indigenous spiritual and health related rituals, ceremonies, and practices until the 1950s and beyond. Over the next several decades, Indigenous people in Canada lost most of their cultural norms. They suffered from the devastating effects of being in residential schools and their suffering continues today impacting their physical and mental health. For more about residential schools see Box 1.1. Recently Western medical practices have largely replaced traditional healing. Health services that are provided in more geographically isolated communities are often limited in staff and supplies, and at times don’t meet the criteria outlined in the Canada Health Act. Few of the goals and standards outlined in Health Canada’s determinants of health have been met and remain a growing concern.

  Box 1.1

Residential Schools. Residential Schools were church-run boarding schools, funded by the federal government, which essentially assumed custodial rights of Indigenous children. The goal was to assimilate Indigenous youth into what was considered Canadian society and culture. One of the first schools opened in 1831 in Brampton, Manitoba, and the last one closed in Punnichy, Saskatchewan 1996, long after the horrors and injustices these children suffered were well known (an estimated 150 000 children). Children were torn from their families and communities, stripped of their identities, language, and culture. They were subjected to varying levels and types of abuse. Mistreatment, inadequate nutrition, and denial of proper care also resulted in the deaths of many of the children. The Indian/Indigenous Residential Schools Settlement in 2007 resulted from lobbying and pressure from Indigenous people who had attended residential schools; this was followed by a formal apology by then Prime Minister Harper in 2008. The settlement acknowledged the suffering and resulting damage done to former

students, and established a multimillion-dollar fund for individual compensation packages to help former students seek treatment, and work towards recovery through, among other resources, the Aboriginal/Indigenous Healing Foundation. The settlement also included the establishment of the Indian/Indigenous Residential Schools Resolution Health Support Program also meant to provide support for those suffering mental health and emotional trauma. Providers include a multidisciplinary team of health care workers including Indigenous elders, social workers, and psychiatrists. The settlement was not without problems and criticisms regarding unethical use of the money and unethical fees charged by lawyers. Note that this information, far from complete, is a brief overview of components of the residential school system and its effects on the Indigenous community. Source: First Nations Health Authority. (n.d.). Our history, our health. Retrieved from http://www.fnha.ca/wellness/our-history-ourhealth. However, there are recent movements to return the responsibility of health care to Indigenous communities and to honor the value of traditional health practices. Many hospitals, clinics, and community health centres now integrate traditional health practices with western medical practices (see Chapter 10). Today the conditions most affecting Indigenous populations include diabetes, heart disease, cancer, mental illness, and addictions to drugs and alcohol. The medicine practised by Indigenous people in North America has a long and rich history. Sometimes referred to as shamans or medicine men (note that the role of healer was not exclusive to men; in many Indigenous cultures, women have long been recognized as equally powerful healers), traditional Indigenous practitioners were believed to have a strong connection to the spirit world and to Mother Earth. Many of the shaman’s teachings and remedies attempted to maintain balance and harmony among spiritual and natural elements and the human populations that depended on these

elements for survival. Current issues and trends related to Indigenous health are discussed in Chapter 10.

  Thinking it Through Health professionals should be knowledgeable about health-related traditions and cultural practices that are important to their patients. Honouring such practices whenever possible will contribute to a positive patient experience, improve patient adherence, and contribute to the patient’s well-being. 1. Are there individuals or groups of people within your community who would benefit from culturally specific approaches to health care? 2. Considering cultural traditions or practices, identify three ways in which you could improve a patient’s experience in a health care setting in your community.

The Development of Hospitals in Canada An order of Augustinian nuns from France who worked as “nursing sisters” established Canada’s first hospital, the Hôtel-Dieu de Quebec, which opened in Quebec City in 1639. The nuns set up several other hospitals in the days before Confederation. In fact, with government funding often limited and unreliable, all of Canada’s early hospitals were charitable institutions that relied on financial support from wealthy people and well-established organizations. It was not until the already-established Toronto General Hospital closed from 1867 to 1870 due to lack of funds that the Ontario government passed an act providing yearly grants to hospitals and other charitable institutions, laying the groundwork for the presentday provincial government funding of hospitals. Hospitals of the early 1800s were crowded places focused on treating infectious diseases, primarily among people of the poorer classes who could not afford private care. By contrast, the wealthier segment of the population avoided hospitals by hiring doctors who

would visit patients’ homes to provide treatment. With the introduction of anesthesia, aseptic technique, and improved surgical procedures in the 1880s, however, hospitals were finally regarded as places to go to get well, and the use of hospital facilities increased. In the early 1900s, tuberculosis sanitariums were developed to isolate and care for tuberculosis patients. The disease was difficult to treat, with surgical removal of diseased organs often the only viable cure, and many tuberculosis patients died in hospital. Special institutions to care for mentally ill people were also established. Because of the shame associated with mental illness at the time, those who suffered from it were often forcibly admitted to these institutions by family members. Most patients never emerged. With grants from federal and provincial governments and advances in medical care, the number of hospitals increased over the next several decades. Physician and hospital services remained outof-pocket expenses for patients, although some had insurance protection through their employers. Charitable and religious organizations continued to assist those who could not afford care. During this time, governments made some efforts to improve access to medical care and to provide an affordable fee structure for it (Box 1.2).

  Box 1.2

Innovation in Newfoundland: The Cottage Hospital System. In the 1930s approximately 1 500 communities in Newfoundland were scattered across 7 000 miles of coastline. To service these communities the provincial government developed the Cottage Hospital and Medical Care Plan in 1934, which funded the building of a network of small hospitals and paid doctors and nurses to travel to port communities along the extensive coastline. One hospital was even built on a boat. Intended primarily to provide outpatient care, these small hospitals were equipped with minimal inpatient facilities (20–30

beds), an operating room, diagnostic facilities, and a well-equipped emergency department. Outpatient services offered included immunizations, prenatal and infant care, and patient follow-up at home. The hospitals were staffed mostly by physicians and nurses with surgical and emergency care experience, and an annual fee of $10 provided a family with health care and use of the cottage hospitals, including transfer to the nearest base hospital when necessary. Not only was Newfoundland’s cottage hospital system innovative and progressive for its time, but also to this day, provincial and territorial systems draw on some of its key elements, such as small clinics for rural communities. Source: Connor, J. H. T. (2007). Twillingate: Socialized medicine, rural doctors, and the CIA. Newfoundland Quarterly,100(424). Retrieved from http://www.newfoundlandquarterly.ca/issue424/twillingate.php.

Segregated Hospitals for Indigenous People What was then termed “Indian” hospitals were initially operated by churches in the late 1800s. After the Second World War the federal government’s Department of Health and Welfare expanded a system of separate hospital care for Indigenous people. Some new facilities built were free standing hospitals, others were refurbished military barracks, “out-buildings,” or annexes affiliated with other hospitals. The facilities overall were underfunded, inadequately equipped, maintained, and staffed (e.g., kitchen and laundry facilities, few nurses/patient numbers, poor heating). Initially the hospitals were established to segregate Indigenous people with tuberculosis (discriminately referred to as “Indian tuberculosis”) as there was a high incidence among the Indigenous population even in youth from residential schools (in part because of overcrowding and poor nutrition). Infected Indigenous people in the far north were transported (some by ship) to hospitals also called sanitoriums in southern communities particularly in the Prairie Provinces, Ontario, and Quebec. Indigenous people were plucked from the schools, their homes, and communities if it was suspected they had TB. There was

an amendment to the Indian Act allowing physicians to put Indigenous people in hospitals involuntarily for the treatment of infectious diseases. There are horrendous recordings of mistreatment in the hospitals including experimentation with various forms of treatment for TB, such as with vaccines and surgery (removing parts of their lungs, which necessitated removing ribs, often under local anesthetic). When the incidence of tuberculosis decreased, many of the Indian hospitals were transitioned into segregated general hospitals operated with little regard for traditional healing practices or Indigenous culture. In Sioux Lookout Ontario, for example, there were two hospitals, the Zone (also referred to at the time as the Indian hospital) and the Sioux Lookout General Hospital. Physicians and staff were separate (working at one or the other). Physicians often rotated in from Winnipeg or other centres. Non-indigenous people were rarely if ever admitted to the Zone hospital and vice versa. When Medicare was introduced in 1968 the federal government initiated closure of the majority of Indian hospitals merging care of the Indigenous and non-indigenous population into the same facilities. As an example, in Sioux Lookout the Zone and General hospitals were moved to a new facility called the Sioux Lookout MenoYaWin Health Centre, which is a fully accredited sixty bed acute care facility offering an additional twenty beds for extended care.

The Role of Volunteer Organizations in Early Health Care In the eighteenth and early nineteenth centuries Canadians’ health care needs were attended to largely by volunteer organizations, which were also relied upon heavily to raise funds for health care because there was little or no funding provided by the government or any other agency. Some of these groups are discussed below. Many will be familiar because they still function today.

The Order of St. John

The Order of St. John (later known as St. John’s International and sometimes St. John Ambulance) provides community-based first aid, health care, and support services around the world. The organization was introduced to Canada in 1883 by individuals from England with knowledge of first aid, disaster relief, and home nursing. The organization and its volunteer responsibilities expanded over the years, providing invaluable assistance and health care to Canadians. Today the organization provides a wide range of health care services at public events and participates in community health initiatives across Canada. They also offer a number of courses (including online) ranging from emergency and standard first aid (including pets) to family, children, and youth courses (St. John Ambulance, 2018).

The Canadian Red Cross Society The Canadian Red Cross Society was founded in 1896. In the early 1900s, the Red Cross established a form of home care designed to keep families together during times of illness. The Red Cross gradually became involved in other public health initiatives, establishing outpost hospitals, nursing stations, nutrition services, and university courses in public health nursing (Canadian Red Cross, 2008). Until 1998 the Canadian Red Cross Society also supervised the collection of blood from volunteer donors across Canada. The society was stripped of this responsibility following the contaminated blood crisis. Two thousand people who had received blood and blood products contracted HIV; another 30 000 people were infected with hepatitis C. After the 1997 report prepared by Mr. Justice Krever, Final Report: Commission of Inquiry on the Blood System in Canada, a new national blood authority, Canadian Blood Services, was created and assumed. On September 26, 1998, Canadian Blood Services assumed full responsibility for the Canadian blood system outside of Quebec (in Quebec, Héma-Québec), and it continues in that role today (Canadian Blood Services, 2014; Picard, 2014; Wilson, 2007). The organization also offers educational courses including those in

cardiopulmonary resuscitation (CPR), first aid, and water safety, and provides Canadians with a variety of community support services.

  Did You Know? Today the Canadian Red Cross remains part of a worldwide humanitarian network providing emergency aid and disaster relief in Canada and abroad. For example, in 2017 the society responded to catastrophic flooding in British Columbia, Ontario, Quebec, and New Brunswick as well as to communities devastated by forest fires (e.g., Fort McMurray, Alberta in 2016, and BC in 2017). Support is based on need. Services range from providing shelter, distributing clothing and food, to overseeing financial aid. The Red Cross has online options through which the public can make donations of all kinds.

Victorian Order of Nurses The Victorian Order of Nurses (VON) was founded in 1897 and was one of the first groups to identify the health care needs of the population, particularly of women and children in remote areas of the country, and to provide services to these groups. For many years VON was the largest national provider of home care in addition to providing a wide range of health and wellness services. In November 2015, ongoing financial difficulties forced the organization to terminate services in Alberta, Saskatchewan, Manitoba, New Brunswick, Manitoba, Newfoundland and Labrador, and Prince Edward Island. Restructuring has allowed operations to continue in Ontario and Nova Scotia.

  Thinking it Through Volunteers have played a major role in the development of health care in Canada over the years. Today, in the face of widespread shortages in health care services, both in hospitals and in the

community, the health care system increasingly depends on volunteers. 1. What roles do volunteers continue to play in health care? Identify four areas that would benefit from the contributions of volunteers. 2. How do you think social and demographic trends will affect the roles of volunteers and volunteer organizations?

Children’s Aid Society The Children’s Aid Society of Toronto was created in 1891 by John Joseph Kelso. He initiated the Act for the Prevention of Cruelty to children and animals along with the Better Protection of Children in 1893, which provided the first social safety net for the many abandoned and homeless children in the city. The Children’s Aid Society (CAS) was established with the mandate to legally provide protection for these impoverished children. The CAS was granted legal right to care for abandoned and neglected children, to supervise their care, and transfer guardianship from the parents’ care to the CAS when necessary (Until the Last Child, 2014). However, the initial focus was providing food and shelter to disadvantaged children. Children at risk for harm or abuse and needing protection were removed from the family environment and placed in foster homes or orphanages with little thought given to maintaining the family unit. Originally the Children’s Aid Society acted as board members and assumed duties that paid professionals perform today. Today the provision of a secure and caring environment for the child is still paramount, but keeping families together is also a priority. The CAS oversees many of the adoptions in Canada.

The Concept of Public Health Is Introduced At the beginning of the nineteenth century, the prevalence of infectious diseases peaked. In 1834, William Kelly, a British Royal Navy physician, suspected a relationship between sanitation and

disease and deduced that water was possibly a major contaminant. Although how disease spread was not clearly understood, many recognized the effectiveness of quarantine practices in limiting the spread. Upper and Lower Canada each established a board of health in 1832 and 1833, respectively. These boards of health enforced quarantine and sanitation laws, imposed restrictions on immigration (to prevent the spread of disease), and stopped the sale of spoiled food. Some health care measures met tremendous public opposition. For example, in the mid-1800s a doctor in Nova Scotia attempted to introduce a smallpox vaccine, which had been discovered and proven successful in England around the turn of the century. Public resistance was strong despite proof that the vaccine protected individuals from the disease. Consequently, the value of smallpox vaccinations was not fully appreciated until the 1900s, and as previously mentioned rarely provided for Indigenous people. In the early 1900s, the provinces began establishing formal organizations to manage public health matters. A bureau of public health was established in Saskatchewan in 1909 and became a government department in 1923. The provinces of Alberta, Manitoba, and Nova Scotia likewise established departments of health in 1918, 1928, and 1931, respectively. These public health units assumed responsibility for public health matters, including activities such as pasteurizing milk, testing cows for tuberculosis, managing TB sanatoriums, and controlling the spread of STIs. Maternal and child health care became a focus of public health initiatives at the beginning of the twentieth century. Both doctors and nurses actively promoted such things as immunization clinics and parenting education.

The Role of Nursing in Early Health Care Nursing care has been an essential part of health care in Canada since before Confederation, when the Hôtel-Dieu Hospital in Quebec launched the first structured training for North American nurses in the form of a nursing apprenticeship (Canadian Museum of History, 2004).

In 1873, the first school of nursing was established at Mack’s General and Marine Hospital in St. Catharine’s, Ontario (Mount Saint Vincent University, 2005). Another nursing school opened at Toronto General Hospital in 1881. Over the next 50 years, many hospital-based schools of nursing were established, and in 1919 the University of British Columbia offered the first university degree program for nurses. The Canadian National Association of Trained Nurses (CNATN) became Canada’s first formal nursing organization in 1908, with a mandate to provide support for nurses graduating from formal programs. In most jurisdictions, graduates of hospital-based programs held a diploma in nursing and were eligible to write provincial/territorial examinations to become Registered Nurses (RN). In the mid-1970s, nursing education was transferred to colleges and universities. Graduates still wrote provincial/territorial examinations and held either a diploma or a degree in nursing (program specific). In the 1990s, diploma programs for RNs were phased out with entry to practise now at the baccalaureate level, except in Quebec. Now there are transfer degree programs where students may begin in community college and enter into a university-degree program to complete their degrees. Nurse Practitioners (NPs) were first introduced in Canada in the 1960s. Today NPs practise in all jurisdictions in a variety of settings (see Chapter 9). Provinces and territories also employ registered practical nurses (RPNs) (Ontario) and licensed practical nurses (LPNs) (all other jurisdictions). Personal support workers (PSWs) also play an important role as members of the health care team. There are numerous specialties that nurses can prepare for (e.g., pediatric nursing or cardiology). It is important to note that for RPNs in Canada, also an acronym for Registered Psychiatric Nurses, educational programs are offered in British Columbia, Alberta, Saskatchewan and Manitoba (more detail in Chapter 9).

The introduction of health insurance Concerned about the continued shortage of physicians within their community, in 1914 the residents of the small municipality of Sarnia, Saskatchewan devised a plan, without government approval, to offer a local doctor $1500 (from municipal tax dollars) as an incentive to practise medicine in the community rather than join the army. The scheme proved successful, and over the next several years attracted a number of doctors to the area. In 1916 the provincial government passed the Rural Municipality Act, formally allowing municipalities to collect taxes to raise funds for retaining physicians, and administering and maintaining hospitals. By 1931, 52 municipalities in Saskatchewan had enacted similar plans. Not long afterward, the provinces of Manitoba and Alberta followed suit. In 1919, the first federal attempt to introduce a publicly funded health care system formed part of a Liberal election campaign. However, once in power, the Liberals were unsuccessful in their negotiations for joint funding with the provinces and territories and the plan was not carried out. In the aftermath of the Depression in the 1930s, public pressure for a national health program mounted. Canadians realized that a more secure, affordable, and accessible health care system was necessary.

First Attempts to Introduce National Health Insurance In 1935, the Conservative government of R.B. Bennett pledged to address social issues such as minimum wage, unemployment, and public health insurance. Bennett’s government proposed the Employment and Social Insurance Act on the advice of the Royal Commission on Industrial Relations. Under the Act, the federal government would gain the right to collect taxes to provide social benefits. However, the Act was declared unconstitutional by the Supreme Court of Canada and the Privy Council of Great Britain on the grounds that it violated provincial and territorial authority.

Although employment and social insurance were deemed the responsibility of provincial and territorial governments in 1937, shortly thereafter the federal government began to secure some gains in overseeing social programs. In 1940, under Prime Minister Mackenzie King, the provincial and federal governments agreed to amend the British North America Act to allow the introduction of a national unemployment insurance program. By 1942, this program was fully operational. Two years later, in 1944, the federal government passed another piece of legislation introducing family allowances for each child aged 16 and under (often referred to as “the baby bonus”), paving the way for more social programs, the modification of existing ones, and formalized health insurance.

Post–World War II: The Political Landscape Major changes in Canada’s political landscape followed World War II. Provinces and territories began to exercise more authority over the social and economic lives of their populations. A shift in thinking, largely due to the devastating effects of the Depression, resulted in the idea that governments were responsible for providing citizens with a reasonable standard of living and acceptable access to basic services, such as health care. Canadians wanted the security and equity that a publicly funded health care system would bring. Canadians, particularly the middle class, had felt the impact of not having access to appropriate health care. The rich could afford proper care; the poor could turn to charities. The expanding middle class was caught in between. At the same time, medical discoveries were advancing treatment, care, and diagnostic capabilities. A shift from home- to hospitalbased care, particularly when complex medical procedures were involved, created a perceived need for a more organized approach to health care. Various social movements advanced this agenda, because people believed the involvement of the federal government would result in more stable and equitable funding, which would then support and promote medical discoveries and treatment options. In 1948, the federal government set up a number of grants to fund the development of health care services in partnership with the

provinces. In 1952, these grants were supplemented by a national old-age security program for individuals 70 years of age or older. That same year the provinces and territories introduced financial aid for people between the ages of 60 and 69, provided on a cost-sharing basis with the federal government. In 1954, legislation permitted the federal government to finance allowances for adults who were disabled and unable to work. All of these measures contributed to Canadians’ health and well-being. Despite increasing public requests for a nationally funded health care system, the provinces, the territories, and the federal government continued to struggle over how the system would be implemented. Who would be in charge of what, and how much power would the federal government hold over matters under provincial and territorial control? The federal government, looking for a workable solution, ultimately decided to offer funds to the provinces and territories to help pay for health care costs; however, it also set restrictions on how the funds could be spent.

Progress Toward Prepaid Hospital Care The National Health Grants Program of 1948 marked the first step the federal government took into the provincial and territorial jurisdictions of health care. Through this program the federal government offered the provinces and territories a total of $30 million to improve and modernize hospitals, to provide training for health care providers, and to fund research in the fields of public health, tuberculosis, and cancer treatments. Welcomed in all jurisdictions, these grants resulted in a hospital building boom that lasted nearly 30 years. The next decade saw little progress in the introduction of comprehensive insurance plans in the provinces and territories. Then, in 1957, the federal government under John Diefenbaker introduced the Hospital Insurance and Diagnostic Services Act. The Act proposed that any province or territory willing to implement a comprehensive hospital insurance plan would receive federal assistance in the form of 50 cents on every dollar spent on the plan,

literally cutting in half the province’s or territory’s expenses for insured services—an appealing offer indeed! Five provinces, along with the Northwest Territories and Yukon, bought into the plan immediately. All remaining jurisdictions were on board by 1961. Even with the financial aid of the federal government, some provinces and territories were not able to implement comprehensive services, primarily because of population distribution. To rectify this problem, the federal government introduced an equalization payment system through which richer provinces would share revenue with poorer provinces to ensure all could offer equal services. The Hospital Insurance and Diagnostic Services Act stated that all residents of a province or territory were entitled to receive insured health care services upon uniform terms and conditions. The Act provided residents with full care in an acute care hospital for as long as the physician felt necessary. It also included care provided in outpatient clinics, but not in tuberculosis sanitariums, mental institutions, or homes for the aged. Services for some allied health workers (e.g., physiotherapists) and other nonmedical professionals, as well as diagnostic procedures, were covered by provincial and territorial health insurance plans only if the care was provided in a hospital setting and under the direction of a physician. This coverage paved the way for a huge increase in hospital admissions, some more necessary than others. If prepaid health care was available with no out-of-pocket fee in the hospital, why would a patient go elsewhere where he or she would have to pay? As a result, spending for hospital services increased dramatically.

Progress Toward Prepaid Medical Care Tommy Douglas, known as the father of medicare (although this remains controversial—Justice Emmett Hall is also sometimes referred to as Canada’s father of Medicare), was the premier of Saskatchewan from 1944 to 1961 (Tommy Douglas Research Institute, n.d.). Douglas long campaigned for a combined comprehensive hospital and medical insurance plan that everyone

could afford. He firmly believed that the implementation of a social health insurance plan was a government responsibility and that private insurance plans, although useful, discriminated against those with lower incomes, disabilities, and serious health issues. In 1939, the Saskatchewan government enacted the Municipal and Medical Hospital Services Act, permitting municipalities to charge either a land tax or a personal tax to finance hospital and medical services—a precursor to comprehensive hospital insurance in the province. Eight years later, in 1947, Tommy Douglas’s government passed the Hospital Insurance Act, guaranteeing Saskatchewan residents hospital care in exchange for a modest insurance premium payment. In 1960, Douglas was ready to take the next step of providing Saskatchewan citizens with comprehensive, publicly funded medical care, in addition to hospital insurance. His initial attempts to introduce medical care insurance inspired fierce opposition from Saskatchewan doctors, who worried they would be controlled by the province. Douglas fought an election campaign with a platform promising to introduce the health insurance program and was reelected in 1960. The following year, Douglas left Saskatchewan to lead the New Democratic Party in Ottawa. Under his successor, Premier Woodrow Lloyd, the Saskatchewan Medical Care Insurance Act was passed in 1961 and took effect in July 1962. The day the medicare law came into effect, the doctors in Saskatchewan launched a province-wide doctors’ strike, which lasted 23 days. In early August of 1962, the Saskatchewan government revised the Medical Care Insurance Act in an attempt to repair the relationship with the province’s doctors. One amendment allowed doctors the option of practising outside the medical plan, but within three years most doctors were working within the plan finding it the easier route to follow. (Billing patients separately and collecting money owed proved expensive and time-consuming and resulted in only a marginal difference in remuneration.) Most other provinces and territories adopted similar plans over the next few years. Today physicians are remunerated in several ways, particularly those working within primary care teams (e.g., capitation-based funding and salaried positions (see Chapter 8)).

  Thinking it Through The Saskatchewan Medical Care (Insurance) Act, which enforced socialized medicine and imposed fee schedules. It is a funding formula that persists across the country today. This means physicians are paid a calculated amount for each patient assessment, dependent on the complexity of the assessment (fee for service). Other funding mechanisms used today include salaries and paying doctors a set amount per year for each patient. The number of times a doctor sees a patient is irrelevant (see Capitation-Based Funding, Chapter 5). 1. Do you know how your physician is paid? 2. Do you think paying physicians for every service is more cost effective than paying them a lump sum per patient, per year (called capitation-based funding)?

Significant events leading up to the canada health act The federal government remained committed to a comprehensive health insurance program. Box 1.3 summarizes the Hall Report, the Medical Care Act, and the Established Programs and Financing (EPF) Act, all of which played a significant role leading up the Canada Health Act.

  Box 1.3

Legislation Leading up to the Canada Health Act. The Hall Report (1960)—Royal Commission on Health Services • Investigated the state of health care in Canada and was instrumental in passing the Medical Care Act (1966) • Passed in the House of Commons December 8, 1966 • Supported the introduction of a national medicare • Required the federal government share the cost of health care plans implemented by jurisdictions meeting the Act’s criteria (a funding formula created by Tommy Douglas) • Suggested the construction of new medical schools and hospitals • Recommended that the number of physicians in Canada be doubled by 1990 • Recommended that private health insurance companies in the country be replaced by ten provincial public health insurance plans

• Recommended the federal government retain strong control over health care financing but allow provinces and territories some authority over the implementation of their health care services

Implementation of the Medical Care Act (1968) • Implemented on July 1, 1968, and accepted by all provinces and territories by 1972 • Allowed all jurisdictions to administer the plan as they saw fit as long as they adhered to the criteria of universality, portability, comprehensive coverage, and public administration (mirroring the Canada Health Act) • Covered only in-hospital care and physicians’ services • Caused the federal government, provinces, and territories to recognize the need for community-based care and restructuring of the funding formula because of soaring costs of physician and hospital care

The Established Programs Financing Act (1977) • Introduced a new funding formula to allocate money to health care and to postsecondary education • Replaced the previous 50/50 cost-sharing formula with a block transfer of both cash and tax points • Reduced restrictions on how jurisdictions could spend money, allowing them to fund community-based services • Provided more transfer money for an extended health care services program, which covered intermediate care in nursing homes, ambulatory health care, residential care, and some components of home care

  Thinking it Through

With the implementation of the Medical Care Act, health care costs rose dramatically, fuelling the claim that health care in Canada is consumer-generated—meaning that because health care is perceived as being free, many have sought care indiscriminately, going to the doctor for almost any complaint. The emphasis today is on health promotion, wellness, and disease prevention, with individuals being more responsible for their own health (e.g., a healthy lifestyle). 1. Do you think consumers should bear more responsibility for system costs by being more discriminating about when and why they access health care? 2. Do you think Canadians as a whole regard health care as “free,” without recognizing they are paying for it (indirectly or otherwise)?

Events Following the Introduction of the EPF Act In the few years following the introduction of the EPF Act, health care spending continued to increase dramatically, resulting in provincial and territorial overspending and necessitating cuts to health care. Hospitals had to make cuts—some staff were let go, some medical services were either delisted or cut altogether, and doctors’ fees were capped. In response, in 1978, outraged doctors began billing patients over and above what the provincial or territorial plan paid (in accordance with the negotiated fee schedule). For example, if the public insurance plan paid $25 for a doctor’s visit, the doctor added an extra amount—say $10—and asked the patient to pay out-of-pocket for that service. This practice was called extra billing and contravened the principles of the Medical Care Act. Opposition to extra billing was swift, with the public claiming that the fees unfairly limited access to health care. Tensions rose between physicians and the public sector. Once again, Justice Emmett Hall was asked to lead a health care services review, with the assistance of Dr. Alice Girard from Quebec. The mandate was to scrutinize issues

that had risen since the previous Hall Report, including the legality of extra billing. Hall’s conclusions were released in 1980 in a report called Canada’s National–Provincial Health Program for the 1980s. The report stated that extra billing violated the principles of the Medical Care Act and created a barrier for those who could not afford to pay. Hall recommended an end to extra billing and suggested that, instead, doctors be allowed to operate entirely outside of the Medical Care Act. This allowed patients the choice of avoiding a doctor who was not working within the boundaries of the provincial or territorial insurance plan. Physicians opting out of the public insurance plan would bill patients directly for their services; patients would then have to collect money from their provincial or territorial insurance plan. Alternatively, the doctor could bill the plan for services, the plan would pay the patient, and the patient would pay the doctor with the money received, plus any amount the doctor charged above the plan’s allowances. It was a lengthy and cumbersome process. Hall also advised that national standards be created to uphold the principles and conditions of the Medical Care Act, that the criterion of accessibility be added to the Act, and that an independent National Health Council be established to assess health care in Canada and to suggest policy and legislative changes when needed. The recommendations from the second Hall Report were taken seriously but put on hold until the Parliamentary Task Force on Federal–Provincial Arrangements completed its review the following year. This task force was to review the funding arrangements under the EPF Act and the other subsidies the federal government provided to the provinces and territories. The task force’s recommendations included adjusting equalization payments, introducing federal responsibility for income distribution, and separating health care funding from higher education funding. Together, the Hall Report and the report of the Parliamentary Task Force on Federal–Provincial Arrangements prompted the Canada Health Act, new and comprehensive legislation that replaced both the Hospital Insurance and Diagnostic Services Act and the Medical Care Act.

The canada health act (1984) The Canada Health Act became law in 1984 under Prime Minister Pierre Trudeau’s Liberal government. It received royal assent in June 1985 and is still in place today, governing and guiding—and perhaps limiting—our health care delivery system. The Act’s primary goal is to provide equal, prepaid, and accessible health care to eligible Canadians (Box 1.4) and thereby meet the objectives of Canadian health care policy (Box 1.5).

  Box 1.4

Eligibility for Health Care under the Canada Health Act. To be eligible for health care in Canada, a person must be a lawful resident of a province or territory. The Canada Health Act defines a resident as “a person lawfully entitled to be or to remain in Canada who makes his home and is ordinarily present in the province, but does not include a tourist, a transient, or a visitor to the province” (Canada Health Act, 1985, s. 2). Each province or territory determines its own minimum residence requirements. Source: Canada Health Act, R.S.C., c. C-6 (1985).

  Box 1.5

The Primary Objective of Canadian Health Care Policy. “To protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.”

Source: Health Canada. (2004). What is the Canada Health Act? Retrieved from http://www.hc-sc.gc.ca/hcs-sss/medi-assur/chalcs/overview-apercu-eng.php.

Criteria and Conditions of the Canada Health Act The Canada Health Act established criteria and conditions for the delivery of health care. To qualify for federal payments, the provinces and territories must adhere to the five criteria discussed below, and also to two additional conditions (Box 1.6).

  Box 1.6

The Canada Health Act: Criteria and Conditions.

Source: Library of Parliament. (2005). The Canada Health Act: Overview and options. Retrieved from http://www.res.parl.gc.ca/Content/LOP/ResearchPublications/94 4-e.pdf.

Public Administration The Canada Health Act stipulates that each provincial and territorial health insurance plan be managed by a public authority on a nonprofit basis. That is, the health insurance plan must not be governed by a private enterprise and must not be in the business of making a profit. The public authority answers to the provincial or territorial government regarding its decisions about benefit levels

and services and must have all records and accounts publicly audited. To meet the criteria of the Act, health plans must be overseen by the Ministry of Health, the Department of Health, or the equivalent provincial or territorial government department. Services provided under the umbrella of the relevant department are distributed via different vehicles, primarily via regional health authorities or the equivalent.

Comprehensive Coverage Provincial and territorial health insurance plans allow eligible persons with a medical need to access prepaid, medically necessary services provided by physicians and hospitals. Select services offered by dental surgeons, when delivered in the hospital setting, are also covered. Services included under the provincial or territorial plan must be equally available to all insured residents of the province or territory; there must be no barriers to access (Case Example 1.1).

  Case Example 1.1 Alois goes to his doctor to have a wart on his hand removed. The procedure may or may not be covered, depending on what province Alois lives in. For example, it is covered in Newfoundland and Labrador, so, as a resident of that province, Alois would have the procedure covered. In Ontario, Nova Scotia, New Brunswick, Manitoba, Alberta, Saskatchewan, and British Columbia though, wart removal on the hand is not a prepaid service, so if Alois lived there, he would have to pay for the procedure himself (or through supplementary insurance). Each province or territory has the latitude to select which services will be covered under its specific plan. Coverage may include components of home care or nursing home care, chiropractic care, eye care under specific conditions, and pharmacare for designated population groups. Comprehensive coverage of these provincially or

territorially tailored services must be offered to every eligible resident in the jurisdiction.

Universality All eligible residents of a province or territory are entitled on uniform terms and conditions, to all of the insured health services that are provided under the provincial or territorial health insurance plan. The federal government allowed the provinces and territories to decide whether they would charge their residents insurance premiums. Where premiums were charged, however, a citizen’s inability to pay could not prevent his or her access to appropriate medical care. The province or territory would then be able to subsidize premiums for those with low incomes, but could not discriminate on any basis—for example, on the individual’s previous health record, current health status, race, or age. Universality means that no matter how young or old, or rich or poor a person is, or what their health condition is, that person is eligible for the same insured health services as anyone else (Case Example 1.2). The exception would be if Juan could afford to access a private facility for some procedures.

  Case Example 1.2 Juan requires surgery. He lives in British Columbia, a province that charges health care premiums. However, Juan cannot afford to pay the premiums. Universality requires that the province subsidize his premium payments so that Juan can have his surgery and any other health care he needs. Premiums aside, even if Juan were very rich and required surgery for which there was a long wait list, he would not be able to buy his way to the top of the list.

Portability Canadians moving from one province or territory to another are covered for insured health services by their province of origin during

any waiting period in the province or territory to which they have moved. Most jurisdictions enforce a three-month wait before public health insurance becomes active. Under the Act, the waiting period cannot exceed 3 months. Individuals moving to Canada may also have to endure a waiting period of up to three months, and therefore are encouraged to have private insurance in place in the interim. Canadians who leave the country will continue to be insured for health services for a prescribed period of time. Every province or territory sets its own time frame (usually six months less a day, or 183 days). Ontario states that a person may be out of the country for a maximum of 212 days in any given year, while Alberta, British Columbia, Manitoba, and New Brunswick state that a person must remain in the province for at least six months to retain coverage. In Nova Scotia, with permission and under certain conditions, a temporary absence of up to one year is allowed. Newfoundland and Labrador offer out-of-province coverage for individuals who remain in the province for only four months of the calendar year—the lowest residency requirement of all jurisdictions, in part due to the number of migrant workers in the province. In addition, every jurisdiction offers coverage for special situations, such as absences for educational or work purposes. Although Canadian residents are covered for necessary care (i.e., urgent or emergency care) while absent from their home province (e.g., for business or a vacation), they are not permitted to seek elective surgeries or other planned care in another province or territory. In some cases, prior approval for coverage may be granted for elective nonemergency surgery (Case Example 1.3). The Web sites of the provincial and territorial ministries of health offer information about the particulars of each jurisdiction’s health care coverage.

  Case Example 1.3 At 69 years old, Nancy is booked for elective hip replacement surgery in six months in her home province of Nova Scotia. However, she decides to visit her sister in British Columbia and have her hip replaced there because surgical wait times are shorter.

To ensure that the Nova Scotia government will cover the cost of Nancy’s surgery in British Columbia, she has to contact the Nova Scotia Department of Health for prior approval. If Nancy has the surgery without requesting approval from the Nova Scotia Department of Health, or if she is denied approval, she will have to pay for the surgery out-of-pocket. However, if Nancy falls down the stairs and breaks her hip while she is visiting her sister, the surgery would be done in British Columbia, and the total cost would be covered by her province of origin without question. Insured services received outside the person’s province of origin will be paid at the host province’s rate, except by Quebec (Case Example 1.4).

  Case Example 1.4 Jeremy, a 20-year-old resident of Ontario, is visiting friends in Saskatchewan. While there he develops a severe and persistent sore throat and pays a visit to a local doctor. Even if the cost of a visit to the family doctor is $20 in Saskatchewan but is only $15 in his home province of Ontario, the Ontario health plan will pay the full $20 required by the doctor in Saskatchewan. Now consider the situation if Jeremy is from Quebec. If the fee for the same doctor’s visit is $15 in Quebec, the Quebec health plan will pay only $15 to the doctor in Saskatchewan, and Jeremy will have to pay $5. Quebec does not honour the host province’s or territory’s fee schedule if it is higher than its own.

Accessibility The criterion of accessibility was added to the Canada Health Act in an attempt to ensure that eligible individuals in a province or territory have reasonable access to all insured health services on uniform terms and conditions. Reasonable access means access to services when and where they are available, and as they are

available. A service may not be available to a person because of where he or she lives—for example, in a more remote community (Case Example 1.5). Or a service may be unavailable because of a shortage of beds or lack of health care providers to supply the service (Case Example 1.6). Individuals needing a service that is not available must be granted access to that service in the closest location it is offered—whether in another town or city, in another province, or in the United States.

  Case Example 1.5 Monique is a 40-year-old woman living in Pickle Lake, Ontario. She has just been diagnosed with breast cancer. Her community does not have access to radiation therapy, but this therapy is available in Thunder Bay, Ontario. In accordance with the accessibility criterion, Monique would be sent to Thunder Bay for her treatments. If radiation therapy was not available in Thunder Bay—or if the wait time was excessive—Monique would be sent to Winnipeg, Manitoba.

  Case Example 1.6 Pang went into labour at 28 weeks’ gestation. Delivery was imminent, and it was concluded that no facilities in her home province of British Columbia or close by could provide the highly specialized care required for the premature baby (reasons for such service unavailability could include no bed being available or a shortage of nursing staff). Pang was transferred by air ambulance to a hospital in Washington. The baby stayed in hospital for three weeks until he was stable enough to be sent back to British Columbia. The BC Medical Care Plan covered all medical expenses. Accessibility applies to wait times as well. Some jurisdictions have established maximum wait times for certain procedures. If a person

has to wait for a procedure (e.g., a hip replacement) beyond that set time limit, the province or territory will send the person somewhere else for the procedure (see Case Example 1.3). Note, however, that a province or territory would pay for a patient to receive an available service only at the closest alternative location, not a location farther afield or one that the patient prefers. The interpretation of reasonable access is controversial. A person living in Churchill, Manitoba, will not have the same access to health care as a person living in Halifax, Toronto, or Vancouver. Today service availability varies even between rural and urban settings. For the purposes of the Canada Health Act, accessibility has been interpreted as access to services where and when available. It does not, in the true sense of the word, guarantee “equality” of services across Canada. The following two conditions were imposed upon provinces in the Canada Health Act: • Information. Each province or territory must provide the federal government with information about the insured health care services and extended health care services for the purposes identified in the Canada Health Act. • Recognition. The provincial and territorial governments must publicly recognize the federal financial contributions to both insured and extended health care services.

Interpreting the Canada Health Act “Medically necessary” is a subjective term that has been hotly debated within the context of the Canada Health Act (also see Chapter 8). Typically, a physician or other health care provider eligible to bill the provincial or territorial plan makes a clinical judgement to provide the patient with specific medically necessary services, which usually include assessment, diagnostic tests, and treatment. Note, however, that some jurisdictions may not cover all diagnostic tests and treatments. Since the Canada Health Act does not detail which services should be insured, the range of insured services varies among provinces and territories.

Medical services (e.g., caesarean section) must not be provided simply for the convenience of the patient or physician. And when more than one treatment is available, a physician must consider cost effectiveness. For example, when faced with two treatment options that have similar outcomes, a physician must recommend the less expensive option. What one doctor considers medically necessary another doctor may not. Consider breast reduction: a surgeon in Manitoba might determine that this surgery is medically necessary for a particular patient with large breasts because of the backaches and muscle strains she suffers. Another surgeon may not think breast reduction is medically necessary for this patient, meaning that the patient would have to pay for the surgery since it would then be considered a cosmetic procedure.

  Thinking it Through The term medically necessary appears in the Canada Health Act to identify procedures and services that are covered by provincial and territorial health insurance. 1. Do you think that the term is too subjective? 2. Are there health services in your province or territory that you feel should be covered but are not? Physicians, through their governing body, and government officials—usually from the Ministry or Department of Health—select which services are medically necessary and are, therefore, insured. At designated intervals, the provinces and territories review their lists of insured services, sometimes adding services, sometimes removing them. For example, a few years ago many jurisdictions removed elective newborn circumcision from the list of insured services because evidence showed no medical reason for this procedure and found other reasons (e.g., a belief that a circumcised penis is cleaner, or that

the baby should resemble his father), to be invalid. However, circumcision is still insured when a valid medical reason exists for doing it. Also addressed in the Canada Health Act are extra billing and user charges—a fee imposed for an insured health service that the provincial or territorial health care insurance plan does not cover. Under the Act, extra billing and user charges are not allowed because they create a barrier to seeking medical care. If a province or territory nevertheless permits extra billing or user charges, the federal government will total the amount of money the province or territory has collected and will deduct that amount from the next transfer of funds. Proponents of user charges believe they play a useful role in today’s health care climate: for example, charging people who use the emergency department for nonurgent complaints (Case Example 1.7) may ultimately improve emergency department wait times.

  Case Example 1.7 Miao, who lives in Alberta, went to the emergency department because she had a bad cold. The provincial plan would cover the cost of the visit, but the hospital charged Miao an additional fee because she came to Emergency instead of going to her doctor. The extra fee is a user charge.

Additional Components of the Act The Canada Health Act specifically outlines extended health care services that are considered medically necessary and are thus insured. Extended health care services insured under the Act include intermediate care in nursing homes, adult residential care services, home care services, and the services provided in ambulatory care centres. A number of services, such as certain components of home care, however, are not covered under the Act and are subject to each province’s or territory’s health insurance plan. Some jurisdictions,

for example, will provide a certain number of home care hours per week. Once the limit is reached, the patient must pay a home care agency for additional care. The legislation prohibiting user charges and extra billing does not apply to extended health care services. Each province and territory chooses which optional services (i.e., services that are not medically necessary) will be covered under its health plan. Optional services may include chiropody (i.e., foot care), massage therapy, physiotherapy, dental care, drug plans, and assistive devices coverage. (Note: services supplied within a hospital or other insured facility are usually covered.) The amount of coverage for optional services will vary. For example, a province’s plan may cover up to $200/month in physiotherapy services. Services in excess of this amount are subject to user charges and extra billing, which, as mentioned, are permitted for services deemed not medically necessary under the Act.

After the canada health act: commissioned reports and accords Most of the resistance to the Act came from physicians and those affected directly by the restrictions set out in the Act. In 1986, Ontario physicians participated in a 25-day strike in opposition to the Act, arguing that the key issue was not money but professional freedom, a claim not well received by the public. That same year, the Canadian Medical Association opposed the implementation of the Canada Health Act on the grounds that it violated the Constitution Act of 1982. The case went to the Supreme Court of Canada but did not proceed. Just prior to the introduction of the Act, most of the provinces and territories had established some form of extra billing, user charges, or both as a result of events leading up to the implementation of the Canada Health Act. These extra fees could not be removed overnight. Over the next two years, the federal government imposed monetary penalties to noncompliant jurisdictions, again fueling resentment and opposition. The federal government decided to reimburse provinces that took corrective action against extra billing and user charges within three years. Most jurisdictions complied, but these practices were not entirely eliminated. Even today, some provinces and territories defy this part of the Act, each year resulting in withheld funding primarily related to user charges at private clinics deemed by the federal government to be operating outside of the law. In the decade following the implementation of the Canada Health Act, the health care system in Canada experienced increasing difficulties that persist today. At first hospitals had trouble functioning within their allotted budgets. Provinces and territories pushed for more money to sustain reasonable levels of care, yet federal funding continued to dwindle. In the early 1990s, hospitals restructured, downsized, redistributed beds, laid off staff, cut services, and closed. Doctors and nurses left the country, and fewer

graduates pursued careers in these roles, leading to widespread staffing shortages. Some provinces and territories responded proactively by establishing innovative and alternative health care strategies (Box 1.7). Home care became a priority across Canada; the concept of “health care teams” reflecting how primary care is delivered today (i.e., the physician working with other health care providers to deliver more comprehensive, patient-oriented care) was introduced; access to primary care services (e.g., through after-hours clinics, telephone helplines, and extended office hours) was improved; and primary health care reform began to take place (Table 1.1).

  Box 1.7

Alternative Health Care Strategies. New Brunswick was one of the first jurisdictions to predict the problems related to funding shortfalls, cutbacks, population changes, and an increased need for hospital beds. The province led the move toward community-based care, called “hospital without walls,” and established the Extra-Mural Program, which focused on shortening hospital stays and providing the appropriate care and support to meet health care needs in home and community settings. This concept was actually introduced in 1979, 5 years before the Canada Health Act was passed. Throughout the 1980s and 1990s, various provinces and territories completed investigations into the state of health; of several, these include: the Royal Commission on Health Care in Nova Scotia (1989), Commission on Directions in Health Care in Saskatchewan (1990), Premier’s Council on Health Strategy in Ontario (1991), and the Health Services Review in British Columbia (1999). National reports were also commissioned—for example, the first, second, and third reports on the health of Canadians, released in 1996 and 1999 and 2003, respectively, examined and summarized the health status of Canadians. A 2016 report on the Health of

Canadians focused on the growing number of Canadians with heart disease. By 2002 public confidence in health care was at an all-time low, with health care topping the list of Canadians’ concerns. Following this concern grew around the services (or lack thereof) for mental health, community care, and the omission of a national pharmacare strategy. Provinces and territories introduced a variety of commissions to study varying concerns regarding health care within their own jurisdictions, some coming to fruition, others not. On a national level, over a number of years, responding to gaps in mental health and homecare services became a priority. In 2006, the Senate Standing Committee on Social Affairs, Science, and Technology completed a Canada-wide study on mental health/illness, recommending, among other things, establishing a Canadian Mental Health Commission to address shortcomings in mental health services. The Mental Health Commission of Canada (chaired by the Honourable Michael Kirby) was created the following year to provide and oversee mental health services at a national level. Creation of the Mental Health Commission of Canada was supported by all jurisdictions, except Quebec. In 2017, the federal government provided targeted funding for both mental and community care initiatives. Medically assisted aid in dying was legalized in response to national pressure to provide dying with dignity, procedures deemed to be the responsibility of primary care practitioners, and overseen by family physicians, and nurse practitioners. Only recently have Canadians become more concerned about the environment than health care. Ironically, environmental concerns (e.g., pollution, contaminated drinking water, poor air quality) squarely interact with health care concerns. Source: South East Regional Health Authority. (n.d.). Extra-Mural Program. Retrieved from https://www2.gnb.ca/content/gnb/en/services/services_renderer. 8975.Extra-Mural_Program.html.

Table 1.1 The Goals of Primary Care Reform. Medical Model of Health Care Physician-based care Illness-focused Hospital-based care Curative (in relation to disease) Problems are isolated Health care provider– dominated

Primary Health Care Reform Goals Team-oriented care Emphasis on disease prevention and health promotion Community-based care Treating maladies, which sometimes results in living healthy lives with chronic conditions Care is comprehensive and integrated (i.e., holistic) Collaborative care involving interdisciplinary teams, patient, family, and loved ones

Social Union In 1997, the provincial and territorial first ministers met with their federal counterparts to form a social renewal program that required that all governments work collaboratively on what the first ministers called a social union (Social Union, 1999). The agreement acknowledged the need to establish national standards for social rights and associated related policies. The principals of the covenant included being recognized equally for all Canadians. All Canadians should be treated with fairness and dignity and equality of rights; they should be afforded equal opportunities and provided appropriate assistance for those needing it; and they should be afforded mobility within Canada. Mobility means Canadians can move freely within the country to see opportunities, and governments will remove any residency-based barriers. Canadians have the opportunity to use monetary transfers from support social programs such as health care. Difficult negotiations followed, primarily around the federal funding formula and the amount of autonomy provinces and territories would have with respect to where and how to spend the money (e.g., cancer treatments, improvements to emergency departments, long-term care). The final agreement was signed by all jurisdictions, with the exception of Quebec, on February 4, 1999 (Asselin, 2001). Quebec was unwilling to sign any agreement that did not clearly support the province’s right to unconditionally opt

out of programs supported by or initiated by the federal government, which the social union did not provide. In the final agreement, the union agreed to maintain the five criteria of the Canada Health Act and to work continuously to improve health care. Also included was a commitment to work collaboratively with Indigenous people, their governments, and their organizations to improve health care and social programs. The federal government then promised to boost health care spending by $11.5 billion over the next five years, which began in the 1999–2000 fiscal year. The success of the social union today is questionable at best. Federal funding formulas changed (see Chapter 8), and the agreement drove a wedge between Quebec and the federal government; certainly inequities related to social programs are evident. Consider the rise in the rate TB among our Indigenous population, particularly the Inuit population, which in 2017 was estimated to be an astounding 290 times higher than in nonIndigenous Canadians.

Commissioned Reports By the end of 2002, three major reports on the status of health care in Canada had been commissioned and released: the Mazankowski Report, the Kirby Report, and the Romanow Report. See Box 1.8 for the key points of each report.

  Box 1.8

Three Major Reports on the Status of Health Care in Canada. The Mazankowski Report: A Framework for Reform (2001) Commissioned by former Alberta premier Ralph Klein in August 2000 and chaired by Donald Mazankowski, former Cabinet member in the Mulroney government

Purpose: to provide strategic advice to the premier on the preservation and future enhancement of quality health services for Albertans Key Points • Supported private health care in that it recommended doctors be allowed to work in private health care venues after devoting a specific amount of time to the public sector • Recommended, after review, delisting selected services currently covered under the provincial plan • Recommended the implementation of province-wide electronic health records and electronic health cards • Suggested that taxes be used as a source of increased revenue and that Albertans pay higher health premiums (not well received) Significant Outcomes: by 2003 Alberta had implemented a province-wide electronic health record initiative, becoming the first Canadian province to do so.

The Kirby Report: The Health of Canadians—The Federal Role (2002) Led by Senator Michael J. Kirby Purpose: to examine the state of the Canadian health care system and the role of the Federal Government in it Key Points • Bore important similarities to the Mazankowski Report • Felt the health care system was unsustainable with existing levels of funding • Recommended the implementation of new taxes or insurance premiums that were geared to income • Recommended setting limits to wait times; once the limit was reached, stated the government should pay for the patient to

receive treatment elsewhere, even in the United States if necessary • Recommended a government-funded assistance plan for medications under certain circumstances related to the cost of medications proportionate to a person’s (or a family’s) income • Recommended an immediate outlay of $2 billion for information technology, including the development of a national system for electronic health records, and another $2.5 billion over five years for advanced medical equipment • Suggested government incentives encouraging health care providers to return to Canada, and outlay of funds to recruit and train doctors and nurses Significant Outcomes: This report was not as widely accepted as the Romanow Report. However, Ontario did adopt payment premiums for health care.

The Romanow Report: Building on Values: The Future of Health Care in Canada (2002) Led by Roy Romanow, former premier of Saskatchewan and chair of the Commission on the Future of Health Care in Canada Purpose: to present recommendations to ensure the survival of Canada’s health care system and to consider health promotion and disease prevention initiatives Key Points • Bore important similarities to the Mazankowski Report • Gathered information and advice from Canadians through public forums and meetings held across the country • Believed that health care was sustainable but that immediate action was necessary by all levels of government (funding and revision) • Opposed privatization of health care, stating that any new plans creating private health care initiatives should be discouraged

• Recommended the creation of the Health Council of Canada to oversee improvements to health care, to conduct regular reviews of the health care system (e.g., home- and communitybased care, primary care reform initiatives, human health resources, implementation of drug plans, wait times), and to report findings to the public • Recommended that reform initiatives be paid for by the federal government’s surplus or by raising taxes (e.g., the federal government could establish a dedicated cash-only Canada Health Transfer) • Recommended adding the criterion of accountability to the Canada Health Act • Recommended extending coverage for home care, diagnostic testing, palliative care, and mental health care • Suggested that Employment Insurance benefits and job security be extended to family members and friends who choose to care for sick or dying loved ones at home • Recommended that catastrophic drug costs, subject to certain terms and conditions (e.g., ability to pay), be covered • Recommended that a national body control the price of drugs, provide a centralized list of drugs covered by public health plans, monitor the safety and cost of new drugs seeking federal approval for use, and review the efficacy and outcomes of drugs in use • Recommended the establishment of another independent agency to review and approve prescription drugs and to ensure that Canadians have clear and concise information about the drugs they are taking • Advocated the organization of a central body to monitor and streamline wait lists, but did not recommend a limit on wait times Significant Outcomes: see Impact of the Romanow Report, later. Sources: Kirby, M. J. L. (2002). The health of Canadians—The federal role. Final report. Retrieved from

http://www.parl.gc.ca/37/2/parlbus/commbus/senate/Come/soci-e/rep-e/repoct02vol6-e.htm; Mazankowski, D. (2001). A framework for reform: Report of the Premier’s Advisory Council on Health. Retrieved from http://www.health.alberta.ca/resources/publications/PACH_repor t_final.pdf; Romanow, R. (2002). Building on values: The future of health care in Canada. Retrieved from http://www.cbc.ca/health care/final_report.pdf ; Until The Last Child. (2014). The history of child welfare in Canada. Retrieved from http://www.untilthelastchild.com/the-history-of-child-welfare-incanada/.

Impact of the Romanow Report Following the release of the Romanow Report, the federal government under Prime Minister Jean Chrétien stated that the report would provide the foundation for the direction of health care over the next several years. In 2004 the federal government earmarked $10 billion for health care to be distributed over a 10-year time frame to address the problems identified in the report. Several of Romanow’s recommendations have been implemented. On April 1, 2004, the Canada Health Transfer (CHT) and the Canada Social Transfer (CST) replaced the Canada Health and Social Transfer (CHST), a set amount of money (a block transfer payment) from the federal government to the provinces intended to pay for health care, postsecondary education, and welfare. See also Chapter 4. Health promotion campaigns have been maintained and further promoted by all levels of government. Limits on wait times were implemented across the country, and current wait times were required to be posted on the Internet. The Health Council of Canada was created as a result of the 2003 First Ministers’ Accord but was subsequently disbanded by the federal government in 2014. At the 2004 first ministers’ meeting, Canada’s first ministers agreed on more funding and initiatives for health care renewal, including funding for family members to remain at home to care for ill relatives. Primary health care reform initiatives have been tested, implemented, and revised across Canada. That process is ongoing as

various primary health care delivery models are continually improved to be cost effective and meet the needs of the communities they serve. Funding was made available for information technology and electronic health records in all regions. In some jurisdictions the money was used effectively and not in others. The implementation of electronic medical records and their effectiveness remains fractured from a national perspective although improvements have been made. A national catastrophic drug plan (see Chapter 4) has not been implemented, although most jurisdictions now have one of their own. Drug coverage is inconsistent across the country. Canada is still the only industrialized nation with universal health care that does not have a national pharmacare program.

  Thinking it Through Despite past recommendations to establish a national drug plan (e.g., The Romanow Report) to date, this has not been done. Some claim that a national drug plan would be cost prohibitive, others claim that a national plan would be cost effective and save billions of dollars. The federal government, as part of the 2018 budget, announced the creation of an Advisory Council on the Implementation of National Pharmacare to assess the impact such a plan would have for Canadians and the health care system. 1. In your opinion, is health care as we know it sustainable? 2. Do you think a national paid-for drug plan and increased coverage for home care would be cost effective?

Accords The following summaries of first ministers’ meetings highlight the most recent health accords between the federal government and the provincial and territorial governments.

First Ministers’ Meeting, 2000

In September 2000, the first ministers met and agreed to work together to identify the significant issues facing health care in each province and territory, to prioritize these concerns, and to pledge to work collaboratively to address these concerns on both a provincial or territorial, and national level. The major issues identified at this meeting included health promotion, timely access to services, the state of primary care services, the shortage of health professionals, lack of funding and services for home and community care, inefficient management of health records, aging diagnostic equipment, lack of equipment, and the high cost of medications for the many Canadians without a drug plan. A number of meetings followed. Agreements were achieved, commitments were made, and funding was pledged to address concerns. The renewed commitment at subsequent meetings built on the promises made at the September 2000 first ministers’ gathering.

First Ministers’ Accord on Health Care Renewal, 2003 In February 2003, the prime minister and the premiers of seven provinces met in Ottawa to outline the immediate direction for health care in Canada. The overriding commitment made was to preserve universal health care under the current Canada Health Act. Most of the concerns are the same as those discussed in the First Ministers meeting in 2000 (First Ministers, 2003). A key component of this accord was establishing standards of care for Canadians, including access to health care providers 24 hours a day, 7 days a week; prompt access to diagnostic services and treatments; the implementation of a nationwide electronic health record system; and financial assistance for those who need medications but cannot afford them. Over a 5-year time frame the Health Reform Fund, created at this meeting, channeled money into primary care, a catastrophic drug plan, and home care services. Through this fund the federal government transferred money to the provinces and territories so that they could address the specific needs of their residents. The ministers also addressed the unique needs of Indigenous people. The federal government pledged to work more closely with provincial and territorial governments and Indigenous leaders to

bring health care services for Indigenous people on par with those provided to other Canadians. The equalization payment program was reexamined to ensure that all provinces had adequate funding to provide comparable health care services to their citizens. As previously mentioned, it was through this accord that the Canada Health Transfer was created, separating the funding formula that had combined federal funding for both health care and postsecondary education. In this accord the federal government also pledged to introduce a compassionate care benefit package through the Employment Insurance program, along with job protection through the Canada Labour Code (as recommended in the Romanow Report), to provide financial security and job protection for individuals who temporarily leave their place of employment to care for a seriously ill or dying parent, spouse, or child. This recommendation was implemented in 2012. In 2016, the federal government extended paid benefits to 26 weeks from 6 weeks. Nova Scotia, the first province to align its labour code with federal legislation, extended the leave to 28 weeks in 2016, followed by Saskatchewan, and Newfoundland and Labrador. In addition, the Health Council of Canada was created and given the responsibility to report to Canadians on health outcomes (it was disbanded in 2014, according to the federal government, having served its mandate).

First Ministers’ Meeting on the Future of Health Care, 2004 The First Ministers’ Meeting on the Future of Health Care was convened to follow up on agreements made in 2003, discuss progress, and move forward with other proposals (First Ministers, 2004). At this meeting, the prime minister and premiers signed a second agreement, with the federal government pledging $41 billion for health care services over a 10-year time frame. Once again, the first ministers renewed their commitment to building on the criteria of the current Canada Health Act and to working together in a

constructive and open manner. They promised to share information and to be more accountable to the public about progress being made. The Health Council of Canada was given increased responsibilities to report to Canadians on health outcomes. The prime minister, first ministers, and Indigenous leaders established the Aboriginal Health Transition Fund, which provided $200 million for improving Indigenous health care services to meet the needs of Indigenous people across Canada.

Annual Conference of Ministers of Health, 2005 At the Annual Conference of Ministers of Health in 2005, particular consideration was given to the catastrophic drug coverage mentioned at previous meetings. The ministers of health discussed measures to move forward with previous recommendations to standardize the price of drugs across Canada and pledged to have better control over the pharmaceutical industry’s relationship with provincial and territorial health insurance plans (First Ministers, 2005).

The Kelowna Accord, 2006 The first ministers met again in Kelowna, British Columbia, where the federal government promised to spend $5 billion over 5 years to improve health, housing, and education for Indigenous people (Kelowna Accord, 2006). The ministers also established the Blueprint on Aboriginal Health, a plan aimed to bring the health outcomes of Indigenous people in line with those of the general Canadian population—although provinces and territories have yet to commit to the plan. A few days later, the Paul Martin minority Liberal government fell, and the promises outlined in the Kelowna Accord were never met.

The Mental Health Commission of Canada (MHCC), 2007 The Standing Senate Committee (the Kirby Report) recommended the creation of a mental health commission to focus attention on mental health in Canada. The MHCC identifies problems related to

mental health and makes recommendations for improvement. Such problems include addictions (e.g., drugs and alcohol) and homelessness (often homelessness goes hand in hand with addictions and other mental health problems). Support includes inmates with mental health issues, housing, health care, and supporting individuals with mental illness as well as their families. More recently the focus has been trying to cope with the opioid crises exploding across the country; supporting addicts with harm reduction centres and rehabilitation programs. The MHCC provides annual reports on its progress, accomplishments, and identifies new strategies. The latest report is Advancing the Mental Health Strategy for Canada: A Framework for Action (2017–2022). The consultations took place in 2015 and included individuals from across Canada with a variety of roles and backgrounds. The common denominator was an interest and investment in mental health (e.g., politicians/policy makers, health care providers, caregivers, concerned individuals, the Indigenous community, and people who have interfaced with the mental health system). Priorities include developing strategies from dealing with the opioid crisis sweeping across the country to providing mental health and support to the surge refugees who have come to Canada over the past couple of years (Mental Health Commission of Canada, 2016).

  Did You Know? The mental health and well-being of refugees is a priority for the Canadian Mental Health Association (CMHA). Supporting new Canadians in need is a complex affair that must consider culture, adjusting to a new way of life, and for many coming to terms with previous trauma experienced (e.g., post-traumatic stress disorder [PTSD]). Communities across the country are including treatment for mental health at clinics as well as specialized centres. For example, in 2016, Woman’s College Hospital in Toronto (Crossroads) collaborated with the CMHA and created a mental

health and wellness program called New Beginnings. Saskatoon includes mental health assessment and treatment at its Refugee Engagement and Community Health clinic. One resource claims that up to 80% of the women and children accepted into Canada require mental health support. Refugees are provided with basic medical health services under the Federal Interim Health Program. Other types of medical services such as mental health care is left up to individual provinces and territories to decide how refugees should access these services.

The 2014 Health Accord In 2011, the federal finance minister announced a new formula for the Canada Health Transfer (CHT). Under the terms of the new accord, (from April 1, 2014 to March 31, 2024), the federal government would continue paying the transfer payments at 6% annually until the 2016–2017 fiscal year. After that time (and at least until 2024) the transfer dollars would be tied to the rate of the GDP and is guaranteed not to fall below 3%. In addition, under this accord, provincial and territorial CHT transfers were adjusted so that payments were to be allocated on an equal per capita cash basis only (excluding tax points). Under this accord, there were no strings attached as to how the money was spent. This Accord was crafted unilaterally by the Federal government—the provinces and territories had no say in the legislation, which resulted in unrest, discord, and divided the provinces and territories. The hope was that if a new government was elected in 2016 that a new agreement would be negotiated. The new government was formed under Prime Minister Justin Trudeau in 2016.

The 2017 Health Accord The federal minister of health met with first ministers late in 2016 to initiate talks on a new Canadian Health Accord. The federal finance minister and minister of health presented a unilaterally drafted offer of a 3.5% annual increase in Canada health transfers and $11.5 billion over a term year time frame to be spent on mental health and home care initiatives. All jurisdictions initially rejected the offer wanting

further negotiations. Presenting a unified front, the first ministers countered, asking for an annual increase in CHT transfers of 5.2%. They also wanted the federal government to retract any conditions on how the money was spent. The federal government refused to negotiate, stating that it was a take it or leave it offer but indicated that the provinces and territories could approach the federal government and negotiate privately. Nova Scotia (receiving $287.8 million), New Brunswick (receiving $230 million), and Newfoundland and Labrador (receiving $160 million) were the first provinces to break the unified front, negotiating their own terms of agreement for a new accord (New Brunswick, Office of the Premier, 2016). Next came deals with Nunavut, Yukon, and the Northwest Territories. Following with Saskatchewan, which in addition to receiving extra funding, addressed an ongoing dispute with the ministry over Saskatchewan’s policy of allowing private (for purchase) magnetic resonance imaging (MRI) examinations and contravenes the terms and conditions of the CHA. The province had to prove that this policy is not a disadvantage to the public system and had to guarantee a publicly funded MRI for each private one purchased. British Columbia’s agreement (February 2017) included receiving $1 billion for home care and mental health plus $10 million to put towards the opioid crisis the province is dealing with (see Chapter 10), which at the time had not spread significantly to other jurisdictions. In March 2017, Ontario signed a 10-year agreement worth $4.2 billion, plus additional funding for home care for $2.3 billion, and mental health initiatives of $1.9 billion (Government of Canada, 2017). Alberta agreed to an agreement giving the province $10.3 billion dollars over ten years with $703.2 million for home care and $586 million for mental health. Quebec’s agreement was completed after Ottawa agreed to recognize Quebec as a distinct region, removing guidelines on how the money was to be spent (recognizing Quebec as a province of “asymmetry”). Manitoba was the last province to sign the accord. The terms included a one-time payment in 2017 of $5 million to be used to help manage the province’s opioid

crisis as well as kidney disease, and additional support for home care programs (Dacey & Glowacki, 2017). In all cases, additional funding received (in addition to the 3% CHT) had to be spent as per the terms of each agreement (e.g., split between home care and mental health services). In addition, all jurisdictions were free to apply for extra funding as circumstances dictate. For example, the North West Territories received additional funding for medical transportation and innovation.

Other Initiatives In addition to meetings and policies made at the federal level, all provinces and territories promote health care initiative within their own jurisdiction. Decisions as to what these programs and policies encompass involve politicians, other stakeholders at all levels as well as individuals living in that jurisdiction. A good example is the Patient First Review launch in 2008. A survey was conducted using a variety of methodologies asking people if the Saskatchewan health care system was putting the patient first, and if they felt the system was being run in an efficient manner (both from a monetary and service perspective). This framework of proposals and recommendations is reviewed at regular intervals—the last in 2015. E-Patient and Family-Centred Care (PFCC) Framework has improved the health care in a number of ways (e.g., lowering surgical wait times).

Summary 1.1 Health care in Canada evolved from European settlers’ bringing doctors and nurses (many of them with the military) to the country in the 1500s and 1600s and integrating many of their practices with those of the Indigenous peoples. In the 1700s and early 1800s, volunteer organizations played a key role in the delivery of health care. The concept of public health emerged in the early 1800s, and with the passage of the British North America Act in 1867, federal and provincial governments shared responsibilities for health care, which, over time, became more structured and formalized. As a result, some government funding of hospitals began around this time, and the first school of nursing was established in 1873 in St. Catharine’s, Ontario. 1.2 Traditional ceremonies and practices of First Nations people date back centuries. Indigenous people were healthy and had numerous ceremonies and practices that were handed down over the years, orally, for the most part. Thus there are few written records of these practices. Most cultural practices were rooted in holistic and spiritual ideals and beliefs as well as an integral relationship with nature and “mother earth.” With colonization, western medicine was deemed more effective. Today across Canada there is a move to integrate traditional health practices and traditions with Western medicine and sometimes replace Western treatments. 1.3 The road toward health insurance began with the first federal attempt to introduce a publicly funded health care system in 1919. Following World War II, governments began thinking that they had an obligation to provide Canadians with a better standard of living, including access to quality health care. Prepaid hospital care was introduced in 1948 and was well received by all jurisdictions. Shortly afterward, Saskatchewan spearheaded an organized push to integrate

both medical and hospital care into the public health care system. 1.4 With the federal government committed to a comprehensive national health care system, a number of reports and pieces of legislation followed. The Hall Report, the Medical Care Act, and the Established Programs and Financing Act all played significant roles leading up to the Canada Health Act. In 1957, the federal government introduced the Hospital Insurance and Diagnostic Services Act, which was the precursor to prepaid health care for all Canadians. Prepaid health care as we know it today came into effect in 1984 with the passage of the Canada Health Act. 1.5 The five criteria established by the Canada Health Act of 1984 for the delivery of health care are public administration, comprehensive coverage, universality, portability, and accessibility. The two conditions included in the Act are information and recognition. The Canada Health Act specifically outlines extended health care services that are considered medically necessary and are thus insured. Medically necessary is a subjective term that has been debated within the context of the Canada Health Act; extra billing and user charges are permitted only for services deemed not medically necessary under the Act. 1.6 There was some opposition to the Canada Health Act by physicians and the Canadian Medical Association on the grounds that it restricted extra billing and user charges and violated professional freedom. In the decade that followed the implementation of the Act, increasing difficulties in the health care system led some provinces and territories to establish innovative health care strategies, and primary health care reform began to take place. In 1997, the first ministers met with the federal government to work toward a social union and clarify the role of the federal government with respect to funding. By the end of 2002, three major reports on the status of health care in Canada had been commissioned and released: the Mazankowski Report, the Kirby Report, and the Romanow Report. Several first

ministers’ meetings over the past 15 years have resulted in the creation of new health accords. 1.7 The health accord negotiated under Prime Minister Paul Martin provided provinces and territories with a funding model lasting until 2014. Federal transfers guaranteed jurisdictions an increase of 6%/year until that time. The Harper government, in 2014, unilaterally imposed an accord that reduced the CHT transfer amount to 3%/year, or to the percentage of the GDP. 1.8 The 2017 accord negotiated (again unilaterally) by the Trudeau government kept the same formula for the CHT, but offered additional funding aimed as specific services (home care and mental health). Provinces and territories initially presented a unified front, refusing the terms of this take it or leave it deal. The federal government offered to negotiate privately with each jurisdiction, and slowly, provinces and territories signed individual agreements. 1.9 The 2003 health care renewal accord introduced the Canada Health Transfer, reexamined the process for evaluating equalization payments, and established the compassionate care benefit package. In this Accord, The Health Council of Canada was given increased responsibilities to report to Canadians on health outcomes.

Review questions 1. What were the health care responsibilities of the federal and provincial governments outlined in the British North America Act? 2. What organizations attended to the health care needs of Canadians in the eighteenth and nineteenth centuries? 3. What are three traditional healing practices of Canada’s Indigenous population? Briefly describe them. 4. How and when was health insurance first introduced in Canada? 5. How and when was the concept of prepaid hospital care introduced in Canada? 6. List and describe three pieces of legislation that played significant roles leading up to the creation of the Canada Health Act. 7. What are the criteria and conditions of the Canada Health Act and what do they mean? 8. What is meant by the terms medically necessary, extra billing, and user charges, and how do they relate to each other in the context of the Canada Health Act? 9. What are the goals of primary care reform? 10. Why was the Indigenous population in Canada so affected by disease when non-Indigenous people came to Canada? 11. Describe two healing ceremonies important to First Nations people in Canada. Which ones are practised today? 12. How did residential schools affect the Indigenous population in Canada? 13. List and describe three major reports on the status of health care in Canada.

References Asselin R.B. The Canadian social union: Questions about the division of powers and fiscal federalism. Library of Parliament. Retrieved from https://lop.parl.ca/Content/LOP/ResearchPublicati ons/prb0031-e.htm. 2001. Canada Health Act. RSC c. C-6. 1985. Canadian Blood Services. Guidelines for the Canadian Blood Services Summer Internship Program 2014. Ottawa: Author; 2014. Retrieved from https://blood.ca/sites/default/files/guidelines-sip2014.pdf. Canadian Museum of History. A brief history of nursing in Canada from the establishment of New France to the present. Retrieved from https://www.historymuseum.ca/cmc/exhibitions/t resors/nursing/nchis01e.shtml. 2004. Canadian Red Cross. Historical highlights. Retrieved from http://www.redcross.ca/about-us/about-thecanadian-red-cross/historical-highlights. 2008. Dacey E., Glowacki L. Manitoba final province to sign health-care pact with feds. CBC News. Retrieved from http://www.cbc.ca/news/canada/manitoba/fundi ng-health-manitoba-1.4255391. 2017. First Ministers. (2003). First ministers’ accord on health care renewal, Ottawa: Author. Retrieved from http://www.hc-sc.gc.ca/hcs-sss/deliveryprestation/fptcollab/2003accord/nr-cp_e.html. First Ministers. First ministers’ meeting on the future of health care 2004: A 10-year plan to strengthen health

care. Retrieved from http://www.hc-sc.gc.ca/hcssss/delivery-prestation/fptcollab/2004-fmmrpm/index-eng.php. 2004. First Ministers. Annual conference of Federal– Provincial–Territorial Ministers of Health. Retrieved from https://www.canada.ca/en/news/archive/2005/10 /annual-federal-provincial-territorial-ministershealth-conference.html. 2005. Government of Canada, Health Canada. Canada reaches health funding agreement with Ontario [Press release]. Retrieved from https://www.canada.ca/en/healthcanada/news/2017/03/canada_reaches_healthfundi ngagreementwithontario.html. 2017. Kelowna Accord. Aboriginal roundtable to Kelowna Accord: Aboriginal policy negotiations. 2006.2004– 2005. Retrieved from http://parl.gc.ca/information/library/PRBpubs/pr b0604-e.htm. Mental Health Commission of Canada. Advancing the mental health strategy for Canada: A framework for action (2017–2022). Ottawa: Mental Health Commission of Canada; 2016. Retrieved from https://www.mentalhealthcommission.ca/sites/def ault/files/201608/advancing_the_mental_health_strategy_for_cana da_a_framework_for_action.pdf. Mount Saint Vincent University. Formal training for nurses, the beginning. Retrieved from http://www.msvu.ca/library/archives/nhdp/histor y.htm. 2005.

New Brunswick, Office of the Premier. (2016, December 22). Revised: Canada-New Brunswick health accord signed [Press release]. Retrieved from http://www2.gnb.ca/content/gnb/en/news/news_ release.2016.12.1242.html. Picard A. Krever inquiry. In: The Canadian Encyclopedia. 2014. Retrieved from http://www.thecanadianencyclopedia.com/index.cf m?PgNm=TCE&Params=A1ARTA0009152. Social Union. A framework to improve the social union for Canadians: An agreement between the Government of Canada and the governments of the provinces and territories. Retrieved from http://socialunion.gc.ca/news/020499_e.html. 1999. St. John Ambulance. St. John Ambulance’s history in Canada. Retrieved from https://www.sja.ca/English/About-Us/Pages/SJAHistory-in-Canada.aspx. 2018. The UN Refugee Agency [UNHCR]. Canada’s 2016 record high level of resettlement praised by UNHCR. 2017. Retrieved from http://www.unhcr.org/news/press/2017/4/58fe15 464/canadas-2016-record-high-level-resettlementpraised-unhcr.html. Tommy Douglas Research Institute. (n.d.). Achievements. Retrieved from http://www.tommydouglas.ca/tommy/achievemen ts/. Until the Last Child. The history of child welfare in Canada. Retrieved from http://www.untilthelastchild.com/the-history-ofchild-welfare-in-canada/. 2014.

Wilson K. The Krever Commission—10 years later. CMAJ. Canadian Medical Association Journal. 2007. ;177(11):1387–1389. https://doi.org/10.1503/cmaj.071333.

2

The Role of the Federal Government in Health Care LEARNING OUTCOMES 2.1 Discuss the basic objectives and responsibilities of Health Canada. 2.2 Describe the organization and primary responsibilities of Health Canada at the ministry level. 2.3 Summarize the responsibilities of departments, branches, and bureaus of Health Canada. 2.4 Discuss the function of the independent agencies that report to the minister of health. 2.5 Explain how Health Canada collaborates with international organizations.

KEY TERMS Branch Bureau Hypoglycemic reaction Indigenous Peoples Inuit Pandemic

Patented drugs Risk assessment Severe acute respiratory syndrome (SARS) How much influence does the federal government have over our health care? Who pays for health care for refugees who have not established residency in Canada? Are there any conditions on the extent of health care they receive? What department is responsible for licensing health products that come onto the market, and who is responsible for overseeing the safety of food, the use of insecticides on our crops, and the type and the cost of medications on the market? What is in the flu vaccine, and why should we get it? How does the World Health Organization (WHO) actually track health threats? What level of government is responsible for making recommendations regarding the numbers of nurses required across the country? To answer most of these questions, one must understand the role of the federal government in health care. The federal, provincial, and territorial governments all play a part in health care. As noted in Chapter 1, the responsibilities of each were originally outlined in the British North America Act in 1867. Today, the federal government possesses little power over the health care of individual Canadians and absolutely no legal power over health care delivered in provincial and territorial jurisdictions. The provinces and territories continually guard their authority over health care in their individual relationships with the federal government. On the other hand, the provinces and territories want and need federal financial support, which comes with stipulations. In fact, it is through its control over medical and hospital care funding that the federal government exerts most of its influence. The federal government also provides leadership, advice, and direction on health care issues on a national and international front. International issues require Health Canada to interact regularly with global organizations, particularly the WHO, which has become more visible over the past several years, especially with respect to issuing warnings and bulletins about regional and global health threats. The Ebola Viral Disease outbreak in west Africa and appearance of the

Zika virus outbreak which spread through the Americas in 2016 are two such global health threats. This chapter examines the role of the federal government in health care, the hierarchical structure of Health Canada, and the functions of the various government departments and agencies. The chapter begins by looking at Health Canada’s mission statement, philosophy, and commitment to health care in Canada. These pledges provide the foundation upon which the ministry was built and the values with which it strives to function. Despite the best of intentions, however, many issues are not addressed effectively and consistently, so problems with the Canadian health care system persist today.

Health canada: objectives and responsibilities Health Canada is the federal government department responsible for health matters. Headed by a minister of health, it consists of a number of sub-departments organized into functional and administrative branches, agencies, and offices. Since Health Canada’s organizational structure changes frequently, this chapter discusses only the ministry’s major components, with a focus on the primary responsibilities of each. Refer to the Health Canada website for information about any recent changes to the organizational structure and allocation of responsibilities (http://www.hc-sc.gc.ca). Health Canada’s detailed mission statement includes information about its purpose, values, and activities. It states that Health Canada is “committed to improving the lives of all of Canada’s people and to making this country’s population among the healthiest in the world as measured by longevity, lifestyle and effective use of the public health care system” (Health Canada, 2016a). With a mandate to provide national leadership for health care and to maximize health promotion and disease prevention strategies, Health Canada has committed to working collaboratively with the provinces and territories on joint ventures such as creating policies and financing projects. The ministry manages funding policies and oversees the transfer of money and tax points (explained in Chapter 1) to the provinces and territories for health, education, and social programs. The 2017 Health Accord saw the majority of jurisdictions negotiating their own agreements with the federal government for health care funding. Health Canada also plays an authoritarian role, ensuring the provinces and territories remain compliant with the Canada Health Act and enforcing penalties on those that function outside of the principles within the Act. Health Canada may restrict funding to noncompliant provinces and territories. As a service provider, Health Canada remains responsible for the majority of health care services for Indigenous communities, the armed forces, veterans, and correctional services employees. In 2012

the federal government passed responsibility for the RCMP to the province or territory in which they reside. Services offered through the Interim Federal Health Program (IFHP), authorizes (temporary) basic health care coverage for protected persons, refugee claimants, and resettled refugees who do not qualify for provincial or territorial coverage. This coverage includes supplemental coverage includes limited vision and dental care, and drug benefits. Syrian refugees brought to Canada had immediate health coverage and were given resident status upon arrival. Refugee claimants are citizens of other countries who arrive in Canada claiming refugee status because they need protection from a threat or danger in their country of origin. Until a refugee claim is settled, the federal government retains responsibility for the claimant’s health care needs. In addition to basic health care (similar to what is provided to Canadians in the provinces and territories), Indigenous Peoples on reserves who are recognized by an Inuit land claim organization receive supplemental benefits (discussed later). Health Canada also provides primary care services in remote and isolated areas when the provincial or territorial government cannot meet these needs. Children of First Nations parents receive health coverage for a year after which time the parents must apply for the child’s Indian status. A primary source of information for Canadians, Health Canada conducts research projects and provides feedback on policy development. The ministry interacts with other nations and with the WHO to keep Canadians up to date on health concerns around the world. In conjunction with the WHO, Health Canada issues travel alerts and warnings for areas where health issues are cause for concern. The ministry also produces and implements national campaigns for health promotion and disease prevention, such as active lifestyle and anti-smoking campaigns.

Health canada organization and structure Ministry Level The prime minister of Canada appoints an elected representative to head Health Canada as minister of health, a position that the prime minister can reassign at any time during the tenure of the party in power. The minister of health is responsible for “maintaining and improving the health of Canadians” (Health Canada, 2013), including overseeing more than 20 health-related laws and associated regulations. On occasion, the federal minister of health may also be responsible for other portfolios. Responsibilities of the minister of health include: • overseeing Health Canada and other agencies, including the Public Health Agency of Canada, Canadian Institutes of Health Research, Canadian Institute of Health Information (see Chapter 6), Hazardous Materials Information Review Commission, Patented Medicine Prices Review Board, and Assisted Human Reproduction Canada; • supervising the collection and analysis of information carried out under the Statistics Act; • working collaboratively with the provincial and territorial governments. The federal minister of health does not routinely become involved in internal matters within the provinces or territories; however, establishing a positive working relationship with the first ministers (i.e., the provincial and territorial ministry heads) is essential for improving Canada’s health care system across the country. Rather than being an elected member of Parliament, the deputy minister of health is appointed from the civil service. The deputy minister works collaboratively with the minister of health, manages designated operations within the ministry, and may assume duties

assigned to the minister of health if the minister is temporarily unavailable. Several assistant deputy ministers of health and an associate deputy minister of health are also appointed from the civil service. Other agencies, such as the Departmental Secretariat and chief public health officer, work collaboratively with the minister of health, deputy minister of health, and associate deputy minister of health. Their primary focus is to provide leadership to the Public Health Agency of Canada, whose principle mandate is to manage health promotion and health safety initiatives.

  Thinking it Through Officials of Health Canada are unelected employees that may work under the authority of different governments. They are considered apolitical and remain in their positions even if a different party assumes power after an election (e.g., a change from a Liberal to a Conservative or NDP government). 1. Do you think having apolitical ministry employees is effective? 2. Would you rather see the deputy ministers of health appointed from within the ranks of the party in power?

Organizational structure of health canada The organizational makeup of Health Canada is complex and sometimes confusing. It is important to note that although the structure changes frequently, as does the appearance, content, and organization of online resources, the overall roles and responsibilities of each division remain relatively consistent. The framework itself includes a large number of branches and agencies each with numerous sub-divisions. At the top of the framework are Ministries and Offices, followed by Branches, Offices, and Bureaus, and lastly, Agencies. Each of these entities provide specific resources of services. Another division (Internal Services) includes activities, services, and resources required by Health Canada to function as an organization, not to any specific program. These include human resources services, financial management, information management, IT services, and others found in most large corporations or organizations (Fig. 2.1).

FIG. 2.1 Health Canada Organizational Chart (Health Canada. (2016a). About Health Canada: Branches and agencies. All rights reserved. Health Canada. Reproduced with permission from the Minister of Health, 2016. Retrieved from https://www.canada.ca/en/health-canada/corporate/about-healthcanada/branches-agencies.html.)

More than 20 branches, offices, agencies, and bureaus operate within Health Canada. Some, such as the Departmental Secretariat, oversee the financing, function, and organization of Health Canada. Other divisions are more directly aligned with public initiatives and health care. Only a selection of key organizations are discussed in this chapter.

Branches of Health Canada

Office of Accountability and Evaluation The Office of Accountability and Evaluation is Health Canada’s independent internal monitoring system. The bureau conducts internal audits and reports to the Deputy Minister of Health. The AAB reviews different departments and bureaus to ensure that they are operating properly, in accordance with their mandate, and in a cost-effective manner. Working with provinces and territories, the Office of Accountability and Evaluation ensures that government grants are used as intended.

Chief Financial Officer Branch The Chief Financial Officer Branch (CFOB) is made up of several organizational units. The CFOB oversees the use of Health Canada’s departmental resources and ensures finances are spent wisely and efficiently. The branch also ensures other departments and organizational units adhere to government policies and regulations; coordinates risk management; enhances performance measurement and reporting; and monitors the execution of the accountability framework. As well, the CFOB oversees the financial management of central agencies including the Public Health Agency of Canada.

Corporate Services Branch Composed of several directorates, the Corporate Services Branch provides support and services to Health Canada in such areas as human resources management, occupational health safety, emergency and security management, access to information and privacy matters, and information technology. This department also supports the Official Languages Act, providing language training and support, and managing related complaints.

Departmental Secretariat An executive office to which other departments report, the Departmental Secretariat acts as the link between the executive (appointed) and the political (elected) levels of Health Canada. This department clarifies, redirects, or responds to communications

received from other divisions of Health Canada addressing requests, for example, that fall under the Access to Information Act and Privacy Act.

First Nations and Inuit Health Branch The First Nations and Inuit Health Branch oversees the federally funded delivery of medically necessary health care services not covered by provinces or territories to First Nations people on reserves (status or registered Indians) and in Inuit communities. These services include primary care, health promotion/disease prevention programs, health education, as well as substance abuse, mental health, and child development programs. Supplementary benefits, such as dental and vision care, drug coverage, and crisis intervention, are available through the Non-Insured Health Benefits (NIHB) Program. Supplemental services are somewhat limited and provided under certain conditions—for example, dental care may be subject to predetermination. Counselling in remote communities is frequently insufficient to meet the needs of its people in the face of a crisis. Also included are transportation when medically required, and medical supplies and equipment. NHIB services are offered to eligible First Nations and Inuit people regardless of residence (e.g., on or off reserves, or in urban settings). The branch also works collaboratively with Indigenous provincial and territorial councils and organizations to address health care needs. As well, the NIHB, under supplemental agreements, provides a variety of health services to Indigenous people regardless of residence. The provision of adequate services remains a challenge, given the unique needs of some communities with respect to geography, demographics, and glaring inequities around general health, access to health services, and standards of living. The system is complex, sometimes with jurisdictional disputes over what governmental department or even what government is responsible for paying for selected health services (e.g., federal or provincial/territorial). This can result in disruption, denial, or delay services required (see Did You Know: Jordan’s Principle).

  Did You Know? Jordan’s Principle Jordan River Anderson was a little boy from Norway House Cree Nation, who upon discharge would require specialized at-home care. The government of Manitoba and the federal government argued over who should pay for Jordan’s at-home care for over 2 years—leaving the little boy in the hospital while the governments argued over payment (when he could have been at home). Jordan died before he could return to his home. He was 5 years old. Following this tragedy, Jordan’s Principle was implemented as the result of a private members bill unanimously passed by parliament in 2007 and is referred to as a child-first initiative. If the family of a First Nations child feel they are not receiving the health care services or supplies that child needs, they must contact regional authorities and make a request under Jordan’s Principle. Contact information is also provided on the https://www.canada.ca website. Jordan’s Principle initially stated that if there is a disagreement between two governments (e.g., provinces/territories/federal government) or two departments within a government about who should pay for services needed by a Status Indian child—and is available to other Canadian children—the government or government department first contacted to procure that service must pay. After that the government or government department can seek reimbursement according to jurisdictional protocol. Therefore the needs of the child are met first. How effectively this principle has been applied in the last decade was not without controversy with some cases going to the human rights tribunal. In 2017, the Canadian Human Rights Tribunal issued a ruling that included an expanded and amended definition of Jordan's Principle. The adjusted principle includes the provisions that:

• First Nations children qualify regardless of place of residence— on or off a reserve, and that it is not limited to children with disabilities (note the original document stated the child must be a Status Indian). • The services required must be provided and paid for by the department/organization first contacted without conferencing, review of policies or other administrative procedures, avoiding delays implementing a requested service. • If a service requested is outside of the standard parameters of services to other children, the department contacted must complete an assessment to ensure equality of culturally appropriate services to that child are provided. • Jordon’s Principal may still apply in some situations not involving jurisdictional or interdepartmental payment/service provision disputes. In 2016–2017 there were over 33,000 requests for products, services and support approved under Jordan’s Principle. Source: Blackstock, C. (2008). Jordan’s principle: Editorial update. Paediatrics & Child Health, 13(7), 589–590. Retrieved from www.ncbi.nlm.nih.gov/pmc/articles/PMC2603509/%3e.

Health Environments and Consumer Safety Branch The Health Environments and Consumer Safety Branch (HECSB) develops and supports programs that promote a safe, healthy lifestyle and environment for Canadians. The HECSB provides information about the risks and benefits of various products and lifestyle habits with the goal of helping Canadians make constructive choices (e.g., an active lifestyle, healthy nutritional habits, and avoidance of self-imposed risks behaviours such as tobacco, drug, and alcohol use). The HECSB is also concerned with environmental containments and other matters, including drinking water quality, air quality indices, and the use of smoke detectors.

