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)
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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.
10
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 Canada, the number of
offenders identified as coping with mental illness and/or addiction
issues upon entering Canadian correctional facilities has increased
by 85% over the last 20 years. Current issues include the lack of
support and proper treatment for such individuals once they enter
the justice system, shortages of correctional officers to cope with
overcrowded prisons, who typically don’t have training and
expertise to deal with inmates with mental health and addiction
issues. As previously mentioned, drug use in prisons is an ongoing
concern, which, along with untreated mental illness, results in
violence among the prison population, suicides, and increased risk
for the safety of correctional officers (Government of Ontario, 2016).
Although not sufficient, mental health services do exist in forensic
hospitals and the forensic community network system with other
services provided by community organizations. Forensic refers to a
connection with the criminal justice system, including the courts,
related institutions, and individuals that work within that
framework. Individuals in correctional facilities who have significant
mental health problems are usually treated in forensic hospitals;
others not requiring care as an in-patient are treated within the
prison system; those who are on probation, or upon release, are
supported through forensic networks within the community.
Assessments determine where offenders fit within the forensic
mental health system. Those with more serious mental illnesses and
who have committed a serious crime most likely require treatment as
an inpatient in a forensic hospital; for example, a person deemed
mentally incompetent to stand trial is not criminally responsible for
the crime they committed.
Forensic hospitals are secure facilities that have the specialized
knowledge, treatment plans, and care to rehabilitate individuals so
they can stand trial and/or safely be reintegrated into the
community in compliance with review board regulations. Offenders
already in correctional facilities who require mental health services
may also be transferred to forensic hospitals as required (under the
Mental Health Act).
Community-based forensic mental health programs provide a
range of services with the goal of rehabilitation and successful
reintegration to the community. Health professionals implement
treatment and recovery plans that are based on the individual’s
needs.
Sometimes individuals who enter the justice system with
addictions are offered the option of accepting mental health and
addiction rehabilitation programs as an alternative to incarceration.
Programs vary with jurisdictions. Conditions are strict, but if met, an
individual can return to the community and receive counselling and
support if needed. Such programs are also part of the forensic mental
health system.
Transition Into the Community
Correctional Service of Canada implemented a program called the
Community Mental Health Initiative. Goals of this program include
identifying mental health problems on admission to a correctional
facility and developing a discharge plan with the help of clinical
social workers, providing ongoing support within the community,
ensuring that staff members are properly trained to provide
appropriate support and working collaboratively with community
services when an individual is released from custody. Clinical nurse
specialists also provide support in the community.
In Alberta, for example, mentally ill individuals, upon release,
receive care mediated by the criminal justice system through services
provided by correctional transition teams. Ongoing support is
maintained by registered psychiatric nurses (Government of Canada,
2015).
These multidisciplinary teams include registered psychiatric
nurses who both prepare and follow up with individuals before and
after release from prison. Since 2010, Alberta Health Services (AHS)
has been responsible for the delivery of health care services to
individuals in prison and after release in Alberta. Corrections
Transition Teams meet with clients in the correctional facility and
assist with their transition into the community (Government of
Alberta, 2018a, 2018b).
Mental Illness and Employment
Employment and income may be the most important determinant of
health, affecting not only working adults, but also their children and
other family members. A reliable, adequate income affects almost all
other determinants, from living conditions and food security to the
worker’s sense of productivity and self-esteem. The workplace itself
is important. Satisfaction with the workplace environment, and coworkers positively impacts a person’s mental and physical health.
On the other hand, a workplace environment that is negative, tense,
with unrealistic deadlines and work productivity demands, can be
stressful and intolerable. Stress and anxiety can exacerbate any type
of mental illness and also negatively affect individuals who consider
themselves mentally well. Consequences can be mild, from anxiety
that an individual can cope with, to severe anxiety, depression, and
posttraumatic stress disorder resulting from ongoing pressure,
negativism, and workplace harassment.
Approximately one quarter of the Canadian workforce report
some form of mental illness that interrupts their ability to work—
some take leave from work, and others are unable to work at all.
This is primarily due to unmet mental health needs (inadequate
services in terms of numbers and mix of services, including available
support and treatment). Depression and anxiety are among the
leading disorders affecting the mental health of Canadians in the
workforce. Depression alone cost the Canadian economy $32.3
billion, and anxiety disorders an estimated $17.3 billion annually.
Industries and businesses that report the largest need for mental
health support services exists within the areas of administrative
support and waste management; accommodation and food services;
and professional, scientific and technical services. If mental health
services were improved in terms of the numbers and mix of services
and accessibility, an estimated 352,000 Canadians suffering from
depression and anxiety alone (excluding other forms of mental
illness) would be healthy enough to enter the workforce annually
until the year 2035 (Conference Board of Canada, 2016a, 2016b).
Some workplaces have taken steps to reduce occupational stress
by providing support and implementing preventive strategies, such
as flexible working hours, work-at-home days, access to counselling,
“sleep rooms,” exercise facilities, and measures to improve job
satisfaction.
