A Public Health Campaign for Legal Marijuana

When I first reviewed the Government of Ontario’s approach to legal marijuana, I was disappointed. I was hoping for an approach with a strong foundation in public health. I feel strongly about this and wrote about my concerns for the Ottawa Citizen.

As I read the views of other health stakeholders in legal marijuana, I could not help but notice that many of these felt that the government had addressed many of their concerns. Both Ontario Public Health and the Canadian Medical Association reported being satisfied with a legal age of 19 for marijuana, even though both had advocated for a higher age. The article I read said these organizations described the government’s approach as “pragmatic”. Why am I not satisfied?

This pragmatic approach focuses on regulations and where marijuana will be sold and the public health relies on regulation to manage the age of use. However, as all clinicians working in youth mental health and addiction, I know that the key to changes in behavior and attitude lie in education, specifically public education through health communication campaigns. In mental health, we are very familiar with how successful these campaigns can be. In the past ten years, vigorous health communication campaigns have  been able to neutralize the stigma that existed for centuries against mental illness and persons with a mental illness. I had hoped that, right from the beginning, the Health Minister would have pledged the funding for a sophisticated health communication campaign to ensure that all citizens understood the health risks of marijuana, especially youth for whom the impact on the developing brain can be significant. There was the promise that such a campaign would be developed, but no firm details were provided as to what steps have been taken to implement the campaign.

The campaign I wanted would include persuasive communications informed by social marketing strategies, with messaging designed for different target groups. The public health messages must be accurate, interesting and stimulating so that different communications might be needed for different groups and especially different age groups. I know that the Ministry of Health and Long Term Care can manage this level of sophistication. In fact, I even found a presentation entitled Developing health communication campaigns on the Public Health Ontario website.

The campaign I wanted would start now so that awareness of the risks of cannabis use and information about safe practices for using legal marijuana would be known by the time legalization comes into effect  in July 2018.

The campaign I wanted for youth would reflect the reality that Canadian young people are already the highest users of marijuana in Canada by age group. It would recognize that rules and regulations cannot be the only tools we use to prevent marijuana overuse and addiction.

Another public health element that I was seeking was the commitment of support for further research to evaluate the impact of legal marijuana. This will help us to understand how the Government’s approach might be improved in the future. It will reassure the public, including mental health professionals, that the Government is prepared to be prudent in ensuring that legal marijuana is introduced safely.

Finally, with the growing demand for mental health services, another element that I had hoped to see was a commitment to improved funding for services for addiction. While I do not believe that the legalization of marijuana will necessarily lead to higher rates of marijuana addiction, we know that the province’s coffers will benefit from increased tax revenues. Many groups were hoping for a commitment to improved services, services that are already much needed.

The legalization of marijuana is an opportunity for the Government of Ontario to demonstrate understanding that addiction is a mental health problem and that those people with an addiction should be assisted and not shunned. The young people that I see with marijuana addiction have higher rates of many psychiatric symptoms including psychosis and suicidal ideation and attempt. Many of the young people I see who are now in recovery would provide great advice on how the public health approach to legal marijuana could engage youth in its safe introduction. I hope the Government will seek the advice of those most at risk – people under 25.

A Children’s March for Ontario

The youth in my practice with the most complex mental health problems are those who have grown up “in care”. The expression “in care” refers to the fact that a child or youth is not living at home but rather with a foster family or in a residential care facility, usually called a “group home”. These young people are victims of assault and neglect in their families of origin, but they are also victims of a system of residential care that shuffles them around from home to home, caregiver to caregiver – a system that is no more supportive than their own family.

In late 2016, the Government of Ontario undertook to improve the lot of these youth. On the usual road, paved with the usual good intentions, the Government introduced Bill 89: An Act to Enact the Child, Youth and Family Services Act, 2016, to amend and repeal the Child and Family Services Act and to make related amendments to other acts. In many respects, the young people in this province who are living in care played a large role in ensuring that such an act is even before the Ontario legislature.

