From October 2011 until February 2012, the House of Commons
Standing Committee on Health heard from witnesses on the issues of chronic
diseases related to aging, as well as health promotion and disease prevention.
A total of 17 meetings were held during which the Committee heard from
government officials as well as witnesses representing health professionals,
disease groups, seniors, patient advocates, researchers, private insurance and
charitable organizations.
In undertaking this study, the Committee recognized that the administration
and delivery of health care services is the responsibility of each province or
territory. Guided by the provisions of the Canada Health Act, the
provinces and territories fund these services with assistance from the federal
government in the form of fiscal transfers. Health care services include
insured primary health care, such as the services of physicians and other health
professionals, care in hospital, home care, and scope of practice.
Life expectancy has reached 80.9 years in this country, according
to testimony quoting Statistics Canada data.[1] In addition, almost 90% of
Canadians report that they believe their
health is good, very good or excellent.[2] In terms of life expectancy,
members of the Committee heard that,
since the early 1900s, the average lifespan of Canadians has increased by more
than 30 years and that 25 of those years
are attributed to advances in public health.[3] However, it was also pointed
out that the number of years lived in good health peaked in 1996 and has since been declining.[4]
The Committee heard that the burden of chronic disease is related
to the dietary patterns, the rates of overweight and obesity and the levels of
physical activity of Canadians. Witnesses stated that healthy eating reduces
the risk of developing chronic diseases. It was suggested that 90% of type 2
diabetes, 80% of coronary heart disease, and one third of cancers could be prevented by healthy eating,
regular exercise, and by not smoking.[5] Members were also told that
as many as 48,000 deaths per year in Canada are related to poor nutrition.[6]
Witnesses spoke of the rising obesity rate, stating that the rate
has doubled and in some cases tripled in several countries since 1980.[7] Data was presented for 2007-2008, which
indicates that one in four Canadian adults were obese and one quarter of
Canadian teenagers were either obese or overweight.[8] Childhood obesity rates have nearly quadrupled in the past three decades,[9] and the rate of obesity among Aboriginal children is significantly higher than
it is for other Canadian children.[10] In terms of cost, the
Committee was told that health costs related to the chronic diseases most
consistently linked to obesity was $4.6
billion in 2008 compared to $3.9 billion in 2000.[11]
Reduced physical activity is also linked to poorer health. The
Committee heard that fewer than half of all Canadians are as active as they
need to be. Only 7% of Canadian children meet the daily physical activity guidelines
and even fewer teenagers meet them.[12] It was told that as many
as 25 chronic diseases are directly linked to physical inactivity, and that an
inactive person will spend 38% more days in hospital use 5.5% more family
physician visits, 13% more specialist
services, and 12% more nurse visits compared to an active person.[13]
The first of Canada’s baby boomers turned 65 years old in 2011,
marking the beginning of the anticipated demographic shift which will give rise
to an increase in the proportion of Canadians aged 65 years and older. The
Committee was told that today, 14% of the population is over 65 years but by
2021, this will rise to 6.7 million people[14] and by 2036, almost 25% of
Canadians, or 10 million people, will be seniors.[15] It also heard that in many regions of low population density — that is rural Canada,
the senior population is already disproportionately high.[16] Furthermore, by 2041, 4% of the population, or about 1.6 million
Canadians, will be over the age of 85 years.[17]
Several witnesses commented on the prevalence of chronic disease,
particularly among seniors, and indicated that chronic disease is the major
cause of death. Among the most prevalent chronic conditions are cardiovascular
disease (heart disease and stroke), cancer, diabetes and respiratory disease. Other
common chronic diseases include arthritis, chronic pain and mental health
issues such as dementia and depression. Witnesses indicated that between 74%
and 90%[18] of seniors suffer from at
least one chronic condition, while about one quarter of the senior population
is affected by two or more of these conditions.[19] In terms of medications, the Committee was told that 74% of seniors were taking
at least one medication[20] while 15% takes five or
more medications.[21]
The Committee heard that chronic diseases cost the Canadian economy
$190 billion annually,[22] $90 billion of which
is attributed to treatment and the remainder to lost productivity.[23] The Committee was told that treatment of chronic diseases consumes 67% of
all direct health care costs.[24] Many witnesses stressed
that more focus on prevention strategies, coupled with improved diagnosis and
management of chronic disease, is needed as Canada heads into the coming years
of an aging demographic.[25]
The Committee heard that the Govenment of Canada is investing in
partnerships to promote the development of conditions for healthy aging. These
partnerships address social inclusion, keeping seniors independent, improving
their quality of life, helping them understand what they need to do to prevent
chronic disease or to delay its onset, and keeping them connected in their
communities.[27]
The Committee heard from officials representing the Public Health
Agency of Canada (PHAC, the Agency) who outlined the federal initiatives aimed
not only at chronic diseases related to aging, but also to health promotion and
disease prevention in general. As such, Committee members were told about a
variety of initiatives across the lifespan but which also promote healthy aging
and address the burden of chronic disease in the elderly. Many of these actions
involve partnerships with provincial and territorial governments,
non-governmental organizations and business. Officials spoke of the importance
of a multi-sectoral, or whole-of-society, approach, not one that is simply
restricted to the health sector. The Committee heard that this approach
complements the recent United Nations’ meeting in September 2011 when Canada
joined in the endorsement of the need to include all sectors when designing
chronic disease prevention strategies.
In 2005, the federal government invested $300 million over five
years in the Integrated Strategy on Healthy Living and Chronic Disease. In
September 2010, these efforts were renewed when Federal, Provincial and
Territorial (F/P/T) Ministers of Health endorsed two initiatives:
a) The Federal/Provincial/Territorial Declaration on Prevention and
Promotion[*] – In
2010, the federal government announced $74.4 million in sustained annual
funding in support of the F/P/T Declaration on Prevention and Promotion. This
Declaration was endorsed by all Ministers of Health and Health
Promotion/Healthy Living and it outlines a shared vision to work together to
make prevention of disease, disability and injury, and health promotion a
priority. The Declaration acknowledges that many actions to be taken in order
to improve health lie outside of the health sector because many determinants of
health lie outside of the health sector. The Declaration also acknowledges the
burden of chronic disease that is associated with unhealthy lifestyles;
b) Curbing Childhood Obesity: A
Federal, Provincial and Territorial Framework for Action to Promote Healthy Weights.[†] The framework includes the following three integrated strategies that build on
the work of the Pan-Canadian Healthy Living Strategy and the Declaration
on Prevention and Promotion:
i. Making childhood overweight and obesity a collective priority for action for F/P/T Ministers of Health and/or Health Promotion/Healthy Living, who will encourage shared leadership and joint and/or complementary action from government departments and other sectors of Canadian society.
ii. Coordinating efforts on three key policy priorities:
§ supportive environments: making the social and physical environment where children live, learn and play more supportive of physical activity and healthy eating;
§ early action: identifying the risk of overweight and obesity in children and addressing it early; and
§ nutritious foods: looking at ways to increase the availability and accessibility of nutritious foods and decrease the marketing of foods and beverages high in fat, sugar and/or sodium to children.
iii. Measuring and reporting on collective progress in reducing childhood overweight and obesity, learning from successful initiatives, and modifying approaches as appropriate.
Committee members heard that the collaborative approach of F/P/T
governments involves the formation of partnerships between the federal,
provincial and territorial governments. PHAC officials explained that creation
of the Agency included the recognition that effective public health strategies
require the participation of all jurisdictions. In this regard, the
Pan-Canadian Public Health Network (PHN) was created which is governed by a
17-member Council that includes representatives from F/P/T governments.
The mandate of the PHN includes: information sharing; providing policy and
technical advice to F/P/T Deputy Ministers of Health; and providing support to
jurisdictions during public health emergencies.
The collaborative approach of the F/P/T governments
includes programs aligned with its three pillars: health promotion, chronic
disease prevention and support for early detection and management of chronic
diseases. Health Canada and its agencies support programs that include
disease-specific strategies and frameworks which have been developed through
partnerships with governmental and non-governmental stakeholders. They include:
cardiovascular (the Canadian Heart Health Strategy), cancer (the Canadian
Strategy for Cancer Control implemented through the Canadian Partnership
Against Cancer), diabetes (the Canadian Diabetes Strategy), respiratory (the
National Lung Health Framework), and mental health (the Framework for a Mental
Health Strategy for Canada). Also included is the Enhanced Surveillance of
Chronic Diseases program and officials emphasized the need for improved
surveillance of chronic disease.
Surveillance falls under PHAC’s mandate, and the Agency maintains a
number of databases for both communicable and non-communicable conditions. With
respect to chronic diseases, the Enhanced Surveillance of Chronic Diseases
program initially provided surveillance data for high blood pressure and
diabetes under the Canadian Chronic Disease Surveillance System. This program
has also provided $15 million over four years for the National Population
Health Study of Neurological Conditions. This study will help to improve the
quality of surveillance data for conditions such as Alzheimer’s disease,
Parkinson’s disease, epilepsy, neuromuscular disorders, etc. Prevalence,
incidence, morbidity and mortality data for chronic conditions including
cancer, cardiovascular disease, neurological conditions, arthritis, mental
health, diabetes and respiratory diseases are provided through PHAC’s Chronic
Disease Infobase as information becomes available.
The Committee heard that federal investments include the
improvement of policy and program decision-making by facilitating access to the
best available evidence on chronic disease prevention and health promotion
practices. These investments include the Best Practices Portal, a knowledge
exchange component and a component to measure uptake in practice activities. The
Best Practices Portal is a compendium of community interventions related to
chronic disease prevention and health promotion that have been evaluated, shown
to be successful, and have the potential to be adapted and replicated by other
health practitioners.[28]
With respect to mental health promotion, the Committee heard about
federal investment in the Mental Health Commission of Canada (MHCC) which has
developed the framework mentioned above and the Canadian Coalition for Seniors’
Mental Health (CCSMH), which has developed practice guidelines for
practitioners.