Increasingly, employers are held responsible for terminating
workers who display behaviours incongruent with workplace
standards, and later have been diagnosed with mental illness.
Human rights tribunals often rule in the plaintiff’s favour, using a
law known as the “duty to inquire,” which puts the onus on the
employer to investigate if odd behaviour is related to a mental health
issue. In addition, employees have the right to designated
accommodations allowing them to continue to work in the presence
of a mental illness. Usually the individual is not obligated to disclose
the specific nature of his or her mental illness to the employer, but
usually must provide official documentation from the employer if
the employee seeks special accommodation (Conference Board of
Canada, 2016b).
Thinking it Through
Pierre was exhibiting depressive behaviours at work. At times he
was argumentative and defensive. His work productivity slipped,
and he was often absent. After several warnings to “improve,” he
was terminated. Pierre filed a human rights complaint. His
employer was found to have wrongly terminated him and without
due process. The employer had to rehire Pierre, make
accommodation for his depression while Pierre was under
treatment, and reimburse him for lost wages.
1. Why do you think Pierre did not tell his employer about the
depressive episode?
2. What steps should the employer have taken other than
cautioning him to improve?
3. What can employers do to make the workplace less stressful
and to deal with employees experiencing a mental health
problem?
The Future of Mental Health Care
Changing Directions, Changing Lives is the first national strategy for
mental health. Released in 2012, the strategy primarily aims to
improve care for people diagnosed with mental illness across the
country and provide them and their families with the necessary
resources and support. The strategy acknowledges that even the best
and most coordinated treatments and services will fall short of
reducing the impact of mental illness in Canada, which remains in
crisis mode. As with physical health, the promotion of mental health
and prevention of mental illness are fundamental.
Despite the system’s problems, most experts believe the move
away from institutionalized care was the right one. Current thinking
still supports the concept of integrating mental health services into
existing primary care systems and improving interdisciplinary
collaboration on the part of all health care providers.
E-Mental Health
For many Canadians, mobile devices are a part of daily life, used for
business, educational purposes, accessing the news, and staying in
touch with friends and acquaintances. Platforms such as Facebook
and Twitter provide the baseline for social connectivity. Digital
technology is very much a part of health care with the widespread
use of electronic health records and electronic medical records,
sharing laboratory and diagnostic test results, and monitoring
patients’ conditions (e.g., diabetes, hypertension) remotely. E-mental
health technology is relatively new. However, individuals can
already connect to a variety of mental health services, thereby
improving access to health professionals, treatment, and support.
Other advantages of e-mental health include shorter waiting times
and improved access to services in the patient’s language. There are
numerous apps on mobile devices to assist individuals in accessing
web-based support, and self-help therapies, which have proven
effective in managing such disorders as depression, anxiety, and
posttraumatic stress syndrome. Mobile device apps can provide
mood-tracking options and social media support forums, giving
individuals an improved sense of control over their mental health
and treatment. E-mental health options are also valuable tools in
assisting individuals maintain balance and work to prevent mental
health issues. There are numerous online solutions, such as
mindfulness exercises to reduce anxiety, which can be accessed day
or night. Online resources provide a variety of services as described
in the following two cases.
Consider Leslie who is a somewhat anxious person prone to
anxiety attacks. She wakes up feeling overly anxious at 3 o’clock in
the morning; no therapist is available. She accesses an app on her
phone, which guides her through breathing and concentration
exercises that quiet her mind so that she returns to sleep, thereby
avoiding a full-blown anxiety attack.
Louise, a 16-year-old Indigenous girl, had been consuming alcohol
for a couple of years, sometimes with her parents, mostly with peers,
and mostly on weekends. She found herself drinking more during
the week, especially when she felt depressed about feeling isolated.
Her brother killed himself a year earlier and talking about “ending it
all” was not unusual conversation among her peers. She went to the
local health centre for advice. Counsellors were in short supply,
rotating into the community every couple of weeks. The nurse spent
time with Louise in addition to helping her download an app that
put her in touch with a peer support group of individuals with
drinking problems. Louise felt at ease with the support group.
Although anonymous, she made online friends from across Canada,
some from three larger cities (Toronto, Winnipeg, and Vancouver),
others from rural communities. She found out she was not alone
with respect to her drinking and her thoughts of suicide, and that
geography was not a unique factor contributing to her situation.
Someone from the group told Louise about an online Indigenous
resource that provided online counselling sessions and traditional
coping sessions. With the support of the nurse at the health centre,
and the online support, Louise was able to curb her drinking and
moved away from thoughts of suicide. She kept in touch with the
peer support group and was able to see a mental health counsellor in
her community every month (Mental Health Commission of Canada,
2017).
Caring for an aging population
More than three quarters of the population feel that Canada’s aging
population is a national concern. The underlying problem is the
increasing numbers of older Canadians proportionate to the rest of
the population and the impact this has on the health care system.