In November 2011, with the support of the Provincial Advocate for Children and Youth of Ontario, youth volunteers from across Ontario convened the Youth Leaving Care Hearings at Queen’s Park in Toronto. This was the first time youth had organized public hearings at Queen’s Park. The reason for the hearings was to address the concerns of the over 8,000 children and youth who are Crown Wards in Ontario – children and youth whose guardian is the Crown, through the Children’s Aid Societies in Ontario. There is a Report on the Hearings, My Real Life Book, and You tube videos. These will help you to understand how many youth live in care in Ontario and how they feel about this experience. I felt very honoured to be one of the adult contributors to the hearings. I remember an interview after my presentation and how emotional I felt during the interview. I had met three youth I had cared for at the hearings and I was so glad to see them doing well after everything they had gone through.

After the hearings, the youth continued to be involved. They participated in the inquests for Jeffrey Baldwin and for Katelynn Sampson, two children who died at the hands of their caregivers while living as wards, even though both these experiences must have been extraordinarily difficult personally. Their work and participation and enthusiasm finally convinced the Government that it had to act to change the existing Child and Family Services Act to better serve the children and youth it was meant to help.

The best part of Bill 89 are the principles it sets out as guidelines:

“The Government of Ontario is committed to the following principles:

Services provided to children and families should be child-centred.

Children and families have better outcomes when services build on their strengths.  Prevention services, early intervention services and community support services build on a family’s strengths and are invaluable in reducing the need for more disruptive services and interventions.

Services provided to children and families should respect their diversity and the principle of inclusion, consistent with the Human Rights Code and the Canadian Charter of Rights and Freedoms.

Systemic racism and the barriers it creates for children and families receiving services must continue to be addressed. All children should have the opportunity to meet their full potential.  Awareness of systemic biases and racism and the need to address these barriers should inform the delivery of all services for children and families.

Services to children and families should, wherever possible, help maintain connections to their communities.”

The worst part of Bill 89 is that, in fact, it may not, in fact, adhere to these principles and it is not at all clear in the text what the measures are to ensure that Children’s Aid Societies and group homes or foster parents will comply with the new measures of the act. Legislation is always complex, and difficult for people to understand. I am very well-educated – 11 years of postsecondary education – and I have trouble completely understanding the bill. Can you imagine how difficult it is for those who have not yet completed their education to understand it? Youth in care in Ontario have worked for many years to bring changes to the Child and Family Services Act. They made submissions to hearings and inquests, telling their stories of being cut off from their families, from those who loved them and from services that would have helped them heal. They told these stories even when it brought back horrible memories of what happened to them. They told these stories even if their mental health deteriorated.

They are, in fact, getting ready to do this again. Bill 89 is now in Committee and the Youth in Ontario want it to meet their needs. There are over 8,000 Crown Wards in Ontario, but there are almost 20,000 living in Children’s Aid Society Care. These are Ontario’s children – literally.

This Act – in fact, every legislative act – needs to be accessible. In simple language, citizens must be able to understand what an Act is saying to ensure that it does what it means to do. No one is blaming the legislators – the lofty goals and language set out in Bill 89 make it clear that the intent is to improve the situation for Children and Youth and Families in Ontario who need support. If the Act is made understandable for the Youth who have worked to get Bill 89 onto the legislative agenda, they will know whether it can be effective.

The Government has also made it clear that these changes are needed quickly and so, as is often their habit, the Committee process is being truncated. This is not fair to the youth who have been working for these changes. Until every submission is heard, from every youth who wants or needs to provide their input, the Committee process should not stop.

Our Voice, Our Turn, My Real Life Book, and the inquests for Jeffrey Baldwin and Katelyn Sampson showed us that the current Child and Family Services Act silenced children and youth and allowed their suffering, even their deaths, to be institutionalized. Let us honour these young people and their heroic actions to make Ontario a better place to grow up. Let us urge the Government to wait, and make Bill 89 as effective as it can be. Let’s match their courage with our own.

