Royal College Environmental Scan - The Royal College of Physicians ...

Cutting through the health system information fog:

Royal College environmental scan

2014 Spring Edition

Introduction This environmental scan is an evergreen document. It synthesizes major health policy related events, data, and other information that were mostly released in 2013. In keeping with previous editions, this reference document provides a national overview of key indicators and trends in the following four domains: • Socio-demographic environment, • Political environment, • Economic environment, • Healthcare system environment: Access, quality, and human resources for health. It is hoped that this summary provides a useful snapshot of information that affected our healthcare system in 2013. Information considered relevant from previous iterations of the report has also been retained. We encourage Fellows and all other readers to contact us at [email protected] if they have any comments, questions, or to suggest new content areas for future iterations of this environmental scan.

Research, analysis and writing team Arun Shrichand, Senior Policy Analyst Danielle Fréchette, Executive Director Office of Health Systems Innovation and External Relations

Socio-demographic environment Health Conditions Chronic Diseases in Canada Chronic diseases are the leading causes of death in the world, accounting for 63% of deaths worldwide. 1 The gross impact of these diseases on deaths and disability resonates in Canada as well. Major chronic diseases such as cancers, diabetes, cardiovascular and respiratory diseases attributed for 72% of deaths in 2008 2, and in a 2011 survey 56% of Canadians aged 12 and over reported that they suffered from at least one common chronic condition. 3 Graph 1: Canada, Leading causes of death by proportion, 2011

All other 30%

Cancers 30%

Chronic lower respiratory diseases 5%

Heart disease and stroke 25%

Source: Statistics Canada, Leading Causes of Death, 2014

Diabetes 3% Alzheimer's disease 2.60%

Unitentional Injuries 4%

Cancer Cancer is the leading cause of death in Canada. Estimates project 187,600 new cases and 75,500 deaths in Canada due to cancer in 2013. 4 Mortality rates are expected to be higher for males than females, with 51% of a new cases leading to deaths in males, in contrast to 49% in females. 5

1

Cases per 100,000

Graph 2: Estimated cases per 100,000, by province, by gender, Canada, 2013 1000 900 800 700 600 500 400 300 200 100 0

Females

Males

3 9 4

3 7 0

3 8 5

3 4 4

3 7 0

4 3 5

4 6 2

4 9 1

4 7 2

4 9 0

5 0 0

4 3 7

ON

QC

NB

NS

PEI

NL

CDA

3 2 9

3 3 7

3 5 7

3 6 6

3 7 9

4 0 2

4 1 5

4 0 6

4 2 8

BC

AB

SK

MB

3 7 1

Source: Canadian Cancer Society, Canadian Cancer Statistics , 2013

Graph 3: Estimated new cases and deaths, major cancers, Canada, 2013 30,000 25,000

25,500

23,600

24,000

23,900

20,200

20,000 15,000

9,200

10,000 5,000 0

5,100

3,900

Prostate

Lung

Source: Canadian Cancer Society, Canadian Cancer Statistics, 2013

Breast

Colorectal

Total New Cases

Deaths

Over half (52%) of all newly diagnosed cases were lung, colorectal, prostate and breast cancers. 6 Lung cancers attributed to a little over a quarter of all cancer deaths. 7 Prostate cancer is the most commonly diagnosed cancer in Canadian males and breast cancer is most commonly diagnosed in females 8. Overall, mortality rates in cancer have declined in the last two decades, with notable decreases in lung, colorectal and prostate cancers for men and decreases in deaths from breast, cervical, and ovary cancers for women. Incidence rates, however, have increased in select cancers such as liver and thyroid cancer over that same time period. 9 Cardiovascular Disease Despite a dramatic decline in the rate of heart disease and stroke over the past 10 years (40%) 10, cardiovascular diseases remain as one of the leading causes of death amongst Canadians. Statistics Canada reports that in 2009, cardiovascular diseases accounted for over 68,342 deaths. 11 315,000 Canadians suffer from the effects of a stroke and it still remains as the main reason for hospitalizations, accounting for 38,341 cases. 12 The Cardiovascular Health in Ambulatory Care Research Team (CANHEART) health index, a measurement for optimal heart health, analyzed responses from 464,883 Canadians that participated in the Canadian Community Health Survey from 2003-

2

2011. Maclagan et al. found that according to their CANHEART health index (which is based on health behaviours and factors that influence heart health), less than 10% of adults and 20% of youth met the criteria for ideal cardiovascular health. The researchers cited increasing trends of overweight/obesity, hypertension and diabetes as key factors that have influenced these scores. 13 Diabetes Statistics Canada reports that in 2012, 1.9 million Canadians aged 12 and over reported living with diabetes. 14 The prevalence rates of diabetes increased by a staggering 70% from 1998-1999 to 2008-2009, with the greatest level of increase being observed in adults aged between 35-44 years. 15 A significant number of diabetics tend to have compounding chronic diseases to contend with. Over a third of Canadian adults with diabetes reported having two or more other serious chronic conditions. Diabetics are also over three times more likely to be hospitalized with cardiovascular disease than individuals without diabetes. It is perhaps no surprise that, although only 3.1% of all deaths in Canada are solely attributed to diabetes, almost 30% of all individuals who died in 2008-2009 suffered from diabetes along with other conditions. 16 Current incidence and mortality rates suggest that the number of Canadians living with diabetes will reach 3.7 million by 2018-19.

1,400,000

Graph 4: Age standardized prevalence and number of cases of diagnosed diabetes, aged one year and older, Canada, 1998-99 to 2008-09

1,200,000

0.05

1,000,000

0.04

800,000 600,000

Number of females

400,000

Number of males

200,000

0.03 0.02 0.01

Total Prevalence (%)

0

Cases

0.06

0

Source: Public Health Agency of Canada, Diabetes in Canada, 2011

Prevalence

Injuries Personal injury is the leading cause of death amongst children and young adults. In 2007, intentional injuries, namely suicides, accounted for nearly a quarter of all injury related fatalities. More than four million Canadians aged 12 years and older suffered an activity-limiting injury. Falls were the leading cause of injury in 2009-

3

2010, with over half of seniors and adolescents suffering from it. Almost half of all injuries for working age adults (20 to 64) were related to sports and work injuries. 17

Graph 5: Injury related causes of death, 2007

Homicides 3% Poisoning 9%

Suicides 24%

Falls 18%

Source: Statistics Canada, Injuries in Canada, 2011

The Royal College has f o r m e d the Advisory Committee on Injury Control and Reduction Advisory Committee (ICRAC). ICRAC’s membership includes physicians who are subject matter experts and the committee will provide advice and recommendations on injury reduction and control actions where the Royal College can have influence and effect under its mandate.

Transport related deaths 21%

Mental Illness The World Health Organization estimates that over a quarter of the world’s population suffers from one of more mental conditions during their lifetime. In terms of prevalence, mental illness arguably impacts the Canadian population at levels similar to major chronic diseases 18. Over a million Canadians are reported to experience a major depressive episode annually. 19 ln the 2012 iteration of the Canadian Community Health survey, 2.8 million Canadians (10.1% of the population) aged 15 years and older reported symptoms consistent with at least one mental or substance use disorder such as a major depressive episode, bipolar disorder, generalized anxiety disorder, and alcohol, cannabis or other drug abuse or dependence. 20

Specialty medicine must continue to strive towards enhancing the provision of health care to all Canadians, including those with mental illness. A commitment that the Royal College takes seriously – the College is partnering with the Mental Health Commission of Canada, Canadian Psychiatric Association, and the College of Family Physicians of Canada to explore approaches to support clinicians in providing optimal health care for patients with mental health conditions. The recently approved Mental Health Core Competencies lay the groundwork for future collaboration

Various epidemiological studies have revealed higher rates of major depression among females, young adults, once-married individuals (widowed, separated or divorced), and low income peoples. 21 The workplace environment has also elicited concerns over mental health; the Mental Health Commission of Canada estimates that mental illnesses account for nearly onethird of all short and long-term disability claims. Furthermore, the MHCC reports mental illness issues in the workplace costs $20 billion – nearly 40% of the total economic burden caused by mental illness annually. 22

4

Risk Factors Obesity The World Health Organization points out that overweight and obesity are the fifth leading risks for global deaths. Additionally, obesity is a major risk factor for numerous diseases, including cardiovascular diseases, diabetes, musculoskeletal disorders and certain cancers. Childhood obesity has also been associated with increased breathing difficulties, risk of fractures, hypertension, cardiovascular concerns and psychological effects. Globally, approximately 1.5 billion were reported overweight, and nearly 500 million people were obese in 2008. 23

As part of efforts of developing a national approach on health promotion and prevention, the F/P/T governments (excluding Quebec) have established a joint framework to address Childhood obesity. Actualizing the framework may be a challenge however. The CIHI and Public Health Agency point out that there is a dearth of evidence on effective interventions, stating that “Relatively few population-level obesity prevention and management interventions, especially public policy approaches that target broader environmental factors, have been systematically evaluated either for their effectiveness or cost-effectiveness. The need for more research is particularly pressing for obesity prevention, for which evidence of efficacy is limited to a small number of studies. (Public Health Agency of Canada, Obesity in Canada, 34) Curbing Childhood Obesity: A Federal, Provincial and Territorial Framework for Action to Promote Health Weights, can be accessed online at http://www.phac-aspc.gc.ca/hp-ps/hlmvs/framework-cadre/intro-eng.php

The preponderance of obesity is reflected in Canada as well. Looking at various Canadian surveys conducted between 1985 and 2011, Twells, Gregory, Reddington & Midodzi found that obesity rates have tripled during this time period. Based on linear regression analysis, the authors project that approximately 21% of adults will be obese by 2019. 24 Provincially, Statistics Canada's Canadian Community Health Survey reports New Brunswick recorded the highest prevalence of obesity at 28% and British Columbia had the lowest rates at 14.1%. As the graph below shows, apart from Yukon, all provinces and territories have witnessed an increase in self-reported obesity over the last decade. Graph 6: Prevelance (%) of self-reported obesity, by province, 2003, 2012, Canada

NL

PEI

NS

NB

MB

SK

AB

BC

NT

22.5% 21.4%

26.4% YK

22.6%

18.4% 21.3%

11.9%

15.9%

20.3%

18.8%

19.9% 18.7%

18.3% ON

14.1%

2012

25.4% QC

15.2%

20.6%

20.4%

21.3%

0%

20.8%

10%

14.1%

17.2%

15%

5%

2003

28.0%

25.1%

20%

26.10%

% of population

25%

26.3%

30%

NUN

Source: Statistics Canada, Health Indicator Profile, 2013

5

Smoking Smoking rates in Canada can be considered as a public health success story. Effective legislations and other interventions have been implemented at the F/P/T level 25, and more households and workplaces have become smoke-free. 26 As few as 16% aged 15 and above classify themselves as smokers, which is a new record low in Canada. 27 These rates are some of the lowest rates of smoking among OECD countries 28 such as the US, where 28% of adults 18 and above reported smoking cigarettes in 2012. 29 Notwithstanding, smoking undoubtedly remains a major risk factor to health outcomes in Canada today. It is the primary risk factor in respiratory diseases such as chronic obstructive pulmonary diseases, asthma, and lung cancer 30. Historical remnants of traditionally high smoking rates in Quebec and Atlantic Canada have been correlated to the high prevalence rates of lung cancer in the two regions today. 31 Taking Different Paths While smoking rates have declined, the prevalence of obesity and overweight in Canada has increased significantly over the last decade.

