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Canada’s Health Accountability Plan Pre-budget Brief to the House of Commons Standing Committee on Finance August 12, 2011 Executive Summary The Canadian Nurses Association (CNA) believes that a productive population is the backbone of a prosperous nation. CNA also knows that a healthy population means a healthy workforce. CNA agrees with the Health Council of Canada that our future success as a nation of healthy and productive citizens depends on all governments working together in the interest of Canadians.1 “Beyond its intrinsic value, improved health contributes to social well-being through its impact on economic development, competitiveness and productivity. High- performing health systems contribute to economic development and wealth.” Tallin Declaration (WHO, 2008) CNA believes that Canada’s health-care systems need an accountability framework, so that Canadians can be sure of getting the best value from every dollar in health-care spending. This transformation needs involvement at the federal level through targeted policies and fiscal intervention. By way of this submission, CNA is calling on the federal government to demonstrate leadership in advancing the health transformation and quality agendas. CNA’s recommendations support the need for an accountability framework to address key health systems challenges and optimize health outcomes for Canadians. They are categorized according to the following three priorities:
CNA recommendations As an essential element of Canada’s Health Accountability Plan, CNA calls on the federal government to do three things: 1. Lead the creation of a national unique identifier (NUI) for all Canadian health professionals. 2. Coordinate strategic priorities across national agencies* to advance community-based health services such as primary care, ambulatory care and home care through research, innovation and knowledge translation. 3. Coordinate the creation of a comprehensive set of pan-Canadian health system indicators that demonstrate quality improvement across the continuum of care. Introduction The policies described in this document are based on the requirements laid down in the pre-budget submission guidelines. There is a wide range of worthy programs in health care that deserve attention at the federal level, such as promoting health in aboriginal communities, a national pharmaceutical strategy and a national healthy aging strategy. However, due to the constraints of space and focus, CNA has chosen to highlight three areas that we believe best meet the requirements of this committee and would bring the best value to Canadians. Canada’s health-care system provides services that are cherished by its citizens. However, challenges exist around universal access, system fragmentation, rising costs in certain areas (e.g., pharmaceutical spending) and wait times, which threaten the effectiveness of our system to deliver health services in an efficient manner. The rising costs of focusing on acute and hospital-based care are becoming more apparent than ever, especially in the face of international comparisons.2 Health promotion, chronic disease prevention and management, and early diagnosis and treatment add up to a healthier and more productive population and less pressure on crowded emergency departments, hospitals and operating rooms. Health system and health-care funding formulas need to be rebalanced to account not just for acute care needs but also for the savings that can be achieved by a comprehensive approach to health promotion and chronic disease prevention and management. Efficiency gains can be realized through the expansion of models of care that optimize the contributions of all members of the health-care team. These models of care will improve access to the most appropriate health-care provider, at the right time and in the right place for individuals and communities in Canada. CNA is an active leader in promoting the need for policies and practices that emphasize a comprehensive approach to primary health care in Canada and around the world.3,4,5,6 In May 2011, CNA launched a National Expert Commission entitled The Health of Our Nation — The Future of Our Health System. The Commission will recommend ways in which the system can be transformed to put the patient and family first, with a renewed focus on quality care in both community and institutional settings. CNA views its contribution to discussions and consultations leading toward the renewal of the federal and provincial/territorial Health Accord in 2014 as a top priority. In pursuit of health systems transformation and quality improvement, Canada’s registered nurses continue to stress the need to move toward a paradigm that shifts the focus from illness to health; from treatment and cure to health promotion and chronic disease prevention and management; from episodic care to continuous care; from problem-based care to comprehensive care; from individual practitioners to collaborative teams of health professionals; from the health sector working in isolation to intersectoral collaboration; from professional dominance to community participation; and from the passive reception of health services to a shared responsibility for health. Long-range planning and investment are necessary to ensure that the infrastructure, technology and, above all, qualified human resources are responsive to the changing health-care needs of Canadians and evolving models of care. Health services (and systems) and policy research, health technology assessments and health impact assessments should drive the development, implementation and evaluation of evidence-informed policy designed to optimize the health, productivity and prosperity of Canadians. Especially important are whole-of-government approaches to incorporating health in all policies.7 CNA believes that efficiency gains can be realized by health systems transformation that emphasizes the following areas:
