Dr' Jeffrey Turnbull, MD, FRCPC

1
Medical Issues Facing Canada
For presentation to the Danish Learning
Partnership September 17, 2009
Dr. Jeffrey Turnbull, MD, FRCPC President-Elect C
anadian Medical Association
Support/Powpoint/Danish-Turnbull.ppt
2
Outline

• Physician Workforce
• Access
• Sustainability
• Quality
• Health Care Transformation

3
Constitutional Responsibility for Health Canada,
1867

• POWERS OF PARLIAMENT (91)
• Quarantine and the Establishment and Maintenance
  of Marine Hospitals.
• EXCLUSIVE POWERS OF PROVINCIAL LEGISLATURES (92)
• The Establishment, Maintenance and Management of
  Hospitals, Asylums, Charities, and Eleemosynary
  Institutions in and for the Province, other than
  Marine Hospitals.
• EDUCATION (93)
• In and for each Province the Legislature may
  exclusively make Laws in relation to Education,
  subject and according to the following Provisions

4
Stakeholders in the Determination of HHR Policy

• Governments
• - health
• - education
• Health Sciences/Faculties of Medicine
• Certifying Bodies
• Regulators
• Professional Associations
• Unions
• Health Care Institutions
• Patients/Public/Communities (e.g., recruitment)

5
Major National Medical Stakeholders

• Association of Faculties of Medicine of Canada
• Canadian Association of Internes and Residents
• Canadian Federation of Medical Students
• Canadian Medical Association
• College of Family Physicians of Canada
• Federation of Medical Regulatory Authorities of
  Canada
• Medical Council of Canada
• Royal College of Physicians and Surgeons of Canada

6

• Physician Workforce

7
Canada and Denmark Key physician workforce
indicators
Source OECD Health Data 2009
8
Women in Medicine 1990 2007/09

• 1990 2007/09
• Females as of 46 57
• first year enrolment
• Females as of 17 34
• practising population
• 2007/08
• 2009

Sources Canadian Medical Association,
Association of Faculties of Medicine of Canada
9
Physicians per 1,000 populationCanada, 1982 to
2007
Source Scotts Medical Database, CIHI
10
First Year Enrolment in Medical Schools
(including 40-50 Visa students) 1983-2008
Task Force I
10 cut
Source Medical Education Statistics, AFMC
11
Projected Physician Supply Status quo from 1999
and 2009
Source 1999 and 2009 CMA Physician Resource
Evaluation Template
12
Projected Physician Supply Status quo and retire
at 65 scenarios
Source 2009 CMA Physician Resource Evaluation
Template
13
Hours worked per week (excl on call)
Source CMA PRQ NPS (CFPC, CMA, RCPSC)
14
Average direct patient care hours per week
(excluding call)
Sources 2007 National Physician Survey, 1986 CMA
Physician Resource Questionnaire
15
Access
16
Selected Indicators International Comparison of
Patient Experience, 2007
Country Indicator With regular
Receiving Saying Reporting doctor/GP
Same/Next Easy to Get GP Offers Day
Appoint. After Hours Weekend Last Time
Sick Care Without Hours
Going to
ER Australia 88 62 28 58 Canada 84 36 2
8 21 Germany 92 65 39 15 Netherlands 100 70
40 8 New Zealand 89 75 41 34 United
Kingdom 89 58 31 11 United States 80 49 28
28
Source Commonwealth Fund 2007 International
Health Policy survey Topline Data
17
2007 National Physician Survey

• 52 of physicians can see an urgent case in one
  day or less.
• 27 of physicians can see an non-urgent case in
  one week or less.
• 20 of family physicians are accepting all new
  patients.
• 57 of family physicians and 34 of other
  specialists considered paperwork as a major
  impediment to delivery of care.
• 61 of other specialists said system funding was
  a major impediment.

18
2007 National Physician Survey
rated by family physicians rated by other
specialists
19
The War on Wait Times 2004 -

• 2004 Federal government provides 5.5 billion
  Wait Time Reduction Fund requires provinces to
  establish medically acceptable wait time for
  cancer, heart, diagnostic imaging procedures,
  joint replacements and sight restoration by
  December 31, 2005.
• 2007 Federal government provides further 612
  million for provinces that agree to implement one
  wait time guarantee by March 31, 2010.