Graph 7: Obesity and smoking rates, 2003-2012, Canada 25%

% of population

20% 15% 10%

Current Smokers < 15 years Self Reported Obesity, Adults

5% 0%

2003

2005

2007

2008

2009

2010

2011

2012

Source: Statistics Canada, Health Indicator Profile, 2012 . Health Canada, Canadian Tobacco Use Monitoring Survey , 2012

Hypertension Globally, high blood pressure is the leading risk for mortality 32, linked to a host of issues to the arteries (ex. aneurism), heart (coronary heart disease, heart failure etc.), brain (stroke, dementia etc.) and kidneys (failure, scarring etc.). 33 Of Canadians aged 12 and above, 17.6% reported high blood pressure in 2011. Historically, females have reported higher blood pressure; however in recent years there has been a convergence between the two sexes. 34

6

Medical conditions such as obesity have been linked to high blood pressure; in 2011, 32.4% of Canadians who were obese reported having high blood pressure, compared to 15.8% of those who were not obese. 35

Health Indicators – How we compare The Conference Board of Canada, an independent research organization, publishes an annual report card on Canada’s performance on various socio-economic indicators compared on a global scale. The report, titled How Canada Performs, assesses population health status through an A-B-C-D grading system, based on the countries’ relative ranking to other peer countries identified in the report. As the table below shows, Canada ranked strong (A grade) compared to its peers in regards to self-reported health status, premature mortality, and mortality due to circulatory diseases. However, in indicators such as infant mortality and mortality due to cancer, diabetes and musculoskeletal diseases, Canada received a ‘C’ grade – potentially areas that merit further consideration moving forward.

Life Expectancy SelfReported Health Status Premature Mortality Mortality: Cancer Mortality: Circulatory Diseases Mortality: Respiratory Diseases Mortality: Diabetes Mortality: Musculoskeletal System Diseases Mortality: Mental disorders Infant Mortality

Canada Australia

B A

B A

A C A

Health Indicators: International Comparisons Denmark Finland France Germany Netherlands

D A

C B

B B

C B

B A

A A A

B D C

B A D

B B A

A B D

B

A

C

A

A

C C

B C

B D

A B

B

B

D

C

B

A

Norway Sweden

U.K.

U.S.

B A

B A

C A

A D B

A B B

A A C

B C C

D B C

A

C

C

A

D

C

A C

B A

B C

A B

B B

A D

C C

C

B

B

D

C

C

C

C

A

B

B

B

A

A

C

D

Source: Conference Board of Canada, How Canada Performs, 2013

7

D A

Populations at Risk Seniors Although Canada’s seniors are living longer, the physical and mental health of the population is an area of concern. The graph below highlights some of the health concerns facing this population group. Select health concerns facing seniors

Three out of every four Canadians aged 65 and older reported having at least one chronic condition*

43% of all new cancer cases will occur in people aged 70 and above**

From 1998-99 to 2008-09, seniors aged between 6064 years had the highest increase in incidence of diabetes***

Nearly half of seniors living in residential care are estimated to live with a diagnosis or symptoms of depression****

* CIHI, Health Care in Canada, 1 ** Canadian Cancer Society, Canadian Cancer Statistics 2013, 27 *** Public Health Agency of Canada, Diabetes in Canada: Facts, 17 **** Public Health Agency of Canada, Report on the State, 18

Canada, like many other nations, has had a notable shift in age distributions towards older ages. The 2011 Census shows that seniors accounted for 14.8% of population in 2011, up from 13.7% in 2006. From 2011 to 2031, Canada’s largest birth cohort, known as the ‘baby boom’ generation (born between 1946-1965), will turn 65 and the proportion of seniors will thus grow at a higher rate 36. Concerns have been expressed over the impact of this cohort on the health care system as a whole. According to the latest available data published in 2013, seniors aged 65 and older, who comprised approximately 15% of the total population in 2011, accounted for 45% of all health care spending in that year 37. While population aging at the aggregage level has been a very modest cost driver overall (contributing an annual average growth of only 0.9%), the patterns are quite variable across Canada, having greater effect in the Atlantic provinces and Quebec compared to Ontario and Western Canada for example. 38

8

Within this subset of the population, seniors aged 80 and above will be of particular concern, given the high costs of care for those near the end of life and those with multiple chronic conditions (which tends to be more prevelant 39 amongst older seniors) . In 2011, per capita spending by provincial and territorial governments for those 80 and older was $20,387, compared to $6,431 for those aged 65 40 to 69. As the graph below shows, seniors aged 80 and over are expected to double in numbers over the coming decades.

Keeping an eye on demographics will be all the more important in years to come. The increasing number of those aged 80 and over has proven to be an important driver of health expenditure growth

Graph 8: Population projection, older seniors aged 80 and over (millions), 2016 - 2036 3.5

population (million)

3

3.1

2.5

2.7 2.3

2 1.5 1

3.3

1.5

1.6

1.8

2.0

0.5 0

2016

2019

2022

2025

2028

2031

2034

2036

*Population estimate based on Medium-growth and historical migration trends from 1981-2008 Source: Statistics Canada, Population Projections for Canada, Provinces and Territories, 2010

Keeping these demographic shifts in mind, experts such as Samir Sinha, geriatrician and lead of the Ontario Senior Care Strategy, point out that hospital care needs to evolve accordingly. He states that “our current acute care model … was developed years ago when most adults tended not to live past 65 … and usually had only one active issue that brought them to hospital”. 41 Indeed, innovative models of geriatric care need to be incorporated across the continuum, from acute care to community and continuing care settings. It merits strong consideration for federal, provincial, territorial and municipal governments (who are now increasingly involved in providing long term care services) to establish a pan-Canadian senior strategy moving forward. Rural populations Canadians in rural areas have higher mortality rates due to high rates of circulatory and respiratory diseases, injury and suicide 42. Higher risk factors such as smoking, obesity and higher blood pressure 43 have also been reported in rural areas and this has been reflected in higher risks of hospitalization. 44

9

There are caveats however - research has intimated that certain rural areas, namely strong Metropolitan Influenced Zones (municipalities with more than 30% of residents who commute to work in an urban core 45) enjoy better health status to the extent that they are in fact less susceptible to certain health conditions than populations in urban areas. 46 Indigenous peoples Indigenous Peoples, who made up close to 4.3 per cent of the total Canadian population in 2011, suffer the worst health of any population in Canada. They face higher burdens of health issues in early childhood development, maternal health, community health, mental health, chronic disease and infectious diseases. 47 The prevalence of diabetes has been shown to be significantly higher among First Nations individuals (17.2%) on reserve compared to the general population (5%). The HIV infection rate for Indigenous Peoples is more than three and a half times higher than the non-Indigenous population. 48 Suicide and major depression rates are high and over a quarter have reported problems with alcohol and a third have experienced sexual abuse during childhood. 49 Obesity is also more prevalent among Indigenous Peoples with over a quarter of off-reserve Indigenous adults being obese in 2007/08 compared to 17.4% of non-Indigenous adults. 50 A 2006 study showed that 39% of Métis, 46% of First Nations not living on a reserve and 68% of Inuit were daily or occasional smokers, compared to 19% of the general Canadian population. One in 20 Indigenous people are former students of the oppressive Residential School System; these victims touch most Indigenous families and communities, perpetuating historical traumas from one generation to the next. 51 Low income peoples Social determinants of health Low socio-economic status groups have poorer health status, reporting lower life The health status of population groups such and higher expectancy rates 52 as Indigenous and low income peoples are hospitalization rates for conditions strongly influenced by limited access to social, cultural and economic resources including mental illness, diabetes, (which for Indigenous populations is further epilepsy, chronic obstructive pulmonary compounded by historical remnants of disease, asthma, heart failure and racism and colonialism). Addressing these 53 pulmonary edema and hypertension . social determinants of health are crucial to health and wellness equity at the individual, The growing income inequality that has community and jurisdictional levels. occurred since the late 1990s in Canada 54 does raise concerns that wealth distribution may continue to influence long term health outcomes in the future.

Utilizing mortality data from the 1991-2006 Canadian censuses, Tjepkema and Wilkins highlight the disparity in life expectancy amongst indigenous Canadians and low income peoples in comparison to the general population. As the graphs below illustrate, there is significant disparity in life expectancy at age 25 for males and females from the highest income quintile than those of indigenous ancestry and low income.

