tag:theconversation.com,2011:/fr/topics/aging-population-2407/articlesaging population – The Conversation2024-03-06T17:15:01Ztag:theconversation.com,2011:article/2244272024-03-06T17:15:01Z2024-03-06T17:15:01ZGeneral practice is in crisis in the UK – and it’s failing the people who need it most<figure><img src="https://images.theconversation.com/files/579216/original/file-20240301-28-25c0vz.jpg?ixlib=rb-1.1.0&rect=14%2C22%2C4969%2C3295&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-giving-checkup-woman-exam-room-14464498">Monkey Business Images/Shutterstock</a></span></figcaption></figure><p>There is <a href="https://www.bmj.com/content/381/bmj.p966">no doubt</a> that <a href="https://www.theguardian.com/society/2022/nov/20/gps-in-england-treat-up-to-three-times-more-patients-than-safety-limit-demands">primary care</a> in the UK – the services that provide the first point of contact in the healthcare system, such as general practice – isn’t working.</p>
<p><a href="https://www.telegraph.co.uk/news/2023/11/12/gps-elusive-species-elderly-patients-phone-appointments/">Patients report</a> <a href="https://inews.co.uk/news/health/patients-struggle-gp-appointments-collapse-nhs-1742850">difficulties in making appointments</a> and seeing the same GP. <a href="https://www.rcgp.org.uk/getmedia/11f26527-5d11-47f2-a593-1a894c2fff1b/Continuity-of-care-in-modern-day-general-practice1.pdf">Continuity of care</a> is an important factor in patient outcomes, particularly for older adults with comorbidities – those living with more than one long-term condition, such as diabetes or asthma. </p>
<p><a href="https://www.telegraph.co.uk/news/2024/02/23/seeing-the-same-gp-fewer-visits-to-the-doctor/#:%7E:text=Patients%20who%20see%20the%20same,to%20return%20after%20shorter%20periods.">Research shows</a> that patients who see the same doctor have fewer hospital admissions and lower mortality rates. However, we also know that <a href="https://www.theguardian.com/society/2024/mar/04/worst-off-find-it-harder-than-well-off-to-access-nhs-care-survey-finds">people on the lowest incomes</a> have much more difficulty getting GP appointments. And when they do, they are much more likely to have a <a href="https://www.england.nhs.uk/about/equality/equality-hub/national-healthcare-inequalities-improvement-programme/what-are-healthcare-inequalities/deprivation/">much worse experience</a> than those who’re more financially comfortable. </p>
<p>Evidence shows that, in particular, older adults who live in poorer areas <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5839575/">struggle to access</a> the primary care that they need. They already have poorer health outcomes, and their life expectancy is lower those living in more affluent areas – yet GP services are not providing the help they should.</p>
<p>Access to <a href="https://www.bmj.com/content/375/bmj.n2916/rr">general practice is vital</a> to maintaining good public health. It’s the entry point to the national health care system, and <a href="https://blogs.bmj.com/bmj/2021/05/14/if-general-practice-fails-the-nhs-fails/">accounts for around 90%</a> of all patient contact with the NHS. </p>
<p>But overall patient satisfaction with general practice <a href="https://www.bmj.com/content/378/bmj.o1764">seems to be in sharp decline</a>. Between 2021 and 2023, the percentage of patients <a href="https://www.kingsfund.org.uk/insight-and-analysis/reports/public-satisfaction-nhs-and-social-care-2022#key-findings">reporting a good overall experience</a> fell from <a href="https://www.england.nhs.uk/statistics/2023/07/13/gp-patient-survey-2023/">71% to 55%</a>. </p>
<p>The reasons for this apparent <a href="https://bmjopen.bmj.com/content/9/2/e026048">crisis in confidence</a> have been covered widely in the media. But reports have tended to focus on GPs rather than the patients who’re most affected. </p>
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<p>For example, it’s been widely reported that the <a href="https://www.rcgp.org.uk/getmedia/155e72a9-47b9-4fdd-a322-efc7d2c1deb4/retaining-gp-workforce-report.pdf">number of GPs</a> <a href="https://researchbriefings.files.parliament.uk/documents/CBP-9731/CBP-9731.pdf">has fallen 4%-5%</a> in recent years and <a href="https://bjgplife.com/stressed-overworked-and-dissatisfied-the-unholy-trio-of-general-practice-in-the-uk/">many doctors</a> who remain in general practice report <a href="https://www.health.org.uk/publications/reports/stressed-and-overworked">feeling stressed and over-worked</a>. It’s no wonder, then, that a significant proportion of <a href="https://www.gponline.com/half-gps-cut-working-hours-ease-workload-poll-shows/article/1811685">GPs have opted to reduce</a> their hours.</p>
<p>There <a href="https://publications.parliament.uk/pa/cm5803/cmselect/cmhealth/113/summary.html">aren’t enough</a> general practitioners <a href="https://www.theguardian.com/commentisfree/2022/jul/03/the-observer-view-on-britain-gp-shortage">to meet growing demand</a>, especially for the <a href="https://www.rcgp.org.uk/getmedia/3613990d-2da8-458a-b812-ed2cf6d600a6/RCGP-Brief_GP-Shortages-in-England.pdf">complex needs of an aging population</a>.</p>
<p>But what of the people disproportionately affected by the crisis in general practice? </p>
<h2>Older, impoverished adults disproportionately affected</h2>
<p>As life expectancy in the <a href="https://www.kingsfund.org.uk/insight-and-analysis/long-reads/whats-happening-life-expectancy-england">UK increases</a>, the <a href="https://www.england.nhs.uk/ourwork/clinical-policy/older-people/improving-care-for-older-people/">role of general practice</a> in keeping people well and living independently <a href="https://www.msdmanuals.com/home/older-people%E2%80%99s-health-issues/providing-care-to-older-people/continuity-of-care">is crucial</a>. This is particularly true in older patients with comorbidities. The often complex nature of their conditions means that these patients need regular monitoring and access to GP services. </p>
<p>In addition, older adults with comorbidities are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9385725/">often socially isolated</a>, and the human contact provided by the therapeutic relationship developed through regular appointments is <a href="https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-019-1189-9">considered vital</a> to their wellbeing. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6853241/">Research has highlighted</a> that the <a href="https://www.health.org.uk/publications/long-reads/measuring-continuity-of-care-in-general-practice">ongoing relationship</a> between GP and patient is particularly important in this group of patients. </p>
<p>However, the <a href="https://www.qmul.ac.uk/media/news/2022/smd/seeing-the-same-gp-is-good-for-your-health-but-only-half-of-patients-are-able-to-do-so.html">continuity of care</a> traditionally provided by the family doctor has declined as primary care struggles to meet the demands placed upon it. In these situations, the influence of <a href="https://patient.info/doctor/health-and-social-class">education and social class</a> on health becomes increasingly apparent. </p>
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<p>A 2024 survey by NHS watchdog <a href="https://www.healthwatch.co.uk/what-we-do">Healthwatch</a> found that already well established links between poverty and ill health are exacerbated by barriers to obtaining healthcare. </p>
<p>The report, which surveyed a representative sample of the population – 2,018 people aged over-16 in England – found that those in poverty were twice as likely to experience problems getting to see a GP than those who identified as “very comfortable” financially. </p>