International cooperation is also a component of the Agency’s
integrated approach to chronic disease prevention. In this regard, PHAC
officials outlined the Agency’s collaboration with the World Health
Organization (WHO) in building surveillance capacity in underdeveloped countries.
PHAC also works with countries in the Americas, called the CARMEN network, to
develop and share case studies having to do with prevention strategies,
primarily with respect to obesity. Through the work of the network, prevention
discussion is advanced and policy change is facilitated. Finally, PHAC
indicated that it works closely with the Pan American Health Organization on
the issue of sodium reduction in food.
Finally, PHAC officials spoke of the report entitled Action
Taken and Future Directions 2011, which was endorsed at the Health
Ministers Meeting in November 2011. The
report highlights actions that had been taken to advance the framework since September 2010, and makes recommendations
and proposed actions that can be taken by Ministers of Health and their
governments, as well as other sectors, until the fall of 2012 and beyond.
PHAC officials described initiatives that are specific to seniors.
The National Seniors Council was created in 2007 to provide advice on emerging
issues and opportunities specific to the quality of life and well-being of
seniors. It reports to both the Minister of Human Resources and Skills
Development and the Minister of Health. Members also heard that Canada
participates in a program that was initiated by the WHO called Age-friendly
Communities. Under this program, PHAC provides leadership to communities in
efforts to enhance or improve the built environment within a community in order
to encourage healthy, active living among seniors. Infrastructure such as
lighting, width of sidewalks and accessible curbs were cited as examples. The
Committee heard that, while over 560 communities across Canada are
participating in this initiative, the majority (316 communities) are in Quebec.[29]
The Age-friendly Communities initiative brings older Canadians into
the planning and design of their own communities to create healthy, safe, and
supportive environments where they can live and thrive. The
initiative has resulted in several communities being safer and more accessible to
seniors, while also putting older Canadians at the centre of policy discussions
about how age-friendly communities are designed.
PHAC officials also mentioned that, outside of the Canadian
Diabetes Strategy, the Aboriginal Diabetes Initiative is delivered through
Health Canada’s First Nations and Inuit Health Branch. This strategy emphasizes
prevention strategies as well as improved management of diabetes, much like the
Canadian Diabetes Strategy, but it is tailored to be more relevant and
effective for the Canadian Aboriginal population.
Finally, members heard that PHAC has developed an assessment tool
for Canadians called CANRISK. This questionnaire is designed to improve the
identification of individuals at risk of developing diabetes and who would
benefit from prevention strategies to delay onset of the disease, or succeed in
preventing the disease altogether.
Witnesses described Canada’s food guide which was first introduced
in 1942 and was updated most recently in 2007. Health Canada’s food guide,
entitled Eating Well with Canada’s Food Guide, was developed
using evidence-based nutrition policy and is designed to help Canadians make
healthy food choices that will meet their nutrient
needs, promote health, and prevent nutritional deficiencies.
With respect to funding initiatives to promote healthy eating and
healthy weights, the Committee was told that the federal government invests
annually over $112 million to support vulnerable children and their families through various programs such as
the Community Action Program for Children, the Canadian Prenatal Nutrition Program, and the Aboriginal Head Start Program in
urban and northern communities. The Canadian Prenatal Nutrition Program was
described as a community-based program delivered by PHAC to help communities
promote public health and provide support to improve the health and well-being
of pregnant women, new mothers and babies facing challenging life
circumstances. Witnesses informed the Committee of the government’s Canadian Gestational Weight Gain Recommendations which are designed to help health professionals
and expectant mothers manage weight
gain during pregnancy. Finally, the Eat Well and Be Active Educational Toolkit from Health Canada is designed to help educators who teach groups
of children and adults about healthy eating and physical activity. Finally, in
order to improve access to nutritious, perishable food to help Canadians living
in isolated northern communities,the federal government invests $60 million
annually to the Nutrition North Canada Program.[30]
Physical activity and active living are important for maintaining
good health. Between 1998 and 2002, physical activity guides were developed by
the federal government and the Canadian Society for Exercise Physiology (CSEP)
for adults, older adults, children and youth. In January 2011, updates to all
four sets of guidelines were released by CSEP.
In March 2011, the federal government announced a $5 million
investment over two years in sports and recreation injury prevention through
collaboration with non-governmental organizations that focus on major injuries.
These include concussions, drowning and fractures incurred during
high-participation activities such as hockey, snow sports, cycling and water
sports.
Throughout the course of the meetings, members heard about research
projects supported by the Canadian Institutes of Health Research (CIHR). CIHR,
comprised of 13 virtual institutes, is Canada’s granting agency for all
types of health research, from biomedical to clinical, to health service
delivery. Its annual budget is around $1 billion. Several of these institutes
are involved in research in the areas of health promotion and chronic disease
prevention and management.
CIHR informed members that it was a founding member of the Global Alliance for Chronic Diseases. This international alliance, announced in
June 2009, involves the collaboration of six health research agencies around
the world which have committed to set priorities for a coordinated research
effort focussing on chronic disease. In the interest of advancing this
priority, the Committee members were told that CIHR’s strategic plan for
2009–2010 to 2013–2014 includes a strategic research priority regarding the
burden of chronic disease and mental illness. Within the context of this
priority, CIHR notes the need to enhance patient-oriented care, the pressures
placed on the health care system due to the aging population and rising rates
of chronic disease, and the importance of leveraging resources by working
collaboratively with other departments, agencies and non-governmental
organizations to address research needs.
The Committee was told that the federal investment in aging
research through CIHR’s Institute of Aging was $122 million in 2009–2010. Of this,
$44 million were awarded in 2010 to support Canadian diabetes research, and
additional funds to support research related to cancer, heart disease, and
stroke.[32] Several witnesses
mentioned the Canadian Longitudinal Study on Aging (CLSA), one of CIHR’s strategic
initiatives. The CLSA will follow a cohort of individuals aged 45 years and
older for 25 years to help understand the evolution of disease, and the psychological
attributes, function, disabilities and psychosocial processes that accompany
aging. The Committee heard that, to date, $38 million have been invested
through CIHR along with $15 million from provincial and other partners.
The Committee heard that CIHR has been active in promoting research
in the areas of health promotion and disease prevention. In addition to ongoing
investment in obesity research, CIHR indicated that it funds research into
disease prevention through its various institutes, as well as health promotion
generally, and more indirectly, on food and nutrition research. In November
2010, CIHR’s Institute of Nutrition, Metabolism, and Diabetes held a
workshop entitled “Advancing Food and Health Research Priorities in
Canada”, which aimed to identify gaps in research.
To increase the capacity of Aboriginal communities to act as partners
in the creation, oversight and application of research to reduce the health
disparities among Aboriginal Peoples, the Committee heard that CIHR has developed
the “Pathways to Health Equity for Aboriginal Peoples”.
The Committee was also told about the Canadian Community Health
Survey administered by Statistics Canada which collects information related
to health status, health care utilization and social determinants of health of
the Canadian population. The survey focused on nutrition in 2004 and it will
be repeated in 2015.
Finally, members were told that, in July 2010, the federal
government announced an $8.2-million investment over five years in CIHR
Strategic Teams in Applied Injury Research. Five injury research teams are
funded under this investment and will conduct research on childhood injuries.
The Committee heard a range of concerns, as well as a number of
suggested approaches, from several witnesses over the course of the Committee
meetings. These issues are outlined below.
Some witnesses voiced their strong concern over inadequate training
of health professionals to properly identify, treat and manage chronic disease
in the elderly. These concerns included not only an inadequate supply of
physicians who specialize in the care of the elderly (geriatricians), but also
the failure to provide adequate training to general practitioners for the care
of elderly patients. For example, members were told that there are only 200
geriatricians in Canada, but that the need is currently for 500-600 and they were cautioned that this need will only
increase as the population ages.[33] Similarly, the Committee
was told that by 2020, there will be a 35% shortage of respirologists.[34] The suggestion was raised that medical training should focus less on
specialties associated with acute care.[35] The salaried remuneration
model for geriatricians, as opposed to the fee-for-service model used for most
other practitioners, was presented on one hand as a disincentive to enter the
specialty,[36] but on the other hand, the
Committee heard that evidence suggests a fee-for-service model does not
encourage interdisciplinary care or the best care.[37] Witnesses indicated that, in terms of training and continuous education, aging
is not sufficiently addressed for physicians and other health professionals.[38]
The Committee heard that improved training of health professionals,
particularly in the provision of chronic care for the aged, is being addressed
through a five-year initiative in Ontario called the Associated Medical
Services Phoenix Project: A Call to Caring. The project was described as
addressing the need to balance compassion and technical expertise in the
provision of patient-centred care.[39] It also heard that this
approach, within a health promotion and disease prevention model, has been
proposed by the Association of Faculties of Medicine of Canada to address the
evolving training needs of future medical practitioners in response to the
increasing burden of chronic disease and the aging population. Witnesses
commented also on access to primary care and stated that not only is there a
shortage of physicians specializing in geriatric care, but also of physicians
being trained for general practice. The Committee was told that as many as
6% of Canadians who suffer from at least one chronic disease related to
aging do not have access to a primary care physician.[40]
While scope of practice is under provincial jurisdiction, it was
raised by pharmacists and paramedics as a way to better utilize health
resources. Pharmacists were described as an accessible health care provider in
the community. The Committee was told that, as such, they are well suited to
provide a “medication management service” through which they assist in chronic
disease management by providing comprehensive medication information, monitoring
individuals for adverse drug reactions, addressing issues of compliance with medication
regimens and communicating with the health providers when identifying problems
and proposing alternate therapies. Members were also told that inclusion of
pharmacists within a collaborative model of health care, which is discussed in
greater detail later on, has the potential to produce a cost saving to the
health care system. As well, pharmacy-based screening programs such as the one
in place for blood pressure monitoring in Ontario, can reduce hospital
admissions.[41]
Paramedics were described to Committee members as the third largest
health care provider group in Canada. The Committee heard that community
paramedicine, which would require an increased scope of practice in some cases,
permits paramedics to provide non-emergency patient care –both preventative
self-care and rehabilitation care, within the community. The argument was
presented that effective care transition from hospital back into the home
through community paramedicine could reduce readmissions to hospital, which
currently stands at 15% within 30 days of discharge. Similarly, community
paramedicine was presented as an effective way to divert 911 calls and reduce
emergency room visits, as well as a means of keeping elderly patients in their
homes, as opposed to a hospital bed, while they wait for long-term care
placement.[42]
The issue of ethnic and cultural
sensitivity and the need to provide services in the appropriate language was
put forward. While the issue was raised as to whether there is an obligation in
Canada to provide health and social services in both officials languages,
Committee members also heard that in cases of dementia, which affects one in
eleven seniors,[43] a person’s capacity for
their second language is one of the first things to be lost.[44] Similarly, members were informed about the need for interventions by family or
other caregivers when language becomes a barrier.[45]
In terms of demographics of ethnicity, the Committee was told that
the urban Canadian population has become progressively more ethnically diverse
in the last two decades, and this trend is expected to continue.[46] The Committee was informed that the Chinese community is one of the largest
ethnic groups and as such, has served as the first group for which culturally
sensitive models of service delivery have been developed. It was explained that
it is not so much health care needs that are unique to any particular ethnic
group, but rather the manner in which they respond to a particular strategy.[47]
Finally, Committee members heard that the recognition of foreign
credentials with respect to health professionals coming to Canada provides an
opportunity to broaden Canada’s base of health professionals who can also
contribute necessary language and cultural knowledge.[48]
Several witnesses commented on the complexity of managing elderly
patients with chronic disease. As indicated earlier, the majority of seniors
suffer from at least one chronic condition and take at least one prescription
drug, while a significant proportion are affected by several and have been
prescribed multiple medications.
