A nursing call to action. The health of our nation, the future of our health system

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1 A nursing call to action The health of our nation, the future of our health system

2 Everything you need to know about the National Expert Commission can be found at Including: 1. About the National Expert Commission 2. Final reports of the research syntheses prepared for the National Expert Commission through a partnership with the Canadian Health Services Research Foundation 3. Summary report of cross-country consultation with nurses and other professionals, and YMCA Canada public consultations, prepared for the National Expert Commission by LBP MASS 4. Summary report of public polling conducted for the National Expert Commission by Nanos Research 5. All written submissions to the National Expert Commission 6. Fact sheets and other documents prepared to support the final report of the National Expert Commission 7. Reference lists 8. Bibliography of key resources This report has been prepared by the independent National Expert Commission as mandated by the Canadian Nurses Association s Board of Directors. The views and opinions expressed in this paper do not necessarily reflect the views of the Canadian Nurses Association s Board of Directors. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, or transcribed, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission of the publisher. Canadian Nurses Association 50 Driveway, Ottawa, ON K2P 1E2 Tel.: or Fax: Commission Website: Canadian Nurses Association Website: ISBN Revised September 2012 Disponible en français

3 Nurses through their sheer numbers and collective knowledge are a mighty force for change. Registered nurses are deeply engaged in system transformation because they care about human health and about delivering responsible health care. But more than caring, it is the professional and social responsibility of nurses to take a strong leadership stand on behalf of Canadians. Nursing science and practice have to be at the core and centre of a new health system, because we know nursing care is effective, it s affordable and it makes sense. Canada s nurses can and must act in collaboration with other health professionals and system leaders to ensure better health, better care and better value for all Canadians. Through their sheer numbers and collective knowledge, nurses are a mighty force for change. Canadians expect nurses to harness that power and act. We present this report to bolster their actions going forward and to support nurses so they are equipped to do their part in shaping Canada s health-care delivery system in the decade ahead. The health of our nation, the future of our health system

4 A Note about our Terminology Patients Canadians and their families may see themselves in many roles as they access health services at different times of life and in different parts of the health-care system. For example, we might join a community support group, or be a member in a local gym where we walk on a treadmill to increase our fitness. Another day we might be a caregiver, providing help to an elderly parent who is a nursing home resident. Or we might be a patient, having an operation in a hospital. We know that not everyone who is using a health service sees him or herself as a patient. But to simplify language and reduce repetition, in some places we chose that term to refer to people who are receiving many different kinds of health services. Primary health care and primary care It is important to distinguish between primary health care and primary care. These are two different and important ideas that often are confused. Primary health care is more comprehensive, referring to a framework of specific health system policies for a population. 1 Starfield said primary health careoriented systems are generally more effective in achieving better health (particularly at young ages) at lower costs than is the case for systems more oriented to disease management and specialty care. 2 The World Health Organization 3 says that primary health care encompasses: 1. Education for the identification and prevention/control of prevailing health challenges; 2. Proper food supplies and nutrition; adequate supply of safe water and basic sanitation; 3. Maternal and child care, including family planning; 4. Immunization against the major infectious diseases; 5. Prevention and control of locally endemic diseases; 6. Appropriate treatment of common diseases using appropriate technology; 7. Promotion of mental, emotional and spiritual health; and 8. Provision of essential drugs. Primary care is one of the elements necessary in a broader framework of primary heath care services. It is largely clinical, having to do with first contact accessibility and use, identification with a regular source of care that is person (rather than disease) focused care over time, comprehensiveness of services available and provided, and coordination (when care from other places is required). 4 Many of us think of our family doctor, nurse practitioner or a walk-in clinic as the place we access primary care that is, our first point of care for health and illness needs. Primary care and primary health care 2 National Expert Commission

5 Table of Contents 2 A Note about our Terminology 4 Message from the Commissioners 6 The Need for Change 8 The Changing Demographics and Health of Canadians 18 Better Health 23 Better Care 26 Better Value 30 The Role of Nursing in Supporting Better Health, Better Care and Better Value 38 Our Plan of Action 48 Conclusion: Transformation is Possible Acknowledgements inside back cover Look for these icons throughout the Report that indicate an additional resource on the National Expert Commission website. Go to and select the corresponding title from one of the categories of information. Read a report Watch a video The health of our nation, the future of our health system 3