<p>Louise Ansari, Healthwatch’s chief executive, suggested that the <a href="https://www.theguardian.com/society/2024/mar/04/worst-off-find-it-harder-than-well-off-to-access-nhs-care-survey-finds">survey’s findings</a> were a warning that the NHS could be moving toward a <a href="https://www.telegraph.co.uk/news/2023/10/20/nhs-care-quality-commission-report-health-service/">“two-tier service”</a> with ease of access closely related to wealth. </p>
<p>Ansari’s concerns seem to be well-founded. In more affluent, middle class areas, the quality of general practice is often better and <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthcaresystem/articles/trendsinpatienttostaffnumbersatgppracticesinengland/2022">more readily available</a>, often because practices have fewer patients. </p>
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<p>Wealthier areas tend to have <a href="https://www.ons.gov.uk/visualisations/censusworkforcequalifications/">more highly educated populations</a>, who tend to be more confident in requesting appointments and articulating their health concerns. </p>
<p>Conversely, people living in <a href="https://theconversation.com/gp-crisis-how-did-things-go-so-wrong-and-what-needs-to-change-208197">less affluent areas</a> with greater levels of deprivation may not always be aware of what they are entitled to, or how to get it. </p>
<h2>Delays in seeking help</h2>
<p>The move to remote consultations is another aspect of the barriers to access faced by those who’re most socially and financially disadvantaged.</p>
<p>While remote consultation <a href="https://bmjopen.bmj.com/content/13/5/e070923">may be appropriate</a> and perfectly satisfactory, even preferable, for many patients, there are people – often from the <a href="https://digitalpovertyalliance.org/uk-digital-poverty-evidence-review-2022/introduction-myths-and-shifts/">most deprived groups</a> – who are <a href="https://www.kingsfund.org.uk/insight-and-analysis/long-reads/exclusion-inclusion-digital-health-care#:%7E:text=Groups%20commonly%20considered%20digitally%20excluded,areas%2C%20people%20from%20low%20socio%2D">digitally excluded</a> (unable to use the internet in ways that are needed to participate fully in modern society) and do not have the resources to access virtual appointments. </p>
<p>But this <a href="https://www.gov.uk/government/news/new-plan-to-make-it-easier-for-patients-to-see-their-gp">lack of easy access</a> for all patients is at odds with public health messaging. </p>
<p>For example, <a href="https://digital.nhs.uk/ndrs/our-work/ncras-work-programme/cancer-awareness-campaigns#:%7E:text=Resources-,Introduction,to%20see%20their%20GP%20sooner">public health campaigns</a> that target older adults, emphasise the importance of early detection of cancer: “<a href="https://www.england.nhs.uk/2022/03/celebrities-join-forces-with-the-nhs-to-encourage-cancer-checks/">if something doesn’t feel quite right … get it checked out”</a>. <a href="https://pubmed.ncbi.nlm.nih.gov/35298272/">Early detection and survival rates</a> in all types of cancer are inextricably linked.</p>
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<p>However, difficulty accessing a GP appointment means that <a href="https://www.bbc.co.uk/news/health-37605573">people are more likely to put off</a> and delay seeking help with their symptoms. The number of <a href="https://www.bmj.com/company/newsroom/every-month-delayed-in-cancer-treatment-can-raise-risk-of-death-by-around-10/">late presentations for cancer</a> in particular means that long term survival rates from cancer are not as good as they should be. </p>
<p>The UK’s ageing population and the recent sharp rise in the cost of living means the number of disadvantaged older people in need of consistent, high quality GP care is rising. But their chance of getting it seems to be ever dwindling.</p><img src="https://counter.theconversation.com/content/224427/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robin Lewis does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Older adults in poorer areas would benefit more from seeing the same GP, but often find continuous primary care harder to access.Robin Lewis, Senior Lecturer in Healthcare, Sheffield Hallam UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2101052023-09-17T12:07:27Z2023-09-17T12:07:27ZOlder Canadians’ savings are shaped by their long-term care preferences<figure><img src="https://images.theconversation.com/files/547630/original/file-20230911-8406-rbs70z.jpg?ixlib=rb-1.1.0&rect=15%2C38%2C5160%2C3406&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A recent study has found that Canadians are highly motivated to save money in preparation of long-term care.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/older-canadians-savings-are-shaped-by-their-long-term-care-preferences" width="100%" height="400"></iframe>
<p>Canada’s aging population is growing. According to the Organization for Economic Co-operation and Development, the proportion of Canadians aged 80 and older <a href="https://www.oecd.org/health/health-at-a-glance/">will surpass nine per cent by 2050</a>, up from 4.3 per cent in 2021. </p>
<p>This demographic shift is happening in most developed nations, and will result in a greater demand for long-term care. Québec, for instance, anticipates that <a href="https://creei.ca/wp-content/uploads/2021/02/cahier_21_01_financement_soutien_autonomie_personnes_agees_croisee_chemins.pdf">600,000 people will need long-term care by 2050</a> — nearly double the current number.</p>
<p>Meanwhile, escalated care expenses in recent years, <a href="https://www.statcan.gc.ca/o1/en/plus/4165-nurses-working-harder-more-hours-amid-increased-labour-shortage">attributed to labour shortages and exacerbated by COVID-19</a>, are a pressing concern.</p>
<h2>The costs of long-term care</h2>
<p>In Québec, <a href="https://bonjourresidences.com/blogue/couts-hebergement-chsld/">the rates (before any income-based subsidy) for public nursing home accommodations are around $2,000 a month</a>. But since public nursing homes have such long waiting lists, some choose private nursing homes instead. The costs of private nursing homes are estimated to be between $5,000 and $8,000 a month.</p>
<p>Home care — <a href="https://theconversation.com/canadians-want-home-care-not-long-term-care-facilities-after-covid-19-170620">a preferred option for many</a> — costs around $5,550 a month, excluding additional expenses like maintenance and food. Consequently, long-term care expenses present a substantial financial risk in old age, potentially motivating people to save for it ahead of time.</p>
<p>While both nursing homes and home care impose financial burdens, their distinct cost structures can influence precautionary savings in different ways. </p>
<p>Nursing homes bundle accommodation and food, offering limited additional services. In contrast, home care recipients can allocate savings for quality-of-life improvements like better food, home maintenance, etc. Additionally, people may inherently value spending more while at home.</p>
<h2>Long-term care and savings</h2>
<p>Our <a href="https://economie.esg.uqam.ca/wp-content/uploads/sites/54/2023/05/2023_02_docdt_eco.pdf">recent research project</a> aimed to understand how preferences for home-based care versus nursing homes affect people’s savings, using both survey responses and a simulation study.</p>
<p>Our research is crucial for two reasons. First, even before the pandemic, a reluctance to be institutionalized — known as <a href="https://doi.org/10.1016/j.jhe.2017.10.001">institutionalization aversion</a> — was documented. Second, COVID-19 has further <a href="https://doi.org/10.1016/j.jebo.2022.06.034">discouraged nursing home entry</a>, possibly due to excess mortality in nursing homes, as has been <a href="https://doi.org/10.1002/hec.4613">documented in many countries</a>.</p>