The Committee heard from witnesses who spoke about the burden of
various chronic conditions. Members were told that there is a strong link
between age and type 2 diabetes, and that being 40 years of age or older is a
key risk factor to developing the disease, followed by overweight and a
sedentary lifestyle. The Committee was told that the prevalence of diabetes is
increasing, affecting 7.6% of the population currently, but expected to rise to
11% of all Canadians by 2020. Factoring in those at risk of developing diabetes
means that currently,1 in 4 Canadians is affected and that this is expected to
increase to 1 in 3 by 2020. Similarly, there is a significant cost to the
health care system. Committee members heard testimony that the current cost is
$11.7 billion, and that this is expected to increase along with the condition’s
prevalence to $16 billion annually.Of particular note is that 80% of this cost
is associated with the complications arising from diabetes, namely heart attack
and stroke, kidney disease, blindness, amputation, and depression.[49] However, the Committee was told that the aging of the population accounts for
an increase of only 1% in the cost of health care services.[50]
The Active Living Coalition for Older Adults has received funding
from Health Canada and PHAC to develop information resources to help older
adults understand that chronic diseases, including diabetes, are often
associated with lifestyle. Information about how seniors can modify their
lifestyle is provided by the Coalition to community leaders and offered to
older people in their communities.[51]
The Committee heard that cancer, which is now considered a chronic
disease due to improvements in treatment and management, is also age-related
and increasing in prevalence. It was told that between 2007 and 2031, the
number of new cancer cases is expected to increase by 71%. About 30% of deaths
are caused by cancer. [52] Funding for the Canadian
Partnership Against Cancer, which was created by the Government of Canada in
2007, has been extended another five years from 2012 to 2017. While 50% of
patients with cancer will die from the disease, patients and families are often
not prepared for end-of-life decisions and conversations. The Committee was
told that the Canadian Partnership Against Cancer works with the Quality
End-of-Life Care Coalition of Canada’s blueprint for action, in order to
advance palliative care in the country.[53]
Heart attacks and stroke, or cardiovascular disease, account for
slightly less than 30% of deaths overall; however, they are the leading cause
of death and disability among Canadians 65 years and older, The Committee heard
that age is the single largest predictor of stroke and that probability of
stroke begins to rise at age 55 and doubles every decade thereafter. Members
were told that, while 50,000 Canadians are hospitalized with stroke each year,
five to ten times as many suffer smaller strokes for which medical attention is
not sought, even though they produce some level of disability. The Committee
was told that the increasing prevalence of obesity and diabetes, combined with
the aging population, will contribute to an increase in cardiovascular disease
in the years ahead.[54]
Committee members heard that respiratory illnesses also become
considerably more prevalent among seniors. Some statistics that were presented
included: 80% of lung cancers occur in people over 60 years of age;
prevalence of chronic obstructive pulmonary disease (COPD, previously known as
emphysema) among people 65-74 years old is triple that for those 35-44 years
old; lung diseases currently cost $15 billion annually and this is expected to
increase to $27 billion annually by 2020; COPD is a contributing factor in 50% of
influenza-related deaths; and the prevalence of lung disease will increase by 33-41%
in the next 30 years.[55] To achieve the goal of
concerted, coordinated action, the federal government has partnered with the
lung health community in a National Lung Health Framework. Under this
framework, an action plan has been developed to improve lung health by
focussing on improvements in prevention, diagnosis and treatment. The Committee
learned that following an initial strategic assessment of the current state of
awareness of lung disease in Canada, it will now undertake targeted actions
that are expected to have a significant impact on reducing lung disease.[56]
Witnesses also spoke of the burden of musculoskeletal diseases,
including arthritis and osteoporosis. Arthritis was presented as the most
frequent cause of disability, affecting one in six Canadians, or
4.5 million people. It affects about 1.7 million seniors. Musculoskeletal
diseases are also linked to other chronic diseases. The Committee heard that
they can directly impact a person’s capacity for physical activity, thereby
having a negative effect on overall fitness level, body weight, diabetes and
mental health.[57] In addition, the Committee
was told that musculoskeletal diseases not only affect individuals, but they
also carry significant implications on the collective workforce. This reduced
capacity for physical activity and increased mental health risk results in a
lower level of productivity and decreased participation in the labour market.
This makes musculoskeletal diseases among the most costly diseases in Canada.[58]
Chronic pain was addressed during this study as an issue that
should be included when studying chronic diseases related to aging. Members heard
that one in five Canadians lives with chronic pain, and this prevalence
increases with age. Chronic pain is often under-diagnosed and under-managed. As
in the case of musculoskeletal conditions, chronic pain affects many aspects of
everyday life. They negatively impact physical activity and social
interactions, thereby contributing to lowered fitness levels, increased body
weight, increased incidence of diabetes, increased heart disease and stroke,
and increased incidence of depression.[59]
The complexity of managing patients with multiple chronic diseases
was expressed by several witnesses. The Committee heard that as many as one in
four seniors aged 65–79 years has at least four chronic conditions,
and this increases to one in three for those aged 80 years and older.[60] It was also noted that these co-occurrences are not necessarily age-related but
life-style related, that is, the lack of physical activity and excess weight
are associated with increased risk of several chronic conditions including
heart disease, diabetes and some cancers.[61] Several factors are
responsible for making the effective management of these patients complex.
There is the overall diminished capacity to tolerate and respond to drugs with
advancing age,[62] the increased probability
for adverse reactions to drugs and negative impacts of one drug on another,[63] the increased incidence of over-medication,[64] diminished capacity to
articulate symptoms and other concerns when compromised by mental health
issues, difficulty in obtaining an overall picture of care when there are
multiple caregivers. This is further complicated by a lack of electronic health
records, and reduced compliance with treatment regimens due to financial and
mobility limitations. Members heard that untangling the symptoms of physical
illnesses from those of mental illnesses requires proper training. As a
consequence, treatable conditions often go undiagnosed and untreated.[65] The Committee was told that financial limitations not only compromise the
patient’s capacity for out-of-pocket expenses associated with their medical and
long-term care, but also impact the individual’s ability to buy nutritious
food, participate in community events and remain physically active.[66]
With respect to the challenge of adverse drug reactions, the Committee
heard of the e-therapeutics+ initiative of the Canadian Pharmacists
Association. Under this initiative, all Health Canada advisories are posted to
disseminate this information to health professionals.[67] The Committee also heard of various initiatives that address the concerns of
physical and social participation amongst older Canadians, which are discussed later
in this section under “Social Determinants of Health”.
Concern for the mental health of Canada’s seniors was frequently
mentioned throughout this study. Witnesses urged the inclusion of seniors’
mental health when considering the issue of chronic diseases.[68] The Committee was told that an individual with mental health issues is not
going to take much interest in their other health problems. As such, it heard,
there is little need to develop strategies to deal with other physical health
concerns if we do not first learn how to address mental health concerns.[69]
Dementia, including Alzheimer’s disease and associated conditions,
was referred to as the godfather of chronic disease. Members were told that, while
dementia in its many forms has a large impact on health care, it has an even
larger impact on alternative levels of care.[70] Members heard that currently,
500,000 seniors suffer from dementia and that this is expected to rise to
1.1 million by 2038. In terms of prevalence, this represents an increase from
1.5% to 2.8% of the overall population, although dementia is diagnosed
primarily in seniors.[71] Several witnesses
emphasized that measurement of dementia’s prevalence does not accurately
measure its actual impact, as it also adds a significant burden on caregivers
in terms of stress, depression and burnout.[72]
Members were told that dementia is the most common reason for
transferring patients from acute hospital bed spots to alternate levels of
care. It was explained that seniors are generally able to manage their chronic
conditions until they are affected by dementia. At that point, self-management
is difficult and the individual enters a cycle of hospitalization,
stabilization, discharge to home, poor self-management, deterioration in
health, and re-admission to hospital. The Committee heard that this cycle often
repeats itself unnecessarily as health professionals fail to identify the
mental health issue.[73] As a result of this
association, many provinces have developed their own Alzheimer’s strategy, some
under a broader seniors’ strategy. The Committee heard that there is ongoing work
in jurisdictions across the country in terms of serving people with Alzheimer’s
and keeping seniors healthy and their minds active.[74]
Depression was frequently mentioned as a significant mental health
issue among the elderly. Members were told that as much as 15% of seniors who
live in the community suffer from depression.[75] However, the Committee
heard that this proportion increases to as high as 80–90% within long-term care
facilities. WHO statistics project that, by 2020, depression will rank second
with respect to both productive and potential life years lost. Witnesses spoke
of the most tragic complication of depression: suicide. The suicide rate among
men aged 90 years and older was stated as being 33.1 per 100,000, almost double
the average across all age groups.[76] Risk factors for suicide
include the chronic conditions discussed above.