(Note: The Children’s March refers to incidents in Birmingham Alabama in 1963 when African American children left school to march downtown to meet the Mayor and speak about their experience of segregation. They were arrested, sprayed with hoses, but kept on marching, causing legislators, and especially President John F. Kennedy, to finally move forward on Civil Rights legislation. Photo is from a Biography documentary.)

The Auditor General, The Minister of Health and The OMA

In the next week or so, there will be so much detailed analysis of the Auditor General’s Report on Physician Billing in Ontario that the small observation I am making here today here will be lost. As I reviewed the 57 pages, the details and references convinced me that the analysis had been seriously undertaken.

Some conclusions seemed quite inaccurate to me, e.g. “Our review of Ministry data noted that for the 2014/15 fiscal year, each physician in a Family Health Organization group worked an average of 3.4 days per week, and each Family Health Group physician worked an average of four days per week.” Most of my colleagues in these models work at least a five-day week.

Other conclusions really did reflect what I have heard from colleagues in all parts of the province, e.g. “A large number of the physicians who responded to our survey emphasized that patients’ demands are the driving force behind health-care costs. Many suggested that patient accountability is required to ensure that only necessary services or procedures are performed and costs are not duplicated.”

I want to focus, however, on one observation about the 14 recommendations, or specifically the Ministry’s response to them. Ten of the 14 recommendations require the Ministry to work with the Ontario Medical Association and, in each case, the Ministry confirms this. The recommendations are simple enough as statements but they are complex with respect to the knowledge and understanding of physicians’ practices that will be required to implement them.

Here is that common theme running through the Ministry’s responses:

“Adjustments to the capitation rate will require the Ministry to engage with the Ontario Medical Association (OMA) through the negotiations and consultation processes of the Ontario Medical Association Representation Rights and Joint Negotiation and Dispute Resolution Agreement (OMA Representation Rights Agreement).”

“Contract amendments, including minimum number of regular hours and consequences for not meeting contract requirements, will require the Ministry to engage with the OMA through the negotiations and consultation processes of the OMA Representation Rights Agreement.”

“Enabling these recommendations would require contract amendments and will require the Ministry to engage with the OMA through the negotiations and consultation processes of the OMA Representation Rights Agreement.”

The problem for the Minister of Health and Long-Term Care is that his preferred way of “engaging” with the Ontario Medical Association and Ontario physicians for the past two years has been through unilateral imposition of cuts and contract amendments. With Bill 41 as the last straw, doctors collectively and the OMA are informing the Minister and the public that working without a contract and being dictated to by legislation do not further a productive relationship.

So the Minister has a problem. By the Ministry’s own admission, 10 of the 14 recommendations in the Auditor General’s Report on Physician Billing will require him to work with his physician partners and the OMA. Over the years, only the Ontario Medical Association has provided realistic ideas about how to implement government recommendations. This is well illustrated in the various examples of real practice situations outlined in the Auditor General’s report. Developing payment models and incentives that improve access for patients is necessary for the health care system to work properly. These models of care promote both a healthy population and a stable, fairly remunerated physician workforce.

Ministers pay attention to the Auditor General’s Reports. I hope the Minister of Health and Long Term Care keeps this report in mind and that he reaches out to the OMA. I hope he does, but I’m not optimistic.

Bill 41 – More Questions

Last week, Dr. Del Dhanoa, a radiologist from Northern Ontario, asked some questions that I decided to answer as another blog since they continue the series I have been working on. The questions also spark further debate about whether the Minister of Health and Long Term Care has completely explained his vision of health care in Ontario, given the degree of change being undertaken in Bill 41.

This is the first question:

“What are your thoughts about Hospital CEOs and Boards? Will they eventually go by the wayside like British Columbia because the LHINs (and Minister) have much more direct control over Hospitals with Bill 41? A Hospital Board Director told me that she/he was ready to hand in his/her resignation after reading Bill 210/41. They feel like they no longer serve a purpose and, after all, their time is largely volunteer based.”