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Read more:
<a href="https://theconversation.com/inquiry-into-coronavirus-nursing-home-deaths-needs-to-include-discussion-of-workers-and-race-139017">Inquiry into coronavirus nursing home deaths needs to include discussion of workers and race</a>
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<p>To model savings in different care settings effectively, we needed to understand how individuals allocated their resources in those settings. To accomplish this, we developed a set of survey questions aimed at uncovering these preferences.</p>
<p>These survey questions were designed to prompt respondents to consider how they would allocate their resources depending on the long-term care setting in a well-defined, hypothetical scenario.</p>
<p>Survey respondents were randomly assigned to different long-term care settings (home care, semi-private room in a nursing home or a private room in a nursing home). Their resource allocation choices allowed us to examine how their preferences for savings varied based on the type of long-term care setting.</p>
<p>Our analysis of 3,000 survey responses shows that Canadians are highly motivated to save money to be better prepared for long-term care. This willingness to save was much larger when respondents expected to use home care; respondents anticipating home care allocated 38 per cent more resources to savings. This reflects the greater financial needs associated with home care.</p>
<h2>Long-term care insurance</h2>
<p>We used the results from our survey to calibrate a simulation study — a computer-based experiment using a combination of economic theories and survey evidence — to simulate how households and individuals make financial decisions.</p>
<p>Our simulation study examined two scenarios: one based on the Canadian system, which includes a universal subsidy that lowers nursing home costs, and one based on the U.S. Medicaid system, which features a purely means-tested subsidy that provides free long-term care and ensures a minimum standard of living for those without sufficient income.</p>
<p>Differences in individual preferences for various care settings largely explain the savings disparities. In the Canada-like system, the prospect of receiving long-term care at home substantially boosts savings. On average, individuals planning to use home care saved $25,000 (8.3 per cent) more by the age of 66, compared to those planning to use private nursing home rooms, and $29,000 (9.8 per cent) more compared to those opting for semi-private rooms. </p>
<p>Under the U.S.-like system, the impacts on savings of different care settings were much smaller. This is because, in the absence of public subsidies, the minimum costs of a room in a nursing home are much higher than those of home care. When comparing the savings of individuals opting for home care versus a private room in a nursing home, the difference in savings was almost null. </p>
<p>However, when comparing savings between those opting for home care versus a semi-private room in a nursing home, we found that the former saved 3.7 per cent more.</p>
<h2>Policy implications</h2>
<p>Assessing how individuals value additional public subsidies for each type of long-term care setting can provide policymakers with valuable insights about how to expand public long-term care insurance effectively. </p>
<p>Our research found that all subsidies are valued well beyond costs, with home care subsidies being more valued than nursing home subsidies. Under the Canada-like system, the average valuation for a home care subsidy was $2.98 per $1 spent, surpassing private ($2.72) and semi-private ($2.35) nursing home subsidies.</p>
<p>Middle-income individuals who aren’t eligible for means-tested programs, but who have limited savings, placed the highest value on these subsidies. This shows that expanding subsidies for home care can be an effective way to protect Canadians from long-term care risks.</p><img src="https://counter.theconversation.com/content/210105/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marie-Louise Leroux receives funding from FRQSC and SSHRC-CRSH. She is affiliated with CIRANO (Montreal) and CESifo (Munich). </span></em></p><p class="fine-print"><em><span>Franca Glenzer receives funding from SSHRC-CRSH. </span></em></p><p class="fine-print"><em><span>Bertrand Achou, Minjoon Lee, and Philippe De Donder do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>While both nursing homes and home care impose financial burdens, their differing structures can influence how older Canadians save money.Marie-Louise Leroux, Professeure titulaire en Sciences Economiques, Université du Québec à Montréal (UQAM)Bertrand Achou, Assistant Professor, Economics, University of GroningenFranca Glenzer, Assistant Professor, Department of Finance, HEC MontréalMinjoon Lee, Assistant Professor, Economics, Carleton UniversityPhilippe De Donder, Research director (CNRS), Toulouse School of Economics – École d'Économie de ToulouseLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2043582023-04-26T18:22:49Z2023-04-26T18:22:49ZCanada’s federal transfer payment system badly needs a tune-up<figure><img src="https://images.theconversation.com/files/522634/original/file-20230424-20-ilgyb.JPG?ixlib=rb-1.1.0&rect=0%2C0%2C7896%2C4362&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Prime Minister Justin Trudeau sits beside Manitoba Premier Heather Stefanson, left, and Québec Premier François Legault, right, as he meets with Canada's premiers in Ottawa in February 2023. </span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Sean Kilpatrick</span></span></figcaption></figure><p><a href="https://www.canada.ca/en/department-finance/programs/federal-transfers.html">Federal transfer payments</a> are at the heart of the Canadian federation. They ensure critical public services are equitably funded right across the country and account for roughly <a href="https://financesofthenation.ca/real-fedprov/">one-fifth of total provincial revenues</a>. For lower-income provinces, they rise to as high as one-third of the total.</p>
<p>While reaching agreements and enacting reforms is never easy — as recent <a href="https://www.ctvnews.ca/politics/federal-provincial-fight-over-health-transfer-percentage-points-is-futile-duclos-1.6150664">federal-provincial wrangling over health transfers</a> demonstrates — kicking the can down the road is no way forward.</p>
<p>But that’s precisely what the federal government has been doing — missing opportunities to seriously explore reforming the federal transfer payments system.</p>
<p><a href="https://www.cbc.ca/news/politics/ottawa-lock-in-equalization-formula-budget-2029-1.6815815">Recent reports suggest</a> that the federal government quietly extended the current equalization formula first adopted 15 years ago until 2029. This is yet another example of the failure of the government to seriously examine whether our system of federal transfers needs a tune-up in the face of growing challenges.</p>
<h2>Multiple strains</h2>
<p>Many of these challenges — especially an <a href="https://macleans.ca/opinion/canadas-aging-population-is-going-to-put-a-strain-on-government-coffers/">aging population</a>, mounting health-care pressures, <a href="https://climateinstitute.ca/reports/the-health-costs-of-climate-change/">climate change</a>, economic uncertainty and <a href="https://www.politico.com/news/2023/03/29/canada-u-s-clean-energy-ira-00089284">energy transitions</a> — are already having an effect on government finances in Canada.</p>