20
The Wait Time Alliance (WTA)

• Who is the WTA?
• 12 national medical specialty organizations and
  the CMA
• When was it formed?
• Established following 2004 First Ministers
  Accords commitment to reduce wait times
• Why was it formed?
• Patients continue to experience lengthy waits for
  health care in Canada
• Purpose Ensure that physicians play leadership
  role in improving patient access (e.g., setting
  wait-time benchmarks)
• Hold governments accountable on their commitments
  to reduce wait times

21
What the WTA has done

• Developed maximum wait-time benchmarks for 13
  specialties
• Annual report card on wait times by province
• Website to encourage information sharing
• Economic Cost of Waiting (participated in)
• Political action (e.g., presentation to
  parliamentary committee on health)

22
Comparison of Government and WTA Wait-Time
Benchmarks (scheduled cases, consultation to
treatment)
23
Wait Times From the Patients Perspective
Wait times measured in 2009 WTA report card
Testing
Family physician/GP consultation Differential dia
gnosis referral as needed
Decision by patient to see family physician
Decision to treat or refer back to family doctor
Specialist consultation
Treatment received

Rehabilitation (if necessary) and follow up with
family physician and specialist
Adapted from prototype shared by The College of
Family Physicians of Canada and from ICES, Access
to Health Services in Ontario, Fig. 1.1
24
Select Results from 2009 WTA Report Card
(National Physician Diary Study)
25
Sustainability
26
Total PT Government Health Expenditure as a of
Total PT Program Expenditure Canada Average
1980-2007
Not including debt charges
Source Canadian Institute for Health
Information. NHEX Table B.4.4.
27
British Columbia
28
Tracking Four Schools of Thought on
Sustainability Canadian Public, 2000-2008
Source Ipsos-Reid/Canadian Medical Association
29
Quality
30
The Dimensions of Quality
Accessibility
Competence
Acceptability
Safety
Utilization Review Occupancy Rates
Bed Allocation Patient Satisfaction
Surveys
Monitoring Wait Lists -
Hiring Criteria Performance
Appraisal Peer Review
Credentialing
Manpower Plan
Program Plan -
Risk Management Patient Safety
Equipment Safety Critical Clinical Incidents -
Patient Satisfaction
Accreditation Cooperative Planning -
Quality Management Process
Department Review
Clinical Appraisal Morbidity and
Mortality Reviews
Outcome Screens
Audits Technology Impact Assessment -
Budget Variance Analysis Workload Measurements
Utilization Review Turnaround
Times Wait Lists Occupancy
Rates -
Practice Guidelines Individual Case
Review Drug Use Evaluation -
Efficiency
Appropriateness
Effectiveness
Source MacIntosh and McCutcheon, Canadian
Journal of Quality in Healthcare, March 1992,
Vol. 9, page 21.
31
Evolution of the Quality Agenda in Canadian
Health Care Since the 1990s
1992 Effectiveness First paper on
evidence-based medicine 1996 Accessibility
federal health funding cuts take effect 2003
Safety Canadian Patient Safety Institute
launched 2010 Appropriateness? Acceptability?
32
Use of Electronic Patient Medical Records in
Primary Care Practice Selected Countries, 2006

• Country
• Netherlands 98
• New Zealand 92
• United Kingdom 89
• Australia 79
• Germany 42
• U.S.A. 28
• Canada 23

Source Commonwealth Fund. 2006 International
Survey of Primary Care Doctors
33
Health Care Transformation
34
CMAs 5 Directions for Health Care Transformation

• Building a culture of patient-centred care
• Incentives to enhance access and improve quality
  of care
• Partial activity-based funding for hospitals
• Pay-for-performance for physicians
• Enhancing patient access along continuum of care
• Comprehensive pharmaceutical coverage
• Appropriate system of continuing care (long-term
  care/home care)
• Helping providers help patients
• IT funding/policy directed at patient-provider
  level
• Ensure adequate supply of health human resources
• Building accountability/responsibility at all
  levels
• Public reporting on performance and outcomes
• Monitor sustainability of system