10

Graph 9: Males, Remaining life expectancy at age 25,by income adequacy quintile and indigenous ancestary 55.3

Highest income quintile 52.6

Total Cohort 48.5

Métis Lowest income quintile

48.2

Non-Status Indian

48.1 46.9

Registered Indian 40

45

50

55

Source: Statistics Canada. Tjepkema and Wilkins, 2011

60 Years remaining

Graph 10: Females, Remaining life expectancy at age 25,by income adequacy quintile and aboriginal ancestary

59.9

Highest income quintile

57.9

Total Cohort

52.5

Métis

55

Lowest income quintile

53.3

Non-Status Indian

51.1

Registered Indian

46

48

50

52

Source: Statistics Canada. Tjepkema and Wilkins, 2011

54

56

58 60 Years Remaining

11

Political environment 2014 Canadian federal budget With a majority government, the Conservative government passed its 2014 budget on February 11th, 2014. It has been billed as a ‘stay the course’ type budget, keeping spending at $279 billion 2014-2015, compared to $280 billion from the year before. 55 56 The Conservative government has stated that the budget is framed around reducing the federal deficit to $2.9 billion in 2014-15, and eventually balancing out to a $6.4billion surplus in 2015-16. Segments of the media 57 speculate this will likely be hailed as a speaking point for fiscal responsibility in the next federal election, which is slated for fall 2015. From a health care lens, some highlights include: •

•

•

•

The Territorial Health Investment Fund: A $70 million investment over three years to the three territories (Nunavut, Northwest Territories and Yukon), to reduce their reliance on outside health care systems and medical travel for care. Goods and Services Tax/Harmonized Sales tax exemption for Canadians receiving professional services from acupuncturists’ and naturopaths, similar to what is already in effect for other health providers such as doctors, dentists, nurses and optometrists. Enhanced funding (specific increase not revealed) for the federal Nutrition North Canada program, which provides subsidies to retailers that provide health foods to isolated Northern Communities. The program has been receiving 60 million a year since 2011. $44.9 million over five years to the government’s National Anti-Drug Strategy. The budget points out that prescribed opioid usage has increased by 200% since the year 2000, and the strategy is in response to the concurrent increase in prescription drug abuse that has been witnessed among Canadians aged 15 and above. The budget states that the funding will “educate Canadian consumers on the safe use, storage and disposal of prescription medications, enhance prevention and treatment services in First Nations communities, increase inspections to minimize the diversion of prescription drugs from pharmacies for illegal sale, and improve surveillance data on prescription drug abuse in Canada.” 58

12

End of the 2004 F/P/T Health Accord In December 2011, the federal government The 2004 accord formalized a surprisingly announced significant changes ten year agreement by First to the Canada Health Transfer (CHT), Ministers on a series of following the expiration of the 2004 commitments to improve Federal/ Provincial/ Territorial (F/P/T) Canada’s health care system. st Health Accord on March 31 , 2014. The The accord established a federal government announced that funding scheme that the following the 2016-2017 fiscal year, there federal government agreed to will no longer be an automatic 6% annual transfer to provincial/territorial increase (termed as the annual escalator) in governments mostly through health care funding. Instead, annual the Canada Health Transfer. increases in the Canada Health Transfer will be tied to nominal Gross Domestic Product (GDP), with a minimum 3% guaranteed. Based on long term trends, the Department of Finance projects annual increases of 4% annually. 59

Graph 11: Federal funding scenarios 60

Billions of dollars

55

50

6% increase

45

4% increase 3% increase

40

35

30

25

201213

201314

201415

201516

201617

201718

201819

201920

202021

202122

202223

202324

6% increase

29

30.74

32.58

33.54

36.61

38.81

41.14

43.61

46.22

48.99

51.93

55.05

4% increase

29

30.74

32.58

33.54

36.61

38.08

39.6

41.18

42.83

44.54

46.33

48.18

3% increase

29

30.74

32.58

33.54

36.61

37.71

38.84

40.01

41.21

42.44

43.72

45.03

Source: CBC News, Premiers Split over Flaherty, 2011

In response, the Council of the Federation (COF), a joint body comprised of Canada’s thirteen provincial and territorial health ministers, determined it needed to explore collaborative efforts in transforming the delivery of health care services across the country. The COF formed the Health Care Innovation Working Group, which released a report in 2012 recommending a pan-Canadian approach for provinces/territories in a myriad of areas including clinical practice guidelines, competitive pricing for pharmaceutical drugs, and team based models in areas affecting senior, aboriginal

13

and mental health. 60 However following the release of this report, the working group’s efforts have been limited to one area - pharmaceutical drugs. A set price for the six common generic drugs was established, resulting in annual savings worth $100 million to the provinces and territories. Additionally, the COF announced that it was currently in negotiations with suppliers of brand name drugs, which is anticipated to result in approximately $60-70 million savings annually. 61 The Federal government’s decision to redesign intergovernmental transfers is arguably merited. Experts have suggested that the automatic 6% escalator in 2004 Accord has encouraged “inflationary spending” 62. Bodies such as The Health Council of Canada, an independent national agency created following accord talks in 2003, have reported that although accord commitments around wait times have been promising, insufficient progress has been made around pharmaceuticals management, electronic health records and health innovation. The agency cited disparate levels of progress across jurisdictions in these areas and suggests that a lack of concrete targets established during the accord contributed to this inequity. 63 These concerns have also been highlighted by the Senate Social Affairs, Science and Technology, which tabled its progress report on the 2004 health accord in March 2012. These issues notwithstanding, the federal While a change in the status government’s changes to the Canada quo is welcomed, the expiry Health Transfer do raise a number of of the 2004 Health Accord concerns. For instance, the Office of the Parliamentary Budget Officer (PBO), raises numerous questions which provides independent financial around the fiscal burden analysis to Parliament, has voiced being placed on concerns in its annual Fiscal Sustainability provinces/territories. Report, stating that "the federal fiscal room created by the change in the CHT escalator has transferred the fiscal burden to provinces and territories and raised the fiscal gap of the PTLA [provincial, territorial, local and aboriginal governments].” 64 The COF has also echoed these fears - projecting that over a ten year span, provinces/territorial governments lose up to $36 billion in CHT funding due to changes to the annual escalator, which leaves them in a “less sustainable” fiscal situation. 65 Looking beyond the changes in the annual escalator, there are also tensions regarding the revamped transfer formula utilized in the new CHT model. The Martin government’s CHT model was redistributive in nature, considering provinces’ capacity to raise tax revenues as part of their funding formula. In contrast, the Harper government’s CHT model abandons these equalization-type measures and adopts a purely per capita based formula (funding based on population numbers). Unlike the annual escalator which comes into effect in 2017-18, this new nonequalized formula is phased in 2014-2015. The graph below highlights the differences in distribution between the Martin government’s CHT and the Harper government’s CHT in 2014-2015. Under Harper’s CHT, all provinces are expected to receive $899 per resident. Therefore, British Columbia and Newfoundland and Labrador (who received a larger share of dollars per capita under the Martin CHT) are expected to incur the largest loss, losing $56 and $107 per resident respectively. Whereas wealthy Alberta, which received the lowest per capita transfer under the Martin CHT, will be the sole gainer under the Harper CHT with an increase of $235 per resident ($954 million in total absolute terms). Not surprisingly, this discrepancy has drawn the ire of certain provincial governments, who claim that the Harper CHT

14

model does not acknowledge the distinct costs and population health needs (e.g. higher proportion of seniors in provinces such as PEI and British Columbia) 66 unique to their respective provinces. Graph 12: Distributional impact of Harper and Martin governments' CHT formula, 2014-2015

1100 1000

$ per capita

900 800 700 600 500 B.C.

Alta.

Sask.

Man.

Ont.

Source: Marchildon and Mou, The Conservative 10-year Canada

Que.

N.B. Martin CHT

N.S

P.E.I.

N.L.

Harper CHT

Lastly, there is the overarching question around what should be the appropriate role of the federal government in health care. The Royal College strongly believes that the federal government has an important role to play. The Harper Government’s decision to revamp the CHT without conditional funding (which was also a shortcoming of the 2004 Accord-agreed CHT 67 68) and an overall lack of direction on fundamental reforms needed in Canada’s health care system are disconcerting. The Canadian public has also appealed for further federal leadership. In a survey conducted for Health Canada by the Strategic Counsel, participants believed the federal government could play a role in a wide array of areas, including audits of the provincial health care systems, acting as a bulk purchaser of drugs, regulating the drug market more effectively, and accelerating the integration of foreign trained doctors other health professionals. 69 Thus far however, the Federal government has steadfastly resisted such calls, pointing out “it will play a leadership role in areas where it has clear jurisdiction”. 70

Changes to the CHT transfers also puts into question the overarching role of the federal government in health care moving forward. The Royal College believes the federal leadership has an important role to play. You can check out various government submissions where the Royal College’s calls for a national human resources for health observatory, among other pan-Canadian initiatives, online at the following URL (http://www.royalcollege.ca/portal/pa ge/portal/rc/advocacy/submissions.)

15

Economic environment Canadian economy: Overview The Bank of Canada reports that Canada’s economy has benefited from improvements in global financial markets. There has been an increase in long-term interest rates in advanced economies and Europe has stabilized following the debt crisis that occurred a few years ago. The Bank of Canada notes that Canada’s domestic markets have been relatively stable, with Canadian banks having continued access to funding markets at attractive rates, and healthy balance sheets. 71 Annual % change

Indicator

2000-2012

2013f

2014f

2015f

Real GDP

2.2

2.0

2.2

2.5

Unemployment rate (%)

7.1

7.0

6.8

2012f

2013f

-16

-4.2

4.2

-18,929

-16,000

-

2000-2012 Federal Budget balance -4.5 ($billions) Provincial Budget Balances -1,924 ($millions) Source: Scotiabank Group, Global Forecast Update, 2013

Notwithstanding, the central bank warns that Canada remains vulnerable to the external pressures of the euro crisis and low interest rate environment in major advanced economies. Internally, the Canadian housing market, namely rising prices and high debt, pose a risk to the stability of the Canadian financial system moving forward. 72

7.1 $millions 2011e

Although not an immediate concern, upsets in the global economy could have serious effects on the Canadian economy

Health expenditure Total spending on healthcare in Canada is estimated to be $205.9 billion in 2012, and is forecasted to reach $211.2 billion in 2013. Canada spent $5,902 per capita in 2012 and is forecasted to spend $5,988 per capita in 2013. 73 Graph 13: Total health expenditure, Canada 1990-2013 250,000.0

$ Billions

200,000.0

Current

Constant (1997)

150,000.0 100,000.0 50,000.0 0.0

Source: CIHI, National Health Expenditure Trends, 2013

As a proportion of GDP, total health expenditure in Canada was 11.3% in 2012 and it is expected to stay consistent at around 11.2% in 2013. 74

16

Graph 14: Total health expenditure as a percentage of Provincial/Territorial Gross Domestic Product, Canada, 20002013 Percentage

14.0 12.0 10.0

9.2

9.7

10.0

10.2

10.2

10.2

10.4

10.2

10.5

11.6

11.6

11.4

11.3

11.2

8.0 6.0 4.0 2.0 0.0

Year Source: CIHI, National Health Expenditure Trends, 2013

In international comparisons, statistics from 2011 show that Canada’s health expenditure as a proportion of GDP was above the United Kingdom’s and Scandinavian countries’ such as Sweden, Norway and Denmark. However, the divergence is much more significant in the United States, which recorded the highest ratio to GDP at 17.7%. 75 Graph 15: Total health expenditure as a % of GDP, select countries, 2011 Norway