<p>They will only become significantly more pressing over time. Local governments are playing an increasing role in delivering <a href="https://tspace.library.utoronto.ca/bitstream/1807/79554/1/imfgpaper_no34_financinginfrastructure_slack_tassonyi_Nov_9_2017.pdf">services and infrastructure but with limited resources</a>. They should be incorporated more fully in the conversation about the future of fiscal federalism.</p>
<p>That’s because getting reform right is critical.</p>
<p>To appreciate this, consider the challenge posed by an aging population alone. <a href="https://www150.statcan.gc.ca/n1/pub/71-607-x/71-607-x2022015-eng.htm">Statistics Canada projects</a> the share of Canadians over 65 will increase from less than one-fifth today to nearly one-quarter by 2050.</p>
<p>Health-care spending could rise by the equivalent of roughly three per cent of GDP. For context, if funded entirely from tax increases, that would require increasing the GST by approximately 10 percentage points. </p>
<p>With the share of Canada’s population participating in the labour force falling rapidly, the implications for economic growth and the potential for even wider fiscal inequalities among provinces are no less dramatic. Overcoming this will involve all levels of government in Canada.</p>
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Read more:
<a href="https://theconversation.com/as-canadas-population-ages-seniors-need-better-access-to-public-transit-151253">As Canada’s population ages, seniors need better access to public transit</a>
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<h2>Concerns about fairness</h2>
<p>An issue that hits closer to home for some Canadians is that of perceived fairness.</p>
<p>A striking example of grievances about the fairness of fiscal federalism is the debate about the federal equalization program, which has faced criticism from wealthier provinces since its inception in 1957. Those criticisms are <a href="https://www.alberta.ca/fair-deal-panel.aspx">especially prominent in Alberta today</a>.</p>
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<p>In the lead-up to the upcoming Alberta election on May 29, Alberta is strongly expressing its concern that the federal government extended the formula another five years. <a href="https://www.alberta.ca/release.cfm?xID=8699673251B49-FA72-7A1B-C2020F81BDA6607E">It offered a detailed suggestion for reform</a>.</p>
<p>Modernizing our fiscal arrangements is necessary to overcome some of these considerable challenges. Our governments should be willing to have important conversations on this issue.</p>
<p>To be sure, the latest federal budget made some adjustments. It detailed more than <a href="https://www.canada.ca/en/health-canada/news/2023/02/working-together-to-improve-health-care-for-canadians.html">$46 billion in boosted federal health transfers</a> to provinces and territories.</p>
<p>Much of this is allocated equally across provinces, according to their population. Some, however, is allocated as fixed payments independent of how large a province is. This provides <a href="https://www.yycpolicy.org/blog/2023/3/12/a-hidden-feature-of-the-new-health-transfers-will-help-smaller-provinces">considerably more support to smaller provinces</a> that face disproportionate challenges from the aging population.</p>
<p>But much more is needed in many other areas, and all governments must work together.</p>
<p>This is especially true for challenges that transcend the ability of any individual government to address, many of which — like climate change — are becoming more significant by the day. </p>
<p>These issues will place a lot of strain on Canada’s highly decentralized system of government. Who should do what, and who should pay for what, are central questions that we need to get right and that we need to adapt when necessary.</p>
<figure class="align-center ">
<img alt="An overpass goes over a flooded highway." src="https://images.theconversation.com/files/433294/original/file-20211122-23-lm1ti9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/433294/original/file-20211122-23-lm1ti9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=411&fit=crop&dpr=1 600w, https://images.theconversation.com/files/433294/original/file-20211122-23-lm1ti9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=411&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/433294/original/file-20211122-23-lm1ti9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=411&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/433294/original/file-20211122-23-lm1ti9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=517&fit=crop&dpr=1 754w, https://images.theconversation.com/files/433294/original/file-20211122-23-lm1ti9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=517&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/433294/original/file-20211122-23-lm1ti9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=517&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">An overpass is pictured going over a flooded Highway 1 near Chilliwack, B.C., in the aftermath of massive floods in 2021.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jonathan Hayward</span></span>
</figcaption>
</figure>
<h2>Details and trade-offs</h2>
<p>A list of specific reforms that Canada should adopt would be helpful, but it isn’t obvious what those are. </p>
<p>From changes to equalization to tax point transfers, health-care funding, municipal infrastructure support and a more fundamental rethinking of the system of fiscal federalism that we have today, there are many details to work out and trade-offs to consider.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-canadas-equalization-program-needs-a-major-overhaul-132233">Why Canada's equalization program needs a major overhaul</a>
</strong>
</em>
</p>
<hr>
<p>Historically, mounting pressure led governments to pursue deep dives into our fiscal systems and enact evidence-based reforms. From the <a href="https://publications.gc.ca/site/eng/9.828175/publication.html">Rowell-Sirois Commission</a> in the late 1930s to the 2006 <a href="https://publications.gc.ca/collections/Collection/F2-176-2006E.pdf">O’Brien Report</a> on equalization, this has been a common approach.</p>
<p>Canada’s intergovernmental and fiscal arrangements have confronted and successfully overcome unique social, political, economic and fiscal pressures over more than 150 years. Today, governments can work together with academics, practitioners and indeed all Canadians to do just that once again.</p>
<p>Avoiding the challenges won’t make them go away.</p>
<hr>