The cost of caring for an older population is significant, and caring
for this demographic is stretching resources. This situation poses two
questions: Does caring for a disproportionately large aging
population reduce resources and services available for everyone
else? Can the existing health care system provide mix, balance, and
availability of resources required to properly care for older
Canadians?
Statistics Canada predicts that between 2015 and 2021 the number
of older Canadians (over 65) will surpass the number of children
under the age of 14. By 2031 one in four Canadians will be over the
age of 65. This shift in demographics is caused by the baby boomers
(those born between 1945 and 1965) getting older, and the fact that
people are living longer (Statistics Canada, 2017a).
Advances in medical science and clinical practice have resulted in
people living longer—some with good health, but many others with
multiple chronic health problems requiring ongoing
medical/surgical intervention and support. Older Canadians use the
health care system more often, require more time, are more likely to
require expensive surgery such as a hip or knee replacement, or need
cataract surgery. Older Canadians are less likely to rebound from
some surgeries, often going on to require continued support at home
or in a long-term care facility. And as they age, the costs of services
and care rise.
Provider’s Time
On average, a healthy older Canadian does not visit the doctor more
frequently than anyone else, but older Canadians with multiple
chronic conditions do, and they require longer visits with their
provider.
Older Canadians (or older adults) rarely have just one health issue
when they visit their provider. The presenting problem may be joint
pain, indigestion, or generalized aches, but this invariably evolves to
the practitioner having to investigate more than one health issue,
which is difficult if the patient has a designated time frame with the
practitioner. In addition, older Canadians are more likely to be on
multiple medications that require constant updating and monitoring.
This means there is less provider time to spend with other patients.
On average, a physician or nurse practitioner can see about 24
patients in an afternoon (in a 4-hour time frame, averaging a patient
visit every 10 minutes). This is reasonable with intermediate and
minor health problems. Older Canadians are likely to take much
longer if there are multiple health issues to deal with, perhaps 30
minutes per visit; this would reduce to 12 the number of patients (on
average) a primary care provider could see in a 4-hour afternoon.
Multidisciplinary health care teams as well as nurse practitioners
(NPs) and physician assistants (PAs), have greatly improved access
to primary care for older Canadians. Services include those managed
by specialized nurses, dieticians, counsellors, diabetic and
hypertension clinics, and monitoring chronic conditions remotely
(e.g., lab values for individuals on blood thinners).
Timely access to specialists is difficult for all Canadians, with longer
waits for some surgical procedures such as hip and knee surgery,
primarily required by older adults. Wait times vary within
communities and also within provinces/territories, but often
benchmark wait times are not met (the benchmark time frame is 6
months for elective joint replacements, primarily hip and knee; and
48 hours for urgent surgery for fractured hips). Repairs for hip
fractures are the most common urgent surgical procedures
performed in Canada, with approximately 30,000 done each year. Of
interest is a research paper released in June of 2018 that found that
urgent surgery for a fractured hip, if done within 24 hours,
significantly lowered the rate of morbidity and mortality. Waiting
longer is associated with medical complications such as blood clots
(Pincus, Wasserstein, Ravi, et al., 2018).
There is an ongoing shortage of gerontologists across Canada,
although primary care practitioners often try to fill the gap. For the
most part, primary care physicians and nurse practitioners provide
medical care in long-term care facilities, referring residents to
specialists as required. They may take extra training in gerontology,
or supplement their knowledge base with courses online, or attend
specialized gerontology conferences.
Residential and Long-Term Care Accommodation
There is a shortage of long-term care (nursing home beds) across
Canada. Individuals on wait lists are coping at home with family or
community assistance, or waiting in hospital occupying an acute
care bed. Individuals waiting in hospital may have been admitted
from home because of declining physical or mental health (or both)
and there is no other place from them to go. Older adults are also
often admitted because of a fall, and particularly following surgery
may find that they can no longer manage independently. It is not
uncommon for an older person to become quite confused after
surgery, sometimes not returning to their previous level of cognition.
If the patient cannot be transferred to appropriate accommodation
promptly when ready for discharge, he or she must remain in an
acute care bed; this is a problem because that bed is unavailable for
someone who needs it (e.g., someone who has had a heart attack, a
stroke, or has been in a serious accident). Finding a transitional bed
of any kind, rehab, or long-term care bed (referred to as alternative
level of care bed) (see Chapter 5), because of wait lists in these
facilities. When a bed is found, there is no guarantee that the facility
will be in the person’s preferred area. In most jurisdictions a person
waiting in hospital for a nursing home bed for example, goes on a
central waiting list, and must take the first bed that is offered. After
that the person or their family can remain on a wait list in the facility
of their choice. See Case Example 10.1. The same often holds true
when trying to arrange home care services at the level the eligible
patient needs.
Case Example 10.1
Mr. Smith had a hip replacement and several days later is ready for
discharge. In hospital he occupied an acute care bed, as he needed
more intensive monitoring and care after the operation because of
complications. Now he is mobile with assistance, and his pain is
under control. He cannot quite manage independently so the
decision was made to find him a bed in a rehab facility (alternative
level of care bed).