Healthy Products and Food Branch

This branch oversees several directorates (outlined later), all of which impact the daily lives of most Canadians.

Biologic and Genetic Therapies Directorate Controls the introduction and use of biologic drugs which are made from living sources such as plants, microorganisms, or animals. Sometimes called biopharmaceuticals, these drugs can be used to treat rheumatoid arthritis and diabetes. The directorate also oversees the use of drugs that have radioactive properties—most commonly used to treat cancers. This directorate indirectly controls blood and blood products.

The Office of Nutrition Policy and Promotion Provides strategies related to nutrition and dietary guidelines, working with public health to deliver nutrition leadership. Initiatives include promotional guidelines for healthy weight, physical activity, and healthy eating facilitated by Canada’s Food Guide. In 2019, the government updated the Canada Food Guide which promotes, among other things, a move to consuming more plant base protein, replacing fruit juices and other beverages with water, eating more fruits and vegetables, grains and lentils, cooking meals at home, and “enjoying” meals with family and friends. The guide incorporates foods recommended for and more readily available to First Nations, Inuit, and Metis populations (e.g., whale, seal, wild game). Indigenous populations are encouraged to continue using the food guide entitled Eating Well with Canada's Food Guide—First Nations, Inuit and Métis (available in Inuktitut, Ojibwe, Plain Cree and Woods Cree) (Health Canada, 2010). Refer to Box 2.1. as a resource for healthy eating. There is ongoing research and ongoing consultations with Indigenous people to provide updated resources for that population group, as well as better access to nutritious foods. Detailed information and a variety of resources are available on the Government of Canada website under Health Canada.

 

Box 2.1

The First Ever Food Guide for First Nations, Inuit, and Métis. In April 2007, and updated in 2010, the first ever national food guide for First Nations, Inuit, and Métis populations, Eating Well With Canada’s Food Guide—First Nations, Inuit, and Métis, was launched in Yellowknife. Previous versions of the Guide have been tailored to specific regions across Canada supporting local traditions and food availability. This is the first guide to reflect the unique needs of Indigenous people at a national level. The general guidelines and principles are the same as the food guide for nonIndigenous people but adds information and choices unique to the First Nations, Inuit, and Metis population groups, addressing cultural differences and traditions, as well as traditional food choices. In addition the 2019 revision of the Canada Food Guide includes food choices and recommendations for Indigenous people.

The Therapeutic Products Directorate Regulates the use of both prescription drugs and medical devices in Canada. Before any product is brought to market, the company, individual, or organization must submit scientific, evidence-based information proving the product’s safety and effectiveness. Pharmaceutical companies must apply to this directorate for permission to begin clinical trials for a new drug. In addition, a health professional, who has found that conventional treatments are ineffective for a patient, may apply to this directorate for interventions that are under review but not yet on the market.

Natural and Nonprescription Health Products Directorate This directorate regulates all health products containing natural ingredients, including homeopathic medicines, vitamins and minerals, and traditional medicines. The regulations summarize and enforce licensing requirements for natural health products and stipulate packaging and labelling requirements—for example, product packaging must state health claims, ingredients, instructions

for use, and potential adverse effects. Natural health product manufacturers must document and report any adverse reactions identified by consumers. Health Canada has the authority to request label changes and to remove any natural health product from the market at any time.

  Did You Know? Despite regulatory efforts, the use of natural products remains a concern to many health care providers across Canada. Not all consumers realize that a natural product may contain harmful ingredients or interfere with prescription medications. For example, combining a prescription antidepressant with St. John’s wort (an herbal mood elevator) can cause nausea, vomiting, restlessness, dizziness, and headaches. St. John’s wort can also reduce the effectiveness of oral contraceptives. Ginseng, another popular herbal medication, can increase blood pressure, so should not be taken by someone with hypertension or on antihypertensive medication. Even garlic, when taken with hypoglycemic medications (used by people with diabetes), can cause a drop in blood sugar, and possibly, a hypoglycemic reaction.

Communications and Public Affairs Branch The Communication and Public Affairs Branch performs a number of duties involving communication activities both inside and outside of Health Canada. It is dedicated to improving the sharing and flow of information with partners in health care delivery, the media, the general public, and other stakeholders. Offices within this branch include the Ethics and Internal Ombudsman Services (a confidential, unbiased resource providing support for Health Canada employees) and the Planning and Operations Division (providing leadership with respect to human resources, contracts, finances, and strategic planning).

Strategic Policy Branch

The Strategic Policy Branch (SPB) develops and implements the federal government’s and Health Canada’s health care policies, including administering the Canada Health Act, creating health protection regulations and legislation, dealing with evolving problems on a priority basis, and authorizing new agencies to report information as required. It aims to promote actionable policies that ensure the delivery of priority-based, cost-effective health care initiatives involving several directorates. The SPB collaborates with numerous professional and research organizations, provincial and territorial ministries as well as various program branches of the government’s health portfolio. The SPB’s programs are carried out by several offices and directorates, some of which are outlined below.

Health Care Policy Directorate This is an organization that plays a key role in reshaping primary health care delivery with the objective of preserving the principles and conditions of the Canada Health Act. The directorate also assesses provincial and territorial needs for financial support for primary health care reform initiatives. The directorate monitors and analyzes the provision of care (community based, continuing, and palliative) across Canada and gathers information that Health Canada uses to develop policies and initiatives that will assist the provinces and territories to improve health care in those areas.

Office of Nursing Policy The Office of Nursing Policy reflects the importance of nursing policy issues within health care. This office collaborates with other organizations, including the Canadian Nurses Association (CNA), and provides advice to Health Canada on select policy issues and programs from the nursing perspective and makes recommendations regarding the nursing workforce to help meet health care service needs. For example, it recommended ongoing analysis of the role of Nurse Practitioners (NPs), and the expansion of their role to maximize their proven contribution to the healthcare system. A 2015 Naylor report, “Unleashing Innovation: Excellent

Healthcare for Canada,” noted that Nurse Practitioners remain an underused resource. In 2016 the CNA recommended: using more NPs; expanding their role in primary health care teams; coordinating their remuneration across sectors and jurisdictions; and providing them with better access to continuing education opportunities (Canadian Nurses Association, 2018). The Office of Nursing Policy also develops strategies to retain nurses by addressing issues such as burnout and frustration related to the occupational environment.

Marketed Health Products Directorate Through the Marketed Health Products Directorate (MHPD)—part of the Health Products and Food Branch—Health Canada collects information about adverse reactions to foods and food products, and ensures that the public is aware of any identified risks. Through MedEffect, a program developed by the MHPD, Canadians can report adverse effects of and obtain safety information on health products and drugs (for online reporting, see Web Resources on Evolve). The Canada Vigilance Program—which functions under MedEffect and is the point of contact for health care providers and consumers—collects and assesses all reports of suspected adverse reactions to health products marketed in Canada (Health Canada, 2011). Information can be submitted via an online form. This information allows Health Canada to continually gauge the safety of health products once they are available to consumers. If a product’s adverse effects outweigh its benefits, Health Canada will act to remove the product from the market, either to reassess and modify it or to ban it completely. Any medically related products and treatment options—therapies and products alike—that are rendered, used, sold, or otherwise distributed in Canada must be licensed by Health Canada (see Did You Know: Health Canada Gives Permission for New Product).

  Did You Know?

Health Canada Gives Permission for New Product Any individual or company must submit a proposal to Health Canada for review and approval of any health-related product. The product must meet certain standards and is subject to a regulatory process. One such product is eSight glasses. A third-generation prototype was introduced in 2017 that must meet or exceed the original standards. The glasses use a video camera, a computer, and LED screens to capture and process images in a manner that significantly increases the sight of individuals with central vision loss, including those with conditions such as macular degeneration, Stargardt disease, and diabetic retinopathy.

e-sight glasses. Source: eSight.

  Thinking it Through A patient tells you that she is taking a number of herbal medications, including synthetic estrogen preparations and metabolism boosters. She found on the Internet that these medications were recommended to combat fatigue and

sluggishness. She believes it is unnecessary to tell her primary care provider. 1. As an allied health care provider, how would you respond? 2. As a medical office assistant in a primary care organization how would you respond? 3. If your answers differ, explain why.

Regions and Programs Branch The Regions and Programs Branch of Health Canada comprises the regions, the Workplace Health and Public Safety Program, and the Programs Directorate. Of note, the Workplace Health and Public Safety Program promotes a best practices philosophy in the workplace with the goal of encouraging physically safe and emotionally positive workplace environments. The program recommends that managers and administrators ensure employees are fit enough to handle jobs assigned to them and encourages the implementation of office ergonomics such as a well-designed desk and chair, appropriate lighting, and a safe computer workstation. The Workplace Health and Public Safety Program also assumes responsibility for the health and safety of federal employees and for visiting dignitaries and politicians. To achieve this goal, the program collaborates with a number of departments, including Emergency Preparedness.

New Additions to Health Canada’s Organizational Structure Two previously separate branches, the Opioid Branch and the Cannabis Legalization and Regulation Branch have been integrated into the Controlled Substances and Cannabis Branch.

The Opioid Response branch Newly created, this branch oversees the Controlled Substance Directorate and the Opioid Response Team.

The Opioid Response Team works with numerous other departments and organizations including the Canadian Institute of Health Information, the Public Health Agency of Canada, the RCMP, and Corrections Services Canada to set out polices and recommendations for responding to Canada’s opioid crisis. The aim is to provide a platform from which to collaborate with provinces, territories, municipalities, health organizations, and other stakeholders to produce effective response strategies. The Controlled Drugs and Substances Directorate works to ensure the appropriate and legal distribution and use of controlled substances, lessoning the negative impact of improper and/or illegal use of these drugs on Canadians. It is important to note that the Controlled Drug and Substances Act operates under the mandates of several pieces of federal legislation and international conventions.

The Cannabis Legalization and Regulation branch This new branch was created to oversee the safe, legal production, use, and distribution of cannabis in Canada. Responsibilities include creating and enforcing policies and regulations regarding medical as well as recreational cannabis as mandated by law.

Agencies of health canada Several independent agencies of Health Canada report directly to the Minister of health. The functions of some agencies are described below.

The Canadian Institute for Health Information This agency is an independent organization providing ongoing information about Canada’s health care system, and the health of Canadians—information that is important to the population health approach and population health disease prevention. The Canadian Institute for Health Information (CIHI) works closely with Canadian Institute for Health Research and Statistics Canada to gather and assimilate information from numerous sources, such as surveys, hospitals, clinics, long term care facilities, and other health care facilities. Much of the information is used to improve the performance of the health care system across Canada (see Chapter 6). Funded by the federal, provincial, and territorial governments, CIHI reports to an independent board of directors that represents government health departments, regional health authorities, hospitals, and health-sector leaders across the country. The data collected, organized, analyzed, and distributed by this agency provide valuable, comprehensive information for organizations and individuals within and outside of Health Canada —the general public, government bodies, hospitals, professional organizations, educational facilities, researchers, and organizations at the municipal level (e.g., regional health authorities). The information facilitates the planning, organizing, and implementation of policies and strategies. CIHI maps the pattern of health care in Canada by working with 28 national and provincial information systems (databases) to gather data about the costing and delivery of health care services and the supply and distribution of health care providers. The organization

produces an annual report of general information and several specific reports, The CIHI developed a strategic plan for 2016–2024 which proposes continual improvement in health care and a focus on the health and health care needs of three population groups—seniors and aging, mental health and addictions, and Canada’s Indigenous population.

Canadian Institutes of Health Research The Canadian Institutes of Health Research (CIHR) directs and funds research across Canada. It distributes research funding based on priority and need, expanding research as required (including initiatives concerning social, cultural, and environmental factors that affect population health), and recruiting and training research scientists. CIHR is also responsible for ensuring that the research information gathered and analyzed is used properly—for example, to craft policies or to generate products and services for which a need has been determined. CIHR operates 13 research institutes nationwide (Box 2.2 contains a list of these facilities) with a multimillion-dollar funding budget. More than 10,000 scientists and researchers in various hospitals, universities, and research institutes are involved with the agency. Targeted, ongoing, health-based research projects include those related to biomedical research, clinical science, and health care systems and services (Canadian Institutes of Health Research, 2014).

  Box 2.2

Canadian Institutes of Health Research (CIHR) Institutes Across Canada. Aging Cancer Research Circulatory and Respiratory Health Gender and Health

Genetics Health Services and Policy Research Human Development, Child and Youth Health Indigenous Peoples’ Health Infection and Immunity Musculoskeletal Health and Arthritis Neurosciences, Mental Health, and Addiction Nutrition, Metabolism, and Diabetes Population and Public Health Source: Canadian Institutes of Health Research. (2015). CIHR institutes. Retrieved from http://www.cihrirsc.gc.ca/e/9466.html#a.

The Canada Food Inspection Agency As an independent agency, the Canada Food Inspection Agency (CFIA) reports to the Minister of health and intersects with numerous government and nongovernmental organizations. The CFIA is Canada's largest science-based regulatory agency and is divided into numerous sub-departments, each with specific responsibilities. The agency ensures safe, sustainable access to animal and plant resources, invokes food recalls and animal alerts (diseases in animals entering the food chain), and provides a forum for the public to report food labelling or safety concerns. Well over 1200 scientists are employed by this agency. Their responsibilities include diagnosing problems within the food chain and surveillance actives. A laboratory in Charlottetown, for example, monitors for diseases in plants and oversees the safety of both imported and exported plant products. The National Centre for Detecting Foreign Animal Disease is located in Winnipeg. On the international front, this facility also serves as an Animal Health reference laboratory for classical swine fever and avian influenza. Saskatoon is home to a laboratory that tests animal feed for parasites and drugs that may have been given to animals.

Patented Medicine Prices Review Board The Patented Medicine Prices Review Board (PMPRB) is a “watch” agency that monitors the prices of patented drugs to ensure fairness to both manufacturer and consumer. A risk-based framework allows the PMPRB to assess patented drugs that have the greatest potential for overpricing. This assessment is based on two factors: (1) the drug’s benefit to the consumer and (2) the impact of a drug’s cost on value and affordability. This process results in an improved assessment of a drug’s impact on population health—for example, newer, more expensive drugs used by an aging population, many of whom are on a limited income. If a manufacturer is thought to be overcharging for a drug, the board will first offer the manufacturer an opportunity to voluntarily adjust its pricing. If the company refuses, a judicial hearing may take place, with a binding federal court decision resulting. The PMPRB also monitors ongoing trends in the sales, price, and distribution of patented drugs and drug products. This board operates independently of other organizations within Health Canada that deal with product safety and inspection. The PMPRB is not involved with the pricing of generic drugs, which are traditionally significantly less expensive than “brandname” drugs. However, the amount that provinces and territories spend on generic drugs fluctuates dramatically. A recent agreement among jurisdictions to buy some generic drugs in bulk has reduced prices for selected drugs

Public Health Agency of Canada Headed by Canada’s chief public health officer, the Public Health Agency of Canada (PHAC) plays a central role in all population health and population health promotion research, policy, and program development. The PHAC works with other organizations within Canada’s health portfolio as well as with provinces/territories, and other stakeholders to prevent injury and disease, promote healthy living and motivate Canadians to adopt healthy lifestyles and reduce risk behaviours. The PHAC also

responds to a variety of public health issues, such as national health emergencies and infectious disease outbreaks (discussed later in this chapter). In Canada, most Web-based data regarding health issues are organized and posted by the PHAC. In terms of “health watch” activities, the PHAC tracks outbreaks of seasonal flu, tuberculosis, measles, and other illnesses, and recommends corrective and preventive measures. Worth special mention is the Centre for Infectious Disease Prevention and Control (CIDPC) branch, which has several departments, including the Blood Safety Surveillance and the Community Acquired Infections Division. The CIDPC works closely with other agencies to promote awareness about sexual health and the risks of acquiring infectious diseases such as hepatitis C or tuberculosis (on the rise in some regions). The division also provides support for individuals who have acquired infectious diseases. Through surveillance and epidemiologic information feedback, the CIDPC collects information about trends in human behaviour that can be used in population health initiatives (e.g., the spread of HIV in various jurisdictions). The CIDPC also works with the Centers for Disease Control and Prevention (CDC) in the United States.

  Thinking it Through Billions of dollars are spent annually on research, development, and clinical trials to test the safety and effectiveness of new drugs. Patent protection allows 20 years for pharmaceutical firms to make a profit on drugs they have brought to market. Companies that produce generic drugs, however, are pushing for a reduction in patent protection time so they can bring cheaper, generic brands of patented drugs to the market earlier. 1. Do you think that the patent protection time frame should be reduced? 2. Bearing in mind the tremendous cost of bringing the original drug to market, should pharmaceutical firms receive

compensation for the money lost to them if generic drugs are brought to market earlier?

  Did You Know? Statistics Canada is a branch of the federal government whose primary purpose is to gather information from every province and territory and to publish accurate statistics on almost every aspect of life imaginable. Statistics Canada is used extensively by government and agencies involved in public health and population health initiatives (e.g., for gathering data regarding births, deaths, and causes of morbidity and mortality). Every five years, in the first and sixth years of every decade, Statistics Canada conducts a national census, sent to one in five households, which by law participating households must complete. In 2010, amid much controversy, the federal government replaced the long-form census with a voluntary short National Household Survey. In addition, in 2011 a short mandatory census was sent to one in three households (to which they added two questions on language). The long-form census was reinstated in 2016. The reinstated census form may be completed online or in paper format and was sent to one in four households. Information collected is used by all levels of government. In the new census, questions about income were eliminated, and Stats Canada was given permission to access Revenue Canada files to obtain information on personal income and benefits files. Questions about religion were eliminated.

Global organizations collaborating with health canada The WHO is a specialized agency of the United Nations (UN) concerned with public health matters on an international level. As the UN’s authority on health issues, the WHO provides leadership in health matters on a global level. The organization spearheads global research, provides technical support to members, monitors and assesses health trends, and sets standards within the fields of health and medicine. The WHO recommends policies and actions regarding population health initiatives to countries around the world. It is also instrumental in gathering information and producing statistics on health matters at an international level, and coordinating responses to global health threats (discussed later in this chapter). A total of 19 countries compose the membership of the WHO. Each member country of the UN may become a member of the WHO by accepting its constitution. Countries outside the UN may be admitted as members if their applications are approved by a majority vote of the World Health Assembly. Jurisdictions without responsibility for their international affairs (regions within a country, for example) may become associate members if approved. The WHO collects data and provides the international community with advice and direction on a wide variety of health topics, including air quality and environmental health, diabetes, obesity, cardiovascular health, mental health, and vaccines and immunization (including travel recommendations). The WHO is also a strong supporter of population health and health promotion initiatives and the use of health indicators such as the determinants of health (discussed in Chapter 6 to promote equitable health standards worldwide). The WHO, like Canada and many other countries, stresses the important role of social determinants of health in influencing an individual’s opportunity to live a healthy life, the risk factors for acquiring illnesses (physical and mental), and their impact on life expectancy.

To respond to increasingly complex international public health issues, particularly those defined by the determinants of health at a global level, the WHO has developed a six-point agenda as a guide for action. These include two health objectives, two strategic needs, and two operational approaches outlined in Box 2.3.

  Box 2.3

The World Health Organization: The Six-Point Agenda. Health Objectives Promoting development. Giving priority to those countries and regions affected by poverty and socioeconomic inequities and other disadvantaged and vulnerable groups. Fostering health security. Tracking and responding to outbreaks of epidemic-prone diseases and implementing measures to control and perhaps eliminate these threats.

Strategic Needs Strengthening health systems. Working to extend health services to all those in need; implementing strategies to reduce poverty and to diminish those elements identified by population health initiatives that contribute to poor health. Harnessing research, information, and evidence. Gathering and distributing relevant health information and using this information to set priorities, shape approaches and plans, and target outcomes.

External Approaches

Enhancing partnerships. Working collaboratively with organizations, including UN agencies, international organizations, and the private sector, to launch health initiatives and programs within countries; making the best use of available resources and facilities. Improving performance. Working to continually improve each organization’s effectiveness in meeting its goals and its many responsibilities. Source: World Health Organization. (2013). The WHO agenda. Retrieved from http://www.un.org/youthenvoy/2013/09/whoworld-health-organisation/.

Public Health Threats: National and International Response Public Safety Canada Departments of Health in all Canadian jurisdictions involved in emergency management work collaboratively with Public Safety Canada to address national and global threats ranging from health and natural hazards to terrorism and cyber attacks. Under Public Safety Canada, the Emergency Management Planning Guide contains a detailed protocol for dealing with hazards and is supported by the Strategic Emergency Management Plan framework. In addition, every level of government, and every department have their own emergency plan tailored to the individual department’s area of responsibility that will harmonize with the emergency management planning guide. Such plans include the National Counter-Terrorism Plan and the Canadian Pandemic Influenza Preparedness Guidance for the Health Sector (CPIP) (discussed further in this chapter). To address national emergencies the Canadian government has taken steps to ensure rapid, effective responses working with Public Safety Canada and the Public Health Agency of Canada. As well, the federal government developed the National Security Policy and National Emergency Response System (NERS). The establishment of

these organizations and policies addresses a wide variety of emergencies and concerns that Canadians may encounter. The PHAC, in particular, is charged with both recognizing and responding to public health threats. The PHAC’s key goals are public awareness, ongoing surveillance, early detection, prompt action to contain viruses, effective communication (in particular, making use of social media) across the health care system, and collaboration among health care providers, organizations, and agencies at all levels of government. The government has created a website for the Centre of Emergency Preparedness and Response to provide access to resources in every province and territory.

North American Collaboration As part of a global health initiative Canada works closely with the CDC, based in Atlanta, Georgia. The CDC is a US federal agency responsible for disease prevention, control, and management on a global level. The CDC collaborates with Health Canada on a continual basis, sharing information, research outcomes, and surveillance initiatives in the presence of national and international health threats. The Canadian equivalent is the Public Health Agency of Canada.

World Health Organization (WHO) As discussed earlier in this chapter, the WHO is a leader in global health matters. This organization address all realms of global health, including the rise of health threats that demand a coordinated international response. Specific WHO initiatives include monitoring for disease outbreaks, issuing global health alerts, and developing guidelines to help countries to prevent the spread of infectious disease.

World Health Assembly The World Health Assembly is the policymaking body for the WHO. The assembly’s executive board comprises 34 members, all with qualifications in the health care field, who are elected for a 3-year

term. Each year, in Geneva, the assembly meets with representatives from member nations to discuss policies of the WHO and to approve a budget for proposed programs for the upcoming year. The executive board tables reports that require further action, study, or investigation, as well as ensures that planned activities for the upcoming year are implemented.

Pan-American Health Organization The Pan-American Health Organization (PAHO) aims to improve health and living standards in the Americas. Among other activities, this international public health agency serves as the Regional Office for the Americas of the WHO and functions as part of the UN. Member countries include the 35 nations that compose the Americas. Because many member states lack basic health care, clean drinking water, and adequate sanitation, one of the PAHO’s main priorities is to promote current, effective, and community-based primary health care strategies.

Organisation for Economic Co-Operation and Development The Organisation for Economic Co-operation and Development (OECD) consists of 30 member countries (including Canada) that adhere to the principles of democracy and a free market economy. Through the organization, governments compare policy experiences and seek answers to common problems. The organization, among other things, measures the quality of medical care in member countries and rates health outcomes. For example, a report called Health at a Glance 2013: OECD Indicators provided valuable information on different aspects of health care performance in member countries. It also identified variations in indicators of health status and health risks and compared these to standards of practice in related health care systems (Organisation for Economic Cooperation and Development, 2013).

Ebola, Zika, Influenza: A Closer Look

The term “outbreak” is often used interchangeably with epidemic, and the difference between these terms can be blurred. Outbreak: a sudden flare up of an infectious disease either globally or within a specific region, or as a localized event (e.g., the seasonal flu/influenza in a long-term care facility or on a floor in an acute care hospital). Epidemic: an epidemic occurs when the incidence of an infectious disease rises (usually suddenly) above the average or expected number of cases within a specific geographic area. An epidemic typically involves more serious health outcomes that affect both healthy individuals and those considered vulnerable (e.g., the very young or older people, those with chronic health problems, and/or who have compromised immune systems). Pandemic: a sustained, worldwide transmission of an infectious disease (e.g., the influenza A [H1N1] 2009 pandemic). The severity of a disease and its mortality rate are not defining characteristics of a pandemic.

The Ebola virus The Ebola viral disease (EVD) outbreak in West Africa was considered to be a regional epidemic as it was, for the most part, limited to three regions in close proximity (Guiana, Serra Leone, and Liberia) with outer cases identified in Nigeria, the United States, and Mali. Occurrences of the disease in other countries (e.g., the United States), were isolated events and contained, with identifiable transmission sources. EVD is transmitted by direct contact such as blood, mucus membranes, body fluids, and tissues of infected animals or people. Although not airborne, it is also thought to be spread by droplets— for example, if an infected person coughs or sneezes and is within two meters of a non-infected person. In 2014, the EVD outbreak in Africa prompted the WHO to issue a global alert. The WHO was asked to make a decision on the ethics of using unproven vaccines to treat individuals with the disease and

those in danger of contracting the disease. It ruled that using the vaccine was ethical, prompting Canada and other nations to ship vaccines to affected areas. EVD has a fatality rate of approximately 50–90% according to the WHO. A reported 11,315 deaths were attributed to the EBV between the initial reported outbreak in March 2014 and December 2016. The WHO had described this epidemic as one of the most challenging it has ever faced, especially in terms of containment and treatment. In an effort to contain the disease and support essential services in affected regions, the United Nations in partnership with the WHO created the first ever UN mission for a public health emergency, called the UN Mission for Ebola Emergency Response. In Canada, any suspected cases of EVD must be reported to the PHAC through the national surveillance system as it is classified as a nationally notifiable disease. Infection prevention and control procedures were enhanced with the introduction of a Health Portfolio Framework for Action on the 2014 Ebola Virus Disease Outbreak that details policies and procedures for dealing with any future outbreaks.

The Zika virus The Zika virus first appeared in South America in 2015, with the majority of cases in Brazil. Transmission of the Zika viral disease (ZVD) is primarily through the Aedes mosquito, although research has shown it can be transmitted sexually and through human-tohuman donation of blood and tissue. ZVD soon spread through the Caribbean and then to Southern Florida and Brownsville, Texas in the United States—many of the infected individuals had travelled in high-risk areas. In January 2018 there were 5635 symptomatic ZVD cases reported in the United States, and over 37,000 symptomatic cases in the US territories of American Samoa, Guam, Northern Mariana Islands, Puerto Rico, and the US Virgin Islands. In Canada, 548 cases of ZVD were reported as of December 2017— four suspected to have been sexually transmitted, the rest related to travel. Out of 37 cases reported by pregnant women, two babies were born with Zika-related birth anomalies.

The WHO declared the emergence of ZVD to be an international public health emergency in 2014 and a serious global threat. It was considered an epidemic, but never evolved into a pandemic. The level of concern was similar as that for the EVD outbreak, although the transmission of the viruses and the consequences of infection are vastly different. A large number of adults who contract ZVD remain asymptomatic. The major concern is the effect on babies born to mothers infected with the virus. Babies, infected in utero, display an array of birth defects (referred to sometimes as congenital Zika syndrome) and other health problems including microcephaly, Guillain-Barré syndrome, and eye problems. It is also thought to cause premature births, spontaneous abortions, and stillbirths. The number of suspected deaths from ZVD are vague with one death suspected in the United States, a sharp contrast to the high mortality rate associated with EVD. Cases of ZVD must be reported to public health authorities in both the United States and Canada. In Canada, suspected cases are diagnosed by the National Microbiology Laboratory in Winnipeg, although some provincial labs test for the virus as well (Health Canada, 2018). Testing is complex and the virus can only be detected within a week or so of the onset of symptoms (clinical signs), creating a narrow window of time to establish a diagnosis (Health Canada, 2016b).

Influenza Individuals at the WHO responsible for making recommendations on the formulation of the seasonal flu vaccine, which is used globally, meet twice a year (in February or March, and September) to review evidence and make decisions. The WHO makes its annual recommendations by analyzing information provided through WHO Global Influenza Surveillance and Response System. The 2017–2018 flu that swept through Europe and North America appeared to have epidemic (bordering pandemic) characteristics. It spread rapidly, with more severe symptoms than usual, and higher rates of hospitalization and mortality. In the event of an outbreak/epidemic, the surveillance, containment, and treatment strategies must follow guidelines determined by regional public

health authorities working collaboratively with other stakeholders such as physicians, hospitals, or long-term care facilities. Outbreaks of influenza are recurrent but unpredictable events that can have serious effects on global and national economies, as well as on the health of populations. It is the responsibility of the WHO to monitor the threat of potential global influenza and issue appropriate alerts based on specific criteria, as outlined in the WHO’s guidance document, Pandemic Influenza Risk Management (often just referred to as “Guidance”). The Guidance put together by health and policy experts incorporates principles from other strategic initiatives, including principles from the WHO’s Guidelines for Emergency Risk Communication, All-Hazards Emergency Risk Management for Health (ERMH), and from its International Health Regulations (IHR). The IHR is a legally binding agreement for member states that details procedures and policies for managing public health threats. The WHO last revised its pandemic guidelines in 2013, incorporating lessons learned from the 2009 AH1N1 pandemic. Changes include the following: • A greater emphasis on risk assessment rather than on geographic location, allowing affected regions to respond accordingly instead of responding at the highest level to a threat (resulting in unnecessarily stockpiling antiviral medications and vaccines). The severity of an outbreak in one area is likely to be different from that in another, and responses should be levelled to suit the national, regional, or local conditions. • Improved communication among countries and decisionmaking bodies, particularly between those making risk assessments, and improved communication with the general public about regional outbreaks (e.g., containment issues, severity, progress, treatment protocols). • Emphasis on the importance of national and regional strategies to deal effectively with outbreaks, rather than relying exclusively on global strategies. During the 2009 pandemic, some member states responded immediately to

the WHO’s pandemic phase alerts, triggering such reactions as high-volume purchases of vaccines only to find that the numbers purchased were far in excess of what was needed. The WHO’s pandemic influenza framework also contains progressive recommendations encouraging the sharing of research and development with respect to technology, effective identification and surveillance of potential health threats, tracking health trends, and risk-management protocols, interventions, containment and treatment—for example, the sharing of information on the development of vaccines (as seen in the Ebola outbreak), and availability of current vaccine stockpiles. In Canada, the Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector (CPIP), is a guideline put together by policy experts from the federal, provincial, and territorial governments in the event of an influenza pandemic. Significant changes were made after the 2006 Severe Acute Respiratory Syndrome (SARS) crisis, and again after the 2009 influenza pandemic which was the first true test of this version of the Guidance. Valuable lessons were learned from both of these events, ranging from communication, surveillance, and tracking methodologies to containment and treatment. The CPIP provides planning guidance to prepare for and respond to an influenza pandemic, working collaboratively with the WHO and its Guidance. Each province and territory has its own legislation to deal with emergencies within its boundaries. However, in the event of a national emergency, federal plans would take priority and be implemented collaboratively with each jurisdiction. New additions to the Guidance emphasize that each level of government, when deemed necessary, must adjust risk management strategies based on the unique needs of any given region or community. The CPIP encourages a “take what you need” approach to its recommendations, recognizing that the most effective way to manage a national health emergency must consider the situation in each community, and that each community—and individuals within those communities—will have different needs.

  Thinking it Through Ethical Use of Vaccines Part of pandemic response must include ethical considerations of any population group. If an experimental vaccine that was developed in a laboratory looked promising, would you consider it to be reasonable to give the vaccine to people during a serious disease outbreak, in hopes that it would provide immunity even though human trials were incomplete? Why or why not? If proven effective, but only a limited number of doses had been produced, how can a health authority equally and fairly distribute the vaccine? What criteria would you deem essential in making such a decision?

Summary 2.1 Through its complex and frequently changing hierarchical structure, Health Canada works to fulfill its mission to make Canadians among the healthiest populations in the world. Contrary to the belief of many Canadians, the federal government has little legal power over health care in the provinces and territories. Health Canada plays an authoritarian role in enforcing compliance with the Canada Health Act in that it can withhold federal-to-provincial transfers of funds when a province or territory breaches the principles and conditions of the Act. 2.2 Health Canada is led by the minister of health, who is supported by a deputy minister, assistant deputy ministers, an associate deputy minister, a chief public health officer, and the Departmental Secretariat. The minister of health is appointed by Parliament; deputies and assistant deputies are not. The primary responsibilities of the minister of health include overseeing other agencies, supervising the collection and analysis of information carried out under the Statistics Act, and working collaboratively with the provincial and territorial governments. 2.3 Health Canada’s internal services include those that provide generalized services, activities, and resources across the breadth of the organization. The Minister of Health, the Deputy and Associate Ministers of Health are at the top of the organizational framework, followed by numerous Branches, Directorates, and Agencies forming working both independently and collaboratively within and outside of the organization. Branches of Health Canada include the First Nations and Inuit Health Branch, the Health Products and Food Branch, the Healthy Environments and Consumer Safety Branch, and the Communication and Public Affairs Branch. These branches are responsible for activities more directly aligned with the public’s health and safety.

2.4 Several autonomous agencies work collaboratively with Health Canada, reporting directly to the minister of health. These agencies include the Public Health Agency of Canada (PHAC), the Canadian Institutes of Health Research (CIHR), the Hazardous Materials Information Review Commission, and the Patented Medicine Prices Review Board. The PHAC plays a significant role in health promotion and disease prevention initiatives; tracks outbreaks of seasonal flu, tuberculosis, measles, and other illnesses; and recommends corrective and preventive measures. The CIHR is instrumental in directing research projects in over 13 sites across the country. 2.5 Health Canada is active on an international level, working with a number of organizations to improve health at both a national and an international level. The World Health Organization (WHO), a key player in such initiatives, provides leadership on health matters globally. The WHO recognizes health threats, such as the H1N1 virus, and initializes pandemic alerts in response to information gathered. The Pan-American Health Organization aims to improve health and living standards in the Americas. The Organisation for Economic Co-operation and Development measures the quality of medical care in member countries and rates health outcomes.

Review questions 1. What are the primary objectives of Health Canada? 2. What general services does Health Canada provide for Indigenous population groups? a. Explain what agencies within Health Canada are also involved with health care. b. Briefly discuss the benefits provided by the NonInsured Health Benefits Program. 3. Explain the primary responsibilities of the minister of health and the deputy minister of health. 4. What is Jordon’s Principle, and what benefits does this principle offer Indigenous children? 5. How do the functions and responsibilities of the Institute of Health Information and the Institute of Health Research differ? 6. How did Jordon’s Principle come about and who does it most benefit? 7. Identify two international organizations Health Canada works with and briefly list their functions. 8. Explain the differences between an epidemic, a pandemic, and an outbreak.

References Canadian Institutes of Health Research. Home page. Retrieved from http://www.cihrirsc.gc.ca/e/193.html. 2014. Canadian Nurses Association. The Canadian Nurse Practitioner Initiative. Retrieved from https://cnaaiic.ca/en/professional-development/advancednursing-practice/nurse-practitioners/canadiannurse-practitioner-initiative. 2018. Health Canada. Eating well with Canada’s food guide: First Nations, Inuit, and Métis. Retrieved from https://www.canada.ca/en/healthcanada/services/food-nutrition/reportspublications/eating-well-canada-food-guide-firstnations-inuit-metis.html. 2010. Health Canada. Drugs and health products: Canada vigilance program—collecting and assessing adverse reaction reports. Retrieved from http://www.hcsc.gc.ca/dhp-mps/pubs/medeff/_fs-if/2011-cvppcv/index-eng.php. 2011. Health Canada. About Health Canada: Health portfolio. Retrieved from http://www.hcsc.gc.ca/ahc-asc/minist/portfolio/index-eng.php. 2013. Health Canada. (2016a). About Health Canada: About mission, values, activities. Retrieved from http://www.hc-sc.gc.ca/ahc-asc/activit/aboutapropos/index-eng.php. Health Canada. (2016b). Laboratory testing recommendations for Zika virus. Retrieved from

http://healthycanadians.gc.ca/publications/disease s-conditions-maladies-affections/laboratory-testingzika-analyse-laboratoire/index-eng.php Health Canada. For health professionals: Zika virus infection. Retrieved from https://www.canada.ca/en/publichealth/services/diseases/zika-virus/healthprofessionals-zika-virus.html. 2018. Health Canada. Canada’s food guide. Retrieved from https://food-guide.canada.ca/en/. 2019. Organisation for Economic Co-Operation and Development. Health at a glance 2013: OECD indicators. Retrieved from http://www.oecd.org/health/healthsystems/health-at-a-glance.htm. 2013.

3

The Role of Provincial and Territorial Governments in Health Care LEARNING OUTCOMES 3.1 Discuss the common structural elements among the provincial and territorial governments. 3.2 Describe the purpose and general structure of regionalization initiatives. 3.3 Explain how provincial and territorial health care is financed. 3.4 Summarize the role of private health insurance in Canada. 3.5 Explain how drug plans help cover the cost of medications.

KEY TERMS Copayment Deductible Dispensing fee Drug identification number (DIN) Enhanced services Formulary list This chapter provides an overview of the structure of the provincial and territorial health care systems, emphasizing the common elements among them and outlining their differences. Although not every detail can be

covered, the chapter will give a general understanding of how each province and territory manages its own health care system within the confines of the Canada Health Act, and how each communicates with the federal government. This chapter follows three families—two who are new to Canada, and one moving from one province to another—as they interface with the health care system within their respective provinces to meet their health care needs. The families will be discussed in the Case Examples: the Jaeger family in British Columbia (Case Example 3.1), the Wong family in New Brunswick (Case Example 3.2), and the Lotons who moved from Saskatchewan to Ontario (Case Example 3.3).

  Case Example 3.1 On February 20, 40-year-old Joseph Jaeger and his family arrived in Vancouver, British Columbia from Germany. Joseph is a Canadian citizen, born in Vancouver. He moved to Germany with his mother and father when he was 10 years old. Joseph’s family includes his wife, Anna 36 (who is expecting twins), and their three children: Anna, 16; Luca, 10; and Alois, 3. Although somewhat familiar with Canada, Joseph has no idea how to apply for health coverage, which documents he needs and where to obtain them, and how to find a family doctor. He is even unsure which services specifically are covered under British Columbia’s medical care plan.

  Case Example 3.2 The Wong’s had applied for immigrant status 2 years prior to their arrival and were accepted 6 months ago. Quang Wong, 36, and his wife, Ling, 35, arrived in New Brunswick, on January 15 with their two children: a son, Huan, 10, and a daughter Niu, 6. Quang, a doctor, would like to certify as a physician in New Brunswick when they are settled and financially stable, but he realizes this will take time and money. Ling is an architect who also would like to return to school when the time is right. At this time their funds are limited. The family has no outstanding health problems.

 

Case Example 3.3 Chris Loton and his partner, Kevin O’Brian are moving from Saskatchewan to Ontario. Chris was transferred by his engineering company. Kevin, a respiratory therapist, plans to look for work when they get settled in Toronto. They have one son, Russell, who is 15.

Provincial and territorial health care plans Division of Powers Both Canadians and non-Canadians often ask, “Does Canada have a national health insurance plan?” The answer is no. Canada has universal health care implemented by thirteen single-payer insurance plans each administered and operated by a province (10) or territory (3). A national plan would mean there would be one plan across the country administered by one organization (e.g., the federal government). Universal health care, on the other hand, means that all eligible citizens of a particular country have insured health coverage, which can be done through a variety of health care plans in each province or territory. There are basic similarities with each plan, but each province and territory is free to deliver health care in a manner that best suits the health care needs or residents within each jurisdiction. As mentioned in Chapter 1, these programs are frequently referred to collectively as medicare. Although the federal government works in partnership with the provinces and territories to deliver health care, the provinces and territories maintain the bulk of the responsibility for its delivery. Under the Constitution Act (Box 3.1), provincial and territorial governments oversee matters relating to the personal health of their populations—the promotion of good health, preventive care, health maintenance, and the diagnosis and treatment of health problems. To receive continued federal funding for health care, however, provinces and territories must abide by the principles and conditions of the Canada Health Act (CHA), which obliges them to operate a health insurance plan that covers hospital care and medically necessary treatment for eligible residents. The Act is not concerned with the specifics of additional public or private health care delivery (unless private services contravene the principles and conditions of the Act). For example, the CHA does not address home care, long-term care, or the coverage of diagnostic services. Each province and territory controls which services are covered and how they are delivered.

  Box 3.1

The Constitution Act: A Clarification. The original British North America Act of 1867 became the Constitution Act in 1982, when Britain surrendered the power to make Canada’s laws, including its Constitution. Among other things, the Constitution Act outlines the division of health care responsibilities.

Structure of the Health Plans: An Overview Within each provincial and territorial government there is a ministry or department of health that is assigned to managing health care. The health ministries or departments oversee a variety of sub-divisions, branches, agencies, and programs that assume responsibilities for various matters and types of health care. Ministries also work with other service partners in the community—some government-funded, others private or nonprofit, and others a combination of government and private initiatives. Each ministry is headed by an elected Member of Parliament appointed by the premier to the position of Minister of Health (MOH). Typically, a government also appoints a deputy minister of health (sometimes more than one), who is not an elected Member of Parliament. One or more associate deputy ministers and a management committee may also be assigned. Ultimately responsible for the health care system in the province or territory, the MOH has numerous organizations within the ministry reporting to him or her. These organizations provide leadership, direction, and support to service delivery partners, which include regional health authorities, physicians, and other health care providers. One of the ministries’ greatest responsibilities is implementing and regulating the provincial or territorial health insurance plan—that is, overseeing hospital and medical care. In some jurisdictions this responsibility belongs to a single authority. In others, two administrative bodies share the duty—one handles hospitals and other health care facilities; the other, medical care. For example, in British Columbia the Medical Services Commission administers the medical care plan. The government, through the Ministry of Health Services, administers hospital services under the Hospital Insurance Act, reimbursing facilities for the medically necessary services they provide. But in Prince Edward Island, Health PEI administers both the hospital and medical services plans. The provincial and territorial ministries must also oversee the negotiation of salaries and other policies with physicians’ professional associations. Committees are typically created to manage these negotiations.

All provinces and territories provide three general categories of health care—primary, secondary, and tertiary—which are discussed later. The interaction between these categories is illustrated in Fig. 3.1.

FIG. 3.1 Access to Primary, Secondary, Tertiary and Quaternary health care.

Primary care refers to “first contact” services to which the public has direct access. Traditionally a person would go to see a primary care provider, who for the most part is a family physician or a nurse practitioner, for medical advice. However, with a multidisciplinary team approach to primary care that may vary, enabling individuals to contact a variety of providers for initial treatment (in addition to a physician or nurse practitioner) ranging from a chiropractor, physiotherapist,

nutritionist, counsellor, or psychologist. Primary care facilities include your provider’s office/facility, a variety of clinics (walk-in, rapid access, ambulatory care), and the emergency department. If your primary care provider cannot manage your health issue and/or feels you need more in depth, specialized assessments, he or she will refer you to a specialist who provides secondary care. Secondary care occurs when a patient is sent to see a specialist (seeking a consultation), which usually requires a referral (e.g., from a physician, nurse practitioner, or midwife). The referring physician is required to send a detailed report about the patient to the specialist, concerning the reason for the referral, including lab and diagnostic tests. A specialist assists the primary care practitioner to diagnose a patient’s problem and orders the appropriate treatment, but the specialist’s involvement is usually short term. Secondary care may involve admission to a general hospital or referral to a highly specialized facility, which provides tertiary care. Highly specialized tertiary care also requires a referral. A cancer centre or cardiology centre, for example, would provide tertiary care. Other examples include facilities that specialize in treating burn patients, neurosurgery, complex mental health, and palliative care. In a tertiary care setting, the patient may receive care from the referring specialist or from another specialist (or both). Once care is considered complete, the patient may be sent back to the referring specialist, who will then discharge the patient back to his or her family doctor. Alternatively, the tertiary care centre itself may refer the patient back to the family doctor. Finally, quaternary care is an extension of tertiary care and even more specialized, sometimes involving experimental procedures. Hospitals that do research (often linked with universities) may provide this level of care. Case Example 3.4 shows how each level of care works in a practical scenario.

  Case Example 3.4

Levels of Care Mr. Anderson who lives in Saskatoon went to see his family doctor about persistent headaches. After a couple of weeks the headaches got worse, which prompted his doctor to order an MRI. The MRI revealed a growth in his brain—primary care. The family doctor referred Mr. Anderson to a neurologist—secondary care. Following further investigation, the

neurologist concluded that Mr. Anderson had a malignant tumor, which may possibly need surgery. The neurologist referred him to a neurosurgeon in the Department of Neurosurgery at the University of Saskatchewan—tertiary care. After a highly specialized surgery with unfavorable results, the neurosurgeon consulted with another specialist who was running clinical trials in neurosurgical oncology for a new procedure that was combined with other interventions—quaternary care. Although ultimately accountable for all aspects of health care, the provincial or territorial ministry or department of health assigns responsibilities to various departments. The most common method of delivering primary, secondary, and tertiary/quaternary care initially was under a regional model using organizations commonly called Regional Health Authorities (RHAs). This is slowly changing, with most jurisdictions moving back to one centralized health authority.

Regionalization initiatives across canada In the early 1990s, because of the rising cost of health care and the increasing demand for services in a variety of settings, many governments conducted public forums, reviews, and other studies to determine a way to improve health care delivery. The conclusion: to decentralize decisions about health care issues through regionalization (Box 3.2), a concept of assessing the need for specific types of care and delivering that care which is best suited to a population group within a given geographic area. Four desired goals for implementing a regionalized approach were shared by all provinces and territories. The first was to amalgamate health care services over a broad continuum of care, the second was to stress health promotion and disease prevention, the third to involve the public, and the last to implement appropriate and effective governance.

  Box 3.2

Regional Health Authorities: A Definition. Regional health authorities (RHAs) are autonomous health care organizations responsible for health care administration in a defined geographic region within a province or territory. Through appointed or elected boards of governance, RHAs manage the funding and/or delivery of community and institutional health care services within their regions. Source: Ferrell, B., & Coyle, N. (2006). Textbook of palliative nursing. New York: Oxford University Press. Regionalization took different forms such as being run by a board. In some regions, the provincial government appoints the board members; in others, board members comprise of a mix of elected and appointed people from a variety of backgrounds. The RHAs across Canada differ in terms of size, structure, responsibility, and name. Regionalization (or centralization) of services was adopted by many jurisdictions as another way to cut costs and increase services. This led to the rationalization (or centralizing) of health services within communities—particularly in hospitals. Larger hospitals were merged under one administrative body offering specialized services at different sites or campuses. In other communities, one hospital

may act as a regional centre for cancer, for example, whereas another would act as the regional centre for cancer or maternal-child services. Women’s College Hospital in Toronto transitioned from an acute care hospital to an ambulatory centre specializing in women’s health. Amalgamating hospitals and redistributing services resulted in the closure of a number of smaller hospitals across the country. Rural areas often allocated services normally found in a larger acute care hospital to smaller hospitals in surrounding towns in order to justify keeping them open. For instance, some rehabilitation services moved to one community hospital, while certain types of surgeries (e.g., cataract surgery) moved to another location. Although the provinces and territories adopted the regionalized approach to health care delivery over a decade, in the past few years several provinces/territories have moved back to a central heath authority. The decision to move back to a central health system resulted from all the bureaucratic “red tape” that was involved with the regionalization initiatives. Other factors were also considered, such as administrative costs and difficulty in accessing services. Prince Edward Island, Nova Scotia, and Alberta now have a single administrative body. Saskatchewan and the Yukon are the most recent to abandon their RHAs. The rationale for centralization: saving money (particularly by reducing administrative costs), eliminating “red tape” associated with layered services, and making services more cohesive and easier to access. It is important to note that no formal evidence-based studies have determined which method works best—centralized or decentralized health care delivery. The desired effects of regionalization on primary care include designing care within a community that provides individuals with the type and level of care best suited within the region— for example, there may be a need for primary care services more suited to an older population, or care more tailored to a culturally diverse demographic. Regional health authorities may also be better able to give providers with remuneration envelopes reflective of their practice requirements and responsibilities; a provider working in a northern region might better suit a global budget than the fee-for-service model as an example. The following is a look at variations in health care delivery in each province/territory.

British Columbia

In British Columbia the Ministry of Health (MOH) works collaboratively with a provincial health authority, five regional authorities, and First Nations Health Authority to deliver health care in the province. The MOH establishes performance and evaluation guidelines for health care delivery and performance outcomes. The regional health authorities oversee planning and delivery of care in their geographic areas both assessing and meeting the needs of the population within their jurisdictions. They are also responsible for ensuring that programs are properly funded (within a given budget). Another regional authority, the Provincial Health Services Authority, collaborates with the five RHAs to implement provincial programs. The First Nations Health Authority, established in 2013, has assumed responsibility for delivering culturally sensitive and appropriate health care programs and services to First Nations people in the province (formerly overseen by Health Canada’s First Nations Inuit Health Branch —Pacific Region). Each RHA has an appointed board and is managed by an executive team, which participates in decision making at the operational level. The RHAs also manage community health councils (CHCs), which offer a variety of services throughout the province, including primary care clinics, health promotion, addictions services, home care, community mental health services, and specialized services, such as assistance for new immigrants, support for new mothers, and youth health drop-in centres. The range of services each CHC offers reflects the needs of the community it serves.

Alberta In 2008, the government of Alberta reduced the nine regional health authorities to one, a new agency called the Alberta Health Services Board. The original Alberta Health Services Board was disbanded by the provincial government (over financial disputes) and reintroduced in 2017. The board is responsible for the governance of Alberta Health Services (AHS), working collaboratively with Alberta Health. The board also assumed responsibility of the Alberta Mental Health Board, the Alberta Cancer Board, and the Alberta Alcohol and Drug Abuse Commission. This new governance model continues to strengthen Alberta’s approach to managing health care services, including surgical access, long-term care, chronic disease management, addiction and mental health services, and primary care access. In 2013, in addition to the province’s 42 primary care networks, AHS introduced the unique concept of family care clinics

(FCCs). FCCs provide direct access to a variety of nonemergency services. FCCs do not have to be headed by a physician, and individuals can see any team member without a physician’s referral. These FCCs have significantly reduced the number of people visiting emergency departments.

Saskatchewan Saskatchewan has partnered with an organization called 3sHealth or Health Services Saskatchewan with the dual purposes of improving health care services and spending health care dollars more effectively. The partnership involves all stakeholders (including cancer care) and shares services where possible, improves access to services, eliminates unnecessary steps regarding access to and receipt of care, and promotes other cost saving strategies—based on the LEAN principle (discussed in Chapter 10). Health also manages payroll services, workplace benefits, and provincial contracts for goods and services. In 2017, the government of Saskatchewan dissolved its 12 regional health authorities (also called health regions) replacing them with one authority, the Saskatchewan Health Authority. The intent was to streamline and better coordinate the delivery of health care and cut costs. The government estimated that moving to a single health authority would save the province approximately $9 million per year. Health services remain unchanged for the most part. The Saskatchewan Health Authority oversees hospitals, emergency response and ambulance services, longterm care and home care programs, community health services (including public health), and mental health and rehabilitation services (Health Shared Services Saskatchewan, 2014). The Saskatchewan Cancer Agency plans and implements most of the cancer services in the province. The agency’s duties include evaluating and developing guidelines for standards of care, treatment, and health promotion initiatives.

Manitoba In 2012, Manitoba’s 11 RHAs were reassigned into five regions: Northern Health, Prairie Mountain Health, Winnipeg–Churchill Health Region, Interlake Eastern RHA, and Southern Health. Each is overseen by a board of directors headed by a chairperson reporting ultimately to the Ministry of Health. The RHAs assess and prioritize community needs and deliver

hospital care, long-term care, home care, public health services, rehabilitative services, ambulance services, and laboratory services. Manitoba also delivers health care services (e.g., medical care, counselling, and health education) through community health centres, divisions of the RHAs run by local community boards.

Ontario In early 2019 the Ontario government implemented sweeping changes to the provincial health care system. Implementation of the new framework will be rolled out gradually; to fully understand the magnitude of these changes, it is important to understand the way in which health care has been delivered over the past few years.

Previous Framework In Ontario, the Ministry of Health and Long-Term Care (MOHLTC) is— and remains—responsible and accountable for publicly funded health care in the province. Until 2019, 14 corporations called Local Health Integration Networks (LHIN) were responsible for implementing health care services for designated regions across Ontario; they were based on a population health/health promotion approach. These nonprofit organizations (responsible to and funded by the MOHLTC) operated within the scope of agreements negotiated with the Ministry. LHIN’s determine, plan, and provide funding for the health services deemed necessary within, and specific to the needs of, their designated regions. LHINs have been directly responsible for hospitals, community support service organizations, primary care, mental health and addiction agencies, community health centres, and Aboriginal/Indigenous Health Access Centres, as well longterm care facilities. In addition, Community Care Access Centres recently managed a number of services, primarily the organization and delivery of home and community care; they were also the point of entry for Ontarians admitted to long-term care facilities. LHINs allocate their designated funds (from the Ministry) to pay for approved services. Restructuring under the Peoples Health Care Act 2019, the Ontario government has created a “super agency” called Ontario Health. It is headed by a chief executive officer and a board of directors. The goals of this restructuring are multiple, including: (1) to provide Ontario residents with simplified access to and navigation of the health care system and (2) to promote integrated care, improving connectivity to services, reduce costs, and improve efficiencies among health care agencies. Under the new

framework, the existing LHINs were dissolved and merged with six other agencies: Cancer Care Ontario, eHealth Ontario, Trillium Gift of Life Network, Health Shared Services (supported the LHINs and digital health platforms throughout the province), Health Quality Ontario (providing oversite regarding the quality of health care), and HealthForceOntario Marketing and Recruitment Agency (responsible for determining the appropriate mix of health providers). Ultimately, all hospitals, community health services, mental health agencies, cancer treatment centres, organ donation programs, home care, and end-of-life care will all be under the direction of Health Ontario. A number of Ontario Health teams made up of local providers (e.g., a hospital, home care agencies, and mental health agencies) will provide coordinated care in specific regions. Ontarians will have one number to call to initiate access to the services they need. (CBC/Radio Canada, 2019).

Quebec In Quebec, the Ministère de la Santé et des Services sociaux (MSSS) is responsible for both health and social services. The MSSS shares these responsibilities with Quebec’s 18 RHAs—15 health and social services agencies and three regional associations in northern parts of the province (the Centre régional de santé et de services sociaux de la Baie-James in the Nord-du-Québec region, the Nunavik Regional Board of Health and Social Services in the Nunavik region, and the Cree Board of Health and Social Services of Baie-James). Responsibilities of the RHAs include hospitals, long-term care, home care, public health, mental health, rehabilitation, social services, and laboratory and ambulance services—a more comprehensive list of responsibilities than those of most other jurisdictions. In 2004, 95 local service networks were established across the province to work under their respective RHAs. These networks provide comprehensive, accessible health care services to the populations in their region. At the heart of these local networks lie health and social services centres, created by merging local community health centres, residential and long-term care centres, and general and specialized hospital centres. By constructing service agreements with partners and stakeholders within the local services networks (e.g., rehabilitation centres, physician groups, medical clinics, youth protection centres, mental health organizations, university hospital centres), these centres ensure seamless access to

primary, secondary, and tertiary care and adequate follow-up for the populations they serve.

New Brunswick The Department of Health (DOH) in New Brunswick is responsible for all health care in the province, including overseeing the funding, planning, and delivery of selected health care services through the province’s two regional health authorities (Vitalité Health Network and Horizon Health Network). A board of directors oversees the operation of each RHA. These RHAs are responsible for hospital services, community health centre services, extramural services, most public health services, mental health and addictions services, and some tertiary services such as cardiac care and neurosurgery. The DOH retains responsibilities for other services such as long-term care and Ambulance New Brunswick. The government has engaged with a public company, Facilicorp NB, to assume responsibilities for certain nonclinical services including the management of their information systems.

Nova Scotia In 2015, the nine previous district health authorities were merged into one —the Nova Scotia Health Authority (NSHA). The NSHA works with the Izaak Walton Killam (IWK) Health Centre, an independent women’s and children’s tertiary care hospital, to plan and deliver primary care, community health, and acute care. The new single authority is also responsible for Nova Scotia’s Cancer Care Program.

Prince Edward Island The Department of Health and Wellness in Prince Edward Island (PEI) established Health PEI in 2010 to promote the concept of a “one island” health care system. The island formerly delivered health care under a regionalized delivery model. Health PEI is overseen by a board of directors who are appointed by the Minister of Health and Wellness. Health PEI consists of two divisions: frontline services and systems supports. Frontline services comprise community hospitals and primary health care, including five primary health care networks, home and longterm care, and mental health and addictions services. Systems supports include responsibility for financial services, the management of health

information, medical affairs (e.g., residency programs, tissue and organ donation), and corporate development and innovation.

Newfoundland and Labrador The Department of Health and Community Services in Newfoundland and Labrador delivers provincial health care through four RHAs, which are responsible for health promotion and disease prevention initiatives, family and rehab services, addictions and mental health, public health, ambulance services, and both acute and long-term care. Also operating under this department are numerous divisions with unique roles and responsibilities (e.g., Memorial University Medical School, the Newfoundland and Labrador Centre for Health Information Services, the Department of Health and Wellness, and the Medical Services Division). The Department of Health and Wellness provides leadership, policies, planning, and direction for the delivery of health care in the province. In addition, the department oversees health-related legislation and finances. The Medical Services Division is responsible for the delivery of medical, pharmaceutical, and dental services in the province. Physicians may work within an RHA or set up an independent practice. The RHAs have the authority to grant hospital privileges to qualified doctors.

Northern Regions Scattered populations and great distances between centres in the northern regions of Canada present unique and complex challenges in the delivery of health care. This vast area comprises of the Northwest Territories, Nunavut, Yukon, and the northern regions of other provinces, particularly British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, and Quebec. Technological advances (e.g., electronic health records, Telehealth, video links to large health centres) have contributed to significant improvements in the quality and accessibility of health care; however, care in the North remains woefully inadequate. Frequently, individuals must be air-lifted to a regional centre, such as Calgary, Edmonton, Winnipeg, or Sioux Lookout, to receive treatment that cannot be provided within the community. Nurses play a significant role in delivering health care in Canada’s North. There are over 600 Indigenous communities alone, serviced by over 70 community care/health centres (sometimes referred to as nursing stations), and nearly 200 regional health centres. Nurses, more often than not, are the first point of contact for health care in the North. They are

employed by the federal government, or through a transfer agreement in communities that assume responsibility for their own health care by the band council. The federal government funds much of the health care for northern Inuit, Métis, and First Nations populations. Health and health care services in Canada’s North are discussed further in Chapter 10.

Northwest Territories In 2016, six of the Health and Social Services Authorities were merged into one body—the Northwest Territories Health and Social Services Authority. The overriding goal was to improve the coordination and delivery of health services with input from residents in the territory. There are two remaining health authorities. The Hay River Health and Social Services Authority will continue to deliver care in its jurisdiction with its own management board whereas the Tlicho Community Services Agency will deliver care under the Hospital Insurance and Health and Social Services Act. As with other provinces and territories, the focus for care is on early child development, chronic diseases, mental health, continuing care, addiction, and child and family services.

Yukon The vast territory of the Yukon consists of fewer people than most midsized towns elsewhere in Canada, with a population of approximately 38 641. This population is expected to grow to 43 000 by 2025. By that time, it is estimated that 18% of the population will be 65 years of age and older, while those under 25 will decrease to 25%. The majority of the Yukon’s population (75%) lives in Whitehorse and the surrounding area. The biggest challenge is providing health care to the rest of the surrounding population. The territory does not have RHAs or similar organizations. The Department of Health and Social Services (DHSS) manages and delivers all components of health care through the following divisions: Health Services, Social Services, Continuing Care, and Corporate Services. The Health Services division is responsible for community nursing and community health programs, including the community health centres, which deliver frontline care and are managed primarily by nurses. The Continuing Care branch oversees residential and home care in addition to

day care and palliative care programs. The territory has three hospitals, managed by the Yukon Hospital Association (Yukon Health and Social Services, 2015).

Nunavut Nunavut spans one-fifth of Canada’s land mass and has 25 communities spread across three regions—Baffin, Kivalliq, and Kitikmeot. Approximately 85% of the territory’s population of roughly 32 000 people are Inuit. In Nunavut, the Department of Health is responsible for the delivery of health care as well as policy development and legislation governing the health care system. As with the other northern regions, primary care is provided by nurses, nurse practitioners, and visiting physicians—with widespread use of videoconferencing. Retaining fulltime nurses is an ongoing problem in this region for several reasons, including geographic and social isolation, and at times a lack of employment for spouses. Nunavut has approximately 22 community health centres and three regional health centres: Cambridge Bay, Rankin Inlet, and the Qikiqtani General Hospital in Iqaluit. The centres in Cambridge Bay and Rankin Inlet have the capacity to keep patients overnight. Iqaluit has a family practice clinic and is the only hospital in Nunavut. Ottawa is the main referral centre. Health care funding is centrally managed and distributed, with a significant portion of expenses going toward medical travel and out-of-territory treatments, as a result of shortfalls in infrastructure such as diagnostic and service capabilities.

Who pays for health care? Provincial/territorial roles Each province and territory has a method (e.g., premiums, payroll tax, general revenues) of financing health care services not covered by federal funding. Private and volunteer organizations provide significant revenue for specific services or hospitals. For example, when a community hospital builds a new wing, a government grant usually covers part of the expense, while volunteer groups and municipal governments frequently make up the balance. A formal building campaign, often launched by the hospital undergoing the expansion, provides a conduit for donations.

Health Care Premiums Alberta, British Columbia, and Ontario charge premiums for health care services. Each province and territory determines how health care will paid. Although premiums paid for private health insurance are tax deductible, premiums paid to public plans are not. Premiums and other tax revenues do not contravene the Canada Health Act as long as residents are not denied medically necessary services because of an inability to pay. The provinces offer premium assistance for those who need it and premiums are income based. Alberta eliminated premiums in 2008 and reintroduced them in 2015 with payments on a sliding scale. Income based premiums range from $200 to $1000 a year for Albertans. However, those earning less than $50 000 annually are exempt. Money raised from these payment premiums will not automatically be streamed back into health care, but into the province’s general revenue coffers. Effective January 1, 2018 British Columbia residents had their health care premium payments cut by 50%. Premiums are income adjusted. For example, families with a net (adjusted) income of $26,000 or less do not pay anything. In a single adult household where the adult makes about $30,001–$34,000 annually, monthly payments would be $23.00; if there were two adults in the household (family), payments would be $46.00 monthly. If a household with one adult was making $46,000 or more, premiums would be $75.00/month and if there were two adults in the family, $150.00/month. When the British Columbia government announced its 2017–2018 budget, it stated its intention to phase out health

care premiums within a 4-year time frame, replacing the lost revenue with a payroll tax (called an employee health tax). The Ontario government introduced health premiums in 2004. The premium is deducted from employees’ pay and pension as part of their income tax, and is income based; individuals who have an annual taxable income below $20,000 do not pay a premium. The amount paid per individual is not linked to the Ontario Health Insurance Plan and does not affect eligibility for health care coverage. First Nations people who are known as Status Indians pay premiums for income earned off a reserve (Ontario Ministry of Finance, 2014). As in British Columbia, no eligible resident can be denied health care based on income.

Payroll Tax Some jurisdictions, including Manitoba, Ontario, Quebec, and Newfoundland and Labrador, levy a payroll tax (Normandin Beaudry, 2012), a tax collected from employers that specifically raises funds for health care that may extend to education and social services. This is also referred to as a dedicated tax. The amount paid depends on many factors. In Newfoundland and Labrador a 2% tax is payable by employers whose annual remuneration is over a predetermined exemption threshold (explained by the government of Newfoundland and Labrador as the total remuneration paid by an employer less its allocated deduction). Employers with a payroll below a certain amount may be exempt; others may pay a reduced amount based on their salary or wage payout. Note that, in Ontario, this tax is in addition to health care premiums paid by residents.

Other Sources of Funds In addition to federal funding (discussed in Chapter 4), provincial, territorial, and municipal governments provide some funds for services such as preventive health measures, medical- and hospital-based services (both inpatient and outpatient), treatment of chronic diseases, communitybased rehabilitation care, and long-term care. Provincial and territorial health ministries fund and regulate hospitals. They may also contribute financially to community health organizations, services delivered by certain health care providers (other than physicians), and teaching and research institutions.

Distribution of Funds Precisely how finances are organized and administered varies among the provinces and territories. In some provinces, for example, the ministry responsible for health care may directly manage hospital and medical insurance, and cardiology and cancer care. Other provinces or territories may establish separate public organizations to oversee and finance these services. Currently, most provincial and territorial governments provide funding—at least in part—to RHAs (except for those jurisdictions such as Saskatchewan and the Yukon, who have transitioned to a single health authority), which, in turn, finance hospitals and health care services within their regions depending on each area’s particular needs. For example, an RHA responsible for hiring community nurses would contract with private nursing agencies to provide care in a certain region. Managing its own funds, each nursing agency would then hire the nurses and deliver care. In some jurisdictions, other ministries provide funds for additional health care–related services. For example, the Ministry of Labour might oversee occupational health matters, and the Ministry of Community and Social Services might provide services (e.g., counselling, group homes, special education) for those with specific health issues, such as learning and physical disabilities. The provinces and territories also allocate funds to supplementary benefits (e.g., medical supplies, prescription drugs, hearing aids). In jurisdictions with a regionalized framework these funds, most commonly distributed through the RHAs, finance regional facilities and services.

  Thinking it Through Some provinces charge premiums for health care; others do not. 1. Do you think that charging premiums is a reasonable way to offset the cost of health care? 2. What other ways could a province/territory generate revenue for health care in your jurisdiction?

Private and public health insurance Third-party health insurance plays a significant role in offsetting the costs of services not covered by provincial and territorial health services. Approximately 60% of Canadians carry private health insurance, provided either through group employment benefits, or purchased personally. Group employment benefits cover the employee and their families and or dependents for a selection of goods and services deemed not medically necessary, such as vision and dental care, physiotherapy, chiropractic visits, private nursing services, assistive devices, and enhanced medical services (e.g., semi-private hospital room). Getting private insurance is not always straightforward; insurance companies, for the most part, require individuals to be in good health. Individuals with high risk factors and/or preexisting conditions may be refused private coverage, or have restrictions on their insurance policy. The 40% of Canadians who do not have private health insurance includes those who are unemployed, underemployed, or self-employed (all risk factors when considering the socioeconomic determinants of health). Lack of drug coverage appears to be the greatest hardship.

Provincial Insurance Plans Eligibility All of the following criteria must be met for a person to be eligible for provincial or territorial health insurance: • Canadian citizenship or permanent resident status; • Resident of the province or territory in which he or she is seeking health coverage; • Physically resides in that jurisdiction for at least 5 months of the year (this criterion varies slightly among jurisdictions). Babies born in a given province or territory are insured from birth in most circumstances. People with study or work permits, issued under the federal Immigration and Refugee Protection Act, may be considered residents for a designated time frame. Permanent residents are not subject to any time frames; a person granted permanent residency has almost all of the same rights and

privileges as a Canadian citizen (they cannot vote or hold public office). Refugee claimants (asylum seekers), protected persons, or convention refutes would be covered under the federal government until such time as they are granted permission to remain in Canada. Terms and conditions for insuring other population groups can be obtained from the provincial or territorial health Web sites. No Canadian can be denied medically necessary hospital or physician care under any circumstances.

Application for Coverage Documents required for provincial or territorial health insurance are similar. Usually, a citizen of Canada must present proof of that citizenship, proof of residency in a particular province or territory, and further (or supporting) proof of personal identification (all original documents). To prove citizenship, a birth certificate, passport, citizenship or Canadian residency card, or similar documentation is required. To show provincial/territorial residency, an income tax assessment, a child tax benefit statement, or a utility or property tax bill is acceptable. Proof of personal identification includes a credit card, an employee ID card, or a driver’s licence. In each province and territory, newcomers must apply to the Ministry or department of health for health insurance coverage. The application process and documentation required can vary. Specific instructions for applying for health care coverage can be found on the individual websites of the provincial and territorial health departments. The application processes of British Columbia, New Brunswick, and Ontario are illustrated as our three families, the Jaegers (Case Example 3.5), the Wongs (Case Example 3.6), and Chris Loton’s family (Case Example 3.7) apply for provincial health coverage.

  Case Example 3.5 The Jaeger’s must apply for health care immediately upon arrival in the province. They have several means of obtaining application forms, the easiest of which is to download them from the Medical Services Plan (MSP) website. The Jaegers can also call a toll-free number to be connected to the nearest Service B.C. Centre for assistance. Forms can be completed online (the information will be saved on the computer until the form is submitted in case completion takes a couple of days). In addition, a formsby-fax service is available from the provincial government 24 hours a day,

7 days a week. Coverage begins 3 months after arrival and showing proof of residency in the province. To complete MSP enrollment and obtain a Photo BC Services Card, the Jaegers must go to an Insurance Corporation of BC driver’s licensing office (effective January 2018). The Jaegers must bring two pieces of identification such as immigration documents, passports, and a credit card (if they have one). Since Joseph was born in Canada, he would need to bring his birth certificate. Joseph and Anna must sign a declaration that they live in British Columbia and have their picture taken. They must bring documentation for Anna, Luca, and Alois as well. Joseph wondered about private insurance instead of the MSP and was told that enrollment in the public plan was mandatory, but he could apply for private, supplemental insurance if he wished. Because the Jaegers are immigrating to Canada, they did know that they had the option of arranging private insurance to cover the 3-month wait time. The Jaegers must also make arrangements to pay their health premiums.

  Case Example 3.6 Quang and Ling may only submit their own application forms for health coverage when they arrive in New Brunswick. The three children can be added to their parents’ form (as for all children under the age of 19 in all jurisdictions). Forms can be downloaded and brought to a Service New Brunswick office or completed and sent electronically. Application forms are not to be mailed. Required original documents must be submitted with the application form. These documents include a copy of all Canadian Immigration identification records, an entry stamp on passports, proof of personal identification (e.g., birth certificate or a baptism certificate), and proof of residency (rental or lease agreement). Once their application has been reviewed and the family is considered eligible, they will be issued a letter of confirmation, which will verify the start date of their health coverage (on or close to the confirmation date). Remember that New Brunswick has eliminated the wait period except for Canadians moving from another province or territory in accordance with the reciprocal agreement. It takes up to 8 weeks for their New Brunswick Medical Card to arrive—via mail—until then they use a temporary paper document with a health number.

 

Case Example 3.7 Chris, Kevin, and their son Russell have moved from Saskatchewan to Ontario arriving on February 14. Because they are moving from another province their coverage would begin on the first day of the third month after their arrival which would be May 1 (the balance of the month in which they moved, plus 2 months). However, the family’s health coverage from Saskatchewan will cover them until OHIP takes over in accordance with the reciprocal agreement. To apply they need proof of Canadian citizenship (e.g., birth certificate or passport), personal ID (e.g., driver’s licence), and proof of residency in Ontario (e.g., utility bill, rental agreement). They can apply for coverage online or fill out a hard copy of the application form and bring it to a Service Ontario centre. Their photo ID OHIP cards will be mailed to them. Their son, Russell, who is 15 will also automatically receive comprehensive coverage for prescription medications until he turns 25. It is worth noting that had they moved from out of the country they would have had to wait a full 3 months. Documents required by anyone moving to Canada (not previously a Canadian citizen) include Canadian Immigration identification records (or a permanent resident document and record of landing, e.g., entry stamp on passports, or a single journey document). Many of the recent refugees from Syria were granted residency status upon landing, so they would include these documents when applying for health care coverage in the province or territory they plan to live. Under the Canada Health Act, as indicated in the three case studies, the waiting period for health coverage is not to exceed 3 months, therefore all provinces and territories must comply, although there are some variations. For the most part, coverage will begin on the first day of the third month after a person or family has moved permanently to a jurisdiction. Other regions will require the person or family to wait a full 3 months (the balance of the month in which they arrived plus 3 more full months) as noted in British Columbia (see Case Example 3.5). New Brunswick (see Case Example 3.6) has removed the condition of having to wait 3 months for most newcomers. Under the reciprocal agreement (Box 3.3), health card holders qualify for health care services anywhere in Canada (other than Quebec), barring some exceptions; for example, people may not seek elective surgery in another province or seek a service that is uninsured in their province or territory of origin.

  Box 3.3

Reciprocal Agreement. The reciprocal agreement supports the principle of health insurance portability (see Chapter 2) among the provinces and territories. Through the agreement, a person’s province of origin will pay for required health services in another province or territory at the rates imposed by the host province. This interprovincial agreement is not mandatory. For example, Quebec has not signed this agreement. As a result of this agreement, Canadians, for the most part, will not face point-of-service charges for medically required hospital and physician services when they travel within Canada. In most cases, a person can receive care in a host province by simply presenting his or her health card, and the patient’s province of origin will pay the host province for services delivery. Source: Health Canada. (2007). Health care system—Canada Health Act.

  Thinking it Through The Arrival of a Syrian Family Kadan, Selda, and their daughter, Milana, have just arrived in Canada from Syria, sponsored by a church group. They have been granted permanent residency status upon landing in the country, which usually means they are immediately eligible for health care under the Interim Federal Health Care program (see Chapter 2). However, they still must apply for a provincial/territorial coverage upon arrival to obtain a health card following proper protocol and with proper documentation. When they apply they will be given a temporary paper health card until the official provincial/territorial card arrives in the mail. Most provinces and territories also offer limited vision and dental care. Milana is in good health but badly in need of dental work, Selda lost her glasses 6 months earlier, and Kadan has been complaining of headaches. The family will need assistance navigating the health care system, coordinating appointments, filling out documents, with the help of an interpreter. Considering the process in your jurisdiction:

1. What are the documents they will need to apply for health care in your jurisdiction? 2. What are the limits to vision and dental coverage (if any) in your province/territory? What provider would Kadan see regarding his headaches? If the services of a specialist were required, would that be covered? 3. How can you in your professional role assist this family with their health care needs?

Health Cards Once an application is approved, the Ministry or Department of Health issues the applicant a health card, identified by a number for the province or territory in which he or she resides. Some jurisdictions assign a number to a whole family, and later when the children reach a certain age, issue the children an individual health number. Other jurisdictions issue a personal health number to each person. In Ontario, for example, babies are issued an individual health number at birth.

Using a health card Almost without exception, health care facilities require individuals to present their health cards at the point of service. If the health card does not contain a picture, the person may also be asked for photo ID (e.g., a driver’s licence) with a current address. (Note: in many jurisdictions, only providers of provincially or territorially funded health care can ask a person to produce a [valid] health card; the card itself should never be used for identification purposes.) Exceptions include British Columbia where the photo ID card is structured for such purposes. Health cards are usually electronically validated each time they are presented at point of care. If an “invalid” message appears (e.g., if the card has expired or was reported lost, or if an unreported address change has since occurred), the cardholder may be asked to pay for the service he or she is seeking. After finding the health card or renewing an invalid one, the person can submit the receipt to the Ministry for reimbursement. In smaller centres where care providers know the patients, they may make exceptions and/or not require the person to show their card at each visit. An invalid health card is much like an expired credit card. Most jurisdictions send a notice to the card-holder well in advance of the expiry date. This date may also show up on the computer when it is validated—if so, the administrative assistant is likely to let the patient know if the card is about to expire.

  Did You Know? Since 2016 Ontario has issued health cards that do not identify a person’s gender. As of 2017, individuals can put an X in the space for their gender on their driver’s licence and passports. This is to ensure inclusivity and respect for individuals who want to remain gender neutral, and also those who have been marginalized with respect to gender identity and nonbinary residents. In 2017, British Columbia issued a baby a health card with “U” as the gender marker, at the request of the parents; they want the child to decide for him or herself what gender to identify with, or even to remain gender neutral. Other jurisdictions, including the Federal Government, are looking at adding a third choice on birth certificates, passports, and other government documents. All jurisdictions across Canada have either adopted or are in the process of adopting a process allowing individuals options other than having to mark “F” or “M” on legal documents. For example, on a document there might be a third box noted as “X” or “U’ to tick.

Health card fraud Health card fraud occurs when a person uses another person’s health card to seek medically insured services, when a nonresident of a province/territory falsifies information to obtain/retain a health card, or when a person continues to use health services in a jurisdiction where he or she is no longer a resident. Health card fraud is a significant problem across Canada, resulting in an enormous cost—in the millions of dollars— to the provinces and territories. It is virtually impossible to detect fraudulent use of older health cards that have no special security features or photo identification. Most jurisdictions now have photo identification health cards for those over a certain age—usually 15 or 16—and increased security measures to protect the information on the cards, such as a holographic topcoat and hidden ultraviolet ink printing that can be viewed only under ultraviolet light. These cards must be renewed at designated intervals, unlike the older-style cards that never expired. Some cards also require signatures. A magnetic strip on the health card contains coded information, such as the holder’s name and address. It is a serious offence in all provinces and territories to knowingly facilitate the illegal use of a health card. Health care providers are encouraged to watch for and to report anything suspicious—for example, a patient unable to provide his or her address, or a person who looks decidedly different from

the picture on the health card. Many jurisdictions have a hotline for health care providers or the public to call if they suspect fraudulent use. Lost cards must be reported immediately, as must changes of address or name. All provinces and territories have a protocol to follow for lost or misplaced health cards. As soon as a card is reported lost or missing, it is invalid. When the user applies for a new card, he or she will be issued a temporary document to use until the new card arrives. Often a hole will be punched in the invalid card to signify it can no longer be used. A person convicted of health card fraud under section 380 of the Criminal Code of Canada can be fined thousands of dollars and/or face prison time.

Insured and Uninsured Services Provincial and territorial governments are responsible for administering the health care insurance plan in their jurisdictions. They must decide on a multitude of things, including the need for different types of hospital beds (e.g., acute care, rehabilitation, and long-term care), the mix of professional health care staff, and the structure of the system that will best serve various regions within the province or territory. In addition, the governments approve hospital budgets and negotiate physicians’ fees with medical associations. Under the Canada Health Act, medically necessary hospital and medical services are insured everywhere in Canada in addition to in-hospital care. The Canada Health Act does not include long-term care, residential, and rehabilitation facilities or home and community care services in its mandate. These services are under provincial/territorial legislation; as a result there is little consistency across the country regarding services offered, the cost of services to the individual, and how they are managed— publicly or privately owned, profit or nonprofit. Some provinces and territories may choose to provide supplementary benefits and services outside of the Canada Health Act. The governments then determine eligibility guidelines for specific services, funding formulas, and the length of time these services will be insured. Supplementary benefits include health care services, such as optometric, dental, and chiropractic services, which are insured by the province or territory, but not mandated by the Canada Health Act. All provinces and territories provide specific services (e.g., eye care, dental care, drug benefits) to certain population groups, such as those receiving income assistance or guaranteed income supplements, adults

over age 65, and disabled persons. Many jurisdictions also provide some of these services to children of low-income families. As noted in Chapter 2, the Federal Government, rather than the Provincial and Territorial Governments, finance the majority of health care provided to Inuit and First Nations Peoples living on reserves. Other groups for whom the federal government provides coverage (e.g., federal public service employees) receive coverage under plans separate from the provincial and territorial ones.

Private Health Care Contrary to what many Canadians believe, private health care, as mentioned earlier, has existed in some form or another since before the inception of the Canada Health Act. Despite some strictly private clinics in Canada being perceived as illegal under the principles of the Canada Health Act, numerous such clinics and services exist across the country. Some circumvent the legal principles of the Act largely by offering services not technically considered medically necessary, since they cannot charge for medically necessary procedures that are covered by the public health plan. For example, private clinics may provide patients with a wide range of diagnostic tests (noted as preventive screening), such as colonoscopies, 3-D imaging of fetuses for pregnant women, or magnetic resonance imaging scans (MRIs) that are not medically necessary for individuals wanting them. Most jurisdictions, however, subcontract selected diagnostic and surgical procedures to private clinics, usually at no cost to the patient. Each jurisdiction that operates private clinics does so under province specific legislation. Canadian Surgical Solutions is a private clinic in Calgary that is owned by Centric Health and is one of five private surgical clinics across Canada. It offers a selection of orthopedic procedures. The facility is accredited by the College of Physicians of Alberta under the Non-Hospital Surgical Facilities Accreditation to perform inpatient stay surgical procedures and day stay procedures. Surgeons at this clinic work in both the public and private system. Most Canadians, even if they were willing to pay for the services, cannot access this and similar clinics under Canadian law. A total hip replacement, for example, would cost over $30,000 (including hospital care). The facility can, however, accept people from out of the country, Workers’ Compensation cases, Federal Government employees, and members of the RCMP. There are also “boutique” private clinics operating across the country offering a bundle of public and privately funded services described as a

personalized and comprehensive lifestyle health plan. The plan usually includes an “executive” or comprehensive annual physical exam, quarterly smaller assessments, and multiple tests. They also offer access to a primary care provider within a couple of days, and prompt access to diagnostic tests (e.g., MRI), consultations with a dietitian, genetic analyses, pharmacogenetics, supportive coaching, and strategy planning sessions. Despite the fact that members pay an annual fee (some as high as $4500), the clinics still charge the provincial plan for a good portion of their services including office visits, and some laboratory and diagnostic tests (Husni, Khan, MacMillan, et al., 2017). Other services, often paid for privately, include counselling, physiotherapy, sports medicine, travel health assessments, genetic testing, and pharmacogenomics testing. The emergence of these private clinics raises many concerns (Box 3.4). Counselling and psychotherapy are woefully underfunded, particularly in the presence of a rising need for mental health services. Most primary care groups will offer limited counselling sessions as part of the basket of preventive and supportive initiatives available to patients enrolled with that particular group. Otherwise, private insurance (if a person has a plan) will cover a limited number of sessions. Insurance plans frequently require a counsellor or psychologist to have a certain level of education (usually a PhD), restricting prepaid access to a large number of mental health professionals.

  Box 3.4

Private Clinics: Concerns. Significant concerns exist across Canada about private clinics. At the forefront lies the worry that the availability of private clinics will lengthen wait times for those using the public system because private clinics use the services of physicians and other health care providers who also work in the public system. Some believe that doctors’ time in the public system will be lessened; others argue that physicians working in the private sector do so on their own time, thus not interfering with services offered in the public system. For example, an orthopedic surgeon may have only 2 days of operating room time available to him or her, leaving 3 days a week during which he or she cannot perform surgical procedures. On such days, the surgeon can see patients in a private clinic, perhaps doing

knee or hip replacements, and conversely, shorten the line in the public system. Another concern is that patients paying for enhanced services will unfairly move to the top of wait lists because of the additional revenue for the clinic. For example, in many jurisdictions, a patient having a hip replacement in the public system will receive offers of “upgrades” to a superior product for the replacement part used in the procedure (e.g., titanium), which generates revenue for the hospital. Some claim that people purchasing such upgrades move up the list. Bundled services, some claim, provide another method by which individuals can jump the queue. For example, a clinic performing cataract surgery can “bundle” an uninsured laser surgery with the insured cataract surgery. The patient paying for the laser portion of the procedure could be bumped up the list, while someone wanting cataract surgery continues to wait. More often than not, the enhanced or bundled service will occur at a private clinic, having no impact on the corresponding public service. Private clinics charge substantial fees to individuals using their services for nonmedically necessary procedures. A growing trend, particularly within the past 5 years, has seen physicians and specialists pooling their services to offer routine and specialized care via “health packages.” Such groups (e.g., the Copeman Healthcare Centres in Vancouver, Calgary, and Edmonton) charge an enrollment fee and an annual membership fee. In return for fairly steep fees ($29 000/year for the “elite” program at Copeman), patients receive the guarantee of prompt access to an impressive team of health care providers, including family doctors, dietitians, psychologists, and specialists, along with an array of other services. Fees are generally tax deductible, and many of the services are covered by third-party insurance. Critics of this type of private health care point out that these fees are well out of reach of the average Canadian family. To what extent a two-tier system will develop in Canada is anyone’s guess. The availability of private clinics and services suggests that, in one form or another, a two-tiered system will continue to exist.

Hospital Services In the hospital setting insured services for inpatients include standard hospital accommodation, meals, certain medications (in some regions, patients are asked to bring their own medications), operating room and delivery room services, anaesthetic facilities, diagnostic and laboratory

services, routine medical and surgical supplies used for hospitalized patients, routine nursing care, and certain rehabilitative services (e.g., physiotherapy). Provincial and territorial plans do not cover private nursing care unless ordered by a doctor, at which point the care becomes medically necessary and is covered. Note that the cost of a private room may be covered by the provincial or territorial plan under some circumstances (e.g., for infection control, isolation purposes, or compassionate reasons). Insured outpatient hospital services include emergency treatment, day surgery, and diagnostic and radiological procedures at a hospital or at private diagnostic centres (e.g., outpatient cancer centre, orthopedic clinic). In addition, most jurisdictions insure physiotherapy, occupational therapy, and respiratory therapy services for a limited period if deemed medically necessary.

Medical Services Under the Canada Health Act, medically necessary care provided by a medical doctor (i.e., family doctor or specialist) is an insured service, with some conditions. In Ontario, for example, a person can claim coverage for only one visit to a medical doctor per day unless the physician submits the claim for special review. What is deemed medically necessary may vary a little across the country but is fairly standard. Rules also govern insured services provided by a specialist. For instance, in most provinces and territories, a doctor must refer a patient to a specialist; the patient may see the specialist again for the same problem within a calendar year. After that, or for a new symptom or complaint, the family doctor must provide another referral. In most jurisdictions, when a patient requests the opinion of a second specialist, the provincial or territorial plan will pay for that visit if the family doctor provides another referral request. After receiving a second opinion, however, the patient would usually have to pay for further consultations even if referred by his or her family doctor. Each province and territory generates its own list of insured services, which is reviewed periodically by the Ministry or Department of Health and the Province’s or territory’s medical association. At this time, some services may be delisted, and others added. Since “medically necessary” is subjective, these services vary from one jurisdiction to another. For example, having wax removed from one’s ear is insured in British Columbia, but not in Nova Scotia (although it is covered for children).

Ontario’s provincial plan no longer covers what used to be called an annual checkup, but now recommends a less extensive assessment, called a periodic health visit, limited to one visit per patient per 12-month period. British Columbia and several other jurisdictions do not cover an annual health exam; rather, the extent of an examination is complaint-driven. Patients can request a complete physical but must pay for it themselves. Physicians, especially in primary care groups, may choose to offer a selection of services to their patients that are deemed not medically necessary by their provincial or territorial health care plan. Because primary care groups offer team-based care, these services can include dietary counselling, podiatry services, grief counselling, access to psychotherapy sessions, and a range of preventive care services. For other noninsured services (e.g., third party physical examinations required for a work-related driver’s licence), physicians may bill patients directly, or they may bill a third party—an insurance company, the Workplace Safety Insurance Board (WSIB), or an employer or other payer. The amount a doctor charges for uninsured services depends on guidelines set out by the governing medical association (Box 3.5).

  Box 3.5

Uninsured (Chargeable) Versus Insured Physician Services.

Note: Services that are uninsured vary; many primary care organizations or groups offer ‘bundled’ services, which may include travel advice, counselling (e.g., smoking cessation, diatetic, and grief), prescription renewals, and telephone advice. These groups also may offer wart clinics (wart removal has historically been an uninsured procedure). Third party physical assessments, certain vaccinations, and completion of most insurance forms often remains uninsured in primary care groups.