6 Message from the Commissioners The Canadian Nurses Association (CNA), the professional voice of Canada s 268,500 registered nurses, plays a key role in developing policies and models of care to enhance the health of Canadians. In May 2011, CNA established an independent National Expert Commission, made up of leaders in nursing, medicine, business, law, academia, economics and health-care policy. Guided by the motto Better Health, Better Care, Better Value, Best Nursing (based on the Institute for Healthcare Improvement s triple aim initiative) 5, we set out to discover the most efficient, effective and sustainable ways to meet the changing and pressing health needs of Canadians in the 21 st century. We heard from people across the country the public, nurses and other health professionals and policy makers in person and via the Internet. We commissioned research, welcomed written submissions, and conducted public polling. This report distills what we learned into practical, evidence-based recommendations The people we heard from told us Canadians need and deserve a health system centred on individuals and families, one that would focus on building lifelong health, while continuing to take care of sickness and injury. It should be based in a robust primary healthcare system, run by teams of professionals, offering care and attention to Canadians in their homes and communities. Adopting such a model would have a profound, positive impact on the health of our nation, and ensure better care for individuals and better value for money. But we did not stop with envisioning an ideal. We also looked at what needs to be done to re-invigorate our current system. We have concluded its sustainability and ability to evolve depends on eliminating waste, taking greater advantage of existing human resources and technology, and establishing options for a broader model of care delivery. This report distills what we learned into practical, evidence-based recommendations about how nurses working collectively and collaboratively can take action to transform the way we deliver health services in Canada to ensure the ongoing health and wellness of all Canadians. Respectfully submitted, Marlene Smadu, RN, EdD Co-chair Maureen A. McTeer, BA, MA, LLB, LLM, LLD (hons), Co-chair 4 National Expert Commission

7 268,500 registered nurses work with Canadians at every age and every stage of life in clinical settings and in education, research, administration and policy across Canada. The Honourable Sharon Carstairs, PC, BA, MAT, LLD (hons) Thomas d Aquino, BA, JD, LLD, LLM Robert G. Evans, OC, PhD Robert Fraser, RN, MN Francine Girard, RN, PhD Vickie Kaminski, RN, BScN, MBA Julie Lys, RN, NP, MN Sioban Nelson, RN, PhD, FCAHS Charmaine Roye, BSc, MDCM, FRCSC Heather Smith, RN Rachel Bard, RN, MAEd (ex officio) Judith Shamian, RN, PhD, LLD (hon), DSci (hon), FAAN (ex officio) Michael Villeneuve, RN, MSc (ex officio, executive lead) The health of our nation, the future of our health system 5

8 The Need for Change Over the Commission s year of work, we have learned that Canadians consider how we achieve health, maintain it, strengthen it and pay for the system to be crucial national concerns. 6 They want a system that helps them be healthy, is there for them when they need treatment and will support them at the end of life and one which is affordable, efficient and sustainable. What is more, a country s commitment to health is a measure of its wealth, success and status in the world. 7 We need the finest health-care system in the world to attract and retain the best people, and to realize together all the benefits of living in a successful, productive, competitive society. Much more can be done to increase freedom from disease and disability, as well as to promote a state of wellbeing sufficient to perform at adequate levels of physical, mental and social activity. However, studies show we often fall short of that vision. 8,9,10 Canadians are living longer and developing more chronic conditions and diseases, such as obesity, diabetes and heart disease. They require ongoing management and care, better delivered at home and in the community than in an institution. At the same time, in hospitals, waits for emergency care and surgery remain unacceptably high. Safety in health care is a serious concern; our fragmented approach to using information technology and electronic records is wasteful and can even put patients at risk. Hon. Mark Lalonde, 1974 When public health insurance schemes were introduced, most care Canadians needed was delivered in hospitals and doctors offices. Today, whether a person has a disease, is living with a chronic condition, or recovering from an accident or surgery, technology and highly trained healthcare professionals offer possibilities for care not even imagined when medicare was established. But we have not yet acknowledged those profound changes with a formal shift to a new model of care that puts the emphasis on wellness, including programs to promote good health (such as smoking cessation and exercise programs) as well as focusing on the external factors that influence health (such as social status, education and living conditions). All governments should formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a comprehensive national health system and in coordination with other sectors. To this end, it will be necessary to exercise political will, to mobilize the country s resources and to use available external resources rationally. From the Declaration of Alma-Ata,World Health Organization, National Expert Commission