<p><em>Charles Breton of the Institute for Research on Public Policy, Colleen Collins of the Canada West Foundation and Steve Orsini of the C.D. Howe Institute contributed to this article.</em></p><img src="https://counter.theconversation.com/content/204358/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Trevor Tombe receives financial support through various grants from the Social Sciences and Humanities Research Council of Canada. His full disclosure statement is available at <a href="https://www.trevortombe.com/post/conflict/conflict/">https://www.trevortombe.com/post/conflict/conflict/</a></span></em></p><p class="fine-print"><em><span>Daniel Béland receives funding from the Social Sciences and Humanities Research Council of Canada. </span></em></p><p class="fine-print"><em><span>Enid Slack does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Modernizing Canada’s fiscal arrangements is necessary to overcome considerable challenges that are impacting the country’s finances, including an aging population and climate change.Trevor Tombe, Professor of Economics, University of CalgaryDaniel Béland, Professor, Political Science, McGill UniversityEnid Slack, Director of the Institute on Municipal Finance and Governance (IMFG) at the School of Cities, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1908872022-09-20T18:35:53Z2022-09-20T18:35:53ZCanada must take action now on dementia: Recommendations to help lower risks in an aging population<figure><img src="https://images.theconversation.com/files/485695/original/file-20220920-18-sqr9n1.jpg?ixlib=rb-1.1.0&rect=502%2C120%2C6156%2C4044&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A new study predicts a significant increase in the number of Canadians living with dementia over the next three decades.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>There is a great deal of sobering news for Canadians in the <a href="https://alzheimer.ca/en">Alzheimer Society of Canada’s</a> new study. The recently released first volume of <a href="https://alzheimer.ca/en/research/reports-dementia/landmark-study-report-1-path-forward"><em>Navigating the Path Forward for Dementia in Canada: The Landmark Study</em></a> predicts a significant increase in the number of Canadians living with dementia over the next three decades. </p>
<p>Among the study’s findings:</p>
<ul>
<li>More than one million Canadians are forecast to be living with dementia by the end of 2030, with the figure predicted to rise to 1.7 million by 2050.</li>
<li>In 2020, 8.4 per cent of Canadians over 65 had some form of dementia. By 2050, when the baby boomer generation is over the age of 85, the percentage of Canadians over 65 living with dementia is expected to increase to 13.2 per cent.</li>
<li>On average, care partners, such as family and friends of people living with dementia, provide 26 hours of care per week. If current trends continue, the number of hours provided by family and friends could reach almost 1.4 billion hours annually by 2050. This is equivalent to over 690,000 full-time jobs.</li>
</ul>
<p>The numbers illustrate the potential for significant challenges for the health-care system, and Canadians should rightly view them as a wake-up call. But the study also offers a glimpse at a more hopeful future, showing several scenarios in which the number of potential dementia cases can be reduced across Canada by addressing the risk factors associated with the condition.</p>
<p>A delay in the onset of dementia by even just a single year would mean 500,000 fewer cases of dementia in Canada by 2050. The impact of this decrease, on both the number of people living with dementia and those who care for them, would be profound.</p>
<h2>Recommendations for action</h2>
<figure class="align-center ">
<img alt="An older couple sitting on a sofa looking at each other, the man with his arm around the woman." src="https://images.theconversation.com/files/485697/original/file-20220920-3560-dob2c4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/485697/original/file-20220920-3560-dob2c4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/485697/original/file-20220920-3560-dob2c4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/485697/original/file-20220920-3560-dob2c4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/485697/original/file-20220920-3560-dob2c4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/485697/original/file-20220920-3560-dob2c4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/485697/original/file-20220920-3560-dob2c4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Care partners, such as family and friends of people living with dementia, provide an average of 26 hours of care per week.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The report makes several recommendations to governments at all levels to support those living with the disease and their care partners. For example, the federal government approved a <a href="https://www.canada.ca/en/public-health/services/publications/diseases-conditions/dementia-strategy.html">national dementia strategy in 2019</a> that included key areas for action — especially a public health approach to risk reduction. As yet, that strategy has not been fully costed or appropriately funded. </p>
<p>Similarly, the strategy sets a goal to fund chronically underfunded research in dementia to a minimum of one per cent of overall dementia care. This has still not been implemented, despite the report’s calls for immediate action.</p>
<p>Another issue is that primary care physicians are the first point of contact for people living with dementia as well as their care partners. Yet, they are poorly resourced to provide appropriate care, with no clear pathway through a complex health system. The new report calls for providing primary care clinicians with more training to make timely diagnosis of dementia symptoms and an improved fee structure that prioritizes the time spent with people living with dementia and their care partners. </p>
<h2>Modifiable factors</h2>
<figure class="align-center ">
<img alt="Older man with a beard reading a book sitting on a sofa" src="https://images.theconversation.com/files/485698/original/file-20220920-16-v7h2bt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/485698/original/file-20220920-16-v7h2bt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/485698/original/file-20220920-16-v7h2bt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/485698/original/file-20220920-16-v7h2bt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/485698/original/file-20220920-16-v7h2bt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/485698/original/file-20220920-16-v7h2bt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/485698/original/file-20220920-16-v7h2bt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Activities that stimulate the brain and encourage lifelong learning include reading, playing games or speaking a second language.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>One of the most effective tools to reduce the prevalence of dementia is to address what are known as <a href="https://doi.org/10.1016/S0140-6736(20)30367-6">modifiable factors</a>. While a person can’t control their sex at birth, age or genetic background, there are actions that can promote overall good health and reduce the risk of dementia, some of which are very specific to dementia. These include:</p>
<ul>
<li>Monitoring and controlling blood pressure and cholesterol levels;</li>
<li>Staying physically fit through regular activities, including walking and exercise;</li>
<li>Enjoying activities that stimulate the brain and encourage lifelong learning, such as reading, playing games or speaking a second language;</li>
<li>Staying in touch with family and friends to keep an active social circle;</li>
<li>Limiting consumption of alcohol and tobacco;</li>
<li>Using hearing aids to deal with hearing loss issues;</li>
<li>Maintaining a positive attitude by finding purposeful, meaningful engagement in life;</li>
<li>Making healthy food choices and avoiding unnecessary stress.</li>
</ul>
<p>Ultimately, the only way to create a world without dementia is by supporting research that will lead to more effective treatments and, potentially, cures. <a href="https://doi.org/10.1016/S1474-4422(10)70304-5">Research is already showing some promising efforts</a> in terms of delaying the onset of dementia. </p>
<p>While there’s room for optimism, we must be clear in our understanding that dementia will be a public health challenge in Canada for many years to come. Providing quality care for people living with dementia is the right thing to do. </p>