 

Thinking it Through Primary care providers (as well as specialists) are required to inform patients of the price of any procedure, assessment, or treatment not covered by their provincial or territorial plan before any uninsured service is carried out. Patients typically pay out-of-pocket each time an uninsured service is performed. Some doctors however, offer patients an alternative called a block payment plan, whereby patients pay a flat fee for selected (uninsured) services over a predetermined time frame usually not less than 3 months. Examples of such services include medicals for employment or camp, return-to-school or return-to-work notes and travel immunizations/shots. The physician must not refuse services, and must not show preferential treatment to patients who pay block fees. 1. If you had a treatment provided by a doctor, learning afterwards that the service was uninsured and that you were required to pay for it, what would you do? 2. Would you be more likely to opt for a block payment plan or a payas-you-go plan for uninsured services? 3. If you considered a block fee payment plan, what questions would you have for your provider?

Ambulance Services In most jurisdictions, land and air ambulance services are either under regional management, and costs are shared with the provincial or territorial government, or these services are delivered privately through performance-based contracts. Because ambulance services are not addressed in the Canada Health Act, provinces and territories can establish their own guidelines, including fee schedules for these services. People using an ambulance even for medically necessary reasons may be responsible for a copayment (Case Example 3.8). However, fees are not usually charged for transportation between hospitals—whether the destination hospital is within a short distance, in another part of the province, in another province altogether, or outside of the country—as long as the transfer is for medically necessary reasons (Case Example 3.9). Interfacility transfers (e.g., from one nursing home to another) usually require a copayment. Most jurisdictions either reduce or eliminate the copayment for low-income individuals and families.

  Case Example 3.8 While tobogganing with his children, Mr. Jaeger fell and broke his ankle. He was transported by ambulance to the local hospital for treatment. Mr. Jaeger was responsible for a copayment of $80 for the ambulance service.

  Case Example 3.9 When Anna Jaeger went into labour with her twins 8 weeks before her due date, her husband brought her to St. Paul’s Hospital in Vancouver. The Obstetrician determined that delivery was inevitable and contacted bed management (called patient flow in some jurisdictions) to find two beds in a neonatal intensive care unit (NICU) for the babies when they were born. The BC Patient Transfer Network (BCPTN) coordinates services in the province to ensure patients get the type of bed and care they will need. The response was that there were no NICU beds available in the province. The BCPTN found space for the babies and Anna in the Regina Regional Hospital, which is the tertiary centre for neonatal services for southern Saskatchewan. Anna was transported by air ambulance to Regina where she delivered two small but generally healthy baby girls, who required ventilation and supportive care for well over a week. Ten days later, Anna and her babies were returned to Vancouver General Hospital. The British Columbia medical services plan covered the entire cost of the round-trip air ambulance because the province was unable to meet Anna’s medically necessary needs at home—as outlined in the CHA. All required care was also paid for by the BC MSP. Copayments (also sometimes called user fees or service fees) vary, and all jurisdictions exempt some people from them, including individuals in long-term care homes or on provincial or territorial subsidized programs. Ambulance services are often used as a mode of transport, which is misuse of the service. In such cases the “user” is charged the full amount of the ambulance transfer.

Insured Health Care Providers Other Than Physicians

For the most part, public insurance plans pay for very few supplemental services such as physiotherapy, chiropractic, podiatry, massage therapy, naturopathy, or osteopathy services (often referred to as paramedical services). Some provinces/territories will pay for limited chiropractic care. In 2017, Manitoba Health reduced the number of chiropractic visits it would pay for from 12 down to seven visits per year, in addition to the amount it would pay for each visit. Alberta provides limited governmentsponsored coverage for seniors, and British Columbia provides limited chiropractic coverage for residents receiving medical service plan premium assistance. As previously mentioned, most primary care organizations offer their patients a bundle of services, which include a variety of premedical services. In all jurisdictions, optometrists are paid by public plans under certain conditions such as age, and the presence of an eye condition requiring medically necessary care. This does not include glasses.

Extended Health Care Services Long-term care homes offer 24/7 accommodation, meals, and nursing care and support to individuals no longer able to live on their own. The terms long-term care facility and nursing home are often used interchangeably, but in some provinces and territories subtle differences may exist. These facilities offer residents more comprehensive care than retirement homes provide. They may be owned and operated by private corporations (either profit or nonprofit), municipal councils, churches, or ethnic, cultural, or community groups. These facilities are overseen by one or more pieces of legislation. The province or territory sets standards of care in long-term care facilities and performs regular inspections to ensure these standards are met. Long-term care facilities are encouraged to seek accreditation through Accreditation Canada (formerly known as the Canadian Council on Health Services Accreditation), an organization that conducts reviews on a 3-year cycle. The Qmentum accreditation program introduced in 2008 has revised some assessment standards and added new ones, such as an improved survey process and more effective tools for measuring compliance. Assessments include reviews of patient care, staff management, information management, administrative management, and partnerships. Accreditation reflects a level of transparency and shows the public that the facility meets national standards of care and operation. Provincial and territorial governments design their own funding formulas for funding long-term care facilities. A long-term care facility

may be funded by municipal, county, and provincial funding (more details in Chapter 4). Most provinces and territories offer a variety of other services: • Home care helps individuals with basic personal care, meals, and household maintenance, allowing them to remain at home even once they find caring for themselves difficult. • Adult day programs provide community day activities as well as respite care and in-home support to individuals with disabilities. • Respite care, which allows nonprofessional caregivers some relief from caring for disabled family members, is often offered in longterm care facilities or the equivalent for a designated time frame. • Assisted living accommodation helps to keep a person in his or her home by providing individualized support and care as required. • Group homes allow persons with disabilities to live in an environment that provides supervision and assistance. • Hospice care is provided in a home-like setting for those unable or unwilling to die at home. Individuals receive nursing and medical care, pain management, counselling, and other supportive care needed while dying. When a community or region builds a hospice, funding is often from multiple sources ranging from community resources to municipal and provincial governments. • Palliative care provides care, medication, and some medical supplies for individuals dying at home. • Medical Assistance in Dying is in accordance with the law, and overseen and paid for by provincial and territorial governments (see Chapter 8).

Assistive Devices and Medical Products Those in need of but unable to afford health care products and assistive devices—mobility devices (e.g., wheelchairs, walkers, motorized carts), prosthetic devices (e.g., postmastectomy products, artificial limbs), bathing and toileting aids, and hospital beds and accessories—can receive supplemental coverage; however, the coverage for such items varies across Canada. In most jurisdictions, patients able to pay are responsible for a portion of the cost of selected assistive devices. For those that cannot pay, the cost is absorbed by the provincial plan. For example, Alberta offers two income-based programs: the Alberta Aids to Daily Living (AADL) and the Dental Assistance for Seniors programs. The AADL offers financial

support to eligible Albertans with a long-term disability, chronic illness, or terminal illness for the purchase of medical equipment and supplies. The dental assistance program provides low- and moderate-income seniors with a maximum value for eligible dental procedures every 5 years.

Drug Plans Medications consume a huge portion of the health care dollars spent across Canada, second only to hospital spending. The immensity of this expenditure stems, in part, from the use of newer, more expensive drugs and an aging population with chronic diseases and multiple health problems, who are prescribed an astonishing array of medications. More detail about drug costing is discussed in Chapter 4. All provinces and territories across Canada offer publicly funded prescription drug programs (often called PharmaCare) to individuals on social assistance, anyone who must make payments that are disproportionate to their income, and Canadians over the age of 65. Nova Scotia and Quebec charge income-based premiums for the PharmaCare plan for seniors; New Brunswick, Quebec, and Alberta offer public PharmaCare plans to those under 65, and also charge income-based premiums. In Quebec enrolling in a drug plan is mandatory, thus all residents of the province have drug coverage. As previously mentioned, Ontario introduced coverage for those under the age of 25 in 2017. In 2018 the Ontario government places some restrictions on this program affecting individuals with private coverage (Clement, Soril, Emery, et al., 2016). As discussed previously, an estimated 60–70% of working Canadians have some type private or employer-sponsored insurance plans with drug benefits. However, many jobs available now are contract positions; in addition, a number of younger Canadians are changing jobs more frequently than in the past. These trends mean that the security of having employer-subsidized benefits are limited or nonexistent, leaving more Canadians in the position of having to buy private health insurance—or rely on the public system. Most private drug plans are fairly comprehensive, but public plans insure only certain medications. Both publicly funded drug benefit packages (discussed later) and private insurance plans have copayments or deductibles (usually percentage based) that beneficiaries pay, depending on their income and drug costs. Private insurance plans also require beneficiaries to pay dispensing fees themselves. For individuals on a public drug plan, the dispensing fee is either calculated as a percentage of the prescription cost or set at a flat rate, depending on the plan. To qualify for provincial or territorial drug benefits, an individual must first apply for assistance. Primary care providers and sometimes pharmacists can assist an individual to navigate their way to the

appropriate organization where they can get more information and/or fill out an application. Most provinces/territories also provide that information online. As a rule, jurisdictions require the family or individual to pay a predetermined deductible for prescription drugs. Once the deductible is reached, the public plan will pay a percentage of the beneficiary’s eligible drug costs. Some jurisdictions also set a maximum amount, or a “cap” that the family or person must pay, after which point, the plan will cover 100% of the drug costs. Some plans (both private and public) will cover only drugs prescribed from a formulary list. Formulary lists, although they include hundreds of drugs, are limited, containing for the most part, cheaper, generic versions of common drugs. Some brand-name drugs may be covered, but only if there is not a less expensive alternative. Combination drugs and time release drugs for example, are more expensive. Most “lifestyle drugs” are not covered such as drugs used for erectile dysfunction (e.g., Viagra), drugs to treat obesity, to prevent hair loss, and also cosmetic drugs (e.g., Botox). Some antibiotics (e.g., Avelox) and inhalers used for asthma (e.g., Symbicort) are excluded. The general thought is there are cheaper drugs available that will be effective. However, most plans will cover a nonformulary drug if the generic drug does not produce the desired therapeutic effect or causes adverse effects (Case Example 3.10). Providers prescribing the drug must seek approval to prescribe a nonformulary drug. Nonformulary drugs also are likely to include high-cost drugs or drugs with a high potential for misuse. Many private insurance plans offer an “open access” plan that will insure all prescription medications approved by Health Canada that are prescribed on an outpatient basis. Drugs are constantly being added to the formulary list, including, rivaroxaban (Xarelto) and dabigatran (Pradaxa), which are new-generation drugs used to reduce clotting times. Unlike previously preferred anticoagulants, these drugs do not require routine laboratory monitoring.

  Case Example 3.10 Quang Wong is receiving assistance through PharmaCare because he does not yet have a job. He has developed an irregular heartbeat, and his doctor put him on Aspirin for its anticoagulant effects. Within days, Quang developed a pain in his stomach and other gastrointestinal (GI) symptoms. The doctor decides that the Aspirin is causing the GI upset and wants to switch Quang to clopidogrel bisulfate (Plavix)—another

drug to prevent clots. This drug is on a limited use list (LU) on the Nova Scotia drug formulary list. The doctor fills 006Fut, a special request form, so that PharaCare will cover the drug. He must note the drug identification number (DIN) and explain the situation. Each formulary includes a limited use (LU) list, which lists drugs deemed unsuitable or too expensive to be on the formulary list. These drugs may, however, have therapeutic benefits in special circumstances— for example, an antibiotic that can treat resistant bacteria. Some drugs are not on either the formulary or the LU list. The prescribing provider must seek special permission to have these drugs covered by a publicly funded drug benefit plan. Some biologics that are used to treat inflammatory diseases (e.g., inflammatory bowel disease and rheumatoid arthritis) require special permission. In 2016, ten provinces spent a staggering $8.8 billion on therapeutic drugs. Drugs used to treat the following conditions (in no particular order) were the costliest: cancer treatment (neoplastic agents), antineovascularization drugs (e.g., for the wet form of macular degeneration), antiinflammatory drugs, antivirals (for hepatitis C), and protein pump inhibitors (for gastric problems).

  Thinking it Through A growing number of Canadians cannot afford the out-of-pocket cost of some prescription drugs—many choosing not to fill prescriptions. Some biologics and chemotherapeutic agents for example, may not be covered by public or private insurance. Note that what drugs are covered varies with each jurisdiction. Drugs for some individuals cost up $100 000 per year for one person, and the person may be required to take the medication for the rest of his or her life. All jurisdictions are already cutting back on services resulting in long wait times for access to providers, diagnostic tests, and surgery. 1. Do you think the public system should cover the cost of drugs, including those that are extremely costly? 2. What provisions are available in your jurisdiction to assist individuals with catastrophic drug expenses? Are there individuals excluded from provincial/territorial assistance? 3. Would you agree to a national drug plan if such a plan meant longer waits and limited access to other services for all Canadians?

Summary 3.1 The Canada Health Act oversees 13 separate health insurance programs—one for each province and territory. Adherence to the principles and conditions of the Canada Health Act binds the provinces and territories to a set of predetermined obligations for health care delivery. Otherwise, each jurisdiction is free to deliver and pay for services deemed appropriate (e.g., assistive devices, long-term care). 3.2 Jurisdictions delivering health care through regional health organizations/authorities do so using a decentralized framework. RHAs assess the type and mix of services appropriate for a geographic area and support services that meet the needs of that region (e.g., the region may have an older population and need more long-term care and community services; another may need more primary care services). Some jurisdictions (Saskatchewan and the Northwest Territories) have moved towards a single health authority to save money and reduce the “red tape” associated with regionalization. 3.3 Payment for health care services is provided in part by the Federal Government. The largest cash transfer is the Canada Health transfer. A blend of taxes at the provincial and territorial level makes up the rest. Two provinces (British Columbia and Ontario) require their residents to pay health care premiums. Volunteer organizations across the country contribute significantly to covering the cost of some services and equipment. 3.4 All those eligible for health care in each jurisdiction receive hospital and medical care deemed medically necessary. Dental care is included only if it is dental surgery done in a hospital (then regarded as medically necessary surgery). Health care that is medically necessary is somewhat subjective, although most insured services are similar across Canada. For newcomers to Canada and individuals moving from one jurisdiction to another, wait times (usually no more than 3 months) or other criteria apply. 3.5 Spending on medications is second only to hospital expenditures. All jurisdictions have a drug plan for individuals who meet specified criteria—for example, those receiving financial assistance, those with drug costs disproportionate to their income, disabled

persons, and older adults. Almost everyone, including those with private drug insurance, must pay a deductible for prescribed medications.

Review questions 1. How would you respond if someone asked you if Canada had a national health care plan? 2. What are the differences among primary, secondary, tertiary, and quaternary care? Give an example of each. a. Identify a secondary, tertiary, and a quaternary care facility in your region. 3. What were the four common objectives for adopting a regionalized approach to health care? a. Why are some jurisdictions moving back to a central health authority framework? b. Does your province or territory use a regionalized approach to health care delivery, or does it have a single health authority? Is the adopted approach effective? Why or why not? 4. What happens if a primary care provider prescribes a medication for a patient on a subsidized provincial/territorial drug plan and that drug is not listed on the provincial/territorial formulary of available drugs? 5. Does charging health care premiums contravene the principles of the Canada Health Act? Why or why not? 6. What is the purpose of the 3-month wait period in most provinces before a person can become eligible for health care, and who is exempt? Explain your answer. 7. What is the purpose of the reciprocal agreement and how does it benefit Canadians? 8. What types of private health care are available in your jurisdiction? a. Are their policies and procedures compliant with the principles of the Canada Health Act? b. Do you feel that a “two-tiered” health care system could work in Canada without compromising our universal health care plan? What would be the benefits and drawbacks? 9. Assume two new families have arrived in your community from another country, both granted the status of permanent residents. One family is sponsored by a private group, the other by the Government of Canada. Outline the steps each family will have to

take to obtain health insurance and find a family doctor. What other challenges might these families face? What resources are available in your community to assist the family that is government sponsored? Consider language barriers, transportation, supplemental health care (if required), and cultural sensitivities.

References CBC/Radio-Canada. (2019). Interview on Metro Morning with Ontario Health Minister Christine Elliott. Retrieved from https://www.cbc.ca/news/canada/toronto/ontariohealth-minister-legislation-super-agency-jobs-agencyconsolidation-1.5035203 and https://www.cbc.ca/news/canada/toronto/doug-fordontario-health-super-agency-lhin-cancer-care-1.5032830. Clement F., Soril L., Emery H., et al. Canadian publicly funded drug plans, expenditures, and an overview of patient impacts. Retrieved from www.health.alberta.ca/documents/Health-SpendingPubliclyFundedDrugPlans-2016.pdf. 2016. Health Shared Services Saskatchewan (3sHealth). Corporate profile. Retrieved from www.3shealth.ca/about3shealth/corporate-profile. 2014. Husni S., Khan Z., MacMillan R., et al. Canada should not allow two-tiered practicing for medically-necessary services [web log comment]. Retrieved from https://www.ivey.uwo.ca/healthinnovation/blog/2017/ 7/canada-should-not-allow-two-tiered-practicing-formedically-necessary-services/. 2017. Ontario Ministry of Finance. Ontario health premium. Retrieved from http://www.fin.gov.on.ca/en/tax/healthpremium/. 2014. Normandin Beaudry. Health insurance premiums and tax. Retrieved from http://www.normandinbeaudry.ca/userfiles/file/Aide-memoire2012_Quickfacts_2012_EN.pdf. 2012. Yukon Health and Social Services. Yukon Health Status Report 2015: Focus on Substance Use. Retrieved from

www.hss.gov.yk.ca/pdf/health_status_report_2015.pdf. 2015.

4

The Dollars and “Sense” of Health Care Funding LEARNING OUTCOMES 4.1 Explain the role of for-profit and not-for-profit organizations in the delivery of health care. 4.2 Outline the levels and mechanisms of health care funding in Canada. 4.3 Examine how hospitals are funded and identify their major expenses. 4.4 Discuss the funding challenges facing home and continuing care in Canada. 4.5 Describe the reasons for, and the effect of, rising drug costs in Canada. 4.6 Discuss health expenditures related to human health resources in health care. 4.7 Summarize the cost of advancing technology to the health care system.

KEY TERMS Active ingredients Alternate level of care (ALC) Capitation-based funding Laparoscopic surgery Nonprofit organization (NPO)

Positron emission tomography (PET) scanner Publicly funded health care Rationalization of services Renal dialysis Residential care Before you begin reading this chapter, write down—even if it is just a guess—what you think Canada spends on health care in one year and how much you think a visit to your family doctor for an intermediate assessment (e.g., for an earache, a sore throat, or a cold) might cost. Next, write down how much you think a knee replacement, a hip replacement, and an appendectomy might cost. Keep these numbers handy to compare with the figures you will see later in the chapter for the true costs of these services. Can you imagine going to the doctor for an ear infection and having the administrative assistant ask for cash or a credit card to pay for the visit? Or a parent, aunt, or uncle having cardiac bypass surgery or a hip replacement and being sent an invoice? Remember that, in addition to these procedures, the patient would need a preoperative physical examination, blood work, and perhaps an X-ray, magnetic resonance imaging (MRI), an arteriogram, or a computed tomography (CT) scan. He or she would have to pay for the hospital stay, tests, nursing care, and supportive care (e.g., physiotherapy, respiratory therapy)—and would even be charged for the use of the equipment to remove the sutures and the bandages covering the wound. What would you do if you needed such a procedure and knew it would cost you thousands of dollars? Many Canadians feel fortunate to have insured services. When they are sick, they seek care, present their health card, and ultimately receive the medical attention they need. If their case proves urgent, the appropriate care is almost always provided within a reasonable time frame. Most of the time, they do not pay for their care. Many Canadians believe that health care is free, perceived because they do not have to pay at the point of service, at the end of the month, or when discharged from a hospital. The reality is that Canadians do pay for their publicly funded health care services. The money comes from the taxes they pay to all levels of government. Residents of Ontario, Alberta, and British Columbia also pay health care premiums (see Chapter 3).

In 2017, an estimated $242 billion was spent on health care, representing 11.5% of the country’s gross domestic product (GDP). That is an average cost of about $6604 for each Canadian (Canadian Institute for Health Information, 2017a). This chapter examines the actual costs of health care and how health care is funded. The numerous statistics and dollar values presented are approximate, because costs change yearly, monthly, and sometimes even daily.

Funding versus the delivery of health care The funding and delivery of Canada’s health care is accomplished through a mix of public and private—both for-profit and nonprofit—businesses and organizations. Funding refers to how health care is paid for, and delivery refers to how health care services are managed, structured, and distributed. In Canada, all medically necessary services are publicly funded, but for the most part, are delivered by either private for-profit or private not-forprofit businesses or organizations. For example, physicians (unless salaried) operate as private for-profit businesses. They deliver health care services and are paid, using varying payment formulas, by the government. Physicians in private practice pay for their own business expenses, including office space and supplies, in addition to staff salaries. Although hospitals are primarily private, not-for-profit organizations, the majority of services in a hospital—food and meal preparation, maintenance, cleaning, security, and laundry—are delivered by private, for-profit businesses. The hospital negotiates for cost-effective services and pays for them out of the funds allotted them by the government. The majority of laboratory and diagnostic services are other examples of private, for-profit services. Some nonessential services within a hospital— for example, a semiprivate or private room, television, or telephone—must be paid for directly by the patient or by a third party, such as through private insurance. Patients can also pay for medical enhancements, such as a fibreglass cast, instead of getting the publicly funded plaster cast. A patient must also pay for any services or treatment not deemed medically necessary—from an MRI scan, to knee or cataract surgery. Any cosmetic surgery not deemed medically necessary is not covered by insurance (either public or private).

Levels of health care funding Canada’s public health insurance is funded, for the most part, by the federal, provincial, territorial, and municipal governments through a blend of personal and corporate taxes, and by workers’ compensation boards. Some provinces also use revenue from sales taxes and lotteries for health care. At the community level, many volunteer organizations (e.g., hospital auxiliaries, service clubs) also raise money for local hospitals to support such initiatives as expansion, updating the facilities, and purchasing new equipment. Often the provincial, territorial, or municipal governments will match funds raised or a portion thereof. A portion of health care is funded privately, through households and private insurance. The Canadian Institute for Health Information (CIHI, 2015) estimates that 30% of health care spending comes out of consumers’ pockets or from private insurance, whereas the remaining 70% is covered by public health plans (CIHI, 2017b).

Federal Health Transfer Payments In 2012, the Government of Canada, through the Canada Health Transfer (CHT), paid approximately $27.2 billion for health programs, representing 10 cents of each tax dollar spent and approximately 20% of total health expenditures (Matier, 2012). The government claims this figure will reach $38 billion by 2018 (Government of Canada, 2011b). The exact dollar figure that the federal government transfers to the provinces and territories is almost impossible to calculate, and the amounts given are continually debated among the jurisdictions. With the Federal Government’s 2014 funding formula (the 2004 Health Accord renegotiation, discussed in Chapter 1), which ties federal transfers, to the provinces and territories, to the gross domestic product (GDP), the transfer totals will be even more challenging to determine. The government claims the revised formula will bring the Federal Government’s share of health care spending to historic lows, warning that provinces and territories must curb spending and find ways to save money. Provinces and territories have implemented a number of cost-saving strategies, including one called Lean (discussed in Chapter 10). Lean operates on the principle of finding more efficient ways to deliver all levels of health care by eliminating wasteful practices. To date, efficiencies have been found by merging some services, cutting others, and requiring Canadians to pay for services

formerly covered by their provincial or territorial plan. Each jurisdiction manages how it spends—and saves—health care dollars. The exact amount of money spent on health care at the provincial and territorial level is also difficult to determine because of the complexity of the various formulas used to calculate the Federal Government’s transfer payments to each jurisdiction, which are made in the form of both cash and tax points (see Chapter 1). Federal health transfer payment amounts are calculated using a complex formula and are distributed through the following four main transfer models: Canada Health Transfer. The CHT is the largest annual cash transfer of funds from the Federal Government to the provinces and territories. Based on the new funding formula as discussed in Chapter 1, the amount paid to provinces and territories is tied to the GDP, but is guaranteed not to fall below 3% of the GDP. Provinces and territories must be in compliance with the terms and the conditions of the Canada Health Act to receive full funding. Extra billing, for example, is not allowed. Money is held back dollar for dollar if providers charge patients for services paid for under provincial/territorial insurance plans. Provinces and territories are seeking a change to this formula: in addition to a base payment, they would like to see a blended formula that includes additional funding to reflect the unique population growth of each jurisdiction (e.g., more older Canadians, and variations in the incidence of disease) (Government of Canada, 2011c). Canada Social Transfer. The Canada Social Transfer (CST) provides funding to the provinces and territories through a two-part payment formula, cash and tax points targeted for social programs, child care, early childhood development and learning programs, and postsecondary education. The money must be applied to these designated areas. The CST will continue to increase at 3%/year until 2024 (Government of Canada, 2011a). Jurisdictions allot the monies as they see fit within the designated areas. Territorial Formula Financing. The Federal Government uses the Territorial Formula Financing (TFF) to calculate money given to the territorial governments for public services. This money—allotted to these jurisdictions because of their unique geography, population distribution, and related high cost of delivering health care and other public services— constitutes over 60% of the total monetary resources in the Yukon and the Northwest Territories and over 85% in Nunavut. Funding is provided by the Federal Government through taxes paid by Canadians across the country. In 2018–2019, provinces and territories will receive $75.4 billion through major transfers (Government of Canada, 2017). Recent

adjustments to the formula have resulted in more revenue for the territories. For example, the territories received an additional $67 million in TFF payments in the 2016–2017 fiscal year, with higher payments for an additional five years. Moreover, continued dialogue between federal and territorial governments are examining the improvements and/or adjustments that need to be considered when the current legislation expires and is renewed in 2020. In 2018–2019 TFF payments to the territories (in millions of dollars) were: $2037 for the Yukon, $1579 for Nunavut, and $1256 for the Northwest Territories (NWT). The TFF payments are in place of the equalization payments (discussed below) and are calculated by a different formula. Equalization payments. Some provinces have more money than others and thus can provide more public services to their residents. Provinces and territories with less money receive equalization payments from the Federal Government to allow them to offer their residents services similar to those available in jurisdictions with more money. The concept of equalization payments was established in the Constitution in 1982 (Box 4.1).

  Box 4.1

Equalization Payments Embedded in the Canadian Constitution. Parliament and the Government of Canada are committed to the principle of making equalization payments to ensure that provincial governments have sufficient revenues to provide reasonably comparable levels of public services at reasonably comparable levels of taxation. Source: Constitution Act, 1982, being Schedule B to the Canada Act 1982 (UK), ss. 36(2). A needy jurisdiction will receive the difference between its fiscal capacity (i.e., its ability to generate income) and the 10-province standard (i.e., the national average). Without equalization payments, these provinces and territories would have to raise their taxes significantly to generate revenue. In 2018–2019 equalization payments to these provinces (in millions of dollars) were: New Brunswick $1874, Prince Edward Island $419, Nova Scotia $1933, Ontario $963, Quebec $11,732, and Manitoba $2037. BC, Alberta, Saskatchewan, and Newfoundland and Labrador did not receive

equalization payments. The provinces and territories are free to determine how they will spend their equalization payments; many use this money, at least in part, for health care.

Negotiating Funds: Health Accords Health care funding is the focus of ongoing bargaining between the provinces, territories, and federal government. Needs are studied and analyzed, proposals are made, and agreements, often referred to as accords, are signed. The latest accord was negotiated in 2016 under the Trudeau government. Changes to the CHT (discussed above) provided additional funding in excess of $11 billion dollars over a specified time frame, and resulted in separate agreements negotiated and signed with each province and territory regarding funds they were given and over what time frame. As mentioned previously, the Federal Government dictated that these funds must be used in the areas of home care and mental health. The provinces and territories decide how these funds are to be distributed within those areas.

Federal Government Costs for Direct Health Care As discussed in Chapter 2, under the Canadian Constitution, the Federal Government is responsible for direct health care services for most of the Indigenous population, serving Canadian Forces personnel, inmates in federal prisons, and specified groups of refugee claimants. In 2016, the Federal Government spent an estimated $6 billion on direct health care services down from an estimated $6.38 billion in 2013. The federal departments that have the highest direct health expenditures are Health Canada, followed by the Department of Veterans Affairs, Solicitor General of Canada, and the Department of National Defence (CIHI, 2017a, 2017b).

Provincial and Territorial Costs for Direct Health Care Provinces and territories spent $144.3 billion on direct health care in 2015, up from $134 billion in 2012, and $138.3 billion in 2013 (CIHI, 2017a). A number of factors influence the per capita spending among the provinces and territories, including the services paid for by the public plan (i.e., what is considered medically necessary), the type and extent of social programs, the mix of health care providers delivering health care, the

relative age of the population (e.g., community and home care programs), the number of individuals in publicly funded health care facilities (e.g., long-term care), and the population density versus geographic profile of the jurisdiction. Note in Table 4.1 that per capita health spending in the Northwest Territories, Yukon, and especially Nunavut is considerably higher than in other jurisdictions. These regions have a lower population base, but their large geographic area and distance between communities make the delivery of health care more complicated and more expensive. For example, population health initiatives, such as doing routine screening for colon and breast cancer and educating people on disease prevention, are more difficult, as is managing diagnosed chronic health problems.

Table 4.1 Provincial and Territorial Health Spending per Capita: 2017 (Estimated).

Source: Canadian Institute for Health Information. (2017). Appendix A: Health expenditure data in brief: Total health expenditure per capita. In National health expenditure trends, 1975–2017 (pp. 33–34). Retrieved from https://www.cihi.ca/sites/default/files/document/nhex2017-trendsreport-en.pdf.

Trends in Health Care Spending Canada’s total health care spending was an estimated $242 billion in 2017 representing about 11.5% of the country’s GDP. Although the GDP continues to rise, health spending per capita decreased by an average of 0.2%/year between 2010 and 2014. This reduction in health care spending is related to a more measured economic growth, and financial constraints imposed by the government in health care and other sectors. The split between public and private spending on health care has remained relatively consistent over the last decade with a 70%/30% split between

the public and private sectors. In 2017, public contributions accounted for the predictable 70% of health expenditures (65% from the provincial and territorial governments and 5% from other parts of the public sector).

The Cost of Poor Health We often think that the cost of poor health relates only to the amount Canada pays directly for health care in terms of treatments and services— nurses’ salaries, doctor visits, surgery, rehabilitation, long-term care. However, indirect costs of illness, injury, and premature mortality (e.g., loss of productivity and earnings while workers are incapacitated because of a disability or illness) is staggering for the general Canadian economy, and individuals. It is not a surprise that governments at all levels want to find ways to reduce health care costs while still providing high-quality health care. Disease prevention and health promotion, early diagnosis, and prompt intervention are deemed some of the most effective approaches to achieve this goal. Financial investments in such initiatives (e.g., focusing on primary care models that educate individuals about a healthy lifestyle, reducing the incidence of diabetes, heart disease, and obesity) are believed to be effective upstream strategies with long-term cost-saving benefits. The social determinants of health directly and indirectly affect the physical and mental health of Canadians, the economy, and the health care system both in terms of resource utilization and expenditures. As discussed in Chapter 7 these determinants include a person’s socioeconomic status, their level of education (which impacts the type of employment they have), where they live and living conditions, employment circumstances (income level, job satisfaction including worklife balance), and their social support network (particularly in times of high stress and adversity). Addressing social determinants of health is important for improving health and reducing longstanding disparities in health and health care. Each of these entities affect both the physical, mental, and emotional wellness of a person. A study published by the Canadian Medical Association supports a strategy of spending less on direct health care and more on social programs that address inequities related to the social determinants of health. The study concluded that this strategy would, in essence, equate to treating the root causes of disease and illness, but would be far more effective both in terms of the health of Canadians and the cost (Dutton, Forest, Kneebone, & Zwicker, 2018).

  Thinking it Through The seasonal flu vaccine and childhood vaccinations are examples of strategies that are believed to have contributed greatly to saving lives and reducing both direct and indirect health care costs. However, in early 2014 there was a resurgence of measles among children who had not been vaccinated against the disease. 1. How do you think vaccinations contribute to a reduction in indirect health care cost? 2. What effect, if any, do you think a resurgence of measles, if not contained, will have on both direct and indirect health care costs?

Expenditures for hospitals As mentioned previously, most Canadian hospitals are not-for-profit facilities. Community-based not-for-profit corporations, religious organizations, and sometimes universities or municipal governments “own” and run these facilities. The province or territory is the main source of revenue for hospitals. Hospitals are, by far, the leading health care expenditure in Canada, as is evident in Fig. 4.1.

FIG. 4.1 Total Health Expenditure per Capita by Use of Funds, Canada, 2017 (Dollars and Percentage Share). (Canadian Institute for Health Information. [2017]. National health expenditure trends, 1975–2017 [Figure 10], p. 18. Retrieved from https://secure.cihi.ca/free_products/nhex2017trends-report-en.pdf.)

Many different types of health care facilities exist, including general and acute care facilities, nursing homes, chronic care facilities, rehabilitation centres, and psychiatric hospitals. All are publicly funded, in part or in whole. Some hospitals treat certain conditions (e.g., Princess Margaret Hospital in Toronto specializes in cancer treatment), or specific age groups (e.g., Vancouver’s B.C. Children’s Hospital). Other facilities (e.g., long-

term care facilities) may be covered only in part by provincial or territorial insurance, in which case, patients pay a portion of the services they use. Psychiatric hospitals, and also the services of psychiatrists, are fully covered in all provinces. Problems that have faced hospitals, communities, and individuals over the past few years include cuts to services, reductions in hospital beds, closures or merging of hospitals, rationalization of services (i.e., improving efficiency by relegating certain types of care to one facility—pediatrics, for example), insufficient and demoralized staff, and long wait lists for surgery, related tests, and admission to hospitals. The following sections will examine how hospitals are funded, how they operate, why operational costs are high, and what is being done to lower costs.

Hospital Funding Mechanisms The provincial or territorial ministry, or department of health, provides the majority of funds to hospitals to deliver services to the community. The hospital is then expected to operate as a business, ending the fiscal year with a balanced budget. In all jurisdictions, hospitals are accountable for their operational plan, and how they manage their funding allotment. To whom they are accountable may vary, but it is usually to a ministry of health, or a central or local health authority. Much like any business arrangement, hospitals sign agreements outlining target goals, and financial and performance outcomes. The specific terms and conditions under which this money is allotted depend on the funding model that guides a hospital’s function. As previously mentioned, in all jurisdictions the government is the largest source of funding, with monies flowing from the provincial/territorial ministry of health (or federally in the territories), either through a provincial/territorial health authority or through local regional authorities as approved by provincial/territorial budgets. On average, this funding covers anywhere from 85 to 100% of the costs of operating hospitals, with additional revenue obtained from such sources as parking, cafeterias, and additional federal revenue including services rendered to veterans (covered by the Federal Government). Funds are also raised by community organizations (especially for specific expenditures such as a new wing or diagnostic equipment), grants, donations, and charitable giving. Many hospitals also operate in a 2P platform—a public/private partnership where required services are provided by a third party based on a revenue sharing agreement.

There are numerous funding models used to determine the amount of money the government provides to a hospital. Almost without exception, the bottom line is how efficiently a facility operates both in terms of cost effectiveness and the provision of quality care using best practices guidelines. The more efficiently a hospital operates, the more funds it usually receives. For example, a given hospital may be allotted a certain amount of money for 100 hip replacements within a certain time frame. If the hospital achieves the set goal (under budget), the government seeing that the hospital is performing efficiently, may provide the hospital with additional funds to do more joint surgeries. Governments will also compare hospitals offering similar services, and address concerns if one emergency department (ED), for example, is spending less than another, which may identify both efficiencies and inefficiencies relative to patient volume in how the ED is managed. The eight funding models more commonly used across the country are outlined below. It is worth noting that most hospitals use a blend of two or more of these payment mechanisms. You will notice that some of these funding models have very similar criteria. 1. Block or global funding model. A hospital’s funding amount is determined by its previous year’s expenditures and an annual lump sum of money is provided based on that analysis. The block funding model can be problematic as there is no consideration of the population the hospital serves, or their specific health care needs. In addition, there is no incentive for a hospital to provide high quality care using a best practices approach. This model does, however, encourage administrators to implement protocols to discharge patients early to either homecare or other facilities in an effort to control costs. Block funding is still relatively prevalent across Canada. 2. Health-based allocation model. The amount of money given to a hospital is based on its expected expenses determined by examining the demographic profile of a given community, and the facility’s clinical history including the mix of services and complexity of care. 3. Line-by-line funding model. Still popular in British Columbia and New Brunswick, this model itemizes the costs of specific services and equipment within a hospital, referred to as line items or inputs, and provides funds to the hospital for each service.

4. Quality-based procedures model. This model is more focused on the number of patients treated, and the procedures performed considering efficiency and a “best practices” approach to each procedure. 5. Patient-based funding model. This model, introduced in Ontario in 2012, is primarily used in larger hospitals. Monetary incentives are provided to the hospital (by reaching targeted goals) to maximize the quality of care delivered in the most cost-effective manner. Also considered are the needs of the population within the geographic region of the hospital (e.g., specialty services required). 6. Service-based funding (also called the case-mix approach). This model identifies the types of cases treated, and the volume of patients seen to facilitate an analysis of expenditure needs. Patients who have similar types of medical problems and undergo similar treatments are grouped using a formula, the cost of their treatments and services is estimated, and the amount of funding the hospital receives relates to how many patients it treats requiring each combination of services. Typically, this model provides funding in the form of a global budget (discussed above). Many hospitals adopting this funding approach also use line-by-line funding. For example, a hospital would receive money to complete a designated number of hip or knee replacements. 7. Activity-based funding. This model pays hospitals in accordance with the number and types of services the facility provides to each patient. The goal of this model is to make the facility more efficient and reduce wait times. Implemented first in Ontario, the model was used to reduce wait times for selected services such as cataract surgery, cardiac bypass surgery, and joint replacement. Alberta implemented activity-based funding in 2010 for selected services, and British Columbia has dramatically reduced wait times for selected services (e.g., shoulder surgery, MRIs, and emergency care) in facilities where this model has been applied. It is also used to some extent in New Brunswick and Quebec. 8. Population-based funding model (sometimes called capitated funding). Used by Alberta and Saskatchewan for several years, this model grants hospitals money based on demographics (e.g., patients’ ages, gender, socioeconomic status). In all, more than 100 different individual prototypes exist based on these criteria, with varying amounts awarded depending on location and on how many

patients fall into certain categories. For example, a hospital in an area with a large population of older adults may receive more funding than one with a mainly younger population. Hospitals catering to patients in a lower socioeconomic group (requiring more health care services) receive increased funding. The hospital’s size and location, in addition to the services it offers, are also considered.

Requirements for Funding Every hospital must be accountable for the funds it requests. After completing its budget, the hospital assesses its financial needs, prepares documentation, and negotiates with the minister of health for appropriate funding. To facilitate these activities, the hospital must track the expenses of all departments and services. At the end of the fiscal year, a hospital must report on its financial status —whether it is in the black (i.e., posting a surplus) or in the red (i.e., posting a deficit). A hospital in the red must look for ways either to reduce costs or to be approved for extra funding—not an easy feat. It must critically examine the services it offers and the cost of each and determine where cuts can be made. A hospital may have to reduce services and staff, close beds, and/or decrease operating time to keep within its budget. Under certain circumstances, the ministry or department of health may grant extra money to hospitals with budget shortfalls.

  Thinking it Through Not realizing that they pay for health care services with their tax dollars, many Canadians believe health care is free, leading to misuse and abuse of the system. 1. If people were given a receipt showing the cost of each doctor’s visit, hospital stay, and services received, do you think they might use health care services more prudently? 2. Do you think that lack of awareness of the costs of services contributes to the attitude that health care is free? 3. Two provinces require health care premiums for services. Do you think these extra charges void the concept that health care is free?

The Cost of Hospital Care Hospitals offer diagnostic tests, treatment, and both inpatient and outpatient (also referred to as ambulatory) care. Patients admitted to hospital usually have serious illnesses and diseases in an acute phase, which cannot be managed outside of the hospital setting. In outpatient or ambulatory care, patients are admitted to hospital, but not for an overnight stay. These visits can include diagnostic services, clinic care, outpatient surgery, and emergency department visits. Many services will include a physician’s services and/or a consultation (usually with a specialist), but these costs are usually counted separately from the hospital component of care. In 2016, the total amount of money (public) spent on the hospital sector was an estimated $65 billion. This represents the largest financial output of any other health care spending category, with the cost of patient care being among the highest cost drivers (CIHI, 2018b). As a result, hospitals are under significant pressure to operate as efficiently and cost effectively as possible—not an easy task. It can also generate concern among Canadians, especially when they experience wait times, and in many cases, actual or perceived deficiencies in care, but are unaware of the financial parameters that a hospital must function within.

Factors That Affect Hospital Costs Numerous factors affect the costs of operating a hospital, including its size and location. Smaller hospitals in rural locations often incur more expenses (about 10% more) than larger facilities; teaching hospitals have more expenses (about 18% more than nonteaching and smaller hospitals); hospitals with rehabilitation facilities on site, on the other hand, see a cost reduction of approximately 3% over those that do not. Another factor is the cost of wages related to the cost of living in the region, and collective bargaining goals achieved by hospital unions. Interestingly, hospitals within jurisdictions that operate under regionalized health systems typically have lower administrative costs. The mix of inpatient and outpatient admissions and related procedures also affects expenditures (CIHI, 2017b).

Costing Details In 2015, the average cost of a hospital stay ranged from approximately $8000 in the Yukon Territory and Alberta, just over $6000 in British Columbia and Nova Scotia, to a low of $5300 in Ontario and New

Brunswick. This averages to a cost per hospital stay of about $1871 per person. The average costs are affected by the cost variables mentioned above and the hospital’s specialty. The largest cost drivers are hospital salaries (excluding physicians’ services), which comprise about 72% of total costs, and drugs comprising 16.4% of total costs (CIHI, 2017e). Physicians’ services are excluded from hospital-based salaries because they are typically paid directly by provincial/territorial medical plans. There are some exceptions, for example physicians hired by a hospital and who are paid a salary (either full time or on contract) for specific services. However, when overall hospital expenses paid by public plans are calculated, physicians’ services account for about 13.4% of the total annual estimated amount. In 2015, Canadians spent almost $65 billion on the hospital sector—the largest amount spent in any health category. When grouped by general categories, the most expensive hospitalizations were for cardiovascular conditions (of interest, a heart/lung transplant is currently the most expensive at $119,989), followed by mental health disorders, diseases of the digestive system, and then diseases of the respiratory system. However, when broken down by diagnosis, diseases of the respiratory system (i.e., COPD, followed by pneumonia) impose the greatest cost to hospitals. Hip and knee replacements were the costliest in terms of hospitalization for interventions, although this is changing (CIHI, 2015). A new technique, called the anterior approach to hip replacement surgery, is less invasive, and is done as day surgery. There are fewer muscles at the front of the hip, so instead of cutting through them, the surgeon separates them reducing trauma, and recovery time. Pregnancy and childbirth, the leading cause of hospital admissions for women of childbearing age, cost $1000 per person on average, although the cost varies with the nature of the delivery—an uncomplicated vaginal delivery costs just under $828, whereas a Caesarean section costs $1270 (CIHI, 2014). The majority of Canadians remain unaware of how much the government pays for various procedures. Table 4.2 provides a list of the costs of some of the more common procedures and conditions for which individuals are admitted to hospital. Imagine having to pay to have a baby, and then your two-year-old needing admission to the hospital for croup, and your dependent father needing a hip replacement due to a fall. How would you handle the costs if you had to pay out of pocket?

Table 4.2 National Average Cost of Procedures and Conditions for Inpatients of All Age Groups, Based on the Average Total Length of Stay, 2014–2015.

Lung or heart transplant

Average Cost per Hospitalization for All Age Groupsa ($) 119 989

Liver/pancreas, duodenum transplant

60 502

26.4

Heart valve replacement

27 473

9.26

Colostomy/enterostomy

22 400

13.9

Hip replacement (one hip)

8 656

3.5

Palliative care

8 919

10

Knee replacement (one knee)

7 635

2.8

Open cholecystectomy

10 537

7.2

Heart failure with coronary angiogram

12 083

9.33

Hysterectomy (diagnosis of cancer)

7 375

3.2

Depressive episode

6 502

10

Stroke

6 712

6

Chronic obstructive pulmonary disease

7 275

4.8

Chemotherapy/radiotherapy/admission 5 438 for neoplasm Hysterectomy (no diagnosis of cancer) 4 984

4.3

Caesarean section (no induction)

4 133

3.1

Diabetes

5 016

4.6

Laparoscopic cholecystectomy (gallbladder removal) Influenza/acute upper respiratory infection Appendectomy (simple)

4 360

4.1

4 101

3.1

3 255

1.7

Symptom of digestive system

3 107

2.8

Croup

1 605

1.76

Procedure/Condition

Average Total Length of Stay (days)b 37.2

2.5

a

Costs exclude physicians’ fees for procedures or in-hospital visits; physicians bill the jurisdiction for services rendered. b

This data is not produced by Canadian Institute for Health Information.

Source: Canadian Institute for Health Information. (2015). Patient cost estimator. Retrieved from https://www.cihi.ca/en/patient-cost-estimator.

Administrative and support services are calculated as part of the amount spent on salaries. This includes administrative expenses, such as human resources (e.g., clinical secretaries, admission clerks), information technology (e.g., communication, systems support), and finance. Support services include materials management, security, housekeeping, volunteer services, health records, registration, food services, and laundry. Registered nurses (RNs), licensed/registered practical nurses, nurses’ aides, orderlies, and personal support workers make up the nursing staff within health care facilities. As previously mentioned, nursing staff work in most departments that interact with inpatients or outpatients. In analyzing their costs, most hospitals calculate the cost of nursing services for inpatient care separately, although these expenditures must be included in the facilities’ overall costing allowance. Expenditures for other nursing staff may be accounted for in the costs of specialized departments (e.g., outpatient clinic, renal dialysis and chemotherapy units, cancer day treatments). Using the funds allotted to a hospital, various departments are expected to function within given parameters—even an individual nursing unit must be mindful of how much it spends on all costs, from communication tools to paper. Each unit also calculates the number of direct patient care hours required for direct nursing care. This is calculated using a workload or time-based costing formula and dictates the number and mix of nurses required by a patient care unit for a given time frame (usually a day). Other hospital departments, such as the operating room, for example, have specific expenses including costs for its use, supplies, instruments, and other equipment (e.g., devices implanted into a patient, such as an artificial hip), and staff with specialized skills (e.g., nurses with specialized training). Likewise, those managing an ED must do so with their budget in mind. Some EDs (also called emergency rooms [ERs]) employ nurse practitioners to see patients with less serious conditions to offset the costs of an employed emergentologist. Some hospitals restrict the hours of operation of their ED; others have closed their emergency departments altogether.

Cost-Reduction Strategies As mentioned, hospitals use a variety of methods to reduce their overall costs. The most commonly applied strategies include decreasing patients’ length of stay and rationalizing services.

Length of Stay The longer a patient stays in the hospital, the higher the cost, detracting from the hospital’s operational budget. Therefore decreasing the length of hospital stays is an important way to reduce costs and make beds available for new admissions. The province or territory determines the cost of an insured bed to a hospital (paid for out of the allotted budget) by estimating the services required by the person occupying the bed. For example, a patient in an acute care bed recovering from cardiac bypass surgery would be deemed more expensive than one recovering from an appendectomy. Interestingly, the use of semi-private and private rooms generates income for a hospital. More income is generated if a patient upgrades his or her accommodation from standard accommodation to semiprivate or private (Case Example 4.1).

  Case Example 4.1 Fraser Health in Vancouver for a knee replacement next week, would like to have semiprivate or private accommodation. Provincial health insurance which will only pay for standard accommodation. A semiprivate room (i.e., a room containing two beds) would cost approximately $165 more per person per day than a ward or standard bed, and a private room would cost a $195 per person per day. Based on a three day stay, a private room Margaretha (or her private insurance if she had it) would have to pay the hospital $585 and a semi–private room $495. The following strategies have helped to reduce the length of stays in hospitals across Canada.

Same-Day Admissions In the past, individuals scheduled for major surgery were admitted 1 or 2 days prior to their operation for tests and preop preparation, which consisted of a medical history, a physical, bowel cleansing, shave if needed, preoperative instruction, and nighttime sedation to ensure a sound sleep. Today, for many surgeries, this preparation is done on an outpatient basis. The family doctor typically performs the physical and takes a preoperative history a week or so prior. Tests, such as blood work and an

electrocardiogram, are done several days before the surgery. Pre- and postoperative instruction are given on an outpatient basis. The patient makes an appointment at the hospital, watches a video, and has an opportunity to have questions answered, usually by a surgical nurse or nurse educator. Any necessary preparation (e.g., not eating or drinking for eight hours before the operation) is done at home by the patient (shave preps are frequently omitted). On the morning of the surgery, the individual is admitted, preoperative information not already obtained is gathered, and the preoperative sedation, if any, is administered. Considering the large number of surgeries that take place within each province or territory each day, omitting one night in hospital for every patient results in a significant savings.

Day Surgery Because of technological advances in many fields, particularly in laparoscopic surgery, many surgeries are now done on an outpatient basis. For example, the routine removal of the gallbladder (called a cholecystectomy) once required a large abdominal incision, but now requires only a small incision using a laparoscope. The patient, admitted as an outpatient, goes home the same day. No matter what the procedure, a patient seldom remains in hospital longer than 2 or 3 days unless there are complications. Many other procedures are also performed as day surgery including cataract surgery, tubal ligations, hernia repairs, some gastrointestinal surgeries for cancer, and increasingly, knee and hip replacement surgery. However, some patients having designated day surgical procedure may encounter difficulties, which prolong his or her hospital stay, each hospital day adding to the cost.

Deliveries For women having babies, the shorter the stay, the lower the cost for the hospital. Most new mothers are discharged from hospital within 24 hours (some within four hours) of an uncomplicated delivery and within two days for a caesarian section. Deliveries of babies at home or in the hospital with midwives are less expensive than a hospital delivery.

Bed Management Efficient bed management is a priority for health care facilities across Canada because of chronic bed shortages, costs associated with prolonged

hospital stays, and inappropriate assignment of beds to patients. Bed management is sometimes called bed allocation management, patient access and flow, electronic bed management, or patient navigation. All terms refer to a system of policies and procedures used by hospitals to coordinate efforts that will facilitate patient access to the right care in the right place at the right time. These systems address the need for timely admission and discharge from an acute care hospital to the appropriate discharge destination. Bed management systems collaborate with home and community care and long-term care facilities to optimize efficiency.

Timely Discharge Even in the presence of effective bed management strategies, hospitals endeavor to discharge inpatients by 10:00 or 11:00 a.m. Depending on the policies of the jurisdiction, hospitals will be charged for an additional 24hour period if a patient is not discharged by a certain time, often noon. If a discharged patient cannot arrange to leave before the discharge time, the nurses will, if possible, have the patient vacate the bed and wait in a lounge so that the room can be cleaned and readied for an admission. Individuals undergoing day procedures are likewise kept until they are deemed stable, and then discharged.

Out-patient and Community Support Many patients can be managed on an outpatient basis including those taking chemotherapy for various types of cancer, and those on renal dialysis. Outpatient cancer treatments are made possible, in part, because of improved chemotherapy drugs and related management regimes, which result in fewer side effects, especially severe nausea and vomiting. Patients needing intravenous antibiotics used to be hospitalized; now they are also managed as outpatients. A patient can either return to the hospital when their antibiotic is scheduled to be given, or a nurse can come to his or her home to administer the medication. A device called a saline lock/PRN adaptor (or similar) is inserted into a vein in the patient’s arm, keeping a vein patent. Patients receiving chemotherapy have a more complicated device inserted that can remain in place for long periods of time and through which chemotherapeutic drugs are administered. Home care services provide nursing assessments and care, managing many of the medical needs of patients previously done in hospital, and on occasion, teach family members to do some procedures. Family members play a significant role in caring for individuals at home.

Tax Credits for Caregivers There is financial relief for individuals who care for infirmed family members in the form of nonrefundable tax credits. Prior to 2017 there were three categories under which individuals could apply for a nonrefundable tax credit when caring for family members at home—the infirm dependant credit, caregiver credit, and family caregiver credit. From 2017 onwards, these credit options were consolidated into the Canada Caregiver Credit (CCC). This credit can be claimed by a family member caring for a spouse or partner (common-law), minor, or a relative (who meets specific criteria) who, because of a mental or physical illness, is dependent upon the caregiver during that taxation year. The amount that can be claimed is predetermined, and adjusted based on the net income of the patient. All jurisdictions also have legislation in place allowing individuals leave to take care of ill family members. Terms vary among jurisdictions (Government of Canada, 2018).

Palliative Care Palliative care is provided to individuals with terminal illnesses. When people become too ill to be cared for at home, they may be admitted to hospital for palliative care including pain control, which cannot be met at home. However, many terminally ill people prefer to spend their remaining time at home. A visiting nurse and other community support services then provide the necessary care, supporting both the family and the patient. Palliative care facilities (hospices) are becoming more popular across the country. The funding to build a hospice is often a joint effort involving the municipal and provincial/territorial governments, and nonprofit organizations (NPOs). Access to hospice care varies greatly across the country. The 2016 Canadian Cancer Society publication (Right to Care: Palliative Care for all Canadians) indicates that 13–59% of Canadians suffering from cancer have access to palliative care and end-of-life services (Canadian Cancer Society, 2016, p. 13). As our population continues to age, the need for more hospice beds, specially trained health care providers, and volunteers increases. The availability of palliative care services within the community (at home or in a hospice) provides expert care to the patient, supports the family members, and reduces both the number and length of admissions to hospital.

Mergers, Rationalization, and Integration of Services

The concepts of merging and rationalizing services were introduced in Chapter 3. Here we are expanding on these concepts, looking at how they affect the cost of health care services. A merger may involve two to several facilities and include acute care hospitals, specialty hospitals, or long-term care facilities. Mergers typically involve hospitals that are located in one geographic area and are headed by a single administrative body or corporation. Hospital mergers occur in two main ways: 1. The horizontal model merges several hospitals under one administration—one board, one CEO, one budget—but maintains several sites. 2. The vertical model merges specific programs within a single organization; however, the administration of various programs may remain independent of one another, thus not be under the direction of one board. The advantages of merging are broad: reduced duplication of services, higher levels of efficiency, lower administration and management costs, and the ability to offer more services with better results for patient care and recovery. Larger institutions are also believed to attract more staff. However, studies have shown some negative outcomes when larger hospitals merge, particularly the adverse effects on staff. Mergers often result in a disruption of a hospital’s culture, lost seniority, and displacement of staff members, either through a reorganization of positions or layoffs. Mergers of smaller hospitals appear to be more successful because the resulting facility broadens its service base while retaining staff and improving care. Whether or not successful mergers reduce costs remains controversial. Integrating services aims to prevent the duplication of services, provide care at the necessary level within a community, and use resources more effectively. For example, in Kitchener, Ontario, cardiac and cancer services are centralized—St. Mary’s Hospital has become the cardiac centre, and Grand River Hospital, the cancer centre. Government funds are invested in both hospitals to continually update, upgrade, and expand services in these specialty areas. Obstetrical services are offered only at Grand River Hospital, although both hospitals maintain a viable emergency department. Eliminating the duplication of services saves money, improves the level of care, and more sophisticated and technologically advanced equipment can be purchased and operated by highly skilled

health care providers. Many smaller, rural hospitals have been closed over the past few years, whereas others have remained viable through relocation of services. For example, in one midsized community, cataract surgery and rehabilitation services were moved from a larger hospital to a smaller one several kilometers away. Rationalization also involves delivering the right kind of care at the right level to the right person. Instituting regional health authorities and similar organizations across the country has improved the delivery of appropriate health care for individual communities.

Continuing care in canada Demographics and Challenges In 2017, approximately 17% of the country’s population was over the age of 65, just over 6 million people. Those over the age of 75 (considered older adults)—about 2.6 million people—are most reliant on the health care system. That number is expected to double over the next 20 years. Individuals in this age category are more apt to have complex medical conditions, often combined with mobility limitations and dementia, and therefore require more intensive support, both medically and in terms of general care. In 2013, for example, the health care costs for individuals between the ages of 70 and 74 was about $8384/year. For those aged 80 and older, costs more than doubled to $20,917. Increasingly, the system that cares for these Canadians (called continuing care) will be under enormous pressure (Canadian Medical Association, 2016). Continuing care refers to measures necessary to support and care for individuals who cannot manage independently; these services can be provided in their homes or in residential or long-term care facilities. Under the Canada Health Act, continuing care is described in vague terms as “extended” services that are not subject to the terms and conditions of the Act. As a result, individuals can be charged for continuing care services. Moreover, services do not have to be publicly owned/operated, offered on a universal basis, or accessible to everyone. The provinces and territories select which continuing care services are publicly funded, and by how much. All jurisdictions publicly fund a huge portion of both home care and long-term care services, although configuration and delivery of these services vary. Despite these variables, provinces and territories are collectively examining frameworks to improve the sustainability of continuing care in a cost-effective manner. This involves examining existing models of delivering care within the community, and in residential and long-term care facilities. The challenges are greater in jurisdictions with older populations. Nova Scotia, New Brunswick, and British Columbia currently have the highest ratio of Canadians over 75 years of age relative to their population base. The Yukon and Alberta are projected to have the greatest increase in older Canadians within the next two decades.

Alternative Level of Care The rising need for continuing care services across the country is, in part, demonstrated by the large numbers of individuals in hospitals who cannot return to independent living and are waiting for home care services, or placement in a long-term care facility. These individuals are referred to as alternate level of care patients—patients who occupy more expensive acute care beds that should be used by those requiring an intensive level of care. This creates a back-log of acute-care patients who languish in the hallways of emergency departments and nursing unit corridors. Some refer to this as hallway medicine, a costly scenario that imposes an emotional and physical burden on patients, and a financial burden on hospitals.

Continuing care: options Home Care In most communities, publicly funded home care is available through a central agency to which an individual must apply. Most people prefer to remain in their homes as long as possible. In general, supporting individuals at home is more cost effective than supporting them in longterm/residential care (Conference Board of Canada, 2012). The challenge is to find more efficient ways to use current resources and implement new strategies to contain the costs of home care and improve services to meet the growing demand. Matching an individual with the proper community resources is an important step in deciding who can be managed at home versus in long term care. This decision-making is highly dependent on the availability of community resources.

Residential Care Residential care refers to living accommodations that offer a variety of support needs, usually for older adults. These accommodations include lodges (public or private), assisted living or supportive services in the community, and long-term care facilities.

Private Residences Older Canadians, who can afford it and want to avoid long-term care facilities, may choose to live in private residential facilities where they can select the type of accommodation and level of care required. Private residential accommodation can cost up to $200,000/year, although this cost varies with location and the “luxury” components of the facility. Choice of accommodation ranges from a single room to larger more spacious suites. The more services required, the higher the cost. Maximum care would be similar to that provided in a nursing home. Federal, provincial, and territorial governments are not responsible for any costs incurred and the resident pays the facility directly.

Long-Term Care Facilities (Nursing Homes)

Most jurisdictions use the term long-term care or nursing homes, although Personal Care Homes is used in Manitoba, Special Care Homes in Saskatchewan, and Residential Care Homes in British Columbia. These facilities provide varying levels of care to individuals—from those who require less support but are unable to live on their own, to those who require total care and supervision for physical or mental reasons—24 hours a day, 7 days a week. Levels of care are classified as independent, semi-independent, and dependent (Case Example 4.2).

  Case Example 4.2 Seventy-two-year-old Olivia has had a stroke. She is fully cognizant and can manage some activities of daily living, but needs assistance with dressing, eating, and moving about. Because she was unable to manage at home despite home care support, she is now in a nursing home, semidependent, and receiving a moderate level of nursing supervision and supportive care. However, if Olivia had severe Alzheimer disease (i.e., had no memory, wandered, and could not feed herself) and fell and broke her hip, she would be placed in a secure unit with maximum nursing supervision and be almost completely dependent. Provincial and territorial governments oversee long-term care for all Canadians, with the exception of those individuals eligible for federal care through Veterans Affairs Canada, workers’ compensation boards, federal government acts, and medical health insurance. Licensed by the provincial and territorial ministries of health, long-term care facilities (often privately owned) must meet standards regarding staffing levels, training, food preparation, pricing, and medical care, including the administration of medications. Unsubsidized and unlicensed residences also exist, but they offer limited or no nursing care and are usually regulated by municipal bylaws, which do not control the quality of care. Provincial and territorial governments control the number of publicly funded long-term beds in their jurisdiction. Public funding provides revenue to subsidize these nursing home beds; however, in addition to the fact that beds in public (or government funded) nursing homes in most jurisdictions are subsidized, the patient must pay a flat rate for basic accommodation (called a copayment). The exception is Nunavut. The portion of costs that residents must pay may depend on their financial

circumstances (Case Example 4.3) and whether they have a spouse living in the community. If they have a spouse, payment would be adjusted so that the spouse can retain enough money to remain in his or her home. All jurisdictions have alternative funding options for those unable to pay, and no one can be denied accommodation or care.

  Case Example 4.3 After falling and breaking her hip, 80-year-old Ibia can no longer live independently at home. Arrangements have been made for her to move to Happy Meadows, a nursing home close by. Ibia has concerns about being able to afford nursing home care and is even more worried about what will happen to her life’s savings and her house. “They will take all of my money,” she laments. “What will happen to my house? I heard they take everything to pay for staying there!” What might happen to Ibia? The answer depends on what province or territory Ibia lives in and the type of nursing home she is moving to. In most jurisdictions, the patient’s monthly income must be used toward payment of his or her accommodation. Ibia need not worry about her house and savings, however. These assets would be protected (although the amount of protection varies across jurisdictions) and would not be accounted for in the assessment of her ability to pay. If Ibia’s monthly income from her pensions is $2000 and the copayment is $3000/month, Ibia would have to surrender the bulk of her income for her accommodation, but would not be required to make the full co-payment. The government would cover the balance, leaving her with enough money for personal expenses. Ibia would be eligible only for basic accommodation. Depending on the minimum accommodations available at Happy Meadows, she may be in a ward with several beds (up to six) or in a semiprivate room with only one other person. If Ibia’s monthly income were $3000 and the cost of her standard accommodation were $2500 monthly, Ibia would be required to pay the full amount, leaving her with $500 left over to spend as she pleases. Rates for a standard nursing home bed, co-payments residents are required to pay (usually based on after-tax income), and the breakdown of how those co-payments are used (e.g., for meals, accommodation) vary across Canada. Regardless of an individual’s financial situation, all jurisdictions leave a percentage of the resident’s income for their personal

use (on average 15%). This means that even if the resident is unable to pay even the minimum amount for standard accommodation, he or she will be subsidized, and left with a stipulated percentage of their income for personal use. No one is denied accommodation based on ability or inability to pay. Some nursing homes offer standard accommodation (up to three or four people in a room), semiprivate (two in a room), and private rooms. Residents pay an additional cost for semiprivate or private rooms. Newer nursing homes may offer only semiprivate and private rooms, or only private. The basic co-payment rates in newer or renovated facilities are higher than in homes offering the three levels of accommodation. All jurisdictions have government subsidies provided to individuals with limited income. The cost to the resident/patient in long-term care varies across Canada. For example, in 2017 the maximum amount paid for standard accommodation in Ontario was $59.82/day or $1819.53/month. An Ontario resident occupying a private room in a newer facility would pay $80.07 or $2435.47/month (Government of Ontario, 2017). In British Columbia the minimum co-payment for basic accommodation is $36.32/day or $1104/month; and the maximum is $106.52/day or $3240.00/month (Sykes Assistance Services, 2017). In July 2018, the copayment (called an accommodation rate) per day in Alberta was $55.00 or $1673/month for a standard room (Government of Alberta, 2018). Beyond the costs of long-term care are concerns around quality—for example, substandard resident/patient care, abuse of residents by staff members, and abuse among residents themselves. These issues are often caused by inadequate staffing levels and poorly trained staff members, and underlying it all, underfunding, with the result that nurses and other staff are underpaid, and insufficient numbers of care providers are hired for the number of residents, who increasingly have more complex needs.

The rising cost of drugs After hospital services, drugs represent the next largest health care expense (see Fig. 4.1). According to the Canadian Institute for Health Information (CIHI, 2017a), drug spending continues to increase, but not as rapidly as in previous years. In 2017, total expenditures on drugs (including public and private insurance and out-of-pocket costs) was estimated to be 39.8 billion, or $1086 per capita. It was estimated that $14.5 billion (42.7%) of prescribed drug spending was paid by the public plan and individuals paid $13.3 billion or $362 per capita (CIHI, 2017b).

Major Cost Drivers for Drug Expenditures Increased drug expenditures can be attributed to several factors, including the fact that more people are taking medications, many taking multiple medications. Drugs used for high blood pressure, high cholesterol, and gastrointestinal disorders are most commonly prescribed. It is worth noting that older Canadians have a significantly higher per capita spending related to drugs, compared to other cost drivers (volume increase and drug mix). Newer drugs being brought to market increase the cost. Many pharmaceutical companies are researching and producing more specialized—and more expensive—medications. These include a class of drugs called biologics (e.g., immunosuppressants and cancer drugs), derived from living material, and are growing in popularity, along with “targeted drugs” that require biomarker testing to ensure they are right for the patient.

Drug Insurance All provinces and territories provide some kind of drug insurance to certain groups, such as older Canadians, people with disabilities, and individuals who earn low incomes or are on social assistance. A copayment or deductible may apply (see Chapter 9), but some pharmacies will waive deductibles and co-payments in certain circumstances. Canada is one of only a few developed countries without a national drug plan. However, most provinces and territories have some form of catastrophic drug coverage, meaning they will assume the cost of very expensive drugs for specific health conditions when the family is unable to

cover the expense. Quebec has had a provincial drug plan since 1997 for those who do not have private drug insurance. However, as part of the 2018 budget the Federal Government announced the implementation of an advisory council to study Pharmacare programs, which included look at the international levels. A drug’s accessibility and coverage through an insurance plan are determined by its category; over-the-counter (OTC) medications can be purchased without a prescription and are rarely covered by public or private health plans; prescription medications can be purchased only with a prescription from a health care provider (e.g., family doctor or specialist; in some jurisdictions, nurse practitioner, or midwife) and may be covered in part or in full by insurance. Occasionally, a province or territory will remove a drug from the list of drugs that may be obtained only with a prescription. Once removed, however, insurance will no longer cover the drug.

Brand-Name and Generic Drugs Brand-name drugs—those that are owned and sold by the company that developed them—cost more than generic drugs. They are protected under a piece of legislation called the Patent Act. Currently patents last 20 years from the time the pharmaceutical company applies to the board for approval to sell the drug in Canada. Once a patent expires, any drug company can produce the drug (called a generic drug) and sell it at a lower cost (a quarter to a half of the brand-name counterpart). Brand-name drug names are always capitalized; generic drug names are not (e.g., ibuprofen is a generic drug; Advil is a brand-name drug). Because they do not have to spend money on research and development, companies producing generic drugs can do so at a greatly reduced cost. Generic drugs contain the same active ingredients, although the other ingredients (called nonmedicinal ingredients) vary. All generic drugs go through an approval process and analysis similar to those of brand-name drugs. Some claim that brand-name drugs are of a higher quality and that different nonmedicinal ingredients can alter the action and efficacy of the drug. Unless a doctor specifically indicates on a prescription “no substitution,” pharmacists may substitute a generic drug for a brand-name one. Over the next few years, patents on a large number of brand-name drugs will expire; generic equivalents will become available, reducing the cost of prescription drugs for patients. Most provincial and territorial

formularies use generic drugs, although brand-name drugs are allowed by special permission if there is not a generic equivalent to effectively treat a specific condition (Cheng, Dhalla, Law, et al., 2012; CIHI, n.d.; University of British Columbia, 2012).

Controlling the Cost of Patented Drugs An independent government agency, the Patented Medicine Prices Review Board (PMPRB), regulates the price at which patentees—pharmaceutical companies—sell their patented medicines in Canada to wholesalers, hospitals, pharmacies, and others (e.g., clinics), called the factory-gate price. Although the PMPRB can ensure that drug companies themselves do not charge excessive prices, the board does not have jurisdiction over the prices retailers charge customers or pharmacists’ dispensing fees. For the duration of the patent, the PMPRB regulates the prices of all patented products, including medication available only through prescription, sold over the counter, and available through Health Canada’s Special Access Program. This program provides physicians with access to existing drugs not currently on the market that might prove effective for treating serious or life-threatening conditions when mainstream medications have proven ineffective, are not readily available, or cannot be tolerated by a specific patient. The PMPRB has no authority to regulate the prices of nonpatented drug products (i.e., drug products that were never patented or for which the patent has expired).

Health human resources The term health human resources (HHR) refers to all people who work in the health care field, ranging from physicians and nurses to laboratory technologists, and respiratory therapists. Estimates suggest that more than 2 444 900 people work in the health care and social assistance fields in Canada (Statistics Canada, 2018). Nurses, followed by physicians, are the largest group of regulated professions in Canada. Physicians and nurses are also the two largest cost drivers of health human resources. How a health care organization best manages the skills and expertise of its employees greatly affects its financial bottom line. For example, it is essential to find the proper balance of nursing staff in hospitals to deliver high quality care within budgetary guidelines. Achieving this balance without patient care suffering, or negatively impacting nursing staff, is a challenge. Canada endured a shortage of health providers in the 1990s (especially physicians and nurses). It has recovered somewhat, but there is still a shortage of primary care providers and also in several other health workforce categories (see Chapter 5). The Canadian Nurses Association predicts a shortage of almost 60,000 full-time-equivalent registered nurses by the year 2022. There was an increase in physicians in Canada in 2016 (2.3% over the previous year), and this trend is expected to continue. Despite this fact, physician shortages across all sectors persist today. Although family physicians are in short supply, many specialists (e.g., general surgeons, orthopedic surgeons, oncologists, critical care specialists, and urologists) cannot find jobs in Canada, despite long waits for patients to see them. The reasons for this conundrum are varied: too many doctors in relation to resources, such as operating rooms and hospital beds; many facilities cannot afford to hire them; numerous specialists are deferring their retirement, making opportunities for others scarce; an overabundance of physicians in some specialties and poor geographic distribution of specialties (Di Matteo, 2013).

Physicians The gross (without any deductions) payments made to physicians for clinical services in 2015–2016 was just under $28 billion. This was paid by provinces and territories for insured medical services—the majority for consultations and physician visits. A physician visit most often refers to an

assessment by a family physician or similar, and a consultation occurs when one physician or other provider requests another physician to see a patient to evaluate the patient’s condition. (CIHI, 2017c). See Case Example 4.4.

  Case Example 4.4 Pierre went to see his family doctor complaining of pain just under the rib cage (substernal). The family doctor did a brief physical examination, took a medical history and ordered several tests, one of which revealed that Pierre had gallstones. The visit took about fifteen minutes. The average clinical payment to physicians in Canada was just over $339,000 in 2015–2016, with the lowest amount in Nova Scotia and the highest in Alberta. The annual amount paid to family physicians decreased, while it increased for specialists. Among specialists, psychiatrists made the least, while ophthalmologists made the most with an average gross annual payment of approximately $714,000.

How Physicians Are Paid: Billing Options Historically, physicians have been paid through a mechanism called fee for service (FFS). Although there has been a shift to other methods of payment in recent years, FFS remains the predominant method of payment, amounting to 70–73% of total clinical payments paid to physicians by provincial and territorial governments. Other funding mechanisms, called alternative methods of paying physicians (APP), include salaries, hourly rates, capitation-based funding, or payment by contract. Almost 30% of all clinical payments made to physicians across the country include a blend of funding models. In 2015– 2016, almost all physicians (97%) billed for some FFS payments and nearly two-thirds of all physicians were paid through alternate payment methods. Younger physicians are more likely to be paid through blended funding as many work in more than one area of medicine. A family physician, for example, might see patients in his or her office 2 or 3 days a week, and work as a hospitalist, as an emergentologist, GP anaesthetist, or even in sports medicine for the remaining time. If Dr. Grey worked in a primary care setting part-time, and as a hospitalist part-time, he would likely bill FFS for some services, have capitation-based funding for his

rostered patients, and be paid a salary by the hospital for those duties, perhaps by contract (CIHI, 2017c). The following sections summarize the most common payment options for doctors in Canada.

Fee-for-Service As mentioned above, FFS is the oldest and, for the moment, most widely accepted method of physician payment in Canada. Using this method, doctors charge the provincial or territorial plan for every service they perform. Each province or territory has slightly different parameters for FFS billing. Invariably though, the amount the doctor bills relates to the complexity and length of the patient visit. Most jurisdictions have three or four main categories for “visit fees” that a physician can charge for: a minor assessment, an intermediate assessment, and a full assessment (e.g., a physical examination). In Ontario, a physician would bill about $33.70 for an intermediate visit and assessment, such as Pierre’s visit described in Case Example 4.4. Within the FFS model, doctors can also bill for things other than the actual office visit. For example, doctors who make house calls can charge more to ensure they are compensated for travel, for seeing a patient away from the office, for the time of day or night the house call is made, and for the patient visits cancelled if making a house call during office hours. Doctors may also bill for procedures such as giving an injection, suturing a wound, or for visiting a patient in hospital. Amounts billed also vary depending on whether the doctor is the most responsible physician (MRP), or is only providing a consultation. (In the hospital, the MRP is the physician with the primary responsibility for caring for the patient; the MRP may be the patient’s family doctor, but is usually a specialist.) Many doctors prefer to retain FFS, at least in part. Some of the primary health care reform models blend capitation-based funding (described below) with FFS. Because of advances in surgical techniques, many procedures (e.g., cataract surgery) can be done much faster than in the past. This enables specialists to do many more procedures in a day; although they can bill the same amount as they did when the procedure took a much longer time. For that reason, many believe the guidelines determining the fees for specific services need to be overhauled.

Capitation- or Population-Based Funding

Capitation-based funding (also called population-based funding) pays the doctor for each rostered patient in his or her practice. This funding format is often used by doctors in private practice who also operate under the umbrella of an alternative health care delivery format, such as a primary health care reform group. Rostered patients of a primary health care network are asked to sign a form to say that they will seek medical nonemergent care only from their family doctor or members of that particular health care group. (For more details, see Chapter 5.) Physicians must receive approval from their provincial or territorial government to form such a group. Once physicians begin working in their selected primary care model, they are usually paid monthly. With capitation-based funding, doctors receive a set amount for each patient that is determined by the patient’s age, health care needs, or both. Therefore a doctor would be paid more per year for an 89-year-old patient with multiple health problems than for a 22-year-old healthy patient. Whether the patient visits the doctor once or 30 times in that year, the doctor receives the same amount of money. Additionally, doctors are paid extra for achieving certain milestones, such as immunizing a given portion of eligible patients or doing routine Pap smears for women in high-risk groups. (Physicians must track women in their practice and implement procedures to do Pap smears in accordance with the criteria of the jurisdiction.) Setting such goals encourages doctors to be actively involved in disease prevention and health promotion. The fundamental components of capitation-based funding are summarized as follows: • Physician payment is based on a given group of patients who are rostered, thus forming the foundation of the doctor’s practice. • The physician receives a guaranteed income based on the defined population base of his or her practice. • The physician may enter into other compensation schemes; for example, a portion of his or her practice may still be FFS. • Incentives provided to the physician incorporate a strong element of disease prevention and health promotion to result in better health outcomes for patients of the practice.

Indirect Capitation Indirect capitation is a funding model through which an organization such as a regional health authority receives a set amount of money to manage

health care—including staff, services, administrative costs, and capital expenditures—for a population base. Employees within the organization may be compensated in various ways.

Global Budget Doctors practising in underserviced areas are paid a certain fee for maintaining these practices. The global budget plan also usually includes ample vacation time and educational leave.

Salary and Contract Doctors on salary receive a negotiated amount of money per time frame (usually a month). Larger hospitals, medical centres, clinics, and some nonprofit clinics often employ this model. A physician would be paid on a contract if hired for a specific period of time by either a hospital or a clinic.

Blended Funding Most physicians in Canada who engage in a form of funding other than FFS also partake in another method of payment. For example, a physician in a primary health care network group can have a certain portion of his or her practice nonrostered and on an FFS funding scheme, and another portion calculated on capitation-based funding.

Specialists’ Compensation At teaching hospitals, specialists may have teaching responsibilities and receive a salary. Most specialists, even if on salary, maintain a private practice as well. In their private practice, they see a patient upon referral from a family doctor until the problem for which the patient was referred is resolved. Specialists not employed by a hospital or other organization rely on feefor-service and therefore bill the province or territory for services rendered. Specialists belonging to a primary health care reform group may receive other forms of compensation reflective of the payment formula for that particular group. In most jurisdictions, after a certain period of time (often one year), if a patient’s health problem recurs, the patient may call the specialist’s office directly and return for another evaluation (called a repeat consultation). If a new problem occurs, or if the same problem returns after the designated time period, the patient will need another referral (called a consultation request) from his or her family doctor. In most jurisdictions, a person

cannot call a specialist’s office and simply make an appointment. Channeling specialist visits through a primary care provider results in specialists seeing only those patients who have legitimate problems and, thereby, creates cost savings (CIHI, 2013).

Nurses As discussed in Chapter 5 there are three categories of regulated nurses in Canada—registered nurses, including nurse practitioners, licensed/registered practical nurses, and registered psychiatric nurses working in health care facilities, the community, and primary care organizations. The number of regulated nurses in Canada grew by nearly 16.4% over the past decade with a total of 425,757 regulated nurses actively registered to practise in Canada. Of these, 301,010 were registered nurses, including 5274 nurse practitioners, 118,810 licensed/registered practical nurses, and 5937 registered psychiatric nurses (CIHI, 2018a). Internationally, graduated nurses make up just over 8% of the regulated nursing workforce, and are primarily from the Philippines, India, and Great Britain. Regardless of the statistical increase in regulated nurses in Canada, shortages remain resulting from large numbers of nurses retiring, many working outside the profession, and lack of funding for new hires (CIHI, 2017d). Using the professional services of nurses in a cost-effective manner is complicated. Each facility and workplace setting requires a specific mix of nursing professionals, particularly in a team setting. As a rule, only registered nurses work in hospital intensive care units and other highly specialized settings where patient care is both complex and acute. In other patient care units, there may be a mix of registered nurses and licensed practical nurses, the ratio depending on patient care needs. Long-term care facilities are more likely to have fewer registered nurses, and a greater number of licensed/registered practical nurses and personal support workers. There is a chronic shortage of workers to meet the demands of home and community care. In most jurisdictions, hospitals are funded a certain amount of money for a given time frame, either by a health authority or directly from the Ministry. Some of that money is assigned to certain pockets for spending (e.g., knee and hip surgery) and some for health human resources. The mix of health professionals hired within the budget is determined by the facility. Nurses working in hospitals, long-term care, and other public facilities are usually paid by the hospital with funds received from the government. Nurses in primary health clinics are paid through the clinic,

or by the physicians for whom they work. Nurse practitioners are paid by the government or by physicians directly.

Midwives In some provinces (e.g., British Columbia, Alberta, Ontario) midwives are independent practitioners, paid a designated amount per course of care. This amount can vary depending on the amount of time in practice and is capped at between 40 and 60 births per year. A first-year midwife in British Columbia earns $1400 per course of care, while an experienced midwife gets $3120. The total number of births is capped at 60, though most midwives’ average 40 to 60 births per year. In Alberta, midwives are paid $4600 per course of care, but are capped at 40 births per year as the primary caregiver. Therefore a base range for gross starting salaries paid in this way would be $56,000 in British Columbia, $81,200 in Ontario, up to as much as $184,000 in Alberta. Some Ontario midwives, notably those working through the Indigenous Midwifery Program, are government employees. In the other provinces (e.g., Quebec and Saskatchewan), midwives are paid government employees. The starting salary in Quebec is $54,000, plus compensation for on-call time. Starting salaries in northern regions such as Nunavut and NWT tend to be higher ($87,000 and $100,015, respectively, plus northern living allowance), and in the case of NWT, overtime and oncall pay. Therefore a starting base salary range for midwives paid as employees (not including additional benefits) starts at $54,000 in Quebec and goes up to $100,015 in NWT.

Other health care cost drivers Technology Technological change has had a significant impact on health care costs, although it is difficult to assign a dollar value. Technology includes information technology (electronic health records and electronic medical records); medical devices, particularly those used for imaging; and tools and procedures to carry out new surgical techniques, such as bariatric (weight loss) surgery, which is expensive and in high demand.

CT, Positron Emission Tomography Scanners, and MRIs Although offering improved diagnostic outcomes, imaging options such as CT scanners, MRI, and positron emission tomography (PET) scanners are expensive to purchase, maintain, and operate. As of September 2015, there were 45 publicly funded PET scanners in Canada, operational in 34 centres. Two of these scanners are located in British Columbia, four in Alberta, one in Saskatchewan, one in Manitoba, sixteen in Ontario, two in New Brunswick, and one in Nova Scotia. In 2018, Newfoundland and Labrador obtained a PET/CT scanner, which uses advanced nuclear imaging techniques and combines PET and CT into one machine. The cost of the PET/CT scanner totaled approximately $46 million, which included the construction of the nuclear and molecular facility required to accommodate the scanner, the price of the scanner, and other necessary equipment needed to run it, such as a cyclotron, which generates the nuclear power to run the scanner. The manner in which equipment is funded varies with provinces and territories. In Ontario, such scanners are usually funded by local organizations along with money from the local hospital’s operational costs. Most jurisdictions cover the cost of PET scans only for specific conditions such as selected cancer and cardiac conditions. Scans are also covered for people who are part of a Health Canada clinical trial. The cost of a single PET scan varies from $956 (in Quebec—possibly because of the large number of scans done there) to $1800 (in Manitoba). The efficacy of a PET scan is not well established by Health Canada. The cost of an MRI machine depends on whether it is purchased new or refurbished, and also on the size and functionality of the scanner. Other costs include items such as room shielding (which can run upwards of $35,000/machine), construction to ready a room, installation costs, and

freight. Ongoing costs for training and employing individuals to operate the machine run from $2 million to $3 million annually (Liewicki, 2014). A new CT scanner costs about $750,000, though this can vary depending on its size (i.e., the number of slices it has). Overall costs are similar to those required to set up and run an MRI scanner.

Outsourcing In many jurisdictions, health care services are contracted out to independent facilities. In Ontario, for example, some independent health care facilities have been licensed to perform MRI and CT scans for medically necessary procedures. To prevent queue jumping, patients must be referred to the facility for these procedures. The provincial government claims that contracting out these services costs 36% less than operating the same services within the hospital setting (Government of Ontario, 2003). These independent facilities may offer uninsured MRI and CT scans (e.g., to athletes or corporate executives whose firms cover such costs) only if they have signed a contract with the government to offer a designated number of insured scans per month. A company can only offer remaining spaces to the private sector once the insured scans have been completed.

Electronic Health Records The amount of health information generated in the Canadian health care system has increased dramatically over the past few years. This requires constant updating of electronic health record (EHR) and related systems to be adequately process, analyze, and use this information properly. A significant portion of health information electronically acquired becomes part of someone’s electronic health record. Having a completely interoperable EHR system requires collaboration and cooperation among all levels of government; initiatives are overseen, for the most part, by the Canada Health Infoway. Established in 2001 the Canada Health Infoway is an independent NPO providing digital solutions for Canada’s health care system. The Infoway invests in projects that contribute to a nationwide digital framework that improves patient care and affords prompt access to a patient’s digital/electronic chart. Over the past several years funding from the Federal Government for the Infoway totaled over $2 billion dollars for an estimated 370 e-health projects Canada wide. A payment of $400 million in 2007 was distributed over five years with the mandate to establish electronic health records for all Canadians by 2016. This goal was

not met. In 2017, the Federal Government committed another $300 million to the Infoway to advance new projects (see Chapter 10). In 2017, an estimated 162,000 health providers across the country accessed electronic health records, which is twice as many as three years prior. In addition, as of March 2017, 94.6% of Canadians had at least some of their health information stored electronically. The Infoway reported in its 2017 budget that electronic health information systems saved $19.2 billion in costs and efficiencies in several areas including drug information systems, telehealth systems, and electronic medical records in ambulatory care clinics (Canada Health Infoway, 2017, 2018a, 2018b). According to a 2015 survey, the CIHI reported that 72.5% of primary care physicians in Canada were using electronic health records (CIHI, 2015).

Conclusion Have you found the answers to the questions you were asked at the beginning of the chapter? How close were your estimates? Review the prices noted in Table 4.2. Were your estimates close? Did you expect the cost of the services to be less, or more? How would paying out of pocket for some of these services impact you or your family? Now consider your health card—just identification you must show when you seek health care services, right? Not really. Your health card is similar to a credit card, but for health care services. What does the future of health care in Canada hold? It is nearly impossible to know, although change is a certainty. Resources are limited, and services may need to be rationed—an alien concept to Canadians. Excluding people from the treatment they need (or want) based on factors such as age, health status, or type of disease seems unthinkable, but it may become a reality. We must use health care resources wisely and continue to promote healthy lifestyles and disease prevention.

Summary 4.1 Although health care in Canada is, for the most part, publicly funded, delivery of health care services is accomplished through a mix of private for-profit and not-for profit organizations. For example, most hospitals are private nonprofit facilities, and although funded by the government, many of the services they deliver are done so by private businesses. Often publicly funded health services contract business to deliver those services, including some home care organizations. Doctors, although paid for with public funds, can be considered small business owners. 4.2 Public funding for health care in Canada is provided by the federal, provincial/territorial, and municipal governments through a blend of taxes and tax points as well as by workers’ compensation boards. Some jurisdictions also use revenue from sales taxes and lotteries for health care, whereas some provinces charge their residents health premiums. At present, the Federal Government uses four models to make transfer payments to the provinces and territories. 4.3 Hospitals, drugs, and human health resources represent the three top health care expenditures in Canada. Most hospitals are nonprofit facilities, and although almost entirely government funded, use an array of private businesses and organizations to deliver their services. Human health resources account for the bulk of hospital spending. 4.4 Long-term care facilities in Canada are primarily publicly funded and regulated by the provincial and territorial governments. Private facilities do exist, offering varying levels of care. In most jurisdictions, the patient is required to make a co-payment for room and board, food, and other services. The amount the patient is required to pay is related to his or her monthly income. 4.5 Although at a slower pace than in previous years, the cost of drugs in Canada continues to rise because there are more people using medications and more people using several medications. In addition, newer drugs, especially a class called biologics, are very expensive. Canada does not have a national drug-funding program, but all jurisdictions cover the cost of most drugs for

certain groups, including seniors, disabled persons, and those on assisted income. 4.6 Human health resources (HHR) are a significant expense to the health care system. Physicians and nurses are the largest of the regulated professions and account for the largest financial output for the HHR sector. Physicians are paid through several funding formulas, with the majority still billing fee-for-service. Although improving, the shortage of physicians and nurses persists. 4.7 Technological advances have been seen in all facets of health care including surgical procedures, diagnostic equipment, and health/medical records. New technologies related to medical imaging promote early diagnosis, prompt treatment, and improved treatment outcomes, but come at a price. Electronic health records are expensive to implement. Putting an actual value to these cost drivers is difficult, and it is thought that many of these advances will actually save the health care system money over time.

Review questions 1. Why do some Canadians regard health care as “free”? Do you feel that way? Why or why not? 2. Explain the concept of equalization payments, including why they are given and how they are calculated. 3. What types of services are covered by provincial and territorial insurance both in and out of hospitals? 4. What are the three largest expenditures for provincial and territorial health plans? 5. List five strategies for reducing the length of hospital stays and thus hospital expenses. 6. What are the key differences between prescription drugs and overthe-counter drugs? 7. How has advanced technology contributed to rising health care costs?