9 Canadians are living longer and developing more chronic conditions and diseases, such as obesity, diabetes and heart disease. For these possibilities to become real options and choices, new models of organization and funding must be developed. 11,12,13,14,15,16 We set out to learn about models of care delivery that would meet the changing needs and expectations of Canadians. We concluded the model we chose must offer several of these elements: It should be centred on what individuals and families need, rather than on how providers and organizations want to function. It should treat the individual as a whole person, part of a family and community, not just a collection of body parts and problems. It should broaden the health-care system beyond hospitals and other institutions to offer care in the community and at home. It should address the social, economic, environmental and Indigenous determinants of health especially poverty, housing, food insecurity, and social exclusion that play such major roles in determining our individual health. It needs to draw upon the progress made in Canada to develop public health and populationbased policies and programs to ensure the greatest possible health outcomes for all Canadians. It should ensure all health professionals, including nurses, work to their full scope of practice. It should be financed by public health insurance and monitored for effectiveness and efficiency. The health of our nation, the future of our health system 7

10 The Changing Demographics and Health of Canadians Canada s population was 33.5 million in Our life expectancy is among the world s highest and expected to grow. 18 The population is aging steadily, with more than 4.7 million Canadians aged 65 and older and 1.2 million of those over the age of The number of people under the age of 15, however, has dropped to a record low. 20 Our fertility rate is less than half what it was in 1950, 21 which means Canada s population growth comes mainly from immigration. 22 Did you know that Canadians spend nearly a third less than the U.S. on health care (relative to GDP) and live 2 years longer? the citizens of Australia, Sweden and Japan live longer lives than Canadians while spending less on health care? University of California Atlas of Global Inequality, n.d. An immigrant-rich nation The number of Canadians from visible minority groups nearly quadrupled to 4 million people between 1981 and 2001, 23 reversing the immigration pattern of a century ago when three-quarters of new Canadians came from Europe. Today, 84 per cent of immigrants to Canada come from outside Europe and 75 per cent are from visible minority groups. These 5 million Canadians are predominantly South Asian, Chinese, Black and Filipino, 24 are younger than average Canadians 25 and tend to settle in Toronto, Vancouver or Montreal. 26 Aboriginal Peoples The Canadian Constitution distinguishes three groups of Aboriginal people: First Nations, Métis and Inuit, a total of more than 1 million people (almost 4 per cent of the Canadian population). 27, 28 More than half (54 per cent) of Aboriginal people live in urban centres 29 and eight of 10 live in Ontario and the four western provinces. 30 The Aboriginal population grew 45 per cent between 1996 and 2006 (compared to just 8 per cent for the non-aboriginal population). Aboriginal people are younger (27 years) on average than the non-aboriginal population (40 years). 31 Canadians and the determinants of health Compared to people in much of the world, Canadians live long and healthy lives, reflecting the nation s affluence, enviable living conditions and health and social-service systems. Scientific advances from antibiotics in the 1940s to robotic surgery in the 21 st century have redefined health care. Many diseases, once fatal, are managed as chronic health problems or cured altogether. But, as the make-up of the population changes, other health problems come to the fore. As well, our understanding of how external factors can affect health is greatly increasing. Made up of social, economic, environmental and Indigenous factors, the determinants of health include issues like income, social support, level of education, security of housing and food, literacy, employment, working conditions and gender. Their impact means some people are at increased risk for health problems. Fact sheets on demographics 8 National Expert Commission

11 Nearly a third of all homeless persons are between 15 and 24 years of age. Young people who feel cared for and supported and have a sense of belonging and engagement report better health and self-worth, and are less apt to be involved in unsafe behaviour. The health of our nation, the future of our health system 9