<p>Meanwhile, the findings of this report can alert Canadians to an issue that, if left unchecked, will affect hundreds of thousands of Canadian older adults and their families.</p><img src="https://counter.theconversation.com/content/190887/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Saskia Sivananthan works for the Alzheimer Society of Canada. She also serves as a member of the Ministerial Advisory Board on Dementia for the Public Health Agency of Canada.</span></em></p>Action is needed to hold off a wave of dementia cases in an aging population. One of the most effective tools to reduce the prevalence of dementia is to address modifiable factors.Saskia Sivananthan, Affiliate Professor, Department of Family Medicine, McGill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1706202021-11-11T15:42:10Z2021-11-11T15:42:10ZCanadians want home care, not long-term care facilities, after COVID-19<figure><img src="https://images.theconversation.com/files/431304/original/file-20211110-27-1tvfyy6.jpg?ixlib=rb-1.1.0&rect=0%2C345%2C4193%2C2628&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People protest outside the Tendercare Living Centre long-term care facility during the COVID-19 pandemic in Scarborough, Ont., in December 2020. </span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette </span></span></figcaption></figure><iframe style="width: 100%; height: 175px; border: none; position: relative; z-index: 1;" allowtransparency="" src="https://narrations.ad-auris.com/widget/the-conversation-canada/canadians-want-home-care--not-long-term-care-facilities--after-covid-19" width="100%" height="400"></iframe>
<p>The COVID-19 pandemic has shed light on the precarious living conditions of the elderly in nursing homes in Canada.</p>
<p>During the first wave of the pandemic, from March to August 2020, more than 80 per cent of Canadian COVID-19 deaths were tied to nursing and seniors’ homes, according to the <a href="https://www.cihi.ca/sites/default/files/document/covid-19-rapid-response-long-term-care-snapshot-en.pdf">Canadian Institute for Health Information</a>. </p>
<p>The pandemic put nursing homes in the spotlight in terms of how they’ve been managed, their lack of staff and COVID-19’s impact on the living conditions of the dependent elderly people who reside within them.</p>
<figure class="align-center ">
<img alt="A person on a stretcher is placed into the back of an ambulance." src="https://images.theconversation.com/files/431302/original/file-20211110-23-1ci2z6l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/431302/original/file-20211110-23-1ci2z6l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=433&fit=crop&dpr=1 600w, https://images.theconversation.com/files/431302/original/file-20211110-23-1ci2z6l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=433&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/431302/original/file-20211110-23-1ci2z6l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=433&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/431302/original/file-20211110-23-1ci2z6l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=544&fit=crop&dpr=1 754w, https://images.theconversation.com/files/431302/original/file-20211110-23-1ci2z6l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=544&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/431302/original/file-20211110-23-1ci2z6l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=544&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Paramedics take away a person from Revera Westside Long Term Care Home during the COVID-19 pandemic in Toronto in December 2020.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span>
</figcaption>
</figure>
<p>COVID-19 and the media coverage of the crisis in long-term care have raised public awareness about the risks associated with such facilities. It may have also permanently affected perceptions and preferences when it comes to long-term care.</p>
<p>In the fall of 2020, we partnered with <a href="https://portal.askingcanadiansprojects.com/">Asking Canadians</a>, a Canadian online panel survey organization, to conduct a poll of more than 3,000 people in Ontario and Québec between 50 and 69 years old. The goal was to learn how the pandemic had affected their views on long-term care.</p>
<p><a href="https://ire.hec.ca/wp-content/uploads/2021/09/cahier_IRE_7_nursing_home_aversion_post_pandemic_savings_long_term_care.pdf">The survey</a> asked questions about long-term care preferences and whether respondents were more supportive of home care because of COVID-19.</p>
<h2>Majority want to avoid nursing homes</h2>
<p>The survey shows the pandemic has dramatically changed perceptions, preferences and ultimately the financial behaviour of Canadians when it comes to long-term care. </p>
<p>A full 72 per cent of our respondents said they were less inclined to enter a nursing home, and 70 per cent of them said the pandemic caused them serious concerns about exposure to health risks in long-term care facilities.</p>
<p>At the same time, about 25 per cent said they planned to save more for old age because of COVID-19 and their desire to avoid entering nursing homes in favour of home care.</p>
<p>Lastly, we observed strong support for tax policy that would subsidize home care, with 70 per cent of respondents calling for it. This increased support for home-care policies in the post-pandemic era is driven by the desire to avoid entering nursing homes.</p>
<p>At its essence, our study shows the COVID-19 pandemic has made Canadians fear sub-standard living conditions in nursing homes and has made them realize the urgency of finding adequate care alternatives and solutions for our elderly population. We can only hope that policy-makers use this opportunity to address the issue.</p>
<figure class="align-center ">
<img alt="A woman sits in her room at a seniors' residence, blinds drawn." src="https://images.theconversation.com/files/338770/original/file-20200601-83297-19rjf36.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/338770/original/file-20200601-83297-19rjf36.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=438&fit=crop&dpr=1 600w, https://images.theconversation.com/files/338770/original/file-20200601-83297-19rjf36.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=438&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/338770/original/file-20200601-83297-19rjf36.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=438&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/338770/original/file-20200601-83297-19rjf36.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=551&fit=crop&dpr=1 754w, https://images.theconversation.com/files/338770/original/file-20200601-83297-19rjf36.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=551&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/338770/original/file-20200601-83297-19rjf36.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=551&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A resident sits in her room at a seniors’ residence in Montréal in January 2020.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Ryan Remiorz</span></span>
</figcaption>
</figure>
<h2>The global population is aging</h2>
<p>The findings of our survey provide important information for any country with aging populations and increasing health needs. According to <a href="https://www.oecd.org/els/health-systems/help-wanted-9789264097759-en.htm">a study by the Organization for Economic Co-operation and Development</a>, the number of people aged 80 and above is expected to grow from four per cent of the total OECD population in 2010 to 10 per cent in 2050. </p>
<p>Canada is not exempt from this trend. The number of people in Québec who need help with the activities of daily living is likely to almost double <a href="https://creei.ca/financement-soutien-autonomie-personnes-agees-croisee-chemins/">from 315,000 in 2020 to more than 600,000 in 2050</a>. </p>