References Canada Health Infoway. Federal Government announces new funding for Canada Health Infoway. Retrieved from https://www.infoway-inforoute.ca/en/what-wedo/news-events/newsroom/2017-news-releases/7387federal-government-announces-new-funding-for-canadahealth-infoway. 2017. Canada Health Infoway. (2018a). What we do. Retrieved from https://www.infoway-inforoute.ca/index.php/aboutinfoway/what-we-do. Canada Health Infoway. (2018b). Year in review, 2016–2017. Retrieved from https://www.infowayinforoute.ca/en/component/edocman/3350-annualreport-2016-2017/view-document?Itemid=0. Canadian Cancer Society. Right to care: Palliative care for all Canadians. Retrieved from https://www.cancer.ca/~/media/cancer.ca/CW/get%20i nvolved/take%20action/Palliative-care-report-2016EN.pdf?la=en. 2016. Canadian Institute for Health Information. (n.d.). National prescription drug utilization information system database. Retrieved from http://www.cihi.ca/cihi-extportal/internet/en/document/types+of+care/pharmaceu tical/services_drug. Canadian Institute for Health Information. Number of doctors in Canada rising, as are payments for their services. Retrieved from http://www.cihi.ca/cihi-extportal/internet/en/document/spending+and+health+wo rkforce/workforce/physicians/release_26sep13. 2013. Canadian Institute for Health Information. Canada’s nursing workforce continues to grow. Retrieved from http://www.cihi.ca/cihi-ext-

portal/internet/en/document/spending+and+health+wo rkforce/workforce/nurses/release_8july14. 2014. Canadian Institute for Health Information. Commonwealth fund survey 2015: Data tables. Retrieved from https://www.cihi.ca/en/access-data-reports/results? query=electronic+medical+records. 2015. Canadian Institute for Health Information. How much does Canada spend on health care? Retrieved from https://www.cihi.ca/en/how-much-does-canada-spendon-health-care-2017. 2017a. Canadian Institute for Health Information. National health expenditure trends, 1975 to 2017. Retrieved from https://www.cihi.ca/en/national-health-expendituretrends. 2017b. Canadian Institute for Health Information. Physicians in Canada, 2016: Summary report. Retrieved from https://secure.cihi.ca/free_products/Physicians_in_Cana da_2016.pdf. 2017c. Canadian Institute for Health Information. Regulated nurses. 2017d;2016. Retrieved from https://www.cihi.ca/sites/default/files/document/regul ated-nurses-2016-report-en-web.pdf. Canadian Institute for Health Information. Understanding variability in the cost of a standard hospital stay. Retrieved from https://www.cihi.ca/sites/default/files/document/cshsvariability-study-2017-en.pdf. 2017e. Canadian Institute for Health Information. Regulated nurses, 2017: Canada and jurisdictional highlights. Retrieved from https://www.cihi.ca/sites/default/files/document/regul ated-nurses-2017-pt-highlights-en-web.pdf. 2018a. Canadian Institute for Health Information. Your health system: Cost of a standard hospital stay. Retrieved from

https://yourhealthsystem.cihi.ca/hsp/inbrief;jsessionid= TM6ljShNyKA8zPl3TXKkH9l3.yhs? lang=en#!/indicators/015/cost-of-a-standard-hospitalstay-cshs/;mapC1;mapLevel2. 2018b. Canadian Medical Association. The state of seniors health care in Canada. Retrieved from https://www.cma.ca/En/Lists/Medias/the-state-ofseniors-health-care-in-canada-september-2016.pdf. 2016. Conference Board of Canada. Home and community care in Canada: An economic footprint. Retrieved from https://www.conferenceboard.ca/temp/c19433cd-5fd047e2-be8b-f595c7a27661/12306_HomeandCommunityCare_PRT.pdf. 2012. Di Matteo L. Trouble ahead for health costs: Doctors working less, making more. In: The Globe and Mail. 2013, July 30. Retrieved from http://www.theglobeandmail.com/globedebate/trouble-ahead-for-health-costs-doctors-workingless-making-more/article13497288/. Dutton D.J., Forest P., Kneebone R.D., Zwicker J.D. Effect of provincial spending on social services and health care on health outcomes in Canada: An observational longitudinal study. CMAJ. 2018. ;190(3):E66–E71. https://doi.org/10.1503/cmaj.170132. Government of Alberta. Continuing care – accommodation charges. Retrieved from http://www.health.alberta.ca/services/continuing-careaccommodation-charges.html. 2018. Government of Canada. Canada social transfer. Department of Finance Canada; 2011a. Retrieved from http://www.fin.gc.ca/fedprov/cst-eng.asp. Government of Canada. Making a major new investment in health care and putting transfers on a long-term, sustainable growth track. Retrieved from Department of

Finance website: http://www.fin.gc.ca/n11/data/11141_1-eng.asp. 2011b. Government of Canada. Canada health transfer. Department of Finance Canada; 2011c. Retrieved from https://www.fin.gc.ca/fedprov/cht-eng.asp. Government of Canada. Federal support to provinces and territories. Retrieved from https://www.fin.gc.ca/fedprov/mtp-eng.asp. 2017. Government of Canada. The new Canada caregiver credit. Retrieved from Revenue Agency website https://www.canada.ca/en/revenueagency/services/tax/individuals/topics/about-your-taxreturn/tax-return/completing-a-tax-return/deductionscredits-expenses/family-caregiver-amount.html. 2018. Government of Ontario. Ministry of Community and Social Services. Retrieved from http://ogov.newswire.ca/ontario/!GPOE/2003/02/21/c2 902.html?lmatch=%3C=_e.html. 2003. Government of Ontario. Bulletin to residents of long-term care homes: Important news regarding long-term care home accommodations charges. In: Ministry of Health and Long-Term Care. 2017. Law M.R., Cheng L., Dhalla I.A., et al. The effect of cost on adherence to prescription medications. Canadian Medical Association Journal. 2012. Retrieved from https://doi.org/10.1503/cmaj.111270. Liewicki N. MRI for Moose Jaw. In: Moose Jaw Times Herald. 2014. Retrieved from http://www.mjtimes.sk.ca/News/Local/2014-0530/article-3744550/MRI-for-Moose-Jaw/1. Matier C. Renewing the Canada health transfer: Implications for federal and provincial–territorial fiscal sustainability. Ottawa: Office of the Parliamentary Budget Officer; 2012.

Statistics Canada. Labour force characteristics by industry, unadjusted for seasonality. Retrieved from https://www150.statcan.gc.ca/t1/tbl1/en/tv.action? pid=1410002201. 2018. Sykes Assistance Services. Long-term care in British Columbia 2017. Retrieved from https://www.sunnet.sunlife.com/files/advisor/english/ PDF/Completereport-LTC-Costs-BC.pdf. 2017. University of British Columbia. One in ten Canadians cannot afford prescription drugs: UBC study. In: Public Affairs. 2012. Retrieved from http://www.publicaffairs.ubc.ca/2012/01/16/one-in-tencanadians-cannot-afford-prescription-drugs-ubc-study/.

5

Practitioners and Workplace Settings LEARNING OUTCOMES 5.1 Describe the various ways in which individuals working in health care are categorized 5.2 Outline the purpose and benefits of regulated health professions. 5.3 Discuss the role and educational requirements of various health care professionals. 5.4 Describe practice settings in which health care is delivered. 5.5 Summarize the current state of primary care in Canada primary care.

KEY TERMS Accredited program Affiliating body Allied health professional Community-based care Controlled act Delegated act Evidence-informed

Geriatrics Health care provider Hospice Interprofessional collaboration Intubate Practice setting Primary care setting Refraction Rostering Scope of practice Specialist Telehealth Title protection Urodynamic Health care in Canada is provided by a wide variety of health care providers—from conventional (or mainstream) medical practitioners to those who practise complementary and alternative medicine. Also integral in delivering care are informal workers: volunteers of community organizations and friends and family members who care for loved ones at home. Practice settings include hospitals, residential care facilities, rehabilitation centres, community care facilities, hospices, a variety of clinics, offices, primary care settings, and the home. Who delivers health care, and when, how, and where it is delivered is undergoing continual change. This is largely an attempt to provide Canadians with timely, cost-effective access to primary, secondary, and tertiary care to accommodate the health needs of an aging population. Many regions in Canada are experiencing a shortage of primary care practitioners. According to Statistics Canada (2014) 14.9% of Canadians, ages 12 and older—roughly 4.5 million people—reported not having a family physician.

To address the issue, the College of Family Physicians of Canada (CFPC) in 2011 proposed a concept called the Patient’s Medical Home (PMH). The proposal builds on existing models used in delivering primary care such as Alberta’s Primary Care Networks, Saskatchewan’s Collaborative Care, Emergency Centres, Ontario’s Family Health Teams, and Nova Scotia’s Collaborative Care Teams. The continuing goal is to ensure that all Canadians have a primary care provider, usually a physician, who is the hub of a team of health care professionals. Added to the original objective is providing a stable medical environment where the patient feels comfortable and can access any health care required. Interprofessional collaboration and the expanding roles of health care providers strengthen the team approach to primary health care. It is important to note that although most Canadians still want the security of having a family physician, there are other options such as nurse practitioners and physician assistants. The amount and type of care rendered within the community continues to expand with many individuals cared for at home. This shift to community-based care has been made, in part, to reduce health care costs by shortening hospital stays, to enhance patient recovery, and to minimize the risk for hospital-based (nosocomial) infections. New procedures, increased community support for homebased recovery, and multidisciplinary teams in primary care settings have facilitated this change. As noted in Chapters 2 and 4, the 2017– 2018 Federal Health Accord provided funding to all jurisdictions directly to improve and expand home and community care services. This chapter will look at some of the different health care workers in Canada—who they are, what they do, and where they work. It will briefly examine some of the professional organizations that support these people, and the regulations, policies, and procedures in place to ensure that care is given by individuals qualified in their field. This chapter focuses mainly on the evolving team-based models of delivering primary care in Canada. The list of health care professionals discussed in this chapter represents a cross section of these providers. The provision of health care involves numerous professionals who are in both essential and supportive roles. Such professionals include

clinical practitioners and those offering IT and administrative support.

Categories of health care providers Health care providers have traditionally been divided into three categories: conventional, core, or mainstream (e.g., physicians, nurse practitioners, midwives, nurses, dentists); allied health professionals (e.g., dental hygienists, dietitians, optometrists, psychologists); and complementary and alternative practitioners (e.g., Indigenous healers, naturopathic doctors, massage therapists). Some sources simply refer to health professionals as either regulated or nonregulated, dispensing with the previously discussed categories. See Table 5.1 for a categorization of some of Canada’s many health care providers.

Table 5.1 Some of Canada’s Health Care Providers. Conventional Health Care Providers Chiropodists (Podiatrists) Dental Assistants Dental Hygienists Dentists Registered Dietitians/Nutritionist Licensed Practical Nurses Medical Laboratory Technologists Medical Radiation Technologists Midwives Nurse Practitioners Occupational Therapists Opticians Optometrists Osteopaths Personal Support Workers (Health Care Aides) Pharmacists Physician Assistants Physicians Physiotherapists Psychologists Registered Nurses Clinical Nurse Specialists Registered Psychiatric Nurses Respiratory Therapists Social Workers Speech-Language Pathologists Audiologists

Complementary and Alternative Health Care Providers Indigenous Healers Acupuncture Practitioners Aromatherapists Chiropractors Homeopathic Doctors Massage Therapists Naturopathic Doctors Reflexologists Reiki Practitioners Therapeutic Touch Practitioners Traditional Chinese Medicine Practitioners Yoga Practitioners

Note: This list is neither exclusive nor definitive. Titles, roles, and categorization vary by region. For example, chiropractors and acupuncture practitioners may well be considered conventional health care providers by some.

However, these categories are controversial, as managing the care of patients has taken on a team approach, with numerous health professionals participating in and contributing to the patient’s diagnosis, treatment, and ongoing care. Moreover, interdisciplinary team members are regarded as partners with respect to rendering patient care, contributing differently but equally, relative to their professional expertise and scope of practice.

Conventional Medicine

Conventional medicine is frequently referred to as orthodox, mainstream, traditional, or Western medicine. Conventional medicine typically encompasses all those modalities not performed by alternative practitioners. They diagnose health problems; treat prediagnosed health problems; and render technical, therapeutic, or supportive care with scientifically proven therapies, medication, and surgery.

Complementary and Alternative Medicine Complementary and alternative medicine (CAM) is practised by all health care providers not considered mainstream. Note, however, that although the terms are sometimes used interchangeably, strictly speaking, a difference exists between alternative and complementary medicine. As their names suggests, complementary medicine (meaning “in addition to”) supports, or complements, conventional medicine, whereas alternative medicine typically provides an option—an alternative—often to the exclusion of conventional medicine. What is considered alternative and what is considered complementary is somewhat fluid and subjective. Moreover, what is considered standard treatment in one country, or even in one province or territory, may not be in another. Acupuncture is standard medical care in China, but considered by many to be part of CAM in Canada. In Canada, although private insurance plans may cover some complementary or alternative therapies, this does not apply to most provincial and territorial insurance plans, and as a rule, these therapies are not used in hospitals. Many of these techniques originate from spiritual, cultural, or religious beliefs and remain unproven by scientific standards. Critics of alternative medicine believe that treatments should be scientifically proven before they are used (also called an evidenceinformed or evidence-based approach). Therapeutic touch, for example, claims to use balance and energy coupled with the healing force of the practitioner’s hands to facilitate a patient’s recovery; however, no scientific evidence exists to prove it alters the course of a disease. That is not to say that therapeutic touch does not benefit the patient by reducing stress and promoting relaxation.

A significant number of Canadians use CAM at some point in their lives. This may be due to many factors, including disillusionment with conventional treatment, difficulty getting appointments with their doctor, cultural influences and belief systems that contradict mainstream medicine, information available on the Internet, and simply that many more people are actively participating in their own health care and treatment options. As long as an alternative therapy is safe and results in some benefits for the patient, many medical practitioners welcome it as a complementary option. Occasionally, a person will seek alternative treatment when conventional medicine has nothing more to offer—for example, in the case of terminal cancer. If the treatment does no harm, it may provide optimism and comfort and perhaps prolong life and ease suffering.

  Thinking it Through Janet was treated for breast cancer 2 years ago with an optimistic prognosis. Last month, she went to her physician complaining of shortness of breath. Magnetic resonance imaging (MRI) revealed metastasis to both lungs (the spread of cancerous cells from their original site). Janet’s oncologist recommended chemotherapy and radiation. This time, her prognosis was guarded at best. Janet, based on her former unpleasant experience with the side effects of these treatments, decided to seek a homeopathic remedy. Considering these alternatives, what would you do if you were this patient? If you were a health provider and Janet approached you for advice regarding her decision, how would you respond? When a patient is using CAM, the best outcomes occur when the patient, CAM practitioner(s), and medical practitioner work together to ensure that no dangerous overlaps occur in care and treatments. For example, herbal medicine can interfere with prescribed medications. St. John’s wort, a common herbal supplement taken to ward off depression, and prescription antidepressant drugs used together can result in an overdose. Many people use herbal medications (available over the counter at health stores and

pharmacies), but fail to inform their doctor. They may believe that herbal medications are harmless, or they may be embarrassed or fearful to admit to taking such medications, believing their physician will disapprove. Health care that embraces both conventional and complementary medicine can help to establish a trusting alliance with patients, and provide medical and psychological benefits.

Chiropractic: Conventional, Complementary, or Alternative? Chiropractors (doctors of chiropractic medicine) form the largest group of CAM practitioners. To obtain a degree to qualify for clinical practice, chiropractors complete 4 to 5 years of postsecondary education. Working in individual or group practices, they diagnose and treat a wide range of conditions that deal primarily with disorders of the spine, pelvis, extremities, and joints, and the resulting effects on the central nervous system. Taking a relatively holistic approach to patient care, chiropractors use various types of noninvasive therapies, such as exercise routines and spinal adjustments. Chiropractors are not licensed to prescribe medicine in the same manner as a medical doctor or to do surgery. Chiropractic care is not covered by most provincial or territorial plans, but most private insurance plans (extended health benefits) will pay for a specified number of visits and treatments. Chiropractic medicine is still considered by many to be on the cusp of alternative and complementary medicine, and the relationship between chiropractors and physicians is variable, some sharing a mutual respect, while others prefer to keep their professional distance.

Regulation of health care professions The majority of health care professions are self-regulated, meaning that a professional body enters into an agreement with the government to exercise control over and set standards for its members. Others are regulated by the government, meaning that legislation controls the conduct and practice of the profession and its members. Regulatory authority is granted through legislation, such as an act or statute that outlines the framework for behaviour and values for a given profession. In Canada, provincial and territorial legislation (e.g., British Columbia’s and Alberta’s Health Professions Act, Ontario’s Regulated Health Professions Act) provides the legal framework for regulating most health care professions. Regulated professions have self-governing bodies called colleges (e.g., College of Registered Nurses of Nova Scotia, College of Massage Therapists of Newfoundland and Labrador), which regulate the conduct and practice of their members. Each province and territory has 20 to 30 regulated health care professions; professions regulated in some provinces and territories may not be regulated in all (Table 5.2). For example, registered psychiatric nurses in British Columbia are regulated by a college unique to their specialty—the College of Registered Psychiatric Nurses of British Columbia—while in Ontario, psychiatric nurses are under the umbrella of the College of Nurses of Ontario. Although regulated professions provide support for its members, the overriding objective of regulated professions is to protect the public, ensuring that safe care is rendered by health professionals working within their scope of practice.

Table 5.2 Regulated Health Care Professions in Each Province and Territory.

•, Self-regulated; ∗, government regulated; **, self-regulation committee.

Sources: Alberta Health. (2018). Regulatory colleges. Retrieved from http://www.health.alberta.ca/professionals/regulatorycolleges.html; British Columbia Ministry of Health. (n.d.). Professional

regulation. Retrieved from www2.gov.bc.ca/gov/content/health/practitioner-professionalresources/professional-regulation; Manitoba Health, Seniors & Active Living. (n.d.). Health regulators. Retrieved from http://www.gov.mb.ca/health/legislation/contact.html; New Brunswick Department of Health. (2016). Health related occupations. Retrieved from www.welcomenb.ca/content/welbien/en/working/content/CredentialsRecognized/Health.html; Newfoundland and Labrador Health and Community Services. (2018). Regulated health professions. Retrieved from www.health.gov.nl.ca/health/publications/index.html%23rhp; Newfoundland and Labrador Council of Health Professionals. (2018). Regulations/Registration. Retrieved from www.nlchp.ca/level2.php%3Fid%3D35; Nova Scotia Department of Health and Wellness. (2012). Regulated health professions. Retrieved from https://novascotia.ca/dhw/phia/documents/chapters/appendixiv-regulated-health-professions.pdf; Nova Scotia Regulated Health Professions Network. (2018). Member listing. Retrieved from www.nsrhpn.ca/member-listing/; Northwest Territories Health and Social Services. (n.d.). Professional licensing. Retrieved from www.hss.gov.nt.ca/en/services/professional-licensing; Nunavut Department of Health. (n.d.). Legislation and policy. Retrieved from https://gov.nu.ca/health/information/legislation-and-policy-0; Ontario Ministry of Health and Long-Term Care. (2017). Regulated health professions. Retrieved from www.health.gov.on.ca/en/pro/programs/hhrsd/about/regulated_p rofessions.aspx; Prince Edward Island Health and Wellness. (2018). Regulated Health Professions Act. Retrieved from https://www.princeedwardisland.ca/sites/default/files/legislation /R%2610-1-4Regulated%20Health%20Professions%20Act%20Practice%20of%20.p df; Conseil interprofessionnel du Québec. (2014). Regulated professions. Retrieved from https://professions-quebec.org/en/the-professionalorders/regulated-professions/; Saskatchewan Ministry of Health. (n.d.). Health professional associations and organizations. Retrieved from https://www.saskatchewan.ca/government/health-care-

administration-and-provider-resources/resources-for-health-carebusinesses-and-career-development/health-professional-associations; Yukon Health and Social Services. (2018). Regulated health professions. Retrieved from http://www.yukoniehp.ca/regulatedhealthprofessions.php; Yukon Health and Social Services. (2018). Nonregulated health professions. Retrieved from http://www.yukoniehp.ca/unregulatedhealthprofessions.php.

Title Protection Regulated professionals—those who belong to a professional body— are licensed to practise their profession and are legally entitled to use a specific designation such as registered massage therapist (RMT). These professions receive title protection, meaning only properly trained persons registered and in good standing with their regulatory body can legally use that title. For example, people who have cared for loved ones at home but have no formal training cannot call themselves licensed or registered practical nurses. Likewise, someone who dropped out of college halfway through a respiratory therapy program cannot call himself or herself a respiratory therapist. Nor can health care aides call themselves nurses. Conversely, someone trained on the job can call themselves a health care aid or equivalent as there is no regulatory body legally preventing this title. Fully trained nurses registered in other countries cannot call themselves registered nurses here until they have met the standards set by the college of nurses in the province or territory they want to practise in. Along with title protection, regulated professions share other collective elements (Box 5.1).

  Box 5.1

Regulated Professions: Common Elements.

• Educational standards • Provincial and territorial examinations • Practitioner’s scope of practice, which outlines skills, acts, and services the practitioner is able to perform competently and safely • Curbing of individual’s practice if standards are not met • Formal complaints process for the public • Complaints investigation and follow-up • Title protection • Competence and quality assurance Any health care profession can apply to the government to become regulated, but it must meet strict criteria. The minister of health and some type of advisory body within the province or territory usually oversee the lengthy and often arduous application process. Just as the possession of a legitimate driver’s licence promises that a person knows how to drive and has passed a driving test, regulation proves a person has undergone training and gained a predetermined degree of knowledge, skill, or ability. Possession of a driver’s licence, however, does not guarantee driving excellence; even in regulated professions, some health care providers offer substandard services. All regulated professionals must practise within a framework of skills and services defined by their governing body. Nurses have certain skills and acts they have been trained to do; physicians have a range of skills and services they have been trained to offer; and respiratory therapists, medical, and other health care practitioners, likewise, have a defined scope of practice. Even within a single profession, different levels of practice exist. For example, registered nurses with special training (e.g., advanced practice) may perform acts that those without this training cannot. Nurses usually have to take specialized courses to acquire the skills to start an intravenous, or managing wound care. Similarly, a medical doctor in family practice is not qualified to remove a gallbladder or do a hip replacement; a licensed practical nurse is not qualified to do a complete physical, but a nurse practitioner is; and a massage

therapist is not qualified to deliver a baby, but a midwife, nurse practitioner, or obstetrician is. In health care, many of these skilled procedures, some specific to certain professions, are called controlled acts.

Performing Controlled Acts Controlled acts (called reserved acts in British Columbia), if not performed by a qualified practitioner, may result in harm to a patient. Examples of controlled acts include giving an injection, setting or casting a fracture, passing a nasogastric tube, and prescribing a medication. Controlled acts are identified by the Regulated Health Professions Act (RHA) or the equivalent in each jurisdiction. For example, the RHA in Ontario has identified 14 controlled acts, which are similar across the country. Acts related to each profession further define which controlled act(s) members of that profession can perform—for example, respiratory therapists and regulated radiation technologists can perform 5 of the 14 acts, physicians can perform thirteen. Some controlled acts can be performed by more than one regulated profession (overlap), but all regulated health professions are allowed to perform controlled acts. Controlled acts may only be performed in response to an order (either direct or indirect) given by a physician or nurse practitioner, for example.

Exceptions Most provinces and territories allow controlled acts to be performed in certain situations by competent yet nonregulated individuals, including the following: • A person with appropriate training providing first aid or assistance in an emergency • Students learning to perform an act under the supervision of a qualified person, as long as that act is within the scope of practice of graduates of the student’s professional program • A person, such as a caregiver, trained to perform an act (e.g., giving injections to a person with diabetes)

• An appropriate person designated to perform an act in accordance with a religion—for example, a rabbi may circumcise a male child Exclusions also apply in the case of body piercing for the purpose of jewellery, electrolysis, tattooing, and ear piercing.

  Thinking it Through Miranda, a personal support worker, is looking after an older woman, Ibia. Ibia has not gone to the bathroom for several hours and is very uncomfortable. Ibia’s visiting RN occasionally has to catheterize her; however, the nurse is unavailable for a few hours. Miranda, who is a fully qualified nurse from England, performed the procedure, successfully draining off the urine, and making the patient comfortable. Clearly, Miranda was performing a controlled act that she was not qualified to do in Canada. 1. Would you have done the same thing? 2. What alternatives did Miranda have? 3. Do you think that because Miranda, a nurse in her own country, who had done the procedure many times, was justified in her actions?

Delegated Acts As our health care system continues to evolve, health care providers’ scopes of practice are also evolving. Reforms in the health care system, in methods of delivery, and in health care providers’ responsibilities, have affected the traditional roles of health care providers. The needs of patients also continue to change—more complex care is required more frequently. For patient needs to be met, occasionally the acts, procedures, and treatments rendered by health care providers must go beyond standard boundaries. A delegated act by definition is the means by which a regulated health professional (authorized to perform the delegated act)

transfers legal authority or permits another person to carry out a controlled act they are otherwise unauthorized to do (procedures that are not controlled acts do not require delegation). The delegated act may include a specific procedure, treatment, or intervention that is not within the scope of practice of the person to whom the act is delegated. For instance, a registered nurse working in the community can delegate the act of giving an injection to a nonregulated provider (personal support worker), or to a daughter caring for her father at home. Physicians can delegate the act of obtaining a pap smear to a nurse, or delegate the act of giving allergy injections or immunizations to an administrative assistant. Not all controlled acts can be delegated. Those that can be delegated are defined by provincial and territorial regulations (under the jurisdictions Regulated Health Professions). For example, a nurse practitioner cannot delegate the act of prescribing a medication to a registered nurse or an occupational therapist. A licensed practical nurse cannot delegate the act of dispensing a medication to a personal support worker, and a respiratory therapist cannot delegate the act of intubating a patient to a physiotherapist, registered nurse, or a nurse practitioner. Acts in most jurisdictions cannot be subdelegated. This means that a person accepting the responsibility of performing a delegated act cannot assign someone else to carry out that act. Guidelines and protocols for delegation of medical acts vary across Canada. In some jurisdictions, controlled acts can be delegated only to a person who is a member of a regulated profession, but in others, certain acts may be delegated by a regulated health professional to a nonregulated health care provider. Generally, the delegated act must be clearly defined and supervised accordingly. Supervision can be direct (i.e., the delegating health care provider is physically present), or indirect (i.e., the delegating provider is available for consultation by phone). In most health care organizations, authorities such as a board of directors or a medical advisory committee or their equivalents must agree to the rules and procedures for delegated acts. This may be agency specific, for example, identifying acts an RN may delegate to a nonregulated care provider to perform. The health care provider with

expert knowledge has a commitment to his or her patient to ensure that the person performing the act—called the delegate—is properly trained and demonstrates competence in completing the act. The delegating health care professional, the delegate, the facility, or environment in which the act is performed share responsibility for the act. The health care professional who teaches or assesses the delegate’s initial performance of the delegated act (and determines the delegate is competent) is accountable for ensuring the act is, in fact, carried out competently. The person carrying out the act is liable if he or she performs the act ineffectually. Usually the patient or patient’s power of attorney for personal care must give informed consent to allow someone other than the regulated health care professional (for whom the act is within his or her scope of practice) to perform a procedure. For acts typically performed by physicians, delegation will occur only with the patient’s consent and only after the physician has assessed the patient, discussed the procedure, and answered any outstanding questions. Details outlining regulations for delegated acts are available on provincial or territorial websites for related nursing and medical associations. It is worth noting that many colleges offer courses to nonregulated individuals on carrying out certain interventions (e.g., giving injections and administering medications) (Case Example 5.1).

  Case Example 5.1 Dr. Wilkinson has decided to allow his administrative assistant, Shandra, to give immunizations to his patients. Shandra decides to take a course on how to give injections at a nearby community college, although she was not required to do so. After the course, Shandra felt more comfortable with both her knowledge base and clinical technique regarding administering injections.

Complaint Process

Regulated professions have a system in place whereby the public can launch complaints against a health care provider. A designated committee investigates all complaints, protecting both the public, who can rest assured that legitimate complaints will be looked into and appropriate action taken, and health care providers, who will have illegitimate or unfounded complaints against them dismissed. Health care providers found to be at fault may face suspension, an order for additional training, the loss of their licence to practise, or even legal proceedings, such as a criminal investigation.

Educational Standards A regulator of a profession has the authority to set educational standards for the training of its professional members, including theoretical and practical components of their education as well as examinations for entry to practise. The educational process both prepares professional members and also provides assurance to the public that the health care provider is competent to practise. Professional bodies often use competency-based assessment programs to ensure the continued maintenance of practice standards, protecting both the health care provider and the public. The requirements may include the use of self-assessment tools, participating in continuing education programs, keeping a record of professional activities, or a combination of these. Often proof that these standards have been met is a requirement for renewal of a professional’s licence to practise.

Licence to Practise In each province and territory regulators of professions, in conjunction with educational facilities and in keeping with provincial and territorial requirements, oversee the licensing of their members. Regulated professions almost always require licence renewal annually. Many now have other criteria that must be met, such as peer reviews or other proof of ongoing education. Moving from one province or territory to another can cause issues for some professionals since not all regulated professions have

agreements and standards in place for members to practise in other jurisdictions (Case Example 5.2).

  Case Example 5.2 Because physicians write a national examination, they are qualified to practise anywhere in Canada, but each jurisdiction must license physicians to practise. Dr. Hiraki, a licensed general surgeon in Newfoundland and Labrador, wants to practise medicine in British Columbia; therefore she must apply to the College of Physicians and Surgeons of British Columbia and follow provincial protocol before working in the province. Although the standards of practice for doctors are the same across the country, medical and legal issues are often different, and every physician practising in a particular jurisdiction must be aware of jurisdictional and legal guidelines that pertain to that region. Once licensed in British Columbia, Dr. Hiraki will be assigned a billing number, which she must use to bill the provincial plan for services rendered.

Nonregulated Professions and Occupations Table 5.2 illustrates the current professions that are regulated in the provinces and territories across Canada. All others work in the many professions and occupations that remain nonregulated, ranging from jobs that require university degrees and in-depth, specialized training, to those requiring very little education or training. People who work within nonregulated occupations do not have federal or provincial legislation governing their occupations. Like regulated professions, however, many nonregulated occupations have professional organizations or bodies that award certification when a person completes a set of written or practical examinations or both—for example, the Medical Secretary’s Association in British Columbia (Ontario no longer has such a body). When a profession is unregulated, a job applicant has not met the educational requirements of his or her regulatory body, the person or organization doing the hiring sets the requirements (Case Example

5.3). For example, to work as a medical secretary, an administrator in a doctor’s office, or as a clinical secretary (ward clerk) in a hospital, a person requires a specialized knowledge base; however, an employer may hire someone with or without a certificate or diploma. A doctor, for example, can choose to hire a person with related experience as a medical secretary and provide additional on-the-job training, or can hire someone who has graduated from a 1-year certificate or 2-year diploma program in medical office administration. A hospital may require a clinical secretary to have a grade 12 diploma with some secretarial experience, or alternatively, a diploma from a 2-year health services administration program.

  Case Example 5.3 The CEO of a primary care organization in Alberta has decided that he wants to hire a nurse to work with the health care team. The nurse must be a registered nurse (as opposed to a graduate nurse). An applicant, Phillip Heinz, graduated 2 years previously from a university nursing program in the province, but did not pass his national examinations. Therefore Phillip is a graduate nurse and not a registered nurse. He has been working in a long-term care facility where his graduate status was not a problem. Another applicant, Marika Smith, also a graduate from a university nursing program successfully completed her national registration examinations (NCLEX-RN) a month earlier, and met all requirements to become a member of the College and Association of Registered Nurses of Alberta. Marika is a registered nurse, and because she has this designation, she is the best applicant. Many nonregulated disciplines have no specific standards to meet. For example, anyone can learn how to do ear candling or aromatherapy and put out a sign inviting the public to seek treatment.

Mainstream health care providers Health care traditionally has been dominated by physicians—from family doctors to specialists. However, a shift toward a team approach to health continues to evolve across Canada, maximizing the skills and expertise of a variety of health care providers, particularly in the primary care setting.

Physicians Entrance requirements for medical school vary across Canada, but most universities require the applicant to complete 2 to 4 years of undergraduate work, usually obtaining a bachelor’s degree, and then write an entrance examination, called the Medical College Admission Test (MCAT), before applying for placement in one of Canada’s medical schools. Medical school consists of 3 to 4 years of study, followed by a residency in the person’s area of specialty (e.g., family medicine, internal medicine, general surgery). A doctor with specialized training in one area, called a specialist, usually sees patients only upon request from a family doctor or another specialist. In fact, most provincial or territorial insurance plans will not cover the cost of a patient visiting a specialist without such a referral. A family doctor will refer a patient to a specialist (also called a consultant) when the patient requires assessment and treatment outside the family doctor’s scope of practice. Many specialists work in solo practice; others work in private or public organizations, or are employed by hospitals.

Family Physicians Family doctors are also called general practitioners or primary care physicians. With a wide knowledge base not limited to any specific disease or system or to any particular sex or age group, the family doctor provides ongoing care that includes the diagnosis and treatment of conditions and diseases not requiring the care of a specialist, counselling, health promotion and disease prevention, and primary maternity and mental health care. Most family doctors work

in primary care team settings (discussed later). A few remain in solo practice, and some in various types of clinics or health centres, especially in more remote regions of the country. Many family doctors also oversee the medical care of patients in health care facilities such as long-term care residences. Some still make house calls, for which the patient must pay out of pocket, but that service is not as prevalent as in the past. In addition, many family doctors now choose to give up their hospital privileges, temporarily turning over the care of their hospitalized patients to a hospitalist or other specialist.

Emergentologists Some physicians, called emergentologists, have chosen careers practising full-time emergency medicine. This specialty has developed because many emergency departments (EDs), also often referred to as emergency rooms (ERs), are choosing to hire full-time physicians, rather than staffing the ED with on-call physicians as in the past.

Geriatricians Geriatrics focuses on the care of older people, typically those over 65. A geriatrician is usually an internist who has additional training in caring for older adults. Geriatrics does not attract a large number of physicians. The assessment and treatment of an individual with complex medical conditions is time consuming. Additionally, geriatricians are typically paid less than other specialists. Most work in private practice, teamoriented practices, or health care facilities.

Cardiologists Cardiologists specialize in conditions and diseases of the heart, ranging from abnormal rhythms and heart attacks to related vascular problems. The cardiologist treats patients from a medical perspective, but does not do surgery. If surgery is required, the patient will be referred to a cardiac surgeon. Aside from seeing patients in the office setting, cardiologists with special training may carry out diagnostic

procedures such as cardiac catheterizations in a hospital or private diagnostic facility.

Gynecologists and Obstetricians Specializing in women’s health, gynecologists diagnose and treat disorders of the gynecological and reproductive systems. Obstetricians focus on the care of pregnant women and the delivery of their babies in both normal and high-risk situations. Closely related, these two specialties are usually undertaken together (resulting in the abbreviation OB/GYN).

Internists and Hospitalists An internist typically diagnoses and renders nonsurgical treatment for diseases of a person’s internal organs (e.g., problems of the digestive tract, liver, or kidneys). An internist often refers patients to other specialists who deal with specific organs. A hospitalist is a physician—usually an internist—who oversees the medical care of patients in the hospital, usually those who do not have a family doctor with admitting privileges to that hospital. Also, a hospitalist will collaborate with specialists as required. Usually employed by the hospital, a hospitalist may or may not have a private practice.

Neurologists A neurologist treats conditions of the nervous system, including chronic and potentially fatal conditions such as Parkinson disease and multiple sclerosis, sleep disorders, headaches, peripheral vascular disease, brain tumors, and spinal cord injuries. Neurologists do not perform surgery. Patients requiring surgery would be referred to a neurosurgeon.

Ophthalmologists Ophthalmologists, medical doctors who specialize in diseases of the eye, can carry out both medical and surgical procedures, such as cataract removal and ocular emergencies (e.g., glaucoma, eye trauma). Although ophthalmologists can perform refractions and

prescribe glasses, these functions have largely been taken over by optometrists (who are not medical doctors). Cataract surgery is done either in hospital or in free-standing medical facilities, such as Lasik MD clinics or the Canadian Centre for Advanced Eye Therapeutics Inc.

Oncologists Oncology is the branch of medicine that deals with all forms and stages of cancerous tumours—development, diagnosis, treatment, and prevention. An oncologist specializes in the care and treatment of people with cancer. Because cancer treatment has become so highly specialized, oncologists may specialize in only certain areas, such as radiation therapy, chemotherapy, gynecological oncology, or surgery. Oncologists usually practise in large hospitals or medical centres specializing in cancer treatment. They also provide ongoing treatment for patients in hospices and related facilities.

Psychiatrists Psychiatrists specialize in mental illness and emotional disorders, including depression, bipolar disorder, schizophrenia, obsessive compulsive disorder (OCD), borderline personality disorder, bulimia, anorexia nervosa, and personal stress issues. As medical doctors, psychiatrists can order laboratory and diagnostic tests and prescribe medicine, unlike psychologists who are not medical doctors. Psychiatrists do not perform surgical procedures. Geriatric psychiatry is an emerging field.

Physiatrists Physiatrists, medical doctors specializing in physical and rehabilitative medicine, work closely with other health care providers, such as physiotherapists, occupational therapists, and geriatricians. Stroke and accident victims and postsurgical patients are among the types of patients that a physiatrist would see. Comprehensive care aims to restore the patient to his or her maximum level of function. The family almost always plays a role in the restorative and rehabilitative process, as treatment is usually long

and arduous. For this reason, social workers, psychologists, or psychiatrists may also participate in the health care team.

Radiologists A radiologist is a physician with additional training in the use and interpretation of imaging techniques to diagnose and treat disease. The radiologist is primarily a consultant to other physicians, but may also be involved in the planning of patient care. Radiologists are primarily found in large diagnostic centres, either hospital- or community-based, private or publicly funded.

Respirologists Respirologists, sometimes referred to as pulmonologists, are medical doctors who further specialize in the diagnosis and treatment of lung disease, such as asthma, emphysema, or pneumonia. Respirologists perform tests to check how well a person is breathing and may use procedures such as bronchoscopy to diagnose a breathing problem.

Surgeons Surgeons complete their surgery residency in their field of choice, usually over a period of 4 years or more, after completing medical school. A general surgeon completes a number of rotations through various specialties. General surgeons are qualified to perform a wide range of procedures, mostly involving the gastrointestinal tract. Many go on to further specialize in specific areas such as gynecology, neurosurgery, or cardiovascular surgery. A surgeon’s scope of practice varies with experience, specialty training, and level of comfort with the type of surgery they are asked to perform (Case Example 5.4).

  Case Example 5.4 Roberta presents in the ED complaining of chest pain. Investigation reveals she has a blockage in a major artery serious enough to require surgery. Dr. Xiong, a general surgeon, is on call. Dr. Xiong is

qualified to assess Roberta’s condition but has no special training in cardiovascular surgery. Roberta is referred to Dr. Silanka, a cardiovascular surgeon who completes all required examinations and tests and performs the surgery.

Nurses Many agree that the nurse, with skills across several disciplines, remains the backbone of the health care system in hospitals, primary care settings, and in the community. Multiskilled and flexible, with a broad knowledge base, nurses frequently assume responsibilities typically assumed by other members of the health care team. For example, when a respiratory therapist is not available, the nurse may do the inhalation treatments or set up oxygen for a patient; when a physiotherapist is unavailable, the nurse ambulates a patient and supervises his or her related exercises; when the chaplain is not available, the nurse counsels and comforts the patient and loved ones. When the clinical secretary is ill, the nurse may also assume administrative responsibilities for the patient care unit.

Registered Nurses All Canadian jurisdictions except Quebec require bachelor degrees in nursing (BN or BScN) to enter the profession. Degrees in nursing can be completed in 2, 3, or 4 years. Accelerated (2-year) programs are available across Canada. The related regulatory body in each province or territory must ensure that the individuals seeking to practise as nurses meet designated levels of competence. To that end, program graduates in all jurisdictions except Quebec must write a national examination. Introduced in 2015, the National Council Licensure Examination (NCLEX-RN) replaces the Canadian Registered Nurse Examination (CRNE) as Canada’s national examination. Applicants for registration as a registered nurse (RN) are required to successfully complete the NCLEX-RN exam, administered by the National Council of State Boards of Nursing (NCSBN). Some jurisdictions require additional examinations. In Quebec, in addition to a provincial examination, applicants must pass a Language Proficiency Licensure Examination

administered by the Office Québécois de la Langue Française—in accordance with Article 35 of the Charter of the French Language. Those applying to practise in Ontario must also write a jurisprudence examination, which tests knowledge about provincial nursing and health care legislation. Postgraduate and ongoing educational opportunities for RNs vary among provinces and territories. Some specialties include critical care, emergency nursing, community health nursing, hospice and palliative care, and perinatal and woman’s health. The RN usually assumes the most complex components of nursing care and also a variety of leadership roles both clinical and administrative. Many hospitals and other facilities employ RNs only in specific areas, such as intensive care units where their specific skill sets, particularly in assessment and decision making, are critical. The number of RNs practising in Canada dropped by 0.3% between 2014 and 2015, but increased by 2.2% between 2014 and 2016, with 95.6% of RNs/NPs working within the profession. In 2015, just over 60% of RNs were employed full-time (Canadian Institute for Health Information, 2016).

Advance Practice Nurses There are two categories of advanced practice nurses recognized in Canada, nurse practitioners, and clinical nurse specialists:

Nurse Practitioners Nurse practitioners (NPs) are registered nurses with advanced training and skills (RN Extended Class), authorizing them to practise in an expanded role with many of the skills and responsibilities formerly relegated to primary care physicians. NPs can autonomously diagnose and treat health conditions, order and interpret some laboratory and diagnostic tests, and prescribe a wide range of medications, including controlled substances (e.g., recently in British Columbia, methadone, an opioid agonist). As with other providers, NPs incorporate health education, disease prevention, and health promotion in their treatment plans. In addition, NPs can carry out specified controlled acts and activities that other nurses, by law, cannot.

There are approximately 28 postgraduate facilities offering NP programs in Canada, the majority at the masters and postmasters levels. Many of these programs are funded by their respective provincial/territorial governments. To obtain a licence to practise as an NP, individuals must be registered and in good standing with their regulatory body in the jurisdiction where they completed their NP education program. Registration exam requirements for NPs vary among the provinces and territories. In Canada, there are three broad streams (or specialties) in which the NP can practise: adult, family (also referred to as primary health care), and pediatrics. In some jurisdictions, neonatology is another area. Candidates must write an examination specific to their chosen specialty. Quebec has different specialties than other jurisdictions, including cardiology and nephrology. British Columbia and Quebec have a clinical examination, called the objective structure clinical exams (although they differ in each province). All other jurisdictions have only written exam requirements. As with protocols governing licensing criteria, NP competencies vary among provinces and territories reflective to the related legislation in each region (Canadian Association of Schools of Nursing, 2014; Case Example 5.5).

  Case Example 5.5 Natalie is applying for a nurse practitioner’s licence in B.C. After she completes the nurse practitioner program, Natalie applies for, writes, and passes the College of Registered Nurses of British Columbia examination, the provinces clinical examination (OSCE) for adults, families, or pediatrics, and one of the written exams in her chosen specialty that is recognized by CRNBC. Natalie chose the family stream or primary care stream. She can choose from recognized examinations including the Canadian Nurse Practitioner examination, the American Nurses Credentialing Center examination, or the American Academy of Nurse Practitioners in family examination.

NPs, like other regulated nurses, must renew their licence yearly. This usually involves practising a minimum number of practice hours and participation in designated quality-assurance programs, ongoing education, or both. Practice settings include primary care and community settings, hospitals under specialty designations (e.g., pediatrics, cardiology), and in emergency departments. In 2016, NPs had the highest fulltime employment rate among regulated nurses in Canada (Canadian Institute for Health Information, 2017).

Clinical Nurse Specialists Clinical nurse specialists (CNSs) are nurses who have a master’s or doctoral degree in nursing in addition to wide-ranging nursing knowledge and skills and clinical experience in a specialty area (e.g., cardiology, oncology, mental health, geriatrics, neonatology). Usually in leadership positions, CNSs work in a variety of roles—as clinicians, consultants, educators, and researchers. In any setting, CNSs contribute to evidence-based practices, continuity of care, improved patient experiences, and enhanced treatment and health care outcomes. CNS is not a protected title.

Registered Psychiatric Nurses Registered psychiatric nurses (RPNs)—not to be confused with registered practical nurses (RPNs) in Ontario—are recognized as a separate regulated health profession in Western Canada (Manitoba, Saskatchewan, Alberta, and British Columbia) and the Yukon. They form the largest body of mental health care professionals providing services in Western Canada. RPNs focus on the mental, developmental wellness (i.e., incorporating a holistic approach including mind, body, and spirit), mental illness, addictions and substance abuse, as well as the physical components of health of individuals within the context of their overall health and life situations. RPNs apply concepts from biopsychosocial and spiritual models of wellness, integrated with cultural norms, to maintain inclusion of a holistic approach to care and treatment. RPNs work with a variety of other health care providers and mental health and community organizations. Practice settings are

diverse and can include crisis stabilization and forensic assessment units, hospitals, the community, and academic facilities. Unique and separate from BN or BScN programs, education for RPNs (available only in Western Canada) is offered at the degree level and incorporates medical and surgical nursing skills with those specific to the area of mental health. The last intake into a diploma program was January 2016. Their national organization, the Registered Psychiatric Nurse Regulators of Canada (RPNRC), is an incorporated, virtual organization. Its nearly 5600 members are from the formal regulatory bodies, including the College of Registered Psychiatric Nurses of Alberta, British Columbia, Manitoba, and Saskatchewan. In the Yukon, the Ministry of Community Services also regulates RPNs. The Canadian Institute for Health Information (CIHI) reports that 94.8% of RPNs were working within the profession between 2015 and 2016, 61.7% employed in full-time positions.

Licensed Practical Nurses To become a licensed practical nurse (LPN), called a registered practical nurse (RPN) in Ontario, a person must complete high school (or the equivalent) and a 2-year diploma program at a community or private college. All jurisdictions require graduates to write the Canadian Practical Nurse Registration Examination (CPNRE) for provincial or territorial registration and to use the professional designation. The skill set and scope of practice of LPNs have expanded dramatically over the past few years, with practical nurses now assuming many of the skills and responsibilities formerly limited to registered nurses. Their skill set includes doing dressings, dispensing medications, and in some facilities, taking charge of units. The practical nurse collaborates with registered nurses and other members of the health care team to render patient care. Practical nurses can be found in almost all practice settings and in the community. In 2016, the CIHI reported that 89.4% of LPNs were working within the profession, but less than half were employed fulltime.

Physician Assistants Physician assistants (PAs) are academically prepared health care providers who work directly with or under the direction of a physician. Their responsibilities are usually outlined in a formal contract between the PA and the physician(s) and may sometimes include the facility in which they work. The PA’s scope of practice ranges from interviewing patients and health teaching to performing physical examinations and selected diagnostic tests. To become a PA, the person must first have a Bachelor of Science degree. Certification is awarded upon successful completion of an entry-to-practice examination, after completion of a 2-year Canadian Medical Association–accredited program. A PA program offered by the Canadian Armed Forces Medical Services School in Borden, Ontario, provides training for the military; civilian programs are limited and offered only in selected jurisdictions. The Provincial College of Physicians and Surgeons regulates PAs in Alberta, Manitoba, and New Brunswick. The terms under which they practise in other jurisdictions vary. In Ontario, where the profession is currently unregulated, a PA may work under the Designated Medical Act and only under the direction of a physician. Physician assistants cannot practise independently.

Pharmacists A licensed pharmacist, among other things, dispenses medications in response to prescriptions. Experts in their field, pharmacists provide other members of the health care team with valuable information about medications. The physician looks to the pharmacist for advice about current prescription drugs and their interactions. The patient looks to the pharmacist for direction and advice about taking medications, their risks, and adverse effects. In most jurisdictions, the provincial or territorial plan will pay pharmacists to periodically review a person’s medication profile, offer advice and counselling or refer the person to his or her physician if need be. To practise pharmacy, a person must earn a bachelor’s degree in pharmacy, complete an internship, and successfully pass a national board examination through the Pharmacy Examining Board of

Canada. Increasingly, pharmacists are assuming expanded roles from giving flu shots to providing funded information sessions and medication reviews with patients. They are recognized as experts in medication management. Prescribing responsibilities vary across jurisdictions. Most pharmacists can renew or prescribe a limited number of medications (e.g., in the Northwest Territories [NWT], Yukon, and Nunavut, with some exceptions). Only Alberta allows pharmacists to independently prescribe a schedule 1 drug (those with a high potential for addiction) if the pharmacist has met certain requirements. Saskatchewan, New Brunswick, Manitoba, Nova Scotia, Quebec, and the territories are not allowed to make therapeutic substitutions for prescribed medications; all jurisdictions with the exception of Quebec and the territories allow pharmacists to give designated vaccines (e.g., travel and flu). Many jurisdictions, including British Columbia, Alberta, Saskatchewan, Manitoba, New Brunswick, Nova Scotia, and Prince Edward Island, allow pharmacists to write prescriptions under designated guidelines. Ontario pharmacists can prescribe smoking-cessation drugs and give flu shots. Since September 2013, Quebec pharmacists have been authorized to write prescriptions, give extensions on existing prescriptions, adjust medication doses, and order and interpret laboratory tests. Pharmacists in some jurisdictions may also order certain lab tests. Those in Manitoba, Alberta, and Quebec can order designated lab tests, with approval in Saskatchewan, New Brunswick, Nova Scotia, and PEI pending. Pharmacists can also change drug dosage or formulation everywhere except in the territories. The goal of adding new responsibilities to the scope of practice for the pharmacist is to reduce the volume of work for doctors, clinics, and emergency departments, and to provide Canadians with easier access to front-line services (Canadian Pharmacists Association, 2016).

Midwives Depending on the jurisdiction, women experiencing normal pregnancies may choose to see a midwife. Midwives provide prenatal care (before the baby’s birth), deliver the baby (either at the patient’s

home, in a birthing centre, or in the hospital), and provide postpartum (after the delivery) and newborn care for up to 6 weeks after the birth. Midwives, in accordance with jurisdictional guidelines will refer a mother to a physician, usually an obstetrician, if her pregnancy becomes high-risk or shows signs of other problems during any phase of the pregnancy, labour, or delivery. A placenta previa (low-lying placenta), or a multiple pregnancy, for example, would be considered high risk. In some jurisdictions a midwife can still provide prenatal care and work collaboratively with a physician until the time of, and after delivery. Midwifery is licensed in most jurisdictions in Canada. New Brunswick licensed the province’s first midwife in early 2017. To register as a midwife in New Brunswick, the (qualified) midwife initially must meet provincial standards and be hired by the New Brunswick Regional Health Authority. Once a midwife is registered, he or she can work anywhere in the province. Provincial regulations are determined by the Midwifery Council of New Brunswick. Licensing midwives in Prince Edward Island is pending. Midwifery remains an unrecognized profession in the Yukon Territory, although the Community Midwifery Association of Yukon (CMAY) was founded in January 2015 to advance the introduction of the profession to the territory. Midwifery regulations in Newfoundland were passed in April 2016 and came into effect on September 30 of the same year.

Optometrists and Opticians Most optometrists obtain an undergraduate degree, often in mathematics or science, before completing a 4-year university program in optometry at one of Canada’s two schools of optometry (Waterloo, Ontario, and Montreal, Quebec). The minimum requirement for entry to these programs is 3 years of undergraduate preparation, preferably in science. Graduates of a school of optometry are awarded a doctor of optometry degree. To practise, optometrists must be licensed by their province or territory. Skilled in assessing eye function and conditions, they may prescribe selected medications (topical and oral) to treat a variety of eye conditions (e.g., bacterial or

viral eye infections, allergic conjunctivitis, glaucoma, and eye drops to dilate the eyes for examination). Optometrists also prescribe glasses and contact lenses to patients who need them. Most optometrists work in group or solo practices. An optician completes a 2- or 3-year college program, sometimes followed by a practical component. Opticians can fill prescriptions for eyeglasses or contact lenses, fit glasses, help patients select frames, organize the grinding and polishing of lenses, and cut and edge lenses so they fit selected frames. They also do a considerable amount of health instruction related to contact lenses and glasses, including providing information about options such as lens coating and bifocal lenses. They may work independently or in a larger centre with other eye-care specialists. Opticians are regulated in nine jurisdictions across Canada.

Osteopathic Physicians Osteopathy incorporates a holistic, manual approach to the diagnosis and treatment of disease. It considers, in particular, the musculoskeletal system and its relationship with the rest of the body in terms of self-healing, self-regulating capabilities. Osteopathy is practised in many countries but remains a nonregulated profession in Canada. International standards for basic training, skills, and responsibilities are set out by the World Health Organization (WHO). The WHO describes two types of training. Individuals with no health background must complete a 4-year university program with a mandatory clinical component; those with health care backgrounds complete a modified training program. Osteopathic physicians are those individuals who have trained in the United States and who hold a medical degree from a university approved by the American Osteopathic Association. Their qualifications are the same as those for a medical doctor, and if they have completed the provincial/territorial requirements, may practise in Canada. There are numerous schools of osteopathy across Canada graduating students who can practise as osteopathic manual practitioners or therapists. Although they may belong to related associations, as a nonregulated profession there is no governing

legislative body that provides oversight, sets standards of education and practice, or provides protection to those seeking their services (e.g., preventing practice by unqualified practitioners). By law, osteopathic manual practitioners or therapists cannot call themselves osteopaths or osteopathic doctors—titles which have protection in the United States. Some insurance companies will pay for their services if the practitioner has graduated from a recognized facility.

Podiatrists (Chiropodists) The term podiatrist is used internationally as the name for a foot specialist. In Canada, only Ontario uses the term chiropodist. Podiatrists specialize in the diagnosis, assessment, and treatment of foot disorders. They treat sports injuries, foot deformities (related to the aging process, as well as misalignments), infections, and general foot conditions, including calluses, corns, ingrown toenails, and warts. Included in their scope of practice is performing specified footrelated surgical procedures, administering injections to the feet, and prescribing medications (e.g., nonsteroidal antiinflammatory drugs and antibiotics, depending on the jurisdiction). Podiatrists refer patients to surgeons or other doctors when necessary. In Canada, the chiropody/podiatry program is offered only at the Michener Institute in Toronto. Although Quebec offers a podiatry program for residents of the province, students are required to do 1 year of training in New York. Individuals can also be trained in the United States, the United Kingdom, and Australia. Practice requirements and scope of practice vary from one jurisdiction to another. In jurisdictions with no regulatory body, there are no standards of practice; essentially anyone can call him- or herself a podiatrist and treat patients. Practice settings include health care facilities, clinics, the community, primary care reform groups, and private practice. Some podiatrists specialize in such areas as biomechanics, diabetic foot care, or foot care in long-term care facilities.

Personal Support Workers

Most jurisdictions recognize a category of health care workers, who provide basic care and carry out auxiliary duties for patients. The title varies: personal support worker (PSW), health care aide, health care assistant, continuing care assistant (used in Nova Scotia), health care support worker (commonly used in British Columbia), home care support worker, resident care aide, orderly, health care attendant, or patient service associate. This category of caregiver is not regulated and may or not be categorized as part of allied health. Educational requirements vary. Certificate programs (approximately 1 to 1 1/2 years) are most common with some components available online. British Columbia and Ontario offer the largest number of certificate programs, distributed between public and private institutions. Training includes classroom and clinical components. In Nova Scotia, community care assistants must have a certificate from the prescribed program from a community college and write a provincial examination in order to work in long-term care facilities or in-home care. In addition, individuals can take a course that enables them to administer medications to stable residents in residential care (one step below care in a long-term care facility) under the supervision of a RN or LPN. These health care providers work in long-term care facilities, home care organizations, adult day care programs, seniors’ residences, and group homes under the direction of other members of the health care team. Other less common practice settings include hospitals, clinics, industry, interdisciplinary primary care practices, and private practice (Association of Canadian Community Colleges, 2012).

  Did You Know? Personal support workers (or the equivalent), one of the largest categories of frontline health workers in Canada, remain nonregulated across all jurisdictions. Some provinces are considering initiatives to implement either a registry or other formal process to provide some form of regulation for this workforce sector. In February 2018, for example, Ontario introduced the Personal

Support Worker’s Registry of Ontario that will be implemented over a 3-year period by the Michener Institute of Education. The Registry will keep track of information concerning PSWs including educational credentials, work history (competence) conduct, and any concerning work-related issues. The Ministry will have the ability to intervene as necessary to hold both employers and employees accountable for standards or practice, and manage a transparent complaints process for both patients and their families. In 2012, Health Canada examined educational standards across Canada, concluding that national standards would provide standardized requirements and outcomes to encourage enrollment, thus addressing an increasing shortage of graduates in this field.

  Thinking it Through Currently PSWs are not regulated in Canada, yet they make up a growing sector of the health care landscape. Across the country, there have been suggestions to provide oversight to this group of caregivers, ranging from a registry to the creation of self-regulated organizations. A registry can keep track of such things as a PSWs employment history and credentials. However, a registry has no authority to manage (or investigate) complaints. The complainant is advised to contact the employer. A regulated body, on the other hand, would provide the same safeguards for patients and PSWs as other regulated professions. Do you see a need for some type of oversight for PSWs? Why or why not? Would you choose a registry or a self-regulated body?

Psychologists Psychologists graduate from university programs at the bachelor’s, master’s, or doctoral level. To practise psychology in Canada, psychologists must be licensed by the regulatory body in the province or territory where they work. Psychologists work primarily as clinicians in hospitals, academic facilities, clinics, primary care facilities, correctional facilities, and

private practice. Psychologists work with individuals and families to treat emotional and mental disorders, mainly through counselling. They administer noninvasive written and practical tests such as personality tests, intelligence tests, assessment tests for attention deficit disorder (ADD), and diagnostic tests for the early stages of Alzheimer disease or dementia. Since psychologists are not medical doctors, they do not have the authority to prescribe medications, perform medical procedures, or order lab or diagnostic tests. Often, a psychiatrist and a psychologist will work as a team for more effective and ongoing patient treatment. Private insurance usually covers a specified number of visits to a psychologist; for the most part, provincial and territorial plans do not.

Speech-Language Pathologists and Audiologists Speech-language pathologists are experts in disorders of human communication. They assess and manage persons with a wide variety of related conditions, including problems with swallowing and feeding, stuttering, and delays in speaking, and also social communication and literacy issues. Practice settings include hospitals, long-term care and mental health facilities, research and academic facilities (schools and universities), group homes, the community, and private practice. Audiologists work with patients with problems related to sound, hearing, deafness, and balance. They provide ongoing education and diagnostic services, as well as create and manage treatment plans for all age groups. In most jurisdictions, audiologists can prescribe and fit hearing aids and other hearing devices. Practice settings are similar to those of the speech-language pathologist, with the addition of industrial settings. In Canada, the minimal requirement to be a speech-language pathologist or an audiologist is a master’s degree in the relevant course of study.

Communications Disorders Assistant

Communications disorders assistants (CDAs) work with, or under the direction of both speech-language pathologists and audiologists. They assist clients to communicate effectively or to use alternative forms of communication, among other things. Their scope of practice includes initiating and carrying out diagnostic tests (e.g., audiology screening), assisting with treatments, and health teaching. CDAs require a graduate certificate along with an undergraduate degree or diploma in a related field such as linguistics, early childhood education, social work, or educational assistants.

Respiratory Therapists To become a respiratory therapist (RT), one must successfully complete a RT program from a college or university that has been accredited by the Council on Accreditation of Respiratory Therapy Education. College programs are 3 years in length; university programs are 4 years long. The Canadian Society for Respiratory Therapists (CSRT) is the national professional association for respiratory therapists and the certifying body for RTs who practise in nonregulated jurisdictions. In regulated provinces, provincial regulatory bodies provide the certification for RTs. To obtain the RT designation and be licensed to practice in Canada, graduates of accredited programs in respiratory therapy must write the national certification examination and meet designated registration criteria from CSRT and their respective regulatory bodies. Respiratory therapists have expertise caring for individuals with acute and chronic cardiorespiratory disorders and perform healthrelated functions—both in and out of hospital settings. In the hospital setting, they are available to evaluate, treat, and support inpatients and outpatients throughout the facility; however, they are especially vital within critical care areas such as the ED, and intensive care units, where they manage advanced life support for patients with cardiopulmonary problems (e.g., persons on respirators). With their advanced skills, RTs respond to emergencies (such as cardiac and respiratory arrests) and are able to intubate patients (a complex procedure inserting a tube into the airway to facilitate the use of a ventilator) and initiate the use of ventilators. RTs are often required in

the transfer of critically ill patients from one facility to another or from an accident scene to a hospital. They are also required in the delivery room when doctors suspect the baby has or may develop respiratory problems. RTs perform diagnostic testing, including arterial blood gases, and pulmonary function tests. In the hospital setting, the RT is often responsible for setting up oxygen therapy or inhalation treatments. RTs also work in medical centres, clinics, complex continuing care and rehab facilities, and in the community.

Physiotherapists Physiotherapists (PTs) are regulated health care professionals who graduate from university at the master’s level and must pass a national exam to enter professional practice. An essential part of the primary care team, PTs work with individual patients to limit and improve upon physical impairments and disabilities, and to prevent and manage pain related to acute and chronic diseases and injury. They work in a variety of settings such as health care facilities and clinics, as part of a primary care team, in the community (home care), and in private practice, often in groups. Some PTs specialize in such areas as geriatrics, sports medicine, or pediatrics. Most jurisdictions cover physiotherapy services under specific conditions and for limited time frames. Many private insurance plans also offer some coverage.

Occupational Therapists Occupational therapists (OTs) are members of a regulated profession who provide support, direction, and therapies to individuals in need regarding almost every aspect of everyday life, from recreation and work to the activities of daily living. For example, they help people learn or relearn to manage important everyday activities, including caring for themselves or others, maintaining their home, participating in paid and unpaid work, and engaging in leisure activities. OTs work with patients who have difficulties as the result of an accident, disability, disease, emotional or developmental problems, or aging. In most jurisdictions, individuals can visit OTs without a referral, although the decision to see an OT is usually made jointly with a

primary care provider. OTs work in hospitals, private homes (usually through provincial or territorial home care programs), schools, longterm care facilities, mental health facilities, rehabilitation clinics, community agencies, public or private health care offices, and employment evaluation and training centres. To practise as an OT in Canada, the minimal educational requirement is a baccalaureate degree in occupational therapy. All OTs must be registered with their provincial or territorial college. Upon passing the national certification exam, OTs can practise anywhere in Canada.

Physiotherapy Assistants and Occupational Therapy Assistants Physiotherapy assistant (PTA) and occupational therapy assistant (OTA) programs are offered at many community and private colleges in Canada. Most programs are 2 years and combine the two disciplines. A number of private colleges have single-discipline programs, usually for PTAs. Program names vary. For example, the Southern Alberta Institute of Technology offers a 2-year diploma program called Rehabilitation Therapy Assistant and graduates students with both OTA and PTA skills. All programs are in the process of becoming accredited through the Occupational Therapist Assistant and Physiotherapist Assistant Education Accreditation Program. OTAs and PTAs work collaboratively with and under the direction of PTs or OTs to administer rehabilitation treatments to individuals who are experiencing physical, emotional, or developmental problems. Work settings include rehabilitation centres, long-term care facilities, the community (e.g., home care), physiotherapy clinics, and sports and medical clinics. Some jurisdictions, such as Alberta, have a professional therapy assistant association for PTAs, OTAs, speechlanguage pathologist therapy assistants, and recreation therapy assistants.

Administrative Roles Health Information Management

Health Information Management (HIM) professionals hold the designation of CHIM—Certified in Health Information Management. They provide leadership and expertise in the management of clinical, administrative, and financial health information in all formats and in a variety of settings (e.g., hospitals, community care, long-term care and nursing homes, physician offices, clinics, research facilities, insurance companies, and pharmaceutical companies). The Canadian College of Health Information Management (CCHIM) administers the National Certification Examination (NCE) on behalf of the Canadian Health Information Management Association (CHIMA), the national body representing approximately 5000 HIM professionals. To become a CHIM, one must graduate from a CHIMA accredited diploma or degree program, offered at colleges and universities across the country, and successfully pass the National Certification Examination, which is offered at one level countrywide. This examination assesses the entry-level competencies of qualified applicants. Successful candidates receive a certificate of registration in the Canadian College of Health Information Management and are eligible to use the CHIM credential and the title Certified HIM Professional. Certified members of CHIMA are required to participate in earning continuing professional education (CPE) credits to maintain their certification. Conestoga College in Ontario offers a Bachelor of Health Information Sciences (BAHIS) degree and will also consider graduates of CHIMA accredited HIM diploma programs for advanced standing opportunities. Detailed contact information on current CHIMA accredited programs, including those offered through distance education, can be found on the CHIMA web site. The HIM profession has four domains of practice: data quality (the collection and analysis of health information, the coding of clinical information, and quality assurance); e-HIM—electronic health information management (the physical to digital conversion of health records, digital cloud storage and distribution of health information, and the management of complex communications systems); privacy (keeping health information confidential and secure, and enforcing privacy legislation as it pertains to the information for which they are

responsible); and HIM standards (records management standards, documentation standards, terminology standards, etc.). Health information managers are involved with almost every aspect of health information throughout its lifecycle, from data and information collection, analysis, and retrieval, to the destruction of information once it is no longer needed. For example, when working with health records, HIMs facilitate the collection of health information and oversee proper access to and use of the information. They ensure that data are stored properly and safely, and when no longer needed, are disseminated and destroyed according to facility and legal guidelines. HIMs also conduct quantitative analysis of health records, ensuring they are accurate and complete, and statistical analysis used for identifying trends, such as births, deaths, diseases, and health care costs. In Canada, HIM professionals are trained in six core competency areas that include biomedical sciences; health care systems in Canada; health information, including the HIM lifecycle; information systems and technology; management aspects; and ethics and professional practice. The HIM professional is playing a pivotal role as Canada continues to work toward the implementation of integrated electronic health information systems at local, provincial and territorial, and national levels. They will be instrumental in directing and reshaping how health care is delivered.

Health Office Administration Every aspect of health care requires some level of administrative support. The responsibility for the day-to-day administrative management of a hospital unit, a clinic, or a physician’s office requires skill, knowledge, patience, commitment, and a high level of professionalism. The name for individuals working in these roles varies from medical secretary or medical office assistant to unit clerk, clinical secretary, or administrative coordinator. People in this role must have a sound knowledge base in several areas, including pharmacology, diagnostic and laboratory testing, medical terminology, anatomy and physiology, disease pathophysiology, and the principles of triage. Those working in a doctor’s office must have both clinical and administrative capabilities to manage electronic

health records, schedule and triage patients, and be able to do provincial or territorial billing. In the hospital setting, administrative staff have to navigate complex computer software systems (e.g., Meditec) for data-entry responsibilities and understand hospital policies and procedures. All must have the ability to multitask, to work efficiently under pressure, and must be flexible, friendly, empathetic, supportive, and comfortable around individuals experiencing health problems. Practice settings include doctors’ offices and group practices, specialists’ offices, all hospital units, and long-term care facilities. Health services or health office administrators are not regulated, so there are no provincial or territorial standards. In addition, no jurisdictions other than British Columbia have a professional organization. The Medical Office Assistants’ Association of British Columbia is an affiliating body specifically for administrative health care providers. The International Association of Administrative Professionals (IAAP) welcomes members from any administrative discipline and has chapters across Canada.

Laboratory and Diagnostic Services The field of medicine depends greatly on laboratory and diagnostic services. Many diagnoses cannot be confirmed without some sort of laboratory or diagnostic test. Providers rely on laboratory tests even when prescribing the appropriate antibiotics. Highly qualified individuals, including physician specialists, as well as growing number of technicians and technologists specializing in a variety of areas, populate this field. Many specialties exist within this area (e.g., pathology, hematology, radiology), most of which are regulated in each province and territory.

Alternative Practitioners Alternative practitioners are valuable contributors to the health and wellness of Canadians. Some disciplines have provincial or national organizations with varying levels of oversight by their associated bodies. Most are unregulated, meaning that there is not a legislative body governing standards of education and practice, and providing

protection for both the patient and practitioner. Educational requirements vary greatly within the discipline, and across provinces and territories. Practitioners who practise acupuncture, for example, often come from regulated professions such as chiropractic and physiotherapy, who meet required criteria to practise acupuncture. Chiropractors must complete over 200 hours of clinical training in addition to taking the required courses and pass examinations offered by Acupuncture Canada.

Volunteer Caregivers Friends, family, and volunteer caregivers (who work in partnership with professional caregivers) provide tremendous support to those who are ill. With current shortages in all categories of health care providers, many patients depend on this group of people to fill in the gaps in their care that cannot otherwise be filled. The hours of care provided by these individuals are uncountable, the output unequalled, and the stress phenomenal. Many ill people could not manage without this supportive network.

Practice settings The practice (or workplace) settings described here provide a cross section of where health care is delivered. Included in some detail are practice settings that interdisciplinary teams work in. Several types of clinic settings are also described.

Care in the Home and the Community Has a friend or family member ever needed home care? If you had the choice, would you rather be cared for at home or in a health care facility? The need for home and community care is increasing for several reasons ranging from an aging population to the continued move to provide care outside of hospital and long-term care facilities (see Chapter 4). Home and community care refers to the practice of effectively managing the health care needs of eligible Canadian’s in their homes or other community setting in which they reside. The objective is to reduce time in hospital or avoid hospital stays altogether, and delay or avoid admission to long-term care facilities. Age is not a barrier to receiving home care, although the bulk of home care services are delivered to older Canadians (Canadian Home Care Association, 2015). A recent report by the CIHI revealed that nine out of ten older adults who received publicly funded home care claimed that the services helped them remain at home. The same survey showed that 91% of older adults stated that they did not require publicly funded home care, while 12% said that they rely on informal caregiving (CIHI, 2018a). In most jurisdictions, individuals are referred to home care services by their primary care provider or community organization. After a referral has been received, the individual is assessed for the type and amount of care that would best meet their needs. Details vary across the country regarding the organizations that initiate assessments and the services they provide. At the time of referral, the person may be at home requiring support to stay home, or in hospital waiting for finalization of home care planning before he or she can be discharged.

Often referrals, assessments, and planning for home care services are activated soon after a person enters the hospital as part of their discharge planning. Requested care may be short or long term in nature. See Case Examples 5.6 and 5.7.

  Case Example 5.6 Fred, an 86 paraplegic, had an outpatient procedure done recently and he requires IV antibiotics and dressing changes. A referral for home care would result in a visiting nurse administering the IV antibiotics and changing the dressings. This would be considered a short-term need for home care services. If mobility was not an issue, an alternative would be for Fred to go to the hospital for the required interventions.

  Case Example 5.7 Asha, 84 years old, has heart disease and hypertension, COPD, low vision, and some mobility issues related to arthritis but with family assistance managed in her own home. She fell and broke her hip, requiring surgery and a period of rehabilitation. After the surgery, it became apparent that she could not manage at home without significant support. A home care assessment (part of Asha’s discharge planning) determined she could go home with the proper community support, which involved several levels and types of interventions. An occupational therapist helped to make modifications to her home, addressing Asha’s mobility issues. Meals on Wheels were engaged to provide her with seven meals a week. A community nursing agency was contacted to provide Asha with a personal support worker for 3 hours daily helping with bathing, dressing, and some home management. An LPN was made available to attend to Asha’s medical needs. The support Asha requires is considered long term.

Home care is provided for individuals with a variety of health issues including acute or chronic illnesses, complex heath needs, palliative care, respite, or rehabilitative care. As noted in Chapter 4, home care services are typically publicly funded for a designated number of service hours per week determined at the intake assessment. If a patient feels he or she needs additional hours of care (e.g., housekeeping, general maintenance, and more supportive care) those services must be hired and paid for privately. In some regions it is difficult to find additional care especially from nurses or PSWs because there is a shortage of health human resources.

Home Care Management in Saskatchewan Some jurisdictions have alternative funding models such as individualized funding provided by the Saskatchewan Health Authority. This option is offered through the province’s home care program and allows the patient or their family/guardian to accept the responsibility of managing and directing supportive services (e.g., personal care or home management services such as meal preparation, house cleaning, or grocery shopping). The level of funding provided for these services is based on the assessed need. Professional services (e.g., those provided by registered nurses or therapies) are excluded from individualized funding, and are provided instead through the Saskatchewan Health Authority. People who choose individualized funding are responsible for hiring, training, and terminating workers, managing payroll under the employment act, and reporting to the Saskatchewan Health Authority at designated intervals. Providing Canadians with a sustainable national home care framework is an ongoing challenge. On a positive note, targeted federal funding contained in the 2017 Federal Budget addresses many of the recommendations outlined in the document entitled The Better Home Care in Canada: A National Action Plan, published 2016 in partnership with the Canadian Home Care Association (CHCA), Canadian Nurses Association (CNA), and the College of Family Physicians of Canada (CFPC). The action plan stressed the need for national standards for home care achieved through collaborative efforts involving all levels of government, health care professionals,

caregivers, and other stakeholders (CHCA, CNA, & CFPC, 2016). How the $6 billion dollars (over 10 years) will be spent is largely up to the discretion of provincial and territorial governments, but must address the home care needs in each jurisdiction. An investment of $184.6 million was put aside to improve home care for Canada’s Indigenous People (CHCA, 2015).

  Thinking it Through An older family member falls ill and requires constant supervision at home for a period of time. Home care options are limited. Assume that you work full-time and have a family of your own. 1. What would you do to ensure your family member receives the care he or she needs? 2. What are the options and services available in your region?

Clinics Urgent Care and Walk-In Clinics Canadian residents who do not have a family doctor, are away from home, or cannot get an appointment with their primary care physician can seek medical care from an urgent care or walk-in clinic. These clinics reduce the burden on emergency departments by providing nonemergency care to patients who would otherwise clog the ED. Typically clinic visits are less costly to the health care system than visits to the ED. Some urgent care clinics offer more immediate access to diagnostic testing, such as ultrasound, and to minor procedures, such as suturing, whereas walk-in clinics often refer the patient elsewhere for these procedures.

Ambulatory Care Clinics In the most literal interpretation, ambulatory care clinics have traditionally encompassed any clinic—for example, a walk-in, urgent care, or private clinic—that offers services and discharges the patient

immediately thereafter—that is, a clinic in which a patient does not spend the night. Ambulatory care, therefore, may include day surgeries, visits to emergency rooms, cast changes, postsurgical assessments (perhaps after hip or knee surgery), and cancer treatment. Within the past 5 years, the term has referred more specifically to facilities that offer groups of services in one location— often, a hospital.

Outpatient Clinics Outpatient clinics offer services that vary from hospital to hospital and community to community in an effort to meet the unique needs of a particular area. An outpatient clinic can operate under the umbrella of an ambulatory care clinic—a clinic within a clinic. Services may include family doctor care, minor surgery, screening procedures (e.g., vascular screening), laboratory and diagnostic procedures, and foot care. Outpatient clinics in large hospitals offer an even wider range of services. Some hospitals divide clinics into areas of specialty and related services; others offer many disciplines within one clinic. For example, in Moncton, New Brunswick, the hospital has divided its ambulatory care clinics into five specialized areas: healthy living (including services to assess and treat ongoing conditions such as asthma, diabetes, and chronic obstructive pulmonary disease); specialty procedures clinics (including urodynamic and eye clinics); treatments and orthopedics; diagnostic clinics (including pulmonary assessment and electrocardiograms); and endoscopy and minor surgery.

Mental Health Clinics Most jurisdictions have clinics that respond to the specific needs of individuals with mental health disorders although services provided are rarely adequate. Some services focus on youth and young adults and include addiction support. For the most part, these clinics collaborate with other organizations and hospital outpatient services to provide short-term, problem-focused therapy, peer support, and system navigation to help individuals find the services they need. For example, a mental health counsellor can fast track a person to a psychiatrist.

Almost all jurisdictions have adult mental health clinics (18 years and older). Some accept walk-in patients, others require referral from a primary care provider, or have a self-referral option. For example, clinics in Saskatchewan offer a variety of services, from individualized to group sessions, which may or may not be problem specific. These clinics also provide access to wellness programs, support groups, counselling for victims of sexual assault and abuse, addiction services, and treatment for common conditions such as depression, acute anxiety, and eating disorders. Clinics in most regions also provide access to a mobile crisis team (also called a crisis response team) staffed by health care professionals with crisis response training (e.g., registered psychiatric nurses and counsellors), who will respond to mental health emergencies within a given geographic area.

Harm Reduction Sites or Clinics Harm reduction sites (also referred to as supervised consumption sites or clinics) are guided by strategies, practices, and procedures that reduce the harm to individuals caused by substance misuse and addiction. More recently, the focus has been on alleviating harm related to the misuse of opioids, such as methadone, oxycodone, hydromorphone, fentanyl (one of the most toxic opioids), and heroin. This pan-Canadian opioid crisis is a public health and societal emergency affecting individuals, families, and communities (see Chapter 10). Harm reduction sites offer a variety of services that vary among provinces and territories. These services include testing drugs for impurities or containments (additives), providing clean needles, responding to overdoses, and in some jurisdictions, distributing prescription grade heroin and operating opioid vending machines (initiated in British Columbia). Some clinics offer counselling services and access to rehabilitation facilities. Clinics can be found in almost every community across the country. Some are temporary, others more permanent. Establishing a clinic requires permission from either municipal and/or provincial or territorial governments. Clinic locations are carefully selected in collaboration with the relevant community.

  Did You Know? Many street drugs are illegally produced with the addition of various combinations of drugs that add to the potency and response unpredictability. For example, carfentanyl (sometimes used by veterinarians as a sedative in large animals such as elephants) is often compounded into pills, making it very difficult, if not impossible, to differentiate it from a prescription opioid. Because of its high toxicity, a very small amount of carfentanyl can cause a severe overdose and often death. The antidote (which reverses the effect of the opioid) is Narcan or naloxone, which is now widely available across the country from pharmacies to libraries. Narcan comes as an injection or in the form or a nasal spray. It takes between 30 seconds and 2 minutes to work.

Methadone Clinics In a methadone clinic, the drug (a synthetically produced opioid) is used to treat individuals addicted to other opioid drugs including heroin, oxycodone, and fentanyl. This treatment is sometimes also called opioid replacement therapy. Physicians prescribe low doses of methadone that are carefully titrated to the individual’s needs. Those undergoing treatment come from all walks of life, many holding down full-time jobs in a variety of professions, but are addicted to opioids and looking for a way to overcome it. Methadone treatment in itself is not a cure for drug addiction. It aims to prevent acute opioid withdrawal. Individuals undergoing methadone treatment must adhere to a strict regime including daily visits to the clinic for regular blood and urine testing. Most clinics provide patients with support, including counselling to help them understand opioid addiction, and how opioid replacement therapy works. Physicians must have special permission to prescribe methadone under section 56 of the Federal Controlled Drugs and Substances Act and (in most jurisdictions) be sanctioned to do so by their licensing body (Government of Canada, 2017). British Columbia,

Saskatchewan, Ontario, and Quebec have their own provincial protocols for prescribing methadone, with the remaining jurisdictions following Health Canada policies.

Nurse Practitioner–Led Clinics Nurse practitioners in some jurisdictions have taken the lead role in seeing patients in a clinic setting. The purpose of these NP-led clinics is to provide care for individuals who do not have access to a primary care provider or primary health care team. Individuals register with a clinic (not with a provider), and are offered routine health and preventive educational services (e.g., prenatal or well-baby care, managing a chronic condition) similar to those received in any other primary care delivery model, theoretically over the course of a lifetime. Basic primary health care services are provided by the NP, not a physician. Other team members are similar to any primary health care team model: registered nurses, registered psychiatric nurses (in the western provinces), social workers, pharmacists, dietitians, psychologists, occupational therapists, physiotherapists, and others. Teams can be designed to meet the needs of the community they serve. The NP can refer patients to specialists and other community resources as required.

Why Clinics Make Sense Clinics have gained prominence for a number of reasons, including the following: • Cost effectiveness. The past few years have yielded a shift toward community-based care. New technologies have shortened surgeries and made them less invasive, allowing for earlier discharges and follow-up in clinics. It costs less to care for patients at home than to maintain them as inpatients. Many tests and procedures formerly done in a hospital are now done in a clinic on an outpatient basis. Having patients see a specialist or other health care provider in the clinic setting on a first-come, first-served basis usually costs less than having them make an appointment with a specialist or

other health care provider. Organizations can staff clinics more efficiently according to perceived need. In addition, equipment booking, if handled centrally, can result in available equipment being maximized. • Timely access, fewer patient visits, and convenience. With proper organization, patients can access more services faster, possibly in one clinic visit. The move toward multidisciplinary health teams in clinics, similar to those found in primary care groups, has enabled clinics to readily provide the patient with a variety of services (Case Example 5.8). With centralized resources, the patient should have to make fewer visits, especially beneficial to patients with multiple health problems, and mobility or transportation issues.   Case Example 5.8 Jim fell, which resulted in a complex fracture of his leg, requiring a cast. Instead of having to make an appointment with the orthopedic surgeon, Jim went to a ‘cast’ clinic at the local hospital. A nurse checked his cast, the circulation in his foot, and answered any questions he had. Jim then saw the orthopedic surgeon, who briefly reviewed his progress, and told Jim to return to the clinic in 2 weeks, unless complications arose.

• Patient focus. Specialized clinics are usually better prepared to work with patients, to consider their individual needs, and to offer streamlined and patient-friendly health education. Clinic staff members typically have experience dealing with a specific condition and take the opportunity to learn from their patients, which increases the professionals’ overall effectiveness in meeting patients’ health care needs.

Primary health care: issues and trends The Ongoing Shortage The need for forming primary care arose in the late 1990s under an initiative called primary care renewal, when there was a shortage of family doctors in Canada at that time. To address the problem, the Canadian government began investing millions of dollars to improve how primary health care was delivered. Initial funding was provided through the Primary Health Care Transition Fund, a financial agreement reached by the provincial and territorial and federal governments. That funding ended in 2011, and since then, monetary contributions from the Federal Government for primary care reform and other health renewal initiatives have been included as part of the overall federal transfer of funds to the provinces and territories for health care. To meet the goals of reducing the number of Canadians without a family physician, the provincial and territorial governments began experimenting with various models for delivering primary care and increasing the number of people accepted into medical school. Since 2009 significant gains were made initially, but these gains were short lived due to several factors. Many physicians leave family medicine (e.g., to become hospitalists or emergentologists) for more appealing work hours, less overhead, and better remuneration. Newer graduates, who do specialize in family medicine, tend to accept fewer patients and work fewer hours in pursuit of a reasonable work-life balance. Other family physicians diversify, practising part-time family medicine, and part-time in another area such as sports medicine or general practitioner (GP) anesthesia. Finally, there are more female physicians who often work part-time, understandably having children and wanting time to spend with them. The result? Thousands of Canadians’ still do not have a primary care provider. Or, for those that do, even getting an appointment in a timely manner is difficult. In a 2016 CIHI survey, only 53% of family physicians reported their patients can get a same day appointment.

One in seven Canadians reported having to wait up to seven days for an appointment.

Strategies for Improvement According to the Canadian Medical Association, prompt or same day appointments (also known as advanced access) has been identified by many Canadians as being one of the most important elements of primary care. To facilitate same-day access, the College of Family Physicians of Canada introduced a number of guidelines and strategies, most of which have been implemented, in whole or in part, by Canadian physicians and with growing success. These include the use of multidisciplinary teams, extended office or after office hours clinics (shared among providers), the use of email, and other communication technologies to manage patients’ needs. For example, in chronic disease management, patients can take their own blood pressure, and enter the results electronically to be tracked and assessed remotely by a health provider. Blood sugar profiles can be managed in this manner, as can monitoring blood tests results for patients on anticoagulant therapy (blood thinners). Some primary care teams have portals through which patients can address questions to the appropriate team member and access their chart and laboratory information (College of Family Physicians of Canada, 2012).

Primary Health Care Groups Primary care groups are groups of health care professionals from a variety of disciplines who work together as an interdisciplinary team to provide patients with comprehensive high-quality health care. Each team member brings his or her unique skills to the group, offering the patient a selection of services, usually under one roof, or in close proximity.

Forming a Group A number of family physicians can unite to create a primary health care group. They first need to choose what particular model or framework they want to use (it must be an acceptable model within their province or territory). In most jurisdictions, the physicians must

apply to the provincial or territorial government or the appropriate body for permission to form the group. Once approved, they enter into a formal contract with their provincial or territorial government, which details the organizational structure, funding mechanisms, and their professional obligations to the group and patients (e.g., hours of availability, clinic hours, telephone availability). The obligations and funding for other members of the group (depending on the mix of health care professionals) is also determined by the type and nature of the model. Organizations can also be modified to reflect the contextual, cultural, and geographic needs of the communities they serve.

Basic Structure and Function In some organizations most of the team members will be located in one facility; others will network with their team members who are in various locations. For the most part, physicians (or in regions, NPs) are at the hub of each organization. The physicians or NPs are responsible for certain aspects of the patient’s treatment, refer the patient to other resources within and outside of the organization as required, and provide oversight for the patient’s overall treatment plan and wellbeing. The objective of an interdisciplinary approach to health care is to treat patients by utilizing the expertise of a number of health providers (as required) to maximize shared treatment goals and optimize patient care. For example, pharmacists have in-depth and current knowledge about drugs, drug interactions, allergic reactions, side effects, and other variables; a dietitian is better able to work out a diet plan for a patient with diabetes or who wants to embark on a weight reduction program. A physiotherapist or a chiropractor can provide expert guidance with respect to musculoskeletal therapy; and a counsellor or psychologist has the training to assist an individual with mental health issues. Nurses with expertise in specific areas (e.g., women’s health, well baby care, management of cardiovascular risks) can provide monitoring, support, and ongoing education for health promotion and disease prevention. The responsibilities of most group members are fairly straightforward; those of physicians and NPs may be more complex

(e.g., on-call hours, clinic availability, Telehealth access, and expectations related to other services offered, and patient care).