9.3%

UK

9.4%

Sweden

9.5%

Denmark

10.9%

Canada

11.2%

Germany

11.3%

France

11.6%

Netherland

11.9%

US 0.0% 5.0% Source: CIHI, National Health Expenditure Trends, 2013

17.7% 10.0%

15.0%

20.0%

Public-Private expenditure The public-private sector share of total health expenditure has remained stable, maintaining approximately a ‘70-30’ split proportionately since 1997 76. In 2013, it is forecasted that the public sector will spend $148.2 billion (70.1%) on health care. The private sector, which primarily consists of health expenditures by households and private insurance companies, will account for $63 billion of spending. The annual growth rates in private sector spending are forecasted to expand at 3.4% and 2.9% in 2012 and 2013 respectively, outpacing growth rates projected in the public sector. 77 Use of funds Hospitals remain the largest component of health care spending, forecasted to amount up to $62.6 billion, 29.6% of total health expenditure in 2013. 78 Drug expenditures and physician services follow, with the former accounting for 16.3%

17

and the latter amounting to 14.8% of healthcare spending. Hospitals and physicians were primarily funded by the public sector while drugs and other health professionals received the majority of financing from the private sector. 79

Graph 16: Proportion of total health expenditure, by sector, 2013* Note: Numbers have been rounded to the nearest percentage. Source: CIHI, National Health Expenditure Trends, 2013

Private Sector , 29.90% Public Sector, 70.10%

Private Sector expenditure, by use of funds, 2013

Other Health Spending* 14%

Hospitals 9%

Public Sector expenditure, by use of funds, 2013 Other institutions 11% Physicians 1%

Drugs 35%

Other Professiona ls (Dental, vision etc.) 30%

Public Health 7%

Other Professionals (Dental, vision etc.) 1%

Other Health Spending* 13% Hospitals 39%

Drugs 8%

Physicians 21%

* spending on capital, public health, administration, research etc.

Other institutions 11%

* spending on capital, public health, administration, research etc.

Fee-for service (FFS) payments represent about 75% of total payments to physicians in Canada, but will it continue to do so in the future? The 2010 National Physician Survey (NPS) suggests otherwise – while nearly half of all specialists report using FFS exclusively, only a third of specialist physicians aged under 35 report doing so, and instead prefer a blended method of payment. What impact will a shift away from FFS and one towards alternative compensation models have on the overall costs of health care in Canada?

18

Provincial Overview In 2012, provincial and territorial government health expenditures are forecast to amount to approximately $135 billion. 80 As the table below shows, total health expenditure per capita varies across the provinces and territories. The territorial governments reported the largest per capita spending in the country. Newfoundland and Labrador and Alberta are forecast to spend more per person than any other province, while Quebec and British Columbia will record the lowest per capita expenditures at $3,651 and $3,721 respectively. 81

Province

Provincial/Territorial Expenditure $ 000,000

N.L.

$per capita

$ 2,685.2

$ 5,249.31

P.E.I

$ 622.4

$ 4,245.15

N.S.

$ 3,914.6

$ 4,124.13

N.B.

$ 3,153.2

$ 4,166.81

Que.

$ 29,630.4

$ 3,651.24

Ont.

$ 50,864.2

$ 3,722.57

Man.

$ 5,602.6

$ 4,380.81

Sask.

$ 4,986.9

$ 4,565.75

Alta.

$ 18,410.4

$ 4,661.84

B.C.

$ 17,481.3

$ 3,721.57

Y.T.

$ 253.0

$ 6,909.56

N.W.T

$ 310.7

$ 7,104.71

Nun.

$ 357.0

$ 10,498.86

An Uncertain Future Ahead In the environs of an growing and aging population, chronic diseases, wait times, and With federal dollars declared decline in federal dollars following the expiry of following the end of the 2004 the 2004 Health Accord funding agreement in Health Accord and 2014, provincial/territorial governments will provinces/territories concerned face difficulties regarding spending and about their fiscal capacity, who questions on how to achieve sustainability of the health care system moving forward. bears the burden of paying for Projected growth rates of private sector health care? spending (pg.17) may further expand as a counter-point to these ongoing public spending pressures. As technology progresses, more services may shift from expensive hospital settings – the traditional sphere of Medicare coverage – to homes and communities. “Passive privatization” in healthcare funding is arguably already taking shape. For instance, in mental health there has been a shift from treating patients in the hospital (e.g., hospital employed psychiatrists) towards treating patients in the community (e.g. psychologists in private practice). Home care and access to outpatient prescription drugs are also two examples outside of the hospital setting where Canadians often assume out of pocket costs. 82

19

While the Royal College recognizes that the involvement of the private sector in health care is a reality in Canada, the Royal College has also long affirmed its support for Canada’s public health care system and the principles enunciated in the Canada Health Act. 83 In light of this, the Royal College will closely monitor these potential trends moving forward.

Passive Privatization is not only reflected in increased private spending (pg.17) but a number of previously covered services are also being delisted from provincial health insurance plans such as select psychological and optometry services.

20

Health System Environment: Human Resources for Health

Access,

Quality

and

Wait Times Following the establishment of evidence based benchmarks on certain ‘priority areas’ in December 2005, there have been positive trends in cancer treatments, cardiac surgery, hip and knee replacement and cataract surgery. National estimates show that approximately eight out of 10 patients receive priority procedures within an appropriate time frame. 84 Access to radiation therapy to treat cancer in particular has been quite encouraging, with 97% of all patients getting treatment within four Since 2011 however, CIHI notes that national progress towards weeks. 85 benchmarks has largely stagnated. 86 As the table below outlines, significant variances continue to exist between the provinces. Proportion patient’s accessing care within wait time benchmarks, by Priority area, April to September 2013, by Province

Benchmark Hip replacements ≤ 26 weeks Knee replacements ≤ 26 weeks Hip fracture repair ≤ 48 hours Cataract surgery (high risk) ≤ 16 weeks Radiation therapy for cancer ≤ 4 weeks

B.C. 76%

Alta. 80%

Sask. 77%

Man. 68%

Ont. 89%

Que. 81%

P.E.I 80%

N.L. 92%

N.S. 58%

N.B. 69%

CAN 82%

65%

72%

66%

58%

85%

78%

61%

93%

43%

60%

76%

83%

85%

82%

89%

83%

n/a

75%

82%

82%

84%

83%

81%

66%

70%

62%

81%

88%

54%

95%

72%

88%

81%

94%

98%

98%

100%

98%

98%

92%

97%

90%

97%

99%

Minimum 5% growth since 2011 in the % of patients receiving care within benchmark. Minimum 5% decline since 2011 in the % of patients receiving care within benchmark. Source: CIHI, Wait Times in Canada, 2013

There are certain instances where the divergence between provinces is significant. Approximately nine in 10 Quebecers who are at high risk receive cataract surgery within 16 weeks, in contrast to only six in 10 in Manitoba. For knee replacements, the proportion of citizens receiving surgery within the established benchmarks is significantly higher in Ontario (85%) than Nova Scotia (43%). In Prince Edward Island, there has been a disconcerting decline in the province by at least 10% from 2009 to 2011 in the proportion of patients having hip and knee replacements, and cataract surgeries. 87

21

The abovementioned variances however highlight the fact that not all Canadians have benefited from improvements in wait times. Indeed, more work needs to be done, including uptake of reporting procedures beyond the five priority areas such as cancer care, diagnostic gastroenterology, and imaging 88, psychiatry. 89

In the 2010 National Physician Survey, physicians rated access in the priority areas accordingly: • • • •

50 per cent of family physicians (FPs) rate access to orthopedic surgeons as fair to poor, 15 per cent of FPs rate access to cardiac care services as fair to poor, 13 per cent of FPs rate access to cancer care as fair to poor and 37 per cent of all physician rate access to advanced diagnostic services (e.g., CTs, MRIs) as fair to poor.

Source: 2010 National Physician Survey (CFPC, CMA, Royal College)

Wait Times: The impact of alternate levels of care stays The Wait Times Alliance (WTA), a coalition of various medical national specialty societies, argues that alternate levels of care (ALC) stays are a growing detriment to wait times in Canada. ALC generally refers to patients who continue to occupy an acute care hospital bed after the acute phase of their inpatient stay is complete. The WTA points ALC patients accounted for 14% of hospital beds in 2007-2008, which results in long wait times and overcrowding in emergency departments. An aging population (vulnerable to health concerns such as dementia), combined with lacking institutional and community support for chronic care patients has exacerbated concerns. The report, Time for transformation: Canadians still waiting too long for health care can be accessed online at the following URL (www.waittimealliance.ca).

Quality of Care: How Canada measures up internationally The OECD has developed 30 indicators that allow international comparisons on aspects of quality of care. Canada ranks highly on certain indicators such as keeping low hospital admissions for asthma and diabetes, influenza vaccinations in seniors 90 and also fares well in screening and survival rates for breast, colorectal and cervical cancer. 91 Graph 17: Avoidable admissions, Asthma and Diabetes, select OECD countries Hospital discharges per 100,000

250

Asthma

217.2

Diabetes

201.4

200 150

117

100

81.2 54.2

50 0

13.6 Canada

19.6 Germany

60.8

71.8

11.4 Italy

United Kingdom

United States

Source: CIHI, International Comparisons, 2014

22

percentage

Graph 18: Breast cancer survival rate: Five-year survival rate, select OECD countries 90.00% 88.00%

89.30% 87.70%

86.30%

85%

86.00%

84.50%

84.00% 82.00%

80.70%

80.00% 78.00% 76.00%

Canada

Germany

Sweden

Source: CIHI, International Comparisons, 2014

United Kingdom

United States

OECD average

In the areas of patient safety and adverse events however, Canada does not fare as well. Canada reported high rates of obstetric trauma 92 and a number of cases where unwanted foreign bodies were left in during procedures. 93 Graph 19: Number of cases of foreign body left during procedure per 100,000, select OECD Countries

United States 4.1 Canada 8.6 United Kingdom 5.5

France 6.2

Italy 3.5

Germany 5.5

Source: CIHI, International Comparisons, 2014

Human Resources for Health (HRH) This section outlines key statistics and information on the physician workforce in Canada. Focusing primarily on specialist physicians, the section highlights HRH data about the number of physicians, their age and sex, and Canadian/International Medical Graduates. The majority of the physician workforce data included in this scan has been collected through two major data holders, the Canadian Institute of Health Information (CIHI) and the Canadian Medical Association (CMA) Masterfile.

