HESA Committee Report

Dissenting Report by the Liberal Party of Canada

Increased longevity and a sharp rise in the incidence of chronic disease have had a significant impact on the delivery of Health Care in Canada, putting increased stress on Medicare. At the same time, Health Promotion and Disease Prevention can have the effect of alleviating that burden. The Committee agreed to the following motions:

• "That the Committee commence a study of Chronic Diseases related to Aging on Wednesday, October 5, 2011, and that the Chair report the Committee’s findings to the House."
• "That the Committee undertake a study of health promotion and disease prevention and that it hold four (4) meetings on this study, starting on Wednesday, November 16, 2011."

For 17 meetings, the House of Commons Standing Committee on health heard from witnesses on these issues. The witnesses ranged from health professionals, Non-Governmental Organizations (NGOs), patient advocates, researchers, and officials from the Health Department.

There was a great deal of commonality amongst witnesses about the nature of the problems and solutions; backed by solid data and research relating to chronic disease, health promotion, and disease prevention.

The Liberal Party does not agree that the report, nor the recommendations, adequately reflect the testimony of witnesses.

For this reason the Liberal Party felt it essential to produce this Dissenting Report.

What the Committee heard:

According to Statistics Canada, life expectancy in Canada is 80.9 years. Much of this can be attributed to progressive public health policies, access to Health Care services and new diagnostic and therapeutic technologies. However, this positive trend has begun to decline. Witnesses attributed this decline to smoking, unhealthy eating, lowered physical activity, and obesity, which accounts for 90% of type 2 diabetes, 80% of coronary artery disease and one-third of cancers. The rate of childhood obesity has quadrupled in the past three decades; the rate of childhood obesity is even higher and amongst Aboriginal children.

Witnesses reported that longevity has contributed to a rise in the incidence of cardio-vascular disease, increased rates of injury, chronic pain, dementia and cancer and indicated that 74 to 90% of seniors suffer from at least one chronic condition. They pointed out that given Canadian demographics there was also a need to develop chronic care models that are culturally sensitive to immigrant and refugee groups and to Aboriginal peoples.

Statistics show that 80% of lung cancer occurs in people over 60. Prevalence of chronic obstructive pulmonary disease (COPD), caused by smoking or asthma, among people 65 to 75 is triple that of younger cohorts and costs the Health Care system $15 billion annually.

Witnesses stated that chronic pain has a significant impact on quality of life and productivity, and must be part of any study on chronic diseases. One in five Canadians lives with chronic pain which is often undiagnosed and undermanaged. Arthritis is the most frequent cause of disability, affecting 4.5 million Canadians.

Witnesses and members of the Committee were aware that the Mental Health Commission of Canada (MHCC) would table its report shortly, but many agreed that mental illness is a chronic health condition, particularly high in seniors. Mental illness in this age group is directly related to physical illness. 15% of seniors who live in the community suffer from depression. This can increase to between 80% to 90% in long-term care facilities. World Health Organization (WHO) statistics projected that globally by 2020, depression will rank second to both potential and productive life years lost. Witnesses highlighted the most tragic component of depression: suicide. The suicide rate among men aged 90 years and older is 33 per 100,000 people, which is more than double most other age groups. Chronic disease is one the highest risk factors for suicide in older age groups.

Witnesses stated that dementia was the most common reason for transferring patients to alternative levels of care and that seniors were generally able, with good support systems, to manage their chronic conditions, until affected by dementia.

The Committee was told that financial limitations compromised many chronically ill patients’ ability to pay for out of pocket expenses, including drugs, food, and participation in the social life of the community, which can lead to isolation.

Witness comments on measures to promote healthy living:

The Committee heard that chronic diseases cost the Canadian economy $190 billion annually; $90 billion due to Health Care costs, and the remainder due to lost productivity. Therefore chronic disease is not only a health issue but also an economic one.

Evidence indicates that many chronic diseases may not be a natural component of aging, and could be prevented with good health promotion and disease prevention strategies as well as social policies to alleviate the negative determinants of health, such as poverty, inadequate housing and unhealthy lifestyles.