<figure class="align-left ">
<img alt="A woman assists an elderly man sitting in a chair by a window." src="https://images.theconversation.com/files/431307/original/file-20211110-19-3gw3o5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/431307/original/file-20211110-19-3gw3o5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/431307/original/file-20211110-19-3gw3o5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/431307/original/file-20211110-19-3gw3o5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/431307/original/file-20211110-19-3gw3o5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/431307/original/file-20211110-19-3gw3o5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/431307/original/file-20211110-19-3gw3o5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Canadians want home care, but it’s expensive.</span>
<span class="attribution"><span class="source">(Pexels)</span></span>
</figcaption>
</figure>
<p>COVID-19 has caused both policy-makers and the population in general to think about alternative solutions to nursing home care, particularly home care. But home care is expensive, even when governmental subsidies exist — <a href="https://www.clhia.ca/web/CLHIA_LP4W_LND_Webstation.nsf/resources/Consumer+Brochures/$file/Brochure_Guide_Long_Term_Care_ENG.pdf">it has a much heftier price tag than public nursing home care</a>.</p>
<p>And for those who don’t have family members who can provide informal care, public long-term care homes are often their only choice.</p>
<p>The pandemic has forced society to question the appeal and expense of home care versus long-term care facilities. Canadians who want to opt for home care will need to start saving for retirement accordingly in case they become dependent and want to avoid nursing homes.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/after-covid-19s-tragic-toll-canada-must-improve-quality-of-life-in-long-term-care-homes-139763">After COVID-19's tragic toll, Canada must improve quality of life in long-term care homes</a>
</strong>
</em>
</p>
<hr>
<p>Policy-makers must also develop adequate long-term care standards to ensure a deadly disaster like the one that occurred during the COVID-19 pandemic doesn’t happen again. That will require building new, safer nursing homes and adequately staffing them, training long-term care workers in safety and sanitation protocols and paying them a better wage.</p>
<p>But our survey shows Canadians would overwhelmingly prefer home care options as they age. Governments must make home care a viable option for their aging citizens by making it more affordable via a variety of means, including subsidies and tax exemptions.</p><img src="https://counter.theconversation.com/content/170620/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Leroux Marie-Louise receives funding from FRQSC and SSHRC-CRSH. </span></em></p><p class="fine-print"><em><span>Bertrand Achou receives funding from SSHRC-CRSH. </span></em></p><p class="fine-print"><em><span>Franca Glenzer receives funding from SSHRC-CRSH. </span></em></p><p class="fine-print"><em><span>Minjoon Lee and Philippe De Donder do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A study shows the COVID-19 pandemic has made Canadians fear sub-standard and dangerous living conditions in nursing homes. They want home care, and tax policies that will support it.Marie-Louise Leroux, Professeure titulaire en Sciences Economiques, Université du Québec à Montréal (UQAM)Bertrand Achou, Associate Researcher, Economics, HEC MontréalFranca Glenzer, Assistant Professor, Retirement and Savings, HEC MontréalMinjoon Lee, Assistant Professor, Economics, Carleton UniversityPhilippe De Donder, Research director, Toulouse School of Economics – École d'Économie de ToulouseLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1163312019-05-02T21:53:54Z2019-05-02T21:53:54ZCanadian health care needs agile leaders and bold visions for the future<figure><img src="https://images.theconversation.com/files/272096/original/file-20190501-113858-136wdmt.jpg?ixlib=rb-1.1.0&rect=148%2C0%2C6927%2C3552&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rapidly advancing technologies, including artificial intelligence, robotics, 3D-printing, smart-phones, smart-homes, precision medicine and diagnostics, promise to disrupt health care as we know it. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>The way we live and work is being disrupted like never before. Various technological, demographic, economic, political and environmental forces are forcing us to rethink the way we run society’s key institutions.</p>
<p>Our <a href="https://www.forbes.com/sites/williamhaseltine/2018/04/02/aging-populations-will-challenge-healthcare-systems-all-over-the-world/#185fcd0a2cc3">global population is aging</a>, the <a href="https://unfccc.int/news/climate-change-impacts-human-health">effects of climate change</a> are more deeply felt with each passing day and industry must adjust its processes given the <a href="https://medium.com/swlh/how-emerging-technologies-are-impacting-industries-b85afc14b5d">pace of technological advances</a>.</p>
<p>While nearly all professional fields must adapt, health care, in particular, will need strong leadership to withstand these forces. Is the Canadian health-care system ready? Does it have the leadership capacity to bring about adaptive system-level changes?</p>
<p>At <a href="https://healthleadershipacademy.ca/">McMaster University’s Health Leadership Academy</a>, we just published new research in answer to this question.</p>
<p><a href="https://healthleadershipacademy.ca/files/2019/04/Alternative-Futures-of-Health.pdf">Our white paper</a> identifies key disruptive forces impacting the health-care sector. The paper imagines alternative plausible futures and identifies the attributes that will be required of tomorrow’s leaders in any of these future scenarios.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/3d-printers-a-revolutionary-frontier-for-medicine-83031">3D printers: A revolutionary frontier for medicine</a>
</strong>
</em>
</p>
<hr>
<h2>Disruptive forces in health care</h2>
<p>Our team carried out a full review of academic research in the field and also conducted a stakeholder dialogue with 60 experts from across the Canadian health system. We identified several driving forces that stand to impact Canadian health care:</p>
<ol>
<li><p>Exponential advances in technology are fuelling an ever-expanding knowledge economy and widespread job displacements. Examples include <a href="https://www.theglobeandmail.com/opinion/article-how-artificial-intelligence-can-completely-revolutionize-canadian/">artificial intelligence</a>, <a href="https://sencanada.ca/content/sen/committee/421/SOCI/reports/RoboticsAI3DFinal_Web_e.pdf">robotics</a>, <a href="https://toplink.weforum.org/knowledge/insight/a1Gb00000038pHMEAY/explore/summary">3D-printing, smart phones, smart homes</a>, precision medicine and diagnostics.</p></li>
<li><p>Economic disparities between the rich and the poor are growing and contributing to the populist movement and nationalism worldwide, with <a href="https://toplink.weforum.org/knowledge/insight/a1Gb00000038pHMEAY/explore/summary">health care becoming increasingly inaccessible</a> to the economically disadvantaged.</p></li>