23

This section also includes new findings from the Royal College’s research on specialist physician employment challengs. Physicians in Canada: Heads Counts and Physician to population Ratios The CMA Masterfile reports that in January 2014, Although commonly there were 74,788 physicians practicing in used, there are a Canada (36,485 specialists and 38,286 family number of limitations These numbers, which reflect physicians). 94 associated with head headcounts, have increased consistently and have in fact outpaced the growth of the Canadian counts and physicianHowever, this population in recent years. 95 population ratios. These growth in numbers has largely compensated for issues are highlighted on a number of factors including: the acute page 25-26. shortages of physicians experienced in the late 1990s and first decade of this century, more complex patient needs (e.g., aging population, the burden of chronic diseases and co-morbidities), and changing practice profiles (e.g., increasing demands on physician’s time for paperwork and administrative duties 96). These and other influencers on the medical supply underscore the need for further progress in medical workforce planning. Graph 20: Number of Family Physicians and Specialists, Canada, 2000-2014 40,000 38,000 36,000

Number

34,000 32,000 30,000 Family Physicians

28,000 26,000

Specialists

24,000 22,000 20,000

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Source: CMA Masterfile, January 2014

In specialty medicine, growing numbers have been observed in many disciplines and across most provinces as well.

24

2014

Graph 21: Number of physicians, select specialties, by year 2002, 2014 4500

2002

Source: CMA Masterfile, January 2014

Graph 22 Number of specialists per 100,000 Population, by province, 2002, 2012

99

107 91

90

2012 80

88

0

N.L. P.E.I. N.S. N.B. Que. Ont. Man. Sask. Source: CIHI, Supply, Distribution and Migration, 2003, 2013

Alta.

B.C.

0 9

32 23

30 13

95

80

2002

61

64

55

20

66

99

108

60 40

102

84

80

104

114

per 100,000

100

123

120

120

140

Y.T. N.W.T. Nun.

In 2012, Nova Scotia had the highest proportion of specialist physicians, recording 123 specialists per 100,000. Since 2002, Newfoundland and Labrador reported the largest gains in the proportion of specialist physicians in a province (progressing from 66 to 114 specialists per 100,000 in 2012). The Northwest Territories was the only province or territory to record a drop in numbers over this time period, falling down from 38 specialists to 23 specialist physicians per 100,000 in 2012. It is important to point out that there are a number of of limitations associated with head counts and physician-population ratios when it comes to workforce planning. Head counts and physician-population ratios assume that all physicians provide services in equal quantity and which are uniform in nature—well known to be

25

1517

1148

1186

1082

1918

1589

1835

1813

3947

2458 1280

2095

0

1939

500

2368

1500

922

2000

2426

2500

2389

3144

3000

2743

3500

1000

2014

4169

4000

inaccurate. The effects of team based models and expanded or complementary scopes of practice of other health professionals are also not factored in these statistics. Lastly, and perhaps most importantly, headcounts and physician to population ratios do not provide any sense of patient “need” for health care. Recognizing these issues, other methodologies have been devised to offer a more accurate representation of physician supply. For instance, the full time equivalent (FTE) methodology developed by CIHI utilizes physician payments as an output measure to estimate whether a physician is working full time. 97 As the graph below shows, FTE counts paint a different picture on the number of specialist physicians per 100,000 in the country. Graph 23: Number of specialist physicians per 100,000 population, by province , by FTE and headcount, 2011-2012, 2012 FTE Count (2011-2012) * **

140

Headcount (2012)

Man.

58 99

Ont.

80

45

52 107

61

Que.

91

N.B.

102

120

43 123

48 104

40

38 84

59

60

68

80

74

100

114

per 100,000

120

20 0

N.L.

P.E.I.

N.S.

* Does not include Anesthesia specialists

Sask.

Alta.

B.C.

**Based on Fee-for-Service Billings

Although certain limitations of the FTE methodology are widely recognized, such as being based on fee-for-service income data, FTE counts arguably better depict physician human resources than simple headcounts. Specialist Physicians in Canada: Age Looking at both ends of the professional lifecycle, 42.3% of specialist physicians were aged 55 and over while approximately 30.7% were aged 44 and under in 2014. 98 From a discipline specific lens, Pediatric Emergency Medicine, Pediatric Hematology and Critical Care Medicine counted the highest proportion of physicians aged 44 and under amongst medical specialties. Given that the disciplines are still relatively young, this is not altogether surprising. In contrast, Cardiology (pediatric stream) and Occupational Medicine reported the largest proportion number of senior physicians, aged 55 and above, 100% and 83% respectively. It is also worth noting that more than half of the medical workforce in psychiatry, dermatology, and public health and preventative medicine were equally aged 55 or more.

26

Graph 24: Medical Specialists, proportion of physicians aged 44 and under, top ten disciplines, 2014 Pediatric Emergency Medicine

100.0%

Pediatric Hematology

93.3%

Critical Care

87.4%

Adolescent Medicine

80.0%

Neonatal Perinatal Medicine

73.3%

Developmental Paediatrics

71.4%

Neuroradiology

50.0%

Child and Adolescent Psychiatry

48.4%

Nephrology

44.4%

Gastroenterology

43.8%

Source: CMA Masterfile, January 2014

0%

20%

40%

60%

80%

100%

120%

Proportion aged 44 and under

Graph 25: Medical Specialists, proportion of physicians aged 55 and above, top ten disciplines, 2014 Cardiology (pediatric stream)

100.0%

Occupational Medicine

69.8%

Psychiatry

54.8%

Public Health & Preventative…

53.7%

Dermatology

51.5%

Rheumatology

46.4%

Paediatrics

44.5%

Nuclear Medicine

44.4%

General Internal Medicine

43.5%

Neurology

43.2%

Source: CMA Masterfile, January 2014

0%

20%

40%

60%

80%

100%

120%

Proportion aged 55 and above

Amongst surgical specialties, Gynecologic Oncology and Colorectal Surgery counted the highest proportion of surgeons aged under 45 at 100% and 90% respectively. Whereas Cardiothoracic Surgery and Ophthalmology counted the largest proportion of surgeons aged 55 and above, at 83.2% and 49.9% respectively.

27

Graph 26: Surgical Specialists, proportion of Surgeons aged 44 and under, By Discipline, 2014 Gynecologic Oncology

100.0%

Colorectal Surgery

90.0%

General Surgical Oncology

78.6%

Maternal Fetal Medicine

75.7%

Gynecologic Reproductive Endocrinology & Infertility

55.6%

Cardiac Surgery

47.5%

Otolaryngology

33.8%

General Surgery

33.3%

Orthopaedic Surgery

33.0%

Neurosurgery

33.0%

Plastic Surgery

30.9%

Urology

30.6%

Obstetrics & Gynecology

30.1%

Thoracic Surgery

26.0%

Paediatric General Surgery

26.0%

Ophthalmology

24.3%

Vascular Surgery

22.7%

Cardiothoracic Surgery

0.0%

0% 20% 40% 60% Proportion aged 44 and under

Source: CMA Masterfile, January 2014

80%

100%

120%

Graph 27: Surgical Specialists, proportion of Surgeons aged 55 and above, by Select Discipline, 2014 Cardiothoracic Surgery

83.2%

Ophthalmology

49.9%

Vascular Surgery

45.5%

Urology

43.3%

Plastic Surgery

42.8%

Obstetrics/Gynecology

42.2%

Otolaryngology

41.0%

General Surgery

39.1%

Orthopaedic Surgery

38.8%

Neurosurgery

38.5%

Thoracic Surgery

33.0%

Paediatric General Surgery

32.5%

Cardiac Surgery

9.3%

Maternal Fetal Medicine

2.7%

Gynecologic Reproductive Endocrinology & Infertility

0.0%

Gynecologic Oncology

0.0%

General Surgical Oncology

0.0%

Colorectal Surgery

0.0%

0% Source: CMA Masterfile, January 2014

20%

40%

60%

80%

Proportion aged 55 and above

28

100%

The age gap among specialists is most apparent in laboratory medicine, with nearly half (49.7%) of all laboratory specialists aged 55 and above and only 21.6% of physicians under the age of 45. Graph 28: Laboratory Specialists, proportion of physicians aged 44 and under, by discipline, 2014 Haematologic Pathology

32.9%

Medical Microbiology

32.6%

Anatomical Pathology

22.0%

Medical Biochemistry

16.1%

General Pathology Neuropathology 0%

Source: CMA Masterfile, January 2014

14.0% 10.0% 10%

20%

30%

40%

Proportion aged 44 and under

Graph 29: Laboratory Specialists. proportion of physicians aged 55 and above, by discipline, 2014 Medical Biochemistry

65.5%

General Pathology

58.2%

Neuropathology

53.5%

Haematologic Pathology

47.4%

Medical Microbiology

45.6%

Anatomical Pathology 0% Source: CMA Masterfile, January 2014

47.1% 20%

40%

60%

80%

Proportion aged 55 and above

29

Specialist Physicians in Canada: Sex The specialist physician workforce remains male dominated – nearly seven out of 10 specialists are currently male. However, as the graph below shows, the gap between the sexes is narrowing.

80%

Graph 30: Proportion of specialist physicians, by sex, by year, Canada

70%

74.70%

71.50%

60%

66.60%

Females Males

50% 40% 25.30%

30%

33.40%

28.50%

20% 10% 0%

2003

2008

2014

Source: CMA Masterfile, January 2014

There are important variations however at the specialty-specific level where men clearly continue to make up the bulk of the workforce and others where women occupy an increasing share of the workforce. The two graphs below detail the top ten disciplines that have the highest proportion of males and females respectively. Graph 31: Highest proportion of males, top 10 disciplines, 2014 Female

Male

Neuroradiology

100.0%

Urology

7.6%

92.4%

Cardiac Surgery

7.6%

92.4%

Orthopedic Surgery

9.6%

90.4%

Cardiothoracic Surgery

9.9%

90.1%

Neurosurgery

9.9%

90.1%

Vascular Surgery

10.1%

89.9%

Thoracic Surgery

87.0%

13.0%

Otolaryngology

18.3%

81.7%

Plastic Surgery

18.7%

81.3%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Source: CMA Masterfile, January 2014

30

Graph 32: Highest Proportion of females, top 10 disciplines, 2014 Maternal Fetal Medicine

Female Male

21.6%

78.4%

Gynecologic Oncology

71.4%

28.6%

Developmental Paediatrics

71.4%

28.6%

Paediatric Hematology

66.7%

33.3%

Paediatric Emergency Medicine

65.5%

34.5%

Adolescent Medicine

60.0%

40.0%

Medical Genetics

59.6%

40.4%

Child and Adolescent Psychiatry

59.2%

40.8%

Geriatric Medicine

56.2%

43.8%

Gynecologic Reproductive Endocrinology & Infertility

55.6%

44.4%

0.0%

Source: CMA Masterfile, January 2014

20.0%

40.0%

60.0%

80.0%

100.0%

Specialist Physicians in Canada: International Medical Graduates (IMGs) IMGs are an important component of Canada’s physician workforce and numbered nearly 18,077 in Canada in 2013, including family physicians. Graph 33: Active IMG physicians (headcount), 2000-2013, Canada 20,000 18,077 18,000

16,000

14,000

12,000

13,356

2000

2002

2004

2006

2008

2010

2011

2012

2013

Source: CMA Masterfile, 2013

While their numbers have trended upwards over the last decade, the proportion of IMG physicians relative to Canadian trained physicians has remained relatively consistent since the 1980s.