I served on the Board of my hospital when I was the President of the Medical Staff. What is most impressive about hospital boards is how deeply they draw into the fabric of the community in which they are located. My main clinical appointment is at the Royal Ottawa Mental Health Centre, a psychiatric hospital in Ottawa. The members of our hospital Board of Trustees include prominent local lawyers, very senior civil servants, patient advocates – all very busy people who volunteer their time to ensure that the citizens of Ottawa have access to the best possible mental health care. They are all volunteers and commit a significant amount of time to the work of the hospital. They have a vision for how the community can best be served that is grounded in the reality of the advantages and disadvantages of living in the national capital and its region. Bill 41 would add another lens to that vision and, unfortunately, it seems to be a lens that could override some of the most important decisions they make.

In the narrative leading up to his question, Dr. Dhanoa mentions the reaction of one of his hospital’s Board Directors. My husband had served on the board of a local Ottawa hospital and he too believes Bill 41 as an interference that that was unneeded. He spoke of the fact that every new directive or initiative from government just added time to board and committee meetings since one often had to work patient needs and priorities around them. For example, governments have had many interventions over the years to improve wait times, as if doctors and hospitals were not already working hard to do this. Really, does the Minister believe we are trying to increase wait times? Or decrease access? Doctors and hospital boards hear concerns directly from patients and can tailor a local response to their concerns.

Here is Dr. Dhanoa’s second point:

“The language in Bill 41 is pretty clear. The Minister can act to change Hospital mandates in the “public interest” and this includes activities that decrease Hospital length of stay. As you know, LOS is the basic currency describing the activities in hospitals: from the Emergency Department to the wards, to the lab and the medical imaging department. Everything in hospitals is based on LOS.

So, really, Bill 41 gives the Minister a lot of power to change the way medicine is practiced in all of Ontario’s Hospitals to meet the LOS metric. While on the outside that sounds great, I have many reservations on how that will play out in Ontario especially when physician input is ignored.”

I think that Dr. Dhanoa makes his own point very well and underlines how important it is for physicians to sit on and participate in their hospital boards because it is one important way in which we have input into how health care is delivered. Having said this, it was the decision of Premier Wynne’s predecessor to stop physicians from having a vote on hospital boards under the changes the Liberal government made to the Public Hospital Act in 2010. Doctors realized then that their input was being marginalized by the Liberal government in Ontario.

The problem with ignoring the input of doctors is that we spend all day every day working to integrate patients’ health care. Integration is the goal of Bill 41. Why ignore the concerns of those who actually understand how this might be achieved?

Physician Activism: Put Your Money Where Your Mouth Is

This is Mental Illness Awareness Week 2015 and I want to talk about my physician heroes for mental health. The doctor heroes of my life and work this week are my colleagues at The Royal, the tertiary care psychiatric hospital in Ottawa that serves Eastern Ontario.

In this especially difficult time, when doctors are facing cuts to patient care and hospital doctors are coping with cuts to hospital funding as well as their own, the 70 doctors at my hospital are donating $1 million to the Foundation for Mental Health. The decision was made at our Associates’ meeting and received overwhelming support.

The donation will support care, education and research at the hospital. It is an extension of the clinical care, research and community action that is typical at The Royal. My colleagues care for patients from all walks of life, from youth to seniors with a dedication that is inspiring. We provide care in the hospital, shelters, community settings like Carlingwood Shopping Centre, group homes and prisons. The research undertaken in the Royal’s Institute for Mental Health Research is world-renowned. Our programing is innovative – we’ve even created an App to help young people cope with stress. My own small contribution to this innovation has taken the form of tweet chats.

My unusual schedule means that I often arrive early at the hospital or leave late. Regardless of the hour, I am rarely the only doctor in the building. I am proud to be a part of this group of physicians but I am also humbled by the talent and generosity around me.

People with mental illness have suffered both because of their illnesses and because of the stigma that has plagued these conditions. The doctors who treat these illnesses have also been stigmatized at times. Do you not know at least one psychiatrist joke? My colleagues know that stigma is not defeated with therapies and medication. Putting your money where your mouth is shows your stake in a cause and 100% of the doctors at my hospital will participate in this donation. I am told that this is unprecedented – no other hospital foundation in Ontario has 100% of its hospital’s physicians contributing.