Canada’s Health Accountability Plan CNA’s recommendations support the need for an accountability framework to address key health system challenges and optimize health outcomes for Canadians. They are categorized according to the following three priorities:
* Agencies include but are not limited to Health Canada (including First Nations and Inuit Health Branch), Health Council of Canada, Canadian Patient Safety Institute, Canadian Health Services Research Foundation, Canadian Institutes of Health Research, Canadian Institute for Health Information, Canada Health Infoway and Public Health Agency of Canada. Ensuring capacity of the health systems by stabilizing and securing Canada’s health human resources CNA Recommendation Lead the creation of a national unique identifier (NUI) for all Canadian health professionals. The aim of health human resource planning (HHRP) is to improve access to the most appropriate number of health-care providers with the right skills, at the right time and in the right place for individuals and communities in Canada.8 The ability to plan and forecast is based on the availability of health-care providers (supply) and the health-care needs of the population (demand).9 Relevance Mobility is an important factor affecting the supply of health-care providers. Giving each of them an NUI has been described as a foundational building block to health human resource planning and management.10 Currently, Canada has a limited ability to track the mobility of its nursing workforce both internally (between jurisdictions) and externally (when nurses leave Canada to work in another country). For example, the only way Canada can report on registered nurses working outside Canada is if they maintain registration with a Canadian province or territory.11 The recommendation of an NUI, specifically for nurses, is found in several studies and reports including the 2006 National Nursing Sector Study, the 2005 Navigating to Become a Nurse in Canada report, the 2004 Nursing Practice in Rural and Remote Canada report and the 2002 Canadian Nursing Advisory Committee report. An NUI for Canadian health professionals would serve several purposes,12 including the following:
An NUI would also ensure the monitoring of trends that can influence workforce stability, including the determination of practice status (active, temporary leave, maternity leave), the correlation between area of practice and retirement age, and movement in and out of the profession (including attrition). The introduction of an NUI for all health professionals is a cost-effective long-term action identified within the Framework for Collaborative Pan-Canadian Health Human Resource Planning.13 However, to this day, an NUI system has yet to be introduced. The CIHI Feasibility Study showed that the implementation of an NUI for nine professions would incur a start-up cost of $17.27 million over three years and a subsequent annual operating cost of $5.18 million.14 Optimizing efficiency and access across Canada’s health systems by strengthening community-based services CNA Recommendation Coordinate strategic priorities across national agencies* to advance community-based health services such as primary care, ambulatory care and home care through research, innovation and knowledge translation. A recent report reveals that Canadians use emergency departments more than citizens of any other country, with 44% having visited one in the past two years.15 According to the Conference Board of Canada, “Well targeted investments in preventive measures have the potential to produce long-term cost savings through reduced demand on health-care services and represent a more effective long-term strategy for spending scarce resources.” 16 Relevance Having the capacity to deliver care in the community is a feature of an efficient health system. However, in 2008/2009, there were 92,000 hospitalizations in Canada of patients who required home and community-based care rather than acute care; 62% of these hospitalizations lasted longer than one week, and 24% lasted longer than one month.17 CNA believes that a national strategy is necessary to address multi-faceted dimensions of community care, in particular home-based care. CNA acknowledges the federal government’s continued investment in the mental health and well-being of Canadians. About 10% of Canadians in the workforce between the ages of 18 and 54 suffer from mental health problems and illnesses. Worldwide, mental health problems are among the leading causes of disability.18 In Canada, economic costs attributed to these conditions (e.g., health care service use, lost workdays, work disruptions) are significant — an estimated $51 billion a year.19 Repeat hospitalizations (11% of all people hospitalized for mental illness in 2008/2009 were readmitted more than twice within the same year) and 30-day readmission rates (11.4% in 2009/2010) for this segment of the population are high,20 indications that mental health service needs are not being met in the community. Targeted improvements in community health can be realized through the implementation of the recommendations outlined in the Mental Health Strategy for Canada, to be released in early 2012 by the Mental Health Commission of Canada (MHCC). This strategy will advance a comprehensive