12 Youth Social and economic factors, including a lack of parental and family support, poverty, unsafe neighbourhoods and lack of good schools can all contribute to poor health among the young. 32 A poor start can affect a person s entire life, 33 limiting choices and opportunities and the capacity to make a successful transition to adulthood. 34 Young people who feel cared for and supported and have a sense of belonging and engagement report better health and self-worth, and are less apt to be involved in unsafe behaviour. 35 Abuse or neglect at home can have damaging effects on young people, pushing some to leave home, sometimes leading to homelessness. 36 Nearly one-third of all homeless persons are between 15 and 24 years of age. 37 Young people who are homeless, of a sexual minority, Aboriginal, visible minority or immigrants are particularly vulnerable. 38,39,40,41 Older Canadians No factor puts older Canadians at more risk than poverty. They are more vulnerable to it than any other group and nearly one in five older persons lives near the poverty line. 42 About 70 per cent of seniors incomes come from fixed sources: pensions and government supplements. 43,44 For many older people, the cost of day-to-day living can be a challenge. Poverty rates for the elderly tend to be highest among those who live alone, women (especially those over 80) visible minorities and immigrants. 45 Poverty affects the ability of older people to pay for proper diet, housing and medication, and can also keep them from support services and care. People with disabilities In 2006, approximately 4.4 million Canadians (14.3 per cent of the population) reported having a disability physical, mental, emotional, or a combination of them. 46 Rates of disability are rising as the population ages and chronic conditions increase. 47 People who are disabled are more likely to have low incomes, 48 to live in inadequate housing, 49 and to live alone. 50 They have considerable difficulty finding employment, gaining skills and building careers. 51 More than 40 per cent of Canadians with disabilities are out of the labour force, and many depend on social assistance benefits. 52 Those who are employed earn 22.5 per cent less, on average, than adults without disabilities. 53 People with disabilities have less access to health-care services and more unmet health needs especially those with mental disorders. 54 In , 14.8 per cent of adults with disabilities could not obtain needed health care or social services. 55 Furthermore, those with severe disabilities are less apt to know how to get the health care they require. 56 The impact of chronic conditions on quality of life is most pronounced for the poorest Canadians. Recent research found that people receiving social assistance had the highest prevalence of 38 chronic diseases. Life expectancy decreases and risk of developing chronic illness rises as one s position in the socio-economic hierarchy drops. What is more, Some people are poor because of their disabilities, while others are ill because of their socio-economic conditions, and both cases reinforce each other. Canadian Academy of Health Sciences, National Expert Commission

13 Costs of care, and accessing transportation to get to the places care is offered are frequent barriers for people with disabilities. 57,58 If they are employed, many disabled people work in jobs that do not offer generous employee benefits and so they may have considerable out-of-pocket costs for visits to health professionals (especially those with severe disabilities). 59 Health inequality and the determinants of health Health inequality can be the result of genetic and biological factors, choices made or by chance. 60 Often, however, it arises from unequal access to key factors that influence health, like income, education, employment and social support. 61,62 Those with low levels of income and education, who live in inadequate housing, with limited access to health care and a lack of early childhood support and social supports, are more prone to poor physical and mental health outcomes than those living in better circumstances. 63 People with disabilities have less access to health care services and more unmet health needs especially those with mental disorders. A rigorous synthesis conducted for the Commission by Muntaner, Ng, and Chung 64 confirmed the findings of the leading research on determinants of health: there is a clear and direct association between income and health. Low-income Canadians have the highest rates of death, illness and health-care use, while middle-income individuals and families have worse health outcomes than the highest-income groups regardless of whether income is measured at individual, household, or neighbourhood levels. 65 Income, housing, food insecurity, and social exclusion are four major determinants in generating and reproducing health inequalities over the life-course, 66 but nothing drives bad health like poverty. The Make Poverty History campaign 67 says more than 10 per cent of Canadians live in poverty and the rate is increasing among young families, youth, immigrants and people of colour. Furthermore, we know that income inequality is a strong health determinant across a society and that taxes and benefits reduce inequality less in Canada than in most OECD countries. 68 Here the Conference Board of Canada gives Canada a C grade ranking twelfth of 17 peer nations noting a significant increase in the income gap in Canada between 2000 and Determinants of health and Canadians at risk The health of our nation, the future of our health system 11