What’s Next?
For the foreseeable future Canadians will continue to live longer,
many with more complex medical, physical, and cognitive health
problems. The number of aging Canadians with cancer is expected to
increase approximately 40% by 2030. This will necessitate a
corresponding increase in cancer treatment services, which are
already stressed. It is estimated that the number of Canadians living
with dementia will rise by an alarming 60% over the same time
frame. Of note, the risk of developing dementia doubles every 5
years after the age of 65. Most long-term care facilities have “locked
units” providing care for individuals with advanced dementia,
which involves more intensive nursing care and supervision. There
are innovative strategies and programs to promote memory comfort
and improve the quality of life for individuals with dementia, but
their care is still demanding and costly.
Long-term care facilities face severe shortages including beds (as
noted earlier) and health human resources. Private facilities are
available, but are well beyond what many families can afford.
The number of Canadians that cannot manage independently is
expected to double within the next 30 years. More and more families
will have to assume responsibilities for their loved ones with
dementia and other chronic conditions, responsibilities that are
frequently too difficult to manage. Currently an estimated one-third
of Canadians are designated as caregivers.
Did You Know?
The relative cost of health care increases with age. 2013 estimates
have calculated the increase to be 0.9% annually. The following 2013
costing estimates for designated age groups (cost per person) yields
a glimpse of how costs will continue to increase relative to age. For
those between 65 and 69 years old, the annual cost per person was
$6298; for those between 70 and 74 years of age, the cost was $8384;
for those between the ages of 75 and 79, the annual cost was $11,557;
finally, for individuals over the age of 80, the amount rose to
$20,917. This means that there is an annual difference of about
$14,702 between the average cost of someone between 65 and 69
years of age and an individual over the age of 80. In 2013 Stats
Canada showed that there were 1,231,448 Canadians over the age of
80. In 2017 there were 1,573,355 Canadians over the age of 80, an
increase of 342,907 people in 4 years. Based on the 2013 figures, the
cost of caring for Canadians over the age of 80 in 2017 was a
staggering $6,946,524,519 and the numbers and costs will only
continue to rise (Statistics Canada, 2018; Canadian Medical
Association, 2016).
Canada, along with numerous countries in the Organisation for
Economic Co-operation and Development (OECD), does not have a
national strategy of caring for older citizens. Although all
jurisdictions do have some type of framework, they vary in scope
and effectiveness. (OECD, 2013). There is general agreement that
Canada should have a national strategy to deal with its aging
population to coordinate services and ensure there is both equality
and consistency of care nationwide. (Senate of Canada, 2017). There
also needs to be a national mechanism to evaluate system
performance so that developing strategies are research-based,
logical, and effective. Performance mechanisms must consider the
needs of older Canadians across the country to help ensure the
recent targeted federal funding for long-term and community care is
properly used, and that best practices approaches are followed, and
solutions are shared across the board.
Examples of a best practices approach include developing
programs for healthy aging, devising strategies to combat ageism,
ensuring better coordination of health and social services for older
Canadians, establishing more clearly defined and transparent
methods for older Canadians to navigate the health care system.
A national strategy can also coordinate solutions for improving
home, community, and long-term care, and must address the
shortage of health human resources. Much can be learned from the
recent inquiry into the Wetlaufer case and how this nurse was able to
murder so many patients without being discovered. This case has
highlighted significant problems, including funding shortfalls for
long-term care facilities, difficulties in getting nurses to work in
long-term care (owing to low wages and often unappealing
workplaces), and ineffective strategies to hold staff accountable for
professional wrong-doing.
Thinking it Through
With an aging population, informal caregivers increasingly must
provide care for older family members. Almost 17% of these
caregivers report stress related to this role.
1. Do you think the use of informal caregivers is important to
keeping down the costs of caring for older Canadians?
2. What supports do you think the health care system could or
should provide to these caregivers?
Home and continuing care
Home care is recognized as a critical component of primary health
care. The current philosophy is that individuals can receive better
and more cost-effective care at home. In addition, people cared for in
the home appear to recover faster and are less likely to acquire an
institution-based infection.
The need for home care services in Canada is rapidly increasing
and is an essential component of the Canadian health care system.
These services are provided by an interdisciplinary team of health
professionals and supportive caregivers (also called “carers”) at
home and in the community, including nurses, physiotherapists,
speech-language therapists, and social workers. Other caregivers,
such as personal support workers or the equivalent, may provide
housecleaning, meal preparation, personal care, or shopping
services. Family members and friends also play a significant role in
providing home care for their loved ones.
The Problems
The demand for home care services (both short term and long term)
has grown, but services have not kept pace with the demand. Across
Canada, one in every six adults is receiving some level of home care
services, the majority of those older Canadians. In 2014 those
between the ages of 15 and 34 accounted for 29% of service usage;
those between 45 and 64 accounted for 31%; those between 65 and 74
used 13%; and those over the age of 75 used 27% of home care
services (Statistics Canada, 2014).