Primary Care Models: Regional Variations Ontario has several models including family health networks, family health teams, and community health centres and health service organizations. Although each model delivers primary care services using an interdisciplinary platform, they all differ in terms structure and services offered. Family Health Teams (FHTs) have emerged as one of the most effective designs with prototypes used in other jurisdictions. In some models, patients can be enrolled or rostered (discussed below) to a single physician within the team or to a group of physicians. FHTs receive funding for an executive director (sometimes called a chief executive officer or CEO), and for electronic medical records. The executive director manages the administrative components of the team including oversight for some team members (e.g., hiring administrative and support staff). Although successful, the government is currently not funding any new models of this kind deeming it to be too expensive. Community health centres (CHCs), located in many jurisdictions (including Ontario), are community-based, nonprofit health care organizations, whose boards are comprised of members from within the communities they serve. The clinic’s physicians and other health care providers are most often salaried and paid by the provincial, territorial, or federal government. NPs often lead clinics, and provide a wide range of care. In some regions NPs go out into the community to deliver care, provide support and counselling, and health education. CHCs stress an intersectoral and interdisciplinary approach to care. They partner with numerous organizations within the community to address concerns related to social and environmental determinants of health, which impact the health and wellbeing of individuals within their geographic area. CHCs, found in rural and urban areas, are staffed by interdisciplinary teams to provide medical care. They are especially important to those with limited access to health care (known as hard-

to-serve communities and populations). In addition to disease prevention and related health teaching, CHCs also examine the underlying social, built, and environmental conditions that may affect a community (e.g., chronic disease, seniors’ needs, poor diet, housing issues, and drug and alcohol addiction). They provide a central location for the community, offering a place to gather, address health and related concerns. Many CHCs have mobile vans that will go out into the community to address the needs of vulnerable populations such as drug addicts. A person does not have to have a health care provider to access a CHC. New Canadians are welcome with or without provincial coverage. Family Care Clinics (FCCs) in Alberta, introduced in 2012, continue to provide care to individuals and families who do not have a doctor. They focus on treating those who have complex health issues, including chronic diseases, as well as addictions or mental health issues. As a comprehensive primary care model, they are staffed by an interdisciplinary team similar to those described above. They are meant to complement the existing Primary Care Networks (PCNs), which are currently considered the basic building block for delivering front-line care in Alberta. The government reviewed the province’s PCNs in 2015, and mandated several changes including expanding after-hours access for patients and implementing a new funding model that encourages the delivery of more team-based care. Alberta also has two organizations: (1) Strategic Clinical Networks (SCNs) that focus on improving health in specific areas including mental health, respiratory and heart health, emergency, and critical care; and (2) Operational Clinical Networks (OCNs) that work to improve general health outcomes for Albertans, for example, by improving patients’ experiences with the health care system, shortening wait times, and ensuring care availability. Both networks work collaboratively with each other and with other primary care organizations and health care providers. In 2012, the Saskatchewan government released its framework for primary health care entitled, “Patient Centered, Community Designed, Team Delivered: A Framework for Achieving a High Performing Primary Health Care System in Saskatchewan.” Its overriding goal is to improve patient access, experience, and care by

implementing an interdisciplinary approach to care primarily through a network or primary health teams, similar to those described above. These teams, however, will (like Ontario’s CHCs) become engaged with the community in which they are located, partnering with community organizations and agencies to address inequities related to the socioeconomic and environmental determinants of health. Continued support for community and home care and managing chronic diseases will be stressed. Currently, Alberta uses a variety of health care professionals loosely networking under the Alberta Health Authority to provide patient care. Most physicians remain in solo or small practices, billing fee for service. There are some clinics, such as community health clinics (four in all), requiring that patients purchase a membership (at a nominal fee) to belong. Doctors may or may not be accepting new patients. In British Columbia, under the 2018–2019 and 2020–2021 service plan, primary care will continue to be delivered through five health authorities (including the First Nations Health Authority); the sixth is the Provincial Health Services Authority responsible for overseeing accessibility, the coordination and delivery of specialized services, and industry protocols. The focus is on providing an integrated strategy for delivering primary care in which divisions of family practice work with health authorities and other resources to implement primary care networks (Canadian Institute for Health Information, 2018b).

Primary Care Groups: Payment Mechanisms Fee-for-service was the most prevalent payment mechanism for physicians prior to the formation of primary care groups. Within the groups, capitation-based funding and blended funding (see Chapter 4) are most popular. There are also billing opportunities for milestones reached for certain services to encourage health care providers to improve patient care outcomes and lower costs. Incentive billing encourages preventive care within a practice. For example, in order to be paid, a physician must ensure that a given percentage of applicable patients have the suggested immunizations, colorectal screening, Pap smears, and mammograms. The higher the

percentage of patients who receive the recommended services, the more the doctor is paid. Bonus payments may also be made when a doctor provides additional services such as diabetic management, smoking cessation counselling, insulin therapy support, and fibromyalgia or chronic fatigue syndrome management. Collectively, these services are referred to as a “basket” of services associated with incentive services.

Patient Enrollment and Primary Care Models (Rostering) Many primary health care groups (including all groups in Ontario) require that a certain percentage of patients formalize their relationships with the group by signing a form agreeing to become part of the doctors’ practice, a process called rostering, patient attachment, or formal registration. The idea is that the physician and patient establish a mutual commitment for care. Signing the form is purely voluntary and not binding; a patient may leave the agreement at any time, or become unrostered. Being rostered, however, entitles the patient to all of the services and benefits offered by that particular primary health care reform group, such as access to after-hours clinics and a telephone helpline (see Chapter 4). If a rostered patient visits another medical doctor for a routine health problem (i.e., not an emergency), the government may deduct from the family doctor’s monthly stipend the fee for that visit (Case Example 5.9). Being rostered is probably not appropriate for a person living in a temporary residence (e.g., a college student living away from home to attend school) because he or she may need to seek health care elsewhere.

  Case Example 5.9 Although rostered with Dr. Gregory, Natalie, who is experiencing extreme stress, has started going to see Dr. Nash, a family physician who exclusively offers counselling services and psychotherapy twice a week. Dr. Nash submits his fee-for-service bill for each of Natalie’s visits to the province at the end of each bill submission cycle. Dr. Gregory, as Nathan’s primary care physician may have the amount

Dr. Nash submitted to the ministry deducted from the amount of money the province pays him for caring for Natalie.

  Thinking it Through You move to a new town and set out to find a family doctor. You find one physician in solo practice who agrees to take you as a patient because he cares for friends of yours. However, you also find a newly formed primary health care group with two physicians taking new patients. Consider the benefits the primary health care group offers versus the close relationship you would be likely to develop with the physician in solo practice. Which would you choose?

Telephone Helplines All jurisdictions offer confidential telephone help assistance free of charge to those who need it. Helpline names vary, for example Telehealth in Ontario, Healthline in Newfoundland and Labrador, and Health Link in Alberta. Helplines offer callers advice from health care providers (usually RNs) 24 hours a day, 7 days a week. Nurses will not provide callers with a diagnosis, but will answer questions, and if needed, direct the caller to the appropriate resource or level of care, ranging from the person’s primary care provider to a clinic or emergency department. Alternatively, the nurse may provide advice to callers on how to handle a situation themselves. In addition to provincial/territorial help lines, some primary care groups have their own helplines. See Case Example 5.10.

  Case Example 5.10 Helena lives in British Columbia and has a 3-year-old daughter, Gillian. Gillian wakes up at 2:00 a.m. She is warm, crying, and has diarrhea. Helena is not sure what to do. Should she take Gillian to the emergency department, or is it something that can wait until

morning? Helena calls HealthLink BC, which offers British Columbians health information and advice from a registered nurse around the clock. The nurse gives Helena some advice on how to care for the little girl, feeling it is nothing serious enough to warrant a visit to the ED. She tells Helena to call her family doctor in the morning if she is still concerned about her daughter, which Helena does. In the meantime, HealthLink BC transmits an electronic report of the occurrence to the family doctor’s office. Although most helplines have follow-up procedures, these are not always foolproof. If a helpline responder does not diligently obey such rules, using telephone helplines can result in a breakdown in communication, as demonstrated in a rather extreme but not entirely unheard-of circumstance in Case Example 5.11. A helpline responder should never assume that the person calling in will follow, or is capable sometimes, of following instructions. The responsibility for reporting calls and following up properly lies with the responder.

  Case Example 5.11 Theo called a telephone helpline at 2:00 a.m. on Monday. He said he’d tried to commit suicide by taking a bottle of Aspirin and half a bottle of sleeping pills. The pills had only made him slightly drowsy. With a change of heart, he wondered what he should do. The nurse advised him to go to the nearest emergency department and offered to call an ambulance for him. He responded that he would go but that he had someone to drive him. Normally a summary of the incident would be entered into his EHR and his doctor’s office notified electronically or by phone, which his physician would receive the next morning. For some reason, this did not happen. The helpline did not follow up with Theo’s family doctor about this call. At 3:00 p.m. on Wednesday, a family friend found Theo semiconscious and dehydrated on the floor in his kitchen and called 911. Theo’s kidneys had failed. Today he is alive but on dialysis awaiting a transplant. If Theo’s doctor had been notified of the event

Tuesday morning, he could have arranged for follow-up immediately and perhaps minimized the kidney damage.

Community Health Centres Primary Care in Northern Regions Primary care in Canada’s northern regions is delivered by nurse practitioners and other health care professionals from a centralized nursing station or clinic. Nurses are available 24/7, meaning they are on call outside of regular clinic hours. Most nurses in the North have specialized training beyond that of a nurse practitioner. Aurora College in Yellowknife, for example (affiliated with the University of Victoria), offers a 1-year postgraduate certification in remote nursing. It involves intensive advanced assessment and clinical skills, and also advanced pharmacokinetics. In most cases these nurses have a broader scope of practice than NPs (although NPs are present in many northern communities). Nurses assess patients and diagnose conditions; order, run and interpret routine laboratory tests (done on site); and prescribe and dispense medication. They respond to routine, acute, and emergency situations. The number of nurses in a community is mostly determined by the size of the community, but also by the patient contact statistics. One community with 600 people and an average of 800–900 patient contacts a month will generally have three nurses; another community with the same population might have 1400 patient contacts in a month, which could justify having a fourth nurse. The number of nurses is also determined by the nature of the community, considering the mix of health problems, and sometimes employment. Norman Wells, in the NWT for example, is a small community; however with the ESSO petroleum base located here, more industrial accidents occur and will increase the patient contact hours. More nurses may be needed in this community. Physicians visit at designated intervals, for example, once a month for several days. Nurses keep a list of people within the community who feel they need to see the doctor. A patient must be referred by the nurse. Appointments with the doctor are reserved for cases that the nurses feel they cannot manage, or that require a second opinion.

Nurses have 24-hour access to a regional physician whom they call for guidance as the need arises.

Summary 5.1 Complementary or alternative medicine includes all health care practitioners not considered mainstream. Although the terms are sometimes used interchangeably, there are differences: complementary medicine supports, or complements, conventional medicine, whereas alternative medicine typically provides an option, or alternative, often to the exclusion of conventional medicine. As the roles and responsibilities of many health care professionals continue to evolve and with a greater emphasis on a team approach to treatment, categorizing health professionals into these categories has become controversial. Even the names of the categories are sometimes questioned as health providers from various disciplines assume more autonomy and central roles in patient care. 5.2 Regulated professions provide the public with a choice of health care providers, with the assurances that the professional they choose meets legislated standards of education and practice. Although regulated professions offer support to practitioners, the emphasis is on providing safe and high-quality care to patients. Practitioners must be in good standing with their regulated body, and standards or practice must be maintained. Nonregulated health professions may still have a professional association, some providing their members with certification, which may require a written examination. Personal support workers represent one of the largest categories of nonregulated health care workers. Initiatives across the country are either experimenting with or have established registries to provide oversight to these workers with the goal of establishing provincial/territorial standards that are in the best interests of the workers and the public. 5.3 There is a large variety of health providers/practitioners in Canada in both regulated and unregulated professions. Many

offer a variety of specialties within the profession, each requiring additional education, both in theory and clinical skills. Roles and scope of practice of various professions are changing to meet current and varied health care demands. Nurse practitioners function independently assessing, diagnosing, and treating patients. The use of physician assistants is becoming more widespread, although they are not independent practitioners. Registered psychiatric nurses in the western provinces continue to provide invaluable support to the mental health community, advocating for their patients and supporting them through the court system as required. 5.4 Practice settings range from hospitals and doctors’ offices to primary health clinics or settings. Optimal primary care is centrally located, with a range of health professionals in one building, or close by. Several types of clinics offer primary care including urgent care, walk-in, and ambulatory care clinics, most using a multidisciplinary team to provide care. Harm reduction sites can be found in communities across Canada providing supervision and support services for individuals with addictions. 5.5 Provinces and territories continue to experiment with various models for delivering primary care. Presently interdisciplinary health teams appear to be the most effective approach to primary care delivery. Primary care groups differ in name, structure, services offered, and method of remuneration. A typical primary health team, for example, might have seven or eight physicians, two or three nurse practitioners, psychologist, podiatrist, nutritionist(s), counsellors, and nurses. Nurses often operate as clinical specialists attending to individuals with a variety of health issues including hypertension, diabetes, and other chronic diseases.

Review questions 1. What are some of the concerns associated with categorizing health professionals as mainstream, allied, and alternative or complimentary? Discuss what you see as the rationale supporting assigning health professions into these categories. 2. What does it mean when a profession is self-regulated? a. What are the benefits of belonging to a regulated profession both for the health practitioner and the public? b. Who can perform controlled acts, and under what circumstances can an act be delegated to someone else? c. Can an act be subdelegated? Why or why not? 3. Under what circumstances can a health provider delegate an act? How does a delegated act differ from an assigned task? 4. What are the benefits of an interdisciplinary team approach to health care? a. Considering these benefits, either individually or in a small group, design what you believe is the “perfect” primary care group for the area in which you live. b. Consider your community’s specific needs, costs, and practitioners that you would have on the team, and also outreach programs if applicable. 5. How is communications technology contributing to better patient care? 6. List three services a pharmacist can offer in most jurisdictions. a. What do you believe are the advantages of these expanded services? b. Investigate which services that pharmacists in your jurisdiction offer. 7. Identify three challenges facing home and community care services.

8. Harm reduction has been established in communities across Canada providing supervision and support for individuals struggling with addiction. a. What are the benefits and potential risks of harm reduction sites? b. Assume a proposal was made to establish a harm reduction clinic in your community that is close to a park where addicted individuals are known to gather and two blocks from a school. What concerns would you have regarding its location? What alternatives would you recommend?

References Association of Canadian Community Colleges. Canadian educational standards for personal care providers. Retrieved from https://www.collegesinstitutes.ca/wpcontent/uploads/2014/05/ReferenceGuide_Canadian-Educational-Standards-forPersonal-Care-Providers_ACCC.pdf. 2012. Canadian Association of Schools of Nursing. Nurse Practitioner Education in Canada: Final Report–2011. Retrieved from https://casn.ca/wpcontent/uploads/2014/12/EnvironmentalScanofNur sePractitionerProgramsEn.pdf. 2014. Canadian Home Care Association. Supporting vulnerable populations by strengthening home care in Canada. Retrieved from www.cdnhomecare.ca/content.php?doc%3D248. 2015. Canadian Home Care Association (CHCA), Canadian Nurses Association (CNA), & College of Family Physicians of Canada (CFPC). Better home care in Canada: A national action plan. Retrieved from www.cdnhomecare.ca/content.php?doc%3D300. 2016. Canadian Institute for Health Information. Regulated nurses. 2016;2015. Retrieved from https://secure.cihi.ca/free_products/Nursing_Repor t_2015_en.pdf. Canadian Institute for Health Information. Regulated nurses. 2017;2016. Retrieved from

https://www.cihi.ca/sites/default/files/document/ regulated-nurses-2016-report-en-web.pdf. Canadian Institute for Health Information. (2018a). Canadian seniors and home care. Retrieved from https://www.cihi.ca/en/canadian-seniors-andhome-care. Canadian Institute for Health Information. Your health system: In depth. Retrieved from https://www.cihi.ca/en/your-health-system-indepth. 2018b. Canadian Pharmacists Association. Pharmacists’ scope of practice in Canada. Retrieved from https://www.pharmacists.ca/pharmacy-incanada/scope-of-practice-canada/. 2016. College of Family Physicians of Canada. Timely access to appointments in family practice. Retrieved from www.cfpc.ca/uploadedFiles/Health_Policy/_PDFs/ 2012_Final_Best_Advice_Enhancing_Timely_Access.p df. 2012. Government of Canada. Methadone program. Retrieved from Health Canada website https://www.canada.ca/en/healthcanada/services/health-concerns/controlledsubstances-precursorchemicals/exemptions/methadone-program.html. 2017. Statistics Canada. Access to a regular medical doctor. 2014;2013. Retrieved from https://www150.statcan.gc.ca/n1/pub/82-625x/2015001/article/14177-eng.htm.

6

Essentials of Population Health in Canada LEARNING OUTCOMES 6.1 Explain the concept of population health. 6.2 Summarize the events leading to the use of a population health approach in Canada. 6.3 Describe the effects the determinants of health on a population. 6.4 Explain the eight key elements in Public Health Agency of Canada’s population health framework. 6.5 Discuss the principles of population health promotion. 6.6 Summarize the current status of the population health approach in Canada.

Key terms Disease prevention Health indicators Health promotion Inequities in health Population health Primary care Primary health care Public health Qualitative research

Quantitative research Upstream investments How healthy are Canadians? What is most affecting their health? What do we need to do to prevent illness in ourselves and in our children? Are we proactive enough in looking at health determinants in our own communities? How can we best implement population health and health promotion initiatives within our communities or within our provinces or territories? Do we know enough about the profound effects of the socioeconomic determinants of health and how they affect individuals and entire communities? Are we able to identify and address inequities in health care, especially for marginalized Canadians? Do the socioeconomic determinants affect those living in geographically isolated communities differently than those in our urban centres? What barriers do refugees and new Canadians face with respect to the determinants of health, and access to equitable health care? The answers are found in a population health approach to health care. These approaches involve all levels of government, communities, individuals, and other stakeholders.

Population health Population health refers to the identification of the health outcomes of a population group and the equitable sharing of those outcomes with that group. A population or a population group can be defined by: ethnicity, geography, a nation, a province or territory, a community, or a setting (e.g., within schools, or the workplace). A population health approach looks at health in broad terms. It considers health to be a resource influenced by numerous factors identified in the determinants of health. A population health approach aims to improve the health status of a targeted population, rather than that of the individual. It is a framework for gathering and analyzing data around related factors that affect a population’s health. This analysis includes identifying the reasons why some groups are healthier than others. Subsequent action looks for ways to improve health and to address inequities in health status through reductions in material and social imbalances. The benefits of a population health approach extend beyond improving the health of a population group to building a sustainable and integrated health care system that meets the needs of a population, is flexible, effective, and equitable. Population health embraces broader definitions of health and wellness incorporating holistic concepts. Population health integrates public health initiatives such as health promotion and disease prevention. Public health transforms the recommendations from population health research into action (e.g., proposing that all children receive the recommended vaccinations, implementing health education initiatives). Public health strategies are funded and implemented by provincial/territorial and municipal governments, which involve collaboration with health care providers, industry, and community agencies. Social media also plays a significant role in the public health arena by providing a platform for public health campaigns; it is a distribution channel for health information (e.g., educational, preventive, and cautionary), and helps to improve health outcomes (see Chapter 10). The terms population health and public health are often used interchangeably but are different entities with a common denominator— health information. See Box 6.1 for an explanation of the differences between population health and public health.

  Box 6.1

Population Health Versus Public Health.

  Did You Know? Until recently, most childhood diseases were considered eradicated because of vaccinations (e.g., polio, measles, diphtheria, pertussis, rubella, mumps, tetanus, rotavirus, Hemophilic influenza B virus). The number of children vaccinated varies across the country, although exact numbers are not known because Canada has no national protocol for gathering this type of information. Some diseases previously deemed to be essentially eradicated are reappearing because of low vaccination rates in some regions. All children attending school should complete the vaccination regimes recommended in their province or territory. This is for their own protection and the protection of others. Ontario and New Brunswick require children to be vaccinated to attend school. Those children who are not vaccinated must present a certificate from a medical authority stating they cannot be vaccinated (the reason remains confidential). In addition to medical reasons, parents can exempt their children from the policy based on religious or conscientious grounds. In Ontario, under the Immunization of School Pupils Act, if the school does not have a completed immunization report, a student can be suspended for up to 20 days (or until such time as the proper documentation has been submitted). In 2017, Alberta passed legislation enabling school officials to crossreference immunization records from school enrollment lists with Alberta Health’s vaccination records identifying unimmunized children. With this information school officials can contact those families asking that their (unimmunized) children stay home if there is an outbreak of a communicable disease in the school. The Alberta law also allows health officials to contact parents of unvaccinated children to provide

information on the benefits of immunization. What are your own thoughts about mandatory protocols? Do you believe the risks of not vaccinating a child outweigh the benefits?

Introduction of population health to canada The reports and conferences discussed in this section were instrumental in the introduction and development of population health in Canada.

The Lalonde Report, 1974 In 1974, Marc Lalonde, then the minister of National Health and Welfare (which became Health Canada in 1993), created a landmark document that introduced the concept of population health to Canada. This document, entitled A New Perspective on the Health of Canadians (informally called the Lalonde Report) is considered the first document acknowledged by a major industrialized nation to state that health is determined by more than just biology, and that improved health could be achieved through changes in the environment, lifestyle, and health care organizations. (The full report can be found on the Evolve website.)

Alma-Ata Conference, 1978 In September 1978, the World Health Organization (WHO) convened the International Alma-Ata Conference in Kazakhstan to address the need for global cooperation on health issues and in health care reform. A slogan that emerged from that conference was “Health for All—2000,” which reflected the shared goal to reduce inequities in health—unfair and unequal distribution of health resources—across the globe through an emphasis on primary health care initiatives. Primary health care, as defined by the conference (Box 6.2), encompassed a broad range of concerns that paralleled those of the population health approach. It is health care with an emphasis on individuals and their communities. It includes essential medical and curative care received at the primary, secondary, or tertiary levels and involves health care providers, as well as community members, delivering care that is cost-effective, comprehensive, and collaborative (i.e., uses a team approach), within the community.

  Box 6.2

Alma-Ata Definition of Primary Health Care. Primary health care is essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation, and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. Reproduced, with the permission of the publisher, from Declaration of Alma-Ata: International conference on primary health care. Alma-Ata, USSR, 6– 12 September 1978. World Health Organization. Retrieved from http://www.who.int/publications/almaata_declaration_en.pdf. The Alma-Ata Conference’s 10-point declaration (see Appendix) claimed health as a fundamental right and stated that attaining an optimum level of health should be given the highest priority by all nations. The declaration called for the right of people and communities to be involved in planning their own health care, and challenged governments to develop strategies to improve primary health care.

  Thinking it Through The Declaration of Alma-Ata identified primary health care as the key strategy for attaining universal health by the year 2000. “Health for All” was universally accepted as the main social goal (i.e., not merely a health goal) by the world health community. Today efforts to improve the delivery of primary health care are underway in all regions across Canada, yet thousands of individuals remain without family doctors. 1. What improvements to health care have you seen in your own community? 2. Are other providers such as nurse practitioners accepted as primary care providers? 3. In your community is health care available to everyone on a fair, timely, and equal basis? 4. If it were up to you, what changes to health care would you implement?

Ottawa Charter for Health Promotion, 1986 The 1986 WHO conference in Ottawa was convened to review and expand on the proposals put forward at the Alma-Ata conference and to determine what progress had been made toward assuring health for all by the year 2000. At the Ottawa conference the original factors affecting health, outlined in the Lalonde Report, were broadened and termed “health prerequisites” and the need for a collaborative approach to address health-related problems was reinforced. Five principles emerged from the conference, including the need for all levels of government to become involved in health promotion and for individuals to assume responsibility for their own health (not just seeing the doctor when sick and expecting him or her to make them well). The charter also looked at strategies at the community level that would enhance health; for example, government-funded day care was cited as a strategy that would ultimately benefit the health and well-being of both the child and parent.

  Thinking it Through Some people believe Canada should have universal day care wherein it is available to every child. Some think that day care should be available to families based on their ability to pay (i.e., free for some, subsidized for others). There are also individuals who feel that child care should be the responsibility of the family and that government involvement only adds to the taxpayer’s burden. 1. Should day care for children be universally funded or subsidized according to income? Why or why not? 2. Do you think that day care facilities would be better regulated, thus safer, if universal funding was implemented? 3. What influence would universal day care have on the social determinants of health for preschool children?

The Epp Report, 1986 The Epp Report, Achieving Health for All: A Framework for Health Promotion by Jake Epp, minister of health and welfare, was released at the 1986 Ottawa conference. It focused on proposals to reduce inequities for

disadvantaged groups, to better manage chronic diseases, and to prevent disease. The report recommended that these initiatives have financial support from all levels of government (Epp, 1986).

The Public Health Program Initiative Designed by the Canadian Institute for Advanced Research, the Public Health Program Initiative reviewed the determinants of health, analyzed their impact on the health of the Canadian population, and assessed the efficiency and effectiveness of the health care system. Completed in 2003, the report supported extending the idea that the determinants of health identified at previous conferences were linked—that is, that health outcomes were tied to multiple factors. For example, low income alone did not contribute to ill health, nor did a low position on the socioeconomic scale. Consider the potential outcomes in the life of Hinze (Case Example 6.1).

  Case example 6.1 If Hinze is in a low income bracket, chances are he will also be in a lower socioeconomic group or subject to less desirable living conditions, or both. As a result, Hinze may have less opportunity or motivation to advance his education or to obtain meaningful and satisfying employment. Perhaps he smokes or drinks alcohol to relieve stress. Cumulatively, he may then feel socially isolated or have low self-esteem and little confidence. He may also have poor nutritional habits perhaps because of a lack of knowledge about nutrition or because he cannot afford nutritious food. Combine these factors, and Hinze is at risk for multiple health problems ranging from depression to cancer or heart disease. Box 6.3 discusses the socioeconomic gradient (SES gradient) in more detail. While Hinze may develop a serious health problem, his friend Gus, who lives an almost identical lifestyle, is the picture of good health. This disparity has frequently been observed among groups of people living in similar conditions. Why are some groups affected and some not, given common denominators? Research in this field continues today. One area under close scrutiny is the inequity in the health of Canadians despite universal access (at least in theory) to health care.

  Box 6.3

Socioeconomic Status Explained. The Socioeconomic Status (SES) is a measurement derived from combining a person’s or a group’s education, occupation, income, social status, and sometimes geography. The results are used to position the person/group on a hierarchical socioeconomic scale or gradient. The measurement is widely used in population health studies, for example, to measure inequities experienced by a selected population related to the determinants of health. The SES is divided into three levels: low, medium or average, and high. At the bottom of the gradient are people who are below the poverty line, perhaps unemployed or underemployed living in a lower socioeconomic environment, and therefore at risk for poor health. As an individual’s or group’s socioeconomic status improves, so does the individual’s or group’s health. For example, those living in what we might consider a middle-class environment tend to be healthier than those in a lower-class group. Those living in the highest socioeconomic bracket, according to the SES gradient, enjoy the highest level of health. We also know, however, that people who are born into a lower socioeconomic environment can enjoy good health and be happy, productive individuals. Thus the theory is not absolute, and variables within and relationships among the determinants are not clearly understood. Usually studies examine a number of population groups and compare the results. A single socioeconomic indicator can be used for measurement (e.g., occupation) or multiple indicators (e.g., socioeconomic and physical/material indices) can be grouped together (e.g., income, education, geography, single parents, persons living alone). The goal is to determine gaps in health across the selected population groups and identify what actions are needed to narrow the gaps. Consider Canada’s Indigenous People, who for the most part are on the lower end of the SES gradient. Poverty, unemployment, and poor living and poor socioeconomic conditions on reserves and in many communities are the norm. If you review the determinants of health as applied to large portions of this population group, you will see how broadly they are affected.

Toward a Healthy Future: The First Report on the Health of Canadians, 1996

The first Report on the Health of Canadians was released in September 1996 by federal health minister David Dingwall and Ontario health minister Jim Wilson. Its recommendations carried forward the proposals made by the Canadian Institute for Advanced Research (CIFAR) in 1989. This report was the first to officially recognize and incorporate the determinants of health into its findings and recommendations. The report concluded that Canadians were among the healthiest populations in the world and emphasized that collaboration among all levels of government, industry, and the private sector must be intensified to improve the health of Canadians (Federal, Provincial and Territory Advisory Committee on Population Health, 1996). Box 6.4 lists strategies specified by the report to improve or maintain the health of Canadians, a further endorsement of the principles of the population health approach.

  Box 6.4

Strategies for Improving the Health of Canadians. • Create a thriving and sustainable economy, with meaningful work for all. • Ensure an adequate income for all Canadians. • Reduce the number of families living in poverty in Canada. • Achieve an equitable distribution of income. • Ensure healthy working conditions. • Encourage lifelong learning. • Foster friendships and social support networks among families and communities. • Create a healthy and sustainable environment for all. • Ensure suitable, adequate, and affordable housing. • Develop safe and well-designed communities. • Foster healthy child development. • Encourage healthy life-choice decisions. • Provide appropriate and affordable health services, accessible to all. • Reduce preventable illness, injury, and death.

Source: Health Canada. (2019). Healthy living. Retrieved from https://www.canada.ca/en/health-canada/services/healthy-living.html.

National Forum on Health, 1994–1997 The National Forum on Health was the blueprint for current Health Canada initiatives. The forum was launched by the Right Honorable Jean Chrétien in 1994 and wrapped up in 1997. An integral part of this forum was public input—the beliefs and values of people across the country were sought through public discussion groups, conferences, meetings with experts, commissioned papers, letters, and briefs. In February 1997, the forum published two final reports: Canada Health Action: Building on the Legacy, Vol. I: Final Report and Canada Health Action: Building on the Legacy, Vol. II: Synthesis Reports and Issue Papers. One of the key recommendations emerging from this forum was the need for more analysis and concrete evidence (i.e., an evidence-informed approach) to support initiatives for improving health. All of these reports, beginning with the Lalonde Report, were significant in initiating a united population health approach to achieving better health for Canadians. Recent reports—including Toward a Healthy Future: The Second Report on the Health of Canadians, 1999; Building a Healthy Future, 2000; Final Report on the Health of Canadians, 2002 (also known as the Kirby Report); and Building on Values: The Future of Health Care in Canada, 2002 (more commonly known as the Romanow Report) (see Chapter 1)—have analyzed the health of Canadians using a population health approach and offered recommendations for action.

Determinants of health The majority of people look at health and illness from a fairly linear perspective (e.g., genetics, biology, and disease). We engage in health promotion, disease prevention, and are aware of various behavioural risks that can adversely affect our health, not recognizing the profound effect of socioeconomic factors or other health determinants. These include the following: education; employment and level of income; the built environment in which we work, live, and play; climate change; early child development (including nutrition, exercise, family dynamics); and our social support networks. The health of a population, population groups, and individuals is dependent on a combination of these factors, many of which seem beyond our control. We are all affected by these variables to varying degrees, which go beyond genetics, biology, and disease. One of these determinants, in isolation, is unlikely to have a great effect on the health of either an individual or a population group but has an effect rather by the interconnectivity of numerous determinants. The Public Health Agency of Canada (PHAC) identifies 12 determinants of health (Fig. 6.1).

FIG. 6.1 Key Determinants of Health. (Based on Public Health Agency of Canada. [2001]. Determinants of health: What makes Canadians healthy or unhealthy? Retrieved May 29, 2009, from http://www.phac-aspc.gc.ca/phsp/determinants/index-eng.php#determinants.)

1 Income and Social Status Income and social status appear to be the most important determinants of health. Extensive research demonstrates the link between income, social status, and health (Public Health Agency of Canada, 2013). A lower socioeconomic status appears to be associated with poorer health and an earlier death, and a higher socioeconomic status, with better health; in other words, an individual’s health tends to be proportional to his or her socioeconomic position (see Box 6.2).

  Thinking it Through Today a higher education does not guarantee a good job and income security. Large numbers of university graduates cannot find jobs in their fields and take lower paying jobs that are unrelated to their skill set. In 2017, the unemployment rate for individuals between the ages of 15 and 24 was almost 13%, significantly higher than the rest of the general

population at 5.7% (Statistics Canada, 2017b; Trading Economics, 2018). In addition, tuition fees in Canada have doubled since the late 1990s. Statistics Canada estimated the average cost of an undergraduate degree to be $23,000 and that does not include supplies or cost of living (Workopolis, 2016). There are twice as many university graduates competing for available jobs. 1. If these trends continue, what effect do you think they will have on the economy? 2. How does this information contradict the indicators related to income, social status, and the SES? 3. How might these trends affect individuals with respect to their health status? Why? Sources: Statistics Canada. (2017). Labour Force Survey, December 2017. Retrieved from https://www150.statcan.gc.ca/n1/dailyquotidien/180105/dq180105a-eng.htm; Trading Economics. (2018). Canada—unemployment, youth total (% of total labor force ages 15–24). Trading Economics. Retrieved from https://tradingeconomics.com/canada/unemployment-youth-totalpercent-of-total-labor-force-ages-15-24-wb-data.html; Workopolis. (2016). The university degrees with the greatest payoff on the Canadian job market. Retrieved from https://careers.workopolis.com/advice/the-universitydegrees-with-the-greatest-payoff-on-the-canadian-job-market/.

  Did You Know? In 2015, Canada’s median household income, after taxes, was $70,336. The median income refers to the income level where half the population has a higher income and half has a lower income. Anyone whose household income is less than half the national median is living below the poverty line. This calculation is referred to internationally as the After Tax Low Income Measure (LIM-AT). In 2015 the poverty line was $35,168; 14.2% of the total population were living in poverty (Statistics Canada, 2017a). The poverty line for a family of two adults and two children in 2017 was $37,542, and approximately 4.8 million people in Canada (or 13.9%) of the population were living in poverty (Corak, 2018; Citizens for Public Justice, 2017). In the 2016 Census, it was reported that 14.2% of Indigenous Peoples earned an annual income below the national average (Statistics

Canada, 2016). In 2017, people on welfare in British Columbia got approximately $710 per month ($8520 per year) (Zussman, 2017). Alberta Works will pay an individual $627 per month ($7524 per year) (Cryderman, 2012), and Ontario $656 per month ($7872 per year) (Brennan, 2015). These amounts increase for families based on the number of adults and children in the household. Individuals living on social assistance struggle financially. Some may experience housing and food insecurity, social isolation, low self-esteem, poor coping skills, and suffer the stigma of being on social assistance. A number of jurisdictions are replacing or have replaced social assistance cheques with debit cards, eliminating the need to wait for cheques to arrive, the cost of cashing cheques, and the convenience of using the card to make purchases. No bank account is needed, and monthly deposits are made on a regular basis by the government. Sources: Brennan, R. J. (2015). Ontario set to replace welfare cheques with debit cards. The Star. Retrieved from https://www.thestar.com/news/queenspark/2015/03/19/ontario-set-toreplace-welfare-cheques-with-debit-cards.html; Citizens for Public Justice. (2017). Poverty trends 2017. Ottawa. Retrieved from https://www.cpj.ca/poverty-trends-2017; Cryderman, K. (2012). Lowincome Albertans and disability workers get boost in 2012 budget. Inclusion Alberta. Retrieved from: http://inclusionalberta.org/news/2012/02/09/news-item/low-incomealbertans-and-disability-workers-get-boost-in-2012-budget/; Statistics Canada. (2016). 2016 census of Population. Aboriginal identity, individual lowincome status. Catalogue no. 98-400-X2016173; Statistics Canada. (2017). Household income in Canada: Key results from the 2016 census. Retrieved from https://www150.statcan.gc.ca/n1/daily-quotidien/170913/dq170913aeng.htm; Zussman, R. (2017). B.C. government set to increase welfare rates and disability assistance. CBC News. Retrieved from http://www.cbc.ca/news/canada/british-columbia/b-c-government-setto-increase-welfare-rates-and-disability-assistance-1.4214828.

2 Social Support Networks The opportunity to share feelings, discuss problems, and receive the clear support of others relieves stress and enhances a sense of well-being. It promotes the feeling of being wanted, supported, and valued, and improves a person’s physical and emotional health. Social support can

come from family members, friends, or a community, which is often not considered. Having close ties to a community provides a sense of belonging and security. Community can include affiliations with work, church, volunteer organizations, or even belonging to a gym, not just the usual perception of a typical neighborhood. The type and level of support a person has or seeks is influenced by many factors, including age, sex, gender, and culture. Typically, men are less likely to form supportive networks and share feelings, although that is changing. Similarly, in some more reserved cultures, sharing personal feelings with others is discouraged. Consider Case Examples 6.2 and 6.3. Individuals who are marginalized or bullied are more likely to feel a loss of control, self-worth, and suffer mental trauma.

  Case example 6.2 Mary is 46 years old and a single parent, new to her community in Vancouver. Her ex-husband lives in Calgary and there is little communication between them. Mary is a respiratory therapist and does shift work. She has discovered that her 16-year-old son, Eric, is experimenting with drugs. Recently she found evidence that Eric was experimenting with heroin as well as other opioids—obtained from various drug dealers. Mary tried talking to Eric about the related dangers and consequences of his actions (e.g., drugs contaminated with fentanyl). He refuses to speak with Mary and is threatening to move out. Mary has no idea who Eric is hanging out with and feels she has nowhere to turn— her nearest family members live out of province.

  Case example 6.3 Kumar is 50 years old and has been married to Reena for 15 years. They have been having marital problems for some time. Kumar is uncomfortable voicing personal problems and does not have a close friend with whom he could discuss personal issues. He bottles up his feelings, and as a result, is argumentative, critical, and bad tempered most of the time. His mood affects his family, friends, and colleagues. He has trouble sleeping, and he was diagnosed with high blood pressure in recent weeks. He has refused counselling. Reena, on the other hand, is

able to reach out to close friends and family for support. She has joined a meditation group. Kumar’s behaviour is not unusual for many men. Statistically, men die at a younger age than women. This may be due, in part, to men’s inability to access a social network for support and advice. In fact, recent reports show a link between the social environment and the risks of morbidity and mortality, exclusive of the effects of other health determinants. Findings also indicate that social environment can influence the course of a disease. For example, a person with cancer or cardiovascular disease will survive much longer if he or she accesses supportive social networks. This may relate, in part, to a reduction in stress and a positive, even optimistic, outlook generated by a loving and caring environment (Haydon, Roerecke, Giesbrecht, et al., 2006; Mikkonen & Raphael, 2010; Koven, 2013; Holt-Lunstad, Smith, & Layton, 2010; Institute of Medicine (US) Committee on Health and Behavior, 2001).

  Thinking it Through In 2016, the Health Status Survey (HSS) reported that individuals with fewer ties to any community were among those aged 20–34. 1. What do you think are the reasons behind this feeling of not belonging to any particular community? 2. Considering social support systems, how might a lower sense of community ties impact this age group? 3. What other support systems do you think would be important here?

3 Education and Literacy Literacy and access to education often encourages a higher level of education, which, in turn, usually leads to better paying jobs with higher social status and an established, steady income. Financial security increases opportunities for a person or a family on many levels. For example, children may benefit from participating in organized sports or taking lessons in another recreational activity. A higher level of education also widens people’s knowledge base, their ability to think logically, and to problem solve. Higher education often motivates people to engage in meaningful relationships, become involved in the community, and, in general, be more satisfied. Yet, there are

individuals with lower levels of education who do very well in life. Their children even grow up with a sense of love and belonging, overcome challenges, and graduate from colleges or universities. What influences this success? Higher education is certainly not limited to mean a university degree. Currently those who have graduated from community skills and in the trades with often find a range of employment opportunities. The 2016 Health Status Survey (HSS) found that the gap between the highest and lowest wage earners is widening despite the fact that in 2015, 90% of students enrolled in schools across Canada finished high school, and 66% of those went on to post-secondary education.

  Did You Know? According to a report by the C.D. Howe Institute, among First Nations people living on a reserve, only 4 in 10 students graduate from high school. For First Nations people living off-reserve it was 7 in 10, and 8 out of 10 Métis people were high school graduates. Indigenous students who leave reserves to attend off-reserve high schools are, on average, 2–3 years behind their provincial cohorts from an academic perspective, necessitating the need for remedial classes. This factor, along with cultural adjustments (such as transitioning from living on the reserve to city living), being removed from their communities, support networks, and families, are barriers that contribute to lower graduation rates. Source: Waubageshig. (2016). First Nations elementary-secondary school education: A national dilemma. C.D. Howe Institute. Retrieved from: https://www.cdhowe.org/sites/default/files/attachments/otherresearch/pdf/Verbatim_Waubageshing_2016.pdf.

4 Employment and Working Conditions Individuals who are underemployed or unemployed, or work at menial jobs in which satisfaction is low and stress is high, tend to have poorer health. These people have a higher mortality rate at a younger age (e.g., death by suicide among Indigenous Peoples living in isolated communities) and higher morbidity rates from chronic diseases (e.g., cardio-respiratory disease). Families of unemployed or underemployed individuals can also have poorer health, likely because of resulting high

stress levels, related emotional problems, and a lower socioeconomic environment. Many who are unemployed or underemployed lack health care benefits and cannot afford such things as prescription drugs or dental services. Unemployment is cited as one of the largest stressors that a person or family can face. Unemployment is estimated to be 11.3% for Indigenous Peoples over 15 years of age, and for all education levels; with less than high school, 19.7%; with high school and some post-secondary, 12.1%; with completed post-secondary, 8.0% (Statistics Canada, 2018). It is important to note that unemployment in Indigenous communities may have a different definition and value, and many people who are “unemployed” continue to contribute to their communities in other ways. Individuals earning minimum wage frequently have two or more jobs in order to generate an income sufficient to pay for basic expenses. Recently, British Columbia, Alberta, and Ontario raised the minimum wage to $14– 15/hr. Ontario raised the minimum wage to $14/hr on January 1, 2018. Further planned increases were cancelled when the conservative government came into power in Ontario in November 2018. There is still a gender wage gap in many countries, which emphasizes the economic inequality women experience and can cause economic hardship. In 2016, the Organisation for Economic Co-Operation and Development (OECD) surveyed 39 countries and Canada was ranked the seventh highest to the have gender wage gap—slightly higher than the United States that came in eighth (OECD, 2018). In 2017, women working full time earned about 74 cents for every dollar men made, also working in full-time positions. A study entitled Work and its Role in Shaping the Social Gradient in Health noted several interesting facts. One is that individuals who work on contract experience significant economic insecurity, and are also adversely affected by loss of support from social networks and stresses related to worrying about their future, including loss of benefits and a sustained pension plan (Clougherty, Souza & Cullen, 2010). Increasingly, individuals who are highly skilled and/or educated are now facing the reality of contract positions, unemployment, and underemployment (along with those in lower paying, unskilled jobs). Researchers do not yet understand the long term socioeconomic and health effects on this group of people. What is known is that the direct effects of protracted underemployment and unemployment increase cardiovascular risk factors.

5 Social Environment

The social environment is constructed by how individuals behave; their relationships with others and their community (including a person’s level of attachment and social comfort regarding a feeling of belonging and relationships); their gender, culture, and ethnic group; their education and roles in the workforce; the conditions and communities in which they live; and how they feel about themselves. These elements overlap with other determinants to influence health and life expectancy. Individuals in the same or similar social environments have been shown to demonstrate similar values, outlook on life, and ways of thinking. The tighter knit and more organized a community is, and the more involved the population is with activities within the community, the greater the health of that community. Keep in mind that the makeup of a community and how it can impact the health of its population can vary. For example, individuals or families living in a condominium may not know their physical neighbours, but may be involved in a church or a sports team. Remote communities, such as those in the northern parts of Canada, are usually close-knit communities, but still lack access to a variety of services and activities available in more populated regions. New Canadians are subject to social isolation as they have left their families, friends, and support networks behind and are trying to adapt to a new culture. Volunteerism promotes a sense of belonging and improves the wellbeing of the social environment, apparently increasing a community’s level of compassion, harmony, and cohesiveness. Volunteers themselves generally live longer and suffer less from depression and heart disease (Public Health Agency of Canada, n.d.).

  Thinking it Through You have an opportunity to volunteer at your community health centre. You know it is a good cause but wonder if you can find the time with all your other commitments at school and home. 1. Do you believe that being a volunteer can contribute to your physical and social well-being? 2. Would volunteering in your chosen field add value to your résumé? Some communities have agencies and resources that support community residents (e.g., community or government sponsored child

care, and resources for older Canadians), which can reduce stress and financial burden. Social stability fosters positive relationships, recognition and acceptance of cultural diversity, and unified communities that inspire confidence, a sense of being valued, and assurances of support—all of which have a powerful effect on reducing health risks.

6 Physical Environment The physical environment consists of natural and manufactured environments. The natural environment includes the food people eat, the water they drink, the air they breathe, and the places they live—the outside or physical world. The “manufactured” environment (also referred to as the “built” environment) refers to the homes people live in, the buildings where they attend school or work in, the roads they travel, and the recreational areas such as parks and community structures they use. How this built environment is structured and constructed affects health status. For example, the phrase sick building or tight building syndrome describes nonspecific illnesses that are attributed to time spent in a specific building. For example, Legionnaire disease is caused by bacteria in the building’s ventilation system (Canadian Centre for Occupational Health and Safety, 2017). Currently environmental issues are top of mind, with widespread concern over drinking water and related infrastructure, air pollution, environmental/global warming, pollution of agricultural land, and depletion of natural resources. Indigenous communities are particularly affected by problems with drinking water and faulty water purification systems (e.g., failed watertreatment plants, water towers). In November 2017, Health Canada reported 130 drinking water advisories in effect in 85 Indigenous communities (Government of Canada, 2017b). Building and maintaining these structures is the responsibility of Indigenous and Northern Affairs Canada.

7 Personal Health Practices and Coping Skills Personal health practices relate to self-imposed risk behaviours, health beliefs, and health behaviours. Personal health practices are often linked to a person’s level of self-esteem, sense of control, and level of confidence. Life’s experiences also influence personal health practices. For example, a person who had a relative who smoked heavily all of his or her life and did not have any health problems may reject the connection between

COPD, cancer, and smoking; a person whose child had a bad reaction to an immunization may now avoid them. Coping skills help an individual deal with situations and problems, and are influenced by both genetic make-up and socioeconomic factors. Some people are better able to deal with problems, stress, and daily challenges than others, even in the face of significant socioeconomic challenges such as family disharmony, financial and employment insecurity, and marginalization. Consider the challenges faced by new Canadians recently arrived from war torn countries. Cultural differences may affect health beliefs, practices and expectations, and socioeconomic influences. Their new environment will have a profound effect on how they are able to adjust and cope in their new home. The more help and support a family has transitioning to life in Canada, the more positive the outcomes will be in terms of confidence and ability to cope.

  Thinking it Through As a student, you are likely faced with new challenges such as living away from home, meeting new people, and dealing with academic responsibilities. 1. How do you respond to these stressors? 2. Are you likely to approach a professor, friend, or family member for support? 3. Are you aware of the resources at your university or college that can offer support? Are they adequate? 4. What impact (if any) have the stresses of being away from home and attending college or university had on you personally?

8 Healthy Child Development Healthy child development begins at conception and before birth, is affected by the health practices (e.g., nutrition) and risks taken by the mother. Drinking, which is linked to fetal alcohol syndrome, drug use, and smoking during pregnancy are widely accepted as detrimental behaviours affecting the developing fetus. There are also serious questions about the safety of the now legalized use of cannabis during pregnancy; some claim cannabis is effective for treating hyperemesis gravidarum (severe nausea and vomiting). Health Canada advices pregnant women not to use

cannabis, stressing that components of the drug are transferred to the fetus through the placenta (also through breast milk). Adverse effects include low birth weight, and later impaired memory function and problemsolving skills, in addition to hyperactivity disorder. There are multiple determinants of health that together affect a child’s physical, social, mental, and emotional development, ranging from employment insecurity to stressors and hardships that contribute to family disharmony and family breakdown. Healthy child development is one of the areas Health Canada is paying particular attention to; research in this area is continuous. Between 2014 and 2017 the Canadian council on Social Determinants of Health formed a task group (The Healthy Child Development Task Group) to create innovative ways in which to advance research on healthy child development in Canada. The goal was to collaborate with researchers, stakeholders, and policy makers to consolidate research outcomes and formulate an evidence-based plan of action. For example, researchers concluded that there is not enough awareness concerning the impact of some of the social determinants of health on brain development in small children (ages 0–3). It is felt that more research is needed to effectively evaluate selected determinants such as poverty, food insecurity, neglect, and lack of stimulation on the development of children in that age group. Researchers concluded that if the relationship (cause and effect) was better understood, definitive interventions such as screening tools and assessments could be implemented.

  Did You Know? In February 2016, the Public Health Agency of Canada (PHAC) published the Health Promotion and Chronic Disease Prevention in Canada: Research, Policy and Practice. The research project assessed the presence of cardiovascular risk factors in children and adolescents. The researchers concluded that risk factors could be identified in Canadian school-aged children. There were differences in sex and socioeconomic gradient indicators, such as obesity and aerobic fitness, with obesity being a major concern (because obesity contributes to diabetes, which in turn can affect the cardiovascular system, and can become a significant risk factor). Boys across all gradients and girls in the lower gradient group were more likely to be obese; girls were more likely to be inactive. Weight management was deemed to be important, as well as exercise across the board (all gradient

groups). The conclusion among other things stated that educating and engaging the parents is thought to be of the upmost importance for interventions to be remotely successful—especially parents with a lower level of education. Thus population health interventions to reduce the socioeconomic status risk factors for cardiovascular disease should begin in early childhood. Source: Shi, Y., de Groh, M., & Bancej, C., (2016). Socioeconomic gradients in cardiovascular risk in Canadian children and adolescents. Health Promotion and Chronic Disease Prevention in Canada: Research, Policy, and Practice. 36(2): 21–31. Retrieved from https://www.canada.ca/content/dam/phac-aspc/migration/phacaspc/publicat/hpcdp-pspmc/36-2/assets/pdf/36-2-eng.pdf.

9 Biology and Genetic Endowment The phrase biology and genetic endowment refers to all the attributes that people inherit from their parents. These inherited attributes can make a person vulnerable to developing specific diseases and other health problems. Individuals can have genetic studies done that will help them understand their risk of developing certain diseases (e.g., Huntington disease, cystic fibrosis, certain forms of cancer—such as breast cancer— and more recently, Alzheimer disease). Such information may also be used to help individuals understand the risk of passing certain conditions on to their children. How individuals use this information varies, and some may choose not to know. Socioeconomic and environment influences can affect biology. If a person grows up and continues to live in ideal socioeconomic and environmental conditions, he or she is more likely to have good physical and mental health. An older adult who has lived a healthy, active lifestyle, with a strong social network and easy access to medical care, may avoid ever suffering from chronic diseases and musculoskeletal decline.

  Did You Know? Genetic testing can assist with diagnosis when someone is ill, or can identify a gene or genetic mutation that is likely to cause disease, and in some cases enable preventive action. For example, Angelina Jolie underwent an elective double mastectomy in May 2013 to reduce her

chances of developing breast cancer. Genetic testing showed she carried the BRCA1 gene, exponentially increasing her risk of developing the disease (prevalent in her family history). Researchers recently developed a test to identify the age at which a person at risk would develop late onset Alzheimer disease, providing an opportunity to engage in potentially preventive measures such as a healthy diet, exercise, and staying mentally alert.

10 Health Services Health services include diagnosis, treatment (both to maintain and restore health), disease prevention, and health promotion—all pillars of the population health and population health prevention approach. The type of health care services offered and their method of delivery affect the health of a population. Greater availability of primary care services and of health promotion and disease prevention programs (e.g., immunizations, preventive care such as breast screening, prenatal care, and well-baby initiatives) can lead to a healthier population. Equally as important are community and long-term care services. There are currently multiple challenges facing health services in Canada such as financial, logistical, and human health resources. Cost restraints affect prompt access to diagnostic facilities, physicians, and procedures, and result in inadequate staffing in hospitals (e.g., nurses). Isolated communities experience inequities (such as access and treatment), and shortages of human health resources remain (e.g., primary care providers, particularly in rural and more isolated areas).

  Did You Know? Primary care and primary health care are often used interchangeably and definitions can vary. Primary care typically refers to the first line of care a person receives from providers such as a nurse practitioner or physician (you go to see your family physician for an earache, and he or she does an assessment, provides treatment, and advice). Primary health care, on the other hand, refers to the broad range of primary care services available within a community from a variety of providers. This can include laboratory and diagnostic services, counselling, nutritional advice, clinics to monitor diabetics and individuals with hypertension. The emergency department

is considered a primary care service. The differences between the terms are vague at best.

11 Gender Gender is a very personal expression of who we are as individuals. Different from biology or sexual orientation, it refers to a range of identities that one assumes and that may change through the life cycle. It includes self-identified social and cultural differences, lifestyle, and sense of self, not only biological status. There are many evolving terms to describe various identities. LGBTQ2 is an acronym for Lesbian, Gay, Bisexual, Transgender, Transsexual, Queer and Questioning, Two-Spirit, people. • Lesbian: a female individual attracted to another female. • Gay: an individual (either male or female) attracted to someone of the same sex and/or gender. • Bisexual: an individual attracted to both male and female people. • Transgender (or trans): an umbrella term that refers to an individual who does not identify (fully or in part) with the gender they were assigned at birth. • Transsexual: a person whose gender identity does not correspond with the sex they were assigned at birth. Some transsexual people have, for example, sex reassignment surgery and/or hormone therapy. • Queer: historically, a derogatory term for homosexuality. Some members of today’s LGBTQ community have reclaimed this term. • Questioning: an individual who is unsure of or still exploring their sexual orientation or gender identity and may want to avoid using another label. • Two Spirit: a modern umbrella term used by some Indigenous people instead of other terms (lesbian, gay, bisexual, trans, queer). The term reflects how all aspects of identity are interrelated (Egale Canada Human Rights Trust, 2018). There are many other terms used to describe other identities as well. For example, gender neutral or androgynous. As a determinant of health, gender identity poses many challenges. Acceptance or rejection by friends, families, and the community has a profound effect on well-being. Employment may be hard to find because

of the stigma of being “different” in the eyes of the employer. The medical community often fails to provide gender sensitive and appropriate care, resulting in inequities related to the health care system itself. Additionally, those transitioning from one sex to the other face long waits, emotionally exhausting physical and mental assessments, and uncertainty as to what procedures are covered under public health plans. The procedures collectively are called sex reassignment or gender confirming surgery. Criteria for coverage in most jurisdictions is based on standards determined by the World Professional Association for Transgender Health for gender dysphoria (discomfort and stress a person experiences when their gender identity differs from their sex as assigned at birth). Surgery required because of this diagnosis is considered to be medically necessary. There are only two facilities in Canada doing genital surgery, one of which is a private clinic in Montreal and the other in Toronto, through Women’s College Hospital. Conditions for the surgery require the person to be in good mental and physical health, and may require the person to take hormones and live in their desired identity for at least a year.

12 Culture Culture can be described as a way of life (e.g., behaviours, values, attitudes, geographic and political factors) that is attributed to a group of people. Ethnicity refers more to race, origin or ancestry, identity, language, and religion. Culture and ethnicity are often linked—and both affect health, particularly in terms of health beliefs, health behaviours, and lifestyle choices. Those with different social, religious, value, and belief systems than others in their community are more likely to face inequities, marginalization, socioeconomic problems, and isolation. This may or may not improve the longer an individual has been in Canada. Minorities are especially at risk because the larger group’s socioeconomic and cultural environments tend to dominate the community, overshadowing needs of minorities. Risk factors for minorities include health beliefs and health behaviours—for example, how and at what point they will approach the health care system. Barriers to seeking care may include fear, language struggles, and noninvolvement of family members. Family members or friends/groups within a community often provide significant support by contacting a physician, providing transportation to the physician’s office or hospital, explaining the rationale for treatments, and translating information when required.

Refugees arriving in Canada over the past 3 or 4 years (the majority of whom have been granted residency upon arrival) have been sponsored by either the government, individuals, or private groups. Those sponsored by individuals or groups have more support adapting to life in Canada, as their sponsors provide assistance with many aspects of resettlement including finding and maintaining a suitable place to live, and connecting to and understanding the health care system. Individuals who have spent long periods of time in refugee camps may arrive with significant health challenges requiring specialized care and dental care, which may or may not be covered. In most cases, the government provides funding for a year. Beyond that, if new Canadians don’t find employment, they rely on provincial/territorial social assistance, which results in financial insecurity —affecting all aspects of daily living. Unemployment weighs heavily on the designated “bread-winner” in the family and may impose feelings of inadequacies. Language can be a huge barrier. For most refugees, access to learning English or French is provided within a certain time frame, but attending classes may be difficult. For example, a family with small children may have to decide which parent goes to these classes. Religion, dress, climate, rules and regulations, community acceptance, and health care practices pose barriers related to multiple health determinants. Another group of people often overlooked are the refugees who have arrived in Canada illegally and are awaiting immigration hearings, which can take up to 2 years. Most have little or no supportive networks, rely on social assistance, and have no permanent place to live, relying on shelters, or any space communities can provide. Large numbers choose to live in larger centres where space is limited and budgets to support them are strained. In terms of health determinants, these people are at risk mentally, emotionally, and physically.

  Thinking it Through Over the past 2 years, Canada has accepted thousands of Syrians and people from other countries. These “new Canadians” face many challenges as they adjust to their new environment, from culture and language to attaining financial independence and acceptance of who they are.

1. Which determinants of health do you think are most likely to pose challenges for these new Canadians? 2. How can communities best assist families who are sponsored by the government? 3. What do you see as the most significant difficulties with respect to health care?

The population health approach: the key elements Implementing a population health approach to health care requires the collaboration and cooperation of a number of agencies, organizations, health professionals, policy makers, stakeholders, and volunteers, and in which the Public Health Agency takes the lead role. Other important partners include The Canadian Institute of Health Information, The Canadian Institute for Health Research and Statistics Canada (see Chapter 2) supported by organizations at all levels of government and by communities. Implementation of population health requires a formal plan, which ensures that steps are executed in a coordinated manner, requires that critical elements are identified, and that the role of agencies or individuals is clearly defined. The Public Health Agency of Canada has constructed eight key elements, which provide the framework for its population health approach.

  Thinking it Through In Canada, it is widely recommended (with a few exceptions) that everyone over the age of 6 months get an annual flu shot. Targeted or high-risk groups (e.g., young children, older adults, individuals with chronic diseases or compromised immune systems, and people working in health care) are especially encouraged to get their flu vaccinations early. The vaccine for the 2017–2018 season contained influenza A (H1N1) virus, influenza A (H3N2) variant virus, and influenza B virus, but was not particularly effective against some of the circulating strains, prompting many not to get vaccinated. Researchers still recommend getting vaccinated claiming that if contracted, the flu may be less severe because of a phenomenon called cell mediated immunity (an immunity built up over the years in vaccinated individuals). There were an average number of adult deaths in Canada for that season, but more children became sick, with several deaths, some confirmed to be from the B strain of the virus (contained in this vaccine). 1. What is your opinion of the flu vaccine?

2. How would you feel if you (or a family member) were in hospital and being cared for by an unvaccinated health care provider? 3. What valid reasons, if any, can you see for refusing the flu vaccine? Source: Public Health Agency of Canada. (2014). Flu watch. Retrieved from http://www.phac-aspc.gc.ca/fluwatch/index-eng.php.

The Public Health Agency of Canada Template A template (also called a framework) is much like a design, or a plan that can be standardized and used by others, or changed to suit a specific project. Health Canada has a population health template that is available to researchers, policy advisors, educators, and other stakeholders for developing population health initiatives. It provides a common framework for health-related policy and program development, maintaining a thread of continuity across projects and jurisdictions. The template, outlining the accepted policies and procedures, is needed to implement a population approach. In addition, using the template allows government authorities to determine the viability and suitability of research proposals. The eight key elements outlined in the framework are considered required steps to develop and implement a population health approach. In Fig. 6.2, the key elements 1 and 2 are considered particularly important as they reflect the very definition of population health.

FIG. 6.2 Population Health Approach: The Organizing Framework. (Public Health Agency of Canada. [2013]. Population health approach: The organizing framework. Retrieved from http://cbpp-pcpe.phac-aspc.gc.ca/population-healthapproach-organizing-framework/.)

Key Element 1. Focus on the Health of a Target Population The targeted population or subpopulation can include individuals within the country, province or territory, city, community within a city, ethnic group, setting (e.g., school or workplace), or age group (e.g., older/aging Canadians) See Box 6.5. A study might be done on the general health of a

target population, or it can be more specific, such as cancer rates, or rates of cardiovascular disease within a geographic area. Information can be gathered over a predetermined time frame (e.g., 6 months) and may include multiple health issues. A mix of selected health indicators are used as measurements, from morbidity, mortality, and hospitalization rates to aggregate indicators, which combine health information for comparative purposes. Contextual elements also affect this phase of the framework— for example, demographics of the selected population, physical character sites (e.g., rural or urban and the related built environment), and the willingness of levels of government to be involved (perhaps with funding).

  Box 6.5

An Aging Population: An Example of Population-Based Surveillance. Canada’s aging population is already stressing the health care system and the economy. According to Statistics Canada (2017) the percentage of older Canadians in the country accounts for 16.9% of the population, for the first time exceeding the percentage of children (under the age of 14, 16.6%). If the pattern continues, there will be 12 million older Canadians and fewer than 8 million children by 2061. Because women live longer, those over 65 will outnumber men aged over 65 by about 20%. Reasons for a proportionately larger older population include the post–World War II baby boom (1946–1965), increased longevity, and lower birth rates (which started in the 1970s). Statistics Canada predicts that by 2056 olderadult Canadians will account for 25–30% of the population. In terms of demographics, this aging population has both social and economic consequences (Statistics Canada, 2017). As older Canadians retire, fewer young people are moving into the workforce. As well as affecting the economy in general, this demographic shift will mean that fewer people are working to support Canada’s social safety net, including seniors’ pensions and health care benefits. Possible solutions that the government may consider include efforts to raise the birth rate and increase immigration. Source: Statistics Canada. (2017). Age and sex, and type of dwelling data: Key results from the 2016 census. Retrieved from

https://www150.statcan.gc.ca/n1/daily-quotidien/170503/dq170503aeng.htm.

Key Element 2. Address the Determinants of Health and Their Interactions Population health considers all of the factors (determinants) that affect health of the target population. As outlined in Fig. 6.2, these determinants are scrutinized in terms of how they interact with one another as well, and indicators are selected. This information then forms the basis for developing and implementing population health interventions. Measuring and analyzing the determinants and how they are interrelated is complicated. One determinant rarely stands alone as a causative factor for a health problem. Consider diabetes that is associated with obesity, and linked to poor nutrition and food insecurity.

Key Element 3. Use Evidence-Informed Decision Making All stages of a population health approach—selecting issues, choosing interventions, deciding to implement and continue these interventions— are supported by decisions based on the most current best evidence available, a process called evidence-informed decision making. An evidence-informed approach uses the full range of data, both qualitative and quantitative in nature. Qualitative research examines the way a population group thinks, how it acts, and its health beliefs and health behaviours. Qualitative research is conducted in a number of ways, including the administration of surveys and holding of open forums. Quantitative research deals primarily with numbers, which are interpreted most frequently as statistics. Data can be generated through epidemiological studies, databases, and surveys such as the census mentioned earlier in the chapter. All evidence gathered must be done in an organized manner, every step of the decision-making process examined and reexamined, and transparency assured to keep information current, relevant, and objective. Determining which interventions will be most effective and implementing them is complex. A number of stakeholders must be involved (including those who will be affected by policy changes and the application of interventions), in addition to contextual considerations. Ongoing

evaluation of interventions and policy changes is essential with modifications made as indicated.

Key Element 4. Increase Upstream Investments The term upstream investments refers to the process of making decisions that will benefit the health of a population group/community before a problem occurs. These investments typically address the root cause of a health problem and work backwards. Proactive investments are likely to address social, economic, and environmental health determinants and influence other community/regional resources. Therefore politicians, community leaders, medical professionals, and other stakeholders must understand and be committed to any actions a population health program may propose. Being proactive regarding health promotion, disease, and injury prevention can save money and give a population a healthier future. Short-term and long-term goals are set and prioritized, and strategies are implemented using evidence-informed decision making. For example, introducing or reinforcing strategies encouraging Canadians to take responsibility for their own health (eating a healthy diet, exercising, reducing or eliminating risk behaviours such as smoking or excessive alcohol consumption) and to partner with their primary care provider to participate in both routine and disease-specific screening initiatives, when needed. Upstream investments and interventions must be reevaluated periodically and necessary adjustments made (PHAC, 2016a). The principle of cost benefit analysis is always considered—applying the best possible set of interventions/actions in a cost-effective manner to achieve the best possible outcomes.

Key Element 5. Apply Multiple Strategies Once a population health goal is set, the next step is to introduce interventions to achieve the goal. No one action is likely to accomplish this, therefore a multifaceted approach must be taken. Actions must relate directly to the situation; suit the age range, health status, and environment of the target population; and be implemented over a chosen time frame. Such interventions must also address all of the health determinants involved across the health care continuum, recognizing that they are interrelated.

Those involved in implementing a population health strategy must accept both the goal and the plan of action. Collaboration is essential. It is up to the government to work with all sectors deemed to have an influence on the success of the interventions (e.g., the individual, the community, industry, related agencies, and local, provincial, and territorial governments). Consider the introduction of the Gardasil vaccine that prevents infection of certain types of the human papillomavirus (HPV). This upstream investment aimed to vaccinate all females at risk. The question was, how to conduct the vaccination effectively and efficiently so that parents would allow their children to be vaccinated, and how to ensure that those reaching the age of majority understand and accept the rationale behind the vaccination program. The government launched a massive public relations campaign, primarily through radio and television advertising, and engaged schools, public health units, and family doctors as champions of the program. Gardasil is now recommended for males aged 9–26, which has required ongoing education usually implemented by public health. Another drug, Cervarix, is approved for use only in females, and treatment requires three vaccines. Recommendations for taking this drug were changed several times, the last in 2017 when new evidence supporting these recommendations emerged from the National Advisory Committee on Immunization (NACI) (Government of Canada, 2017a).

Key Element 6. Collaborate Actions Sectors and Levels Intersectoral collaboration involves developing partnerships between different segments of society—private citizens, community groups, industry, health and educational agencies, and various levels of government—to improve health (PHAC, 2016b). Each group comes to the table with its own values, outlooks, opinions, agendas, and action plans. Harmonizing these variables is a challenge, but the benefits are profound: a commitment to common goals, and an assurance that plans are implemented to meet these goals. For such partnerships to work, sharing basic ideals and working towards improving health outcomes is essential. The Pan-Canadian Public Health Network brings together individuals, public and private organizations, politicians, policy advisors, writers from all levels of government, and scientists from across the country. An excellent example of intersectoral collaboration, this network works together discussing health concerns and strategies for intervention. As part

of its mandate, the network shares public health best practices that are province/territory specific, while respecting the autonomy of each jurisdiction to implement actions suited to their own needs. Between 2014 and 2017 the organization’s plans included working with all levels of government to develop a framework and create a list of priorities relating to mental health, and to create a framework to promote healthy weight, prompted by the alarming rise in childhood obesity, and the alarming rise in type 1 diabetes (Pan-Canadian Public Health Network [PHN], 2016). Intersectoral collaboration at an international level is ongoing. The WHO, along with numerous countries, worked together to contain disease and treat world populations when the Ebola outbreak occurred, and more recently when the Zika virus crisis arose. Any disease outbreak that poses an international threat requires international cooperation with respect to tracking and containing the outbreak, and sharing best practices for infection control and treatments. The first phase of a randomized study underway in Canada has found a vaccine for the Ebola virus, is well tolerated in human subjects, has no appreciable side effects, and promotes high levels of antibodies six months after the vaccine was given (Canadian Medical Association Journal, 2017).

Key Element 7. Engage the Public Without public support, most health-care–related implementations will fail, in part because it is the public’s health at issue, and primarily its tax dollars that fund implementation. Public involvement increases the likelihood that citizens will embrace a plan in a meaningful way. The key is to capture the public’s interest early and in a positive manner. Plans to achieve positive public interest must be carefully considered and executed so as not to turn public opinion against the plan—attempting to reverse public opinion can be difficult, if not impossible. Engaging the public requires the establishment of trust and an open process of decision making and implementation. Questions must be addressed promptly, properly, and persuasively. Take the current opioid crisis as an example. According to the Public Health Agency of Canada, there were almost 4000 opioidrelated deaths in the year 2017 (PHAC, 2018) (see Chapter 10). Across the country, politicians at every level of government, health organizations, and the public at large are involved in determining the best course of action to deal with this problem, including harm reduction centres, and dispensing naloxone kits to users, police, first responders, outreach workers, and others.

Key Element 8. Demonstrate Accountability for Health Outcomes A population health approach emphasizes the accountability for health outcomes—that is, the ability to determine if any changes in health outcomes can actually be attributed to specific policies or programs. The concept of accountability has an impact on planning and goal setting since it encourages the selection of interventions or strategies that produce the greatest health results. Important steps in establishing accountability include determining baseline measures (i.e., a standard against which to gauge progress), setting targets, and monitoring progress so that a thorough evaluation can be done. Evaluation tools provide criteria for determining the impact of policies or programs on population health. Finally, publicizing evaluation results is critical for gaining widespread support for successful population health initiatives.

Population health promotion model A newer concept of population health promotion looks at population health and population health promotion as an integrated model. This is, in part, based on the knowledge that many factors affect both the health of a population and an individual. From an Integrated Model of Population Health and Health Promotion (IMPHHP) perspective, health status is influenced by a wide range of health determinants. This integrated model draws heavily on information from past policies, documents, and health promotion programs (PHAC, 2016b). The model organizes population health into three areas: 1. What—looking to the health determinants to measure the health of populations 2. How—creating and implementing prioritized strategies to improve health 3. Who—engaging multiple stakeholders to participate in health improvement strategies The population health promotion model demonstrates the complexity of health promotion. The model emulates the population health approach by using the determinants of health as indicators to measure health and to gather information for health promotion initiatives. Decisions about health promotion policies are made using three sources of evidence: 1. Research studies on health issues (i.e., the underlying factors, the interventions, and their impact); 2. Knowledge gained through experience; 3. Evaluation of current programs to anticipate strategies needed in the future—in other words, upstream investments in health promotion. Collectively, stakeholders should address the full range of health determinants when adopting a population health promotion approach. Particular organizations, however, may wish to focus on specific determinants.

The population health promotion model can be used by any level of government, community agency, or group and can be accessed from any point of entry, depending on the health issue. The model can be altered or updated as determined by the user. Consider current issues facing Canadians in terms of mental health issues, including the use of opioids. All levels of government including municipalities are involved in a variety of actions to reduce deaths attributed to overdoses (largely from contaminated drugs), provide rehabilitation opportunities, and keep communities safe.

Population health in canada and abroad The population health approach has been relatively successful in most regions in Canada, but requires ongoing research, strategizing, funding, and commitment by all levels of government to have a truly positive impact on the health of Canadians. All provinces and territories have agencies that address their own population health needs, and also work collaboratively with organizations at the federal level. Information gathered by the PHAC and other departments at the federal level may have similar implications for all jurisdictions, but differences may arise in how each province or territory deals with any given issue (e.g., planning for more hospital and long-term care beds as their population ages). Likewise, strategies and goals set may have different priorities and timelines. Consider Alberta’s Vision 2020, which outlines five goals—from improving the delivery of health care across the board to strengthening public health services—in order to improve the health of Albertans by the year 2020 (Alberta Health and Wellness, 2017). Specific areas targeted for improvement include more equitable use of health care facilities, and shorter wait times for some services (Alberta Health Services, n.d.). British Columbia has also developed a framework for public health. It identifies seven goals, including strategies to enhance methods of preventing communicable diseases. The framework supports a population health approach and a public health role to ensure health equity (British Columbia Ministry of Health, 2013). In 2012, Saskatchewan updated its framework for population health promotion to provide guidance for health promotion practitioners on Mental Health and Addiction Services, and to promote the benefits of population health promotion programs in the province. This updated model retains the four original strategies for action in the Ottawa Charter, and adds two new ones: “Evaluate and Report Progress Regularly” and “Take Collective, Comprehensive Action Using a Determinants-Based Lens.” Additionally, a new category entitled “Areas for Action” includes changing life stages, life settings, and life conditions. These three additions are considered important elements for a person or community to achieve good health. At a national level, the PHAC has engaged in a number of new health promotion initiatives including maternal and child health, the prevention of violence, measures to address food insecurity, and measures to address health inequity. The PHAC provides oversight of the mental health

promotion program, working with provincial and territorial counterparts and other mental health organizations (e.g., the Mental Health Commission of Canada). It aims to address mental health issues and the underlying causes linked to the determinants of health (poverty, unemployment, homelessness, and substance abuse). An important consideration is the number of mentally ill Canadians languishing in prison and detention centres without the proper care and support (PHAC, 2014). The Canadian Institute of Health Information in its 2016–2020 strategic plan has committed to improving the methods it uses to gather information, and distribute information to those that need it. Another part art of the plan is to address the health of vulnerable populations (including older Canadians), mental health and addictions, Indigenous populations, and children and youth.

Summary 6.1 Population health refers to the identification of the health outcomes of a population group and the equitable sharing of those outcomes with that group. The definition of a group is varied and can be determined and be defined by ethnicity, geography, a nation, a province or territory, a community, or a setting (e.g., within schools or the workplace). A population health approach (overseen by the Public Health Agency of Canada) considers health to be a resource influenced by numerous factors identified in the determinants of health. The population health framework considers health promotion, disease prevention, diagnosis and treatment of diseases, and treatment intervention. The aim is to improve the health of all Canadians. 6.2 Several reports and conferences discussed were instrumental in the introduction and development of population health in Canada. The 1974 Lalonde Report entitled A New Perspective on the Health of Canadians is considered to be the first to state that health is determined by more than just biology and the significant role the determinants of health play on our health and well-being. AlmaAta conference (1979) in Kazakhstan addresses the need for global cooperation on health issues and in health care reform emphasizing the importance of primary, secondary, and tertiary care. Other notable conferences include the Ottawa Charter for Health Promotion, 1986, The Public Health Program Initiative, The Public Health Program Initiative, and the National Forum on Health, 1994–1997. 6.3 The health of a population, population groups, and individuals is dependent on a combination of these factors, many of which seem beyond our control. We are all affected, sometimes profoundly, by these variables, which go beyond genetics and biology to include the determinants of health. There are ten generally accepted health determinants, the most significant of which appear to be those that affect the socioeconomic factors of our lives and health. These determinants in isolation are unlikely to have a great effect on the health of either an individual or a population group but rather by the interconnectivity of numerous determinants.

6.4 Effectively implementing population health measures across Canada requires the collaboration of organizations, health professionals, volunteers, policy makers, and other stakeholders spearheaded by the Public Health Agency of Canada. The PHACs framework for implementing population health includes eight key elements, which provide guidance for the process ranging from how to focus on a target population group to engaging the public in the process, and assuming accountability for health outcomes. 6.5 The Public Health Agency of Canada has developed a template and a logo for population health. The agency uses the template as a tool for the ongoing measurement of the health of Canadians and for the subsequent development of strategies to improve health. 6.6 The population health promotion model arranges population health into three segments: what, how, and who, through which it identifies what the problem is, how it can best be dealt with, and whom it affects. Evidence-based decision making is a critical component for making strategies effective. Population health models have been modernized, first in Saskatchewan followed by other jurisdictions, and the Federal Government. The 8 key elements of health promotion provide a platform from which to adjust and continually modernize health promotion initiatives. 6.7 Information gathered by various organizations at the federal level is available to all provinces and territories across Canada. Each jurisdiction may use the information differently, tailoring it to the specific needs of its population.

Review questions 1. Compare and contrast the principal elements of population health, population health promotion, and public health. 2. What role did the Declaration of Alma-Ata play in developing population health initiatives? 3. Explain the purpose of the Public Health Agency of Canada’s population health template. 4. What is the relationship between health care services and the health of a population? 5. What are inequities in health? 6. State the advantages of engaging the public in developing population health initiatives. 7. How does the population health promotion model differ from population health itself? 8. What might make the population health needs of one province or territory different from those of another? 9. Research the how health care is distributed in your jurisdiction. Who makes decisions about health care needs locally? 10. What elements of rationalization of care do you see in your area? Have hospitals merged and redistributed services? Explain how. What do you see as the benefits and drawbacks? Do you see the manner in which services are accessed and distributed as equitable? Cost-saving? What would you change?

References Alberta Health Services. (n.d.). Population health promotion program. Retrieved from https://www.albertahealthservices.ca/info/service.aspx? id=3677. Alberta Health, Wellness. Vision. 2017;2020. Retrieved from http://www.health.alberta.ca/initiatives/vision2020.html. Brennan, R. J. (2015). Ontario set to replace welfare cheques with debit cards. The Star. Retrieved from https://www.thestar.com/news/queenspark/2015/03/1 9/ontario-set-to-replace-welfare-cheques-with-debitcards.html. British Columbia Ministry of Health. Promote, protect, prevent: Our health starts here. Retrieved from http://www.health.gov.bc.ca/library/publications/year/ 2013/BC-guiding-framework-for-public-health.pdf. 2013. Canadian Centre for Occupational Health and Safety. Indoor air quality: General. Retrieved from http://www.ccohs.ca/oshanswers/chemicals/iaq_intro.h tml.12. 2017. Canadian Medical Association Journal. Ebola vaccine developed in Canada shows promising results. Science Daily. 2017. Retrieved February 5, 2018 from www.sciencedaily.com/releases/2017/06/170619092219.h tm. Citizens for Public Justice. (2017). Poverty trends 2017. Ottawa. Retrieved from https://www.cpj.ca/povertytrends-2017. Clougherty J.E., Souza K., Cullen M.R. Work and its role in shaping the social gradient in health. Annals of the New

York Academy of Sciences. 2010;doi:10.1111/j.17496632.2009.05338.x. Corak M. Economics for public policy. Canada’s official poverty line: What is it? How could it be better? Retrieved from https://milescorak.com/2018/08/21/canadasofficial-poverty-line-what-is-it-how-could-it-be-better. 2018. Cryderman, K. (2012). Low-income Albertans and disability workers get boost in 2012 budget. Inclusion Alberta. Retrieved from: http://inclusionalberta.org/news/2012/02/09/newsitem /low-income-albertans-and-disability-workers-get-boostin-2012-budget/. Egale Canada Human Rights Trust. LGBTQ terminology. Retrieved from http://www.cglcc.ca/uploads/2/5/2/3/25237538/lgbtq_ terminology_-_echrt.pdf. 2018. Epp J. Achieving health for all: A framework for health promotion. Ottawa: Health and Welfare Canada; 1986. Retrieved from http://www.hc-sc.gc.ca/hcssss/pubs/system-regime/1986-frame-planpromotion/index-eng.php. Federal, Provincial, and Territorial Advisory Committee on Population Health. Report on the health of Canadians. In: Retrieved from. 1996. http://publications.gc.ca/collections/Collection/H39385-1996-1E.pdf. Government of Canada. Human papillomavirus (HPV) prevention and HPV vaccines: Questions and answers. Retrieved from https://www.canada.ca/en/publichealth/services/infectious-diseases/sexual-healthsexually-transmitted-infections/hpv-prevention-vaccinesquestions-answers.html. 2017a.

Government of Canada. Short-term drinking water advisories: First Nations south of 60. Retrieved from Indigenous Services Canada website https://www.canada.ca/en/indigenous-servicescanada/services/short-term-drinking-water-advisoriesfirst-nations-south-60.html. 2017b. Haydon E., Roerecke M., Giesbrecht N., et al. Chronic disease in Ontario and Canada: Determinants, risk factors and prevention priorities. In: Ontario Chronic Disease Prevention Alliance and the Ontario Public Health Association. 2006. Health Canada. Healthy Living. Retrieved from https://www.canada.ca/en/healthcanada/services/healthy-living.html. 2019. Holt-Lunstad J., Smith T.B., Layton J.B. Social relationships and mortality risk: A meta-analytic review. PLoS Medicine. 2010. Retrieved from https://doi.org/10.1371/journal.pmed.1000316. Institute of Medicine (US) Committee on Health and Behavior: Research, Practice, and Policy. Social risk factors. In Health and behavior: The interplay of biological, behavioral, and societal influences. Washington, DC: National Academies Press (US); 2001. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK43750/. Koven S. Social support matters in cancer survival. KevinMD.com Retrieved from http://www.kevinmd.com/blog/2013/10/socialsupport-matters-cancer-survival.html. 2013. Mikkonen J., Raphael D. Social determinants of health: The Canadian facts. Toronto: York University School of Health Policy and Management; 2010. Retrieved from http://www.thecanadianfacts.org/The_Canadian_Facts.p df.

Moyser M. Women and paid work. Statistics Canada. Retrieved from https://www150.statcan.gc.ca/n1/pub/89-503x/2015001/article/14694-eng.htm. 2017. Organisation for Economic Co-Operation and Development (OECD). Gender wage gap. Retrieved from https://data.oecd.org/earnwage/gender-wage-gap.htm. 2018. Pan-Canadian Public Health Network. Overview. Retrieved from http://www.phn-rsp.ca/index-eng.php. 2016. Public Health Agency of Canada. (n.d.). Volunteering as a vehicle for social support and life satisfaction, Factsheet, p. 1. Public Health Agency of Canada. Population health approach: The organizing framework. Retrieved from http://cbpp-pcpe.phac-aspc.gc.ca/population-healthapproach-organizing-framework/. 2013. Public Health Agency of Canada. Mental health promotion. Government of Canada; 2014. Retrieved from https://www.canada.ca/en/publichealth/services/health-promotion/mentalhealth/mental-health-promotion.html. Public Health Agency of Canada. Key element 4: Increase upstream investments. In: Population health approach: The organizing framework. 2016a. Retrieved from http://cbpp-pcpe.phac-aspc.gc.ca/population-healthapproach-organizing-framework/key-element-4-increaseupstream-investments/. Public Health Agency of Canada. Key element 6: Collaborate across sectors and levels. In: Population health approach: The organizing framework. 2016b. Retrieved from http://cbpp-pcpe.phac-aspc.gc.ca/population-healthapproach-organizing-framework/key-element-6collaborate-sectors-levels/.

Public Health Agency of Canada. (2018). Special Advisory Committee on the Epidemic of Opioid Overdoses. National report: Apparent opioid-related deaths in Canada (January 2016 to December 2017; released June 2018). Retrieved from https://www.canada.ca/en/publichealth/services/publications/healthy-living/nationalreport-apparent-opioid-related-deaths-released-june2018.html. Statistics Canada. (2016). 2016 Census of population. Aboriginal identity, individual low-income status. Catalogue no. 98-400X2016173. Statistics Canada. (2017a). Household income in Canada: Key results from the 2016 census. Retrieved from https://www150.statcan.gc.ca/n1/dailyquotidien/170913/dq170913a-eng.htm. Statistics Canada. (2017b). Labour force survey, December 2017. Retrieved from https://www150.statcan.gc.ca/n1/dailyquotidien/180105/dq180105a-eng.htm. Statistics Canada. (2018). Table 14-10-0359-01. Labour force characteristics by Aboriginal group and educational achievement. Retrieved from https://www150.statcan.gc.ca/t1/tbl1/en/tv.action? pid=1410035901&pickMembers%5B0%5D=1.1&pickMemb ers%5B1%5D=3.6&pickMembers%5B2%5D=5.1. Trading Economics. (2018). Canada–unemployment, youth total (% of total labor force ages 15–24). Trading Economics. Retrieved from https://tradingeconomics.com/canada/unemploymentyouth-total-percent-of-total-labor-force-ages-15-24-wbdata.html. Workopolis. (2016). The university degrees with the greatest payoff on the Canadian job market. Retrieved from https://careers.workopolis.com/advice/the-university-

degrees-withthe-greatest-payoff-on-the-canadian-jobmarket/. Zussman, R. (2017). B.C. government set to increase welfare rates and disability assistance. CBC News. Retrieved from http://www.cbc.ca/news/canada/british-columbia/b-cgovernment-set-to-increase-welfare-rates-and-disabilityassistance-1.4214828.

7

Health and the Individual LEARNING OUTCOMES 7.1 Discuss the key concepts of health, wellness, illness, disease, and disability. 7.2 Explain the main models of health. 7.3 Discuss changing perceptions of health. 7.4 Examine the psychology of health behaviour. 7.5 Describe the wellness–illness continuum and the impact of selfimposed risk behaviours. 7.6 Summarize the changing trends related to the leading causes of morbidity and mortality in Canada.

KEY TERMS Cardiovascular disease Cerebrovascular disease Compensation Culture Disability Disease Etiology Exacerbation Health behaviour Health beliefs Health model

Holistic Indigenous peoples Infant mortality Life expectancy Morbidity Mortality Remission Self-imposed risk behaviours Sick role behaviour Signs Symptoms Wellness Wellness–illness continuum Anyone entering a health care profession, either as a hands-on health care provider or as a contributor of administrative or technical expertise, will find it helpful to understand the concepts of health and wellness. It is also important to know what makes Canadians ill. Many of the medical conditions most health care workers encounter in their career are preventable to a large extent. Why then do people engage in risky behaviours—those that cause disease and illness or lead to disability? Why do some individuals ignore basic advice regarding health promotion and illness prevention? For one thing, many people take good health for granted until they are faced with illness or another incapacitating event. Many think they are invincible or immune—it won’t happen to them. Understanding patients’ perceptions of health, their health beliefs, and health behaviours, as well as their corresponding response to diagnosis and treatment, enables health professionals to maximize patients’ health outcomes. Health, wellness, and illness mean different things to different people. Some people will consider themselves well despite the presence of significant health problems, seeking help when absolutely necessary, and minimizing their health status if asked how they are by family and friends. Others readily succumb to even minor alterations in their health state and require more intervention, understanding, and support.

Definitions of health, wellness, illness, disease, and disability evolve constantly, along with social consciousness, the delivery of health care, the affordability of health care services, and advances in medical science. It is important to recognize the impact of a global society on the health of Canadians—patients as well as health professionals. Diseases formerly considered isolated to certain parts of the world (e.g., Ebola and the Zika virus) are no longer isolated to specific geographic areas, especially with increased international travel and changing immigration policies—Canada will raise its annual immigrant intake by an estimated 13% by 2020. Health professionals must be prepared to effectively manage diseases previously not seen, or rarely seen in this country. This includes adjusting screening guidelines in addition to interventions (e.g., infection prevention and control protocols [IPAC]). The Ebola (also called EVD for Ebola virus disease) outbreak provoked significant research and policy changes in efforts to identify and treat exposed individuals. Health providers were required to screen a patient’s history for travel and potential exposure. It was a requirement to implement more inclusive and specific IPAC measures at point of care to protect themselves and also the patients. The World Health Organization (WHO) and Health Canada post information on their websites warning people not to travel, or to travel with caution, to areas where disease outbreaks are considered high risk. For example, because of the Zika virus, Health Canada posted warnings particularly for pregnant women to avoid certain areas in North America, in the Caribbean, Central America and Mexico, South America, and Southeast Asia. Canada is seeing a resurgence of diseases that were considered all but eradicated, for example measles and tuberculosis (TB). Measles is appearing again among children who are not immunized. The incidence of tuberculosis is 300 times higher among the Inuit population compared to the nonindigenous population in Canada. The disease spreads easily, especially where there are overcrowded living conditions, poverty, and food insecurity—all relate to inequalities evidenced by the socioeconomic determinants of health (see Chapter 6). You will read Jennifer’s story in Chapter 10. Jennifer, who is Inuit and lives in Cape Dorset in crowded conditions, is expecting a baby and found out one of her little brothers had “sleeping” TB. She was told simply to get as much fresh air as possible and to stay active. Sleeping TB means that her brother has the TB bacillus in his body, but it is latent or inactive at present. However, the bacillus could become active at any time, risking exposure to everyone in the household. When considering the health of the individual, the cultural norms and health practices of new Canadians must be considered. There are

deficiencies in the provision of care for newcomers settling in the country, from helping to navigate the system, to understanding different cultural norms, and language barriers. There are also deficiencies within the system related to the care of Canadians in general, for example, in the area of mental health and drug coverage (see Chapters 3, 4, and 10). Social media has had a profound effect on the health of the individual (e.g., access to health information), including public health campaigns, and how one perceives health and health outcomes (see Chapters 3 and 10 for more detail). This chapter will explore these issues, provide information on changing trends, and the leading causes of morbidity and mortality in Canada. We will also discuss the impact of self-imposed risk behaviours on the individual and on the health care system in terms of disease, disability, and cost. It will also explain that the health care provider’s goal, as part of the health care team, is to help his or her patients maintain their existing health, assist them in coping with illness, and support them on the road to recovery. Understanding health belief models, the psychology of health behaviour, the ways individuals respond to illness, and the concept of the wellness-illness continuum will assist those pursuing careers in health care how to best support their patients.

Health, wellness, and illness: key concepts For a long time healthy meant “not sick,” and sick meant “not well.” Today the key concepts of health, wellness, and illness are defined in less blackand-white terms. Health care providers should understand the evolution of these definitions—how they have changed to become more multifaceted and inclusive over time.

Health What does it mean to be in good health? In the past the word health meant a state of being, of sound mind, and generally suggested a wholeness of the body—that the body was functioning well. Over time the concept of mental health was integrated into the meaning. Thus an individual must have both a healthy state of mind and physical well-being to be considered in good health. In 1948, the World Health Organization (WHO) took the important step of acknowledging that health is multidimensional, and not merely the presence or absence of disease. Although a vast improvement over previous definitions, the WHO’s definition (Box 7.1) has not formally changed since 1948 and remains largely out of step with current concepts of health and wellness.