If you are looking for doctors #OnCall4ON, here are 70 you can mention. If you are looking for champions during Mental Illness Awareness Week, look no further.

(Note: The attached photo is used with the permission of The Royal. The Doctors in the picture are, from left to right, Dr. Vinay Lodha, Dr. Michele Mathias, Dr. Alain Labelle, Dr. Ameneh Mirzaei and Dr. Pierre Blier.)IMG_9345

Getting Blood from a Stone

My consideration today is on the government practice of cutting back in healthcare, specifically on hospital and physician services in Ontario, and the impact this has had over the past few years.

Let’s begin with the hospital cutbacks. This month, in my community, three hospitals have announced staff reductions in order to match this year’s reduction in funding by the Government of Ontario. On March 11, 2015, the Children’s Hospital of Eastern Ontario announced that it would have to cut 40 – 50 positions in order to balance its budget. (Reference: http://ottawacitizen.com/news/local-news/cheo-to-cut-40-to-50-jobs-to-meet-budget-target). Then on March 24, 2014, The Ottawa Hospital announced that 35 full time positions would be cut. ( Reference: http://www.1310news.com/2015/03/24/job-cuts-at-the-ottawa-hospital/ This is on top of 80 jobs lost last year and 290 the year before at the region’s largest hospital. My own hospital, The Royal, will cut 18 jobs. (Reference: http://ottawacitizen.com/news/local-news/mental-health-funding)

For the next few months, these hospitals will do their best to work out how they will cut back their spending while trying to maintain the level of care they provide. They will cut positions by not replacing people who are retiring, or sick, or on parental leave. In some cases, there will be no option but to shut down operating room for a few weeks in the summer, or manage acute units, outpatient clinics or emergency rooms with fewer staff. All of these measures are service cutbacks, no matter what the Minister of Health or Deputy Minister say. On a one time basis they may be manageable but our hospitals in Ontario have had similar cutbacks for years. According to the Ontario Hospital Association, for the past three fiscal years, Ontario hospitals have received 0% increases in base operating funding. This is despite the fact that our hospitals are among the most efficient in the country, with the second lowest per capita funding after Québec. Ontario also has the lowest rate of age-sex standardized acute care hospitalization, clearly the work of those fewer but harder working health professionals and diligent care by physicians and their allied health colleagues in communities. (Data from: http://www.oha.com/Pages/Default.aspx )

It’s possible that patients do not notice the cutbacks, especially if they are not aware of what the cutbacks are. Perhaps they never knew a time when wait times were so long. Perhaps it would be more evident if hospitals could call parking fees what they really are: user fees in a so-called publicly funded health care system. The change in amount of care is evident if you have a chronic condition. You may suddenly notice that your doctor is now working without a nurse or a social worker. During this past year, I worked without a nurse for about six months. During that period, because of managing the week to week care of outpatients who required a more intense level of care than their monthly appointment with me, I was unable to provide new consultations, increasing the wait list from 2 months to 9 months. The funniest thing was my learning to use the newfangled blood pressure cuff from the inpatient nursing staff. Thanks to my nursing colleagues, I have not had to use a blood pressure cuff since I was in private practice. Everybody, patients and staff, realized that I was outside of my usual scope of practice and, amusing as it was, it was not the best use of my time.  Also, everyone else, patients included, were very much aware of the change in care. Patients and staff are also aware that health professionals are going the extra distance to offset government cutbacks. The government can rely on this because of the intrinsically caring nature of those who choose healthcare as a career. But the government has cut back too much and the change is evident. Fewer health care providers ultimately manage fewer patients. Patients get less care and less access to care. The government pretends that it is managing spending, but it is passing its deficits down to the hospitals which can be mistakenly blamed for poor productivity and high parking fees.