The Committee heard that some work has been done with older adults
by creating user-friendly brochures to educate them about depression and other
common mental health issues. This initiatve will help to remove the stigma of
mental illness, to allow seniors to identify symptoms and to help people feel
more comfortable about raising the issue with their physicians and ask for
help.[77]
The Committee was told of the Seniors Advisory Committee of the
Mental Health Commission of Canada and of its contribution to Commission’s
Mental Health Strategy, which was subsequently released on 8 May 2012. The
Advisory Committee has developed guidelines for comprehensive mental health
services for older adults. Members heard that research regarding health service
delivery has also focussed on mental health.[78] Research has also been
exploring the role of physical activity as well as social participation and
their positive effects on mental health.[79]
Several witnesses commented that chronic disease is not an
inevitable consequence of aging.[80] Healthy living, including
nutritious diet, active lifestyle and the avoidance of unhealthy or risky
behaviours, goes a long way in preventing or delaying the onset of chronic
diseases. Witnesses indicated that the majority of seniors are able to remain
in their home and maintain a level of independence for most of their life. This
includes retaining control over their health care and managing any necessary
treatment in consultation with their health care providers.[81]
The Committee heard about initiatives that encourage older
Canadians to maintain a physically and socially active lifestyle. As mentioned
earlier, Canada participates in the Age-friendly Communities initiative,
developed by the WHO. This initiative, which is particularly active within
Quebec, provides leadership to communities to improve their suitability to
older Canadians for adopting healthy, active lifestyles. Central to this is a
focus on social participation. This was described as being essential to an
overall sense of belonging and contributing to society, which in turn has a
positive effect on overall physical health, reduces depression and helps to
slow down cognitive decline.[82] It was also suggested that
cognitive stimulation can, in some instances, outperform medication.[83] The Canadian Partnership Against Cancer has also designed an initiative which looks
at healthy communities called Coalitions Linking Action and Science for Prevention.[84] Similarly, Canada’s Active Living Coalition for Older Adults promotes, through
partnerships with national, provincial and local organizations, active
lifestyles among seniors as a means to contribute to their overall well-being.
This is done through increasing public awareness of the benefits of an active
lifestyle, providing resources and social supports to older adults to encourage
uptake of healthy lifestyles, and identifying, supporting and sharing research
priorities.[85] Finally, the Canadian Chiropractic
Association spoke of the Best Foot Forward program, a campaign aimed at
seniors that provides strategies for preventing falls, along with promoting
balance and strength.[86]
In addition to the personal responsibility for adopting healthy,
active lifestyles in support of preventing and delaying the onset of chronic
conditions, witnesses spoke of the need to promote self-care in the management
of health issues. Self-care was described as a means of empowering seniors and
their caregivers to be active partners in disease management.[87] It was suggested that there should be public awareness campaigns which promote
active self-care to encourage all Canadians and communities to take
responsibility for their own health, as well as national guidelines specific to
the self-care of various chronic conditions.[88]
In addition to promoting personal responsibility by embracing
healthy lifestyles to prevent or delay the onset of chronic disease, and by
adopting self-care practices and taking ownership of an individual’s health
issues, the Committee also heard from the insurance industry that Canadians
should take personal responsibility when it comes to coverage for long-term
care. They suggested it was the individual’s responsibility to plan for this
possible eventuality, either through personal savings or private long-term care
insurance coverage.[89]
As the Committee heard, the majority of older Canadians live
independently in their homes, and want to remain there. It was told that only
7% of Canadians over 65 years of age reside in health care institutions[90] and that between 20 and 30% of long-term care residents do not have to be in
those institutions. It was informed that often, they are there because they
cannot perform the activities of daily living, but cannot afford assisted
living within a seniors’ residence.[91] In fact, there is often no
compelling reason to send many of our seniors to long-term care in terms of
health needs.[92] Witnesses urged improved
community-based services, including home care, as a means of reducing hospital
and emergency room visits and allowing seniors to remain in their homes and
live independently for as long as possible.[93]
In terms of community-based care, the Committee heard that the
system needs to be strengthened through improved integration of services and
better utilization of the scopes of practice of all health care professionals
and home care providers.[94] Witnesses suggested that
community-based services could include mobile health clinics, after-hours
services, home visits, community outreach programs, paramedicine for non-urgent
care, medication management service by pharmacists and mobile emergency nurses
to respond to non-urgent calls.[95] Members heard that there
are also Scandinavian models of community-based care that Canada could look to
for direction.[96]
Several witnesses commented on the need to improve provision of
home care services as one element of community-based care. It was pointed out
that the need for comprehensive, publicly-funded home care has been highlighted
previously, such as in the reports of the Royal Commission on the Future of
Health care entitled Building on Values — The Future of Health care
in Canada[97] and of the Special
Senate Committee on Aging entitled Canada’s Aging Population — Seizing
the Opportunity.[98] They noted that the 2004
Health Accord provided for specific focus on home care but indicated that this
has not yet been adequately addressed.[99]
Members were told that currently, home care services are focussed
on post-hospital recovery as opposed to chronic disease management.[100] They heard that the health care system revolves around acute care within
hospitals and clinics and does not extend to continuing care to address quality
of life issues for individuals with chronic conditions.[101]
It was suggested that this involves not only regulated health
professionals but also better support for informal caregivers. Some witnesses
acknowledged the recent federal incentives, including extended employment
insurance benefits on compassionate grounds for caregiving purposes, as well as
the non-refundable tax credit. Others called for additional caregiver support,
such as training and education, which falls under provincial jurisdiction.[102] It was suggested that such training could include patient care issues as well
as training to assist caregivers in navigating the health system.[103] As mentioned above, stress, fatigue and burnout of informal caregivers have
emerged as concerns when considering the care of those with chronic, as well as
terminal, conditions. The Committee heard that extended benefits to caregivers
should include mental health supports and providing respite, which also fall
under provincial jurisdiction.[104]
With the aging demographics, the need for long-term beds will increase.