Overview of current chronic disease care in Canada:

Government’s initiatives:

Officials from the Public Health Agency of Canada reported on a variety of initiatives dealing with chronic diseases, health promotion and disease prevention in general; many of these involved partnerships with provincial and territorial governments, NGOs, and private partners. Officials spoke of the importance of a multi-sectoral approach, not just restricted to the Health Care portfolio. Canada endorsed this approach to chronic disease prevention strategies at the recent United Nations meeting, September 2011.

Many initiatives were issue-related dealing with healthy eating and healthy weights, diabetes strategies, age-friendly communities, Aboriginal nutrition, prenatal nutrition programs, child nutrition programs, and physical activity and injury prevention.

In 2010 Federal, Provincial, and Territorial governments declared a shared vision for prevention of disease, disability, and injury with health promotion as a priority. This agreement acknowledged that many determinants of health lie outside of the Health Care sector. A Pan-Canadian Public Health Network was created to share information, provide policy and technical advice to FPT Ministers and support to jurisdictions during public health emergencies.

The Canadian Best Practices Initiative responded to the need for sharing data. It includes the Best Practices Portal to share knowledge and measure uptake in practice activities as well as provide a compendium of community interventions related to health promotion and disease prevention that have been evaluated.

Current status of federal research:

Much research on chronic diseases is done by the Canadian Institute of Health Research. CIHR is active in health promotion and disease prevention, especially in diabetes, obesity and applied injury research.

The CIHR Institute of Aging and Pathways to a Health Equity for Aboriginal Peoples was recently developed to advance research on health disparities within these particular population groups.

Status of Health Human Resources relating to chronic disease care:

Many witnesses voiced concerns over inadequate training of Health Care professionals to identify, treat, and manage chronic diseases in the elderly and expressed the need for an integrated approach on health human resources. For example, witnesses said there were only 200 geriatricians in Canada whereas the current need requires 500-600, which will only increase as the population ages. It was predicted that by 2020 there would be a 35% shortage of respirologists to deal with COPD and there were insufficient physicians trained for primary care.

Witnesses recommended that the recognition of foreign credentials of Health Care professionals be fast-forwarded to broaden Canada’s base of Health Care providers who can also contribute needed cultural and language knowledge.

The way forward:

The Committee heard that individuals need to take some responsibility for adopting healthy, active lifestyles as a way of delaying chronic illness. It was suggested that public awareness campaigns would promote active self-care.

Witnesses mentioned the current model for dealing with chronic illness is no longer cost-effective or appropriate. Many patients with chronic illness, including the elderly, receive care in hospitals and long-term care facilities when a community care based model would improve the quality of life, health outcomes, and the ability of seniors to age in their own homes for as long as possible.

They advised that community-based, patient-centred, primary care models with multi-disciplinary teams integrated with social and housing services would provide the best outcomes.

While government and health care professionals provide the bulk of care, many families are burdened with the responsibility of providing informal care and suffer stress, fatigue, and burnout. Family members need financial and mental health supports and respite. Witnesses felt that the extension of employment insurance benefits for informal caregivers and the non-refundable tax credit do not fully address these problems; instead the tax credit should be refundable to allow low- and modest-income families to benefit.

Social Determinants of Health:

Witnesses reminded the Committee that major determinants of health were related to income status and housing, and that one cannot separate health and social services in providing chronic care.

Healthy Living:

Witnesses commented that the impact of high sodium and trans-fat levels in foods have not been addressed satisfactorily, and reiterated the need for appropriate labeling and regulations to help consumers make informed, healthy choices about the food and beverage products they purchase. As much as 80% of foods and beverages marketed to children are unhealthy; high in fat, sugar, and salt, and low in nutrients. Witnesses also recommended that the federal government re-evaluate food taxation policies to create incentives for consumption of healthy foods and disincentives for unhealthy foods.

They commented that there was a greater need to encourage and facilitate more physical activity and active living to the population in general, but especially to children and seniors. Some witnesses suggested that the Children’s Fitness Tax Credit should be made refundable and an adult fitness tax credit added. Physical activity not only prevents many chronic diseases, but also prevents injury. They also commented that resources allocated to health research and injury were inadequate given the high cost of the economic and social burden associated with injury.