The government is now attempting to transfer this model of cutback to physician services. It has plans to limit the budget for physician services by just not paying anymore year after year – no matter how many babies are born in Ontario, how many people move here or if there happens to be a public health emergency, like the SARS epidemic. Never mind cutting back on actual physician numbers because the Minister and his Deputy are, as usual, pretending that they’re not actually cutting care and so the number of physicians can continue to grow.

The cutbacks to the overall Physician Services budgets mirror exactly what happened to hospital budgets. While the necessary care by doctors to Ontario’s increasing and aging population grows by 2.7% annually, the government has decided to limit what it will pay for to 1.25%. They are also imposing cuts to primary care and care for chronic diseases – two areas of physician services that can least sustain cuts. How does one explain that to the 900,000 patients in Ontario who need a family doctor? New family doctors and rural family doctors are absorbing greater cuts – no logic there either.

The Ontario Medical Association has offered that doctors’ fees could be frozen for two years – a measure not undertaken in any other Canadian jurisdiction. In other jurisdictions – for example, British Columbia and Manitoba – governments continue to fund the natural growth in the system and to provide doctors with small fee increases. The doctors in Ontario know better than to expect increases and so a fee freeze has been offered. It has learned from the experience of our hospitals that you can’t get blood from a stone.

Medicine is Not About Money

Last night I spoke to the physicians of the Montfort Hospital in Ottawa about the unilateral cuts that the Government of Ontario has made to physician services in Ontario. Resolute, solemn, confused: these were the expressions on their faces as I described the cuts to the Physician Services Budget, the budget for doctors’ fees that pays for all physicians’ services in Ontario.

At the end of the presentation, there were one or two questions – not more – and a few people spoke about the impact primary care reform has had for patients in the Ottawa region. To these doctors, it was incomprehensible that the government is dismantling the team-based care that both patients and doctors prefer.

I was shown the letters the government had sent to the hospital, notifying the physicians of reduced contracts with a “Take it or leave” message. These are terse letters in bureaucratese without even the common courtesy of thanks or a greeting.

One of the programs being cut is payments for on call coverage. If you have ever required care at night or on a weekend, the physician caring for you was “on call”, often working at the end of a full day in the office. At the very least, they are working at a time when others are usually at leisure, a sacrifice for them but also for their families. The amount of money a physician receives for being on call in Ontario is not excessive and to receive any funding for being on call is relatively new. I was first paid for being on call about eight years ago, having worked for almost 20 years not being paid. When I am on-call, I must be within one half hour of the hospital, available for phone calls, patient assessments and consultation at all hours. I was on call last Friday from 4 p.m. until 8 a.m. Saturday morning for which I will receive $100. I can also bill fee-for-service whenever I see a patient. For me, and for most physicians, that small stipend was recognition of the sacrifice that I and my family make because I provide the service of being on call. The lack of regard demonstrated in cutting back this funding is insulting, as are all of these cuts. The government is saying to physicians, “You do not deserve to earn what you do.”

This was the first time I have given this presentation and I was worried about facing angry questions and blame for what is happening. This was not the case. As I said at the outset, my colleagues were resolute, solemn and confused – sad and disappointed. They nodded when I asked that they do their best to continue to provide the best care possible, despite these cuts, and vigorously agreed that we must continue to be engaged in the improvement of patient care and the health care system. Their applause at the end of the presentation was heartfelt and several people shook my hand or hugged me and thanked me for everything the Ontario Medical Association is doing.

This is what the compassion and devotion of the medical profession looks like in the collective. These men and women know that taking care of patients in the best way possible is their job and they will do it, as best as they can, with whatever resources are available. Their response to the OMA Board’s rejection of the Government’s proposed contract, to my presentation – applause and thanks – is compelling. These doctors deserve the Government of Ontario to be as engaged with the health care system as they are.

Doctors have a tradition of working hard through the day and night. We can be repaid with a patient’s smile and a family’s appreciation. One of my young patients thanking me can make my day. My colleagues’ thanks and appreciative if solemn applause when I am bringing bad news is enough to make me work harder for the partnership with the government that they deserve – it’s not about money. The sooner the Government of Ontario understands this, the better.