31

Graph 34: Proportion of IMGs, 2000-2013 40.00% 35.00% 30.00% 25.00%

23.41%

24.26%

23.31%

20.00% 15.00% 2013

2012

2011

2010

2008

2006

2004

2002

2000

10.00%

Source: CMA Masterfile

Within the provinces and territories, there are considerable differences in the proportion of IMGs in the specialist workforce. In 2012, Saskatchewan (40%) and Newfoundland and Labrador (37%) and New Brunswick (36%) had the highest percentage of IMGs and in contrast Nunavut (0%) and Quebec (12%) recorded the lowest proportion. Graph 35: Specialist physicians, proportion of International Medical Graduates, by province, 2012 50%

40%

40%

37%

36% 31%

30%

26% 21%

25% 26% 19%

20%

27% 23%

20%

12% 10%

0%

0%

Source: CIHI, Supply, Distribution and Migration, 2013

32

The United Kingdom, Ireland, South Africa, United States and Egypt are the top five suppliers of IMG specialist physicians in the country. Graph 36: Specialist physicians, number of International Medical Graduates, top five Countries of M.D. Graduation, 2012

1,200

1,011

1,000

957 681

800 510

600

412

400 200 0 United Kingdom

Ireland

India

South Africa

United States

Source: CIHI, Supply, Distribution and Migration, 2013

In 2012, 42% of all specialist IMGs trained in one of these five countries. However, as the graph below shows, new specialist IMGs that have set up practice in Canada over the last five years (2009-2013) reveals that IMGs are coming from a diverse range of countries such as Iran, Pakistan, Saudi Arabia and Libya as well.

120

Graph 37: New IMG specialists, top 10 Countries of M.D. Graduation, 2009-2013

100 80 60 40 20 0 Kuwait

China

Source: CMA Masterfile

Egypt Pakistan Ireland

Libya

USA

Iran

India

Saudi Arabia

Canadians themselves are increasingly becoming a growing subset of the IMG cohort. In 2012, out of 407 foreign trained graduates matched to a postgraduate medical education program, 232 graduates were Canadians studying abroad (CSA). This is the largest number of CSAs to have Canadians are becoming a been matched through the CaRMS match. growing subset of the IMG In 2010, CaRMS estimated that 3500 Canadians were studying in medical cohort. In 2012, over half schools abroad in countries such as Ireland of foreign trained and Poland. An overwhelming 93.8% of graduates matched to a CSAs studying in Ireland at the time residency program were reported that they plan to pursue Canadians studying postgraduate medical education in abroad. Canada. 99

33

Other Health Professionals Other Health professionals outside of medicine are increasingly expanding their clinical roles in the diagnosis and treatment of patients. Nurse Practitioners in Manitoba, for example, can order diagnostic tests 100 and in Prince Edward Island they can take an independent caseload of patients 101. In Ontario, Paramedics now have an enhanced role in providing homecare services for seniors 102 and Pharmacists now administer vaccinations 103, which used to be traditionally provided by physicians and nurses. New health professions such as physician assistants have also been introduced in Manitoba, Ontario, New Brunswick and Alberta. With the advent of such regulations, there has been a predictable increase in the number of other health professionals over the last decade as well. Graph 38: Number of providers, select health professions, 2005-2012 20,000 Physiotherapists

18,000 16,000 14,000

15,772 14,715

12,000

8,000

16,853 Psychologists

Respiratory Therapists

10,000

18,469

10,775

7,636

6,000 4,000 2,000 0

Midwives 520 2005

2008

1,080 2012

Source: CIHI, Canada's Health Care Providers, 2013

There is growing literature that showcases the promising impact of other health professionals on quality of care, outcomes, and cost-effectiveness. However, there are a number of issues that need to be taken into account as the scopes of practice of other health professions evolve. The Royal College has called on regulators and governments to incorporate the following control measures during the uptake of new or redesigned scopes of practice of health professionals 104: • Ensure the health provider has quality specialized skills training throughout the continuum of education. This includes a review of the accreditation process of educational programs and the learning activities pursued through continuing professional development. • There needs to be supporting research and data on population health needs, patient health outcomes, patient satisfaction and health system performance including cost effectiveness.

34

•

Earnest consultations, communications and collaboration are undertaken with key stakeholders including the physician profession and the public when significant changes to scope of practice are being considered.

Specialist physician employment problems The Royal College released its report synthesizing two years of research on the scope and drivers of physician employment challenges in Canada. The chart below shows that employment challenges persisted in 2013, with a constantly increasing number of respondents reporting that they were at the end-point of training and without a job or were continuing training as an alternative to unemployment. Graph 39: Summary profile of under- unemployed newly certified specialists Royal College Employment Study, 2011, 2012, 2013 405 400

339 320

317

303

240

Additional training planned

Found employment

219 191

No job placement: further training pursued

160

97 74

80 48

62

49

37

No job placement: not pursuing further training

0 2011

2012

2013

Source: Royal College. Job Placement Survey 2011, 2012, 2013. Specialists & Subspecialists

35

Consistent with the findings reported in 2013, surgical disciplines and those that are resource intensive continued to be where employment challenges were most prevalent.

Specialty/Subspecialty

Year 2011

Year 2012

Year 2013

Anesthesiology

Numbers unemployed n/N

13 (65/129)

10 (61/142)

12 (54/137)

Diagnostic Radiology

Numbers unemployed n/N

4 (28/97)

4 (25/114)

11 (57/121)

General Surgery

Numbers unemployed n/N

5 (18/98)

8 (32/99)

7 (44/99)

Nuclear Medicine

Numbers unemployed n/N

2 (4/14)

2 (3/7)

1 (3/9)

Ophthalmology

Numbers unemployed n/N

7 (17/42)

6 (13/42)

5 (24/39)

Orthopedic Surgery

Numbers unemployed n/N

6 (30/80)

9 (31/88)

14 (42/88)

Numbers unemployed

0

5

4

n/N

(5/23)

(12/32)

(13/36)

Numbers unemployed

1

3

5

n/N

(8/24)

(11/30)

(8/26)

Radiation Oncology

Numbers unemployed n/N

4 (13/30)

10 (16/30)

16 (23/34)

Urology

Numbers unemployed n/N

1 (5/30)

5 (11/31)

5 (14/29)

Otolaryngology

Plastic Surgery

n- sample size N- population size (total number of certificants) Source: Royal College. Job Placement Survey 2011, 2012, 2013. Specialists & Subspecialists

36

Conclusion Given the fluid nature of the political, policy and practice environments, one can expect many themes and questions highlighted in this environmental scan to further foment in 2014. For instance: •

•

•

•

•

The Harper government’s revamped CHT funding to the provinces/territories takes effect in 2014-15. Will there be a response from the Council of the Federation? In December 2013, an annual poll conducted by Nanos Research and the Institute for Research on Public Policy revealed that issues such as the Senate expense scandal have significantly hampered Canadians’ opinions on the Harper government. What measures will the Harper government undertake in the coming year to restore the “Harper brand” as Canada moves closer to its next federal election, slated for fall 2015? Quebec’s proposed Bill 52, which decriminalizes euthanasia, is anticipated to pass in 2014. Although temporarily stalled by the Marois government’s recent electoral government defeat, newly elected Premier Philippe Couillard has signalled that his Liberal government intends to pass the bill. Given that the Federal government has opposed the bill in the past, will 2014 set the stage for another challenge between the two levels of government - one that will ultimately have to be arbitrated by the Supreme Court? How does Canada strive to address health inequities within its diverse population? New research continues to reinforce the disconcerting disparity in care that exists. How will planners address the changing scopes of practice of health professionals and growing trend of unemployed specialists?

These and other issues that influence and shape our health care systems will be featured in future iterations of this living document. As mentioned previously, we encourage Fellows and all readers to contact the Office of Health Policy at [email protected] if they have any comments, questions, or to suggest new content for future iterations of this environmental scan.

37

Endnotes 1

World Health Organization, 10 facts on noncommunicable diseases World Health Organization, Noncommunicable diseases country profiles, 45 3 Public Health Agency of Canada, Report on the State, 1 4 Canadian Cancer Society, Canadian Cancer Statistics 2013, 6 5 Ibid, 19 6 Ibid, 6 7 Ibid, 43 8 Ibid, 65 9 Ibid, 35 10 Heart and Stroke Foundation, Statistics 11 Statistics Canada, Mortality, Summary List 12 Public Health Agency of Canada, Tracking Heart Disease and, 3-4 13 Mclagan et al., The CANHEART health index, 185 14 Statistics Canada. Diabetes 2012 15 Public Health Agency of Canada, Diabetes in Canada: Facts, 4 16 Ibid, 4 17 Statistics Canada, Injuries in Canada: Insights 18 Patten and Juby, A Profile of Clinical, 4 19 Ibid, 4 20 Pearson, Janz & Ali, Mental and Substance Abuse in Canada, 1 21 Patten and Juby, A Profile of Clinical, 6 22 Mental Health Commission of Canada, Issue: Workplace 23 World Health Organization, Obesity and Overweight 24 Twells et al., Current and Predicted Prevelance 25 Health Canada, Looking Forward: The Future 26 CBC News, By the Numbers 27 Health Canada, Canadian Tobacco Use Monitoring 28 CIHI, Learning from the Best 29 US Department of Health and Human Services, Vital and Health Statistics, 37 30 Public Health Agency of Canada, Chronic Respiratory Diseases 31 Canadian Cancer Society, Canadian Cancer Statistics 2011, 21 32 World Health Organization, Global Health Risks, 9 33 Mayo Clinic, High Blood Pressure (Hypertension) 34 Statistics Canada, High Blood Pressure 2010 35 Ibid 36 CIHI, Health Care in Canada, 9 37 CIHI, National Health Expenditure Trends, 1975-2013, 56 38 Ibid, 57 39 CIHI, National Health Expenditure Trends, 55 40 Ibid, xiv 41 Born, Yiu & Tierney, How far along are 42 Kulig and Williams, Health in Rural Canada, 23 43 Ibid, 23 44 Pong et al., Patterns of Health Services, 24 45 Statistics Canada, Metropolitan Influenced Zone 46 Kulig and Williams, Health in Rural Canada, 23 47 Mikkonen and Raphael, Social Determinants of Health, 42 48 Public Health Agency of Canada, Population-Specific HIV/AIDS Status, 19 49 Mikkonen and Raphael, Social Determinants of Health, 42 50 Public Health Agency of Canada, Obesity in Canada, 1 51 Aboriginal Healing Foundation, Misconceptions of Canada’s Indian, 52 Statistics Canada, Disparities in Life Expectancy 53 CIHI, Hospitalization Disparities by Socio-Economic, 5 54 The Conference Board of Canada, Hot Topic : World Income 55 Kwan, Jennifer, Federal Budget 2013 2