As discussed, one way to mitigate this is to make better use of home and
community care resources, so that those who have been admitted to long-term
beds are those who need to be there. Witnesses also commented that this will
result in shorter stays for individuals within the long-term care setting. The
Committee heard that progress has been made in this regard. Committee members
were told that seniors who are transferred to long-term care facilities are
spending the last one to two years of their life there.[105] This is shorter than has been the case in decades past when stays averaged 8-10
years. Nevertheless, witnesses emphasized that optimized community-based care
could effectively reduce this stay even more[106] and that ultimately,
residence in long-term care facilities or nursing homes should be only a few
months.[107] Achieving this outcome,
however, is inhibited given that long-term care has the lowest proportion of
funding of any sector in which health care is provided, the fewest number of
researchers interested in the field, and the lowest rates of research funding.[108]
Committee members heard that the onset of chronic illness, in
addition to being linked to unhealthy living habits, is also linked to an
individual’s biological and genetic makeup and social environment. The social
environment was described as including social determinants of health, namely
income status, education level, housing and social isolation.[109] Witnesses spoke of the important role played by housing and income status as a
determinant of a person’s health. Committee members heard of the burden of
out-of-pocket expenses for care and treatment of chronic conditions[110] for many seniors, and that investment in social housing would have a direct
impact on health status.[111] In a broader context,
members were told that the health of older adults is being analysed in relation
to social inequalities. Research shows that these inequalities become more
pronounced as a person ages, such that those individuals at more of a
disadvantage with respect to social determinants of health bear an even greater
than expected health consequence. This was referred to as “accumulated
disadvantages”.[112] Members were told that, with
respect to caring for older persons living with chronic conditions, it is not
possible to separate health from social services.[113]
Several witnesses emphasized the need to transform the current
acute care model of health service delivery to one which better accommodates
the needs of those struggling with chronic conditions, particularly the
elderly. Witnesses also talked about the need to expand the scope of primary
care beyond simply family practice.[114] It was explained that such
a change in policy would require a shift from involving mainly acute disease to
including the significant role of chronic disease, and in so doing, needs to
move away from institution-based care to a network of health care.[115] They described the integration of a variety of services delivered by a range of
sectors within society.[116] Within the health sector,
witnesses insisted that silos need to come down so that all health
professionals can work collaboratively in the best interest of individuals in
need of the complex care required for effective management of chronic
conditions.[117] In terms of integrating
other sectors, witnesses spoke of the unique needs of the elderly with chronic
conditions and urged continuing care services which may not currently be
considered as medically necessary.[118]
An inter-disciplinary model of care involving the integration of
services provided by a range of health professionals was presented as essential
in providing the complex care required for older adults with chronic
conditions. The Committee heard that such a model of care would be best suited
to support patients as they struggle to manage their own health needs and
maintain a good quality of life.[119] Members were told that
such a team-based model would have to be patient-focussed and work seamlessly
out in the community, as well as within health centres, senior residences and
long-term care settings.[120]
Models of integrated care for the elderly have been designed and
implemented both within Canada and elsewhere. Committee members heard about two
research programs in Quebec, the SIPA (System of Integrated Care for Older
Persons with Disabilities)[121] and PRISMA (Program of
Research to Integrate the Services for the Maintenance of Autonomy)[122] models of integrated care for the elderly. The SIPA model integrates
institution-based and community-based care and has been shown to increase
patient satisfaction. The PRISMA model also involves interdisciplinary teams
with case managers, and aims to keep people at home longer. The Wagner Chronic
Care Model,[123] which has been designed
specifically for chronic care, views chronic disease management as part of the
health and social care delivery system. In this model, health care is
completely integrated within community services and aims to empower patients in
terms of decision-making and self-management. Witnesses spoke of
patient-centred care and suggested that it could include a funding model in
which the money follows the patient.[124] Finally, the Committee
was told that this integrated approach to health care is required by 5-8% of
the elderly population living in private homes and in the community.[125]
Witnesses suggested that an efficiently integrated system would
include utilizing all health professionals to the full scope of their practice.[126] The Committee heard that non-urgent paramedic services, or community
paramedicine, could reduce pressure on the acute care system.[127] Paramedics could be integrated into a chronic care model in which they provide
post-surgical home care, chronic disease monitoring, routine assessments and health
education so that patients are better able to self-manage. The integration of
pharmacists within a chronic care model was presented as a valuable addition
for monitoring of adverse reactions, providing medication management services
and providing health and medication information to patients.[128]
Several witnesses indicated that true inter-disciplinary care will
require the development and implementation of information systems, including
electronic health records and electronic prescribing systems.[129] The Committee heard that all community health providers should have access to
all necessary information regarding any given condition and about any
individual in their care.[130] These were presented as
essential to increasing efficiencies within the health care system and to
improving continuity of care.[131]
The multi-sectoral model incorporates the inter-disciplinary
approach, or team-based care, within a broader “whole of society” approach
involving a variety of non-health related services. Witnesses commented that
many seniors require social services in order to manage their health and live
independently. House cleaning, meal preparation, transportation, built
infrastructure to encourage and facilitate active living, were some of the
examples raised. Witnesses felt that any changes to the way health and social
services are provided must not penalize seniors with lower incomes.[132]
The Committee heard that 5% of people currently utilize 50% of the
health care resources, primarily those who are elderly with chronic conditions.[133] Further, it was told that home care is 40–75% less costly than
institutionalized care.[134] Finally it heard that
there are improvements to the quality of care when health providers are
integrated and utilized to the full scope of their professions, and that
research has suggested that such a system could be established with no
additional funds.[135] The Committee was told
that the current model does not accommodate the aging population, no matter how
much it is massaged or adjusted. In order to be responsive to the needs of Canada’s
aging population, members heard, there needs to be a fundamental change to
clinical and professional practice.[136]
The Committee heard about theTranslating Research in Elder Care
Program, or TREC, which is a five-year, $5 million study funded by the CIHR to
explore the conditions in nursing homes in three provinces – Alberta,
Saskatchewan and Manitoba. TREC analyzes the factors that influence the use of
best practices and determines how their use influences resident as well as
system outcomes. Resident outcomes include quality of daily life, quality
end-of-life and safety issues. System outcomes include support for family and
caregivers, improved care practices, and identification of strategies to engage
and mobilize front-line staff to work on and improve care practices.[137]
Witnesses commented on the negative health implications associated
with sodium and trans fat in food. The Committee heard about the Trans
Fat Task Force which was co-chaired by Health Canada and the Heart and
Stroke Foundation of Canada.[138] This task force, created
in 2005, was a multi-stakeholder group whose role was to provide
recommendations and strategies to the Minister of Health to eliminate or reduce
the amount of processed trans fat in prepared foods. Its report,
“TRANSforming the Food Supply”, was submitted to the Minister in June 2006, and
made several recommendations in the areas of regulations, incentives and
research.
Witnesses informed the Committee that as much as 80% of the foods
and beverages marketed to children are unhealthy – either high in fat, sugar or
salt, or low in nutrients.[139] The Committee heard that
the Canadian Children’s Food and Beverage Advertising Initiative,[140] which was launched in 2007, encourages the marketing of healthy food choices
and discourages the marketing of unhealthy food choices specifically to those
under 12 years of age. It is endorsed by 19 food and beverage companies. Additionally,
members were made aware of the Long Live Kids initiative created by
Concerned Children’s Advertisers. It encourages healthy eating, active living
and improved media literacy among children.
Some witnesses talked about
Quebec’s Consumer Protection Act and that it is the only
law in Canada that prohibits advertising directed at children.[141] Quebec has one of the lowest soft drink consumption rates in Canada and the
lowest obesity rate among children aged between 6 and 11.[142] Some witnesses recommended adopting Quebec’s
ban on marketing and advertising of unhealthy food to children,[143] not only in television, but also in other media such as Internet.[144] A few suggested that escalated and sustained action is needed to promote
healthy weights for children and youth using a multi-pronged approach.[145]
Several witnesses commented on the need to encourage and facilitate
more physical activity and members were told of some of the initiatives
undertaken by various organizations in this regard. ParticipACTION described its Sports Day in Canada, which was
held in September 2011, to celebrate all sport from grassroots to
high-performance levels. Members were also told about ParticipACTION’s Sogo
Active program, a physical activity movement to help young Canadians between the ages of 13 and 19
become more active. The Canadian
Association of Occupational Therapists described the active-living guide that
it is being developed in collaboration with university researchers.
Physical and Health Education Canada (PHE Canada), in partnership
with GoodLife Kids Foundation, discussed its initiative to support schools and
communities in developing and delivering after-school programs that emphasize physical activity. PHE Canada works with educators
and professionals to develop the resources, tools, and supports to ensure that every Canadian child acquires
the knowledge, skills, and habits to be physically active. The Committee
was told that PHE Canada is developing a
pilot initiative for children and youth to provide the resources and
tools for teachers to assess levels of physical literacy. Finally, the
Committee was told that ParticipACTION, in partnership with PHE Canada and other stakeholders, is launching
Active Canada 20/20, a national strategy for physical activity.[146]
In terms of provincial strategies, the Committee heard about Québec
en Forme, which was created in 2002 by the Lucie and André Chagnon Foundation
and the Quebec government, to promote healthy living among disadvantaged children
aged between 4 and 12 years old. Finally,
the Committee heard about the Toronto Charter For Physical
Activity: A Global Call for Action.[147] The Charter is a call for
action and an advocacy tool to create opportunities for physically active lifestyles for all. The four key areas of the Charter are: the implementation
of a national policy and action plan, the introduction of policies that support
physical activity, the reorientation of services and funding to prioritize
physical activity, and the development of partnerships for action.
Some witnesses shared concerns about youth injuries and asked the
federal government to assume a more active role. While the recently enacted Canada
Consumer Product Safety Act was applauded, the establishment of a national
strategy for child and youth injuries and injuries across the lifespan was
suggested.[148] The pillars of this
strategy would be research, public awareness and policy. The Committee was told
that resources and funds allocated to health research
on injury were small compared to the economic and social burden associated with
injury.[149] Moreover, the
Committee heard that there would be a high return on investment of effective
strategies for injury prevention, namely the lives saved and the reduction of
health care costs.[150]
The Committee was told that, for
the 2011-2012 fiscal year, all levels of government combined allocated 0.9% of
total public health spending on health promotion, physical activity and
sport.[151] The Committee was
informed that increasing this investment to 5% would bring savings to the
health care system in the medium term.[152] In this regard, members were told
that a recent study in the United States suggested that, within 25 years,
investment in prevention would prevent premature deaths due to chronic
conditions and reduce overall health care
costs.[153] The Committee heard
that the federal government should adopt a health promotion and disease
prevention vision that engages individuals
and community in healthy living activities and provides leadership.[154]
Members were told that persuasive technology on mobile devices has
recently emerged as a promising approach to health promotion and disease prevention.[155] The goal is to design
technology that can encourage change in human behaviour or attitudes
without using coercion or deception. Such technology could reach a large
proportion of the population since the penetration rate of mobile devices in
Canada was around 70% in 2010. [156]
Several witnesses acknowledged that the provision of health and
social services is primarily the responsibility of the provinces and
territories. However, a number of suggestions were made about the actions that
could be taken by the federal government in the areas of health promotion,
chronic disease prevention and disease management. These are outlined below.