Older Canadians want to maintain their independence for as long
as possible. Living at home with the proper support is often a better
option to living in long-term or continuing care. Although home care
is more cost effective, many problems exist: insufficient numbers of
trained home care workers; limited provincial and territorial
insurance coverage for these services; inconsistent, poorly
coordinated, and poor-quality care; and scheduling or
communication problems between caregivers (Statistics Canada,
2014).
Did You Know?
Home care is provided for Canadians in their homes,
residential/senior’s residences, hospitals, and in ambulatory care
clinics. For example, in most jurisdictions an individual living in a
private senior’s residence can still apply for home care support.
Recipients of Home Care
Because more people are treated on an outpatient basis, have day
surgery, and are being discharged from hospital earlier after surgery,
the demand for short-term home-care services has grown
considerably. The need for long-term home care also continues to
grow for those who have complex medical problems, for individuals
with chronic conditions who are not sick enough to remain in an
institution or hospital, but who cannot manage independently; and
for those who, because of age or a disability, cannot live
independently, but can get by with a little help. Home care offering
specialized palliative support has also become a viable option for
persons wishing to die at home and for whom access to a hospice is
unavailable, or not a desired option.
Accessing Home Care Services
In most jurisdictions individuals requiring home care first need a
referral, either from a primary care provider, or some other central
agency. After a referral is received, the organization will determine
the specific need for home care services by conducting a needs
assessment. If proper home services are unavailable, the person in
question could end up in some type of residential care such as a
nursing home; alternatively, there may be increased demands placed
on family members to provide care, or pay for care privately
(Canadian Home Care Association, 2013).
Most jurisdictions continue to experiment with different funding
and delivery models in efforts for system-wide improvement. The
current mix of public/private funding mechanisms have resulted in
inconsistencies in home care services across the country.
The Future
All jurisdictions have a mandate to improve home care services with
the targeted funding received from the Federal Government in 2017.
This includes developing policies, procedures and strategies to
address problems, most of which are discussed above. It is important
to remember that the demographics of an older population vary
with jurisdictions, resulting in variation in funding formulas as well
as the specific needs and concerns in each community. There are
some common goals that most provinces and territories want to
achieve, most depending on an adequate financial base. These
include but are not limited to the following:
• Increasing the number of (funded) visits home care recipients
can receive from health professionals and support workers to
eliminate shortfalls in care required
• Developing a system to recruit and retain human health
resources
• Developing an effective strategy to make the best use of
existing resources
• Advocating for the recommended national “carers” strategy
to support and fund resources for individuals providing care
for family members (sometimes called care clients),
supported by the Canadian Home Care Association and the
Canadian Cancer Action Network
• Advancing the use of technology to improve access to, and
the coordination of services
• Improving safety in the home for both care providers and
patients by providing improved access to training for
providers, much of which could be available online (Home
Care Ontario, 2018).
As previously mentioned, the funding from the Federal
Government is to be distributed over 10 years, and the amounts per
year will vary with jurisdictions. Establishing an efficient, cost
effective, and comprehensive home care system in each province and
territory will take time. Effectively using home care services and
promoting a collaborative framework will optimize current
resources. Organizing services to avoid duplication and taking steps
to reduce supply wastage (e.g., supplies such as materials to do
dressings, intravenous equipment, syringes, ostomy supplies, etc.)
are also important steps that can be taken. Once supplies are brought
to a person’s home, they can no longer be used anywhere else.
Improving communication and organization of scheduling can
ensure that same care provider stays with the same care recipient as
long as possible. This improves the continuity of care and can reduce
time a care giver, familiar with the patient’s needs, spends on each
visit.
Thinking it Through
There are increasing calls for public health insurance plans to add
comprehensive home care services and medications to insured
services. However, if implemented, these additions will cost
enormous amounts of money that will compromise funding for
other services.
1. Do you think funding home care services and prescription
drugs is a good idea?
2. Can you see a workable compromise?
Drug coverage
Prescription drugs are the fastest-growing cost driver in the health
care system today. As discussed in Chapter 4, Canadians’ use of
prescription drugs has increased in general, but particularly so
among older Canadians, who tend to take more medications as they
age.
Funding
Although the provinces and territories provide some coverage to
vulnerable populations (e.g., low-income individuals, and older
adults), Canada has neither a universal pharmacare program nor a
national catastrophic drug plan, leaving a large portion of Canadians
unable to pay for the medications they need. As discussed in
Chapter 2, the Federal Government finances drug plans through
various agencies for selected Indigenous populations, veterans, some
members of the Royal Canadian Mounted Police, and federal
offenders; Citizenship and Immigration Canada covers drug costs
for specified refugee claimants, and the Department of National
Defence, for members of the Canadian Forces. There are still many
Canadians who carry no private drug insurance and suffer financial
hardship when they need medications.
The Future
The debate about a national pharmacare system and why Canada
doesn’t have one is important and frequently debated in the media.