population-based approach to mental health — one that emphasizes comprehensive community-based services and recovery-based approaches and acknowledges the pivotal role of consumers and front-line providers in implementing system change. Resources to support knowledge translation and change management opportunities will be necessary to support the implementation of the MHCC’s recommendations. Chronic diseases are estimated to cost over $90 billion annually in treatment and lost productivity.21 Up to 80% of cases of heart disease, stroke and Type 2 diabetes — as well as more than one-third of cancer cases — could be prevented by eliminating shared risk factors such as smoking, unhealthy diets, physical inactivity and the harmful use of alcohol.22 CNA believes that interprofessional teams including nurse practitioners, registered nurses and clinical nurse specialists add value to health-care systems through community-based chronic disease prevention and management programs, which improve patients’ participation in their health and reduce the number of unnecessary and costly admissions and readmissions to hospital. An example of a primary health care approach to improving the health of Canadians is currently being piloted in Hamilton, Ontario. The internationally recognized and community-based Nurse-Family Partnership (NFP) is backed by 30 years of research. This cost-effective program has demonstrated improvements in pregnancy outcomes for first-time mothers with low incomes and better health and social outcomes for them and their children.23 It is estimated that for every dollar invested in NFP, savings of more than $5 can be achieved through reduced health and social costs.24 * Agencies include but are not limited to Health Canada (including First Nations and Inuit Health Branch), Health Council of Canada, Canadian Patient Safety Institute, Canadian Health Services Research Foundation, Canadian Institutes of Health Research, Canadian Institute for Health Information, Canada Health Infoway and Public Health Agency of Canada. Strengthening public accountability across the health-care systems by establishing quality indicators CNA Recommendation Coordinate the creation of a comprehensive set of pan-Canadian health system indicators that demonstrate quality improvement across the continuum of care Improving public accountability across health care systems in Canada can be assured only when common objectives have been identified and there is public reporting of meaningful quality indicators. Currently, a vast number of differing quality indicators are being used at many levels of health service planning and delivery. This does not allow for effective comparative monitoring of progress or accountability. Relevance The federal government is well placed to play a leadership role in the creation of a comprehensive set of pan-Canadian health system indicators that demonstrate quality improvement across the continuum of care and enable monitoring and reporting of progress toward a high-performing health system across Canada. The 2004 Health Accord negotiations emphasized jurisdictional monitoring, increasing access to care across the continuum, and reducing wait times for particular services. While this created positive effects in very narrow areas of service (cataract and joint replacement surgeries, for example), it did not affect the overall access needs and quality outcomes for all Canadians.25 We know that prolonged wait times result from a series of inefficiencies that exist throughout many parts of the health system. A true solution requires a comprehensive, coordinated response on several fronts.26 While Canada is lagging behind other developed countries in the performance of its health-care system, the false perception that there is no big problem with quality of care in Canada has led to a lack of action on many key areas of performance, as is indicated by the following quote: A 2007 Commonwealth Fund report ranked Canada fourth out of six nations on performance overall, and last for delivering effective, coordinated, patient-centred care. … Other studies have cited Canada as having poor access to care, low immunization rates, limited technological infrastructure and discrepancies in services across regions with varying degrees of rurality and high mortality rates due to cancer, diabetes and other common diseases.27 CNA brings nursing leadership from the largest group of health professionals in Canada to the practical work of identifying and promoting common quality indicators. Our organization “stresses the importance of achieving consensus among all health-care actors on what are valid and relevant metrics and indicators.” 28 Closing Comment The federal government’s leadership in advancing health system transformation is paramount to achieving a healthy population, a productive workforce and a vibrant economy. CNA encourages the federal government to consider the development of Canada’s Health Accountability Plan based upon the priorities and recommendations outlined above. Optimizing quality and realizing efficiency gains will support a sustainable health system that will meet the needs of Canadians today, tomorrow and into the future. End Notes 1 Health Council of Canada. (2011). Progress report 2011: Healthcare renewal in Canada. Retrieved from http://www.healthcouncilcanada.ca/docs/rpts/2011/progress/2011Progress_ENG.pdf 2 Commonwealth Fund. (2010). 