Some witnesses suggested that the Canada Health Act is too
restrictive.[157] The Committee heard that
the focus should not be limited to acute care but rather, that home care should
also be considered as medically necessary under the Act.[158] Similarly, the Committee heard that there should be a statute governing
continuing care, a Long-term Care Act, which would cover community and residential
care and include the same principles as the Canada Health Act.[‡],[159] Members were told that dedicated resources for home care initiatives would
provide Canadians with the option of receiving care in their home, and in doing
so, would reduce the reliance on costly acute care services.[160] The Committee was told that a publicly-funded model mandated through federal
legislation may be more efficient in terms of health outcomes than a private, for-profit
model, or a mixed model of both publicly-financed non-profit and private,
for-profit provision of services.[161]
Members heard that healthy eating habits could be better encouraged
if some changes were made to the food labelling regulations. In this regard,
testimony was given that front-of-package nutrition labelling should be
required. Front-of-package labelling was described as a means to help Canadians make nutritious choices. The “Nutrition Facts
table” currently required on pre-packaged food was portrayed as unnecessarily
complicated. The Committee was told that concise front-of-package information
could be implemented, as it has been in some other jurisdictions. Such
labelling would allow consumers to quickly scan food packages for nutrition
information, such as whether the salt or fat content of a food is considered
low, medium or high.[162]
Several witnesses who appeared before the Committee drew attention
to the anticipated discussions for the renewal of the Health Accord in 2014 as
a strategy for addressing age-related chronic disease. Some witnesses suggested
that the renewal of the Health Accord in 2014 presents an opportunity for
federal leadership by investment in health transfers,[163] particularly in key priority areas, such as home care, pharmacare and
continuing care.[164] While the use of a Health
Accord to promote accountability, pan-Canadian standards, federal leadership
and multijurisdictional coordination was suggested by witnesses, they also
specified how the Health Accord could be used to mitigate the impacts of
chronic disease related to aging. For example, the Health Accord could
encourage a variety of reforms such as: integrated health services that utilize
various types of health care providers;[165] technological advances
like electronic health records to encourage collaboration among health
professionals;[166] primary care reform to
include the integration of homecare and community care services;[167] nationally coordinated disease prevention and health promotion strategies;[168] and dedicated funding to stimulate best practices, innovation, and research.[169]
Some witnesses argued that implementing these changes would
reorient Canada’s current health care system to become more attentive to the
changing needs of Canadians and make better use of available health services.[170] As a result, witnesses suggested, the health care system would become more
accountable, efficient and cost-effective.[171]
The Committee heard from several witnesses representing the
research community. Testimony was offered outlining the important research
underway as well as on research gaps that need to be filled. Members heard that
CIHR’s Institute on Aging has incorporated an integrated approach because
health policy decisions on re-structuring health service delivery must be evidence-based.[172] Members were told of a number of areas where additional research is required,
such as in strategies for extending independent living,[173] the provision of long-term care,[174] the utilization of health
professionals to the full scope of their practice,[175] and the integration of health and social services for the elderly.[176] In terms of health promotion and disease prevention, witnesses commented on the
need to do more research on how to get people to change habits in favour of healthier
lifestyles.[177]
Several witnesses described national disease-specific strategies
that have been implemented such as the Canadian Stroke Strategy,[178] the National Lung Framework,[179] the Canadian Strategy for
Cancer Control implemented through the Canadian Partnership Against Cancer,[180] the Canadian Diabetes Strategy,[181] the Canadian Heart Health
Strategy,[182] and the National Pain
Strategy, which is expected to be announced soon.[183] The Committee also heard about the National Mental Health Strategy[184] (including a strategy for neurological diseases), which has subsequently been
released. While several of these are funded under the F/P/T governments’
collaborative approach to chronic disease and healthy living, some witnesses
emphasized that for individuals affected by more than one chronic condition,
primarily the elderly, management of chronic diseases is more complex than the
sum of its parts. As such, the Committee heard, a National Strategy for Healthy
Aging should be developed. It heard that a comprehensive pan-Canadian healthy
aging strategy should include measures to foster health promotion and early
detection of disease, promote health promotion and disease prevention
strategies through healthy lifestyles, support formal and informal caregivers,
address the determinants of health, facilitate better access to health
services, including appropriate continuing and end-of-life care, and help keep
people in their homes longer.[185]
With respect to healthy living, several witnesses suggested areas
where the federal government could increase its involvement. These included the
development and implementation of a Canadian food and nutrition strategy for a
healthy and safe food supply, including food security for all Canadians.[186]
The Committee heard about knowledge translation — the translation
of research into practice. Several witnesses commented on the need for the
federal government to facilitate knowledge translation by providing a mechanism
whereby information, including research results and best practices and
innovations across jurisdictions, can be shared across the country.[187] Members heard that the creation of partnerships and national strategies have
been useful tools in promoting the sharing of best practices.[188] Witnesses spoke of several successful regional projects and suggested that a
robust mechanism is required for sharing these across Canada.[189] Members were told that it is difficult for provinces to make the policy changes
needed in order to adapt the health care delivery system for chronic care, but
that better sharing of information and best practices could facilitate it. In
addition, members were told that CIHR’s Institute on Aging has recently
introduced a program called “Best Brains.” This program brings researchers together
with public policy figures in order to provide them with the available research
evidence.[190] Finally, the creation of
a Centre for Innovation on Aging was described as a means of facilitating the
sharing of information and best practices, not only from regions across Canada,
but also from jurisdictions globally.[191]
Several witnesses identified the groups for which the federal
government has a responsibility for the provision of health care and suggested
that it lead by example in implementing the changes necessary to transition
from the current acute care model to one more responsive to the needs of those
affected by chronic conditions.[192] For example, members
heard that veterans, First Nations on-reserve, Royal Canadian Mounted Police, and
Canadian Forces should be provided with the full continuum of care, including
integrated service delivery, to better prevent and manage chronic conditions.[193]
The Committee was told that the Aboriginal population is
disproportionately affected by diabetes and chronic respiratory and other
conditions, and that an integrated approach in the delivery of health care
would be beneficial.[194] However, the approach
must be tailored to the population and be culturally sensitive.[195]
In relation to the federal groups, members heard that the federal
government should strengthen and maintain its investments in healthy living for
First Nation communities, with special attention
given to northern and remote communities,
since these populations bear the greatest burden of disease. The Committee was
also told about the need for a coordinating mechanism for evaluation, synthesis, and mobilization of
real-world evidence emerging from community-driven initiatives in local Aboriginal
communities.[196]
The Committee agrees that health promotion should begin early in
life and must continue throughout a person’s lifetime to reduce the risk of
chronic disease in later years. Members also understand that, even in later
life, health benefits can be garnered by exchanging old habits for healthier
lifestyle choices. However, changing habits is no simple task. Members concur
that a multi-pronged approach is necessary. While the federal government has a
role to play, equally important contributions are to be made by other levels of
government, health professionals, active living organizations, the food and
fitness industries and individuals.
The Committee acknowledges that while personal responsibility
cannot be ignored when it comes to healthy lifestyles, an individual’s
circumstances can often make it difficult to make the best choices. As such,
members applaud PHAC’s involvement in supporting projects that reduce health
inequities brought about by disadvantages in the social determinants of health.
The Committee understands the concerns raised relating to the health
needs of those suffering from chronic disease, particularly in the senior
years. It is concerned about the prevalence of mental health issues and
supports the efforts of the Mental Health Commission of Canada. The Committee
looks forward to further consideration of the recently released Mental Health
Strategy. Members encourage the provinces and territories to work closely with
the Mental Health Commission to implement the Strategy.
Members agree that the management of elderly individuals who
suffer from one or more chronic diseases can become complex and that an
interdisciplinary approach to care may be optimal. Such an approach involves
reforming the way in which primary care is currently delivered to individuals,
particularly the elderly who suffer from chronic disease. It requires the
creation of health teams, as well as expanding the scope of practice for some
health professionals for better utilization of existing resources. The “whole
of society” approach to care may often extend beyond that which has
traditionally been labelled as health care services, and also involves domestic
cleaning, help with meal preparation, transportation and changes to community
infrastructure so as to encourage and facilitate active living. Informal
caregiving plays an important role in this and the Committee is sympathetic to
the call to provide additional supports such as training, education, mental
health supports and respite.
While the Committee is supportive of these approaches, it would
also like to emphasize that the role of the federal government should be one
that focusses on leadership and collaboration to facilitate and encourage
jurisdictions to adopt best practices wherever appropriate. In this respect,
the Committee is encouraged by the recently announced health care innovation
working group, a provincial and territorial initiative. The Committee agrees
that the federal government can play a key role in encouraging the sharing of
information and best practices. With respect to those groups for whom the
federal government is responsible for health care, the Committee is supportive
of the concerns raised by witnesses who suggested that an integrated approach
to health care delivery should be implemented.
Therefore, the Committee recommends that:
The Minister of Health continue to engage the provincial and
territorial Ministers of Health and Health Promotion/Healthy Living in a
discussion about the need to adapt primary health care to a more
interdisciplinary and multi-sectoral model;
The Minister of Health continue to engage with provinces and
territories to share Best Practices on:
- scopes of practice of health professionals;
- the potential use of health teams;
- multi-sectoral approaches to care that involve not only traditional health services, but also those social services necessary to maintain a good quality of life and manage health conditions; and that
The Government of Canada continue to use integrated multi-sectoral approaches
to care where needed and appropriate.
Considerable focus was placed on the research that is underway in
Canada pertaining to health promotion, disease prevention and chronic disease
management. While many witnesses commended the amount of work underway at the Canadian
Institute for Health Information and CIHR, many also identified research gaps
that still need to be filled, and called on the federal government to address
them. In this regard, the Committee is pleased to see the efforts underway by
the CIHR to identify strategic research priorities and commends the CIHR for
encouraging research which will: enhance patient-oriented care; identify the
pressures on the health care system due to the aging population and rising
rates of chronic disease; and address the importance of leveraging resources by
working collaboratively with other departments and agencies as well as
non-governmental organizations. It suggests that research could also extend to
health human resources research, as some witnesses stressed the need to
increase the number of people being trained in certain specialties. Finally,
witnesses discussed the importance of translating research results into practice.
The Committee agrees that research results need to be made accessible and useful
to stakeholders.
Therefore, the Committee recommends that:
The Canadian Institutes of Health Research continue to support
research that addresses chronic diseases;
Health Canada continue to work with relevant industry to encourage
them to offer healthy choices to Canadians on a voluntary basis; and that
Health Canada continue to promote healthy lifestyle choices for all
Canadians with the goal of making the healthy choice an easy choice.