Although the need for a national drug plan has long been
recognized and the topic is under consideration by all levels of
government, there are no concrete plans in place. The need for a
national strategy, however, is being considered at the federal level
(see Chapter 1). A national pharmacare plan would offer many
benefits, including the creation of a central agency to control the
price of drugs and to monitor the quality and price of new drugs
introduced to the market.
Cannabis
Cannabis became legal in Canada in October 2018 (see Chapter 8).
Concerns over decriminalizing recreational cannabis will continue to
evolve; some will be successfully addressed, and others will not, at
least in the short term. Issues are multiple, and include the
following:
• The use or misuse of cannabis in the workplace; should it be
banned much like alcohol? It is not against policy in most
workplaces if an employee goes to lunch and consumes a
small amount of alcohol, in that he or she does not appear
inebriated. How would you measure that regarding the
consumption of cannabis?
• Driving under the influence; how much is too much? Limits
must be established and the proper tools to measure how
high a person is must be readily available to law
enforcement officers. How accurate are subjective roadside
tests?
• Use in the armed forces is an ongoing concern where
individuals may be in combat, piloting aircraft, or operating
heavy vehicles such as tanks. Are small doses enough to
impede function and judgment?
• The provision for allowing individuals to grow four plants at
home is an issue particularly for landlords and people living
in condominiums, particularly if individuals exceed the limit
(and the potential for abusing this provision is huge).
Manitoba and Quebec plan to ban this provision.
• The Federal Government has stipulated that the possession
limit is 30 grams of dried cannabis, and individuals having
more than that can be charged; questions remain as to how
accurately that can be monitored, and what about the
possession of edible products?
• The availability of cannabis online is an ongoing debate; how
can it be controlled and kept out of the hands of youth?
• Concerns have arisen over how to keep edible cannabis
products away from children. Brownies, for example, if left
out would be something a child would likely be interested in
eating (New Brunswick requires that cannabis be stored in a
locked room or container). This is a difficult, if not
impossible thing to monitor.
• Many Canadians feel that there is not enough known about
the long-term effects of cannabis, especially in youth and
younger adults, or if it will be a stepping stone to individuals
using hard drugs.
Did You Know?
Cannabis is extremely toxic to pets (most commonly seen in dogs,
less so in cats); even licking out the pot in which marijuana
brownies were made can cause serious harm to a pet, as can
exposure to second-hand smoke. There is a real risk of a dog or cat
being severely compromised or even dying from cannabis ingestion.
Observable signs of cannabis toxicity include loss of balance
(staggering), drooling, dilated pupils or nystagmus, vomiting,
dribbling urine, breathing problems, and seizures.
Indigenous health care
Demographics
Indigenous peoples are the original inhabitants of what is now
Canada, and have lived here for millennia before first contact with
Europeans. Today Indigenous people include First Nations, Inuit,
and Métis. Overall, the population base is both growing and
younger than the rest of the population of Canada. In 2016 there
were 1,673,785 Indigenous people in Canada, representing just under
5% of the population of Canada. This population group has risen by
42.5% over the previous decade, more than four times the growth of
the country’s non-Indigenous population. The Indigenous
population is on average 10 years younger than non-Indigenous
Canadians, with a median age of 31.1 years. In 2016, 7.3% of the
Indigenous population was over the age of 65; this is expected to
double by 2036. Métis people have had the largest percentage of
growth, followed by First Nations, and then Inuit (Statistics Canada,
2017b).
The Indigenous population faces ongoing, multiple problems,
including compromised mental and physical health and wellness
overall, and a lack of adequate medical services. The causes are
equally complex. Significantly, the Indigenous population overall is
disproportionately affected by the socioeconomic determinants of
health, a situation, which is compounded by the generational impact
of colonization, residential schools, racism, and discrimination.
Although Indigenous peoples have a younger population
compared to the rest of the country, they have a higher incidence of
injury and chronic disease (e.g., obesity, diabetes, cardiovascular
disease), a higher morbidity and mortality rate in adults and
children, and a higher incidence of mental illness, family violence,
substance misuse, and suicide.
For the most part, the plight of the Indigenous population makes
headlines only when an overwhelming event occurs, such as a large
number of suicides, or drinking water contamination on a reserve, a
rash of suicides within a community, or a housing crisis. In 2012,
Chief Teresa Spence, widely known for her association with the Idle
No More movement, thrust First Nations people into the spotlight
when she went on a hunger strike to bring attention to the need for
livable housing on the Attawapiskat First Nations reserve (a
community north of Timmins, Ontario).
Despite crises and protests, Indigenous populations continue to
face large disparities in socioeconomic conditions. Even when
solutions to problems are identified (e.g., improved housing, water
treatment plants, access to supplies by improving infrastructure), the
required help is slow or inadequate in many communities. In 2017
the railway connecting Churchill, Manitoba, to the southern part of
the province was partially washed out in flooding. In 2018, repairs
had still not begun, with the Federal Government and the company
who owns the railway arguing about who should be responsible for
the cost. Everything had to be shipped in by air, or (during the
summer season) by boat, inflating the costs, and resulting in
shortages of everything from food to fuel.