  Box 7.1

Health: An Evolving Definition. In 1948, the World Health Organization (WHO) originally defined health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” As perceptions of health evolved, components of this definition have come into question. For instance, some suggested that the word complete is unrealistic: How many people can claim to be completely healthy—and what does completely healthy mean? The ambiguity of this term is particularly evident today, with individuals living much longer with chronic diseases such as diabetes and cardiovascular disease, as well as

those with physical disabilities and mental health challenges. Even some forms of cancer are now considered a chronic condition. Accepting such challenges has led individuals to consider themselves healthy within the context of the health issues they are dealing with; their new “normal.” This definition also fails to include holistic concepts, such as spiritual wellness and cultural norms. Nurses, for example, must be aware of and respect the spiritual and cultural needs of their patients (e.g., by ensuring patients have access to religious or spiritual resources) when establishing a nursing diagnosis and implementing nursing interventions. Consequently, the WHO has expanded its concept of health adding to its definition “the ability to identify and to realize aspirations, to satisfy needs, and to change or cope with environment. Health is therefore a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capabilities” (World Health Organization, 1986). Sources: World Health Organization. (1948). Preamble to the constitution of the World Health Organization as adopted by the International Health Conference. New York; World Health Organization. (1986). Health promotion: Concepts and principles in action—a policy framework. Copenhagen: WHO Regional Office for Europe.

Wellness Although wellness and health are often used interchangeably, the two words are not synonymous; however, they share similar concepts. Wellness goes beyond having good health. It considers how a person feels about his or her health as well as his or her quality of life. From a holistic perspective, to achieve wellness a person must take responsibility for his or her own health by leading a balanced lifestyle and avoiding self-imposed risk behaviours. The path toward wellness is not static; it is continuous and must be a lifelong pursuit. Wellness develops from the decisions people make about how to live their lives with quality, good health (remember, good health is relative), and meaning.

Dimensions of Wellness The concept of wellness embraces several categories including, but not limited to, physical, emotional, intellectual, spiritual, and social health. Some wellness models have more recently incorporated environmental and occupational wellness. An even newer and emerging concept is family

wellness, which looks at each person in the family unit. If each person is well, the family seems to do well. If a family member considers themselves to be unwell, depending on numerous factors, the family unit, especially relationships, may be adversely affected. A fine line exists between some descriptions of these categories and how they are grouped; various wellness models may divide or label them differently. It is worth noting that some literature refers to the “dimensions of health” rather than the “dimensions of wellness,” or the “wellness–illness” continuum rather than the “health–illness” continuum, but are similar in that they consider more than physical and mental health (Fig. 7.1).

FIG. 7.1 Dimensions of Wellness.

Some individuals judge themselves to be well despite the presence of disease or infirmity. For example, a patient was diagnosed with ALS (amyotrophic lateral sclerosis, a progressive neurogenic disease for which

there is no cure), but he is receiving good medical care and is able to enjoy his family and things that are important to him despite his advancing physical limitations. Therefore in the present he considers himself to be well. Embracing a wellness approach to health for many includes a holistic outlook to health and health practices, which may involve combining traditional medicine with more nontraditional (sometimes called alternative), less invasive treatment modalities. These range from naturopathy and acupuncture to aromatherapy, therapeutic touch, medication, and yoga. Others may reject western/traditional medicine altogether in favour of alternative therapies in their quest for wellness and good health.

Physical wellness The dimension of physical wellness entails maintaining a healthy body by eating a nutritious, balanced diet; exercising regularly; making intelligent, informed decisions about one’s health; and seeking medical care when necessary. People must understand how lifestyle choices affect physical health to achieve physical wellness.

Mental wellness The WHO defines mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.” Mental wellness adds a holistic dimension to the definition of mental health. It is being in relative harmony with the dimensions of health and wellness. Mental wellness, like physical wellness, is not static, nor does it mean the absence of mental illness. A person with a diagnosed mental illness under treatment may feel that they are coping well. Consider a person with bipolar disorder. Someone who is bipolar can be well and controlled for long periods of time with the proper interventions. A person with schizophrenia, who responds well to treatment, may also consider themselves to be well most of the time. A person may consider it a matter of accepting their diagnosis and all that goes with it—their new “normal.” Sometimes just knowing what is wrong and being stabilized with treatment would move the person to the wellness end of the continuum (discussed later in the chapter). For many Indigenous people, mental wellness along with physical health

exists in balance with spirituality and nature, sometimes referred to as Mother Earth.

Emotional wellness Emotional wellness and mental health are often, but not necessarily, interdependent entities. Emotional wellness includes people’s ability to understand themselves, to recognize their strengths and limitations, and to accept who they are. The emotionally adapted person effectively handles and controls his or her emotions, communicates well, and seeks support when needed. Good mental health allows a person to react proactively when things go wrong—to view adversity as an opportunity to learn and grow. Emotional health very much contributes to this ability. Mental illnesses, such as schizophrenia, bipolar disease, and depression, can affect a person’s capacity to deal with situations effectively, especially when a situation poses challenges or problems. Mental illnesses usually have a physiological etiology (the origin or cause of a disease). An emotionally well person can deal with reasonable stress—this is more difficult for most in the presence of a mental illness. Remember that everything is relative, no situation is the same, nor are people’s reactions despite the presence or absence of emotional health, mental health, or mental illness.

Intellectual wellness Intellectual wellness reflects people’s ability to make informed decisions that are appropriate for and beneficial to themselves. From their experiences and learnings, intellectually well people are able to gather information throughout their lifespan and to use that information to make the best of situations. Moreover, these people apply critical thinking skills, prioritize data, and keep informed on current health research, treatments, and health-related issues. Intellectual wellness may also include occupational health—personal satisfaction from one’s career and the ability to balance career with other activities like family and leisure time.

  Thinking it Through Spirituality has been linked to good health and wellness, with reported benefits ranging from fewer health issues, including anxiety and

depression, to a faster recovery. Many people also claim that spirituality provides them with an enhanced ability to deal with stress. 1. What does spirituality mean to you? 2. Why do you think spirituality may contribute to better health? 3. How would you respond to a patient who told you that he or she wanted to try self-healing through spiritual practice instead of accepting medical intervention for a diagnosed medical condition?

Social wellness Social wellness is about relating effectively to others, including being able to form close, loving relationships, to laugh, to communicate effectively and empathically, to be a good listener, and to respond appropriately. Socially well individuals work agreeably in groups and within the community, are tolerant and accepting of others, and can form friendships and supportive networks. Confident and flexible, socially well people contribute to the welfare of others.

Spiritual wellness Spiritual wellness is different for most people, and entirely personal. It frequently involves a search for, or achievement of, a sense of purpose or meaning in their lives. It may be based on a faith of some kind, or religion, or encompass a search for harmony and balance with life, themselves, and others. It may encompass a sense of balance—connecting various components of the person’s life—achieving a feeling of productiveness and inner peace. Achieving spiritual wellness can involve prayer, meditation, or other spiritual practices. Attaining spiritual wellness may afford a person peace, joy, a purpose in life, and the ability to relate to others in a positive, kind, and meaningful way. Spirituality is an important part of the Indigenous culture and congruent with a holistic approach to personhood, health, and wellness. The spiritually well person often seeks to contribute to society, plays an active role within the community, and displays gratitude and generosity.

Environmental wellness Newer models of wellness take into account one’s relationship with the environment (environmental wellness). An environmentally well person is one who engages in a lifestyle that is friendly to the environment. Friendliness to the environment entails consciousness about preserving the

external world, such as walking or biking (instead of driving), recycling, choosing products that are less harmful to the environment (e.g., less packaging). It may also include creating a safe internal environment; for example, by protecting one’s eyesight (e.g., using good lighting when reading or working), or limiting loud noises (e.g., controlling music volume).

Occupational wellness Occupational wellness occurs when a person feels secure, confident, and valued in his or her workplace setting. Occupationally well people manage work-related stress effectively, grow professionally, and balance the demands of their job with their personal lives. The level of enjoyment people have with their job affects most aspects of their lives—and those of the people around them.

Meditation and wellness Wellness is a holistic concept and is often enhanced by meditation— considered a holistic modality. Meditation means to reflect, to concentrate, or to focus on one’s breathing or a calming visual image. Individuals who routinely practise meditation claim it provides them with mental, spiritual, emotional, and physical benefits. They claim it connects the body, mind, and spirit instilling a sense of wellness. Meditation draws one’s attention away from whatever is bothersome, calming the mind and spirit. There are several kinds of meditation such as transcendental and mindfulness. Primary care providers sometimes recommend meditation for conditions such as chronic pain, hypertension (reflection of the body–mind connection, as a calm state of mind has been proven to lower blood pressure), and anxiety disorders, which are among the most prevalent in Canada (Statistics Canada, 2015). Many therapists will introduce their patients to a variety of medication techniques and/or mindfulness (another therapeutic technique) to treat anxiety.

Illness The term illness, often used to denote the presence of disease, can also refer to how a person feels about his or her health, whether or not a disease is present. Despite the absence of pathology or disease, a person may feel ill as a result of tiredness, stress, or both. Although this state differs from feeling healthy and energetic, by definition, it is not a disease.

Disease Disease typically refers to a condition in which a person’s bodily or mental functions are different from normal. Usually biological in nature, disease may affect various organs of the body and have symptoms that are either observable or difficult to detect. Causes of diseases include the presence of organisms such as bacteria, a virus, or a fungus. Schizophrenia is an example of a disease in which mental functions are affected, resulting in behavioural or psychological alterations, and has a biological or biochemical explanation. The term disease may be also be used to describe a group of symptoms (more accurately called a syndrome), which are not related to a clear-cut disease process. Disease is often used interchangeably with the vague words: ailment, disorder, condition, or dysfunction. Disease is also sometimes used incorrectly to refer to a disability. A disease may run a predictable course and subside—with or without treatment (e.g., pneumonia or influenza), or it may be chronic and controllable, but not curable (e.g., asthma, diabetes, human immunodeficiency virus [HIV], acquired immune deficiency syndrome [AIDS]). Other diseases are long term and have symptoms that disappear and recur (i.e., go into a period of remission). This reappearance of symptoms and reactivation of the disease is known as an exacerbation of the disease (e.g., as happens with multiple sclerosis). Remission of a disease can occur spontaneously or be induced by treatment. In the case of multiple sclerosis, for example, the use of immunosuppressive medications can result in a treatment-related remission. A remission’s length varies. The main aim of treatment for leukemia is a complete remission—that is, no signs of the disease from a symptomatic or pathological perspective. If a remission lasts more than 5 years, some consider the person to be cured. In the case of any kind of cancer, however, the word cure is used cautiously; some physicians avoid ever saying a person is cured, regardless of the length of time he or she has been cancer free.

  Thinking it Through Suppose you had a chronic condition such as multiple sclerosis, but were managing reasonably well most of the time, for instance, if your multiple

sclerosis (MS) was in a period of remission. Reflecting on your own definition of wellness, answer the following: 1. Do you think you would consider yourself to be well? 2. Do you think your outlook would by influenced by periods of remission or exacerbation of the condition? 3. Answer the first two questions considering two chronic diseases that people you know may have.

Disability A deviation from normal function, a disability can be physical, sensory (e.g., blindness, deafness), cognitive (e.g., Alzheimer’s disease), or intellectual (e.g., Down syndrome). A disability can occur in conjunction with, or as a result of, a disease (e.g., a person with diabetes may undergo amputation of part of a leg because of impaired circulation); be caused by an accident; or be present at birth, either as a result of genetics or due to complications during delivery (e.g., an absence of a limb, cerebral palsy, spina bifida). The language used to describe people with a disability has changed over the years, moving toward more sensitive, less hurtful terminology. For example, today, a person with a cognitive or intellectual disability is most likely to be deemed intellectually impaired. Along with improved terminology has come the recognition that people with disabilities deserve the same rights and opportunities as all other members of society. Individuals with disabilities still face a degree of ableism; others are often impatient with and dismissive of individuals with either cognitive or physical limitations. Invisible disabilities can face similar challenges (Box 7.2).

  Box 7.2

People With Disabilities: Rights Are Formally Recognized. Historically, people with disabilities have been viewed as individuals who need societal protection, evoking sympathy rather than respect. In an effort to change this perception and to ensure that all people have the opportunity to live life to their fullest potential, December 2016 marked

the tenth anniversary of the United Nations formally adopting the Convention on the Rights of Persons With Disabilities. This was the first such inclusive human rights treaty of this century. The convention covers a number of key areas, including accessibility, personal mobility, health care, education, employment, rehabilitation, participation in political life, equality, and nondiscrimination. All jurisdictions have acts or other pieces of legislation to protect people with disabilities, and almost all are constantly being improved. After consultation with all jurisdictions including Indigenous peoples and individuals with disabilities, Canada ratified this Convention in 2010 and is bound to it by international law. In 2015, the UN’s initiative “Transforming our world: the 2030 Agenda for Sustainable Development” maintained a commitment to ensure that people with disabilities and other vulnerable populations are specifically included in all of the Agenda’s goals. These goals are broad and include, for example, people, planet, prosperity, peace, and partnership; each has a clearly defined target intended to stimulate defined actions over the next 15 or so years. The statement related to People for example states, “we are determined to end poverty and hunger, in all their forms and dimensions, and to ensure that all human beings can fulfil their potential in dignity and equality and in a healthy environment” (United Nations, 2015). In Canada, federal legislation protecting people with disabilities includes the Canadian Charter of Rights and Freedoms, Canadian Human Rights Act, and the Rights of People with Disabilities. Source: Government of Canada. (2018). Rights of persons with disabilities. Retrieved from https://www.canada.ca/en/canadianheritage/services/rights-people-disabilities.html; United Nations. (2015). Transforming our world: The 2030 Agenda for Sustainable Development. Retrieved from https://sustainabledevelopment.un.org/post2015/transformingourworld.

  Did You Know Terry Fox: A Continuing Legacy Terry Fox, despite his disability, embraced a challenge, leaving a legacy that persists today. An awareness and fundraising initiative that continues to this day originated with a person by the name of Terry Fox. Terry was born in

Winnipeg, Manitoba in 1958. A recognized athlete in high school, at 18 years old Terry was diagnosed with osteosarcoma (bone cancer), which eventually resulted in the need for amputation of his right leg just above the knee. Embracing his physical disability, Terry made the astonishing decision to run across Canada to raise money for cancer research. He began his run—his “Marathon of Hope”—on April 12, 1980, in St. John’s, Newfoundland. Terry ended his run near Thunder Bay, Ontario, when, after seeking medical attention for returning symptoms of osteosarcoma (shortness of breath, fatigue, and chest pains), it became apparent that his cancer had returned. Terry died on June 28, 1981, 1 month short of his 23rd birthday. Every year, Canadians around the world work with communities with support from the Canadian Forces, embassies, and high commissions to organize the Terry Fox Run raising money for the Terry Fox Foundation. By the end of 2017, an estimated $750 million had been raised worldwide. Along with the money, the Terry Fox Marathon of Hope continues to raise an awareness of cancer—a disease that touches so many. Sources: Terry Fox Foundation. (n.d.). Terry Fox. Retrieved from http://www.terryfox.org/TerryFox/T_Fox.html; Terry Fox Foundation. (n.d.). Facts. Retrieved from http://www.terryfox.org/TerryFox/Facts.html.

Health models A person’s health, wellness, illness, disease, or disability—and the resulting interaction with health care providers—usually relates in some capacity to a health model. Defined as a design for delivering health care, a health model can influence both a health care provider’s practice and his or her delivery of health care, which in turn affects treatment, priorities, and outcome measurements. The three most common types of health care models are the medical model, the holistic model, and the wellness model, all of which continue to evolve. The principles of the wellness model—stressing wellness and illness prevention—are most commonly pursued in our current health care climate. Physicians are embracing evidence-informed decision making and using best practices to deliver patient-focused care in a team-oriented environment.

Medical Model The medical model was founded on a simple definition: health is the absence of disease. More recently, this model has expanded to consider aspects of functioning, disability, and limitation of activity, and the ability to perform the activities of daily living, thus accepting that a person with physical limitations may nevertheless be healthy. In the twenty-first century, critics of the medical model argue that the model’s scope is too narrow and that the presence or absence of disease alone does not define one’s health. This model does not consider social causes of disease that are beyond an individual’s control (e.g., disparities in socioeconomic status and education). By emphasizing the diagnosis and treatment of disease, the medical model ignores the role of prevention— efforts to stop disease and disability before they occur (Larson, 1991).

Holistic Model The holistic approach to health considers all parts of the person. This approach has been used for many years’ time by alternative practitioners, such as naturopaths; only recently has it been integrated into mainstream medicine. Focusing on the positive aspects of health—not on the negatives of illness and disease that inform the medical model—the holistic model

strives for a state of health that encompasses the entire person, rather than just aiming for a lack of disease and disability. Although similar to the original WHO definition of health introduced in 1948 (see Box 7.1), the holistic definition of health goes much further by recognizing the impact of factors such as lifestyle, spirituality, socioeconomics, and culture on an individual’s health. Although initially described as “utopian” (i.e., impossible to achieve), the holistic model has become widely accepted as a better alternative to the medical model (Larson, 1991).

  Thinking it Through There are many other definitions of health. Consider some of the WHO’s international classification systems such as the International Classification of Functioning, Disability (which measures the relationship between health and disabilities at an individual and population level). These systems are sometimes used in developing current concepts of how health should be defined. The WHO definition does not clearly address individuals with disabilities. Can someone with a spinal cord injury not consider him or herself to be healthy? Can individuals who participate in the Special Olympics or the Invictus Games not consider themselves healthy? Participants cope with physical as well as mental challenges and show remarkable strength, courage, and perseverance as they achieve their goals. Can anyone really define health in terms that would suit everyone, or is it individual? What would you consider to be a realistic, inclusive definition of health study?

Indigenous Wholistic Theory for Health With similar concepts to the holistic model above, the wholistic model is also known as the Indigenous wholistic theory. This wholistic approach to health considers mental, physical, cultural, and spiritual well being, not only of the individual person, but of the entire community. The framework incorporates the medicine wheel (Fig. 7.2), the circle, and the four directions beginning in the east and moving methodically through the south, west, and then to the north. The east addresses the discussion of spirit and vision; the south discusses the value and importance of relationships, community, and heart; the west concentrates on Indigenous knowledge and the importance of continuing knowledge production;

lastly, the north encompasses concepts and ideas about healing, movements, and actions that guide practice (First Nations Child and Family Caring Society of Canada, 2018). The circle represents wholeness and the interconnectivity of the self, individual, the family, the community, society as a whole, and creation. Another part of the holistic concept is understanding the nature of balance, harmony, and living a good life. An individual who experiences altered health, evidenced by symptoms or presenting problems, is considered to be out of balance or experiencing disharmony.

FIG. 7.2 Indigenous Medicine Wheel. (Source: Joseph, B. [2013]. What is an Aboriginal medicine wheel? [Web log post]. Working effectively with Indigenous Peoples. Retrieved from https://www.ictinc.ca/blog/what-is-an-aboriginalmedicine-wheel.)

It is important to note that the medicine wheel is interpreted uniquely by each culture. The order of the colours is not the same in each culture, nor are the attributes, and generalizations should not be made. For most Indigenous communities, the circle itself is significant in that it represents how many cultures view the world (in a circular manner representing the circle of creation). It demonstrates how life, viewed as a process, evolves, and how, with nature, all things are connected moving towards an end purpose, or destiny (see Fig. 7.2).

Wellness Model The wellness model builds on the medical and holistic models. It considers health a process that continues to evolve and to progress toward a future state of improved health. This model requires individuals to practise healthy choices and try to lead a balanced lifestyle. One’s perception of health is based on how they feel about their disease or disability rather than the objective manifestations. The wellness model encompasses an individual’s or a group’s ability to cope with health-related challenges. In the wellness model, people assume responsibility for their own health and make informed choices about such things as lifestyle and self-imposed risk behaviours—actions (such as smoking tobacco) that a person willfully engages in despite knowing they pose a danger to their health. The wellness model also considers a person with a disability or illness to be healthy if that person can function, meet self-imposed goals, and is not incapacitated by pain. The common thread linking the holistic and wellness health models is the inclusion of a broad spectrum of factors—physical, spiritual, social, emotional, economic, and cultural.

International Classification of Functioning Disability and Health Introduced in the 1980s by the World Health Organization, the International Classification of Functioning Disability and Health (ICF) is both a classification system and a health model. As a classification system, the ICF measures the health of individuals in addition to the health of designated populations. It considers health and health-related issues from the perspectives of the environment, the body’s structure and function, and the individual’s health-related activities (promoting personal health). As a model, the ICF considers health and disability a little differently. It holds that everyone at some point during the lifespan will experience altered health and may then experience some form of disability. Disabilities are considered common, experienced by many, not just a few. This model also considers the social components of living with a disability and the effects a disability has on affected individuals and those around them; it emphasizes the effects of a disability rather than the cause. As a model, the ICF is used clinically by health care providers to access patients’ social and functional challenges and capacities, set realistic goals, formulate treatment plans, and measure outcomes.

Changing perceptions of health and wellness How a person views or perceives health and wellness will affect how that person responds to alterations in health. A person who is feeling happy and optimistic may pass off a minor illness as trivial or as something he or she can cope with. However, if that same person is feeling down, stressed, or otherwise vulnerable, the same illness may seem more significant. Circumstance and time of day or night can profoundly affect how a person views their health. For example, people sometimes feel more vulnerable at night or in the early hours of the morning. They may wake up in the night and start thinking about things and magnify those things in their mind. A minor illness or concern may seem more profound, or a minor irritation may produce great stress. Conversely, when people get up in the morning, interact with others, and start focusing on daily activities, they feel more positive and things that alarmed them in the night seem less onerous. Consequently, a positive frame of mind can help a person deal more effectively with stress and fight disease.

Past Approaches Until the early-to-mid 1960s, most Canadians held the attitude that if they were sick they would seek medical care, and the doctor would make them better. People took little responsibility for their own health and rarely participated in decisions related to their treatment. They did what the doctor told them to do and most doctors did not expect to be questioned. Doctors and patients functioned very much within the realm of a paternalistic medical model. Few people recognized the impact of lifestyle on their health and safety. Engaging in self-imposed risk behaviours, such as a sedentary lifestyle, poor nutritional habits, smoking, and alcohol abuse, was rarely directly linked to changes in health status. Within the medical community there was limited education related to promoting a healthy lifestyle. This approach began to change in the 1960s and 1970s. With the help of government initiatives and the establishment of a population health approach to health care (see Chapter 6), Canadians started to see the value of prevention and to consider what they could do on a personal level to stay healthy—that is, they began to take more

responsibility for their own well-being. Slowly, community and group involvement in health promotion and disease prevention emerged. The 1980s and 1990s saw the beginning of changes in the structure and function of how primary care was delivered further encouraging individuals to not only take responsibility for their own health, but to participate in making decisions about their treatment, which is the norm today. Canadians are now more informed, sometimes looking up pertinent information on the internet and bringing it in to their health care provider. Although some information is accurate, some is not; this can have harmful consequences promoting anxiety and stress. Sometimes providers are overwhelmed with the amount of intimation presented to them by their patients. On the whole, people have become self-advocates, seeking answers if they are not satisfied with what they have been told, perhaps asking for a second opinion. There are also more choices available. Currently most primary care groups offer a team of health professionals for the patient to access that can include a nurse practitioner, dietician, or a counsellor. Individuals are more likely to seek out alternative modalities for treating ailments—anxiety, stress, various diseases, and physical problems. Increasingly (though not always), physicians are happy to work with alternative practitioners, offering their patients the best of both worlds. Public education regarding lifestyle changes continues to have at least a moderate effect. A federal public initiative, aptly called ParticipACTION, launched in 1971, still promotes a healthy lifestyle through increased physical activity. ParticipACTION has evolved into a network of both public sector and nongovernment organizations (NGOs), whose goals are to promote physical activity, including participation in sports activities. Other organizations do their bit to encourage a healthy lifestyle. The Heart and Stroke Association, for example, sponsors riveting commercials on lifestyle choices (e.g., smoking, inactivity) and related risks. Antismoking campaigns along with related legislation (including laws governing electronic cigarettes, see Chapter 8). Similarly, ongoing campaigns (such as Mothers Against Drunk Drivers [MADD]) and laws against drinking and driving continue to reinforce the risks and push for the reduction of alcohol consumption. Now, with the implementation of the legalization of marijuana, new challenges are posed in terms of health and safety (see Chapter 8). Canadians, on the whole, pay attention to information being offered and are supportive of related legislation, recognizing that prevention goes a long way. Today Canadians have a much broader-based understanding of the link between lifestyle and health. Most people

recognize that smoking causes lung cancer and respiratory disease. And many know that being active can lower their chances of developing high blood pressure, osteoporosis, cardiovascular disease, and even some types of cancer. People are more aware than ever before that there is a link between obesity, inactivity, and diabetes. Obviously, how individuals respond to this knowledge depends on how they view health, wellness, and their own vulnerability. Still, much work remains to be done.

  Thinking it Through A close friend of yours, a very heavy smoker (two packs of cigarettes daily), is diagnosed with high blood pressure and has a family history of cancer. In spite of being aware of his history and the related risks, he refuses to stop smoking, stating, “It’s my life, and I love to smoke.” You believe that he does not comprehend the consequences of his habit and feel very strongly that he should quit. How might you influence his decision—or would you try?

The psychology of health behaviour Demonstrated by a person’s response or reaction to altered health, health behaviour has a significant impact on what a person does to maintain good physical and psychological health. Many factors, including what a person believes to be true about health, prevention, treatment, and vulnerability, influence how people act when they are ill or perceive they are ill. Health behaviour also depends on a person’s level of health knowledge, personal motivation, cognitive processes, and perceived risk factors. One’s culture and ethnicity will invariably affect all of these areas. To explain human health behaviour, several models have been developed, including the transtheoretical model, the social–ecological model, the protection motivation theory, and the health belief model (developed in the 1950s by the United States Public Health Service). Elements of the health belief model are relevant in one way or another to all of the other models, so it is described in detail below.

Health Belief Model People’s health beliefs affect their health behaviour. Health beliefs are things people believe to be true about their personal health and susceptibility to and about illness, prevention, and treatment in general. Beliefs are acquired largely through social interaction and experience. For over 6 decades, the concept that health beliefs affect health behaviour has been widely accepted and is based on a number of assumptions—for example, if people feel that by taking a certain action they can avoid a negative outcome, they will take that action (Case Example 7.1).

  Case Example 7.1 Marcy is 17 years old and sexually active. A number of her friends are sexually active as well. Jenna, one of her best friends, became pregnant, claiming that she and her boyfriend were using condoms. Marcy is convinced that if she takes the birth control pill, initially something she wanted to avoid, she will avoid becoming pregnant. She has decided that she will no longer rely on condoms and the rhythm method.

Many things can stop people from following a recommended course of action to avoid a negative health event—for example, how “at risk” a person feels. Consider Marcy as an example. She may know that taking a birth control pill will prevent a pregnancy, but she may also feel that the chances of an unplanned pregnancy happening to her is so slim that she is inclined not to bother taking the pill. Her friend, Jenna, becomes pregnant, but Marcy feels that Jenna was careless using protection. She may convince herself that using the withdrawal or rhythm method will be enough to prevent pregnancy. In other words, she does not believe that she is vulnerable, despite what happened to Jenna. Another factor that influences people’s choices and level of concern is the perceived seriousness of the condition or illness if acquired. Marcy may think that a pregnancy would be devastating, or may believe that she and her boyfriend will get married and live happily ever after. She may also think that an abortion is a viable option if pregnancy were to occur. Culture and religion also influence health beliefs and value systems. As a multicultural country, Canada requires health care providers to pay close attention to and to respect cultural and religious traditions and practices. The respect, or lack thereof, shown for such beliefs can affect how the patient feels about seeking health care (e.g., at what point and from whom) and following treatment plans (adherence). Culture and religion may affect a patient’s outlook on mental and physical health, wellness, disease, and disability. These beliefs often include the etiology or origin of the infirmity and how it should be treated. Western medicine is largely scientifically based—for example, western scientifically based medicine typically holds that an acute infection is caused by a pathogen, whereas some other cultures may believe that spirits, the supernatural, or disharmony with nature may be the cause. Specific beliefs as to the origin of an illness will likely dictate what type of treatment the person will accept and comply with. One cannot assume that every person from a specific culture will have the same beliefs or practices, as there are other variables involved such as the person’s personal outlook, their upbringing, and experiences. A second-generation Canadian may have the same health beliefs as their grandparents for example. It is best to identify cultural beliefs, preferences, and practices first hand; if language is a barrier, arrange for someone to act as a translator, or ask that the individual bring a friend or family member to translate for them. In Canada, the patient’s right to participate in his or her health care is valued. Over the past decade primary care providers have placed great emphasis on involving the patient as a partner in the decision-making

process: giving the patient the required information, treatment options, and letting the patient (perhaps with advice from their family) make the final decision. In other cultures, however, the patient’s autonomy to make personal health-related decisions is not considered necessary or important; instead, a family member may assume this responsibility. Often in these cultures (e.g., Asian and some Indigenous cultures), the welfare of the whole family is considered in making decisions, possibly without even consulting the patient. Some cultures view doctors and other health care providers as figures of authority, so patients may find discussing their treatment options difficult because they are accustomed to doing as they are told. People within some cultures may not report cognitive problems or mental illness because of perceptions that such illnesses are spiritually induced (i.e., possession by demons), reveal a lack of self-control, or are a source of shame. Religion, cultural customs, education, and language barriers also influence health behaviours and beliefs and decisions around death and dying. For example, people of Chinese or South Asian descent, Muslims, and Orthodox Jews may question requests for organ donation or the withdrawal of life support, even if the patient is deemed brain dead; the belief that life is sacred dominates. It may be that second- and third-generation Canadians do not hold the same beliefs—or do, but not to the same degree—as their parents. Sometimes, within a family, generational differences of opinion may cause conflict when it comes to treatment plans (Euromed Info, n.d.).

Transtheoretical Model The transtheoretical model (TTM) of health behaviour is a framework for promoting adaptive changes in a person’s health behaviour. The concept proposes that people must progress through the following series of steps before their health behaviour completely changes (i.e., improves): precontemplation, contemplation, preparation, action, maintenance, and termination. Integrated into these steps are ten cognitive and behavioural activities that further facilitate change. For example, during the precontemplation stage, although aware that a behaviour modification may improve his or her health, the person may initially have no desire or motivation to make a change. During the contemplation stage, the person is ready to seriously think about making changes and may consider the risks and benefits of a behaviour change. The action phase is when the person implements his or her plan like going to the gym—perhaps engaging a personal trainer, or preparing and eating a healthy meal. The

ongoing support of others is important during this phase. If the person is able to adhere to their plan for at least 6 months they are ready to move into the maintenance phase, which must continue for 2 years—continuing with an exercise program and eating a balanced diet. Once achieved, the individual enters into the termination phase. At this point the person’s behavioural changes are integrated into their lifestyle and considered permanent.

Social–Ecological Model The social–ecological model (SEM) maintains that many levels of influence shape health behaviour, with a focus on health promotion for individuals as well as groups of people within organizations. Such influences include a person’s education, occupation, or profession; the type of social support (personal, community) he or she has; his or her environment (e.g., workplace, availability of health care); and the public policies of various levels of government. SEM considers how various entities that put people at risk for developing health, behavioural and socioeconomic problems citing individual, relationship, community, and societal factors. Recognizing that there is an interplay between multiple factors promotes an understanding that one affects another (Centers for Disease Control and Prevention, 2017). The ideal situation is one wherein the determinants of health are the foundation for policy development collectively promoting good health, health education, and a healthy workplace.

Protection Motivation Theory Building upon the health belief model (discussed below), the protection motivation theory asserts that self-preservation is what motivates a person to change his or her health behaviour. The fear of illness, physical decline, physical disability, mental health problems, or even death can encourage adaptive (or maladaptive) health behaviours. The person’s actions depend on how severe he or she perceives the severity of the threat (e.g., cancer); how likely is one to succumb to the threat (e.g., actually get lung cancer from smoking, or contract a sexually transmitted infection [STI] from having numerous sexual partners); how likely is the preventative action(s) to be successful? For example, if a man fears that he will develop lung cancer, his health behaviours will be altered by how vulnerable he thinks he is (i.e., his likelihood of actually getting lung cancer), what he has to do

to avoid this threat (e.g., quit smoking), and his ability (or motivation) to take action. See Case Example 7.2.

  Case Example 7.2 Lasha’s doctor tells her at a recent visit that her blood pressure, which has been creeping up, is now a concern. Her last blood panel also reveals a rather alarming rise in her cholesterol levels. He tells her that given the fact that she is also overweight, she is at serious risk for a cardiovascular event. Lasha enjoys fast food and is inactive. She feels that her lifestyle to date has not contributed to any serious health problems. She has tried losing weight in the past by changing her diet and exercising but has never been very successful. She knows people in their seventies who have similar lifestyles to her own and are doing well. Some of them are on antihypertensive and lipid lowering medication, which more or less normalizes their clinical signs. How do you think Lasha perceives the threat of a heart attack or stroke? Do you think she feels like she is at risk? Does it appear that she is motivated to engage in lifestyle changes given the information she receives from her doctor? What do think could change Lasha’s way of thinking? Why?

The health–illness continuum No matter what health beliefs and religious or cultural background a person has, everyone measures their health (or wellness) and illness in some manner. A continuum is a method of measurement usually represented by a straight line with an opposing state at each end. The wellness–illness continuum measures one’s perception of their state of health or level of wellness between “optimum health” and “poor health” or “death.” In the middle is a neutral section sometimes referred to as compensation (Fig. 7.3). The wellness–illness continuum includes all of the dimensions of health and wellness, from physical, mental, and emotional health to social, spiritual, and environmental, similar to Health Canada’s determinants of health (see Chapter 2).

FIG. 7.3 The Health Continuum (Also Called the Wellness–Illness Continuum).

Movement on the continuum is constant. An individual may wake up feeling good and then develop a headache 2 hours later, altering his or her perceived placement on the continuum. Also, one person may have a bad cold but not feel particularly ill, therefore may place themselves on the “good health” part of the continuum. Someone else with a similar cold may feel unable to function and place themselves in compensation on the continuum. Angela is experiencing some epigastric pain—with the diagnosis of a gastric ulcer; to some this is more serious than a cold, but she also considers herself to be in the compensation zone (Case Example 7.3).

 

Case Example 7.3 Angela has always enjoyed good health and, for the most part, eats sensibly and exercises regularly. Recently, however, she began to have some epigastric discomfort. She was diagnosed with an ulcer and treated accordingly. Symptoms began to improve within a couple of days. On the health–illness continuum, Angela considers herself to be in compensation but moving toward good health or the wellness end of the continuum. For Angela, the direction of movement would be noted by an arrow moving toward optimum wellness. Fig. 7.4 shows Angela on the continuum near “fair health” and moving toward “optimum health.” What factors might cause Angela to move towards the illness end of the continuum?

FIG. 7.4 Wellness–Illness Continuum: Angela.

People with disabilities also place themselves on different places on the continuum. Consider Dr. Stephen Hawking (who passed away in March of 2018) who was a world-famous physicist and had ALS for many years, and despite his impairments he pursued life with a vengeance. Likely he would have himself in the compensation range of the continuum. He might even have considered himself to be closer to the wellness end of the continuum, accepting his limitations to be within normal limits for him. Rick Hanson is another individual who embraced his physical limitations, and is living a full and productive life. Ryan Straschnitzki, a 19-year-old hockey player on the Humboldt Broncos hockey team, sustained a spinal injury in a bus/truck collision in April 2018 rendering him paralyzed from the chest down. He has shown great strength and courage facing his limitations. Likely Ryan at this early stage would put himself at various points on the compensation portion of the continuum, but heading towards wellness. Others who choose not to face a progressive disability or terminal illness may consider their health to be closer to the negative end of the spectrum and find themselves making some difficult choices.

For the competent adult in Canada, the right to end one’s life with medical assistance is now possible as long as they meet the current criteria for medical assistance in dying. Likewise, a person with a mental illness may place themselves on the negative end of the continuum, and wish to end their life (which is not a viable reason to seek medical assistance in dying, see Chapter 10).

  Did You Know? Medical Assistance in Dying in Canada Bill C-14 governing medical assistance in dying passed on June 17, 2016. This follows legislation in Quebec, which legalized medical assistance in dying 6 months earlier. By the end of 2017 over 13,000 people have died with medical assistance. The number is estimated to be higher because there is inconsistency in how data is reported among provinces and territories. Cancer has been reported to be the primary condition for which medically assisted death has been performed, followed by neurological diseases. Source: CBC News. (2017, April 20). Nicole Ireland. 1,300 Canadians have died with medical assistance since legalization—here’s one man’s story. Retrieved from www.cbc.ca/news/health/medically-assisted-dying-canadians-robrollins-1.4056700.

Sick Role Behaviour It is widely accepted that when people are ill, their behaviours, roles, and attitudes change. This response to illness is sometimes referred to as sick role behaviour or behavioural illness response to disease or illness (Thompson, 2017). The stress of being ill can alter people’s perceptions and the way they interact with others, from those close to them to the health professionals they deal with. Illness can also influence the behaviour of those associating with the unwell person, in large part because these people often have a burden placed on them. They may be required to provide extra support to the ill person or to assume their responsibilities, which may result in a change in their daily routine and increased stress. To better understand sick role behaviour, consider the fact that we all behave differently at different times, with different people, and in different

situations. These varying behaviours affect, among other things, the diverse roles and responsibilities we assume throughout our lifetime. Persons who are ill are often relieved from the roles and responsibilities they have in society—which ones and to what extent depend on the nature and severity of their illness. The majority of people respond to their illness in an adaptive manner. Others will respond by being “more of what they are.” For example, sometimes people who consistently complain about their health, call frequently, and rely heavily on health care providers will likely become more extreme in these behaviours. Alternatively, components of a person’s character not usually seen can emerge. A normally easygoing patient may become inwardly focused and quiet, or uncommunicative for several reasons, including fear (Case Example 7.4).

  Case Example 7.4 Ashma, a student nurse, was looking after a young mother (Doreen) in labour and delivery. Because there were serious signs of fetal distress, after discussing options with Doreen and her husband, the decision was made to do a caesarean section. The mother became uncommunicative, answering with one word, or not at all, making it impossible for Ashma to assess her needs accurately. The next day, when she went to see Doreen on the postpartum unit, Ashma was greeted by a big smile and an outgoing, chatty, and cheery demeanor. Ashma could not believe this was the same person. When asked how she felt, Doreen responded “good and my baby boy is fine, but that’s it. I will never have another child. I have never felt so helpless and afraid in my life. I thought my baby was going to die.” The anxiety and fear of the unknown, and worry about the outcomes for her baby, had greatly affected Doreen’s normal behaviour and her outlook in terms of wanting to go through a pregnancy again. Where do you think Doreen would place herself on the continuum when the decision to have a caesarean birth was made? What about afterwards? Although pronounced changes in attitude are more apt to be evident when a person suffers a serious illness, the stress of a relatively minor illness or accident (for example, a broken leg or pneumonia) can also be problematic—especially if the illness limits or alters the patient’s activities, role functions, or ability to work, even for a short period of time. Such limitations will invariably affect the person’s attitude and outlook, as well

as the attitudes of those close to the patient. As noted at the beginning of this chapter, culture may also affect a person’s response to illness. Health care providers can do their part by maintaining their professional role and respecting the fact that patients will present moods and attitudes that differ from those they display in good health (influenced also by the health belief model they affiliate with, and if their locus of control is internal or external). Family members may also become upset, shorttempered, and demanding. It is important to remember that they are also coping with the stress of altered roles and functions and are probably frightened and concerned about their loved one who is ill. Managing patients and family members in such situations requires the ability to remain calm, listen to their concerns, answer questions simply and honestly, and connect them to the appropriate resources as required. A calm, caring, and supportive demeanour most often brings about the most positive responses. Sick role behaviour may be affected by the setting, such as if a person is hospitalized, treated in the community setting (e.g., at home with home care), or despite their health problem, they are still able to carry on with their usual routines of work, and looking after a family. Hospitalization is most likely to affect how someone responds to an illness because they are removed from their home and community, and their activities are highly restricted—from the time they get up to the time they are expected to go to bed, and the time that meals are served. Patients more or less lose their sense of autonomy. Take into account the fact that language barriers or cultural or religious beliefs are likely to affect how a patient responds to hospitalization and medical care. Read the patient’s body language and responses. As health care providers, influenced by western medicine, we are taught that touch (even a hand on the arm or shoulder) can be comforting to a patient, no matter the setting—and that eye contact is important. This is not entirely accepted by everyone. Eye contact for the most part is a behaviour influenced by culture. Many Canadians are taught that establishing eye contact engages another person, demonstrating interest and warmth, particularly if accompanied with a smile. Eye contact on the other hand, particularly if sustained, is perceived by some cultures as a sign of disrespect or even aggression. They avoid direct eye contact, thereby appearing disinterested, nervous, or upset. In fact, avoiding eye contact, especially with someone deemed to be in authority is, by some, considered a sign of respect and politeness. The person may feel that if they establish eye contact they may be perceived as

being impolite or aggressive. Modesty is also a concern of people from some cultures (Case Example 7.5) (Chin, 1996; Nursing, 2005; Schwartz, 1991; Thompson, 2017). Sometimes it is necessary for health care providers to seek the help of other team members to ensure optimal care and treatment. Personal space is another variable health providers must be aware of. Although personal to some degree, there are cultures that are comfortable with someone moving close to them, and others that are not. Touch, even just putting a hand on a patient’s arm, can be perceived invasive by some and not by others.

  Case Example 7.5 Nishtha, a 65-year-old woman from India, refused to let David, a registered nurse, assist her with her bed bath. She drew the covers up under her chin and waved him away. Confused, David reported that Nishtha had refused care. In Nishtha’s culture, modesty is very important, and female caregivers are preferred. What would you do if you were in David’s place? It is important to note that health care providers must avoid stereotyping or generalizing behaviour based on the patient’s cultural background. For example, Nishtha’s daughter was born in Canada and may not share the same level of modesty.

Stages of Illness: Influence on Patient Behaviour A patient’s acceptance of a diagnosis and treatment plan normally follows a relatively predictable path through the stages of illness. But a person’s response and choice of course of action depend on their health beliefs, health behaviours, and other variables (e.g., the seriousness of the health issue) discussed in this chapter. A person may have an illness “brewing” for some time before symptoms appear. How long the illness has been present will affect the nature and severity of the signs or symptoms (frequently called manifestations) of the illness once they do become apparent, as well as the outcome of the illness. The stages of illness and probable responses are summarized in Box 7.3.

  Box 7.3

Stages of Illness. Preliminary Phase: Suspecting Symptoms • Symptoms, possibly subtle, appear; they may progress or abate. • Person either acknowledges or ignores symptoms. • Person may seek immediate medical advice or look for information elsewhere (e.g., on the Internet).

Acknowledgement Phase: Sustained Clinical Signs • Person decides symptoms cannot be ignored. • Person seeks advice from family or friends, self-treats, or considers making an appointment with the doctor.

Action Phase: Seeking Treatment • Symptoms become problematic and concerning. • Person seeks medical advice.

Transitional Phase: Diagnosis and Treatment • Person receives a diagnosis, a treatment plan, or both. • Person may seek a second opinion if the diagnosis is serious. • Person may accept treatment, becoming involved in the treatment plan, or may refuse treatment or even deny the diagnosis (e.g., in the case of a terminal disease).

Resolution Phase: Recovery and Rehabilitation • Person may recover completely with minimal intervention or may require surgery, ongoing care, or rehabilitation. • Person may or may not embrace and comply with the rehabilitation plan; if the illness becomes chronic, the person will reposition him- or herself on the health–illness continuum.

  Thinking it Through Twelve-year-old Justin is a well-controlled diabetic and has been monitoring his own blood glucose levels and adjusting his own insulin according to his doctor’s orders. He has an app on his smart phone (as do his parents) that allows them to check his blood glucose levels regularly (he wears a patch on his skin allowing for wireless monitoring). Prior to his first semester examinations his parents noticed that for several days Justin’s blood glucose levels have been much higher than they should be. His parents also noticed that Justin is not eating well, and hiding chocolate bars in his room. His parents tried talking to him about it, but he refuses to discuss the problem, and tells them they are overreacting. His parents contact his diabetic counsellor and make an appointment for him to see her. As a dietary assistant, you have been asked to review his meal plan with him. Justin grumbles about the fuss everyone is making and does not understand the need for any changes to his diet or his lifestyle. What approach would you take with Justin? What do you think is the problem?

Self-Imposed Risk Behaviours Examples of self-imposed risk behaviours include smoking, unhealthy eating habits, inactivity, alcohol or drug misuse, and sexual promiscuity. People engage in risk behaviours for a number of reasons, including simple enjoyment, habit (which often becomes addictive behaviour like smoking), and thrill-seeking. A common initiator among young people is peer pressure. For example, if a teen’s friends smoke or take drugs, they may try it rather than risk not fitting in. Risk behaviour in one person often will affect another. For instance, people who choose not to smoke may nevertheless find themselves in danger of inhaling second-hand smoke (they may not realize the implications, or find it difficult to remove themselves from the situation), or they may drive sensibly but voluntarily ride in a car with an impaired driver. Risky behaviour is dangerous for the individual, and when medical/surgical intervention is required, it places the burden of cost on the health care system. Some risk behaviours are less obvious, especially in terms or accepting responsibility for one’s own health, including awareness of one’s own health risks as dictated by family history (genetics) and current health issues. Consider the large number of hip and knee replacements done across the country. Waiting lists are long

and the procedures are expensive. In many cases maintaining a reasonable body weight and staying physically active will reduce or delay the need for joint replacements. Most primary care providers follow provincial/territorial “best practices” guidelines with respect to preventive medicine. For example, preventive screening tests such as pap smears, breast screening, and when medical history dictates, a colonoscopy. Health care professionals will sometimes notify their patients when they should be considering medical screening. However, the onus is on the individual to have the screening done. Health promotion and illness prevention initiatives undertaken by all levels of government aim to reduce self-imposed risk behaviour for two reasons: to ease the financial burden on our health care system and to promote the health and longevity of Canadians.

The health of canadians today Canadians are living longer. The life expectancy for both men and women continues to rise. Life expectancy is derived from statistical data of how long populations are expected to live. As of 2012, Statistics Canada is no longer posting average ages for life expectancy. However, based on the latest data (available in 2014) the Canadian life expectancy at birth reached 79.6 years for men and 83.8 years for women (Statistics Canada, 2017a). On a global perspective, men have the longest life expectancy in Iceland, Switzerland, and Australia respectively, whereas women’s longest expectancy is found to occur in Japan, Spain, and Switzerland. In Canada, among the Indigenous population the Inuit community have the lowest projected life expectancy. In 2017, it was reported that the average life expectancy was 64 years for men and 73 years for women. First Nations and Métis had a range of 73–74 years for men and 78–80 years for women. It is estimated that the life expectancy for Canada’s Indigenous population has increased by about 2 years since the early 2000s. In 2017, Indigenous peoples made up an estimated 4.1% of the Canadian population (Statistics Canada, 2017b). More information of life expectancy is in Table 7.1.

Table 7.1 Life Expectancy at Birth, 2014–2016.

Notes: Life expectancies are calculated with a method that uses 3 years of data.

Sources: Statistics Canada. (2018). Life expectancy and other elements of the life table, Canada, all provinces except Prince Edward Island. Table: 13-10-0114-01. Retrieved from https://www150.statcan.gc.ca/t1/tbl1/en/tv.action? pid=1310011401; Statistics Canada. (2018). Life expectancy and other elements of the life table, Prince Edward Island and the Territories. Table: 13-10-0140-01. Retrieved from https://www150.statcan.gc.ca/t1/tbl1/en/tv.action? pid=1310014001&pickMembers%5B0%5D=1.4&pickMembers%5B1%5D=3. 3&pickMembers%5B2%5D=4.8. The rate of infant mortality is often used as a measure of the effectiveness of a country’s health care system. Canada’s infant mortality rate has declined over the last several decades, but not as fast as the rate in other developed nations. The national infant mortality rate in 2006 was 5.7% and dropped to 4.3% by 2016 (Statista, 2018). The infant mortality rates in percentages for infants under a year in 2016 were, by jurisdiction: British Columbia 3.5; Alberta 4.4; Saskatchewan 5.8; Manitoba 5.4; Ontario 4.6; Quebec 4.3; NB 5.0; NS 4.9; PEI 7.7; Nunavut 17.7; Yukon 7.4; and North West Territories 6.1 (Statistics Canada, 2018a).

  Did You Know?

Calculating Infant Mortality Countries calculate infant mortality rates differently; Canada and the United States, for example, include in their rates very premature babies, whose chances of survival are low, elevating their statistics, and some countries do not register infant deaths occurring within the first 24 weeks of life. According to research, if corrected neonatal mortality rates are applied, Canada ranks twelfth, not sixteenth (CBC News, 2012). Other factors responsible for Canada’s poor showing on the world stage include advances in technology that may increase the number of premature births (e.g., more multiple births resulting from fertility treatments). According to statistics Canada, the infant mortality rate in Canada from 2007 to 2017. was at approximately 4.5 deaths per 1,000 live births. Source: CBC News. (2012). Canada’s rank on infant mortality index called unfair. CBC. Retrieved from http://www.cbc.ca/news/health/story/2012/02/17/health-infantmortality-study.html.

Leading Causes of Death in Canada The leading causes of death in Canada are malignant neoplasms (cancer), heart disease, cardiovascular disease (e.g., stroke), and lower respiratory diseases (e.g., chronic obstructive pulmonary disease [COPD], asthma, and accidents) (Statistics Canada, 2018b). For infants, the leading cause of death is congenital abnormalities, followed by premature births, and low birth weight (Statistics Canada, 2015). Accidents are the leading cause of death for individuals aged 1 to 34, cancer for those aged 35 to 84, and heart disease for those 85 years of age and older. Accidents, suicide, and homicide are the leading causes of death for young adults aged 15 to 24. The following is a brief discussion on the three leading causes of death in Canada: cancer, cardiovascular disease, and cerebrovascular disease (Fig. 7.5).

FIG. 7.5 Leading Causes of Death in Canada. (Source: Data from Statistics Canada. [2012]. Table 102-0561 - Leading Causes of Death, Total Population, by Age Group and Sex, Canada, Annual. Ottawa: Statistics Canada. CANSIM database. Retrieved from http://www.cancer.ca/en/cancer-information/cancer101/cancer-statistics-at-a-glance/?region=on#ixzz5Po1aMwJj.)

Cancer One in two Canadians are expected to develop cancer in their lifetime, with slightly higher rates among women—most over the age of fifty (Canadian Cancer Society, 2017). Lung, breast, colorectal, and prostate are the most common types of cancer in Canada (Canadian Cancer Society 2017). There are various causes of cancer. The incidence of different types of cancer is influenced by such things as risk behaviour (smoking), environment factors (pollution), socioeconomic factors (poverty), lack of education related to disease prevention and health promotion, and access to cancer medical services such as cancer screening. These factors affect the number of cases and types of cancer seen across the country (e.g., What cancers are seen more frequently in some regions and not in others?). British Columbia, Alberta, Ontario, and Saskatchewan have the lowest rates of cancer, whereas Newfoundland and Labrador, Northwest Territories (NWT), Yukon, and Nunavut have the highest rates. This is

likely impacted, in part, by geographic isolation, which may contribute to unemployment and even poverty, accessible medical services, and other elements negatively affecting the determinants of health. It is interesting to note that although Newfoundland and Labrador has one of the highest rates of all cancers, it has the lowest rate of breast cancer among all provinces and territories (Conference Board of Canada, 2015). While the incidence of some types of cancers have decreased (e.g., throat and stomach), others (e.g., breast cancer) have seen a moderate increase and some (e.g., liver and thyroid) have seen significant increases. Breast cancer is the second leading cause of death in Canadian women, responsible for 25% of all cancers. In 2017, on average 72 women were diagnosed with breast cancer daily, and an estimated 14 deaths each day. While the incidence of breast cancer is up slightly, there are fewer deaths because of early detection, and more effective treatments (Canadian Cancer Society, 2018). In Canada, prostate cancer is the most common type of cancer among men, responsible for an estimated 21% of all cancer diagnosis in 2017. The Canadian Cancer Society estimates one in seven men were diagnosed with prostate cancer in 2017, and 1 in 29 died from it. Mortality rates for prostate cancer are relatively low because of early diagnosis, treatment when indicated, and because most prostate cancers are slow growing. Because of the low mortality rates, there is controversy over how aggressively to screen for and treat diagnosed cases of prostate cancer. The age of the individual is a factor in treatment. Monitoring the progress of prostate cancer is achieved through periodic assessments of the person’s prostate-specific antigen (PSA) levels. Most jurisdictions (e.g., Ontario and British Columbia) will cover the cost of a PSA test if recommended by a health care provider for monitoring purposes. The cost is not covered for routine screening in most jurisdictions—a person can request the test but will have to pay out of pocket (according to the 2017 fee schedule in Saskatchewan this would cost $54.85) (Prostate Cancer Canada, 2014). Lung cancer remains the leading cause of all cancer-related deaths in both males and females, with an estimated 28,600 new cases diagnosed in 2017, and 21,100 deaths the same year (Public Health Agency of Canada, 2017). The incidence of lung cancer is higher in males than in females. From a global perspective, according to the World Cancer Research Fund International (2017), Puerto Rico has the lowest rate of all age-related cancers and Denmark has the highest. (Canada has the 12th highest rate out of 50 countries.)

Cardiovascular Diseases Cardiovascular disease (CVD)—also referred to as ischemic heart disease —is the second leading cause of death in Canada and responsible for 29% of all deaths (Government of Canada 2017). Cardiovascular diseases include coronary artery disease (CAD), congestive heart failure, arrhythmia (abnormal heartbeat), and peripheral vascular disease (problems with circulation, primarily in the legs). Of these, CAD is the most common. Primary risk factors for developing heart disease include smoking, high blood pressure, high cholesterol, inactivity, and obesity. Genetics are also a contributing factor. The incidence of heart disease has decreased slightly over the past few years, likely because of improved screening (and treatment) for risk factors, education related to health promotion and disease prevention (risk reduction), and lifestyle changes. An estimated one in 12 Canadians over the age of 20 is living with some form of heart disease. Mortality rates increase with age. Men are more than twice as likely to develop heart disease even though men are typically diagnosed on average 10 years younger than women. Indigenous Canadians are approximately twice as likely to develop heart disease, particularly those who live on-reserve and are subject to a wide range of cardiovascular risk factors including food insecurity, obesity, and inactivity. Generally, population health initiatives implemented by both federal and provincial/territorial governments have contributed to lower mortality rates from heart disease and a healthier lifestyle. Other organizations such as the Heart and Stroke Foundation and the Canadian Society for Exercise Physiology also encourage an active lifestyle. ParticipACTION’s 2016 Report Card on Physical Activity for Children and Youth also addresses the importance of adequate rest (combined with activity). Based on this report, ParticipACTION Canada developed the world’s first 24-Hour Movement Guidelines (ParticipACTION, 2016). With heart health in mind, the organization has also recently introduced regulations forcing manufacturers to lower the amount of trans fats in prepared foods, launched public campaigns to encourage manufacturers to lower sodium content in foods, and made efforts to reduce the sale of unhealthy foods in schools.

Cerebrovascular Disease Cerebrovascular disease includes a number of conditions that affect the flow of blood to the brain, the most serious of which is stroke. Stroke

occurs when there is a blockage of oxygen to part of the brain, which is caused by an interruption in the blood flow, most commonly a blood clot. Stroke is the leading cause of adult disability, the third leading cause of death, and is more common in women than men (Statistics Canada, 2013). Nine in ten Canadians have at least one risk factor for stroke; the risk factors are the same as those for heart disease (Heart and Stroke Foundation, 2017). Heart disease and stroke together are also the leading causes of hospitalization in Canada, and according to the Conference Board of Canada, cost the Canadian economy $20.9 billion/year (Heart and Stroke Foundation, 2014). Nunavut (which is puzzling given the risk factors in that jurisdiction) and Quebec have the lowest mortality rates from heart disease and stroke, while Labrador and Newfoundland and the NWT have the highest (Conference Board of Canada, 2018). A 2013 report on the health of Canadians sponsored by the Canadian Heart and Stroke Association claims that without immediate action, older Canadians (mostly baby boomers) will spend the last 10 years of their lives living with illness, disability, and mobility problems (Heart and Stroke Foundation, 2013b). Supporting this, Stats Canada reports that there is a gap “between how long we live, and how long we live in health” (Heart and Stroke Foundation, 2013a). One can only assume from these facts, the message that we Canadians can do much to reduce our risk factors for acquiring a variety of infirmities, including stroke and heart disease, is somehow not getting through, even though access to health information and teaching materials has been greatly enhanced by the Internet. More work is clearly needed to teach Canadians that adopting a healthy lifestyle at an early age will increase the chances of enjoying better health in one’s later years.

Summary 7.1 Today, the key concepts of health, wellness, and illness are defined in less black-and-white terms. Definitions of health relate to such things as an individual’s own culture, background, and experiences. Wellness goes beyond having good physical and mental health and considers how a person feels about his or her health and quality of life. The many dimensions of wellness include physical, emotional, intellectual, spiritual, social, environmental, and occupational health. Disease refers to a condition in which a person’s mental or bodily functions are different from normal. The term illness, often used to denote the presence of disease, can also refer to how a person feels about his or her health, whether or not a disease is present. A disability can be physical, sensory, cognitive, or intellectual and can occur in conjunction with or as a result of a disease, or be caused by an accident. 7.2 How health care is delivered is reflected in a design, a philosophy, and an approach. Three approaches, or models, are most frequently used: the medical, holistic, and wellness models. The (w)holistic framework is an approach to health used by many Indigenous people, and is based on the circle, the medicine wheel, and the four directions of east, west, south, and north. Some people prefer a natural approach to health care—noninvasive, leaning away from mainstream diagnosis and intervention. Others have more faith in proven treatments. Still others will blend philosophies. 7.3 Several factors influence how people respond when their health is compromised. These include past experiences and one’s outlook on life (e.g., optimistic, pessimistic). Over the past several years, Canadians, for the most part, have assumed more responsibility for their own health, assessing their own risk behaviours and focusing on health promotion and disease prevention. 7.4 Health behaviour is how a person responds to all aspects of altered health. How they react affects their relationship with health care providers, family members, and others close to them. A person’s response to an altered health situation is unique to each person and influenced by his or her background, social and cultural beliefs, and past experiences with the health care system.

Understanding that deviations from a person’s normal behaviour are just that—and supporting him or her appropriately—will go a long way to helping a patient recover. 7.5 By some standards, such as the health–illness continuum, a person’s health is measurable. How a person feels about his or her health changes frequently and is influenced by the type and severity of an infirmity, personal health beliefs, and the health model the person most closely relates to. 7.6 Overall, the health of Canadians has improved over the past decade, yet challenges remain in providing prompt and effective care, particularly for those with cancer, cardiovascular diseases, and diseases of the respiratory system—the leading causes of morbidity and mortality in the country. Aboriginal peoples are particularly at risk for socioeconomic reasons, and for many, because of the lack of proximity to larger treatment centres.

Review questions Describe the dimensions of wellness, and explain how wellness goes beyond having good health. 1. Differentiate between a disease and a disability and provide examples of both. 2. Compare and contrast the medical, holistic, Indigenous wholistic, and wellness models/theories of health, identifying the key points of each. 3. What challenges face individuals with physical and mental impairments? 4. Explain how Canadians’ attitudes toward their health and wellbeing have changed over the past several decades. 5. Differentiate between health beliefs and health behaviours. 6. Briefly describe how a person’s health behaviour can affect how you as a health care provider treat that person. 7. How can you best provide culturally sensitive health services to a new Canadian? 8. Explain how sick role behaviour may affect where someone places him- or herself on the health–illness continuum. 9. Describe how the different stages of illness may influence patient behaviour. 10. How and why have the leading causes of death in Canada changed over the past 10 years?

References Canadian Cancer Society. Cancer statistics at a glance. Retrieved from http://www.cancer.ca/en/cancerinformation/cancer-101/cancer-statistics-at-a-glance/? region=on. 2017. Canadian Cancer Society. Breast cancer statistics. Retrieved from http://www.cancer.ca/en/cancerinformation/cancer-type/breast/statistics/?region=on. 2018. Centers for Disease Control and Prevention. Violence prevention. The social-ecological model: a framework for prevention. Retrieved from https://www.cdc.gov/violenceprevention/overview/soc ial-ecologicalmodel.html. 2017. Chin P. Chinese Americans. In: Lipson J.G., Dibble S.L., Minarik P.A., eds. Culture and nursing care: A pocket guide. San Francisco, CA: University of California—San Francisco Nursing Press; 1996:74–81. Conference Board of Canada. Mortality due to cancer. Retrieved from http://www.conferenceboard.ca/hcp/provincial/health/ cancer.aspx. 2015. Conference Board of Canada. Mortality due to heart disease and stroke. Retrieved from http://www.conferenceboard.ca/hcp/provincial/health/ heart.aspx. 2018. Euromed Info. (n.d.). How culture influences health beliefs. Retrieved from http://www.euromedinfo.eu/howculture-influences-health-beliefs.html/. First Nations Child & Family Caring Society of Canada (FNCFCS). Indigenous children, youth and families in the next 150 years. First Peoples Child & Family Review, 12(2).

Retrieved from http://journals.sfu.ca/fpcfr/index.php/FPCFR/issue/vi ewIssue/27/24. 2018. Government of Canada. Heart disease in Canada. Ministry of Health. Retrieved from https://www.canada.ca/en/publichealth/services/publications/diseases-conditions/heartdisease-canada.html. 2017. Heart and Stroke Foundation. Canadians face decade of sickness in later years. In: Retrieved from. 2013a. http://www.heartandstroke.ab.ca/site/pp.aspx? c=lqIRL1PJJtH&b=8554975. Heart and Stroke Foundation. (2013b). 2013 report on the health of Canadians. Retrieved from https://www.heartandstroke.ca/-/media/pdffiles/canada/2017-heart-month/heartandstrokereportonhealth2017.ashx. Heart and Stroke Foundation. Statistics. Retrieved from https://sagelink.ca/heart_and_stroke_foundation_statisti cs. 2014. Heart and Stroke Foundation. 2017 Stroke Report. Different strokes: Recovery triumphs and challenges at any age. Retrieved from http://www.heartandstroke.ca/-/media/pdffiles/canada/stroke-report/strokereport2017en.ashx. 2017. Larson J.S. The measurement of health: Concepts and indicators. New York: Greenwood Press; 1991. Nursing 2005. (2005). Understanding transcultural nursing. Nursing 2005, 35, 14, 16, 18, 21, 23. Retrieved from https://journals.lww.com/nursing/Fulltext/2005/01001/ UNDERSTANDING_TRANSCULTURAL_NURSING.2.as px

ParticipACTION. 2016 The ParticipACTION report card on physical activity for children and youth. Retrieved from https://www.participaction.com/sites/default/files/dow nloads/2016%20ParticipACTION%20Report%20Card%20 -%20Highlight%20Report.pdf. 2016. Prostate Cancer Canada. Support PSA tests for Ontario. Retrieved from http://www.psatestsforontario.ca/. 2014. Public Health Agency of Canada. (2017). Lung Cancer. Retrieved from https://www.canada.ca/en/publichealth/services/chronic-diseases/cancer/lungcancer.html. Schwartz E. Jewish Americans. In: Giger J.N., Davidhizar R.E., eds. Transcultural nursing. Chicago, IL: Mosby; 1991:491–520. Statista. Canada: Infant mortality rate from 2006 to 2016 (in deaths per 1,000 live births). The Statistical Portal. Retrieved from https://www.statista.com/statistics/806726/infantmortality-in-canada/. 2018. Statistics Canada. (2013). The 10 leading causes of death, 2013. Retrieved from https://www150.statcan.gc.ca/n1/pub/82-625x/2017001/article/14776-eng.htm. Statistics Canada. (2015). Ten leading causes of infant death, by sex, Canada. Table 2. Retrieved from https://www.statcan.gc.ca/pub/84-215x/2012001/tbl/t011-eng.htm. Statistics Canada. (2017a). Mortality: Overview, 2012 and 2013. The life expectancy of men is slowly catching up to that of women. The Daily. Retrieved from https://www150.statcan.gc.ca/n1/dailyquotidien/170712/dq170712b-eng.htm. Statistics Canada. (2017b). Projections of the Aboriginal populations, Canada, provinces and territories, 2001 to 2017.

Catalogue number 91-547-XIE. Retrieved from https://www150.statcan.gc.ca/n1/pub/89-645x/2010001/c-g/c-g013-eng.htm. Statistics Canada. (2018a). Deaths and mortality rates, by age group. Table: 13-10-0710-01. Retrieved from https://www150.statcan.gc.ca/t1/tbl1/en/tv.action? pid=1310071001. Statistics Canada. (2018b). Leading causes of death, total population, by age group. Table: 13-10-0394-01. Retrieved from https://www150.statcan.gc.ca/t1/tbl1/en/tv.action? pid=1310039401. Thompson, V. (2017). Administrative and clinical procedures for the Canadian health professional. Toronto: Pearson Education. World Cancer Research Fund International. (2019). Global Cancer Data by Country. Retrieved from https://www.wcrf.org/dietandcancer/cancertrends/data-cancer-frequency-country. World Health Organization. (1986). Health promotion: Concepts and principles in action—a policy framework. Copenhagen: WHO Regional Office for Europe.

8

The Law and Health Care LEARNING OUTCOMES 8.1 Describe the health care legislation. 8.2 Explain the federal and provincial jurisdictional framework related to health care 8.3 Outline the concerns about and the issues related to health care as a right. 8.4 Discuss the legality of offering private services in Canada. 8.5 Discuss the basic principles of consent to treatment. 8.6 Explain the health record related to privacy legislation. 8.7 Describe the role of regulated health professions in legal matters. 8.8 Identify some other important legal issues in Canadian health care.

Key terms Act Civil law Code of ethics Common law Confidentiality

Conflict of interest Constitutional law Contract law Controlled Drugs and Substances Act Criminal law Duty of care Electronic health record (EHR) Electronic medical record (EMR) Fiduciary duty Good Samaritan law Implied consent Incident report Informed consent Malpractice Negligence Oral consent Personal Information Protection and Electronic Documents Act (PIPEDA) Power of attorney Privacy Professional misconduct Quarantine Act Regulation Regulatory law Statutory law Tort Whistleblower Workplace Hazardous Materials Information System (WHMIS) legislation

This chapter is not meant to replace a separate legal course you may take in your program, but rather provides a practical overview of the relationship between the law and some elements of health care in Canada. It concentrates on selected basic elements of health care and the application of related legal issues, rather than on specific laws and legislation. Because laws vary among the provinces and territories, it is more meaningful for students to research those within their own jurisdiction to access specific information. Most health care providers, health care facilities, regional health and other governing authorities, and regulated professions are governed by legislation, regulations, or guidelines, which affect how they function. This chapter begins by examining the division of legislative powers between the Federal Government and the provincial and territorial governments where health care is concerned. It also discusses the legal responsibilities of the Federal Government with respect to safety legislation and sections within criminal law that affect health care. This chapter also looks at the legal rights of Canadians to health care under the Canada Health Act, the law according to the Charter of Rights and Freedoms. Private enterprise in health care is growing across the country often clashing with the principles of publicly funded health care, and legislation regarding private enterprise varies among jurisdictions. Many Canadians embrace the chance to choose between public and private services, others do not. This chapter briefly discusses restrictions imposed on Canadians with regard to seeking health care from private clinics and the right of Canadians to purchase private insurance for medically necessary services that the provinces or territories cannot provide within reasonable time frames. Other topics discussed include the legal guidelines and responsibilities of health care providers regarding consent to treatment, and how to mediate requests for medical assistance in dying. The effects of the law on health care providers, as well as on their moral and legal obligations to patients, are also highlighted. Finally, this chapter addresses health information management, confidentiality, and current privacy legislation—and the challenges presented by electronic health records.

Laws used in health care legislation Laws in Canada include both statutory law (i.e., derived from acts) and common law (i.e., made by judges in deciding cases). Various levels of government are authorized to create laws. Some laws apply to the health care industry more than others, including constitutional, statutory, regulatory, and common (or case) law, all of which are described in the sections that follow.

Constitutional Law Constitutional law addresses the relationship between the people and their government, and establishes, allocates, and limits public power. In Canada, cases challenging a person’s right to health care have been based on the Canadian Charter of Rights and Freedoms, part of the Canadian Constitution. Under the Constitution, everyone has the following fundamental freedoms (Canadian Charter of Rights and Freedoms, 1982): • Freedom of conscience and religion • Freedom of thought, belief, opinion, and expression, including freedom of the press and other media of communication • Freedom of peaceful assembly • Freedom of association A Canadian citizen denied any of these rights can challenge the person, persons, or organization denying him or her such rights based on the related section of the Charter.

Statutory Law A statute is a law or an act. Statutory laws are the laws passed in Parliament (i.e., at the federal level) or in the provincial or territorial legislatures. Examples of statutory laws under federal authority

include those dealing with immigration, taxation, and divorce. Statutory laws under provincial or territorial jurisdiction include those related to education, family, and health care.

Regulatory Law Regulatory law, also referred to as subordinate legislation, is a form of law that possesses the legally binding feature of an act, because it is usually made under the authority of an Act. Although regulatory law may be left to government departments and agencies to complete, regulatory law is not made by Parliament (i.e., at the federal level) or by provincial or territorial legislatures but rather by delegated persons or organizations, such as an administrative agency or a tribunal. The authority to implement regulations, however, must be specifically outlined in a federal, provincial, or territorial act—for example, in Manitoba, the Regional Health Authorities Act gives regional health authorities the power to make, implement, and enforce regulations. Federally the Food and Drugs Act oversees Health Canada’s Food and Drug Regulations. In health care, regulatory law affects hospital boards, health care institutions, and bodies governing health care providers. Under provincial and territorial health care professions acts (e.g., Ontario’s Regulated Health Professions Act), the Minister of Health oversees the manner in which health care professions operate and govern themselves and also retains the power to request that a council make, amend, or revoke a particular regulation.

Common (Case) Law and Civil Law in Canada In Canada, law in all provinces and territories except Quebec is based on common law. Quebec, however, operates under civil law and statutory law, based on the French Code Napoléon or Civil Code. Common law is not established within legislature or formally written like statutory law. Also called case law, it results from the decisions of the courts. These decisions are based on a variety of historically established laws, consistent with previous decisions or

higher court decisions, interpretations of written laws, and other legal principles not outlined in statutory law. Although Quebec’s civil law system relies heavily on written laws, judges in Quebec courts often seek guidance from previous decisions and must also interpret written laws, as is done in common law systems. In addition, common law may govern litigation conducted before the Federal Court of Canada, which operates throughout Canada, including Quebec.

Classifications of Law: Public and Private Law Laws are classified as public or private. Public law pertains to matters between an individual and society as a whole, and therefore includes criminal, tax, constitutional, administrative, and human rights laws. For example, when an individual breaks a criminal law, his or her breach is considered a wrong against society, not just a wrong against another person or a select group of people. There may be variations in public law among jurisdictions. Private law governs matters concerning relationships between people or legal entities and includes contract and property law, matters relating to inheritance, family law, tort law (e.g., negligence), and corporate law. A person can sue a business, a dentist, a doctor, a hospital, a primary health care organization, or any individual for damages under private law. These suits can include torts of libel and slander, breaches in privacy and confidentiality, and negligence suits. The following example illustrates the difference between public law and private law. If a nurse believed a patient was better off dead and actively helped that person to die (active euthanasia), the police, acting on behalf of the state, would arrest the nurse and charge him or her under the Criminal Code, part of public law. If found guilty, the nurse could be sentenced to jail or be ordered to pay a fine (i.e., to the state). The victim’s family could also launch a civil suit against the nurse under private law. If the family were awarded damages, the nurse would have to pay these directly to the family. All jurisdictions have some type of specialized agency, sometimes called Criminal Injury Compensation Boards or similar. In Newfoundland

and Labrador, the Newfoundland Crimes Compensation Board is an example of where a victim (or the family of a victim) can apply for damages, bypassing the necessity of launching a civil suit, once an individual has been convicted in a criminal court. The government assesses the damages, which are awarded from public funds. In British Columbia, a landmark civil case fundamentally changed access to health care for the hearing impaired across Canada, and although the case occurred over 20 years ago, the ruling established a precedence, thus still has implications for others with disabilities today (Box 8.1).

  Box 8.1

Equality of Care for Hearing Impaired People. Linda and John Warren, and John Eldridge were born deaf. For many years, a private, nonprofit organization provided sign interpreters to help them communicate with health care providers during doctors’ appointments, hospital visits, medical tests, and the like. Sign language was their preferred method of communication. In 1990, because of funding shortfalls, the organization that had provided the interpreter discontinued this service. Several appeals for financing proved futile, and the trio was left with no support to hire an interpreter. They claimed that the absence of a sign interpreter interfered with their ability to effectively communicate with health care providers, increasing the opportunity for errors in diagnosis and treatment and impeding their ability to understand treatment options and to make informed decisions. Requests to the provincial and federal governments for support were repeatedly denied. After a long legal battle ending at the Supreme Court of Canada, the Court ruled that the Hospital Services Act and the Medical and Health Care Services Act contravened section 15(1) of the Charter (equality rights) by failing to address the need for services for individuals to communicate effectively with health care providers.

The Supreme Court directed that both acts—as well as those of other provinces and territories—be changed to accommodate these rights. Source: Eldridge v. British Columbia (Attorney General), 1997, 3 SCR 624.

Tort Law A tort occurs when one person or that person’s property is wronged or harmed by another, either intentionally (deliberately) or unintentionally. Tort law cases can be complicated—for example, proving negligence over an intentional act.

Intentional tort An intentional tort occurs when the harmful act is deliberate. In health care, it usually involves physical aggression or forcing unwanted medical treatment on a patient. Two examples of an intentional tort are: a health care aide was proven to have treated a patient roughly, resulting in injury to that patient, or if a health care provider successfully performed cardiopulmonary resuscitation (CPR) on an individual who had a known do-not-resuscitate order.

Unintentional tort An unintentional tort occurs when the act caused physical or emotional injury or property damage, but was not deliberate or calculated. Unintentional torts usually result from acts of human error, misjudgment, or negligence. For example, human error might be considered the cause if a respiratory therapist gave an inhalation treatment to a child and mistakenly used the wrong drug. A physiotherapist might misjudge a patient’s ability to ambulate, resulting in a fall the first time they tried to get up independently. Negligence is one of the most common torts, and cases are often complicated.

Negligence

Negligence is the same is a type of tort law. Negligence can be in the form of malpractice, or depending on the case, professional misconduct. Negligence occurs when a health care provider (unintentionally) fails to meet the standards of care required of his or her profession. Negligence can occur when a duty of care owed a person is not completed. In health care, examples may include forgetting to perform a necessary action, not caring or confirming whether a particular and necessary action is performed, providing improper or substandard care, providing a patient with unclear instructions, or failing to successfully instruct a patient in how to follow a treatment plan (Case Example 8.1).

  Case Example 8.1 Andrea, a physiotherapy assistant, has been asked to get 85-year-old Edgar (who has advanced Alzheimer disease) up for a short walk and then help him back to bed. After leaving the floor, Andrea remembers that she failed to put up Edgar’s bed side rail. Running late, she thinks, “Someone will have done it by now,” and leaves the hospital. Edgar falls out of bed, breaking his hip. His family sues the hospital and Andrea, the assistant. Health care providers may find themselves accused of a tort if a patient experiences physical or emotional injury resulting from something the health care provider did, and negligence is proven. In Canada, an injured party who cannot prove negligence would rarely receive compensation. Duty plays a significant role in both medical ethics and medical law. Health professionals are often held more accountable in terms of their duty to their patients than people in many other professions. Health care providers will face litigation if it is proven that they failed to fulfill their duty to the patient. Duty becomes part of the patient–health care provider relationship as soon as the professional relationship begins. For example, Jeremy has made an appointment with a new doctor. Their professional relationship begins once the doctor has seen Jeremy, assessed him, and recommended a treatment

plan. Before the appointment, Jeremy could not claim that the doctor was negligent in a health-related matter and bring legal action against him or her. The doctor is responsible for Jeremy’s care until the doctor–patient relationship ends and Jeremy has transferred his care to another practitioner. Facilities likewise can be held responsible for incidents when substandard care is proven (e.g., inadequate staffing levels in a nursing home resulting in harm to a resident), because the facility itself is responsible for setting and maintaining standards of care.

Litigation and the duty of care Almost all health care providers are bound by a duty of care that is in keeping with their profession’s standards of care. Litigation in such cases considers the standard of competency that a “reasonable person” possessing the required competencies is expected to meet. This standard set out by any regulated profession (e.g., the Ontario Nurses Association or the Nurse Practitioner’s Association of Alberta) must be met by all members of that professional association.

Contract Law Contract law involves private agreements that are generally enforceable by the courts like many other laws, provided the agreement does not violate other governing laws or is otherwise illegal in purpose. For example, contracts can exist between an employer and an employee, or a health care provider and a patient. They also may be either expressed (i.e., openly spoken or written) or implied (i.e., unspoken but considered understood). A breach of contract occurs when one of the parties fails to meet the terms of the agreement. A plastic surgeon, for example, can agree to perform a facelift on a patient for a given price. If, for some reason, the physician fails to complete the procedure, or if the patient refuses to pay the agreed-upon price, one can sue the other for breach of contract. Another example: a private health care organization hires a dentist on a one-year contract. After two months, the dentist finds a higher-paying position and leaves. The health care organization can sue the dentist for breach of contract.

Criminal Law In Canada, criminal law, with a few exceptions, is set out in federal legislation. Most laws can be found in the Criminal Code of Canada, which details descriptions of crimes and criminal law procedures. It is a category of public law that deals with crimes against people and/or property and those deemed intolerable with society (e.g., murder, racism, theft). In most cases to be guilty of a crime a person must perform a wrongful act—actus reus (what was done) and a wrongful intent—mens rea (a guilty mind). For example, a health care practitioner who willfully engages in a harmful act with the intent of harming his or her patient. Criminal charges involving health professionals and patients consider the “duty of care,” the principle of “do no harm,” and a health professional’s degree of authority, which would be considered in tort liability and could impact sentencing in criminal cases. Unless the law specifically imposes special duties of care, the law is the same for all. Although an extreme case, consider the nurse Elizabeth Wettlaufer, who pleaded guilty, among other charges, to killing eight older Canadians in nursing homes in London and Woodstock, Ontario in 2016. She was in a position of authority, her patients were vulnerable, and helpless to defend themselves. She was indicted under the Criminal Code of Canada. Box 8.2 suggests ways for those in clinical practice to avoid legal problems in the health care environment.

  Box 8.2

Strategies for Avoiding Legal Problems. • Most health care facilities require criminal checks both for potential employees and for students who apply to complete a work or co-op placement. Complete any such checks as requested, and in most areas, criminal checks can be attained for

a fee by contacting the nearest police station. The check may take several days or several weeks. • Work only within your scope of practice and competencies (things you have been taught how and deemed competent to do and that are legally within the scope of your professional practice). If asked to do something outside of your scope of practice or something you are not licensed to do, say no. If you feel unsure about how to perform a specific task within your scope of practice, ask for help. It may be a task or procedure well within your legal boundaries, but which you have not done recently and are not confident you can do properly (e.g., administer an inhalation treatment, start an IV, or change a complex dressing). It is not a crime to seek assistance; you could harm a patient, be subject to disciplinary action, or face litigation if you do not. • Complete, concise, and accurate documentation protects everyone—you, the organization you work for, and your patient. Keep required charting current and accurate. Prioritize what you are charting, adhering to the protocol of the organization you work for. In the event of litigation, the medical record may be the most important document in determining the outcome of a case. This may be a challenge with computerized charting and documentation, flow charting, and charting by exception. Always adhere to the rules regarding passwords, logging in and out of a computer system, and never allow someone else access to your login or to sign a chart under your name. • Most facilities maintain a formal process for the reporting of adverse events. These procedures usually involve prompt reporting to the proper authorities, completing a form called an incident report. Information on this form must be concise and accurate. In most cases, if the incident involves a patient in the hospital setting, the information recorded on the incident report appears on the patient’s medical chart only if it relates directly to the patient’s health. The incident report itself is sent to the risk manager, who uses it to assess the occurrence and to implement measures to prevent similar future occurrences.

• Adhere to privacy and confidentiality laws (both in and away from your place of employment). Think before you speak about work or information relating to work. Never access anyone’s files (electronic or written) unless you have a legal right to do so. Being a friend or relative does not give you legal access to another’s private health information even something as innocent as disclosing if a mutual friend has her baby yet. Remember, good news related to health information also must remain confidential. • In a health care facility there may be unrealistic workloads requiring you to prioritize care. Always do your best. Never provide substandard care or treatment. If there are things you can’t do, document what it is. If possible, take the extra time to complete a task properly. An ounce of prevention goes a long way. • Be an advocate for your patients. If you suspect that something is wrong, use the appropriate chain of command and talk to someone, rather than ignoring the incident. Your patient may be afraid to address the situation personally, or may feel that he or she will simply be ignored. • Do not ignore unethical or illegal activities. Follow protocol, policies, and procedures. • Ensure that you have some type of liability insurance through your place of employment or your professional college or organization that will cover you for mishaps or wrongdoing. • Be mindful of wrongdoing as well as unethical practices of others. If you have strong feelings that something is wrong, seek advice. Do not become involved in something you feel or know is illegal. • Take care of yourself. If you experience harassment in your workplace, seek out the best possible plan of action. Others may be experiencing the same problem. These situations are tricky and sometimes do not end well if not handled appropriately. A person charged with a criminal offence may be found not guilty in a criminal court, but later be found guilty in a civil court (Case

Example 8.2).

  Case Example 8.2 Jessica, a respiratory therapist, was charged with criminal negligence after she administered the wrong inhalation treatment to Hanna, a patient. Hanna suffered a cardiac arrest because of an allergy to the medication administered. Jessica was found not guilty of criminal negligence, but when Hanna brought a civil charge against Jessica, the civil court upheld the charge and awarded Hanna $200,000 in damages.

The law, the division of power, and the jurisdictional framework The British North America Act (now the Constitution Act) was passed in 1867, granting jurisdiction over some areas of health care to the Federal Government and jurisdiction over other areas to the provincial and territorial governments. Government jurisdiction means that it has authority over specific designated geographic and legislative areas and also possesses the right to draft, pass, and enact laws within its area of authority. Initially the provinces assumed responsibility for “the establishment, maintenance, and management of hospitals, asylums, charities in and for the province, other than for marine hospitals” (Constitution Act, 1982). As discussed in Chapter 1, health care is essentially a provincial power; however, there are some areas that the power is left to the Federal Government, because select populations are left under federal mandate (e.g., federal inmates, and Indigenous Peoples falling under the Indian Act). In addition to enforcing the terms and conditions of the Canada Health Act and providing financial support to the provinces and territories (see Chapter 2), the Federal Government oversees certain components of health care activity covered under the Criminal Code of Canada. Some of these components are outlined in the Federal Food and Drugs Act in addition to the Controlled Drugs and Substances Act. The Federal Government has the authority to establish prohibitions and penalties when violations of the Act occur. By virtue of the vague phrase “peace, order, and good government” (Constitution Act, 1982) the Federal Government has the authority to pass legislation on matters that would normally fall under provincial or territorial jurisdiction—in particular, the enactment of emergency powers, and matters of national concern such as an epidemic. The next section examines federal authority in key areas of health care.

Workplace Safety Several Canadian organizations—including the Canadian Centre for Occupational Health and Safety (CCOHS), the Workers Compensation Board (WCB, or equivalent), and systems such as WHMIS—strive to maintain the health of working Canadians by ensuring that they have safe and healthy workplaces. Health care providers may have to interact with CCOHS and WCB in some manner, possibly by helping a patient regain health and mobility in order to return to his or her current workplace or to transfer to a new career. The following is a brief overview of these agencies.

Occupational Health and Safety Occupational health and safety legislation has fourteen jurisdictions in Canada—ten provincial, three territorial, and one federal. Each jurisdiction enacts its own occupational health and safety legislation related to the rights and responsibilities of the employer, the supervisor (if applicable), and the worker. The Federal Government manages labour affairs for certain sectors, including employees of the Federal Government and of federal corporations. The Federal Government also has jurisdiction over individuals working in occupations that cross provincial and territorial lines (e.g., transportation and communication, pipelines, and some Indigenous activities), and in the federal public service sector. The Occupational and Safety Act in each province and territory applies to workplaces within that region (with the exception of those overseen by the Federal Government) and work done by owners in private residences. Oversight is the responsibility of the ministry or the department of labour in most jurisdictions, or the Workers Compensation Board (or commission).

Occupational Health and Safety Legislation: Objectives Aiming to ensure a safe workplace for all Canadians and to support the rights of workers to a safe environment, occupational health and safety legislation sets guidelines, provides for legal enforcement of

these guidelines, and outlines the rights of employees, including the following: • The right to be aware of potential safety and health hazards. • The right to take part in activities (e.g., by serving on committees or acting as a health and safety representative) aimed at preventing occupational accidents and diseases. • The right to refuse to engage in dangerous work without jeopardizing his or her job.

Occupational Health and Safety and Workers Compensation Boards Workers Compensation Boards work hand-in-hand with the CCOHS, but concentrate specifically on assisting injured employees by providing wage replacement, rehabilitation, and training. Legislation related to these boards or commissions, drafted and administered by each province and territory, is typically named the Workers Compensation Act. The Northwest Territories and Nunavut share a Workers Compensation Board.

Workplace Hazardous Materials Information System The CCOHS oversees the Workplace Hazardous Materials Information System (WHMIS) legislation, which became law through complementary federal, provincial, and territorial legislation in October 1988. The national standards for WHMIS legislation were established by the federal Hazardous Products Act and the Controlled Products Regulations. Enforced by the federal, provincial, and territorial governments, this legislation applies to all Canadian workplaces in which identified hazardous materials are used. The national office for WHMIS operates as a division within Health Canada. Some may think that WHMIS legislation would apply only to industrial settings, but hazardous materials are present in many areas of the health care industry. Hospitals, for example, house hazardous substances used in diagnostic testing (e.g., radioactive

products), chemotherapeutic agents, combustible agents (e.g., oxygen), infectious material, and medical waste.

Drugs and the Law Canada’s drug laws are covered primarily by federal legislation called the Controlled Drugs and Substances Act. This Act replaced the Narcotic Control Act and parts of the Food and Drugs Act (Parts III and IV) in May 1997. The new Act established different categories of drugs, called schedules. The classification system addresses the properties of drugs and their potential for harm. Schedule I, for example, includes cocaine, heroin, opium, oxycodone, morphine, and codeine; Schedule II addresses cannabis (Government of Canada, 2018b). Amendments are frequently made to the Act.

Controlled Drugs and Prescriptions The Controlled Drugs and Substances Act outlines who can prescribe controlled substances, and the conditions and terms of use for prescription narcotics. The prescribing of controlled substances occurs under combined federal, provincial, and territorial legislation.

Dispensing controlled drugs in facilities Most hospitals and other health care facilities maintain a closely monitored supply of restricted drugs (e.g., hydromorphone). These drugs must be prescribed by a qualified practitioner, and carefully dispensed by the pharmacy. Most jurisdictions require that health care facilities stocking such drugs keep them under double lock at all times. In almost all acute care facilities even controlled drugs are electronically dispensed (with appropriate protocols), reducing the margin of error and misuse. Each dose is carefully recorded. In the past, only a registered nurse was allowed to handle or dispense controlled drugs in acute care settings. Increasingly, however, registered or licensed practical nurses (RPNs or LPNs) are also assuming this responsibility. In almost all nursing homes, LPNs (RPNs in Ontario) may dispense and sign for narcotics.