14 Impact on disease Poverty makes health problems worse. For example, Aboriginal Canadians are at greater risk of acquiring tuberculosis infection than other Canadians; 70 poor living conditions and overcrowded housing, together with limited access to health professionals in remote areas, play a significant role. 71 Urban homeless people also are at higher risk. 72 Poverty, homelessness, lack of social support, sexual and physical abuse and lack of education contribute to the spread of HIV 73 and other communicable diseases. 74,75,76 People living in poverty are three to four times more likely to report only fair or poor mental health. 77 They are more likely to be hospitalized repeatedly for mental illnesses 78 and suicide rates in the lowest income neighbourhoods were almost twice those seen in the wealthiest neighbourhoods. 79 The basics that help maintain mental health such as a balanced diet, regular physical activity, proper sleep, avoiding overuse of alcohol or illegal drugs, coping mechanisms for stress and a support network 80 are often missing from the lives of people with low incomes. Meeting the future health needs of Canadians Canada s population could exceed 40 million by with one in four Canadians expected to be foreign-born by A third of us will belong to a visible minority group, and the Aboriginal population could reach 2.2 million. 83 Nearly a quarter of us are likely to be over the age of and the number of centenarians could triple or quadruple. 85 We are already seeing changes in the patterns of illness. Most of the communicable diseases that killed Canadians in the 19th and early 20th centuries are now controlled by vaccination and other public-health measures, and people are much more likely to live for many years with chronic diseases. Nowadays, non-communicable diseases cause 89 per cent of deaths in Canada 86, and chronic illnesses are the major drivers of health-care costs and lost productivity. More than 40 per cent of Canadian adults report having at least one of seven common chronic conditions arthritis, cancer, emphysema or chronic obstructive pulmonary disease, diabetes, heart disease, high blood pressure, and mood disorders, not including depression. 87 Many of those conditions are amenable to healthy public policy, preventive care and treatment focused on monitoring and maintenance of health. But such approaches will require us to change our approach to health care in fundamental ways, and reshape what we understand to be essential services. Today, a patchwork of health services is offered in the community; and public funding for health is still focused on hospitals, despite changing demographics and our knowledge of the impact of the determinants of health. Canadians may be uncertain about the value of more spending in Commissioners believe that prevention, early identification, and management of chronic diseases are fundamental to controlling future health care costs as our population ages. Healthy aging and chronic disease management both align well with the knowledge and practice of nurses. 12 National Expert Commission

15 areas beyond acute care. Public opinion of the system does seem to improve when more is spent in areas like hospital care, while spending in other health-care domains is not clearly associated with improved public assessments of the system. 88 Perhaps this result reflects all the focus on hospitals, even when Canadians realize on some level (as we discovered) that the system is not working for us as it should. Meeting the changed and changing health and wellness needs of Canadians in the 21 st century means shifting our focus from hospitals to primary health care networks, run by teams of professionals that ensure continuity of care. Public health policy and education that encourage healthy life choices need to be emphasized. As well, the providers and organizations offering these new types of care will need to embrace cultural awareness, be able to offer care in multiple languages, and be sensitive to the traumatic backgrounds of many Aboriginal people and those from areas of political and military unrest. Services will have to be designed to meet the needs of a growing proportion of older patients. Health in older age Statistics Canada projects that the number of seniors could more than double to 9.8 million by Aging is a phase of life, not a disease, and in Canada the majority of seniors perceive that their health is generally good. 90 More than nine in ten seniors live at home and want to stay there as long as possible. 91 Nevertheless, it is a time when the percentage of people with overall good health and independence declines sharply. After age 65, per capita health spending doubles every decade, hitting $8,425 at age 75, then $16,821 at age Three quarters of home care clients are seniors, nearly a third of clients have high needs and one in five has dementia. An aging population, living longer, has more (and different) health needs. The Canadian Community Health Survey showed rising rates of cancer, diabetes and high blood pressure among seniors between 2003 and The vast majority of dementia occurs in people over 65. The risk of falls increases; about 40 percent of admissions to nursing homes by older people are due to falls. 94 Threats to health are not just physical. Seniors who lack social interaction are vulnerable to social isolation and loneliness 95 and 10 to 15 per cent of seniors suffer from depressive symptoms or clinical depression, 96 with older men particularly at risk for suicide. 97 Older people are also vulnerable to abuse, which can take many forms at home, in the community or in institutional settings. 98 The situation calls for increased attention to disease prevention and health promotion to keep older people as healthy and independent as possible, postpone chronic disease and reduce disability. We will also need support for family and caregivers, and affordable and accessible resources in communities and homes. Such strategies would reduce health-care costs and the need for long-term care. 99 Fact sheet on diseases affecting Canadians The health of our nation, the future of our health system 13