Health Determinants and Challenges
As discussed in Chapter 6, the determinants of health affect the
extent to which a person, a community, or a population can grow,
adapt and enjoy a healthy, happy and productive life. Most
significant are the social determinants of health. To properly address
the continuing health inequities that impact the Indigenous
population, the context in which they occur as well as each group’s
history and culture must be considered. Biomedical causes of poor
health fade in comparison to those related to the social determinants
of health. Inequities imposed by one determinant leads to inequities
in another. For example, under-employment or unemployment leads
to poverty; poverty can lead to food insecurity, inadequate housing,
and overcrowding. Poor self-esteem, substance misuse, and family
violence can augment these problems. The mental and emotional
trauma resulting from residential schools profoundly affects the
ability of some individuals to cope in any environment, let alone one
in which disparities are so prevalent. Jennifer faces a number of
challenges as she embarks on motherhood, many related to the
determinants of health such as lack of adequate housing,
under/unemployment, and financial insecurity, but she remains
positive about her future. Jennifer and her family were not exposed
to residential schools.
Addressing Some Specific Issues
There are numerous other difficulties that are unique to Indigenous
populations, particularly those living in more remote communities.
For example, a large number of Indigenous youth do not complete
high school, in part because numerous communities do not have
secondary education. Teenagers must often leave their communities,
travelling long distances to attend high school. This means
separation from family, friends, and support systems, and in many
cases discrimination, which they are unlikely to be exposed to at
home.
Poverty and food insecurity are common. Causes include underor unemployment (related to lack of education or required skills, or
more likely, few job opportunities), the high cost of food (the more
remote the community the higher the cost), limited nutritional food
resources, and deterioration in opportunities to pursue traditional
ways of gathering food, especially living off the land, hunting,
trapping, and fishing; these resources yielded fresh, high quality
food that was a mainstay of traditional diets. Mental health issues
and emotional trauma also take their toll, especially if combined
with poor self-esteem and coping skills, lack of knowledge, and
experience on how to function as a family unit (often a direct result
of children being removed from their homes), depression, and
substance misuse.
Systems of Health Care Delivery for Indigenous People
Care partners
Indigenous Services Canada collaborates with corresponding
departments and organizations at the federal, provincial, and
territorial levels, and with Indigenous communities and health
providers, to coordinate and deliver health care to Indigenous
people (see Chapter 2 details health care services provided). The
collective goal is to improve socioeconomic conditions, thus
improving health and delivering health care services as equitably as
possible. Additional interventions and services are provided by
other organizations, municipal governments and the Public Health
Agency of Canada. Unfortunately, disruption of services occurs
frequently, primarily because coordination and communication
among the varying levels of governments, agencies, and other
stakeholders is lacking.
There is no consensus on the best approach to delivering health
care in an effective and culturally safe manner. Increasingly, it
appears that health care would be best controlled and managed
locally, for example, by bands in communities or on reservations.
Depending on local and provincial or territorial agreements, some
Indigenous groups have the option of managing their own health
care programs. Many communities have taken on this responsibility,
usually with reasonable success.
The concept bears a resemblance to regional health authorities (or
their counterparts), wherein people within a given community or
region can make decisions about the mix of services each population
group requires. Additionally, individuals from the community can
better motivate and direct fellow members of the community to
accept help, adopt balanced lifestyles, and participate in disease
prevention and health promotion utilizing traditional medical care
and in a culturally appropriate manner. A good example is the First
Nations Health Authority (FNHA) in British Columbia (the first
province-wide health authority in Canada), which in the fall of 2013
assumed responsibility for Health Canada’s First Nations and Inuit
Health Branch Pacific managing all aspects of health programming,
delivery, and finances. Among its many initiatives, the Authority
established the Health Promotion and Prevention Healthy Living
Unit supporting First Nations people in the region. Included in
addition to health promotion/disease prevention strategies is
ongoing culturally appropriate training for health and para-health
professionals. E-health programs the Authority has invested in use
various electronic technologies such as electronic health records,
telehealth capabilities, and Panorama, a software application used
nationwide connecting the FNHA to other health organizations
sharing information and promoting public health initiatives. The
FNHA functions under unique governance and accountability
guidelines and acts as a resource for Indigenous communities across
Canada wanting control over their own healthcare (First Nations
Health Authority, 2018).
Access to Services and any Provisions
It must be noted that Indigenous people can access the same health
care services as any other citizen or resident of Canada. Therefore in
an urban setting, or a rural setting close to hospitals and clinics, the
principles (of the Canada Health Act [CHA]) of access and
universality are more easily met than for those in geographically
remote communities.