Finally, the Committee was told that in the last year all levels of government spent only 0.9% of total public health spending on health promotion, physical activity, and sport. Recent studies in the United States showed that within 25 years, investment in prevention would prevent premature deaths and reduce overall Health Care costs and economic loss associated with decreased productivity.

Health Transfers and the Health Accord:

Witnesses stressed the need for a variety of reforms in Health Care that would improve health outcomes, accountability, and cost-effectiveness and be more attentive to the changing needs of Canadians. They felt that the 2004 Health Accord had highlighted some of these innovations and that they were looking forward to a 2014 Health Accord, which would strengthen the transformative changes anticipated in the 2004 Accord.

Recommendations:

Based on what the Committee heard from expert witnesses, department officials and advocates regarding the impact of chronic diseases on human health and productivity;

Based on testimony and long-standing evidence of the cost to the Health Care system of treating chronic diseases;

Based on the evidence that showed many of these diseases to be preventable;

Based on evidence that many chronic diseases have more cost-effective and better quality of life outcomes when managed in the home, in community care models, and outside of hospital; and

Based on evidence that shows the high cost of medications for those who have chronic diseases leads to lack of affordability of, and non-compliance with, treatment and the subsequent exacerbation and worsening of illness;

The Liberal Party recommends:

1.    That a pan-Canadian health promotion and chronic disease prevention strategy that is culturally appropriate and funded to 5% of the overall health budget be implemented with the following elements:

a.    A national sodium reduction strategy to lower the daily intake (to below 2,300mg per day), including regulated levels for food industry, and the development and funding of education programs to raise awareness of the dangers of high sodium intake and the existence of lower sodium products;

b.    Mandatory regulations of trans-fat levels to 2 grams per every 100 grams of oil or fat;

c.    Regulate energy drinks to be sold as a drug under the direct supervision of  a pharmacist, as recommended by the federal government’s expert panel and prohibit advertising, promotion, and sale of energy drinks to youth under the age of 18;

d.    Ban advertising and promotion of unhealthy foods to children under the age of 12, using the Quebec model as a best practice;

e.    Examine feasibility of taxation policy on foods high in fat, sodium, and sugar, using the Scandinavian models as a best practice;

f.     Adopt a progressive food labeling system to communicate better to consumers the nutritional contents of food;

g.    Increase daily physical activity among all youth and children, by investing in community sport infrastructure (including playgrounds), supported by trained coaches and other professionals;

h.    Reinstate full funding to the Federal Tobacco Control Strategy; and

i.      Reverse cuts and enhance funding to suicide prevention programs at the Department of National Defence including support for post-traumatic stress disorder; and

j.      Reinstate full funding to the National Aboriginal Health Organization, Aboriginal Diabetes Initiative, Aboriginal Health Human Resources Initiative, Aboriginal Youth Suicide Prevention Strategy, and the Aboriginal Health Transition Fund.

2.    Integrate within the Best Practices Portal, best practices in primary, patient-centred, multidisciplinary, comprehensive, community and home care models, including housing and social services, which are currently under pilot project status within the 2004 Health Accord. Develop and utilize indicators to measure cost-effectiveness and patient wellness outcomes;

3.    The federal government return to and implement the following collaborative, cross-jurisdictional objectives agreed to in the 2004 Health Accord;

a.    develop a pan-Canadian pharmaceutical strategy that will make medically required therapeutics accessible to all Canadians with chronic and life-threatening diseases. This strategy must also contain a plan of action to anticipate, identify, and manage drug shortages;

b.    develop a pan-Canadian Health Human Resources Strategy;

c.    develop a pan-Canadian dementia strategy as part of the home and community care reforms agreed to in the 2004 Health Accord.

4.    That the federal government take a leadership role in developing, with provinces, territories, and other partners, a comprehensive, integrated, National Pain Strategy as tabled by the Canadian Pain Coalition.

5.    That the federal government implements multidisciplinary, integrated, culturally sensitive, “full continuum” of home and community care service delivery models to manage and prevent chronic diseases within the population cohorts for which the federal government has a direct responsibility: veterans, First Nations, Inuit, and Canadian Armed Forces.