56

Cheadle, Bruce, Budget Squeeze Continues Babbage, Canada Budget 2014 58 Department of Finance Canada, The Road to Balance, 197 59 Department of Finance, 2011, Backgrounder on Major Transfer 60 The Health Action Lobby, Contributing to the Council, 4 61 The Council of the Federation, Canada’s Provinces and Territories 62 Marchildon and Mou, The Conservative 10-Year Canada, 52 63 Ibid, 24 64 Office of the Parliamentary Budget Officer, Fiscal Sustainability Report 2013, 3 65 Council of the Federation, Assessment of the Fiscal Impact 66 Mcleod, Alberta gets bulk 67 Health Council of Canada, Health Care Renewal, 3 68 Standing Senate Committee on Social Affairs, Science and Technology, Time for Transformative, xxxxi 69 Canada.com, Canadians want Feds 70 Health Edition, Health care dragging, 1 71 Bank of Canada, Financial System Review, 1 72 Ibid 73 CIHI, National Health Expenditure Trends, xiii 74 Ibid 75 Ibid, 66 76 Ibid, xiii 77 Ibid, 13 78 Ibid, 26 79 Ibid, xiii 80 Ibid, xiv 81 Ibid, 41 82 Canadian Health Services Research Foundation, Myth: Medicare covers all, 1-2 83 Royal College, Safeguarding the Quality, 84 CIHI, Wait Times in Canada, 2 85 Ibid 86 Ibid 87 Ibid, 7 88 Ibid, 8 89 Wait Times Alliance, Shedding Light on Canadians’, 1 90 CIHI, Learning From the Best, 1 91 Ibid, 9 92 Ibid, 16 93 Ibid, 15 94 Ibid 95 CIHI, Supply, Distribution and Migration, 3 96 CFPC, CMA, Royal College, National Physician Survey 2010 97 CIHI, Full-Time Equivalent Physicians Report, 3 98 CMA, Statistical Information on Canadian Physicians 99 Sullivan, Bulletin, 1212 100 Province of Manitoba, News Release: Nurse Practitioners 101 The Guardian, Nurse practitioners taking on 102 Ottawa Citizen, Ontario paramedics to provide 103 Canadian Pharmacists Association, Summary of Pharmacists’ Expanded 104 Royal College, Position Statement : Managing Evolving 57

Bibliography Aboriginal Health Foundation. Misconceptions of Canada’s Indian Residential School System. Last retrieved April 21, 2014, from Aboriginal Health Foundation’s website: http://www.ahf.ca/downloads/misconceptions.pdf Babbage, Maria. Canada Budget 2014: Tories Build up Fiscal Arsenal Ahead of 2015. Last Retrieved March 17, 2014, from Huffington Post’s website: http://www.huffingtonpost.ca/2014/02/11/canada-budget-2014-2015election_n_4769842.html Bank of Canada. Financial System Review: December 2013. Last retrieved April 15, 2014, from the Bank of Canada’s website: http://www.bankofcanada.ca/2013/12/fsrdecember-2013/ Born K., V Yiu & M Tierney. How far along are we in making hospitals more ‘senior friendly’?. Last retrieved April 14, 2014 from the Health Debate’s website: http://healthydebate.ca/2014/04/topic/politics-of-health-care/senior-friendly-hospitals Canada.com. Canadians want feds to show 'leadership' and fix health care: report. Last retrieved April 7, 2014, from Canada.com’s website: http://www.canada.com/business/Canadians+want+feds+show+leadership+health+car e+report/6661099/story.html Canadian Cancer Society. Canadian Cancer Statistics 2013. Last retrieved March 24, 2014 from Canadian Cancer Society’s website: http://www.cancer.ca/en/cancerinformation/cancer-101/canadian-cancer-statistics-publication/?region=bc Canadian Cancer Society. Canadian Cancer Statistics 2011. Last retrieved January 24, 2012 from Canadian Cancer Society’s website: http://www.cancer.ca/canadawide/about%20cancer/cancer%20statistics.aspx Canadian Health Services Research Foundation. Myth: Medicare Covers all Necessary Health Services. Last retrieved January 24, 2013 from the Canadian Foundation for Healthcare Improvement’s website: http://www.cfhifcass.ca/publicationsandresources/Mythbusters/ArticleView/11-05-12/dd2b140f-7405461c-a077-06ad45256fb1.aspx Canadian Institute for Health Information. Full-time Equivalent Physicians (FTE) Report, 2004-2005. Last Retrieved March 16, 2014, from the CIHI’s website: https://secure.cihi.ca/estore/productSeries.htm?locale=en&pc=PCC37 Canadian Institute for Health Information. Governance and Accountability. Last Retrieved March 16, 2012, from the CIHI’s website: http://www.cihi.ca/CIHI-extportal/internet/en/subtheme/about+cihi/governance+and+accountability/cihi010704

Canadian Institute for Health Information. Health Care in Canada, 2011: A Focus on Seniors and Aging. Last Retrieved January 17, 2012, from the CIHI’s website: https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1677 Canadian Institute for Health Information. Physicians. Last Retrieved April 16, 2014, from the CIHI’s website: http://www.cihi.ca/CIHI-extportal/internet/EN/TabbedContent/spending+and+health+workforce/workforce/physicia ns/cihi010672 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status for Males and Females. Last Retrieved April 18, 2014, from the CIHI’s website: https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1552&lang=en&medi a=1 Canadian Institute for Health Information. International Comparisons: A Focus on Quality of Care. Last Retrieved March 26, 2014, from the CIHI’s website: http://www.cihi.ca/CIHI-extportal/internet/en/documentfull/health+system+performance/indicators/international/oe cd_etool_results Canadian Institute for Health Information. National Health Expenditure Trends, 1975 to 2013. Last Retrieved February 17, 2014, from the CIHI’s website: https://secure.cihi.ca/estore/productSeries.htm?pc=PCC52 Canadian Institute for Health Information. Learning from the Best: Benchmarking Canada’s Health System. Last Retrieved February 17, 2014, from the CIHI’s website: https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1676 Canadian Institute for Health Information. Supply, Distribution and Migration of Canadian Physicians, 2012. Last Retrieved January 26, 2013, from the CIHI’s website: https://secure.cihi.ca/estore/productSeries.htm?pc=PCC34 Canadian Institute for Health Information. Wait Times for priority procedures in Canada, 2014. Last Retrieved April 15, 2014, from the CIHI’s website: https://secure.cihi.ca/estore/productSeries.htm?pc=PCC395 Canadian Medical Association. Statistical information on Canadian physicians. Last Retrieved January 17, 2014, from the CMA’s website: http://www.cma.ca/index.php?ci_id=16959&la_id=1 Canadian Pharmacists Association. Summary of Pharmacists’ Expanded Scope of Practice across Canada. Last Retrieved April 10th, 2014 from the Canadian Pharmacists Association’s website: http://www.pharmacists.ca/cpha-ca/assets/File/pharmacy-incanada/ExpandedScopeChart.pdf CBC News. By the Numbers: The Decline of Smoking in Canada. Last retrieved January 23, 2012, from CBC website: http://www.cbc.ca/news/canada/story/2011/07/29/fsmoking-statistics.html

Cheadle, Bruce. Budget squeeze continues but federal deficit nearly gone: Flaherty. Last Retrieved April 22, 2014, from CP24’s website: http://www.cp24.com/news/budgetsqueeze-continues-but-federal-deficit-nearly-gone-flaherty-1.1680262#ixzz2ze5JvhY2 College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada. National Physician Survey. National results by FP/GP or other specialist, sex, age, and all physicians, 2010. Last Retrieved January 17, 2013, from the NPS’ website: www.nationalphysiciansurvey.ca. Conference Board of Canada. How Canada Performs: A Report Card on Canada, 2013. Last Retrieved January 17, 2014, from the Conference Board of Canada’s website: http://www.conferenceboard.ca/hcp/default.aspx Council of the Federation. Assessment of the Fiscal Impact of the Current Federal Fiscal Proposals. Last retrieved February 4, 2013, from the Council of the Federation’s website: http://www.councilofthefederation.ca/pdfs/CoF%20Working%20Group%20on%20Fiscal %20Arrangements%20Report%20and%20Appendices_July.pdf. Council of the Federation. Canada’s Provinces and Territories Realize Real Savings in Healthcare through Collaboration. Last retrieved February 4, 2014, from the Council of the Federation’s website: http://www.conseildelafederation.ca/en/latest-news/132013/339-canada-s-provinces-and-territories-realize-real-savings-in-healthcarethrough-collaboration Department of Finance. The Backgrounder on Major Transfer Renewal. Last retrieved January 16, 2012, from Department of Finance website: http://www.fin.gc.ca/n11/data/11-141_1-eng.asp Finance Canada. The Road to Balance: Creating Jobs and Opportunities. Last Retrieved April 17, 2014, from Finance Canada’s website: http://www.budget.gc.ca/2014/homeaccueil-eng.html Health Canada. Canadian Tobacco Use Monitoring Survey 2012. Last Retrieved March 19, 2014, from Health Canada’s website: http://www.hc-sc.gc.ca/hc-ps/tobactabac/research-recherche/stat/ctums-esutc_2012-eng.php Health Canada. Looking Forward: The Future of Federal Tobacco Control. Last Retrieved January 23, 2012, from Health Canada’s website: http://www.hc-sc.gc.ca/hcps/tobac-tabac/body-corps/index-eng.php Health Council of Canada. Progress Report 2011: Health Care Renewal in Canada. Last retrieved January 5, 2012, from the Health Council’s website: http://healthcouncilcanada.ca/rpt_det.php?id=165 Health Edition. Health Care Dragging down Provinces. Last retrieved October 5, 2012, from the Health Edition’s website: http://www.healthedition.com/archives/100512_m.pdf