Prescribing controlled drugs Under federal legislation controlled drugs can only be prescribed for legal, therapeutic purposes. The legislation states that prescribing practitioners must remain alert for behaviours that suggest patients are seeking drugs for unlawful purposes. Among the prescription drugs that are commonly abused are tranquillizers or benzodiazepines (e.g., diazepam, lorazepam), and opioids such as oxycodone, hydrocodone, codeine, morphine, and Percocet (a combination of oxycodone and acetaminophen). Other drugs (most often used illegally), include heroin, and synthetic opioids such as fentanyl (see Chapter 10) (Canadian Centre on Substance Abuse, n.d.). These powerful drugs have addictive properties and are targets for illegal use and trafficking, in particular, the opioids. If misused the effects can be tragic, ranging from addiction to death.

The Opioid Crisis Health Canada has called the continuing number of opioid related overdoses and deaths a national crisis. It has sanctioned a number of initiatives to address the problem, by working with provincial/territorial governments, organizations, and other stakeholders. One example is the Joint Statement of Action to Address the Opioid Crisis, which outlines a collaborative commitment of numerous organizations to respond to this crisis (Government of Canada, 2018a). The joint goal is to address ways to improve treatment, prevention, and harm reduction strategies at a national level. One such strategy is the 2017 prescribing guidelines released by the Canadian Medical Association detailing best practices recommendations regarding how to prescribe opioids. These guidelines include using opioids as a last resort for pain control for patients, identifying individuals at high risk of addiction, who should not be prescribed these drugs, and recommending nonmedication interventions (see Chapter 10).

 

Did You Know? In 2012 the Federal Government made amendments to the Controlled Drugs and Substances Act, which added mandatory minimum penalties for individuals found guilty of illegally using selected drugs in varying circumstances. Do you believe that mandatory minimum sentences are a help or a hindrance in dealing with individuals who have addictions? Some would say that substance addiction is a disease and should be considered a disease in the same way as any other health condition. What do you think?

Are Prescription Drugs Safe? Despite strict monitoring of the acquisition, storing, prescribing, and use of controlled drugs, misuse does occur. Individuals looking for controlled medication devise innovative ways to acquire nonprescribed drugs. Some people will often offer a variety of explanations as to why they want prescriptions renewed. Some explanations may be entirely legitimate; however, repeat requests from the same person may indicate drug-seeking behaviour and should be regarded with a degree of concern. Health care providers may also find themselves approached by unfamiliar patients with atypical stories that cannot be verified. Case Example 8.3 illustrates a situation in which a patient presents with a suspicious explanation.

  Case Example 8.3 Manny comes to the office to try to have his prescription for diazepam (Valium) renewed before his current prescription runs out. He says, “I dropped my bottle in the sink, and the pills went down the drain.” Practitioners eligible to prescribe drugs are legally and morally bound to prescribe properly (i.e., to meet the patient’s health care needs while also adhering to the law) and to identify any circumstances that raise suspicions about drug abuse. A prescriber

suspecting drug abuse should take action—for example, by treating the patient with another drug if the patient overuses a prescribed narcotic or by reporting suspected criminal action (e.g., selling of drugs) to the police.

  Thinking it Through You work as an office manager for a family doctor. Genève, a patient, tells you that her cousin Jason, another patient, is selling oxycodone that the doctor prescribed for him for pain. Jason does have a slightly suspicious history of losing his pills or forgetting them when he goes on vacation and has presented with numerous excuses to have more oxycodone prescribed. But he has somehow managed to stay off the radar. Genève tells you not to say anything to the doctor because she would get into trouble if Jason found out. She “just thought you should know.” What would you do? Regardless of the care providers (e.g., nurse practitioners and physicians) take to prescribe addictive drugs responsibly, some patients will inevitably obtain prescription drugs for their own use or to sell. If a nurse practitioner or physician is deemed to prescribe controlled drugs too liberally, their practices may be reviewed by their governing body. Under federal legislation, prescribing practitioners must keep detailed records of all controlled substances prescribed and provide authorized inspectors access to these records upon request. In order to dispense controlled drugs, pharmacies must have an original signed prescription. Health Canada routinely inspects pharmacies selling prescription drugs over the Internet or by mail order to ensure they comply with the Food and Drugs Act and Food and Drug Regulations. Such pharmacies must maintain an established licence to act as a wholesaler, and under federal legislation, only certain categories of drugs may be sold in this manner (subject to change).

Cannabis (Marijuana) Legalization of Recreational Cannabis The use of recreational cannabis was legalized in Canada in 2018 and is regulated under Bill C-45, federal legislation enabling The Cannabis Act and amendments to the Controlled Drugs and Substances Act, the Criminal Code and other Acts. The Act details the legal framework for the production, distribution, sale, and possession of cannabis for recreational use, but does not change the policies and procedures for the use of cannabis for medical purposes, which has been legally available for over two decades and is controlled by the Access to Cannabis for Medical Purposes Regulations (ACMPR) (Watts, Austin, and Mack, 2017). Bill C-45 also identifies a range of penalties for anyone breaking the law(s), particularly related to illegal distribution of cannabis to younger Canadians. Constitutional powers involving matters affecting cannabis legislation are shared between the Federal Government and the provinces/territories (Watts et al., 2017).

The Role of the Federal Government The Federal Government has the authority to determine what type of cannabis-related products may be sold across Canada, and also to approve the packaging and advertising of products. For example, plain, nondescript packaging with health warnings is to be used. The Federal Government also regulates the size of products sold, the potency of the products, which is balanced by the ratio of cannabidiol (CBD) and tetrahydrocannabinol (THC) (the main active ingredients) in cannabis products.

The Role of the Provincial and Territorial Governments Because matters affecting the legislation of cannabis are split between federal and provincial/territorial governments, differences in regulation occur among provinces and territories (Health Canada, 2018). In compliance with federal policies, provincial and territorial governments can license and regulate the distribution and sale of cannabis (where they are sold and under what terms). The provinces

and territories are at liberty to adjust the minimum age for purchasing products (e.g., 18 years of age) and set limits for personal possession. The provinces and territories may also change the rules for home-grown cannabis, for example, how many plants may be grown in a household. Like regulations for smoking, restrictions on where cannabis can be consumed is also a jurisdictional discretion (Health Canada, 2016).

  Did You Know? The cannabis plant has numerous active ingredients called cannabinoids. The two main ingredients are delta-9tetrahydrocannabinol (THC) and cannabidiol (CBD). THC causes the “high” when cannabis is consumed and is considered therapeutic in treating such medical conditions as posttraumatic stress disorder (PTSD), stimulating the appetite, and reducing nausea. CBD, on the other hand, has little or no psychoactive properties, but appears effective in moderating symptoms in neuromotor diseases such as organic brain disorder, epilepsy, and Parkinson disease. Cannabis products can contain varying levels of either ingredient. CBD is the main ingredient in medical cannabis.

Cannabis sales There is ongoing discussion regarding the distribution of revenue from the sale of cannabis. Should these products be taxed and how would this be done? One example is linking taxation to the amount of THC (the psychotropic component) in the drug. It is widely recommended that medical marijuana (prescribed pharmaceutical products derived from cannabis have a Drug Identification Number [DIN]) should not be subject to taxation.

Prescribing medical cannabis Although physicians can prescribe cannabis for their own patients, in many jurisdictions physicians or nurse practitioners can refer patients to cannabis clinics for assessment and treatment if

physicians think the person will benefit from the use of medical cannabis—for example, relief for: nausea and pain for individuals with conditions such as cancer; HIV or acquired immune deficiency syndrome (AIDS); severe muscle spasms related to multiple sclerosis or spinal cord injury; epilepsy; and intractable pain caused by severe arthritis. Some clinics require a referral from a primary care provider, others do not. All practitioners prescribing cannabis must adhere to practice guidelines set out by their regulatory body and to federal/provincial/territorial law. Patients must be carefully screened for suitability and associated risk factors. In some jurisdictions practitioners are advised to use a risk assessment tool aimed at identifying patients at risk for addiction and substance diversion, and with mood disorders. Special consideration is to be given before prescribing to youth. Prescriptions must be carefully considered in terms of the product type and strain of cannabis. Patients are closely monitored for therapeutic response and sensitivity to the drug—a benefit not associated with simply smoking recreational cannabis to self-treat. Medical marijuana clinics in most jurisdictions are funded by the province or territory but may be privately owned and operated. If a patient is rostered by a primary care group, their status within the group may change. For example, in an Ontario Family Health Team, the patient may be “derostered.” The person can still be seen by their primary care provider but will lose additional supports offered by the team.

  Thinking it Through Recreational marijuana, now legal in Canada, is still a controversial topic among Canadians. Decisions made about where it should be sold, the types of products that should be available, and the legal age for use vary among jurisdictions. 1. How do you think marijuana should be regulated?

2. If you were on a committee choosing where products should be sold, what products should be available, what should be the age of access, and what factors would you consider in making your decisions?

Advertising prescription drugs In Canada, direct-to-consumer advertising of prescription drugs is strictly controlled and must meet certain criteria. Under the Food and Drugs Act, advertising a prescription drug is defined as “any representation by any means whatever for the purpose of promoting directly or indirectly the sale or disposal of any food, drug, cosmetic or device.” Some drugs can be advertised in Canada under the following two conditions (Health Canada, 2005): 1. Reminder advertisements. Manufacturers can advertise drugs using their brand names, but cannot directly mention their uses. For example, television ads for “Celebrex” or “Viagra” merely hint at the drug’s intended use and end by suggesting that viewers ask their doctor. 2. Disease-oriented ads. Rather than mentioning a brand name, these commercials discuss a condition, suggesting that the consumer consult his or her physician for available medication.

Health Canada’s Emergency Powers The Constitution states that the Federal Government has an interest in “peace, order, and good government.” As a result, the Federal Government retains the power to enact laws to manage healthrelated emergencies of national concern, such as the 2003 SARS epidemic, West Nile virus, and avian influenza. The speed at which these infectious diseases spread has taken many countries by surprise, including Canada, prompting the Federal Government to renew the severely outdated Quarantine Act. Even 15 years ago, immigration, air travel, and the import and export of food and other products did not pose the same level of threat as they do today in

terms of furthering the spread of disease. As a result of today’s global village, it may only be a matter of time before some type of worldwide pandemic occurs. The 2009 outbreak of the H1N1 virus fueled fears of a full-blown pandemic. The World Health Organization (WHO) put the world on alert, adjusting the phase of pandemic alert accordingly (see Chapter 6).

The Quarantine Act A new Quarantine Act (Bill C-12) received royal assent and became law in May 2005 (Government of Canada, 2005). Administered by the federal minister of health, the Quarantine Act complements the International Health Regulations (discussed next) by allowing Canadian authorities to respond more rapidly to health threats at Canadian borders and better preparing authorities to deal with threats and risks to global public health. The Act is also designed to complement existing provincial and territorial public health legislation. Provisions under the Act address concerns and threats in society today. The Federal Government now has the authority to: • divert aircraft or cruise ships to alternative landing or docking sites; • designate quarantine facilities anywhere in Canada; • restrict or even prohibit travelers, who represent a serious public health risk, from entering Canada. The Act also created two new occupational categories: environmental health officers and screening officers. These officers have the authority to assess, screen, and detain individuals, who pose a health risk, at the borders; to investigate and detain ships; and to examine goods and cargo crossing into or out of Canadian borders. It is important to note that this Act does not restrict the movement of Canadians from one province or territory to another.

International Health Regulations

The International Health Regulations outline strategies to prevent the global spread of infectious diseases and to minimize any resulting disruption to the world economy. The regulations initially monitored six serious infectious diseases: cholera, plague, yellow fever, smallpox, relapsing fever, and typhus. By 1969, only three diseases remained reportable: cholera, plague, and yellow fever. But by the 1990s, others had resurfaced—cholera outbreaks occurred in South America, and plague in India. Since the revision of the International Health Regulations, the WHO declared four public health emergencies of global concern: H1N1 influenza (2009), polio (2014), Ebola (2014), and Zika virus (2016). International regulations offer many benefits in monitoring and containing risks. Under the WHO’s constitution, all member states are bound by law to adhere to the International Health Regulations, which provide ways to identify a global public health emergency and outline measures for quickly gathering and distributing information and global warnings, including travel warnings. Today the Centres for Disease Control and Prevention are working with countries around the world to meet the goals of the International Health Regulations, addressing more than 400 diseases, conditions that are associated with significant morbidity, and mortality rates, and/or cause disabilities. Partners involved in related programs include experts in surveillance, epidemiology, informatics and diagnostic systems, health ministries, and public health authorities in WHO member countries (CDC, 2016).

Health care as a right Whether health care in Canada is a right is, at times, subject to interpretation with respect to both the Canadian constitution and the Canada Health Act. For example, although all jurisdictions are expected to abide by the terms and conditions of the Canada Health Act, because of the jurisdictional division of powers related to health care, the Federal Government cannot legally force the provinces and territories to do so. The Federal Government can, however, use its constitutional spending power (contributing financially to health care programs) as leverage to ensure jurisdictional compliance. For the most part, all jurisdictions do comply with the terms and conditions of the Act, thus health care is considered to be a legal right. This right to health care remains limited by the principles and conditions of the Act in terms of the subjectivity of interpretation of some component of the Act. Therefore application of the Act varies among jurisdictions, depending on interpretation, resources, finances, and so on.

Medically Necessary: What Does It Mean? The term medically necessary appears throughout the Canada Health Act because the principles of the Act mandate that Canadians are to be insured for health care that is deemed to be medically necessary by providers for their health and well-being. At first glance, the term seems straightforward: when one is sick, the services needed to make one well; when one is well, the services needed to maintain that health. However, as previously noted, medically necessary (and therefore covered by public insurance) is a subjective term at best, which varies not only among provinces and territories but also within provinces and territories. In recent years, decreasing financial and human resources have increased limitations regarding whether medical care is necessary or not and who should receive it, for example, restrictions placed on transplants for older Canadians.

With strained resources there are long waits for some medical/surgical procedures, at times prompting individuals to turn to the Charter of Rights and Freedoms for legal means to gain access to specific health care services. Canadians, for the most part, cannot purchase private insurance for medically necessary procedures as it is disallowed by the Canadian government to avoid creating a twotiered system that would run counter to the concept of universal health care.

The Canadian Charter of Rights and Freedoms The Canadian Charter of Rights and Freedoms, embedded in the Canadian Constitution, guarantees Canadians certain rights and freedoms, but is tempered by the phrase “subject only to such reasonable limits prescribed by law as can be demonstrably justified in a free and democratic society” (Canadian Charter of Rights and Freedoms, 1982). The Charter does not specifically identify health care, nor does it guarantee in specific terms that Canadians have a right to health care. The Charter does, however, demand that health care be provided to all persons equally and fairly. The following sections within the Charter have met with legal challenges relating to the right of Canadians to health care: • Section 7—life, liberty, and security of person. To determine whether a person’s rights have been violated, the court must consider three things: (1) the medical resources available at the time of the person’s illness, (2) the demands made on those resources, and (3) the urgency of the individual’s medical needs. Under the law, everyone has the right to fair assessment, but this right does not guarantee access to specific services. • Section 15—equality. Section 15(1) states, “Every individual is equal before and under the law and has the right to equal protection and equal benefit of the law without discrimination and, in particular, without discrimination

based on race, national or ethnic origin, colour, religion, sex, age or mental or physical disability.” A defendant must prove discrimination (i.e., that he or she has been treated unequally) on the basis of one or more of the criteria outlined in this section. Several notable challenges regarding people’s right to health care have been made over the past few years. One of the first was prompted by long waits for access to surgical services. Probably the most significant is the case of Chaoulli v. Quebec (Attorney General). George Zeliotis, who required hip surgery, argued that his long wait time for the surgery caused him immeasurable pain, suffering, and immobility impacting almost every aspect of his life. He claimed he had the right to make decisions that would preserve his quality of life, including the right to timely health care. The Supreme Court of Canada ruled that Quebec’s ban on private insurance in the face of long wait times violated the Charter of Human Rights and Freedoms. The courts held that when the public system is unable to deliver care within a reasonable time frame, alternative actions must be considered. The Supreme Court essentially removed restrictions prohibiting individuals from using private insurance to pay for services offered by the public system. The Court held that removing this restriction would guarantee freedom of choice for individuals and improve accessibility of care. Although viable in Quebec, this ruling did not lead to significant changes in legislation across the rest of the country. It did, however, prompt provinces and territories to set benchmark timeframes wherein certain surgeries should be performed (e.g., hip, knee, and cataract). Provinces and territories now have their wait times posted online. If a person has to be sent elsewhere for a procedure, even to the US, provincial/territorial plans will, in some circumstances, cover the costs). Many Canadians now know that opportunities to access private health care are available, albeit marginally, and believe that privatization of health care will grow, creating a parallel system to publicly funded health care. Private health care has existed in various forms for some time, particularly in Quebec, Alberta, and British Columbia. Moreover, the Quebec ruling in the Chaoulli case

has opened the door for other such cases challenging provincial and territorial governments for the right to private insurance coverage for medically necessary procedures.

  Thinking it Through Over the past few years, wait times for diagnostic tests, specialists’ visits, and some types of surgery have become longer. 1. Should the provincial and territorial governments have to pay for treatment elsewhere (even out of country) if it cannot be provided within a designated time frame? 2. What criteria should be used to define a “reasonable wait,” given that every case differs?

The Law, the Constitution, and End-of-Life Issues Advanced Care Directives Advanced care directives (part of the overall process of advanced care planning) are instructions prepared by a mentally competent individual who must be, in most jurisdictions, 16 years of age or older, outlining their wishes concerning health care decisions in the event they can no longer decide for themselves. A person may express in advance their wishes about what intervention, medical treatments, or levels of care they will either consent to or refuse. Physicians and other health practitioners must honor the person’s decisions, even when the recommended treatment can potentially prolong the person’s life or otherwise be beneficial to their health. On the other hand, a physician can refuse a decision by the patient’s substitute decision-maker (a person designated to make decisions when a patient is no longer capable of doing so) that is contrary to the patient’s wishes, if the physician believes the patient has changed his or her mind, and/or that the substitute decision maker is unfamiliar with the patient’s wishes.

When entering a long-term care facility, decisions about a person’s end of life wishes are usually discussed during the admission interview. Levels of care and related interventions are determined at that time. Based on the person’s wishes, levels of care (or intervention) can range from comfort measures only to transfer to an acute care hospital with active treatment including cardiopulmonary resuscitation (CPR).

Types of advanced care directives There are two types of advanced directives: instructional and proxy. Instructional directives (sometimes referred to as living wills, although living wills termed as such have no legal status in Canada) can be specific or general in nature. Specific instructions are detailed, and explicit, outlining the persons wishes clearly relative to presumed circumstances; for proxy advanced care directives, general instructions include principles to be followed, but give the decision maker the latitude to make decisions on a situational basis (Health Law Institute, Dalhousie University, n.d.). Legislation determining the details related to legal policies and procedures for advanced care directives are province/territory specific. In addition, each jurisdiction has different versions of forms for advanced care planning as well as detailed information regarding form completion that can be downloaded from the government website.

Medical Assistance in Dying Medical Assistance in Dying (MAID) became legal in Canada in 2016 (Bill C-14, which amended the criminal code and received Royal Assent on June 17, 2016). Two sections of the criminal code were struck down: Section 25 of the criminal code held that helping an individual to end their life was an indictable offence; Section 14 held that it was unlawful for a person to ask someone to help them end their life. Bill C-14 is binding across Canada (Supreme Court of Canada, 2015). That said, health care is the responsibility of provinces and territories, so many variations exist: how the law is interpreted and/or applied; related training for physicians/nurse

practitioners (NPs); the application and approval process, the forms used, and the protocol(s) leading up to and for the actual procedure. It is expected that over the next few years there will be challenges to eligibility criteria for MAID, and amendments made to the existing legislation. A particularly contentious issue is related to the current restriction that a person must be of sound mind at the time of the procedure, meaning that a person with dementia cannot make the decision in advance (prior to a time when they would be considered incapable of answering the question at the end as to whether or not they want to change their mind) (see Chapter 10).

Types of Medically Assisted Death There are two ways in which MAID may occur. A health provider (physician or NP) may administer the lethal medication, or they can prescribe medication that the applicant can self-administer. The choice is made by the applicant and will to a large degree depend on the individual’s physical ability to take medication, as well as his or her comfort level with the process. A person who is very sick, weak, has trouble swallowing is likely to have the physician or NP administer the medications. The person may also feel more confident that the medication will work effectively and promptly if administered (usually by the intravenous route) by the practitioner.

Eligibility A person must meet all of these criteria: • Be over the age of 18 and mentally competent (to make health related decisions) to apply for medical assistance in dying, although the Federal Government is examining the concept of including “mature minors.” • Have a valid health card in the province or territory in which they live, or have health coverage through the federal governance (this essentially precludes visitors to Canada from applying for MAID). • Have a serious disease, illness, or disability, or other irreversible medical condition and meet all of the following

related criteria. The person must be: • in the later stages of decline with no hope of reversing the health condition; • experiencing unbearable mental or physical pain that cannot be alleviated under conditions acceptable to the person; • at a point where the person’s death is reasonably foreseeable. Note, however, that the individual does not have to have a terminal illness, or a specific prognosis related to when he or she will die. Some of the eligibility criteria is subjective, and allows for significant variations in assessment.

Health Professionals Involved in MAID Physicians and NPs are allowed to oversee a request for MAID as well as facilitate the process. Other health professionals (e.g., nurses) are often present to provide assistance. Family members may, at the request of the patient, be present to provide him or her with support, love, and help as requested.

Consent Informed consent, as with any medical procedure that requires the applicant to be competent, must ensure that a patient is made aware of, and understands, all the necessary medical details and options the person may not have tried. This includes pain control and other palliative care measures, such as counselling and support for mental and emotional issues, including related anxiety and depression (the latter must be ruled out as the sole reason behind a decision to apply for MAID). It is reasonable to assume that many individuals applying for MAID are experiencing stress, and perhaps are depressed because of their situation, but of sound mind and thus clear and certain about their decision. If practitioner is unsure about the person’s mental status (including depression), he or she can order a psychiatric consult.

All details of the procedure itself must be understood by the applicant. The applicant must sign a consent form at the time of the initial interview when the request is made, and again prior to the assisted death. There must be a specified time frame (e.g., 10 days) from the date of signing the request to the day on which MAID is carried out. This time frame can vary from one jurisdiction to another. In all jurisdictions, the person can withdraw consent at any time. The physician/NP must ask the person one more time prior to the event if the person wishes to withdraw his or her request.

Additional Safeguards Additional safeguards (other than those discussed earlier) ensure that MAID is not abused or mishandled. These include stipulating that the applicant must make the initial request in writing, or have a competent adult who understands the process, its implications, and outcomes make the request for them with the applicant present. A competent adult independent witness must be present when the request is made. This person must also understand the process and its implications. This person cannot be involved in the applicant’s circle of care, or benefit in any way from the death of the applicant. In addition, a physician/NP must agree that the applicant meets eligibility criteria applicable in his or her jurisdiction, and have this assessment confirmed by an independent physician/NP (Government of Canada, 2018c).

  Thinking it Through One of the criteria set out in Bill C-14 states that the person requesting MAID is mentally competent and must be able to consent once again to the procedure at the time of implementation. This poses a dilemma for people who may become confused during the time between being approved for MAID and when the actual procedure is scheduled to occur. What are your thoughts? Do you think this is reasonable? Do you see a legal, ethical, or moral way around this stipulation? Are you comfortable with it as is?

The legality of private services in canada As mentioned, for the most part, a Canadian cannot buy insurance for, or access private health for medically necessary procedures (e.g., cardiovascular or orthopedic surgery). Those in favour of a strictly purely public health care system may fear that parallel private health services have the potential to erode our public health care system and reduce access to health care for those who must rely solely on the public system. Consequently, controversy continues over whether there’s a place for expanded private health care (for medically necessary services and procedures) beyond complementary and supplementary services. All provincial and territorial governments fund certain types of medical/surgical care—for example, cataract surgery, hernia repairs, and knee surgery—in private clinics under specified conditions. Governments also pay for other services, such as diagnostics in private clinics with which they hold contracts. And Canadians everywhere can purchase private insurance for nonmedically necessary health care. In 2017, it was estimated that there were over 70 private clinics in Canada with the majority in British Columbia (BC), followed by Ontario, Quebec, Alberta, and Saskatchewan. These clinics offer screening procedures, diagnostic imaging, ophthalmology, and surgical procedures. Some offer overnight accommodation, which must be approved by the government. Some clinics charge the patients for services performed within the clinic, referred to as enhanced services or private options. These include charges for consultations, assessment reports, accommodation, better quality medical devices (e.g., parts used in hip or knee replacement) or superior cataract lens, and lab tests that may or may not be covered by the public plan. The amount that clinics charge patients varies widely. For example, a person might pay an annual fee for what is called an “executive wellness plan.” This allows prompt access to a

physician (who may be paid at least in part by the clinic and working both inside and outside of the provincial plan). A physician in this type of position has two sources of income. For example, a specialist who has a private practice and bills the province/territory on a fee-for-service basis, and who also performs procedures within a private clinic and is paid by the clinic.

Independent Health Care Facilities Health care providers can become involved in other medical businesses or services in addition to their professional responsibilities. There are hundreds of independent health care facilities across Canada (e.g., medical/surgical clinics, laboratories, physiotherapy, and diagnostic centres). Patients are often referred to these private facilities by their health care providers. Theoretically speaking, private facilities can compensate the referring health professional for such referrals, causing legal and ethical concerns. Any health care provider who is directly or indirectly part of a private clinic, doesn’t disclose their connection, and obtains monetary gains from referrals is acting both illegally and unethically (Case Example 8.4).

  Case Example 8.4 Jeremy, a sports medicine specialist, owns a private physiotherapy clinic in partnership with his wife, Tamara, who sells herbal supplements in the same commercial space. Often Jeremy would recommend herbal supplements to his patients to treat various conditions to assist with their physiotherapy. These supplements are sold by his wife.

  Thinking it Through Dr. Isaac is an orthopedic surgeon who owns a private clinic, Selkirk Surgical. At the clinic, he along with two other surgeons perform

surgeries for the hip, shoulders, and knees. In addition to owning the clinic, he also has a busy practice and operates two days a week in the public system. Nancy, who has been suffering from a knee problem for several years was referred to Dr. Isaac. She was told she would have to wait 8 months just for a consultation, and that potential surgery would be at least another 6 months wait. Nancy is distraught and asks to be notified if there is a cancellation. The medical assistant taking her information suggests Nancy may want to go see the doctor for a consultation at his private clinic. The cost of the private consultation is $600.00. The surgery at the clinic would cost $2000.00 and could be performed within a month. 1. What conflicts of interest, if any, have occurred here? 2. Did Nancy’s course of action affect the public system in any way? In Canada, common law governs some conflict of interest concerns. The law binds providers to behave with honesty and integrity (i.e., to act according to a fiduciary duty) with regard to their patients and medical practice (see Chapter 9). This includes the duty for the provider to inform patients of any potential conflicts of interest regarding their practice. As is the case with most aspects of health care, provincial or territorial legislation directs the operation of private health care facilities in Canada. In Ontario, for example, the Independent Health Facilities Program (implemented under the Independent Health Facilities Act) licenses—in some cases, funds and coordinates— quality-assurance assessments for private facilities. Additionally, these facilities are subject to routine inspection, often by the provincial or territorial college of physicians and surgeons. In Alberta, the Health Care Protection Act oversees surgical services provided outside of hospitals. Private surgical facilities must have the approval of both Alberta Health and Wellness and the College of Physicians and Surgeons of Alberta; must secure a contract with a regional health authority to provide insured services; must comply with the principles of the Canada Health Act; must be a required

service within their geographic location; and must not negatively affect the public health system. Private clinics, such as the False Creek Healthcare Centre locations in Vancouver, British Columbia, and Winnipeg, Manitoba, provide services such as several types of surgery, family practice, urgent care, and sophisticated diagnostics. Another site in Winnipeg is a state-ofthe-art facility with operating rooms, recovery beds, and overnightstay rooms. This centre legally provides services for Workers Compensation Boards and other designated groups as well as for private citizens (False Creek Surgical Centre, 2014). Organizations such as Timely Medical Alternatives assist Canadians in accessing any type of health care services—some of which can be obtained within Canada, whereas others are outsourced to the United States. In most cases, patients pay for these services themselves. Ottawa-based La Vie Health Centre, Calgary-based Foothills Health Consultants, and Toronto-based Medcan Health Management are just a few of the clinics across Canada that offer services aimed at the prevention and early detection of health problems. For a price, a person can enroll for a one-day comprehensive assessment that includes a 3- to 4-hour block of time dedicated to testing, screening, and receiving advice, health education, and planning (e.g., working out a diet or exercise plan) from health care providers. Because this service does not involve medically necessary procedures, it does not contravene the Canada Health Act. All of the services offered by these organizations are available at publicly funded doctors’ offices through the provincial and territorial health plans, but will entail waits and multiple visits to different health care providers.

Informed consent to treatment Throughout Canada, before a health care provider may treat a patient, they require the informed consent of the patient. In order to provide informed consent, a patient must understand, consent to, and accept the treatment and its foreseeable risks; the patient must also be made aware of alternative choices available. When doubt exists about a person’s capacity to understand the information provided, in most cases, the health care provider must determine whether the person is capable of giving consent to treatment. Importantly, an individual’s capacity to give consent can change. Persons quite capable on one day may be incapable on another day, depending on their mental and physical state. If a previously capable patient becomes unable to understand the nature of an intervention, the issue of consent must be readdressed. If a patient has had sedation or is taking any other drug that may affect cognition, their ability to sign consent must be assessed. Consent must be both informed and voluntary: • Informed. Patients must understand the treatment or procedure—the nature and purpose of the proposed treatment, the risks, side effects, benefits, and expected outcomes. Patients must also understand the implications of refusing the recommended treatment and be made aware of alternatives, if any, to the proposed treatment so that they have choices. The health care provider has an obligation to use language that is at an appropriate level and to discuss the information when the patient is not stressed or unhappy. • Voluntary. Patients must not feel compelled to make a decision for fear of criticism, nor must they feel pressured toward any particular decision by the information provider or anyone else. Sometimes in health care, only a fine line exists between coercing and making a recommendation, especially when the health care provider feels strongly that

the patient should consent to a treatment, and the patient is leaning toward refusing it. The Supreme Court of Canada supports the basic right of every capable person to decide which medical interventions he or she will accept or refuse. An individual also has the right to withdraw consent at any time, even if a procedure has started. For example, Andrew is undergoing an angiogram (to which he has consented) and experiences pain and flushing in the initial stages of the procedure. He has the right to halt the procedure until further investigation reveals the cause of his symptoms, even if the physician feels there is no danger in continuing the procedure. Involving patients in their health care is becoming more common. Not only does it show respect for the patient and his or her right to autonomy; it also improves patient compliance with treatment regimes. Each province and territory has enacted its own legislation addressing informed consent. Therefore policies vary somewhat among the jurisdictions. Relevant legislation may include the Adult Guardianship Act, the Mental Health Act, and the Health Care Consent Act. Increasingly, physicians and other health care providers are advised to obtain written consent for even minor medical services such as immunizations as opposed to relying on implied or verbal consent. Written consent also ensures that the patient has had the necessary information explained to them and protects the patient and health care practitioner. All health care providers in a position to provide care to a patient (e.g., physiotherapists, respiratory therapists, laboratory technicians, nurses, doctors) have both legal and ethical obligations regarding that patient’s consent to proposed care. The ethical components of consent are discussed in Chapter 9.

Types of Consent Express Consent

Express consent can be written or oral (which may be directed by agency policy) and indicates a clear choice on the part of the patient. Express consent usually requires that the individual be fully informed as to the benefits, risks, and consequences of any treatment options.

Written Consent All major medical interventions require signed, written consent as confirmation that the appropriate process for obtaining consent was followed and that the patient has agreed to the proposed intervention. Ideally, the person signing the consent form understands what the intervention is, including its risks and benefits. Although written consent provides health care providers with evidence of consent, a signed consent form may be weighed against any conflicting evidence, and therefore may not provide a solid defence in the case of legal action. Most consent forms have to be signed by the patient, dated, and witnessed. People qualifying as a witness to consent vary among jurisdictions and health care organizations. For medical procedures, including minor or major surgery, a physician or registered nurse will usually witness the consent. The witness should be comfortable that the patient understands what he or she is signing (e.g., a nurse getting a consent for surgery from a patient and signing as the witness). If any doubt remains, the appropriate person (e.g., usually the physician, nurse, or technologist doing the procedure) should speak to the patient and provide clarification. In some situations (e.g., in the hospital) reviewing the nature of the procedure is important, as medical terms can sometimes be confusing or misleading; the witness, if a health professional, should ensure that what the patient has been told agrees with the nature of the procedure he or she is consenting to (Case Example 8.5). Consent forms may be mailed/emailed to patients beforehand to be reviewed and signed—in this case it is incumbent upon the patient to seek further information if required.

 

Case Example 8.5 Prepared to sign a consent form for a straightforward hysterectomy, Pia reads through the form given to her by the nurse. The type of surgery named on the form is a pan-hysterectomy, which Pia may not understand. If she does not ask for clarification, she will sign consent for removal of her uterus, fallopian tubes, and ovaries. Note that a multicultural environment may present challenges surrounding consent because of religious, cultural, gender, or social concerns, as well as language barriers. Most hospitals maintain a list of volunteer interpreters should the need arise; however, interpreters capable of delivering health-related information clearly and accurately are not always available. Often, medical staff must rely on a family member to translate for the patient. As a result, what is presumed to be “informed consent” may not be.

Oral Consent Equally binding as written consent, oral consent is given by spoken word over the phone or in person. At times, someone other than the patient may be asked to sign consent to surgery; however, depending on the situation, some facilities ask that two health providers validate a telephone consent. For example, if a husband gives telephone consent for a procedure for his wife, assuming she is unable to give consent, two health care providers must be on the telephone to validate the husband’s consent—that consent was given, that he has had all of his questions answered, and that he fully understands the circumstances under, and for which consent is being provided. Protocol may vary among facilities and jurisdictions. When a health care provider receives oral consent, he or she should carefully document it in the patient’s chart, describing the intervention discussed, stating that the patient has acknowledged understanding of the intervention, and noting that the patient has agreed to it orally. Written consent remains the preferred alternative, however, for complex treatments.

Implied Consent Implied consent occurs by virtue of the fact that an individual seeks the care of a physician or other health care provider. For example, many people have received an immunization or another treatment from a family physician without having signed a consent form; the immunization or treatment has been provided under the umbrella of implied consent. As previously mentioned, however, more and more health care providers are requesting written consent, even for immunizations. By allowing themselves to be admitted to hospital, patients imply their consent to certain interventions (e.g., allowing the nurse to give them a bath or to take their vital signs). This also includes the sharing of medical information among those caring for the patient, but not anyone outside their circle of care. However, it is proper and respectful to ask the patient if they are comfortable with certain interventions (e.g., “Roger, I am going to begin your exercises now. Is that okay?”; “Emiko, I would like to change your dressing in about an hour. Are you okay with that?”). Patients may provide or deny consent through their actions, such as by nodding (“yes”) or shaking their head (“no”). A patient’s refusal to treatment should be documented in detail on his or her medical record, along with any reasons provided.

Consent in an Emergency Situation Even in emergency situations, health care providers should obtain consent from a patient before providing treatment if at all possible. Under some circumstances (e.g., the individual cannot communicate because of a language barrier or because he or she is unconscious), a health care provider can administer emergency treatment without the patient’s permission if, in the professional’s opinion, a delay will result in serious harm or injury. In such circumstances, however, the health care provider must provide clear, detailed, and concise written documentation explaining the decision to give treatment in the patient’s medical record.

Who Can Give Consent

A competent person receiving the intervention most often gives consent for the treatment. If the individual proves incapable of providing consent (e.g., is not mentally competent or is unconscious), the person’s legal representative or next of kin (subject to provincial and territorial law) assumes the responsibility. In most jurisdictions, the person who legally has power of attorney for personal care, the person who is named as substitute decision-maker (also called durable power of attorney) for health care decisions for the patient, or a person related to the patient usually takes on this duty. Legal agreements assigning someone to make decisions for an incapable person are called representation agreements. In the absence of a legally assigned person, most provinces and territories will allow a spouse (whether legal or common law) or another family member to legally provide consent. Some jurisdictions outline a designated order, depending on the availability of particular relatives—for example, a spouse will have such control before a father or mother, who would have control before a sibling, who would have control before an aunt or uncle, and so on.

Age of Consent for Minors The age of majority as the benchmark for giving consent for medical treatment is becoming irrelevant. Instead the maturity of an individual as a marker for giving consent is the benchmark in all jurisdictions except Quebec. In Quebec, the age for consent for treatment is 14 under the Civil Code. In addition, if the young person is older than 12 and requires a hospital stay longer than 12 hours, a parent or guardian must be notified. Other jurisdictions may still have a specified age range where they feel consent is required, but these ranges are usually considered guidelines. As long as the minor fully understands the treatment and its risks and benefits, he or she can make an informed decision about accepting or rejecting the treatment, and health care providers must respect his or her wishes. This is also true if the young person refuses a treatment (e.g., chemotherapy). The primary care provider must determine if a minor is competent to provide or refuse consent by assessing the minor’s physical,

mental, and emotional development. To help determine capacity, the provider may have the minor person repeat back what they have been told, and encourage them to ask questions. When required, either parent who has legal custody of the minor (or a legally appointed guardian) can provide consent for treatment. If children are travelling, the legal guardian or parent can provide written permission to another adult travelling with the minor to consent to medical treatment in case of an emergency. In extraordinary circumstances, a province or territory can seek temporary guardianship and order that treatment be implemented. Although the Charter holds that Canadians have the right to freedom of religion, when children are, in the view of the courts, too young to hold and express beliefs or to understand the consequences of receiving treatment or not receiving treatment, courts usually uphold requests made to intervene on the children’s behalf.

Consent for Deceased Organ Donation Provincial/territorial legislation determines the terms and conditions under which individuals can give consent for organ donation, although fundamental similarities exist across the country (Canadian Blood Services, 2019). In most jurisdictions, an individual must be 16 years of age or older to consent to be an organ donor, usually by signing a document such as a donor card or a driver’s licence. Younger individuals may also make their wishes known to their parents. Individuals can register online to be a donor in British Columbia, Alberta, Manitoba, and Ontario. Saskatchewan is the only province that does not link an individual’s permission to be an organ donor to either their health card or driver’s licence. Donations are considered a gift thus organs cannot be sold. It is important that individuals who wish to be organ donors discuss these wishes with their family or a close friend to ensure that if the event arises, their wishes are made known to the medical team, even if they have taken formal steps to give consent. Except for Nova Scotia, Canada doesn't have presumed consent legislation wherein individuals automatically donate their organs and tissue after death unless he or

she opts out. In April 2019 N.S introduced this legislation under, The Human Organ and Tissue Donation Act.

  Did You Know? Signing a donor registration form doesn’t mean you will become an organ donor. Statistically few registered donors are actually suitable for organ donation as medical criteria (hospital policies and procedures) imposes limitations. For example, the person must die in the hospital, most often in an ICU or must be surviving on a ventilator (meaning that without a ventilator death would be imminent). Physicians must determine whether the patient is brain dead (neurologically), or facing cardiocirculatory death if not on life support. Organ donation can only be considered after all efforts have been made to save the patient. Eight vital organs are potentially used—heart, lungs, pancreas, intestine, kidneys, and liver. BC, Ontario, and Quebec are among the jurisdictions with the highest donation rates in Canada. These provinces have “donation after circulatory determination of death” programs, and mandatory referral and reporting of impending cardiocirculatory and neurological deaths, alerting specialized teams, which approach family members with information about organ donation options. In 2016, there were about 2800 transplants performed in Canada, a 32% increase over the number of procedures done in 2007. Provinces and territories continually embark on organ awareness campaigns with variable results. However, since Logan Boulet’s death, the 21-year-old Humboldt Broncos player who donated his organs to six patients following the tragic bus collision in April 2018, there has been a surge in the number of individuals registering across the country.

The health record Any person who has received health care in Canada at any time possesses a health record, an accumulation of information relating to his or her interactions with health care services. People who work in the health care industry and deal directly with patients are often in a position to access and record health information relating to services provided for the patient. A significant portion of health information today is electronically recorded and stored. Depending on the nature of the facility and those involved in the patient’s circle of care, a health record may consist of information gathered from many sources. A health record in the hospital setting will have more components than one in a dentist’s office, a chiropractic clinic, or a physiotherapy clinic. In the hospital setting, records (manual or electronic) will contain numerous and varied reports including an admission sheet, patient history, medication records, diagnostic reports, medical or surgical records, flow sheets, and interdisciplinary notes. Interdisciplinary notes are recordings of patient care entered by any health care providers (e.g., nurse, respiratory therapist, social worker, and dietician) who render that care or carry out any intervention for the patient. Clinics or offices may also maintain a variety of reports: diagnostic reports, consultation reports, history sheets (sometimes called a cumulative profile), and a record of what happened at each encounter (e.g., details of visits to the family doctor, including the reason for the visit and the treatment received).

The Importance of Accurate Recording In most disciplines, health care providers must, by law, record information clearly, concisely, and accurately. Possibly one of the most important tasks in the field of health care, careful recording provides valuable information that can ensure continuity of patient care. All entries must be dated and signed or initialled (according to agency protocol) either manually or electronically.

What is recorded and how an entry is worded are also important. A person not in a position to diagnose must use words such as appears to have instead of has, and must never record suppositions or inadvertently label someone (e.g., Mr. Smith is a schizophrenic). Each discipline provides related guidelines for appropriate charting. In nursing, several charting methods may be used. For example, if charting by exception, nurses will only do narrative charting in the presence of an abnormal situation, charting only abnormal data, thereby saving time. Other assessments such as vital signs are electronically recorded on graphs or flow sheets. If something is out of a normal range, for example a blood pressure or a temperature, additional charting will address any issues. Narrative charting, on the other hand, usually affords more detail, but usually focuses on abnormal or out of the ordinary assessment results, lab reports, and events. Health care providers must regard anything that they enter into a health record as information potentially required in any type of litigation. Health records may prove important in a legal proceeding.

Ownership of Health Information It is important to note that all jurisdictions have legislation that balances the right of access to personal information with appropriate protection of that information. Privacy legislation is discussed later in the chapter. The health care facility or doctor’s office that collects the information and creates the health record owns the patient’s physical chart. Physicians, dentists, other health care providers, and health care facilities that maintain such records act as custodians of that information. The health information itself, however, belongs to the patient. Patients retain the right to request a copy of their information, including consultation reports and copies of reports generated by other physicians at the request of third parties, such as insurance companies. However, patients may not physically remove the record from the facility or alter its data. Office staff should supervise patients viewing their charts to avoid any unauthorized changes that

may be made by the patient and that may pose legal problems for the health care provider or the facility. Changes, including additions, may be made, but only if the health care provider agrees. Such revisions to data in the chart must be dated and initialled. When a third party requests a patient’s health information, the patient must provide written consent for its release, or a court of law may order the release of such information, without patient consent. Often patients who are moving or changing physicians will request a copy of their chart, which may be given to the patient or sent directly to the new physician electronically. If the chart predates an electronic version, then a paper chart (or parts deemed essential) may be sent by registered mail or courier, usually for a fee based on the amount of photocopying required (accounting for both time and paper). Patients should be advised in advance of the cost to receive a copy of their chart. Under some circumstances, usually to avoid serious negative effects on the patient’s mental, emotional, or physical health, a physician may deny a person access to his or her medical information or may selectively remove information from a patient’s chart before providing the patient with a copy of it. Although existing provincial or territorial legislation aimed at safeguarding health information usually supports denying a patient access, the physician must be able to justify any such decision. A patient can usually appeal a denial.

Storage and Disposal of Health Information If a physician moves, ceases to practise for some reason, or retires, the medical information he or she accumulated must be retained and stored in such a manner that patients and other health care providers providing care for that patient can access them (with the patient’s permission) as needed. If another health care provider assumes responsibility for the practice at the same location, the patients’ charts often remain at that location. Patients must receive notification of the change of provider. When physicians or other health care providers form a group, they should immediately clarify ownership of the charts—for example,

does each own the charts of the patients they regularly see, or do all of the records belong to the organization? When a health care provider leaves a practice and no one assumes direct responsibility for the records (e.g., no one takes over the practice), a custodian—a person or business legally allowed to store or otherwise keep medical records—may take over the charts. Medical file storage companies can charge patients several hundreds of dollars for photocopies of their files. Provincial and territorial governments and regulatory bodies specify guidelines for the storage of records, including how long they must be maintained. The Canadian Medical Protective Association advises that physicians retain medical records for at least 10 years from the date of the last entry, or in the case of minors, for at least 10 years from the date when the age of majority is reached. Each jurisdiction sets its own policies on health records retention; for example, in British Columbia, physicians are required to keep their records for 16 years from the date of last entry or of a patient’s age of majority (College of Physicians and Surgeons of British Columbia, n.d.). Alberta physicians are advised to keep records for a minimum of 10 years after the patient was last seen, or in the case of a minor, the greater of 10 years or 2 years beyond the patient’s age of majority (College of Physicians and Surgeons of Alberta, 2010). The Canadian Medical Association encourages all physicians across Canada to retain records for a longer period if at all possible (Canadian Medical Protective Association, 2008). The ultimate destruction of medical records must be accomplished in a manner that will ensure the information can never again be accessed. For example, a health care provider cannot just delete medical information from their computer; rather, the hard drive on which the information is stored must be professionally wiped clean.

Federal Legislation and Privacy Laws Each of Canada’s provinces and territories implements its own privacy legislation. Some provinces, including Alberta, Manitoba, Saskatchewan, and Ontario, have privacy legislation specific to

health care service providers. (See Web Resources on Evolve for a link to privacy legislation for each of the provinces and territories.) Two related federal acts—the Privacy Act (1983) and the Personal Information Protection and Electronic Documents Act (2004), known as PIPEDA—contribute to this protection.

Privacy Act Enacted in July 1983, the Privacy Act requires federal government departments and agencies to limit the private information they collect from individuals. The Act also restricts the use and sharing of any collected information. Additionally, the Privacy Act allows individuals to access any information federal government organizations have about them.

Personal Information Protection and Electronic Documents Act PIPEDA protects personal information preserved in the private sector. The Act supports and promotes both online and traditional commercial activities by protecting personal information that is collected, used, or disclosed under certain circumstances. It defines personal information as “information about an identifiable individual” and includes any factual or subjective information, recorded or not, in any form. For example, the following would be considered personal information: • name, address, telephone number, gender; • identification numbers, income, or blood type; • credit records, loan records, existence of a dispute between a consumer and a merchant, and intentions to acquire goods or services. Known as consent-based legislation, PIPEDA requires any organization collecting and using personal information to present patients with consent forms that fully disclose how their personal information will be collected and managed, and to have these forms signed. For example, a dentist’s office collecting information for

research purposes for commercial gain must reveal to the patient all personal information gathered and seek permission before using it. For a number of years now, all Canadian businesses have had to comply with the privacy principles set out by PIPEDA, except those businesses in provinces with privacy legislation similar to PIPEDA (e.g., British Columbia, Alberta, and Quebec). PIPEDA protects information throughout Nunavut, the Northwest Territories, and Yukon because most organizations, other than hospitals and schools, remain under federal jurisdiction there. PIPEDA does not usually affect hospitals and other health care facilities since most are not overtly involved with commercial activities. Some commercial endeavors in hospitals, such as thirdparty enterprises operating within the facility (e.g., coffee shop, television rental, or paid parking) must comply with PIPEDA unless there was similar provincial/territorial legislation that would override it. Any health care providers with private practices and involved in any type of commercial activity (e.g., dentists, chiropractors, and optometrists) are subject to PIPEDA unless similar public (provincial/territorial) legislation applies. The legality of exempting some publicly funded organizations from PIPEDA legislation has been questioned, because some functions within health care facilities (e.g., a privately owned diagnostic clinic operating within the hospital) mimic those of a private organization. In most jurisdictions, personal information collected by health care facilities remains under the protection of province- or territorygenerated, public-sector legislation (e.g., in Ontario, the Personal Health Information Protection Act [PHIPA]; in British Columbia, both the Freedom of Information and Protection of Privacy Act [FIPPA] and Personal Information Protection Act [PIPA]). FIPPA, for example, gives individuals the right to access their own records as well as the right to insist that any errors found are corrected. At the same time, the Act outlines limited exceptions to the right to access. Newfoundland and Labrador, New Brunswick, Nova Scotia, Ontario, Manitoba, Saskatchewan, and Alberta have personal health information legislation that applies to hospitals and other health care

sectors. Quebec's Act respecting health services and social services contains provisions for personal health information. PEI enacted privacy legislation in 2017. The Northwest Territories enacted The Health Information Act in 2014, and Yukon, The Health Information Privacy and Management Act in 2016. British Columbia has no fewer than six laws encompassing the privacy of health information, including an E-Health Act, which applies to the privacy of information in specialized databases of electronic health information allowing secure transmission of health information among health authorities and provider.

Confidentiality All health care providers must legally and ethically keep all health information confidential. The concept of confidentiality refers to the health care provider’s moral and legal obligation to keep a patient’s health information private. Conversely, the concept of privacy refers to the patient’s right for his or her health information to remain confidential and to be released only with his or her consent. Any health care provider involved directly in a patient’s case—the circle of care—legally has access to that relevant portion of the patient’s information. In the hospital setting, the circle of care may include the doctors, nurses, social workers, physiotherapists, and other members of the health care team who are instrumental in the patient’s care and rehabilitation. Administrative personnel also have access to a person’s health information and likewise must keep it confidential. Almost all places of employment—particularly in the health care sector—require employees to sign a confidentiality agreement (see Web Resources on Evolve for a link to a sample agreement) and to adhere to the principles and policies within the document. Every facility will have policies and procedures for protecting the patient’s right to confidentiality, from the fact that they are seeking care, to any and all health information in all forms, including oral exchanges between or among health care providers. As a rule, health care providers should never discuss health information with anyone other than members of the health care team responsible for the patient’s care. It is unacceptable to mention to a

friend that Sally just had a baby boy or that Pang broke his leg and has a cast (Box 8.3).

  Box 8.3

Confidentiality: An Age-Old Concept. The concept of confidentiality was outlined in the Hippocratic Oath 2500 years ago as follows: Whatever, in connection with my professional practice, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times. But should I trespass and violate this Oath, may the reverse be my lot. Source: The Internet Classics Archive. (n.d.) The oath, by Hippocrates. Retrieved from http://classics.mit.edu/Hippocrates/hippooath.html. Health care providers, both morally and legally, must keep a patient’s health information secure and restricted to only those who have the need to know and the right to access that information; however, under some circumstances, health care providers may have a moral and legal responsibility to release confidential health information (e.g., when an individual has harmed, or is in danger of harming themselves or others). Also, some health conditions, such as communicable diseases, must be reported to the local public health authority. A patient who discovers a breach of confidentiality can bring a lawsuit against the individual and/or organization responsible for the breach, whether the breach was intentional, or not (Case Example 8.6).

  Case Example 8.6 While at a party, Alicia, a student nurse, was conversing with a classmate, Ruby, who commented on how fast their mutual friend Heather delivered her baby boy last week. “Imagine,” said Ruby. “Heather’s delivery lasted only 3 hours. That’s really fast for her first baby.” Alicia responded, “But that wasn’t her first delivery, and second babies usually come much faster.” The minute she uttered the words Alicia knew she had broken a confidence, but the damage was done. Heather had had a baby 4 years prior, as a teenager. She’d given the baby up for adoption and told no one. Now the secret was out, causing hurtful and damaging information to circulate among Heather’s friends. Think of the possible implications if Heather’s husband did not know her history! Have you ever been in a situation where you have inadvertently broken a confidence? What, if any, steps could Alicia take now?

Security Health records of any type must be kept in a manner that is both safe and secure, meaning they should be protected from fire and damage from environmental disasters such as flooding, among other possible scenarios. In the case of electronic records, the use of encrypted software and passwords is essential. All health information must be stored in such a manner that access is restricted to authorized persons. Hard copies of electronic information and copies of paperbased information must be carefully tracked. Anyone who has access to health information must be bound by confidentiality agreements (from physicians to administrators to nonregulated health care providers). Every functioning electronic system should have a functioning audit trail. Any health care worker who suspects an unauthorized person of trying to access health information, whether within a clinic or a hospital unit, should question the person’s identity and intent. Most health care providers and health facilities

have protocols for both storing and allowing access to health information they are responsible for.

Electronic Health Information Requirements Both electronic and hard-copy records are subject to the principles of confidentiality and the protection of health information. However, the electronic environment poses unique challenges to maintaining confidentiality and privacy standards. Electronic health records and electronic medical records are separate collections of the same material. Whereas electronic medical records (EMRs) are housed in one facility and pertain only to care received at that facility, electronic health records (EHRs) provide the “bigger picture.” Compiled in a central database accessible to authorized persons for the purpose of providing care, electronic health records contain information from several different sources. Since an electronic health record contains information from various sources, several people will have access to the information. The more people involved, the more likely it is that a breach of confidentiality can result. As with all electronic information, the potential exists for information theft by hackers or by individuals who gain unauthorized access to information because of carelessness with passwords. The physical components of computers present the opportunity for files containing health information about thousands of people to be carried off by one person—quite within the realm of possibility compared to someone trying to walk off with thousands of files in hard-copy format. There are times when medical records stored in offices, clinics, or in other secure facilities go missing. Although electronic records are deemed more secure than paper records, neither is foolproof. In May 2008, four computer tapes containing confidential information about residents of New Brunswick and British Columbia, who had received treatment outside of their own province, disappeared while en route from New Brunswick to Health Insurance B.C. The devices were being transferred to British Columbia as part of the reciprocal agreement whereby provinces reimburse one another for health services administered in other provinces (with the exception of

Quebec). The information, on magnetic tapes, was not encrypted. For 3 weeks the fact that the tapes had not arrived in British Columbia went unnoticed. Not until 2 months after they had gone missing did the Ministry of Health notify the Office of the Information and Privacy Commissioner for British Columbia (Canadian Press, 2007). In 2011, Cancer Care Ontario reported that the health records of thousands of Ontarians were lost in the mail— an event that might have been avoided had the information been transferred electronically. The records contained names, provincial insurance plan numbers, and test results (Canadian Press, 2011). The consent rules that apply to information stored in hard-copy format also apply to information managed electronically, according to PIPEDA and territorial and provincial health privacy legislation. The information custodian must disclose to the patient who will have access to the information and any auxiliary purposes for which the information may be used. The patient also has a right to know what safeguards the facility has in place to protect the information. Some information custodians believe that once people give consent to have their information stored on an electronic health record, implied consent allows for other uses of that information. Not so. Any new, previously undisclosed initiative requires renewed consent from the patient. Many health care facilities use patient information for research purposes. Strictly speaking, the health care facility should obtain the patient’s consent, and additionally provide clear and accurate information about the research.

Health care professions and the law The regulation of health care providers is discussed in detail in Chapter 5. This section briefly looks at the significant legal applications of regulated health professions.

Regulated Health Care Providers Most of those health care providers who hold a professional designation in Canada belong to a regulating body that assumes a high level of responsibility for the ethical, moral, and legal conduct of its members. All regulated professions have a system in place for dealing with complaints against their members and for dealing with members charged with an offence. Likewise, they will support members when claims prove unfounded, and they do so in a collaborative manner when violations involve the courts. Increasingly, the emphasis of regulated professions is to provide protection for the public. Patients who have complaints against health care providers may launch a legal complaint as well as a complaint to the related regulatory organization. In the case of the latter, the organization’s regulatory committee will assess the complaint, and if it finds the health care provider at fault, impose a penalty that may range from a reprimand or a suspension of the health care provider’s licence to the permanent cancellation of his or her licence. The offending individual may also be subject to legal penalties. Although litigation against health care providers happens far less often in Canada than in the United States, it is becoming increasingly common here; therefore, all health care providers should purchase some type of liability insurance. Most regulated health care providers obtain malpractice or liability insurance through their professional college or the organization they work for. Every profession has a code of ethics (see Chapter 9) that provides moral and ethical guidelines for health care providers to follow in their professional practice. However, codes are not legally binding documents. Rather they advise the public what to expect from the

health care provider. Adhering to the principles of one’s professional code of ethics is a good way to avoid unethical or illegal practice.

Unions, Health Care, and Legal Implications Many health sector employees are involved with one or more organizations (e.g., a regulatory body, professional organization, or union). Each organization has its own mandate, structure, and purpose, although there is some overlap. All of them advocate for the well-being of the employee, and share concern for the public in terms of having access to safe, high quality health care. A union is an organization that represents and advocates for its members usually regarding employee-employer issues. A union like other organizations has rules, regulations, policies, and protocols. The exact value of a union is determined by the labour legislation (or similar regulatory body). Unions represent groups of workers within a facility and advocate for, and protect the social and economic rights of its members, often in the form of collective bargaining. Issues may relate to human rights, improving employees' wages, hours worked, working conditions, and benefits. They also provide member support in the face of complaints. Unions are not legally obliged to represent members in anything other than labour relations. Some unions will have insurance, which all members have access to for legal representation and advice in other forums. Such complaints can include college complaints, human rights complaints, testifying in coroner’s cases, and in other litigation. When criminal charges are filed, the support offered may range from none at all to allowing reimbursement if a not guilty verdict is returned. For discipline hearings and terminations, a union provides a representative to be present at all meetings between members and the employer. The union representative ensures that procedures are followed correctly, that members are made aware of their rights and that support is provide for members as required (e.g., challenging a termination or disciplinary action, perhaps in the form of a grievance, or going to arbitration).

A union will also protect an individual’s job. For example, if someone outside of the hospital applied for a clinical secretary’s position as well as someone deemed equally qualified from within the facility, the existing collective agreement would ensure that, if proper protocols are followed, the individual already employed within the hospital generally gets the job. Depending on the terms of the collective agreement, it could be that the person employed by the hospital was working in housekeeping, but either trained on the job or took relevant courses, and the individual applying externally was a graduate from a 2-year health office administration program and had an undergraduate degree in health sciences. If it can be proven that the hospital employee can meet job qualifications, that person will likely get the job. Unions will also defend members if a complaint is made against them and there is no other organization to represent the individual. This does not extend to criminal cases. The number of unions representing individuals in a facility can depend on the size of the organization and the number of employees. The Labour Board may stipulate that the union must represent all employees although there may be some exceptions. Relative to the number of employees, if several professions are represented, unions may choose to create separate bargaining units for each. In such cases it would be unlikely for more than one category of worker to legally be in a strike position at the same time. In larger organizations, such as hospitals, different categories or professions may be represented by different unions such as the provincial/territorial Nurses Association for Registered Nurses and the Canadian Union of Public Employees (CUPE for L/RPNs). Such situations may well be dependent upon or influenced by the unions involved and workforce actions. What a union environment looks like in any particular workplace is usually influenced by the collective will of those who work there and who are eligible to organize as a union. Hospital based registered employees, who are designated essential services, don’t have the right to strike and must submit any disputes (e.g., contract demands) to arbitration. Health care providers who are not designated essential services don’t have access to arbitration.

They must settle at the bargaining table, strike, or risk being be locked out.

“Sorry, I Made a Mistake” Although an apology legislation is not limited to the medical profession, the focus here is on health provider–patient incidents. When an adverse event occurs because of human error, the health professional has the legal and moral obligation to inform the patient of all relevant facts. Examples include a medication error, negligence contributing to a patient falling, misinterpretation of a diagnostic test, or an incorrect diagnosis. Apologizing for the mistake has been seen as opening the door to impending litigation. One of the objectives of apology legislation is to reduce concerns regarding liability in a variety of situations. Currently in Canada, only Quebec does not have apology legislation. British Columbia was the first province to do so, and New Brunswick, the Northwest Territories (NWT), and Yukon the latest. The principles of the Canadian legislation are similar in all jurisdictions in terms of protection under the various Acts and those outlined by the Canadian Medical Protective Association. Most pieces of legislation hold that an apology does not constitute an admission of fault or liability, must not be taken into consideration in determining fault or liability, and is not admissible as evidence of fault or liability. Protection offered by this legislation is effective in tribunals, college disciplinary committees, coroner’s inquests, and before the courts. The offer of an apology reduces the tendency of patients to resort instantly to litigation and allows health care providers to deal with their patients humanely—by recognizing the importance that an apology can play in settling disputes. Apologizing can reduce anger and hostility, showing that the health care provider is caring and acknowledges regret.

Ending a Physician–Patient Relationship A primary care provider (usually a physician or a NP) becomes legally responsible for the care of a person when active treatment

begins. If a physician or other health care provider refuses or ceases to care for a patient without due process (e.g., notifying the patient), he or she can be charged with abandonment. Unfortunately, a variety of situations will cause a patient and a provider to part ways, such as significant disagreement between the patient’s expectations and the provider’s ability to meet those expectations, or aggressive or unacceptable behaviour on the part of the patient. De-rostering a patient is not the same as firing a patient. In most jurisdictions, the provider must address the termination of a patient–provider relationship after documented written and verbal warnings, and finally, in writing in the form of a letter (often called a Dear John letter). The administrative assistant working for the physician or NP usually bears the responsibility of handling this correspondence, which is most often sent by registered mail or courier to gain proof that the letter was received. Physicians must continue to provide care for any such patient until the patient has found another doctor—a challenge, given the current shortage of doctors in Canada. Conversely, patients can simply walk away from their provider— with no formal separation process—never to return. If they return, even after a protracted time frame, they are entitled to treatment unless the practitioner or group have terms addressing such situations that are made known to the patient.

Physician Authority: Involuntary Confinement In all jurisdictions, under a provincial or territorial Mental Health Act, doctors have the power to temporarily commit a patient to a mental health facility under certain circumstances, whether acting either independently or in conjunction with the patient’s family. In some jurisdictions, patients who pose a danger to themselves or others and who are noncompliant with requests to receive treatment may be subject to a physician’s enacting this authority. Some regions require the physician and a judge to sign a form, which designates a time frame (e.g., 72 hours) within which the patient will receive an evaluation. Afterward the patient can be discharged; and, if need be, readmitted on a voluntary or involuntary basis. In the case of the last situation, to protect the rights of the patient, a physician other than

the one who signed the original form would have to provide an assessment. In most jurisdictions, the patient and his or her family must also have access to a trained rights advisor or advocate, who may provide an avenue for appeal of the decision for involuntary commitment.

Nonregulated Health Care Providers Nonregulated health care providers are discussed in detail in Chapter 5. The current landscape and structure of health care in Canada increasingly uses nonregulated health care providers, primarily in community-based care. For the most part, hiring agencies provide liability insurance for nonregulated health care providers. Personal attendant caregivers, usually hired by the family of an ill person, however, may or may not have liability insurance, sometimes creating a grey area in which the family and the caregiver have little legal protection.

Other legal issues in health care The Use of Restraints Restraints are most frequently used for patients who have cognitive impairment or psychiatric conditions, or who are temporally and disproportionately disoriented and agitated for other reasons. Restraints should be used only when all other interventions have failed and when the patient’s behaviour poses a danger to self or others or disrupts essential treatment. Restraints can be mechanical, environmental, physical, or chemical (medications). The use of restraints of any kind must be ordered by a physician, and in the best-case scenario, with permission from the patient’s family or the person who has the power of attorney for personal care. The actual application of restraints falls primarily to the nursing domain. Most facilities have a “least restraint policy,” which means that health care providers must reserve the use of restraints as a last resort, employing every possible intervention to calm the patient before restraints are used. Only in rare and exceptional circumstances should a health care provider apply restraints without an order. Injury can result from using restraints, perhaps more easily than when they are not used in a situation. Almost all facilities have procedures and policies establishing the use or nonuse of physical restraints. Restraints are rarely used. If someone were to apply restraints in a health care facility it is likely they would be in violation of the facilities policies and procedures and could potentially face litigation if the patient was injured.

Patient Self-Discharge From a Hospital Unless confined under legislation, any inpatient can leave a hospital at any time without a physician’s permission. Typically a doctor will decide to discharge a patient when he or she feels that hospital care is no longer required because the patient can manage at home or in

an alternative facility. The doctor writes a discharge order on the patient’s chart, and the patient leaves. When a patient decides to leave a hospital without a doctor’s permission, the facility should have the patient sign a form releasing the hospital, the physician, and other members within the patient’s circle of care from responsibility for that patient’s well-being. Once the patient leaves, he or she assumes all responsibility for any unforeseen effects of this action.

Good Samaritan Laws Good Samaritan laws legally protect anyone who offers to help someone in distress if something goes wrong—as it did in Case Example 8.7. Most jurisdictions in Canada have some form of Good Samaritan legislation. For example, Manitoba, British Columbia, and Ontario have Good Samaritan acts, and Alberta has its Emergency Medical Aid Act. Under Quebec’s Civil Code, every citizen must act as a bon père de famille, meaning that every person must act wisely and in a reasonable manner to help someone in distress if it does not pose a serious threat to the person. In other words, any person responding to an urgent situation is expected to do so within his or her scope of practice, knowledge, and level of expertise. A person with no medical training would be held less accountable than would a nurse or a doctor.

  Case Example 8.7 Greg was having a heart attack. Ishim found him on the ground with no vital signs. Trained in first aid, Ishim began CPR. Greg survived but suffered a punctured lung as a result of a rib that was broken when Ishim initiated cardiac compressions. In provinces with a Good Samaritan law, Ishim would likely be protected if Greg tried to sue him for causing the broken rib and collapsed lung. What are the Good Samaritan laws in your jurisdiction? Would you be inclined not to start CPR if you were in a similar situation, for fear of litigation?

Whistleblowing A whistleblower is a current or past employee or member of an organization who reports another’s misconduct to people or entities with the power and presumed willingness to take corrective action. Unfortunately, whistleblowers often suffer a backlash, such as demotion, suspension, or termination for their efforts. Employees who report wrongdoing within their organization to law enforcement officials have some protection under Section 425.1 of the Criminal Code of Canada (Government of Canada, 1985). Under this law, it is an offence for employers to threaten, take any type of disciplinary action, or terminate an employee for whistleblowing. It does not protect employees if they report to other sources, for example, the media. In addition, the Federal Government provides legislation to protect public servants. The Public Servants Disclosure Protection Act covers the entire federal public sector and Crown corporations; this includes public sector employees who have made protected disclosures. In its current form, the federal legislation places the onus on the whistleblower to prove that the employer has discriminated or otherwise taken action against them – a provision that has drawn criticism from across Canada. In June 2017 a subcommittee in the House of Commons tabled a report recommending significant changes to the Act, providing more protection for whistleblowers. Provinces and territories have their own legislation that enhances whistleblowing legislation for both the public and private sectors. For example, Whistleblower Programme was implemented in Ontario in 2016 (the first in the country), based on a “bounty for tips” initiative, which offers financial rewards to individuals who report corporate wronging. In addition to provincial legislation, individuals may have protection under their local Occupational Health and Safety Act in the case of violations to enforcement of the rules, regulations, and policies of the organization. However, whistleblowers in both the public and private sectors must rely chiefly on the protection offered by common law. Under common law, an employee owes their employer the general duties of

loyalty, good faith, and in appropriate circumstances, confidentiality (Public Service Whistleblowing Act, 2002). When an employee breaches these duties by revealing a confidence or some information, believing it is in the public interest, the employer usually takes disciplinary action, which may include dismissal. In the face of such punishment, employees may seek protection from the courts, or if they are governed by a collective agreement, through a grievance procedure.

Summary 8.1 In Canada, various levels of government are authorized to create laws, including constitutional, statutory, regulatory, common, and civil law. Most of these apply to health care in varying degrees. Constitutional law, for example, involves challenges to a person’s right to health care have been based on the Canadian Charter of Rights and Freedoms. Tort law is commonly applied when negligent acts on the part of health care workers are proven to occur or because of a compromised standard of care within a health care facility. Criminal law, with a few exceptions, is legislated by the Federal Government. Amendments were made to the criminal code of Canada to accommodate the legislation legalizing medical assistance in dying. 8.2 Under the constitution, jurisdictional authority over some areas of health care is primarily the responsibility of the provincial governments. The Federal Government provides funding and ensures that the provinces and territories are compliant with the principles and conditions of the Canada Health Act. The Federal Government also has legal authority over spending, issues related to some areas of workplace safety, criminal law (e.g., the regulation and distribution of controlled drugs), and the right to enact federal powers in the event of a national emergency. Although there are jurisdictional divisions in law, all levels of government are working together to address issues such as the current opioid crisis, and to continually improve policies and procedures related to the legalization of cannabis. 8.3 As the Canadian health care landscape changes, so do the expectations for our health care system. Many Canadians regard health care as a fundamental right, even though it is not specifically identified as such in the Canadian Charter of Rights and Freedoms. Under a universal health care system, certain health care services are indirectly guaranteed under

the Canada Health Act. Access to health care services is not always equal, for example in remote communities. In addition, what is deemed medically necessary is at times subjective, thus a procedure that is covered in one jurisdiction may not be in another. This can sometimes lead to both inequities and barriers to the type of care people believe they are entitled to. Challenges relating to the right to health care, however, often arise under sections 7 (life, liberty, and security of person) and 15 (equality) of the Charter. A recent successful challenge ended in the legalization of physician assistance in dying. 8.4 Canada prohibits its citizens from purchasing private insurance for health care services that are publicly funded (for example joint replacement or cardiovascular surgery). The fear is that allowing parallel systems of health care, public and private, will lead to inequities in care and a twotiered system. Canada has always had a mix of private and public health care, with private services regulated by federal, provincial, and territorial governments. With few exceptions a service considered medically necessary, theoretically, can be privately purchased, Private health care services have flourished more in some provinces than in others; whether it is complementary to, or in opposition with, the concept of universal health care remains a question. Canadians can buy private insurance for dental care, medications, optometric services as well as anything not considered medically necessary. 8.5 Consent to treatment is a complicated and sometimes controversial subject. Express consent means that a person gives clear written or verbal consent for a procedure; implied consent can be ambiguous. Most providers now ask for consent even for minor procedures such as giving immunizations. Also contentious is the right for minors to make their own decisions (legal now in most provinces and territories if the individual is deemed to be a mature minor) and situations wherein parents make decisions for children

that contravene what a health care provider deems best or essential. 8.6 Confidentiality, the protection of health information, and consent to treatment are issues covered, in some cases, by both federal and provincial and territorial legislation. The Personal Information Protection and Electronic Documents Act (PIPEDA) federally regulates how organizations may collect, store, and use personal information, including medical records, for commercial purposes. Provinces may displace provisions of this federal legislation by implementing their own similar legislation. 8.7 Almost every major health profession has a regulatory body that governs (or controls) such things as educational standards, provincial, territorial, or national registration, and entry-to-practice requirements for that profession. They also maintain standards of practice, and will review complaints against a professional member submitted by the public. Title protection ensures that only qualified professionals can use a designated title, for example, that of a Registered Nurse. Each profession also has a code of ethics, but such codes are not legally binding. 8.8 Some important legal issues in Canadian health care include the use of restraints, self-discharge from a health care facility, and whistleblowing.

Review questions 1. Under what conditions might the federal government enact emergency powers under the Quarantine Act? Give examples in your answer. 2. How did the Federal Government and the provinces/territories respond to the Ebola threat? 3. What is the purpose of occupational health and safety legislation? 4. What are some drug-seeking behaviours to watch for in your profession? 5. Why is an individual’s right to health care sometimes contentious? 6. a. What are two controversial components of the legislation limiting an individual’s right to apply for medical assistance in dying? b. If you could change parts of the medical assistance in dying legislation, what would those changes look like? 7. Under what circumstances would a health practitioner who owns a private health care facility be in conflict of interest? 8. What are three essential criteria for a person to be able to give informed consent? a. What is a mature minor? b. Do you think an age limit should be imposed on giving consent? Justify your answer. 9. What is the purpose of a power of attorney for personal care? 10. How long must a health care provider or facility retain medical records? 11. What is meant by chemical restraints?

References Canadian Blood Services. Organ and tissue donation and transplantation. Retrieved from https://blood.ca/en/about-us/organ-and-tissuedonation-and-transplantation. 2019. Canadian Centre on Substance Abuse. (n.d.). Prescription drugs. Retrieved from http://www.ccsa.ca/Eng/topics/PrescriptionDrugs/Pages/default.aspx Canadian Charter of Rights and Freedoms. Part I of the Constitution Act. 1982, being Schedule B to the Canada Act 1982 (UK) c. 11. 1982. Canadian Medical Protective Association. Retaining medical records. Retrieved from https://www.cmpaacpm.ca/cmpapd04/docs/resource_files/infoletters /2005/com_il0520_2-e.cfm. 2008. Canadian Press. Confidential medical records go missing. CTV News. Retrieved from http://www.ctv.ca/servlet/ArticleNews/story/CTV News/20071211/medical_records_071211/20071211? hub=Health. 2007. Canadian Press. Lost medical records a big deal: McGuinty. CTV News. Retrieved from http://toronto.ctvnews.ca/lost-medical-records-abig-deal-mcguinty-1.675786#ixzz2ZKhzdHir. 2011. Centers for Disease Control and Prevention (CDC). Global Health Security: International Health Regulations (IHR). Retrieved from https://www.cdc.gov/globalhealth/healthprotectio n/ghs/ihr/index.html. 2016.

College of Physicians and Surgeons of Alberta. Patient records. Retrieved from http://www.cpsa.ab.ca/Resources/StandardsPractic e/PracticeManagement/patient-records. 2010. College of Physicians and Surgeons of British Columbia. (n.d.). FAQs. Retrieved from https://www.cpsbc.ca/for-public/faqs Constitution Act. (1982). 1982, being Schedule B to the Canada Act 1982 (UK). c. 11, s. 92. Retrieved from http://lawslois.justice.gc.ca/eng/CONST/INDEX.HTML. False Creek Surgical Centre. Vancouver surgical centre, plastic surgery & MRI/CT scan. Retrieved from http://www.falsecreekhealthcare.com. 2014. Government of Canada. Criminal Code. R.S.C. 1985, c. C-46 as amended. Retrieved from www.criminalcode.ca/criminal-code-of-canada-section-425-1-1threats-and-retaliation-againstemployees/index.html. 1985. Government of Canada. Quarantine Act (S.C. 2005, c.20). Retrieved from http://discussions.justice.gc.ca/eng/AnnualStatutes /2005_20/. 2005. Government of Canada. Commentary: Broadening our understanding of Canada’s epidemics of pharmaceutical and contaminated street drug opioidrelated overdoses. Retrieved from https://www.canada.ca/en/publichealth/services/reports-publications/healthpromotion-chronic-disease-prevention-canadaresearch-policy-practice/vol-38-no-92018/commentary-broadening-understanding-

canada-pharmaceutical-contaminated-street-drugopiod-overdoses.html? _ga=2.151804541.579390969.1538517245102442482.1526561708. 2018a. Government of Canada. Controlled Drugs and Substances Act (S.C. 1996, c.19). Last amended 21 June 2018. 2018b Retrieved from https://lawslois.justice.gc.ca/eng/acts/C-38.8/FullText.html. Government of Canada. Medical assistance in dying. Retrieved from https://www.canada.ca/en/healthcanada/services/medical-assistance-dying.html. 2018c. Health Canada. Drugs and health products: The distinction between advertising and other activities. Retrieved from http://www.hc-sc.gc.ca/dhpmps/advert-publicit/pol/actv_promo_vs_infoeng.php. 2005. Health Canada. Understanding the New Access to Cannabis for Medical Purposes Regulations. Retrieved from https://www.canada.ca/en/healthcanada/services/publications/drugs-healthproducts/understanding-new-access-to-cannabisfor-medical-purposes-regulations.html. 2016. Health Canada. Legalizing and strictly regulating cannabis: the facts. Retrieved from https://www.canada.ca/en/services/health/campa igns/legalizing-strictly-regulating-cannabisfacts.html. 2018. Health Law Institute, Dalhousie University. (n.d.) End of life law & policy in Canada: Advance directives. Retrieved from http://eol.law.dal.ca/?page_id=231

Public Service Whistleblowing Act. Bill S-6. Retrieved from http://dsp-psd.tpsgc.gc.ca/CollectionR/LoPBdP/LS/362/s13-e.htm. 2002. Supreme Court of Canada. Judgment in Appeal. Carter et al v. Attorney General of Canada. 2015 SCC 5. Retrieved from https://scc-csc.lexum.com/scccsc/news/en/item/4815/index.do? r=AAAAAQAjY2FydGVyIHYuIGNhbmFkYSAoYXR 0b3JuZXkgZ2VuZXJhbCkB. 2015. Watts M., Austin M., Mack A. Cannabis in 2017: Setting the stage for legalization. Retrieved from http://www.mondaq.com/canada/x/659326/food+ drugs+law/Cannabis+in+2017+Setting+the+stage+f or+legalization. 2017.

9

Ethics and Health Care LEARNING OUTCOMES 9.1 Define relevant ethical terms. 9.2 Discuss ethical theories that shape health care decisions. 9.3 Explain the ethical principles that are important to the health care provider. 9.4 Summarize the rights Canadians have with respect to health care. 9.5 Describe ethical behaviour expected of health care professionals. 9.6 Explain ethical considerations relating to end-of-life issues. 9.7 Discuss ethical considerations relating to the allocation of resources in health care. 9.8 Briefly discuss the moral and ethical issues related to abortion and genetic testing.

KEY TERMS Active euthanasia Advance directive Autonomy Beneficence Compassionate interference

Continuity of care Deontological theory Divine command ethics Double effect Duties Ethical principles Ethical theory Ethics Fidelity Fiduciary relationship Involuntary euthanasia Medical Assistance in Dying (MAID) Morality Morals Nonmaleficence Passive euthanasia Paternalism Rights in health care Role fidelity Self-determination Teleological theory Values Values history form Virtue ethics Voluntary euthanasia Health care providers are held to a high level of accountability because the personal and sensitive nature of health care demands it. Entering a health care profession means entering into a moral and

ethical contract with patients, peers, and other members of the health care team. A person must employ the highest standards of professionalism and ethical behaviour and make a commitment to excellence in practising in one’s chosen field. Anyone entering the health care field must respect the rights, thoughts, and actions of patients; advocate for them; put aside biases; and assist patients in their quest to achieve wellness. Finally, health care providers must work collaboratively with all health care team members, respecting their areas of expertise and scopes of practice. Ethical decisions made in the same situation by different people may differ based on their own moral ethical codes. This chapter briefly outlines four ethical theories that form the basis for most ethical decisions. Recognizing the perspective from which a person makes an ethical decision helps those who disagree with the decision to show tolerance. Understanding and supporting the patient does not require one to compromise his or her own beliefs and values. Health care providers have a duty to adhere to six ethical principles that have particular relevance to the health care profession. This chapter addresses these principles from the perspective of clinical and administrative practice, emphasizing the importance of ethical behaviour, professionalism, and patient autonomy.

What Is Ethics? Ethics is the study of standards of right and wrong in human behaviour—that is, how people ought to behave, considering rights and obligations, as well as virtues such as fairness, loyalty, and honesty. Various systems, approaches, and conceptual frameworks deal with how human actions are judged. Ethics examines the criteria we use to determine which actions are right or wrong. Ethics also involves values, duties, and moral issues. Ethics is neither religion nor determined by religion—if it were, nonreligious persons would be considered unethical. Ethics also remains separate from the law, although ethical and legal issues are at times closely connected. Ethical choices do not always fit with what is legal, and things that may be legal—or legal decisions—are not always ethical. Moreover, being ethical does not mean following social norms; behaviour considered ethical in one society may be deemed unethical in another (e.g., polygamy). The term ethics also refers to a code of behaviour or conduct. Our behaviour reflects our belief system, which is shaped by many factors, including how we are parented, our home environment, and societal factors such as religion, friends, and school. Our ethical viewpoints are continually influenced by events and experiences and change over time. Ethical standards are influenced by morals, values, and a sense of duty—all elements critical to ethical practice in health care.

Morality and Morals Almost always linked to ethics, morality extends from a system of beliefs about what is right and wrong. It encompasses a person’s values, beliefs, and sense of duty and responsibility and can extend to those actions a person believes are right or wrong. Morals are what a person believes to be right and wrong regarding how to treat others and how to behave in an organized society. For example, a person may have a moral belief that one must always tell the truth, regardless of the consequences.

Morals can be said to define a person’s character. Ethics can be described as an individual’s collection of morals. More broadly, ethics is a social system in which a collection of morals from a number of people are applied. As a professional code of conduct, ethics encompasses the morality and moral beliefs of the profession. People bring their own moral code to their profession; it influences how they behave as professionals and the degree to which they honour their profession’s code of ethics. The differences between morals and ethics are subtle and may be best illustrated by an example. Suppose the Taylor’s and their physician have agreed to apply a do-not-resuscitate (DNR) status to their infant son because of his clinical condition, which is incompatible with life. The baby has at best a few days to live. Amy, a registered nurse working in the neonatal intensive care unit, does not morally agree with the decision, believing that all attempts to save the infant’s life should be taken, including cardiopulmonary resuscitation (CPR). However, ethically (i.e., out of respect for the parent’s choice, and their autonomy) Amy must abide by the decision the parents and the doctor made, and refrain from initiating CPR should she be present when the infant has an arrest. Health care providers who understand their own values and moral standards come better prepared to deal with issues that may arise in their professional role. Moreover, they typically possess a better sense of their commitment to practise in an ethical manner. Many grey areas exist in ethics and in beliefs regarding what is morally right or wrong. Often, no absolute right or wrong exists, and the health care provider’s personal beliefs may affect how they deal with difficult situations or react to patients. Understanding and feeling comfortable with one’s own beliefs in such areas can make accepting the decisions of others easier. Importantly, respecting the decisions of others does not mean compromising one’s own values. Morally charged topics include the right to die, withholding treatment, DNR orders, withholding information from a patient, and interfering with the patient’s right to self-determination—the freedom to make his or her own decisions. Less dramatic moral issues are more common as follows: Is it proper to accept a gift from a patient, or will the act bind a health

care worker to providing the patient with preferential treatment? Is it morally acceptable to cover up a medication error that did not cause harm to a patient? Is it acceptable for a health care provider to chart on care not given because he or she was so busy that there was time only to do the basics? Is it okay to take hospital supplies home for personal use as long as there are plenty left for the patients? Is it morally acceptable to treat a patient disrespectfully or tell a colleague something you were asked to keep in confidence? How one decides what is acceptable and unacceptable behaviour will depend on his or her moral code and values.

Values Values, beliefs important to an individual, guide a person’s conduct and the decisions he or she makes. People can have personal values, social values, and workplace or professional values. A person who greatly values friendship may consider their relationship with a particular person more important than, for example, a material object. And although a person may value friendship in general, one friend may be more valued than another. Context may also influence values, and therefore behaviour (Case Example 9.1).

  Case Example 9.1 Tony, an occupational therapy student, clearly values professional conduct at work more than he does personal conduct at school. At work, he maintains an excellent attendance record, is never late, and does his job well. However, at school, he talks in class, hands in assignments late, does not study for tests, and has poor attendance —especially on Friday afternoons. He also often misses a day of classes prior to an exam or test. He may place more importance on work for several reasons, including earning money for rent and other amenities. He may not (at least not yet) value his education or see it as a means to an end—establishing a career and becoming financially secure.

In health care, particular value is placed on certain virtues— truthfulness (veracity), respect for others, empathy, compassion, competency, responsibility, and the right for autonomy and to proper medical care. For example, one cannot effectively establish therapeutic relationships with patients or trusting relationships with colleagues without truthfulness (the foundation for trust) and respect for others. A nurse may not particularly “like” his or her manager for any given reason as a person, but may value their managerial qualities of honesty, compassion, and fairness. Suppose Rose, a respiratory therapist, had a friend, Jeremy, who was also a colleague. If Jeremy broke a confidence by telling Rose something another friend had asked him not to disclose, what would Rose think? Could she trust him either as a friend or at work regarding the disclosure of patient information? At times, another person will make a decision that violates one’s moral beliefs and values. After all, health care providers face situations that challenge deep-rooted values and interfere with the preservation of life, as illustrated in Case Example 9.2.

  Case Example 9.2 Jennifer seeks an abortion to terminate a pregnancy. She is only 18 years old and in her second year of respiratory therapy. A baby is simply not in her plans and would disrupt her education, and life in general. The father of the baby is not someone Jennifer wants in her life. Her primary nurse, Sanga (a new graduate), cannot understand how Jennifer could make that decision. Sanga values life believing that life begins at conception. However, Sanga also values trust, respect for others, the right of others to make their own decisions (autonomy), and integrity. For that reason, she can give Jennifer the care and support she needs and respect Jennifer’s right to make the decision best for her. She realizes that caring for Jennifer in a respectful manner does not compromise her own values and beliefs.

Sense of Duty

Duties often arise from others’ claims. If a patient depends on you (i.e., has a claim on you) for your professional services, you have a duty, or obligation to deliver these services. As a member of the health care profession, you also have a duty to behave in an ethical, moral, and competent manner. Alternatively, duties may be selfimposed. For example, a person who values honesty will make it their duty to be truthful. Health care providers, by the very nature of the field they work in, have a moral and ethical duty to care for their patients in a competent manner, in addition to a legal obligation, called the “duty of care.” As discussed in Chapter 8, the legal component of this duty requires health care providers to provide patients with a reasonable standard of care in accordance with their profession’s standards of practice. In terms of a moral obligation, health care providers are expected to provide care even in situations that may threaten their own lives or health; however, they may not be legally bound to do so.

  Thinking it Through The worst Ebola epidemic began in West Africa in 2014. The disease is highly infectious with a high mortality rate among those infected. The Canadian Red Cross sent health professionals including physicians, nurses, and other disaster response personnel. Sasha, a nurse, contracted the virus and was transferred back to your hospital in Canada. He has been placed in isolation. You have been asked to provide his treatment despite considerable risk of contracting the infection yourself. 1. Would you carry out your professional responsibilities because it is your duty to, or would you refuse to treat Sasha because of the risks involved? 2. Would your decision differ if Sasha was suspected of having the H1N1 virus?

Ethical Theories: The Basics Health care providers face making ethical decisions that affect them individually, that affect other members of the health care team, and that affect their patients. These professionals also face exposure to ethical situations in which decisions made by others may affect them, perhaps not directly, but emotionally. An ethical theory guides people toward making an ethical decision. The discussion of ethical theories that follows, although not in-depth, will help you see how individuals make difficult decisions.

Teleological Theory Teleological theory, also referred to as consequence-based theory, defines an action as right or wrong depending on the results it produces. Theoretically, the “right” action brings about the most benefit for the most people. Consider Case Example 9.3, a real-life situation.

  Case Example 9.3 Postsurgery it is discovered that a sponge was left inside a patient. The patient, a man with metastatic cancer, has a limited life expectancy. The staff members present, along with Nima, an operating room technician, decide it is in everyone’s best interests to say nothing. The sponge will not hurt the man, but opening him up and removing it would hasten his death and cause him more pain. The family, already trying to cope with the man’s impending death, would be distressed over the incident. It is a simple mistake—why get the surgeon and nurses into trouble? In Case Example 9.3, to say nothing becomes the group’s ethical decision. The individuals involved determine what they think would be the best result and make their decision accordingly. Of less

importance to them is that by choosing this action, they will conceal the truth (not to mention the legal implications of their decision—by law, in most jurisdictions a patient must be told when a medical error has occurred).

Deontological Theory Deontology developed from the word duty. In the case of deontological theory, a moral and honest action is taken, regardless of the outcome. If in Case Example 9.3 the team had used a deontological approach and did the “right” thing, they would have removed the sponge, or they would have told the family what had happened, explained the risks, and allowed them to make the decision.