During the course of its study, the Committee heard from various
witnesses that healthy lifestyles, even adopted later on in a person’s life, have
a strong positive impact on the health status and can help to reduce the
prevalence of chronic disease. In an effort to encourage Canadians to improve
their health status, government officials and various national and local stakeholders
informed the Committee of initiatives designed to promote and support healthy
living, as well as to reduce the number of people affected by chronic disease. Reducing
the burden of chronic disease through the adoption of healthy lifestyles
requires primarily engagement by individuals. Nevertheless, initiatives from
all levels of government are key to promoting healthy behaviours. Moreover, officials
from CIHR and academic researchers presented their findings to the Committee on
ways to address the burden of chronic diseases and to help people adopt
healthier habits. The Committee encourages those who undertake research on
chronic disease and health promotion, and looks forward to the translation of
this work into improved health care. Finally, the Committee is confident that
the federal government will continue to play a leadership role in encouraging
jurisdictions to optimize their approach of promoting healthy living and
managing the care of Canadians suffering from chronic diseases.
[1] Public Health Agency of Canada (PHAC), Evidence, October 5,
2011
[2] PHAC, Evidence, December 5, 2011.
[3] Canadian Public Health Association (CPHA), Evidence, December
7, 2011.
[4] YMCA Canada, Evidence, December 12, 2011.
[6] Centre for Science in the Public Interest (CSPI), Evidence,
February 2, 2012.
[7] ParticipACTION, Evidence, December 12, 2011; Canadian
Institutes of Health Research (CIHR), Evidence, December 5, 2011.
[8] Canadian Institutes of Health Research (CIHR), Evidence, December
5, 2011.
[9] YMCA Canada, Evidence, December 12, 2011.
[10] Martin Cooke, University of Waterloo, Evidence, February 9,
2012.
[11] Physical and Health Education Canada (PHEC), Evidence, December
12, 2011.
[12] ParticipACTION, Evidence, December 12, 2011.
[14] Canadian Pharmacists Association (CPhA), Evidence, October 31,
2011
[15] PHAC, Evidence, October 5, 2011
[16] Mark Rosenberg, Queen’s University, Evidence, November 28,
2011
[17] Margaret McGregor, University of British Columbia, Evidence, November
30, 2011
[18] Canadian Medical Association (CMA), Evidence, October 17,
2011; National Initiative for the Care of the Elderly, Evidence, October 31,
2011; and Public Health Agency of Canada, Evidence, October 5, 2011
[19] PHAC, Evidence, October 5, 2011
[20] CPhA, Evidence, October 31, 2011
[21] CMA, Evidence, October 17, 2011
[22] PHAC, Evidence, October 5, 2011
[23] Canadian Nurses Association (CNA), Evidence, October 17, 2011
[25] Canadian Chiropractic Association (CCA) and CNA, Evidence, October
17, 2011; Canadian Diabetes Association (CDA), Canadian Partnership Against
Cancer, Heart and Stroke Foundation (HSF), and Canadian Lung Association (CLA), Evidence, October 19, 2011, Adult Living Coalition for Older Adults, Evidence,
October 24, 2011, Elizabeth Badley, Evidence, November 2, 2011.
[26] PHAC, Evidence, October 5, 2011.
[29] PHAC, Evidence, October 5, 2011; Suzanne Garon, Evidence,
October 31, 2011.
[30] PHAC, Evidence, October 5, 2011.
[31] CIHR, Evidence, October 24, 2011.
[32] CIHR, Evidence, December 5, 2011.
[33] Canadian Geriatrics Society (CGS), Evidence, October 17, 2011.
[34] CLA, Evidence, October 19, 2011.
[35] CMA, Evidence, October 17, 2011.
[36] CGS, Evidence, October 17, 2011.
[37] Dorothy Pringle, Evidence, October 31, 2011.
[38] Sylvie Belleville, Evidence, November 30, 2011, CIHR-Institute
of Aging, Evidence, October 24, 2011.
[39] Associated Medical Services, Evidence, October 26, 2011.
[40] Canadian Association of Retired Persons, Evidence, October 24,
2011.
[41] CPhA, Evidence, October 31, 2011.
[42] Emergency Medical Services Chiefs of Canada, Evidence, November
28, 2011.
[43] CGS, Evidence, October 17, 2011.
[44] Fédération des aînées et aînés francophones du Canada, Evidence,
October 24, 2011.
[45] CPhA, Evidence, October 31, 2011.
[46] Mark Rosenberg, Evidence, October 28, 2011.
[47] National Initiative for the Care of the Elderly, Evidence, October
31, 2011.
[48] Canadian Association of Retired Persons, Evidence, October 24,
2011.
[49] CDA, Evidence, October 19, 2011.
[50] Fédération interprofessionnelle de la santé du Québec and Associated
Medical Services, Evidence, November 16, 2011.
[51] Active Living Coalition for Older Adults, Evidence, October 24,
2011.
[52] Canadian Partnership Against Cancer, Evidence, October 19,
2011.
[54] HSF, Evidence, October 19, 2011.
[55] CLA, Evidence, October 19, 2011.
[57] Elizabeth Badley, Evidence, November 2, 2011.
[58] Abbott (written submission).
[59] Canadian Pain Coalition, Evidence, October 26, 2011.
[60] Canadian Coalition for Seniors’ Mental Health, Evidence, October
26, 2011.
[61] Elizabeth Badley, Evidence, November 2, 2011.
[62] CPhA, Evidence, October 31, 2011.
[64] National Initiative for the Care of the Elderly, Evidence, October
31, 2011.
[65] Canadian Coalition for Seniors’ Mental Health, Evidence, October
26, 2011.
[66] CDA, Evidence, October 19, 2011; Elizabeth Badley, Evidence,
November 2, 2011; HSF, Evidence, October 19, 2011.
[67] CPhA, Evidence, October 31, 2011.
[68] CMA and CGS, Evidence, October 17, 2011; Active Living
Coalition for Older Adults and CIHR-Institute of Aging, Evidence, October
24, 2011; Canadian Coalition for Seniors’ Mental Health and Canadian Pain
Coalition, Evidence, October 26, 2011; National Initiative for the Care
of the Elderly, Evidence, October 31, 2011; Elizabeth Badley, Evidence,
November 2; 2011, and Sylvie Belleville, Evidence, November 30, 2011.
[69] Active Living Coalition for Older Adults, Evidence, October
24, 2011.
[70] CGS, Evidence, October 17, 2011.
[71] CGS, Evidence, October 17, 2011; Canadian Coalition for
Seniors’ Mental Health, Evidence, October 26, 2011
[72] CGS and CMA, Evidence, October 17, 2011; Canadian Association
of Retired Persons, Evidence, October 24, 2011; Canadian Coalition for
Seniors’ Mental Health, Evidence, October 26, 2011; National Initiative
for the Care of the Elderly, Evidence, October 31, 2011; and Sylvie
Belleville, Evidence, November 30, 2011.
[73] CGS, Evidence, October 17, 2011.
[74] PHAC, Evidence, October 5, 2011.
[75] Canadian Coalition for Senior’s Mental Health, Evidence, October
26, 2011; and National Initiative for the Care of the Elderly, Evidence,
October 31, 2011.
[76] Canadian Coalition for Seniors’ Mental Health, Evidence, October
26, 2011.
[77] Canadian Coalition for Seniors’ Mental Health, Evidence, November
16, 2011.
[78] Canadian Health Services Research Foundation, Evidence, November
2, 2011.
[79] CIHR-Institute of Aging and Active Living Coalition for Older Adults, Evidence, October 24, 2011; and Canadian Coalition for Seniors’ Mental
Health, Evidence, October 26, 2011.
[80] CMA, Evidence, October 17, 2011.
[81] National Initiative for the Care of the Elderly, Evidence, October
31, 2011.
[82] Suzanne Garon, Evidence, October 31, 2011; and Baycrest Centre
for Geriatric Care, Evidence, November 28, 2011.
[83] CGS, Evidence, October 17, 2011.
[84] Canadian Partnership Against Cancer, Evidence, October 19,
2011.
[85] Active Living Coalition for Older Adults, Evidence, October
24, 2011.
[86] Canadian Chiropractic Association, Evidence, October 17, 2011.
[87] Canadian Coalition for Seniors’ Mental Health, Evidence, October
26, 2011.
[88] CCA, Evidence, October 17, 2011.
[89] Canadian Life and Health Insurance Association, Evidence, November
23, 2011.
[91] CGS, Evidence, October 17, 2011.
[92] Emergency Medical Services Chiefs of Canada, Evidence, November
28, 2011.
[93] Baycrest Centre for Geriatric Care and Emergency Medical Services
Chiefs of Canada, Evidence, November 28, 2011; CNA, Evidence, October
17, 2011; Active Living Coalition for Older Adults, Evidence, October 24,
2011.
[94] CNA and CGS, Evidence, October 17, 2011.
[95] CNA, Evidence, October 17, 2011; CPhA, Evidence, October
31, 2011; and Emergency Medical Services Chiefs of Canada, Evidence, November
28, 2011.
[96] Associated Medical Services, Evidence, November 16, 2011.
[97] Canadian Association of Retired Persons, Evidence, October 24,
2011.
[98] Canadian Coalition for Seniors’ Mental Health, Evidence, October
26, 2011.
[99] CNA, Evidence, October 17, 2011; Canadian Association of
Retired Persons, Evidence, October 24, 2011; and CPhA, Evidence, October
31, 2011.
[100] CNA, Evidence, October 17, 2011.
[101] Canadian Association of Retired Persons, Evidence, October 24,
2011.
[102] Canadian Association of Retired Persons, Evidence, October 24,
2011; National Initiative for the Care of the Elderly, Evidence, October
31, 2011; and Fédération interprofessionnelle de la santé du Québec, Evidence,
November 16, 2011.
[103] Canadian Association of Retired Persons, October 24, 2011; and National
Initiative for the Care of the Elderly, Evidence, October 31, 2011.
[104] National Initiative for the Care of the Elderly, Evidence, October
31, 2011; Baycrest Centre for Geriatric Care, Evidence, November 28,
2011; Michel Bédard, Evidence, November 30, 2011; and Parkinson Society
Canada (written submission).