Heart and Stroke Foundation. Statistics. Last retrieved January 24, 2014 from the Heart and Stroke Foundation’s website: http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3483991/k.34A8/Statistics.htm Kulig J., A Williams. Health in Rural Canada. Last Retrieved January 18, 2012, from the UBC Press Website: http://www.ubcpress.ca/books/pdf/chapters/2011/HealthInRuralCanada.pdf Kwan, Jennifer. Federal budget 2013: Flaherty unveils ‘stay the course’ budget. Last Retrieved April 22, 2014, from Yahoo Finance Canada’s website: https://ca.finance.yahoo.com/blogs/balance-sheet/federal-budget-2013-flahertyunveils-stay-course-budget-222447222.html Maclagan, Laura, Jungwee Park, Claudia Sanmartin, Karan Mathur, Dough Roth, Douglas Manuel, Andrea Gershon, Gillian Booth, Sacha Bhatia, Clare Atzema & Jack Tu. 2013. The CANHEART health index: a tool for monitoring the cardiovascular health of the Canadian population. Canadian Medical Association Journal. 186 (3): 180-187 Marchildon, Gregory & Haizhen Mou. The Conservative 10-Year Canada Health Transfer Plan: Another Fix for a Generation? In How Ottawa Spends, 2013-2014, edited by Stoney, Christopher & G. Bruce Doern. McGill-Queen’s University Press, 47-63 May Clinic. High Blood Pressure (Hypertension). Last retrieved January 24, 2012 from the May Clinic’s website: http://www.mayoclinic.com/health/high-bloodpressure/HI00062 Mcleod, Paul. Alberta gets bulk of new health transfers in federal budget. Last Retrieved April 13, 2014, from Herald News’ website: http://thechronicleherald.ca/canada/1186361-alberta-gets-bulk-of-new-healthtransfers-in-federal-budget Mental Health Commission of Canada. Issue: Workplace. Last retrieved March 24, 2014 from Mental Health Commission of Canada’s website: http://www.mentalhealthcommission.ca/English/issues/workplace?routetoken=c5feff32e 9056b0b5b2b7888c3e7bb4d&terminitial=30 Office of the Parliamentary Budget Officer. Fiscal Sustainability Report 2013. Last retrieved April 17, 2014, from PBO’s website: http://www.pbodpb.gc.ca/files/files/FSR_2013.pdf Ottawa Citizen. Ontario paramedics to provide more homecare to seniors. Last retrieved from Ottawa Citizen’s website:http://www.ottawacitizen.com/health/Ontario+paramedics+provide+more+hom ecare+seniors/9412827/story.html Patten S., H Juby. A Profile of Clinical Depression in Canada. Last retrieved January 25, 2012 from the University of Calgary’s website: http://dspace.ucalgary.ca/handle/1880/46327

Pearson, Caryn, Teresa Janz & Jennifer Ali. Mental and substance use disorders in Canada. Last retrieved January 23, 2014 from the Statistics Canada’s website: http://www.statcan.gc.ca/pub/82-624-x/2013001/article/11855-eng.pdf Pong R.W., M. DesMeules, D. Heng, C. Lagacé, J.R. Guernsey, A. Kazanjian, D. Manuel, J.R. Pitblado, R. Bollman and I. Koren. 2011. Patterns of Health Services Utilization in Rural Canada. Chronic Diseases and Injuries in Canada. 31 (Supplement 1): 1–37. Last retrieved January 23, 2012 from the Public Health Agency of Canada’s website: http://www.phac-aspc.gc.ca/publicat/cdic-mcbc/31-1-supp/pdf/31supp1-eng.pdf Province of Manitoba. News Release: Nurse Practitioners can now order life-saving MRI tests. Last Retrieved April 15th, 2014 from the Province of Manitoba’s website: http://news.gov.mb.ca/news/index.html?archive=2013-02-01&item=16716 Public Health Agency of Canada. Chronic Respiratory Diseases. Last retrieved January 24, 2012, from Public Health Agency’s website: http://www.phac-aspc.gc.ca/cd-mc/crdmrc/index-eng.php Public Health Agency of Canada. Obesity in Canada. Last retrieved January 24, 2012, from Public Health Agency’s website: http://www.phac-aspc.gc.ca/hp-ps/hl-mvs/oicoac/index-eng.php Public Health Agency of Canada. Report on the State of Public Health in Canada. Last retrieved February 2, 2014, from Public Health Agency’s website: http://www.phacaspc.gc.ca/cphorsphc-respcacsp/2012/index-eng.php Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective. Last retrieved January 23, 2014 from the Public Health Agency of Canada’s website: http://www.phac-aspc.gc.ca/cd-mc/publications/diabetesdiabete/facts-figures-faits-chiffres-2011/pdf/facts-figures-faits-chiffres-eng.pdf Public Health Agency of Canada. Population-Specific HIV/AIDS Status Report. Last retrieved January 23, 2012 from Public Health Agency of Canada’s website: http://www.phac-aspc.gc.ca/aids-sida/publication/ps-pd/aboriginalautochtones/pdf/pshasrap-revspda-eng.pdf Public Health Agency of Canada. Tracking Heart Disease and Stroke in Canada. Last retrieved March 23, 2014 from Public Health Agency of Canada’s website: http://www.phac-aspc.gc.ca/cd-mc/cvd-mcv/sh-fs-2011/pdf/StrokeHighlights_EN.pdf Royal College of Physicians and Surgeons of Canada. Safeguarding the Quality of Medical Education and the Workforce. Last retrieved February 10th, 2014 from Royal College’s website: http://www.royalcollege.ca/portal/page/portal/rc/advocacy/policy/safeguarding Royal College of Physicians and Surgeons of Canada. Ensuring Safe, High Quality Care: Managing Evolving Scopes of Practice of all Health Professionals. Last Retrieved April 10th, 2014 from the Royal College’s website:

http://www.royalcollege.ca/portal/page/portal/rc/common/documents/advocacy/scopes _of_practice_e.pdf Standing Senate Committee on Social Affairs, Science and Technology. Time for Transformative Change: A Review of the 2004 Health Accord. Last Retrieved February 18, 2013, from the Parliament of Canada’s website: http://www.parl.gc.ca/Content/SEN/Committee/411/soci/rep/rep07mar12-e.pdf Statistics Canada. Metropolitan Influenced Zone. Last retrieved April 13, 2012 from Statistics Canada’s website: http://geodepot.statcan.ca/Diss/Reference/Tutorial/MIZ_tut2_e.cfm Statistics Canada. Diabetes, 2012. Last Retrieved March 17, 2014, from the Statistics Canada’s website: http://www.statcan.gc.ca/pub/82-625-x/2013001/article/11835eng.htm Statistics Canada. Disparities in Life Expectancy at Birth. Last Retrieved April 17, 2014, from the Statistics Canada’s website: http://www.statcan.gc.ca/pub/82-624x/2011001/article/11427-eng.htm#a6 Statistics Canada. High Blood Pressure, 2010. Last Retrieved January 17, 2012, from the Statistics Canada’s website: http://www.statcan.gc.ca/pub/82-625x/2011001/article/11463-eng.htm#ft1 Statistics Canada. Injuries in Canada: Insights from the Canadian Community Health Survey. Last retrieved January 23, 2012 from the Statistics Canada’s website: http://www.statcan.gc.ca/pub/82-624-x/2011001/article/11506-eng.htm Statistics Canada. Leading Causes of Death, 2011. Last Retrieved April 17, 2014, from Statistics Canada’s website: http://www.statcan.gc.ca/tables-tableaux/sumsom/l01/cst01/hlth36a-eng.htm Statistics Canada. Mortality, Summary List of Causes. Last Retrieved March 17, 2014, from the Statistics Canada’s website: http://www.statcan.gc.ca/pub/84f0209x/84f0209x2009000-eng.htm Statistics Canada. Population by sex and age group. Last Retrieved April 21, 2014, from the Statistics Canada website: http://www.statcan.gc.ca/tables-tableaux/sumsom/l01/cst01/demo10a-eng.htm Statistics Canada. Table 105-0501 - Health indicator profile, annual estimates, by age group and sex, Canada, provinces, territories, health regions (2012 boundaries) and peer groups, occasional. CANSIM (database). Last retrieved January 25, 2014 from Statistics Canada’s website: http://www5.statcan.gc.ca/cansim/a26?lang=eng&retrLang=eng&id=1050501&paSer=& pattern=&stByVal=1&p1=1&p2=37&tabMode=dataTable&csid=

Sullivan, Patrick. 2012. Canadians who studied abroad find residencies. Canadian Medical Association Journal. 184 (10): 1212 The Guardian. Nurse practitioners taking on greater health-care role. Last Retrieved April 14th, 2014 from the Guardian’s website: http://www.theguardian.pe.ca/News/Local/2012-12-05/article-3133902/Nursepractitioners-taking-on-greater-health-care-role/1 The Health Action Lobby. Contributing to the Council of the Federation’s Health Care Innovation Working Groups: Some Health Provider ABC’s. Last Retrieved February 17, 2013, from Health Action Lobby’s website: http://www.healthactionlobby.ca/images/stories/gov_submissions/2013/CoFBackground erformembersJanuary162013.pdf Twells, Laurie, Deborah Gregory, Jacinta Reddigan & William Midodzi. 2014. Current and predicted prevalence of obesity in Canada: a trend analysis. Canadian Medical Association Journal. 2 (1): E18-E26 US Department of Health and Human Services. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2012. Last retrieved April 22, 2014 from Centers for Disease Control and Prevention website: http://www.cdc.gov/nchs/data/series/sr_10/sr10_260.pdf Wait Times Alliance of Canada. Shedding light on Canadians’ total wait for care. Last retrieved February 27, 2014, from the Wait Times Alliance’s website: http://www.waittimealliance.ca/media/2012reportcard/WTA2012-reportcard_e.pdf World Health Organization. 10 facts on noncommunicable diseases. Last retrieved Marc 25, 2014 from WHO’s website: http://www.who.int/features/factfiles/noncommunicable_diseases/en/index.html World Health Organization. Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risks . Last retrieved January 25, 2012 from WHO’s website: http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf World Health Organization. Noncommunicable diseases and mental health. Last retrieved April 11, 2014 from WHO’s website: http://www.who.int/features/factfiles/noncommunicable_diseases/en/index.html World Health Organization. Obesity and Overweight. Last Retrieved January 18, 2012, from the WHO’s website: http://www.who.int/mediacentre/factsheets/fs311/en/index.html