Access and universality (conditions of the CHA) pose the greatest
challenge for those living in more remote communities, especially in
fly-in (no road access) regions (see Chapter 5). Almost all of these
communities have community health centres, small clinics, or
hospitals with a limited number of beds and services. Where
feasible, ambulance services (mostly air ambulances) are available
although limited. Larger fly-in communities with roads may have
road ambulances and use the air ambulance when residents must
leave the community.
Health Centres (replacing nursing stations) typically have one or
two examination rooms, a treatment room, and two or three beds in
case a patient requires a short-term stay or must wait for air
ambulance transport to a larger centre. Although health centres,
nursing stations and clinics they facilitate tend to be well equipped
by most standards, the extent of care provided is limited to less
serious conditions and trauma cases.
All too often, individuals with serious trauma or complex
conditions, those needing palliative care, screening procedures,
specialist’s visits, or women giving birth, must leave their
community for treatment. In fly-in communities, patients are
transported by air ambulance to the closest facility that can meet
their medical needs, usually without a choice of where they are sent.
For the most part parents can go with their children in an air
ambulance, but there have been situations when they have been
denied that opportunity. Jennifer’s story at the beginning of the
chapter reveals that she must go from Cape Dorset to Iqaluit if she
needs any diagnostic tests done relating to her pregnancy, even a
routine ultrasound. She also must be flown to the hospital in Iqaluit
up to a month before her due date to have her baby. That means she
has to stay in accommodation away from home even though she is
feeling well and is perfectly healthy. One of her wishes is to have a
midwife in her community, with facilities allowing her to stay with
her family and partner when their baby is born. In the Inuit culture,
childbirth is an important event involving immediate and extended
family. Traditional beliefs hold that the child chooses his or her
parents from the spirit world, and the delivery is the baby’s journey
from the spirit word to the family. Jennifer understands the rationale
for having go to a larger hospital for her delivery, and continually
says she is thankful for the extent and quality of prenatal care she
does receives in Cape Dorset.
Health Care Providers
Health Centres are primarily staffed by nurse practitioners and other
highly specialized advanced practice nurses (see Chapter 5),
registered paramedics, or a combination of these professionals.
Larger centres (and “larger” is a comparative term here) have a
limited number of doctors, usually general practitioners, who visit
neighbouring communities on a rotating or as-needed basis.
Practitioner Retention
Retaining medical and nursing staff is a challenge, however, and
turnover is high. Living in an isolated area is a significant deterrent,
especially when they are away from their families. Access to ongoing
education/professional development is a concern, although there are
more educational programs available online.
In an effort to retain practitioners in northern regions, provincial
and territorial governments offer financial, tax, and other benefits as
incentives (e.g., longer paid vacations, living allowances, educational
opportunities). Nurses usually work in remote communities on a
rotational basis which vary. Short rotations of 3 weeks in and out of
communities managed by Indigenous Services Canada. Otherwise, 1
to 3 months per rotation are usual with nurses, although at times a
nurse may be asked to stay longer if there are staffing shortages.
Nurses often establish bonds with individuals in their community,
which draws them back. The nurses provide care described as from
“birth to death” acting not only as primary care providers, but as
counsellors, and advisers to the people in the community.
Related Organizations
The Canadian Indigenous Nurses Association (CINA) provides support
and resources for nurses with an interest in Indigenous health. One
of the association’s many and ongoing objectives is to encourage
interest in Indigenous health and to facilitate the continuing
development of courses, within the Canadian health care system, on
Indigenous health and cultural safety in nursing. Another objective
is to make both the Canadian and international communities aware
of the health needs of Indigenous people in Canada and promote
Indigenous involvement in making decisions that impact their health
care services. The CINA partners with organizations, such as the
Canadian Nurses Association, to promote Indigenous health. The
CINA also collaborates with the Canadian Network of Nursing
Specialists, linking with 45 national associations each representing a
specialized area of nursing. This provides for the sharing of
specialized knowledge, philosophies, and concerns. The expertise
concerning Indigenous health care, traditions, and cultural practices
shared by the CINA go a long way to helping nurses across the
country provide culturally safe care across the country.
Culturally Safe Health Care
Many Indigenous people are concerned about the different
philosophies and treatment modalities between Western and
traditional healing practices. All too often Indigenous people receive
health care based solely on Western medical beliefs, practices, and
procedures.
However, a number of health centres in rural, urban, and remote
settings, although serving a general population, now focus on the
needs of Indigenous people within their catchment area and
incorporate traditional healing practices into their programs (Box
10.1).
Box 10.1
The Sioux Lookout Meno Ya Win Health
Centre.
Andaaw’iwewin egkwa Mushkiki (Traditional Healing Practices
and Medicines) is a culturally sensitive program that incorporates
traditional practices, principles, and spiritual healing ceremonies
that usually take place in a specially designed ceremonial room and
include vigils, smudging, and healing circles. The room has an open
fire pit with circular seating. Ya Win Health Centre has a roster of
traditional practitioners who are available to patients requiring their
services. These practitioners must go through a process of
certification administered by a traditional practitioners committee.
In addit