2010 Commonwealth Fund international health policy survey. Retrieved from http://www.commonwealthfund.org/Content/Surveys/2010/Nov/2010-International-Survey.aspx 3 World Health Organization. (1978). Declaration of Alma Ata: International conference on primary health care, Alma Ata, USSR, 6-12 Sept., 1978. Retrieved from www.who.int/hpr/NPH/docs/declaration_almaata.pdf 4 Canadian Nurses Association. (2002). Fact sheet: Effective healthcare equals primary healthcare. Ottawa: Author. Retrieved October 2010, from http://www.cna-aiic.ca/CNA/documents/pdf/publications/FS17_Effective_Health_Care_Equals_Primary_ Health_Care_Nov_2002_e.pdf 5 Canadian Nurses Association. (2003). Primary health care: The time has come [electronic version]. Nursing Now: Issues and trends in Canadian nursing. Ottawa: Author. Retrieved October 2010, from http://www.cna-aiic.ca/CNA/documents/pdf/publications/ NN_PrimaryHealthCare_Sept_2003_e.pdf 6 Canadian Nurses Association. (2005a). Primary health care: A summary of the issues. Ottawa: Author. Retrieved October 2010, from http://www.cna-nurses.ca/CNA/documents/pdf/publications/BG7_Primary_Health_Care_e.pdf 7 World Health Organization. (2010). Adelaide statement on health in all policies: Moving towards a shared governance for health and well-being. Retrieved from http://www.who.int/social_determinants/hiap_statement_who_sa_final.pdf 8 Birch, S. (2002). Health human resource planning for the new millennium: Inputs in the production of health, illness and recovery in populations. Canadian Journal of Nursing Research 33(4),109-114. 9 Birch, S., Kephart, G., Tomblin-Murphy, G., O’Brien-Pallas, L., Alder, R. & MacKenzie, A. (2007). Human resources planning and the production of health: A needs-based analytical framework. Canadian Public Policy, XXXIII supplement. 10 Canadian Institute for Health Information (2010b). National unique identifier for health care providers: Feasibility study - summary report. Ottawa: Author. Retrieved from http://www.cihi.ca/CIHI-ext-portal/pdf/internet/NUI_FEASIBILITY_STUDY_EN 11 Canadian Institute for Health Information (2010a). Regulated nurses: Canadian trends, 2005 to 2009. Ottawa: Author. Retrieved from http://secure.cihi.ca/cihiweb/products/nursing_report_2005-2009_en.pdf 12 Canadian Institute for Health Information (2010c). National unique identifier feasibility study FAQ. Ottawa: Author. Retrieved from http://www.cihi.ca/CIHI-ext-portal/pdf/internet/NUI_FAQ_EN 13 Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources (ACHDHR). (2007). Framework for collaborative pan-Canadian health human resources planning, p. 15. Retrieved from http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb- dgps/pdf/pubs/hhr/2007-frame-cadre/2007-frame-cadre-eng.pdf 14 Canadian Institute for Health Information (2010b). National unique identifier for health care providers: Feasibility study - summary report. Ottawa: Author. Retrieved from http://www.cihi.ca/CIHI-ext-portal/pdf/internet/NUI_FEASIBILITY_STUDY_EN 15 Health Council of Canada. (2010). How do Canadians rate the health care system? Results from the 2010 Commonwealth Fund international health policy survey. Toronto: Author. Retrieved November 2010, from http://www.healthcouncilcanada.ca/docs/rpts/2010/comm/Commonwealth_FINAL_E_Nov2010.pdf 16 Conference Board of Canada. (2008). Healthy people, healthy performance, healthy profits: The case for business action on the socio-economic determinants of health. Ottawa: Author. Retrieved from http://www.conferenceboard.ca/documents.aspx?did=2818 17 Canadian Institute for Health Information. (2010). Health care in Canada 2010. Ottawa: Author. Retrieved from http://secure.cihi.ca/cihiweb/products/HCIC_2010_Web_e.pdf 18 World Health Organization. (2008). The global burden of disease: 2004 update. Geneva: Author. Retrieved from http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf 19 Mental Health Commission of Canada. (2010). Mental health in the workplace: A perfect legal storm. News release. Retrieved from http://www.mentalhealthcommission.ca/SiteCollectionDocuments/News/en/Tracking%20the%20Perfect%20Legal%20Storm%20news %20release.pdf 20 Canadian Institute for Health Information. (2011). Health indicators 2011. Ottawa: Author. Retrieved from http://secure.cihi.ca/cihiweb/products/health_indicators_2011_en.pdf 21 Mirolla, M. (2004). The cost of chronic disease in Canada. Ottawa: Chronic Disease Prevention Alliance of Canada. Retrieved from http://www.gpiatlantic.org/pdf/health/chroniccanada.pdf 22 International Council of Nurses. (2010). Delivering quality, serving communities: Nurses leading chronic care. Geneva: Author. Retrieved from http://www.ghdonline.org/uploads/Delivering_Quality_Serving_Communities_-_Nurses_Leading_Chronic_Care.pdf 23 Burke, J.-M. (2010). Grassroots nursing for impoverished parents. Registered Nurse Journal, July-August,12-17. 24 Olds, D. (2010). The nurse-family partnership. In R. Haskins & W. Barnett (Eds.), Investing in young children: New directions in federal preschool and early childhood policy (pp. 69-77). Washington, DC: Brookings and NIEER. Retrieved from http://www.brookings.edu/~/media/Files/ rc/reports/2010/1013_investing_in_young_children_haskins/1013_investing_in_ young_children_ haskins_ch6.pdf 25 Canadian Nurses Association. (2011). Registered nurses: On the front lines of wait times - moving forward. Ottawa: Author. Retrieved from http://www.cna-aiic.ca/CNA/documents/pdf/publications/Wait_Times_Paper_2011_e.pdf 26Ibid. 27 Canadian Health Services Research Foundation. (2010). Metrics for healthcare quality: The leader’s role. Ottawa: Author. Retrieved from http://www.chsrf.ca/migrated/pdf/CEOForumReport_EN.pdf 28 Bard, R. & Robinson, M. (in press). Responsibility for Canada’s healthcare quality agenda: Interviews with Canadian health leaders. Commentary. Healthcare Papers. |