[105] Carole Estabrooks, Evidence, October 31, 2011; and Baycrest
Centre for Geriatric Care, Evidence, November 28, 2011.
[107] Baycrest Centre for Geriatric Care, Evidence, November 28, 2011.
[108] Carole Estabrooks, Evidence, October 31, 2011.
[109] CMA, Evidence, October 17, 2011.
[110] CDA, Evidence, October 19, 2011.
[111] Fondation Docteur Benoît Deshaies, Evidence, November 23, 2011.
[112] Canadian Coalition for Senior’s Mental Health, Evidence, November
16, 2011.
[113] François Béland, Evidence, November 28, 2011.
[114] Dorothy Pringle, Evidence, October 31, 2011.
[115] CIHR-Institute of Aging, Evidence, October 24, 2011.
[116] CNA, CCA, and CGS, Evidence, October 17, 2011; Canadian
Association of Retired Persons, Evidence, October 24, 2011; Carole Estabrooks
and Dorothy Pringle, Evidence, October 31, 2011; Canadian Coalition for
Senior’s Mental Health, Fédération interprofessionnelle de la santé du Québec
and Associated Medical Services, Evidence, November 16, 2011; François
Béland and Mark Rosenberg, Evidence, 28 November 2011; Margaret McGregor
and Sylvie Belleville, Evidence, November 30, 2011.
[117] CMA, Evidence, October 17, 2011; Canadian Pain Coalition, Evidence,
October 26, 2011; CPhA, Evidence, October 31, 2011; Canadian Health
Services Research Foundation, and Elizabeth Badley, Evidence, November
2, 2011.
[118] Fédération interprofessionnelle de la santé du Québec, Evidence,
November 16, 2011.
[119] Margaret McGregor, Evidence, November 30, 2011.
[120] Associated Medical Services, Evidence, November 16, 2011.
[121] CIHR-Institute of Aging, Evidence, October 24, 2011; Dorothy
Pringle, Evidence, October 31, 2011; Fédération interprofessionnelle de
la santé du Québec, Evidence, November 16, 2011; and François Béland, Evidence, November 28, 2011.
[122] Dorothy Pringle, Evidence, October 31, 2011; and François
Béland, Evidence, November 28, 2011.
[123] PHAC, Evidence, October 5, 2011.
[124] CIHR-Institute of Aging, Evidence, October 24, 2011.
[125] François Béland, Evidence, November 28, 2011.
[126] Canadian Health Services Research Foundation, Evidence, November
2, 2011.
[127] Emergency Medical Services Chiefs of Canada, Evidence, November
28, 2011.
[128] CPhA, Evidence, October 31, 2011; and Canadian Health Services
Research Foundation, Evidence, November 2, 2011.
[129] CMA and CNA, Evidence, October 17, 2011; CaPhA, Evidence,
October 31, 2011; Canadian Health Services Research Foundation, Evidence,
November 2, 2011; Baycrest Centre for Geriatric Care, Evidence, November
28, 2011; and Margaret McGregor, Evidence, November 30, 2011.
[130] CIHR-Institute of Aging, Evidence, October 24, 2011.
[131] Canadian Health Services Research Foundation, Evidence, November
2, 2011.
[132] CGS, Evidence, October 17, 2011; Fondation Docteur Benoît
Deshaies, Evidence, November 23, 2011.
[133] Fédération interprofessionnelle de la santé du Québec, Evidence,
November 16, 2011.
[134] Canadian Association of Retired Persons, Evidence, October 24,
2011.
[135] Canadian Health Services Research Foundation, Evidence, November
2, 2011.
[136] Associated Medical Services, November 16, 2011; and François Béland, Evidence,
November 28, 2011.
[137] Carole Estabrooks, Evidence, October 31, 2011.
[138] Food and Consumer Products of Canada, Evidence, February 2,
2012.
[139] Chronic Disease Prevention Alliance of Canada, Evidence, December
7, 2011.
[141] Chronic Disease Prevention Alliance of Canada, Evidence, December
7, 2011; CSPI, Evidence, February 2, 2012; BC Healthy Living Alliance, Evidence,
February 9, 2012; and Dietitians of Canada (written submission).
[142] Chronic Disease Prevention Alliance of Canada, Evidence, December
7, 2011.
[143] Chronic Disease Prevention Alliance of Canada, Evidence, December
7, 2011; and Dietitians of Canada (written submission).
[144] CSPI, February 2, 2012; BC Healthy Living Alliance, Evidence, February
9, 2012.
[145] Chronic Disease Prevention Alliance of Canada, Evidence, December
7, 2011.
[146] ParticipACTION, Evidence, December 12, 2011.
[148] ThinkFirst Canada, Evidence, February 7, 2012.
[149] Safe Kids Canada, Evidence, February 7, 2012.
[151] Physical and Health Education Canada, Evidence, December 12,
2011.
[153] BC Healthy Living Alliance, Evidence, February 9, 2012.
[155] Rita Orji, Evidence, February 9, 2012.
[157] François Béland, Evidence, November 28, 2011.
[158] Fédération interprofessionnelle de la santé du Québec, Evidence,
November 16, 2011.
[159] Carole Estabrooks and Dorothy Pringle, Evidence, October 31,
2011.
[160] Canadian Association of Retired Persons, Evidence, October 24,
2011.
[161] Margaret McGregor, Evidence, November 30, 2011.
[162] CSPI, Evidence, February 2, 2012; and Dietitians of Canada
(written submission).
[163] HSFC, Evidence, October 19, 2011 and Canadian Health Services
Research Foundation, Evidence, November 2, 2011.
[164] CPhA, Evidence, October 31, 2011.
[165] CNA Evidence, October 17, 2011; Canadian Association of Retired
Persons, Evidence, October 24, 2011; Canadian Coalition for Senior’s
Mental Health, Evidence, October 26, 2011/16 November 2011; and Margaret
McGregor, Evidence, November 30, 2011.
[166] CPhA, Evidence, October 31, 2011.
[167] CNA, Evidence, October 17, 2011; Canadian Association of Retired
Persons, Evidence, October 24, 2011; National Initiative for the Care of
the Elderly, Evidence, October 31, 2011; Fédération interprofessionelle
de la santé du Québec, Evidence, November 16, 2011; Margaret McGregor, Evidence,
November 30, 2011.
[168] Canadian Association of Retired Persons, Evidence, October 24,
2011; CPhA, Evidence, October 31, 2011; and Fédération
interprofessionelle de la santé du Québec, Evidence, November 16, 2011.
[169] CMA, Evidence, October 17, 2011; HSFC, Evidence, October
19, 2011; and Canadian Coalition for Senior’s Mental Health, Evidence, October
26/November 16, 2011.
[170] CNA, Evidence, October 17, 2011; Canadian Association of Retired
Persons, Evidence, October 24, 2011; and Canadian Coalition for Senior’s
Mental Health, Evidence, October 26/November 16, 2011.
[171] Canadian Association of Retired Persons, Evidence, October 24,
2011; and CPhA, Evidence, October 31, 2011.
[172] CIHR-Intitute on Aging, Evidence, October 24, 2011.
[173] Suzanne Garon, Evidence, October 31, 2011.
[174] Carole Estabrooks, Evidence, October 31, 2011; and Sylvie
Belleville, Evidence, November 30, 2011.
[175] CPhA, Evidence, October 31, 2011; Canadian Health Services
Research Foundation, Evidence, November 2, 2011; Emergency Medical
Services Chiefs of Canada, Evidence, November 28, 2011.
[176] Baycrest Centre for Geriatric Care, Evidence, November 28, 2011.
[177] Rita Orji, Evidence, February 9, 2012.
[178] HSFC, Evidence, October 19, 2011.
[179] PHAC, Evidence, October 5, 2011.
[180] Canadian Partnership Against Cancer, Evidence, October 19, 2011.
[181] CDA, Evidence, October 19, 2011.
[182] PHAC, Evidence, October 5, 2011.
[183] Canadian Pain Coalition, Evidence, October 26, 2011.
[184] Canadian Coalition for Senior’s Mental Health, Evidence, October
26, 2011; and Parkinson Society Canada (written submission).
[185] CNA, Evidence, October 17, 2011; and Parkinson Society Canada
(written submission).
[186] BC Healthy Living Alliance, Evidence, February 9, 2012.
[187] CMA, Evidence, October 17, 2011; CLA, Evidence,
October 19, 2011; Canadian Association of Retired Persons, Evidence, October
24, 2011; Canadian Health Services Research Foundation, Evidence, November
2, 2011; Baycrest Centre for Geriatric Care, Mark Rosenberg and Francois
Béland, Evidence, November 28, 2011; and Margaret McGregor, Evidence,
November 30, 2011.
[188] Canadian Partnership Against Cancer and HSFC, Evidence, October
19, 2011.
[189] CMA, Evidence, October 17, 2011; Canadian Association of Retired
Persons, Evidence, October 24, 2011; Canadian Health Services Research
Foundation, Evidence, November 2, 2011.
[190] CIHR-Institute of Aging, Evidence, October 24, 2011.
[191] Baycrest Centre for Geriatric Care, Evidence, November 28, 2011.
[192] CLA, Evidence, October 19, 2011.
[193] CCA, Evidence, October 17, 2011; Fédération des aînées et aînés
francophones du Canada, Evidence, October 24, 2011; Canadian Health
Services Research Foundation, Evidence, November 2, 2011; and François
Béland, Evidence, November 28, 2011.
[194] CDA and CLA, Evidence, October 19, 2011; Active Living Coalition
for Older Adults, Evidence, October 24, 2011; and Mark Rosenberg, Evidence,
November 28, 2011.
[195] Canadian Partnership Against Cancer, Evidence, October 19, 2011;
and François Béland, Evidence, November 28, 2011.
[196] Chronic Disease Alliance of Canada, Evidence, December 7, 2011.
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