16 Access to prescribed drugs The Canadian Institute for Health Information reports that in 2009, among eight Organisation for Economic Co-operation and Development (OECD) comparator countries, Canada had the second highest level of total drug expenditure per capita, after the United States. 100 However, the same study showed public funding covers only about 39 per cent of total drug spending in Canada the second lowest of eight comparator OECD nations and just ahead of the United States. 101 In Denmark, England, France, Germany, the Netherlands and Sweden, public health insurance covers medication prescribed outside of hospitals, with limited or no co-payments by patients. In Canada, it s mainly people on social assistance and seniors for whom some or all of their prescription drug costs are covered. Others A Canadian Medical Association study found that costs keep one in ten Canadians from obtaining required medications and the problem is worse when income is lower. may get coverage through their employee benefits (in Quebec, anyone without workplace coverage is eligible for a provincial plan). A Canadian Medical Association study found that costs keep one in ten Canadians from obtaining required medications and the problem is worse when income is lower. 102 Cost is also the reason about 13 per cent of adults with disabilities (and nearly a quarter of those with very severe disabilities) were unable to obtain medication, or took less of it at least once during The idea that drugs are an adjunct to hospital care is out of step with a 21 st century approach to health care. In his 2002 review of the health system, Roy Romanow observed that, prescription drugs continue to be on the sidelines of Canada s health-care system rather than integrated, as they should be, with primary health care and with other aspects of the health-care system. 104 Responding, first ministers agreed, saying No Canadians should suffer undue financial hardship in accessing needed drug therapies, and directed their ministers of health to develop and implement a national pharmaceuticals strategy. 105 However, that has not happened. It is time for pharmaceutical care to be included in medicare. Home care The move to more care at home is an inevitable result of a health-care system focused on the needs of patients. Even when they are gravely ill, most people want to be at home, not in a hospital. Although we heard some concerns about the need for more long-term care beds, there was little call in our consultations or in the research evidence we gathered for more care inside hospitals and other institutions. If people must go to an institutional setting for care, most want to be home as soon as possible. Home care must be safe, 106 and must be designed to serve health needs in two major areas: To support those who cannot live fully independently; this includes older Canadians, people living with chronic illnesses (mental or physical) or disabilities, and children with special needs; and To provide services after hospital care for an acute or episodic illness medical, surgical or post-partum for example and for palliative patients. Use of prescription medications by older Canadians 14 National Expert Commission

17 4.7 million Canadians are aged 65 and older and 1.2 million of those are over the age of 80. No factor puts older Canadians at more risk than poverty. They are more vulnerable to it than any other group and nearly one in five older persons lives near the poverty line. The health of our nation, the future of our health system 15

18 Home care could be a source of significant cost savings. Moving 25 per cent of the 6,000+ palliative care patients in Ontario from acute-care beds (costing $19,900/patient annually) to home care (costing $4,700/patient annually) could mean savings of more than $15,000 per patient. We also know that 5 per cent of Ontario s population accounts for 84 per cent of costs, in large part because of high hospital readmission rates. Readmissions of patients having co-morbid chronic conditions, and who are high users of hospitals services could be reduced by better home care. Looking just at those high users in Ontario, some 130,000 patients, even a 10 per cent reduction in the $8 billion it costs to provide their hospital care could result in potential savings of $800 million annually. 107,108 Projected nationally, Browne, Birch, and Thabane calculate that $2.4 billion in savings could be used to enhance community care and social determinants of health per cent of Canadians who die can benefit from palliative care but some 70 per cent do not receive these services. Carstairs, June 8, 2010 So home care holds the promise to provide effective, affordable services as a mainstay of health care in Canada. The challenge, however, is to fund it properly. Like other health services that didn t exist when our hospital- and physician-oriented public health insurance plans were developed, home care is not necessarily covered by medicare. Some services, including medications, prescribed by a physician to continue care begun in a hospital may be covered, but many are not. As a result, there is variability in access to and provision of home-care services and differences in the use of and application of co-payments and user fees that create inequities among Canadians. 110 Commissioners call upon the federal government to make the development and funding of national home care a priority to be achieved by Palliative and end-of-life care Canada s growing and aging population inevitably means an increase in the number of deaths, which is expected to grow to some 300,000 per year within a decade up from 235,000 in The Canadian Hospice Palliative Care Association estimates that each death in Canada affects the immediate well being of an average of five other people, or almost 1.25 million Canadians each year disrupting their lives, affecting their income, and causing grief and other psychological issues, including depression and anxiety. 112 Although more Canadians are dying at home or in long-term Health Council of Canada s fact sheet on home care care, 113 most of us still die in hospitals or other institutions. 114,115 The Canadian Institute for Health Information found just 16 to 30 per cent of Western Canadians have access to and receive palliative or end-of-life care. 116,117 By contrast, 90 per cent of Canadians who die can benefit from palliative care but some 70 per cent do not receive these services National Expert Commission