Virtue Ethics Virtue ethics looks at the ethical character of the person making the decision, rather than at his or her reasoning. This theory operates under the belief that a person of moral character will act wisely, fairly, and honestly and will uphold the principles of justice. Therefore virtue ethics, unlike teleological and deontological theories, do not provide guidelines for decision making. In Case Example 9.3, several people were present for the postsurgery discovery. Person A may have decided that it would be best not to divulge the incident about the sponge, whereas Person B may have decided the incident must be exposed. Each person would make an individual decision based on their own set of values and morals. However, a common decision must often be reached. When people disagree about the course of action to take, sometimes the majority will rule; other times, one person may have the authority to make a call. However, each person should still feel comfortable with their own actions, because each person might have to take responsibility for such actions. In the case example, individuals following the principles of virtue ethics may believe that the surgeon has high moral principles, and therefore will refrain from questioning the surgeon’s decision. In addition, they may believe

that loyalty to the surgeon is a virtue. Then again, the act is both illegal and contrary to hospital policy, so these individuals may take a personal risk by complying with the decision not to report the incident. Ultimately, each person must weigh the situation, determine to whom they owe the greater loyalty, and decide according to their own conscience.

Divine Command The most rigid ethical theory, divine command ethics, follows philosophies and rules set out by a higher power. For example, Christians must live by the Bible’s Ten Commandments, a list of religious-based moral laws. Muslims follow the rules outlined in the Koran, such as maintaining a just society and engaging in “appropriate” human relationships. In Case Example 9.3, followers of divine command ethics would without question decide that the incident should be reported because honesty makes up a significant part of the divine command theory.

  Thinking it Through Dr. Kowalski decides not to reveal to Jake (an older patient with no relatives or emotional support system) the nature of his illness— amyotrophic lateral sclerosis (ALS), which causes progressive paralysis eventually leading to the inability to swallow or breathe. The physician believes that she is sparing Jake unnecessary grief, at least for the short term. 1. Is Dr. Kowalski justified not telling Jake about his condition and the prognosis? 2. Would it make any difference if Jake had family or friends to support him?

Ethical Principles and the Health Care Profession Common to all ethical theories, ethical principles—acceptable standards of human behaviour—provide guidance for decision making and therefore form the basis of ethical study. Ethical principles can be personal or professional in nature. In the best-case scenario, individuals practise similar principles in both their personal and professional lives. Personal principles predominantly guide a person’s actions and form the foundation from which professional principles evolve. People who believe in showing kindness and helping those in need in their personal life, will likely do the same in their professional life. Those with an uncaring, indifferent attitude toward others in their personal life are unlikely to show support, respect, or adequate care to a patient. Outlined later are a number of ethical principles that lend themselves particularly well to health care. These important elements of ethical decision making almost always appear in the codes of ethics adopted by health care professions.

Beneficence and Nonmaleficence The foundation of health care ethics, beneficence refers to showing kindness to, or doing good for others. No matter what ethical theory is used, beneficence guides the process towards a morally right outcome. Often treated as a separate principle from beneficence, nonmaleficence refers specifically to causing no harm, whereas beneficence encompasses the duties to prevent harm and to remove harm when possible. All health care providers have a duty to do good, to prevent harm, and to not cause harm. Similar to beneficence, the principle of double effect requires a person to choose the option that achieves the most favourable outcome or that causes the least harm. When secondary and potentially negative outcomes or side effects can be predicted, these must not be the intended outcome of the action. For example,

Augusta, who has terminal cancer, takes high doses of morphine sulphate controlled-release (MS Contin), which has proven to be the only means of controlling her pain. However, she now experiences respiratory distress—a known side effect of MS Contin—which could well lead to her death. Despite this, making Augusta comfortable is considered ethically and morally the action of choice.

Respect Another key ethical principle is respect. All patients have the right to be treated with respect by those who care for them. Health care providers and their colleagues also have this right. Respecting others involves honouring their right to autonomy (see later), being truthful, not withholding information, and honouring their decisions, whether stemming from personal, religious, cultural, or societal influences.

Autonomy Autonomy comes from the Greek autos, meaning self, and nomos, meaning governance. The ethical principle of autonomy underscores a person’s right to self-determination. Autonomy recognizes the right of a mentally competent individual, given all of the relevant facts, to make independent decisions without coercion (i.e., pressure or force). Health care providers may try to influence a patient’s decisions, often unintentionally, thinking they know what is best. However, patients have the right to choose their own course of treatment or to refuse treatment altogether.

Truthfulness Truthfulness (also referred to as veracity), a valued principle that patients should expect of a health care provider, contributes to building a bond of trust vital to any patient–health care provider relationship. Without this bond an effective relationship is impossible. Withholding the truth is rarely justifiable, shows disrespect, and works against a person’s autonomy and rights.

A special relationship, called a fiduciary relationship, exists between health care providers and their patients. To some degree, the health care provider retains a position of power over the patient, considering the patient’s dependence on the health care provider for his or her care. In such a relationship, patients should expect the health care provider to care about them as well as for them, and to be honest and trustworthy.

  Thinking it Through Mekhi has a serious illness, but a treatment option that will potentially cure his illness is available. His doctor tells him about the treatment, but fearing Mekhi may decide to refuse the treatment, he does not inform him of the serious side effects that he will likely experience. 1. Do you think the physician is showing respect for Mekhi? 2. What ethical principles has the physician breached?

Fidelity The principle of fidelity—faithfulness or loyalty—requires health care providers to adhere to their professional codes of ethics and the principles that define their roles and scopes of practice, and also to fulfill their responsibilities to patients by practising their skills competently. The term fidelity comes from a Latin root word meaning to be faithful. Fidelity therefore requires faithfulness and loyalty to patients, colleagues, and employers (Case Example 9.4). Health care providers are also expected to uphold the rules and policies of the organization (or person) for which they work. In the workplace, role fidelity becomes an important ethical principle for health care providers as they work to honour patients’ wishes and to earn the trust essential to the professional–patient relationship.

 

Case Example 9.4 Cecelia, who manages a number of urgent care clinics, is on a bus and overhears a conversation between two young women in the seat in front of her. “That clinic is the worst,” says one. “They expect me to do everything they ask, and they want it done, like, yesterday.” “Yeah,” responds the other, “I know what you mean. I bet you hate working there. It sounds like that manager is a real dragon. I’d never go to that clinic—unless I was dying and there was nowhere else to go!” Cecelia recognizes one of the women as an employee. Needless to say, the clinic staff will be subject to a discussion about loyalty the next day.

Justice The principle of justice applies, in one way or another, to most ethical situations. In health care, for example, it raises questions such as the following: Do all patients get the appropriate (i.e., just) treatment? Are health care resources fairly distributed? Are the patient’s rights honoured? The three main types of justice are distributive, compensatory, and procedural. Distributive justice deals with the proper and equitable distribution of health care resources. Distribution may not be equal because it is prioritized and based on need. Compensatory justice relates to the paying of compensation for wrongs done (e.g., if a person can prove that they developed cancer from working with asbestos, the company may have to compensate that person financially for pain and suffering and cover pertinent medical expenses). Procedural justice points to acting in a fair and impartial manner (e.g., seeing patients on a first come, first served basis; not giving preferential treatment to a friend). The Canada Health Act entitles all Canadians to equal access to prepaid health care and physician and hospital services. However, with resources stretched to their limits and long waiting lists for many services, equal access is compromised, along with other principles of the Act. Health care providers must do what they can to provide the best services to their patients.

Health care providers must practise within the boundaries of the law and report any actions that break the law or compromise the health or safety of a patient. Most organizations set up a process for reporting unethical or illegal behaviour. It is important to learn this process and to follow it, no matter whom—an employer, a peer, or a superior—one finds acting unethically. By simply having knowledge of an illegal or immoral act and not reporting it, a person may be considered guilty in the matter. Consequences can range from a tarnished professional and personal reputation to legal action and patient harm. In Case Example 9.3, Nima may disagree with the decision not to report the missing sponge, but by not reporting it she could share the guilt in any ensuing legal action. Justice in health care also considers the allocation of health care resources, which raises questions about whether health care services are spread evenly across Canada. The allocation of resources is discussed in more detail later in this chapter.

Patients’ Rights in Health Care Numerous moral controversies surround rights in health care, such as the right to die, the right to self-determination, the rights of a fetus, the rights of women to abortion, smokers’ rights, and the rights of an individual to health care. These are addressed in one way or another under the Canada Health Act and the Canadian Charter of Rights and Freedoms (see Chapters 1, 3, and 8). Technological advances have raised questions about an individual’s right to certain health care services and procedures, including, for example, in vitro fertilization (IVF). Depending on the jurisdiction, the cut-off age in Canada for IVF ranges from 45 to 50 years old. But is it fair to place such limits on who may receive the procedure? Should older women be given a right to it? Should the number of embryos implanted be limited? If such limits are put in place, and a woman travels out of the country to have multiple embryos implanted, should her provincial or territorial plan be responsible for her medical costs? In vitro fertilization in older women and the implantation of multiple embryos into a woman’s uterus, regardless of her age, both present significant risks to mother and baby (or babies). When complications arise, they cost the health care system millions of dollars.

  Did You Know? Public funds that are designated for infertility treatments vary and are provincially regulated. Most jurisdictions do not pay for IVF treatments, but will cover such procedures to rectify some causes of infertility such as unblocking fallopian tubes. Each IVF treatment costs $10,000 or more per cycle. In Ontario, the public system will pay for one cycle per patient for all forms of infertility but for IVF the woman must be under the age of 43, and there are restrictions on the number of embryos implanted. Quebec was the first province to publicly fund IVF for both medical and social infertility (mostly

defined as when a woman is older, delaying pregnancy for social and perhaps cultural reasons).

Rights in Health Care Rights are entitlements or things that can and should be expected of health care providers and the health care system. Rights may be tangible (real, something measurable, physical, e.g., the right to receive a vaccination covered under the provincial or territorial plan) or intangible (something you cannot see or touch, not easily measurable such as how you treat someone). Patients’ rights in Canada are vaguely addressed in the Canadian Charter of Rights and Freedoms. They are also outlined in the Canada Health Act, and although theoretically guaranteed equally across the country, subtle variations occur in each province and territory. All Canadians have explicit rights to health care itself, and certain rights within the system such as the right to timely health care. Other rights that are more vague, have been challenged under the Charter, for example, the right to physician assistance in dying, discussed later and in Chapter 4. Rights within health care, established in law in most provinces and territories, include patients’ right to their own medical records, the right to confidentiality concerning their health affairs, and the right to informed consent. Intangible rights are vaguer, such as the right to be treated with respect, compassion, and dignity; the right to privacy; and the right to a reasonable quality of care, including continuity of care. Usually contained in the codes of ethics of health care professions, these latter rights tend to be described more as elements health care providers must deliver, rather than as rights the patient is entitled to. 1. Although difficult to enforce and, at times, subjective, the principles of the Canada Health Act address Canadians’ right to health care (with limitations). Services offered within each province and territory vary, with some jurisdictions offering services that surpass the requirements of the Canada Health Act. Some newer procedures, however, remain uncovered by provincial or territorial plans, resulting in those who cannot

afford them doing without, thus creating the basis for the argument that a person’s right to adequate health care is violated (see the Did you Know box). Not every couple can afford IVF treatments—either in those jurisdictions that do not cover it at all, or in those who limit the number of cycles paid for publicly (it often takes more than one cycle for a woman to conceive). Does Ontario discriminate against older women? Should there be limits on the number of embryos implanted? Is it ethical for jurisdictions to fund fertility treatments as they see fit, or should the treatments be offered across the country? 2. A growing movement claims that Canadians should also have the right to timely health care—that is, reasonable wait times for both urgent and nonurgent medical services. Governments have made strides in improving wait times for some procedures, but there is a long way to go. Improving wait times for services requires further government financing, increased human health resources, and a redistribution of health care services; thus remains an issue not easily addressed. Currently no legislation guarantees a person’s right to prompt medical care, and only limited legal avenues exist for a patient to pursue a related complaint. Despite commitments from the federal, provincial, and territorial governments to shorten wait times, waiting lists are, in most regions, actually getting longer (see Chapter 10). Many countries have developed a patients’ bill of rights—a statement of the rights patients are entitled to when they receive medical care—that usually include rights to information, fair treatment, and autonomy over medical decisions. Legislation in countries such as Norway, New Zealand, the United States, England, Spain, Sweden, and Italy supports these bills of rights. In some other countries, patients’ bills of rights exist only as guidelines, not laws. In Canada, provincial and territorial governments have adopted a range of approaches:

• Quebec implemented legislation defining patients’ rights in 1991. • In Ontario, a patient’s bill of rights was redefined in 2015 producing a 12-point agenda put together by the Patient and Family Advisory Council, a group of volunteers made up of both patients and partners in health care. This patient’s bill of rights integrates those contained in Ontario’s 2010 Excellence for Care for All Act, which identifies a number of criteria for health care providers in hospitals to follow. • In New Brunswick, the Health Charter of Rights and Responsibilities Act, the first such act in Canada, was introduced to the legislature in April 2003. This bill of rights was revised and republished as a booklet using the concept of clear or plain language to enhance patient understanding or their rights. The booklet also answers common questions a person may have when visiting a physician’s office, visit to an emergency department, or a dentist’s office. • Other provinces have set health care goals, objectives, and expectations in planning and policy documents for patient’s bill of rights, but these have not been formally legislated. Most hospitals create their own patient’s bill of rights. Many include a section outlining the responsibilities of the patient, which include sharing accurate health information with health care providers; taking an active role in their health care; being courteous to health care providers, other patients, and staff members; and respecting hospital property.

Duties and Rights If a patient has a right within health care or to health care, for the most part, the health care provider has the responsibility, or duty, to grant that right. At the heart of patients’ rights in health care is the principle of autonomy, which has prominence over most other things. Thus duties, rights, and autonomy are necessarily joined. To fulfill one’s duty to honour patients’ rights, the health care provider must either act to carry out a responsibility or refrain from

acting or interfering in a situation. In other words, a patient’s right to something may require one to take steps to provide a service (e.g., educate the patient to aid his or her decision making); alternatively, it may require one to do nothing (e.g., refrain from pointing a patient toward a particular treatment option). Patients’ rights include noninterference regarding some aspects of their health care.

Autonomy and the Patient The principle of autonomy serves as the basis for the principles involved in informed consent and self-determination regarding treatment choices. As discussed in Chapter 8, patients must be mentally capable and fully informed about their situation to be able to make autonomous and knowledgeable decisions about their health care. It falls upon the health care provider to ensure that patients have the appropriate information, to help patients understand the information, and to answer patients’ questions regarding their situation. Patients also have the right to seek a second opinion. Attitudes toward patient autonomy have changed over the years —health care has shifted from being physician-directed (paternalistic) to patient-centred. A society that embraces paternalism allows the doctor to assume the responsibility of decision making on behalf of patients or to sway patient decisions in choosing treatments. Because the concept of paternalism may restrict a person’s rights, it clashes with modern theories and philosophies. This attitude change has resulted in a contemporary version of the Hippocratic Oath that is more aligned with modern concepts, philosophies, and practices (Box 9.1). Although this oath is associated with physicians, it reflects on values and ethical implications that impact all healthcare providers.

  Box 9.1

A Modern Version of the Hippocratic Oath. I swear to fulfill, to the best of my ability and judgement, this covenant: I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow. I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of over-treatment and therapeutic nihilism. I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug. I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery. I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God. I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick. I will prevent disease whenever I can, for prevention is preferable to cure. I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body, as well as the infirm. If I do not violate this oath, may I enjoy life and art, and be respected while I live and remembered with affection

thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help. Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University. Source: Nova Online. (n.d.). The Hippocratic Oath: Modern version. Retrieved from http://www.pbs.org/wgbh/nova/doctors/oath_modern.html. As a result of this shift toward patients’ independently determining what is best for themselves, physicians committed to beneficence may face moral dilemmas, for instance when a patient refuses life-saving treatment. In most cases, however, health care providers both respect and uphold patients’ decisions. When, on occasion, they do not, significant stress and often litigation result.

  Thinking it Through Patients frequently ask health care providers for advice based on their specific professional knowledge and expertise. For example, Jennifer, an asthmatic, may ask a respiratory therapist whether she should use her inhalers as often as prescribed by her medical specialist (e.g., an internist) 1. Is it acceptable for a health care provider to give treatment advice to a patient based on their own judgement and experience—for example, “If I were you, I would do this?” 2. Where do you draw the line between strongly suggesting the patient follow your advice and allowing the patient to make an independent choice? 3. What alternatives can you think of if you disagree with the medical practitioner’s recommendations?

Truthfulness All patients have a right to the truth, and health care providers, as discussed earlier, have a duty to provide it. Expecting that others will be truthful and honest is central to trust, even in our daily lives. The patient-focused (not physician-focused) approach to treatment requires physicians to keep the patient fully and truthfully informed. Denying information to patients or deceiving them causes more harm than good in most situations. Being truthful supports key ethical principles, those acting with beneficence or doing only what is proper and right, and refraining from doing harm, or nonmaleficence and autonomy (the right to self-determination). It is also necessary to tell the truth to uphold these principles and to adhere to the concept of duty, which is central to health care ethics. See Case Example 9.5. Does postponing telling a patient the truth justify withholding information?

  Case Example 9.5 Ira is 75 years of age, retired only a few years from his own business, and active in the community. His wife has noticed that he has been misplacing things, and sometimes has difficulty finding words. Ira is also aware of some memory loss. His wife dismisses the incidents, saying she has days when she does the same type of things. Ira’s family doctor, however, sends Ira to a memory clinic just to “rule out” anything serious. Of note, Ira’s father had Alzheimer disease along with a cousin, who took his own life after receiving the same diagnosis. Ira’s tests did not reveal anything conclusive, but the clinician’s impression was that he was in the very early stages of dementia, but too early to assign that diagnosis. Ira, still aware that he has memory problems asks his family doctor if there are medications he can take, and tells the doctor he is going to make some life-style changes. He also told the doctor he would never be a burden on his wife, and that he was well aware that anyone with cognitive problems would be ineligible for medical aid in dying. Ira’s wife wants to delay telling him what the doctors are

thinking, and the family doctor isn’t sure what to do. There are medications that can help Ira’s memory, but the only indication for these medications is Alzheimer disease. Ira would be suspicious if he was prescribed them. They decide to wait for the next few months, have another assessment, and to go from there.

Parental Rights, Ethics, and the Law When a patient is considered an adult, self-determination takes precedence over paternalistic intervention, even when the patient’s life is at stake. However, paternalism and the legal system sometimes join forces when life-saving treatment is thought to be necessary for a minor, yet is refused—for example, when parents make decisions for their minor children that the health care provider believes will compromise the health or life of the child, as in the case of Jehovah’s Witness parents refusing a blood transfusion that would save their child’s life. In these cases, the parent’s or guardian’s rights are not absolute, and the provincial or territorial courts will almost always obtain legal custody for the child and allow the recommended treatment. Numerous cases have surfaced over the past few years involving children from newborns to teenagers. All involved parties want what is best for the patient, but what one considers best may differ from what another considers best. Values, cultural and religious beliefs, and ethical codes can conflict. Who is to say which path should be followed? Do parents not have the right to make decisions for their underage children? Do physicians not have a both a moral, ethical, and legal obligation to preserve life? There are times when individuals, parents, guardians, and even persons considered minors make decisions that conflict with the recommendations of the physician—even in the face of serious, even deadly outcomes. It comes down to the rights of the person from an ethical and sometimes legal perspective. Decisions can be related to numerous entities including personal, social, and cultural values. A very good example is the 2015 case of Makayla Sault, an 11-year-old First Nations (Ojibwe) girl from Ontario who was diagnosed with a form of leukemia; she was given a 75% chance of going into remission with chemotherapy. After experiencing the

difficult side effects of chemotherapy, Makayla along with her parents decided to terminate this treatment plan (based on spiritual and cultural beliefs), exercising her Indigenous rights (and legal rights awarded to her under the Health Care Consent Act) to pursue traditional and alternative therapies. This case had been the centre of numerous discussions from a number of perspectives not the least of which concerns the right for “minors” to make life and death decisions, as well as the need to both understand and respect Indigenous health traditions and practices even if you believe that “western” medicine (e.g., the chemotherapy) offered the highest chances of survival. What do you think? A person also has the right to make decisions based on religious beliefs. Adult Jehovah’s Witnesses are able to make their own decisions in the face of life-threatening situations where the recommended treatment involves a transfusion of blood or blood products. In the case of minor children, the adults make the decision for them. They do not want their children to die, nor do they refuse other medical treatments, including surgery. Their religious beliefs dictate their course of action. Physicians, on the other hand, observe duty ethics; their duty is to treat the patient. Some might argue for a teleological approach—treating the patient saves the patient’s life, and in the end benefits everyone involved. Could that outcome be argued, however, if the patient is ostracized by his or her community for having had a blood transfusion, and if the patient feels wronged for having been forced to do something contrary to their religious beliefs? If you were a health care provider and were tasked with trying to convince someone to accept a blood transfusion (adult or an adult making a decision for a child), what course of action would you take? Would you be comfortable abiding by the person’s decision, or would you do everything you could to persuade them otherwise?

Rights and Mental Competence Conflict with a patient’s autonomy frequently arises when a question of mental competence exists. Consider a person with anorexia nervosa, a devastating eating disorder that primarily affects young

women, although both men and women of all ages are vulnerable. It is often caused by another physiological disorder, or vice versa. Conditions associated with anorexia include obsessive compulsive disorder, borderline personality disorder, bipolar disorder, posttraumatic stress disorder, and depression. The nature of these diseases often hinders the patient’s ability to make rational decisions. Does a person whose illness skews his or her ability to make rational decisions have the right to self-determination? Concerns over such situations led a psychiatrist by the name of Marian Verkerk to propose the concept of compassionate interference, wherein physicians could justify treating individuals against their will. Dr. Verkerk (1999) argues that treatment restores patients to a sound physical and mental state, allowing them to make informed decisions. This is an ethical concept, not a legal approach to treatment, bearing in mind that all jurisdictions have laws governing the rights of individuals to refuse care, and legal steps that must be taken if care is imposed (see Chapter 4). As discussed, there are numerous cases when parental authority has been removed when parents or guardians refuse medical treatment deemed necessary to save a child’s life. These cases can become even more complex—for example, when the child in question also refuses treatment, but is considered mentally unfit to make such a decision. Another contentious issue is one allowing individuals who are severely mentally handicapped to have children. If they are considered incapable of raising a child without full-time assistance (often involving social assistance) is it reasonable to have the authority to have the mentally handicapped person sterilized? If that was the case, should that authority be extended to making decisions for individuals who are severely physically handicapped, for they would also require 24/7 assistance to care for a child? Would there be a difference if the person was financially able to pay for this assistance versus being on social assistance? Whose rights do you consider? Is there a duty to consider allocation of resources used for health care and social assistance?

Ethics at work All regulated health care professions have codes of ethics, as do many places of employment. Review the one belonging to your profession or organization. If none exists, you should consider recommending that one be implemented. Many ethical situations arise in the health care industry, and codes of ethics significantly help professionals make appropriate decisions.

The Code of Ethics A formal statement of an organization’s or profession’s values regarding professional behaviour, a code of ethics provides guidance for ethical decision making, self-evaluation, and best practices policies. Most codes cover expectations related to professional conduct that, if violated, can result in loss of the person’s professional licence, dismissal from employment, or legal action.

Special Boundaries and Relationships With patients Personal relationships between patients and health care providers in any discipline are, for the most part, prohibited while the formal relationship remains, and sometimes even for a period of time after the professional relationship ends. Codes of ethics for physicians clearly outline these boundaries. Doctors may not establish personal relationships with patients under their care. In most circumstances, a physician may not date a former patient for 1 year after the termination of the patient–physician relationship. Most other health care professions take a similar, though often not as strict, stand on developing personal relationships with patients. For example, no formal objection exists to a physiotherapist starting a relationship with a former patient several weeks after their professional relationship has ended.

Often, especially in small towns, a patient admitted to hospital knows many of the staff members. Depending on the nature of the relationship, this may or may not cause concern. If the health care provider feels uncomfortable caring for a particular patient, or the other way around, it would be in the best interests of both to have someone else assume that patient’s care.

  Thinking it Through In the workplace setting, you will meet a wide range of people, some of whom you are drawn to and feel a natural desire to want to develop a friendship with. 1. Is it ever ethical for a health care provider to exchange phone numbers with a patient with the intent of dating after the patient is discharged? 2. Does it make a difference if the exchange of phone numbers is for the purpose of developing a platonic friendship? 3. What moral or ethical problems could arise from either scenario?

With colleagues Inevitably, you will develop friendships in the workplace. Unless these friendships interfere with how you do your job, doing so is not considered unethical. However, you must remain impartial and not choose favourites among the staff. Developing alliances by forming cliques at the expense of others is both unprofessional and destructive. Tight-knit groups in the workplace make it difficult for new staff members to integrate and feel welcome. Starting a new job is difficult enough. A warm and inviting environment goes a long way toward helping new employees fit in and begin to function competently as a member of the health care team. Personal business has no role in the workplace, either. Discussing last night’s party, tomorrow’s trip, or someone’s recent breakup remains inappropriate in any work environment.

In the hospital setting Health care providers employed in a hospital setting are expected to carry out their duties in a professional, legal, and ethical manner. All health care facilities have procedures, policies, and guidelines governing ethical conduct. Employers also expect health care providers to uphold the ethical codes of their individual professions. Although members of the health care team should support each other, overstepping certain boundaries can breach ethical conduct (e.g., moving a colleague’s family member up a wait list). Health care providers also have an obligation to report a fellow health care provider’s misconduct or incompetence, whether regarding their job performance or a violation of the principles of confidentiality. Most health care environments develop procedures outlining what to report and whom to report it to. Ethical issues unresolved at a lower level, in most facilities, will be reported to an ethics committee.

Rationale for Boundaries Trust A health care worker providing medical services for a patient does so within a therapeutic relationship. Patients trust the health care provider to perform his or her professional services impartially and competently. Not only is changing the nature of that relationship ethically and morally wrong; it can also interfere with the care, and compromise the ability of the health care provider to fulfill his or her professional duties. The higher the professional’s level of responsibility (e.g., a physician versus a physiotherapist, respiratory therapist, or medical secretary), the more damaging such a change can be.

Vulnerability The patient occupies a vulnerable position within the patient–health care provider relationship. As a result of this vulnerability, the patient may exhibit sick role behaviour (see Chapter 7) and feel dependent.

Balance of power and transference In a physician–patient relationship, decisions made by the physician can have a significant impact on the patient’s health and recovery. Along with feeling vulnerable, the patient may be in awe of the physician and misread feelings for him or her. Patients somewhat commonly feel a sense of “falling in love” with physicians or other health care providers. The health care provider has a responsibility to recognize the relevant signs and to ensure the relationship remains formal. In some cases, physicians have to stop providing care for the patient. All health care providers dealing with patients should be aware of the possibility of such situations. Patients have a right to equitable and fair care—and to trust that they receive it. Therefore any personal ties with a patient have the potential to interfere with the care of that patient or others, to interfere with a trusting relationship, and to put the patient in a vulnerable position.

Accepting gifts Patients often give gifts to health care providers who have cared for them, usually as an expression of gratitude. Little literature is available about the ethics of accepting gifts. A box of chocolates for the nursing station when a patient leaves the hospital, some flowers sent to the office, or a card with a small ornament are examples of acceptable gifts. Accepting anything more is inappropriate and may place the health care provider in a difficult position because the patient may expect favouritism, such as access to special treatment or an appointment whenever he or she wants it. Some health care providers make it a policy not to accept anything—ever. If an employer or regulatory college has guidelines about accepting gifts, these must be followed. Seasonal gifts may be an exception. During the holidays, patients often give health care providers and their office staff gifts, such as home baking, wine, or other tokens of appreciation—usually with no strings attached. Some people get a true sense of satisfaction from the opportunity to express gratitude. Common sense and familiarity

with the patient are the best guidelines when accepting seasonal gifts if the workplace or regulatory college does not address the issue.

The Ethics Committee An ethics committee consists of a group of people—often volunteers —who listen to, evaluate, and make recommendations about acts perceived as unethical. Members of such committees usually come from a variety of backgrounds and may include doctors, nurses, social workers, physiotherapists, lawyers, ethicists, and members of the public. Public members do not require special qualifications other than the ability to listen and assist with making fair and unbiased decisions. Members remain on the committee for designated time frames. Aside from evaluating unethical acts, ethics committees may provide health care providers with guidance in making controversial medical decisions and compile research for policy development within the facility. In the health care profession, decisions are often neither unanimous nor easy. All matters discussed and reviewed by an ethics committee remain strictly confidential.

End-of-life issues End-of-life issues that raise ethical concerns range from establishing do not resuscitate (DNR) protocols, a patient wishing to withdraw life-saving measures, and requesting supportive or palliative care, to requesting medical assistance in dying. Do not resuscitate orders are seen frequently both in hospital and in long-term care facilities, usually requested by individuals who are gravely ill (regardless of their age), and who feel that extending their lives would be one void of quality. The phrase allow natural death (AND) is sometimes used as an alternative to DNR, and is deemed less harsh and perhaps more appropriate, allowing nature to take its course. Withdrawing life-saving measures is different from a DNR order in that interventions sustaining life are withdrawn, and when death occurs is variable. Supportive measures include those to provide patient comfort, but are not active interventions that prolong life. Palliative care is also supportive in nature, avoiding active treatment. In Canada, physician assisted death was first legalized in Quebec in in June 2014 when the province’s then controversial Bill 52 was passed in a free vote at the National Assembly (Gollom, 2014). On June 17, 2016 Bill C-14 received royal assent, enacting legislation that made medical assistance in dying for eligible Canadian adults legal in the rest of the country (see Chapter 8).

  Did You Know? The term suicide is applied widely to the action of taking one's own life for any reason and is one of the major causes of premature and preventable deaths globally. It was the leading cause of death globally in 2015. Suicide is voluntary, often committed out of despair, depression, and other forms of mental illness. The term euthanasia is more frequently associated with the taking of life to alleviate pain and suffering, either with or without the request of

the person, for example, voluntary euthanasia (the patient asks someone to end their life, also called assisted suicide), or nonvoluntary euthanasia (someone deliberately ends the patient’s life without their express consent, which likely ends in a charge of murder). The term euthanasia is used less frequently now that physician assisted dying is legal in Canada, not to say that it does not still occur. Source: World Health Organization. (2018). Suicide data. Retrieved from http://www.who.int/mental_health/prevention/suicide/suicidepr event/en/.

Euthanasia Various categories of euthanasia exist. Voluntary euthanasia occurs when a person causes the death of another with the dying person’s consent—often in the form of a living will or advance directive (involuntary euthanasia occurs when a person causes the death of a dying person without the latter’s consent, usually associated with murder). Active euthanasia refers to the taking of deliberate steps to end another’s life (e.g., with a lethal injection such as in the case of Elizabeth Wettlaufer using insulin to kill her patients, see Chapter 4); passive euthanasia refers to the process of allowing a person to die by removing life support or other life-sustaining treatment. This can occur at the patient’s request expressed close to the time of death, by means of a living will, or in some cases a decision made by the physician or a proxy decision maker. In the case of medical assistance in dying (MAID), the doctor provides the patient with the means to end his or her own life; the patient, however, carries out the act. This of course is now legal in Canada. With the exception of passive euthanasia, and medical-assistance in dying where legal, the act of ending or assisting to end a person’s life is illegal in most countries. Euthanasia including MAID remains a highly controversial concept, and depending on the situation, has both legal and ethical implications. Any act that takes someone’s life

act conflicts with the moral values of most societies, which respect the sanctity of life and the duty of the health care provider to save or preserve life. On the other hand, allowing physician assisted aid in dying respects the autonomy of the person who wishes to die.

  Did You Know? Medical Assistance in Dying There are actually two categories assigned to medical assistance in dying. The first occurs when the physician or nurse practitioner injects a drug or drugs (usually into an intravenous line) causing death. Previously known as voluntary euthanasia, the newer term is clinical-assisted medical assistance in dying. The second type occurs when the physician or nurse practitioner prescribes a drug that will cause death for the patient, and the person administers the medication by themselves. This equates to what was previously called physician assisted suicide or simply assisted suicide and has been replaced with self-administered medical assistance in dying. MAID will always be controversial, with some Canadians quite happy to be able to make the choice, and others who disagree with the concept for a variety of reasons. There are also those who remain ambivalent. The concept raises a number of concerns, including fears of misuse of the process for disabled and otherwise vulnerable people—for example, ending Aunt Sally’s life to inherit her money, or trying to arrange for the death of a person (adult of child) who is disabled to the point where they cannot make their own decisions, but for whom you see death as a relief and a kindness. Case Example 9.6 summarizes a real-life situation that exemplifies some of the fears that advocates have with respect to MAID and the disabled, although this tragic situation took place long before MAID was legal.

 

Case Example 9.6 The Latimer Tragedy A noteworthy and historic case of involuntary active euthanasia, with ramifications that persist today, is that of Robert Latimer, a Saskatchewan farmer who killed his daughter, Tracy, in 1993 by placing her in a car and rerouting exhaust fumes to euthanize her. Tracy, a 40-pound, 12-year-old quadriplegic with cerebral palsy, functioned at the level of a 3-month-old. According to most reports, she suffered constant and severe pain. Her father could not bear to see her life continue indefinitely in this manner. Convicted of second-degree murder, Mr. Latimer was sentenced to life in prison (which was a mandatory minimum sentence of 10 years), with a chance of parole after 10 years. Parole was granted in 2010 with some conditions. In July 2013, the Parole Board of Canada lifted the requirement that Mr. Latimer continue with one-to-one psychological counselling, stating that he was now able to manage his emotions. He is still prohibited from caring for a disabled person and must apply to the parole board if he wants to travel outside of the country.

  Thinking it Through Debate over the ethics in the Latimer case and the severity of the sentence Mr. Latimer received continues to this day. At Mr. Latimer’s second trial, ordered because of jury interference in the first trial, the jury upheld the charge of second-degree murder, but recommended Mr. Latimer be eligible for parole after 1 year. In this trial, Justice Ted Noble tried to distinguish between murder and mercy killing. He called Tracy Latimer’s murder a “rare act of homicide that was committed for caring and altruistic reasons. That is why for want of a better term, this is called compassionate homicide” (CBC News, 2010). Did Robert Latimer ever present a danger to society? Most would say no. However, in 1994 the Saskatchewan Court of Appeal overturned Judge Noble’s ruling, imposing the mandatory minimum sentence: 25 years, with no

parole for ten years. Latimer’s first bid for parole in 2007 was denied because he maintained his belief that he killed Tracy for her benefit and would not express remorse. Groups championing the rights of disabled persons argued that showing leniency would endanger disabled persons and rate them as second-class citizens. Canadians with disabilities continue to campaign for protection of what they deem a fundamental human right—the right to life (CBC News, 2010). Today, after 25 years, Robert Latimer at home on his family farm (on parole) still has no regrets. He feels he did the right thing. He holds a veiled hope that the current Federal Government will pardon him. 1. What are your thoughts? 2. Should he be pardoned? What moral and ethical values prompted Mr. Latimer to kill his daughter? 3. What values do you think come into play that motivate Mr. Latimer to still believe that he did the right thing? Source: CBC News. (2010, December 6). “Compassionate homicide”: The law and Robert Latimer. CBC News. Retrieved from http://www.cbc.ca/news/canada/compassionate-homicide-thelaw-and-robert-latimer-1.972561.

Ethical Principles and Medical Assistance in Dying Rights A person’s right to self-determination is central when it comes to medical ethics. This includes, but is not limited to, the right to equitable health care, the right to accept or refuse treatment, and with respect to this discussion, the right to die with dignity in accordance with the MAID legislation. The principals involved in legalizing MAID include the right of a person to autonomy and dignity. Opposing values concerning the sanctity of life were considered when MAID was legalized, but the rights of a person to

end his or her life to prevent intolerable pain and suffering took precedent. The rights of physicians and nurse practitioners who facilitate the process of MAID must also be considered. In Canada, health practitioners are not obligated to actively participate in the process based on conscientious objection; this may be for religious, spiritual, social, professional, personal, or institutional reasons. At present, physicians are required to refer patients to a physician who will navigate them through the process of seeking medical assistance in dying. This is in part because health practitioners have a duty of care to their patients and should not abandon them. Institutions that refuse to actively participate in MAID do so because of religious beliefs and principles (ones with religious affiliations), but will refer and transfer a patient to another location or facility that participates in MAID. This protocol is a discussion all on its own and brings into question the right of a hospital to refuse this type of care if it is publicly funded.

Autonomy Proponents of medical aid in dying claim that the legislation supports the rights of the individual to autonomy, selfdetermination, and the right to choose their destiny when faced with an illness or disability causing intractable, intolerable pain, and suffering. The principle of self-determination is often central in medical decisions. The key is that the person is mentally competent to make their own decision.

Values When weighing the ethical rightness or wrongness of seeking medical aid in dying, a person’s values must be considered. For example, most people value their personal dignity. Personal dignity may include a person’s self-worth and sense of pride—for example, in being able to look after themselves in the final stages of an illness. He or she may fear a loss of dignity if they cannot render self-care, depend on others for meeting such needs as feeding, and elimination, entities the person associates with quality of life (or lack

there-of). Loss of dignity is almost always associated with cognitive impairment, and feared as an illness progresses.

Trust Primary care providers almost always have a mandate to preserve life, to do no harm, and to bring about good (the principles beneficence and nonmaleficence). The concept of deliberately bringing about or contributing to a person’s death violates almost every principle of duty ethics that health care professionals pledge to uphold. Does this weaken trust between a patient and health practitioners who participate in MAID? Medical assistance in dying and whether it is right or wrong will always depend on an individual’s own ethical and moral beliefs and values. The process will continue to pose more questions than answers. In addition, the policies and procedures including eligibility still require adjustment. What does foreseeable death mean? It is subjective and it is up to the clinician to make that decision. Some judges have already ruled (in response to specific legal challenges) that there is no time limit on when death might occur, and have deemed a person eligible for MAID even when their medical state is not terminal. Are there enough safeguards in place to prevent misuse of the process? Will it become “ordinary” so that those assessing eligibility become complacent, creating a slippery slope that could lead to misuse of the process? Should individuals diagnosed with Alzheimer disease and other forms of dementia be allowed to make arrangements for MAID while they are still mentally competent? Should those with mental illness be eligible? Should minors be allowed to make such decisions? Is it reasonable to allow someone to have assistance in ending their life to end lifelong suffering, even when death is not imminent?

Preparation for End-of-Life Decisions Many individuals as they get older, and who may or may not be suffering from a poor quality of life as a result of illness, want some measures in place that will direct their care and end-of-life decisions should they become unable to do so (excluding MAID, which must

be requested by the patient with respect to a current health problem). In the face of deteriorating health these requests may include specific interventions such as restricting interventions to those that will keep them comfortable, removal from life support (e.g., ventilators), do not resuscitate orders, or they may want all measures aimed at preserving life implemented (although that is not usually the case). There are steps in all provinces and territories that individuals can take to facilitate implementation of their end-of-life decisions, some more complicated than others.

Do Not Resuscitate Requests A person entering a health care facility can request a do not resuscitate order (DNR) usually with the support of their family. The doctor must sign a DNR order, which becomes part of the patient’s medical record. In an acute care facility, the attending physicians and staff must be aware of this decision. If a person is transferred from a long-term care facility to an acute care hospital, a DNR order on the chart should be part of the health record transferred with the person. Protocols for making this request may vary with both facilities and jurisdictions. It is important for all those within the person’s circle of care to be aware of such requests; if there is not a written, signed order, health professionals are obliged to initiate CPR. If there is a signed order on the patient’s chart, health care providers are legally bound to honour such requests, which can be difficult for those who believe that active measures should be taken at all costs. Importantly, a person can reverse his or her DNR request at any time.

  Thinking it Through Currently hospitalized Pierre suffers a cardiac arrest. His nurse, Nayla, is in his room at the time and knows that he has a written and signed DNR order because he was constantly reminding the staff of it. However, because of Nayla’s religious beliefs, she feels that saving a person’s life takes precedence over everything else. Not resuscitating Pierre is a difficult choice for her to make, but

resuscitating him would violate the patient’s personal request and thus his right to autonomy. 1. What should Nayla do? 2. What course of action would you take if there was no written/signed DNR order because the family objected, but you knew that was want Pierre wanted? 3. Would you be exempt from litigation if you acted on compassionate grounds? An advance directive, also called a living will or treatment directive, specifies the nature and level of treatment a person would want to receive in the event that he or she becomes unable to make those decisions at a later time. People prepare advance directives so as to ensure their wishes are known and honoured by family and loved ones and carried out by medical caregivers. Advance directives that appoint a power of attorney for personal care are most likely to result in the person’s instructions being followed. A values history form is a comprehensive document that guides people in thinking about treatment options they would or would not want in the event that they were to become unable to make decisions about their own health care. People can detail their feelings, thoughts, and values as they relate to medical interventions. The form may also assist loved ones who might have to make decisions on the person’s behalf, and also clarify the person’s choices if disagreements among loved ones occur (Case Example 9.7).

  Case Example 9.7 Sam, a 67-year-old who recently suffered a severe stroke, created an advance directive expressing his wish to receive no active intervention if he has another stroke. However, concerned that another stroke may leave him unable to communicate, and on a ventilator, he begins to have doubts about his decision, fearful that if he has a change of heart, he would be unable to communicate it.

(Many people who have decided against intervention change their minds when actually facing death.) Some family members know of his recent second thoughts about his advance directive. Sam decides to complete a values history form to clarify his feelings and thoughts about medical intervention. This form might help Sam’s family if they ever have to make treatment decisions for him. Levels of care reflects a choice of end-of-life interventions usually assigned to nursing in long-term care facilities. They are discussed with the individual and their family members or proxy decision maker upon admission to a long-term care facility. Once established, the information is entered onto the person's chart. The person (usually called a resident in long-term care) or their family members may change their minds at any time. Levels of care most frequently change when a person’s state of health begins to deteriorate. Should this occur, the physician or other health provider along with the nurses almost always consult with the family, updating them on the resident’s condition, and evaluating options. Although specifics will vary, most facilities offer four options. Note that levels 1 and 2 are congruent with allowing the person to die naturally where they are living at the time. Level 1. The resident wishes to stay in their home (e.g. long-term care or nursing home), receiving comfort and supportive measures only. This includes pain control, but not usually intravenous therapy for hydration. Level 2. The resident wants to stay in the facility and receive all treatments, medications, and interventions that are possible at that facility. This would include pain control and antibiotics if the patient developed an infection, pneumonia, or a urinary tract infection. Other medications may include those to treat cardiovascular problems. Intravenous hydration may or may not be considered. Level 3. A resident choosing this level of care would be transferred to an acute care facility from their long-term care facility. They would receive recommended imaging and diagnostic tests, an intravenous if required, antibiotics, and

other medications as needed. Level 3 does not include CPR protocol, or transfer to the intensive care unit. Level 4. This level requires the person be transferred to an acute care facility for all active measures required to sustain life. Some individuals refuse their daily medications (e.g., antihypertensive medication, diuretics) in an attempt to accelerate their demise. Such refusal is perfectly legal, but may pose moral questions for those involved in the individual’s care.

Palliative Care Palliative care, an increasingly important component of medical care in Canada, addresses the physical and emotional needs of those who are dying. Individuals opposed to any kind of interference with the natural course of death believe that palliative care can facilitate a peaceful and painless natural death. Whether delivered in a hospital, in a hospice, or at home, palliative care can aid any person who is in the latter stages of a terminal illness, or cannot otherwise cope with their disease without specialized support. Teams of experts work with patients and their families to manage physical discomfort and psychological distress and to meet spiritual needs.

Care in a Hospice Hospice care is a form of palliative care offered in a facility especially designed and staffed to deliver patient and family-centred care for patients who are in the latter stages of a terminal illness. The main goals are patient comfort, relief of pain and other symptoms, and support for the person’s family and loved ones. A medical and holistic approach to care and support are integrated with spiritual, mental, and emotional needs of both the patients and their families. The nurses, physicians, and other health practitioners are experts in pain control and related interventions. It is often argued that proper palliative support for the patient is a better option than physician assisted dying, and that properly managed, a patient can die with dignity without pain or undue stress. There are also those that argue

that even the best palliative care cannot always meet the needs of the patient. and for those who are ethically, spiritually, and morally comfortable with MAID, it is their right to pursue that course of action.

Allocation of resources The term allocation of resources refers to who gets what, when, and for what reason. Rising health care costs, expensive technologies, and limited access to many services have made the allocation of resources an increasing concern in the health care industry. And limited resources mean that “Who gets what?” becomes a huge ethical problem. A brief discussion of select limited resources follows, with the intent of promoting thought and discussion.

Organ Transplantation The advancements that led to the ability to transplant organs, a scarce resource, have introduced several ethical issues. Consider Case Example 9.8.

  Case Example 9.8 Rothea was admitted to hospital in acute liver failure. She has been on the transplant list for a little over a year. Terms of being a transplant recipient include abstaining from drugs and/or alcohol forever as well as being drug and alcohol free for at least a year prior to being placed on the transplant list. Rothea was alcohol and drug free for 10 months. She had a setback because of some family problems, in addition to the death of a friend. Because of this, upon her admission assessment she was no longer considered eligible for a liver, even in the face of failing health. She (and her family) pleaded publicly for a second chance, claiming that one setback should not remover her from the transplant list. Ethically speaking, should this be the case? Should the authorities ignore the fact that Rothea was involved in alcohol and drugs, give her the next suitable liver, displacing someone who had not violated the rules?

In Case Example 9.8, Rothea has been unable to overcome the disease of alcoholism. Although she has managed to give up drinking for limited periods of time, her ability to maintain sobriety remains questionable. A return to drinking would sharply decrease her chances of maintaining even reasonable health with a transplanted liver. Should she therefore be denied a chance at a new life? Joe, on the other hand, lives a healthy lifestyle yet has contracted a disease typically considered less preventable than alcoholism. But what if, as is debated in modern medicine, alcoholism was more commonly considered a disease rather than a moral failing? Would Rothea then be in a more favourable position to compete for the liver? Would she be on equal footing with Joe? Other considerations from a medical perspective encourage the following questions: Who would be more likely to see significant improvements in his or her health with the new liver? What damage has alcoholism done to Rothea’s overall health? Alcoholics tend to have lower success rates with transplantation since their general health is usually poorer. A return to drinking would interfere with compliance with the necessary posttransplant treatment regime, which requires taking immunosuppressant drugs. Nonetheless, do any of these factors provide a solid reason to deny Rothea?

Finances and Resources In Canada, the demand for health care resources—including finances, health care providers, and medical services such as diagnostic tests and hospital beds—sometimes exceeds supply. The allocation of resources in health care presents an ethical problem because it raises questions about fairness and justness. Priorities should be based on need, but how does a person, organization, or government assess need? Health care funding in Canada, for the most part, is distributed in such a way that each region can set its own priorities and make decisions about how best to meet the health care needs of the populations it serves. If funds increase, however, how are they distributed? If funds decrease, which services are maintained, and which are sacrificed? How can someone make a decision, for

example, to fund expensive treatment for a small number of autistic children if that same amount of money might be spent on cancer treatment that could save thousands of lives? Sometimes the Federal Government will, in an attempt to make funding more equitable, step in and provide targeted funding for specific areas. This happened over a decade ago when funding was directed toward disease prevention and health promotion (preventive care) raising awareness of the importance of breast screening and Pap smears for women, immunizations for children, colon cancer home tests, and a healthy lifestyle (e.g., a proper diet, regular physical activity, and avoidance of self-imposed risk behaviours such as smoking). The healthier the Canadian population is, the fewer health care dollars ultimately need to be spent. Although many consider immunizations among the most important advances in preventive care, others argue that vaccines pose more risks than do diseases such as polio, measles, mumps, typhoid, and rubella, suggesting that immunizations have caused autism in some Canadian children (no definitive proof of this claim exists). Unvaccinated children pose a risk to others in the presence of a disease outbreak (e.g., measles). In 2018, funding was directed towards home care and mental health. Both areas in dire need of funds, the lack of funds has been restricting the availability of human health resources and increased services in some areas. Many groups compete for health care dollars—some for treatments for rare conditions that would empty the health care pot of millions of dollars. Teleological theorists, however, would suggest that funds should go to those services that meet the needs of the most people. Most Canadians take the stand that treatment should be available to all Canadians and that governments should ensure such universal availability without imposing financial hardship on an individual or family.

  Thinking it Through Thousands of Canadians suffer from relatively rare conditions that are incurable. but that can be treated with some success. These

treatments, however, are often extremely expensive—sometimes drugs are not covered by the public plan, and sometimes treatments do not fall within the definition of “medically necessary.” 1. Is it ethical to spend a large amount of money on a few individuals when that money could be used to improve health care services for a much larger group? 2. Does each life not deserve the same consideration? New technologies continually introduce treatment modalities that preserve and prolong life, and Canadians feel a sense of entitlement to these technologies most of which are very costly. However, funds are limited; if every life-saving or treatment measure were offered to every person in need, the health care system would collapse. For example, significant (and costly) advancements have been made in sustaining life for very premature babies; however, these infants often have little hope of recovery or a satisfactory quality of life if they do recover (Case Example 9.9). Some medications are very costly, such as biologics (see Chapter 4), with a small percentage of the population using a disproportionate amount of money allocated for drugs. Is this reasonable, if the money could be used to pay for the cost of drugs for thousands of Canadians who cannot afford their prescriptions? With health care costs rising, Canadians may ultimately be asked to consider how their choices will affect costs.

  Case Example 9.9 Raja delivered a baby, Damian, at 23 weeks gestation. Damian was transported to the nearest neonatal intensive care unit. Three days later, the doctors told Raja that her baby had a 30% chance of survival and that if he did survive, he would likely be blind, require multiple heart surgeries, suffer from a seizure disorder, and have cerebral palsy. They asked whether she wanted them to continue treatment to attempt to save the baby’s life. The cost to the health care system would be enormous, and the quality of life the baby

would have, questionable. Left to make her very difficult decision, Raja had to consider the small margin of hope that her son would live, and if he did survive, the complications he would have to endure. The last thing on her mind was the expense of the treatments—they were covered by the health care system.

  Thinking it Through Communities in Canada’s far North are geographically isolated, generally with small population centres spread over this immense area, often with living conditions that are harsh in comparison to life in what northerners call "the South." Most communities have health centres staffed by nurse practitioners or registered nurses. Doctors visit some of the communities on a rotation basis. There is limited availability to diagnostic equipment, treatment, and surgeries. Even giving birth requires evacuation of the mother to a larger centre weeks before the delivery date. Having to leave their community for medical care, in addition to coping with illness outside of one's community without the support of family and loved ones, brings added stress. 1. How could resources be more fairly allocated to address these inequities? 2. Is it reasonable to spend a disproportionate amount of money, relative to the population size, to bring more health services to remote communities (e.g., CAT scan, MRI, chemotherapy, surgical services)? 3. As a health professional, would you be willing to work in a remote community? If your answer is yes, under what circumstances could you see yourself working in Canada's North?

Other Ethical Issues in Health Care Abortion Abortion has been available in Canada without restrictions since 1984 when the Supreme Court of Canada declared that abortion could not legally be forbidden because doing so would violate section 7 of the Charter of Rights and Freedoms. As you may recall, section 7 states that “everyone has the right to life, liberty and the security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice.” Further, the court declared that forcing a woman to carry a fetus to term is a violation of her “security of the person” (Canadian Charter of Rights and Freedoms, 1982). In Canada, abortions remain legal to the point of “viability,” defined as a fetus weighing more than 500 grams or having reached more than 20 weeks gestation with gestation beginning at conception (Canadian Medical Association, 1988). Second-trimester abortions are allowed only under certain circumstances, usually when the mother’s life is at risk. Third-trimester abortions may also be performed under such circumstances; however, new technologies have given most babies born at that stage a reasonable chance of survival. Babies born after 28 weeks gestation receive the best chance of achieving a healthy life. Access to and coverage for abortion varies among the provinces and territories. As with medical assistance in dying, health care providers are not obligated to perform abortions, and can refuse to perform them because of religious or moral beliefs. Individuals can self-refer to abortion clinics. The moral and ethical issues around abortion concern two main issues: the right of the fetus to life and the right of women to make decisions that involve their own bodies. These issues also include philosophical, religious, and political components. Pro-life groups believe that personhood (i.e., the state of being considered a person) begins at conception—the moment the sperm

meets the ovum. From a spiritual perspective, some believe that the soul enters the body at this point. Pro-lifers consider any deliberate interference that threatens the life of this “person” murder, believing that the fetus shares the same rights as all other humans, including the right to life. Pro-choice groups argue that the mother has the choice to carry the baby to term or to end the pregnancy, maintaining that abortion is a constitutional right and that safe and timely access to hospitals and clinics must be guaranteed. Views among pro-choice groups vary as to when the fetus becomes a person with rights. People who believe that personhood does not begin until the start of the second trimester or later assert that an abortion occurring prior to 13 weeks is both moral and ethical if it reflects the wishes of the pregnant woman. The debate over whether abortion is right or wrong, ethical or unethical, will continue. The argument comes down to personal, moral, religious, and cultural values and beliefs.

Premature Deliveries There is current disagreement as to when extreme measures to save a premature baby should be abandoned, many recommending that a baby born prior to 22 weeks gestation should not be aggressively treated. This is very controversial as some babies born at 22 weeks have survived. Questions regarding the accuracy of gestational age also come into play. Others include the rights of the baby versus the chance of surviving with a good quality of life. Who decides? What is a good quality of life to one person may be different from that of another. Should cost be considered, weighted against the odds of survival?

Genetic Testing An increasing number of Canadians are having genetic testing—the examination of one’s deoxyribonucleic acid (DNA)—done through a number of online organizations such as www.23andMe.com and www.Ancestry.com providing direct-to-consumer results. Through

genetic testing people can learn whether they carry any genes that put them at a higher risk for disease, such as certain types of cancer (e.g., breast), Alzheimer disease, and Huntington disease. Similarly, carrier testing determines whether the potential exists to pass on a genetic disease (e.g., sickle cell anemia and cystic fibrosis) to offspring. A couple who undergo such tests and have positive results must then weigh the severity of the potential disease and the chances of its occurrence when deciding whether to bear children. Prenatal diagnostic screening can determine a fetus’s risk for certain genetic disorders, aid in earlier diagnosis of fetal abnormalities, and provide prospective parents with important information for making informed decisions about a pregnancy. Genetic testing raises a number of moral and ethical questions, however. For instance, if an insurance company obtained records showing that a prospective patient carried a gene that put them at risk for developing cancer, would that person be considered uninsurable? Would an employer with access to similar information decide against hiring that person? Some protection is provided for individuals in possession of genetic testing results revealing health concerns that could impact their purchase of insurance policies. Bill S-201, an Act to Prohibit and Prevent Genetic Discrimination, was passed in Canada in early 2017 (Government of Canada, 2017). Under the Act insurance companies are barred from asking clients to provide them with the results of genetic testing they may have had done when applying for life insurance under the amount of $250K, or for health insurance. The Act amends the Canada Labour Code to prohibit employers from requiring that employees have genetic testing done, or from revealing test results already in the employee’s possession. The Act also amends the Human Rights Code to prohibit any type of discrimination of a person based on genetic characteristics (e.g., someone with obvious characteristics of Down syndrome). There are still concerns if damaging genetic information somehow fell into the wrong hands, and it can still be requested by insurance companies for more expensive life or health insurance policies. Do you think the fact that Canada has a universal health care system lessens the potential harm of being required to reveal genetic test results when purchasing private health insurance?

What the individual does with the information obtained raises further issues. For example, a woman who learns she has the breast cancer gene might elect to have her breasts and ovaries removed. The famous American actress Angelina Jolie had a prophylactic double mastectomy based on a family history and on a positive BRCA genetic test. Two years after this surgery, Jolie had her ovaries and fallopian tubes removed prophylactically.

  Thinking it Through The presence of the BRCA1 or BRCA2 genes can predispose a woman to cancer of the pancreas and the uterus as well. Not all women elect to have any of these surgeries, even if they have either or both of these genes. Instead, some will opt for close monitoring for disease detection. 1. Would you want to know if you carried either of these genes? 2. If you tested positive, what course of action do you think you would choose? 3. What ethical principles, if any, might affect your decisions? Canadians are encouraged to think carefully (i.e., to ask what the benefit is in knowing) before having genetic testing for presumed or established conditions. For example, would it help a person to know that they may develop Huntington disease, an incurable neurological disorder? Such knowledge might provide relief from uncertainty and give a person an opportunity to get their affairs in order. On the other hand, the anxiety produced from living with the risk of contracting an incurable disease can be overwhelming and debilitating in itself.

  Thinking it Through

Assume that several members of your family have suffered from Alzheimer disease. A genetic test will tell you whether you carry the inherited gene, which would increase your likelihood of developing the disease. 1. Would you want to know if you carried the gene? 2. What advantages and disadvantages exist in either knowing or not knowing? Although demand for genetic testing in Canada is growing, resources are limited, and individuals who turn to private laboratories usually surrender the advantage of receiving counsel from their own doctors. Results can be indefinite, stressful, damaging to family relationships, and harmful to careers. Genetic tests covered under public insurance in Canada include those for breast and ovarian cancer, colon cancer, high cholesterol, and Alzheimer disease. • Provincial and territorial governments have questioned the cost effectiveness of some types of genetic testing (i.e., allocation of resources), and have agreed that the cost effectiveness depends on the test and resulting benefits. For example, genetic testing for colon or breast cancer is probably cost effective since individuals who test positive can undergo more intensive screening as a preventative measure. Those at a higher risk for colon cancer, for example, can have periodic colonoscopies, whereas others (considered low risk) can have less expensive screening tests (e.g., stools for occult blood). Expert genetic counselling accompanies genetic testing in some Canadian jurisdictions, but not all. Genetic counselling aims to provide individuals with an understanding of the implications of a positive test, both for themselves and for their relatives, and to ensure individuals make an informed choice about taking the test.

Summary 9.1 Ethics is the study of what is right and wrong in how we behave. It encompasses a number of principles including fairness, loyalty, and honesty. The study of ethics examines people’s morals, values, and sense of duty. Ethics also refers to a code of conduct expected of a person in their professional role. In health care, it is important to respect the decisions of others even when those choices may not be congruent with your personal ethical code. 9.2 Understanding your own moral and ethical beliefs, your values, and your method of making ethical decisions will help you to understand your responses to ethical problems encountered in your professional role. Four ethical theories (teleological theory, deontological theory, virtue ethics, and divine command) define how most people make ethical decisions, providing some explanation for decisions that individuals make about their own health or the health of those they love. 9.3 Six principles (beneficence and nonmaleficence, respect, autonomy, truthfulness, fidelity, and justice) provide the foundation for ethics in health care. Beneficence—doing what is right and good for the patient—dates back as far as the practice of medicine itself as illustrated in the Hippocratic Oath, which has been modernized in keeping with changing trends. Although physician oriented, the oath reflects fundamental values expected of most health professionals. Establishing a trusting relationship with patients and being respectful, honest, and truthful allow them to make their own decisions. This approach also supports the principle of autonomy, or the patient’s right to self-determination. In most circumstances, paternalism is no longer acceptable in health care. Patients retain the right to have active treatment withdrawn, to refuse treatment, and to die with dignity.

9.4 A person’s right to health care is sometimes ambiguous. Rights generally considered viable include the following: access to one’s own health information; the right to confidentiality; the right to informed consent; the right to timely health care deemed medically necessary; and the right to have health care needs addressed in a timely manner. 9.5 Health care providers must establish and maintain therapeutic and respectful relationships with their patients. The balance of power that exists between a health care provider and a patient puts the patient in a vulnerable position in which feelings can be misinterpreted. Health care providers faced with a relationship issue must respect the codes of ethics of their profession, their employer, or both. 9.6 The decisions a person makes with respect to end-of-life issues can be both complex and controversial. A person’s decisions are usually based on their personal code of ethics and may be influenced by the nature of their illness. A person may decide to refuse treatment or seek active methods to end their life, such as medical assistance in dying. Levels of care offers individuals a choice of what type of interventions they want when their health is deteriorating—a concept that is part of the policies in most long-term care facilities. The first two levels are congruent with allowing a person a “natural” death. Decisions made by the patient, and/or his family, can be changed at any time. Do not resuscitate directives must be in the form of an order signed by the physician and present on the patient’s medical record. It is important for health care providers to respect the decisions a person makes, even if the decision is incongruent with one they would make for themselves in similar circumstances. This is not always easy and in some circumstances health professionals can remove themselves from a situation that requires them to act in opposition to their beliefs and values. This is called conscientious objection and can be applied in cases involving abortion or medical assistance in dying, as examples. 9.7 With health care costs continuing to rise, provinces and territories have become more conscious about where, when,

and how to distribute resources, particularly when related to cost. Should the allocation of resources be based on need, cost-effectiveness, or the principle of equal distribution? Portions of recent funding from the Federal Government have, in part, been assigned to home care and mental health to improve services in those areas. This is called targeted funding, and provides some level of assurance that deficits in these areas will be addressed. 9.8 Many areas of health care (e.g., abortion, genetic testing, and medical assistance in dying) cause controversy in the application of morals, values, and ethics. For the most part, no right or wrong answers exist—only what beliefs and values dictate. It is essential for health care providers to maintain an open mind, respect the rights of others to make their own decisions, and recognize that such respect can be achieved without compromising one’s own beliefs and values.

Review Questions 1. Differentiate among ethics, morals, and values. 2. Giving examples, differentiate among ethics, values, and morals. 3. How do deontological and teleological ethical theories differ? 4. How are paternalism and the principle of autonomy in opposition to each other? 5. Is role fidelity the same thing as functioning within one’s scope of practice? Explain. 6. What is meant by the “balance of power” between a health care provider and a patient? 7. Explain the difference between a values history form and an advance directive. 8. Ania , who is mentally competent, has been accepted for medical aid in dying. Her family is vehemently opposed to her decision, vowing to try to intervene stating that for religious reasons she should not be allowed to proceed. Does the family have the right to intervene? Explain your answer. 9. Would Sasha, who is in the early stages of dementia, be eligible for physician assistance in dying? Why or why not? Discuss implications of this. 10. What is meant by the “allocation of health resources,” and why does it present an ethical problem? 11. What are the benefits and drawbacks of having genetic testing done? 12. How would you define personhood? 13. Would it be ethical or moral to make vaccinating children for common childhood diseases mandatory? Support your answer. 14. Following an assault on a nurse by a mentally ill patient, a hospital stipulated that all mentally ill in-patients considered potentially ‘violent’ or with violent tendencies must wear colored armbands identifying them as such. Is this ethical? Does it violate the patient’s rights? If so, which ones and on

what grounds? What about the rights of the nurses to a safe environment? Is this policy discriminatory?

References Canadian Charter of Rights and Freedoms. s. 2, Part I of the Constitution Act, 1982, being Schedule B to the Canada Act 1982 (UK) c. 11. 1982. Canadian Medical Association. Induced abortion. CMA Policy. Retrieved from http://policybase.cma.ca/dbtwwpd/PolicyPDF/PD88-06.pdf. 1988. CBC News. “Compassionate homicide”: The law and Robert Latimer. CBC News. Retrieved from http://www.cbc.ca/news/canada/compassionatehomicide-the-law-and-robert-latimer-1.972561. 2010. Gollom M. Will the end-of-life-care bill turn Quebec into a euthanasia tourist destination? CBC News. Retrieved from http://www.cbc.ca/news/canada/will-the-end-oflife-care-bill-turn-quebec-into-a-euthanasia-touristdestination-1.2667383. 2014. Government of Canada. Genetic Non-Discrimination Act (S.C.2017, c.3). Retrieved from http://discussions.justice.gc.ca/eng/AnnualStatutes /2017_3/index.html. 2017. Verkerk M. A care perspective on coercion and autonomy. Bioethics. 1999;13:358–369.

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Current Issues and Future Trends in Health Care in Canada LEARNING OUTCOMES 10.1 Discuss the state of mental health and addiction and the related services in Canada. 10.2 Summarize the challenges in managing health care for Canada’s aging population. 10.3 Explain the problems facing home care services in Canada. 10.4 Describe current issues related to pharmacare and the legalization of marijuana in Canada. 10.5 Outline the major health care issues and related concerns facing Indigenous Peoples in Canada. 10.6 Explain the impact of electronic health records and information technology in health care. 10.7 Discuss future initiatives for primary health care. 10.8 Summarize the advantages and risks of using social media in health care.

KEY TERMS Food insecurity Forensic psychiatric hospitals Reserve

Consider the following stories. What do they suggest about the current state of health care in Canada?

  Demetria is 19 and in her first year of college. She lives in a private room in residence. The stress of being away from home, feeling like she does not quite fit in, and academic demands were unexpected. Three months after arriving on campus, Demetria became very depressed and anxious to the point where her grades were suffering. She kept to herself and did not want to get up some mornings. She felt flat, anxious, and miserable. Demetria sought help from the university health centre, but was told there was a 4 month wait to see a counsellor. Demetria felt abandoned, helpless, and did not know where to turn.

  At 78 years of age, Merle is legally blind, has congestive heart failure, debilitating osteoarthritis, hypertension, diabetes, and chronic pain. Merle manages at home with a support worker coming in every day for 2 hours. She fell and broke her hip, which had to be pinned. Following surgery, Merle’s mobility was greatly impaired. Merle, along with her son, decided that her best option was to be discharged to long-term care. The wait list for any nursing homes close by was 2–3 years. She was put on a list for the next available bed anywhere within the county. She could not afford the option of going to a private residence.

  Jennifer lives in Cape Dorset. Jennifer is 18 years old, a high school graduate, working for the territorial government (contract position). She lives with her dad, stepmother and five little brothers in an apartment. Recently Jennifer found out that she is pregnant. The baby’s father is just 16 and living at home. Jennifer continues to live with her family; because of crowded conditions she often stays with friends or sleeps on the couch at her boyfriend’s place. Jennifer is

overjoyed at the prospect of having a baby, but worries about where she will stay long term, as there is a 5-year wait for accommodation (an apartment or house). She worries about adequate nutrition because of the shortage and high price of fresh fruit and vegetables. In addition, she worries about her limited finances (she will be on social assistance), and the at present has no opportunities for sustainable employment or post-secondary education. Another stressor is the fact that she must go to Iqaluit a month before she is due to have the baby, removing her from her family and support systems. Jennifer remains thankful, however, that her medical expenses (including travel) are covered by the government, and that intrapartum care is provided within her community. She is well aware of the challenges she faces, especially now that she will be responsible for her child, but remains optimistic that she will find a job or the opportunity to start a small business such as day care.

  Hakeem, a new immigrant to Canada is 27, works part time, and needs medication for asthma. Although he can access clinics, he has no family doctor, so his care and medical records are fragmented. He has no drug plan and does not qualify for provincial drug coverage. As a result, he goes without his medication most of the time. These stories illustrate some of the major issues facing the Canadian health care system, which will be discussed in this chapter. As you read through, see if you can find or recommend solutions to improve the health care or access to health care for the individuals in these stories. Consider what determinants of health affect each individual. As you have likely noted throughout the book, despite numerous positive things about health care in Canada there are inadequacies as well. Health care in Canada is in transition, struggling to adapt to changing demographics and economic realities. Implementing strategies to make Canadians healthier is a nation-wide priority. Health Canada along with its provincial and territorial partners are

addressing health care concerns and developing strategies for improvement, largely based on examining the social determinants of health, coupled with population health initiatives. The Health Canada website is currently undergoing change, emphasizing the social determinants of health as their basic framework. There is widespread agreement that numerous actions can be taken to improve the health and well-being of vulnerable Canadians from a socioeconomic perspective. These include improving living conditions, reducing unemployment, addressing problems related to mental health, addiction, and social isolation as well as providing adequate support (a social safety net) that is equitable and readily available. Examples include adequate social assistance, child benefits, employment insurance, and retraining programs. Specific strategies involve addressing homelessness (e.g., social housing, and counselling), addressing infant and child nutrition and development, ensuring adequate income, and home and residential care for seniors. Also important are continuing strategies to encourage Canadians to take responsibility for their own health (e.g., healthy living, health promotion, and disease prevention). Canadians must have an awareness of the needs of those new to Canada as they adjust to the challenges and demands of living in a different country (e.g., adapting to a new culture, customs and language, finding meaningful employment and living accommodations, establishing a supportive social network, and finding culturally sensitive health care) (World Health Organization, 2013). This chapter will address some of the issues considering current and future perspectives. The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) is the product of more than 10 years of effort by hundreds of international experts in all aspects of mental health. Their dedication and hard work have yielded an authoritative volume that defines and classifies mental disorders in order to improve diagnoses, treatment, and research (American Psychiatric Association, 2018).

Mental health and addiction Mental illness refers to a number of different disorders that influence our thinking process and the manner in which we behave, ranging from depression and anxiety to personality disorders, bipolar illness, and schizophrenia. Addiction disorders include problems with gambling, misuse/abuse of solvents, and a variety of drugs. If you think of health care services and initiatives that have or should have priority, what comes to mind? Is it increased funding for hip or knee replacements, strategies to shorten wait times for cardiovascular and cancer surgery, or improving access to primary care services (e.g., ensuring every Canadian has a family physician)? Although these are important considerations, your answer probably does not include funding for better access to mental health services. Yet currently, mental illness is the leading cause of disability in Canada, with one in five Canadians experiencing some type of mental illness in their lifetime (Society of Policy in Ontario, 2018). Mental illness and issues related to addiction (or both) directly or indirectly affect every Canadian, by association with a family member, a friend or loved one, or a colleague. Mental illness can affect anyone, regardless of such factors as transience, age, gender, educational level, income, and culture—no one is immune. Those most frequently affected are lower income and younger Canadians, in particular those between 15 and 24 years of age (Canadian Mental Health Association, 2018). The overall annual cost of treating mental illness in Canada is more than $50 billion (Mental Health Commission of Canada, 2018). This includes the direct costs of hospitalizations, social services (e.g., counselling and other supports), prescription medications, income supports, and the indirect costs of lost productivity (e.g., time away from the workplace—one in four people report absence from work or school with mental health related issues, which account for approximately 30% of worker compensation claims) (Canadian Psychological Association, 2013). Timely access to appropriate care remains a central concern for individuals with mental health issues. Systemic concerns include

chronic underfunding (with renewed optimism following the recent targeted funding from the Federal Government discussed in Chapter 4), a shortage of specialized health human resources, and lack of strategic planning for such things as collaborative community-based mental health services. For individuals with mental illness, the stigma attached to having a mental illness, although improving, is still an issue, as is knowing where to go to get the help they need.

Structure and Implementation of Services In Canada, mental health falls under the jurisdiction of the provincial and territorial governments, working together with agencies such as Health Canada, the Public Health Agency of Canada, the Mental Health Commission of Canada, the Canadian Mental Health Association and its jurisdictional counterparts, to plan strategies and interventions aimed at caring for mentally ill people. Provinces and territories share responsibilities with the Federal Government for individuals who require mental health services when they become involved with the criminal justice system. In general, mental health care is offered in tertiary care psychiatric hospitals, forensic psychiatric hospitals and clinics, community mental health centres and related agencies, some correctional facilities, adolescent assessment and treatment facilities, alcohol and drug treatment programs, and long-term care facilities. In most jurisdictions, acute care hospitals offer a range of mental health services, ranging from inpatient units to outpatient programs, day treatment programs, or partial hospitalization programs (for those needing more frequent, rigorous therapy, and counselling). As with other components of health care, the Federal Government retains responsibility for treating mental illness and addictions for the following designated population groups: First Nations on reserves and Inuit communities, veterans, members of the armed forces, inmates in federal correctional facilities, individuals working in the federal public service, and some classes of refugees, including those accepted on compassionate or humanitarian grounds (for a limited time frame). Different departments within the Federal

Government fund mental health services for various groups; for example, First Nations and Inuit Health Branch under the direction of Indigenous Services Canada funds services for eligible Indigenous people, Correctional Services of Canada funds inmates in the federal system, and the Department of National Defense organizes and funds services for members of the armed forces.

Services for Armed Forces Armed Forces services include predeployment preparedness, treatment for addiction, crisis intervention, and short-term counselling; services are fragmented, and accessibility varies. Individuals returning from deployment abroad who are diagnosed with posttraumatic stress syndrome frequently seek counselling services. Waiting lists to access services are common and these services may not meet their needs for ongoing support. They often seek services within the civilian sector.

Community-Based Services Community-based mental health care is provided in a variety of ways. Many jurisdictions offer a centralized point of contact to help people navigate the mental health care system and to provide them with direction about their legal rights, when required (e.g., Alberta’s Access Mental Health initiative). In every province and territory, health organizations provide care and public education. For example, the Canadian Mental Health Association and its nationwide branches deliver services and support to those with mental health and addiction challenges. This organization depends heavily on a dedicated team of volunteers to deliver and maintain its community programs. Other organizations such as the United Way fund some uninsured services for those unable to pay, although many services remain accessible only to people who can afford them.

Mental Health Practitioners

Primary care physicians, psychiatrists, psychologists, nurses, social workers and counsellors (many of whom are in private practice) are core members of the mental health primary care team.

Registered Psychiatric Nurses Registered psychiatric nurses (see Chapter 5) practising in western Canada provide the bulk of primary care mental health services. These nurses practise both autonomously and as part of primary health care teams. They work in communities, providing care and support for individuals, families, and groups. They work within a holistic model of health care with a focus on the whole person, integrating the physical, psychosocial, and spiritual needs of their patients to promote health and wellness.

Family Physicians Just under 90% of Canada’s family physicians have some component of their practice devoted to caring for patients with mental illness, ranging from depression and anxiety to more serious problems. Family physicians will refer individuals for specialized mental health services when they feel the patient needs more support and direction than they can provide. In addition, many prefer not to become involved in counselling because it is time consuming (usually a minimum of a half hour per session per patient), reducing their availability to see other patients. In a half hour a family physician could otherwise see three to four patients. Referring patients to mental health and counselling experts poses challenges, including a lack of psychiatrists (whose services are covered by public plans), and the cost of seeing a psychologist or counsellor, whose services must be paid for privately or through private insurance. Some primary care organizations will offer limited paid access to a psychologist (e.g., four visits in a year). Most insurance companies will pay for a designated number of visits to a psychologist (with a PhD), but not for someone with fewer credentials (e.g., a master’s degree). This limits access as well.

Mental Health Commission of Canada

The Federal Government commissioned the Senate Standing Committee on Social Affairs, Science, and Technology to produce a Canada-wide study on the state of mental health and related services in the country. In 2006 the completed report, entitled Out of the Shadows at Last – Transforming Mental Health, Mental Illness and Addiction Services, recommended the establishment of an independent, arms-length agency to examine the state of mental health and mental health services in Canada. As a result, the Mental Health Commission of Canada (MHCC) was formed. In 2009 the MHCC released the results of a research initiative called Opening Minds, which studied the stigma of mental health illness (discussed later). In 2012 the MHCC completed the first draft of a national mental health strategy, called “Changing Lives, Changing Directions: The Mental Health Strategy” (referred to as the Strategy), the first ever pan-Canadian strategy with the goal of improving both mental health services and access to these services across the country. The Strategy made six recommendations: (1) the need for open communication to reduce the stigma of mental illness; (2) promoting mental health for all Canadians in multiple places (home, schools, community, and the workplace); (3) focusing on suicide prevention; (4) providing the right mix of mental health services for those in need; (5) evaluating and improving risk factors associated with mental illness (e.g., determinants of health such as poverty, unemployment and underemployment, social isolation) for vulnerable populations; and (6) providing the proper support and services to meet the unique needs of Indigenous people in Canada. The Strategy also stressed the need for additional, targeted, incremental funding rolled out over a 10-year period (2007–2017). Targeted funding did not begin until 2017 when the funding was announced by the Federal Government. Since the Strategy was implemented there has been progress in bringing mental illness into the public domain, and increasing awareness through multimedia (radio, television, and social media) such as the growing influence of Bell Let’s Talk campaign. This campaign has resulted in Canadians from all walks of life, and of all ages, engaging in dialogue about mental illness, reducing stigma, facilitating conversations about mental health, and raising millions of dollars for mental health

services. By 2018 the campaign had raised $93.4 million of the tagged amount of $100 million by 2020 (Bell Canada, 2018). Open communication and public awareness of issues within certain groups has also led to corrective action (e.g., dealing with harassment within organizations such as the RCMP, correctional facilities, and many other workplaces). The “Me Too” movement and others like it have paved the way for many victims of sexual assault to go public without the fear of shame and public condemnation, and led to charges against many perpetrators who would otherwise continue their destructive behaviours.

The Stigma of Mental Illness One of the most significant barriers both to living with mental illness and seeking mental health services for individuals and their families is the stigma attached to having a mental health or addiction problem. According to the Mental Health Commission of Canada (MHCC), 60% of people with mental health issues will not seek help because they are afraid of being stigmatized—and with good reason (Mental Health Commission of Canada, 2018). Despite improved public understanding of mental illness, and the fact that more people are talking about it, people with any form of mental illness are still subject to stigma, prejudice, and discrimination. How many people do you know who would readily admit they went to the doctor seeking help for anxiety or depression, as compared to help a sore throat, arthritis, or a heart problem? Most people would admit they are taking an antibiotic, thyroid medication, or heart medication, but may not as readily if they are taking an antidepressant. The MHCC’s initiative, Opening Minds, continues efforts to reduce stigma, improve how people think about mental illness, and promote fair and equitable treatment of those who suffer from it. Stigma affects all aspects of a person’s life. Mindful of this, Opening Minds targets four main groups: health care providers, to create positive, accepting, and caring attitudes; youth, to identify those at risk and promote early intervention; the workforce, to encourage understanding and tolerance at work; and the media, to positively influence public views and attitudes.

  Thinking it Through Many Canadians are reluctant to admit to being diagnosed with mental illness or that they have a substance addiction. A person with suicidal thoughts/ideation, despite initiatives such as the Bell Let’s Talk campaign, may be reluctant to approach someone for support fearing they will be judged and that people will think less of them. 1. Would you be more likely to keep quiet about a mental illness or addiction disorder than a physical disorder? 2. If you were on an antidepressant, would you feel comfortable telling anyone as opposed to revealing you were taking another type of medication? Why or why not? 3. If a friend told you he or she was depressed and had thoughts of suicide, what would you do? Would that revelation change the nature of your friendship? 4. How would you respond if a friend revealed they were using opioids?

Mental Health and Addiction Disorders Alcohol and drug addiction, and mood disorders (major depression, generalized anxiety disorder, and bipolar disorder) are among the most common mental health problems. Currently provinces and territories are struggling to deal with opioid addictions and the alarming number of deaths related to overdoses (see Chapters 5 and 8). New concerns have arisen with the legalization, regulation, and selling of recreational cannabis, especially for youth and vulnerable people in regions where alcohol and drug misuse are a concern. Many communities in Canada’s northern regions are considered vulnerable population groups. Contributing factors include geographic and social isolation, and adverse socioeconomic conditions, leading to and compounded by misuse of alcohol, solvents, and drugs. Community members have disproportionately higher rates of suicide and suicide ideation (Canadian Centre on

Substance Abuse and Addiction, 2018). Government reports acknowledge these problems, along with the fact that there is no single solution. Governments agree that funding shortfalls for mental health services, along with addressing the social determinants of health, are a necessary part of any solution (House of Commons, 2017). Suicide related to undiagnosed or poorly managed mental health problems is a significant concern. Approximately 4000 Canadians take their own lives each year, most of whom were confronting or dealing with a mental illness (Mental Health Commission of Canada, 2018).

Drug Misuse The misuse of any drug is problematic—opioid (e.g., fentanyl, morphine) and opioid analogues (synthetic reproductions) are currently of particular concern. Every province and territory in Canada has been affected by the national opioid crisis. There were an estimated 2946 deaths related to opioid use in 2016, and an estimated 2923 deaths from January to September 2017; over 90% were accidental. Only one quarter of these deaths were among females, and those in their thirties accounted for the largest age group. Most deaths involved fentanyl or fentanyl analogues, and in 2017 occurred mainly in British Columbia, followed by Ontario. The fewest deaths were in the territories and Prince Edward Island (Government of Canada, 2018a).

Actions Taken Against Drug Misuse Aside from attempts to stem the use of illegal drugs, the federal, provincial, and territorial governments, along with organizations at all levels, have collaborated to manage this opioid crisis. Safe consumption sites (SCS, also called safe/supervised injection sites) established in communities across the country, are part of the Canadian drugs and substances harm reduction strategy. These sites have been sanctioned based on national and international evidence showing lives are saved. Narcan kits (the antidote) are available in numerous locations such as pharmacies and walk-in clinics, in the

form of a nasal spray and injection. Available locations vary in jurisdictions and are publicly funded. Training in the use of these kits is also provided, usually by a health provider on a volunteer basis. Since October 2018 Health Canada has mandated that all opioids dispensed by prescription have a yellow warning label on the side of the medication container, in addition to a pamphlet given to the patient by the pharmacist, outlining the abuse risks of the drug. Health Canada also ruled that pharmaceutical companies must implement risk management plans for the opioids they produce indicating the dangers related to their use (addictive properties), and signs of potential addiction (Health Canada, 2018). As discussed in Chapter 8, the Canadian Medical Association has released guidelines for health care providers who write opioid prescriptions. The federal and provincial governments provide online information, videos, and contact information about opioid use and misuse (e.g., Canada.ca/opioids). In June 2018 Correctional Service of Canada implemented, under much controversy, a trial needle exchange program with the goal of reducing infectious diseases in federal penitentiaries (Government of Canada, 2018b).

Mental Illness and Homelessness The causes of homelessness are multiple and complex. Almost without exception, predisposing factors include inequities related to the socioeconomic determinants of health, such as lack of education, unemployment, social or cultural disconnection (or both), and poor coping skills. Not all homeless people are mentally ill or suffer from substance misuse. A homeless person may have a significant preexisting mental health issue or may have one that becomes significant because of the stresses associated with homelessness (anxiety, depression, poor self-esteem, altered decision-making skills). A large number of individuals with a mental health and/or a substance misuse problem have a disproportionately higher (approximately 25% to 50%) homeless rate (or experience precarious homelessness) than other Canadians (Munn-Rivard, 2014). Individuals without a permanent address often experience poor

physical health, have higher suicide rates, and find it difficult to access social support and proper medical and mental health services. The emergency department is an accessible (24-7) point of care for the homeless, who are usually disconnected from their primary care practitioner (if they had one), and who may not be close to their original community (Ali, 2017). The cost of homelessness to Canadians is estimated at $7 billion annually (Gaetz, Donaldson, Richter, et al., 2013). This figure includes health care costs, legal fees, and social services expenditures for this population. Individual communities bear most of the responsibility for looking after the homeless—some programs receive government funding; others rely entirely on volunteers.

Reducing Homelessness Strategies to reduce homelessness vary with provinces and territories, as well as within communities, and are determined by available resources, demographics, and varying needs of the homeless in each community. Resources available may or may not include government funding, funding, fundraising events, planners and policy makers, service providers, medical and mental health authorities, community groups and volunteers. Housing First is a framework widely used across Canada for developing housing programs for mentally ill homeless people. Housing First is a product of a Federal Government sponsored 5year research project called At Home/Chez Soi. It is an informationor evidence-based (meaning based on evidence gathered by research), best-practices platform to reduce homelessness across the country. One of the key elements within the Housing First framework is finding permanent homes for homeless people, who are suffering from mental illness and addiction, without preconditions or eligibility criteria—for example, the individuals do not have to maintain sobriety or attend treatment sessions before being considered for permanent housing. Providing homeless people with housing through programs like Housing First dramatically reduces visits to the emergency department and improves the overall health of homeless individuals. Because individuals have a permanent address, it is

easier for them to arrange and keep appointments with health providers, thereby improving continuity of care. Seven cities in Alberta reported that because of the program, overall hospital stays by homeless people (days spent in hospital) were reduced by 64%, and visits to the emergency department were reduced by 60% (7 Cities, 2018). In Medicine Hat, Alberta, the Housing First initiative, in conjunction with other community agencies, has all but eliminated homelessness in the city. The initiative aims to have every homeless person connected with a support worker, on average within 3 days, and ideally be moved into permanent housing within 10 days (Lawrynuik, 2017). A first-ever National Housing Strategy for Canadians was announced in the fall of 2017. Building on past frameworks, the Federal Government pledged to invest $40 billion into housing programs for vulnerable populations over a 10-year time frame. Of this, $2.2 billion was set aside for homelessness, adding to a previously pledged $11.8 million. This national housing strategy is projected to double the annual budget targeted for homelessness by 2021–2022 when compared to the budgeted amount distributed in 2015–2016. Through Reaching Home (discussed later), increased funding will be earmarked to reduce homelessness among the Indigenous population in Canada, in consultation with Indigenous communities, providing culturally sensitive recourses and support to meet the unique needs of vulnerable individuals within that population base. Members of the committee who made recommendations for reducing homelessness were from diverse backgrounds, including individuals with actual experience (i.e., who have experienced homelessness), ensuring that strategies and recommendations embraced demographic and cultural needs. It is important to note that the former and new Strategies have considered jurisdictional barriers (both historic and current) identified by the Truth and Reconciliation Commission and acknowledged that implemented practices must be consistent with the Commission’s Calls to Action. Under the new national housing program, the previously mentioned Homeless Partnering Strategy was restructured and renamed Reaching Home: Canada’s Homeless Strategy (effective

2019). The new goal of Reaching Home is to reduce homelessness in Canada by 50% within a 10-year time frame (by 2028). This strategy provides direct funding for municipalities and service providers at the local level. Although there are some guidelines, the Federal Government does not specifically dictate how funds are to be used in each community. Some funding does target Housing First programs as well as those organizations that provide emergency shelter, support, and services when housing is unavailable. Housing First programs are encouraged to adapt their programs to respond to the unique needs of youth, Indigenous Peoples, women seeking refuge from violence, and veterans. Under the restructured framework, communities not already receiving support can apply for funding. The Strategy will provide ongoing support in terms of information, advice, and the tools they need to structure and deliver systembased plans to reduce homelessness in a coordinated manner, utilizing services and resources within their communities. Despite the best efforts in any community there will always be homelessness. Why? Some of the reasons include the high cost of housing in some cities; unavailability of housing and rental units; stigma (i.e., people not wanting homeless persons sheltered in their neighborhood); lack of funding; lack of coordinated, effective strategies; and an increased incidence of mental illness and addictions, with inadequate mental health services. There will always be individuals who require emergency shelters (many of whom won’t find a bed due to shortages in hostels and shelters) forcing an individual to remain outside. During the cold Canadian winters, homeless people are particularly vulnerable. Cities across Canada scramble to provide accommodation, sometimes opening facilities as temporary sanctuaries. Alternatively, outreach workers canvas known locations providing food, warm drinks, blankets, and sleeping bags (Government of Canada, 2018c). There are numerous organizations across Canada that provide temporary and emergency shelter for homeless people. These include the Salvation Army (operating in over 4000 communities across Canada), Out of the Cold (a network of churches and other religious organizations rotating available facilities), the Scott Mission in Toronto (providing family accommodation), Young Parents No

Fixed Address, Toronto (focusing on pregnant women and those with children, and counselling services to young parents), Inn from the Cold, Calgary (which opened Calgary’s first emergency shelter), Hope Mission in Edmonton, (also operates a 24-7 rescue van supplying blankets, lunches, and supplies needed by homeless individuals), Bissell Centre in Edmonton (providing shelter and warm meals), the Lighthouse in Saskatoon (offering shelter and affordable housing). In 2017 Vancouver offered over 300 spaces for homeless individuals, with funding from the province and the city. Ending homelessness, if indeed it can ever be ended, is complicated, and complex; meeting the needs of homeless individuals with mental illness and addictions is an added challenge and will require continuous support, innovative strategies, and a dedicated workforce, including health professionals and volunteers (Government of Canada, 2018c).

Mental Illness and the Justice System According to Correctional Service of C