19 $47 trillion Estimated cost to the global economy over the next 20 years from cancer, diabetes, mental illness, heart disease and respiratory illnesses. A report to the Senate, Raising the Bar: A Roadmap for the Future of Palliative Care in Canada, made 17 recommendations to create palliative care for Canadians that would be intensely human and caring and focused on life and living. 119 It was widely endorsed, including by the Canadian Hospice Palliative Care Association and Royal Society of Canada s Expert Panel on End-of-Life Decision Making. The society said efforts should be made to ensure resources that could be better used for wanted palliative care are not diverted to unwanted acute care. 120 Commissioners fully endorse the report to the Senate on palliative care and call upon governments to act upon its recommendations by The impact of disease beyond the patient The impact of chronic disease is not limited to the suffering of the patient. Caregivers of people with chronic diseases are more likely to have insufficient time for sleep, self care and exercise, to feel isolated, 121 and those who are highly stressed are more likely to suffer clinical depression and use more prescription drugs and alcohol. 122 Highly stressed caregivers had a higher mortality rate over a four-year period. 123 Caregivers of people with chronic diseases are more likely to have insufficient time for sleep, self-care and exercise, to feel isolated Across society, chronic disease has resulted in significant productivity loss. People with chronic diseases are more likely to be disabled and absent from work, and report decreased workplace effectiveness and work quality. 124 They also may die prematurely. Productivity losses are projected to grow as more working age Canadians aged 34 to 64 live with chronic disease. 125 In fiscal terms, chronic diseases cost Canadians at least $190 billion annually. 126 Kirby and Keon 127 concluded that mental health problems and illness not only affect millions of Canadians, but also cost the national economy up to $33 billion a year. On a global level, a study commissioned by the World Economic Forum estimated that cancer, diabetes, mental illness, heart disease and respiratory illnesses could cost the global economy $47 trillion over the next 20 years. 128 Sharing First Nations teachings about death, loss and grief The health of our nation, the future of our health system 17

20 Better Health There is no question that ensuring the better health of Canadians will require concerted action and leadership by all levels of government working together. The evidence is clear that better health for Canadians will require public spending on a broad range of social and economic programs beyond health care, to level life s playing field and give those who face disadvantages a better chance of equality in health. 129 The best way to achieve sustainable health is to address the inequities at the determinants of health The best way to achieve level. Health will follow. 130 But we are equally adamant that sustainable health is to individual Canadians must take responsibility for their own health. Research clearly shows that many of the conditions address the inequities at the from which we suffer are heavily influenced by our individual determinants of health level. circumstances and lifestyle choices. That means each of us has at least some power to control our health and lessen the impact Health will follow. of those conditions in the first place. Reading & Reading, 2012 Becoming a healthier nation In our national consultations, we heard Canadians say that we all need to be more active in achieving and maintaining health. Our Fall 2011 public poll, conducted by Nanos Research, revealed about 13 per cent recommended more activity, and a further 13 per cent healthy eating, as the change they thought would best improve the health of Canadians. People told us about the effectiveness of healthy breakfast programs in schools, walking clubs in workplaces and about tax incentives for joining a gym. We also heard about the importance of starting young. Many people suggested daily physical activity should be compulsory in all grades in all schools. Our April 2012 Nanos Research poll found that 85 per cent of Canadians agree and another 10 per cent somewhat agree that regularly scheduled physical activity should be compulsory in all schools, from kindergarten to high school. Despite these findings, the most common answer to our original question about what would improve the health of Canadians was unsure, so Canadians seem to need vision and information about improving population health. Aboriginal health: a case study As we discuss the role of personal choices and responsibilities for our own health and treatment, we cannot ignore the fact that for many Canadians, changing their life circumstances is a difficult, if not impossible, task. Canada is a privileged nation, but our wealth and opportunities are not equitably distributed. Dramatic differences in life chances observed within countries worldwide 131 are found in Canada too where they can be stark and shocking. Canada placed sixth in the 2011 ranking of nations based on Human Development Indicators, which include life expectancy, education and economic well-being. 132 But the story is very different for Aboriginal people. 133 Niagara Region Public Health Department... health, not health care What is the single best thing we can do for our health? Preview of Andrée Cazabon s film, Third World Canada 18 National Expert Commission

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