<li><p><a href="https://www.forbes.com/sites/williamhaseltine/2018/04/02/aging-populations-will-challenge-healthcare-systems-all-over-the-world/#185fcd0a2cc3">An aging population</a>, coupled with <a href="https://www.massmedic.com/wp-content/uploads/2018/03/Ontario-Office-of-the-Chief-Health-Innovation-Strategist.pdf">other demographic shifts</a> (such as the growth of a more multicultural population across Canada), places heavy demands on an economically stretched health-care system. The growing challenges of mental health, addiction, <a href="https://canadiancentreforaddictions.org/drug-use-and-abuse-in-canada/">drug trafficking</a> and <a href="https://theconversation.com/how-the-opioid-crisis-is-disrupting-hospital-care-103600">the opioid crisis</a> add further pressures.</p></li>
<li><p>The rapidity and magnitude of climate change threatens the environment, but also the <a href="https://unfccc.int/news/climate-change-impacts-human-health">health and well-being of individuals</a>. Not only does climate change bring heatwaves, flooding and other extreme events, it also impacts food security and increases the transmission season and the geographical range of many diseases.</p></li>
</ol>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/272089/original/file-20190501-113867-1f6rarf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/272089/original/file-20190501-113867-1f6rarf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/272089/original/file-20190501-113867-1f6rarf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/272089/original/file-20190501-113867-1f6rarf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/272089/original/file-20190501-113867-1f6rarf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/272089/original/file-20190501-113867-1f6rarf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/272089/original/file-20190501-113867-1f6rarf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">More than 500 wildfires burned in British Columbia in August 2018. Wildfires cause many health problems, from anxiety and PTSD to asthma and low birth weight in children.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/climate-change-will-increase-deaths-by-suicide-102156">Climate change will increase deaths by suicide</a>
</strong>
</em>
</p>
<hr>
<h2>Agility, integrity, ‘big picture’ thinking</h2>
<p>Our research underscores the growing importance of <a href="https://doi.org/10.1186/s12960-016-0171-2">transformational</a> and <a href="https://doi.org/10.1186/s12913-019-3883-x">shared leadership</a> within health care.</p>
<p>No matter what the future holds, emerging health leaders must be able to identify, and have the courage to act upon, opportunities that present risk but also offer transformational change — to improve the patient experience.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/272091/original/file-20190501-113861-17mylv8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/272091/original/file-20190501-113861-17mylv8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=410&fit=crop&dpr=1 600w, https://images.theconversation.com/files/272091/original/file-20190501-113861-17mylv8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=410&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/272091/original/file-20190501-113861-17mylv8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=410&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/272091/original/file-20190501-113861-17mylv8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=515&fit=crop&dpr=1 754w, https://images.theconversation.com/files/272091/original/file-20190501-113861-17mylv8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=515&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/272091/original/file-20190501-113861-17mylv8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=515&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">How will Canada’s health-care leaders develop health solutions for our aging society?</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>For example, robots are now widely used in <a href="https://www.reuters.com/article/us-japan-ageing-robots-widerimage/aging-japan-robots-may-have-role-in-future-of-elder-care-idUSKBN1H33AB">elder-care facilities throughout Japan.</a> These robots take on human characteristics and help stem the loneliness of residents. There are even “<a href="https://www.theverge.com/2018/12/20/18149817/lovot-groove-x-home-robot-japan-designed-to-be-loved">cat bots</a>,” as proxies for pets, in these elder-care facilities. </p>
<p>Here, advanced technologies are being harnessed to deal with a demographic crisis in Japan — a rapidly aging population with fewer young people to provide elder care. It took bold leadership to spearhead these initiatives (and overcome resistance grounded in the perceived emotional coldness of non-human caregivers). Here, one driving change (technology) was used to deal with the issues emanating from another of the driving changes (demographics).</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-robots-are-helping-doctors-save-lives-in-the-canadian-north-104462">How robots are helping doctors save lives in the Canadian North</a>
</strong>
</em>
</p>
<hr>
<p>Our health-care leaders will need to be resilient, agile, fast learners, smart and adaptable. They will need to be of high integrity and have a systems-wide, “big picture” mindset.</p>
<p>They will also need to cultivate a dynamic community of shared leadership that includes patients and their families. For example, <a href="https://www.ideou.com/blogs/inspiration/creative-confidence-series-design-thinking-in-healthcare">health-care professionals might use design thinking</a> as part of a broad and inclusive consultation. </p>
<p>The design thinking process builds empathy and a more nuanced understanding of how patients and their families feel, think and see their care experience. An example would be consulting directly with patients, family and care providers concerning their experiences on a palliative care unit, and implementing their ideas for bettering these experiences and improving well-being for all parties.</p>
<h2>Diversity within leadership ranks</h2>
<p>As for current system readiness, our research identified several deficiencies. There is little coordinated effort, for example, across provincial and territorial health-care systems to pursue leadership development.</p>
<p>Without a collective, shared vision for what effective health-care leadership should look like, navigating the disruptive forces at play will be quite challenging.</p>
<p>The <a href="https://www.forbes.com/sites/williamhaseltine/2018/04/02/aging-populations-will-challenge-healthcare-systems-all-over-the-world/#185fcd0a2cc3">global patient population is aging,</a> but so too is the <a href="https://www.modernhealthcare.com/article/20180505/NEWS/180509944/building-the-bench-hospitals-and-health-systems-prepare-for-boomer-retirement-wave">health-care leadership workforce</a>. Our research revealed that succession planning is not consistent, nor are selection practices for emerging health leaders.</p>
<p>The increase in <a href="https://canadianimmigrant.ca/guides/moving-to-canada/diversity-in-canada-an-overview">cultural diversity across Canada</a> must be considered in the design and administration of our future health system, given that the number of foreign-born immigrants now represent <a href="https://www12.statcan.gc.ca/nhs-enm/2011/as-sa/99-010-x/99-010-x2011001-eng.cfm.">around a fifth of the Canadian population</a>. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1118885850710888452"}"></div></p>
<p>We must also integrate the unique health-care and social needs of Indigenous populations as part of our collective responsibility towards <a href="http://www.trc.ca/">Truth and Reconciliation</a>. The health system must make culturally appropriate services more readily available. </p>
<p><a href="https://healthleadershipacademy.ca/files/2019/04/Alternative-Futures-of-Health.pdf">Many of our research participants</a> anecdotally shared that they still observe a significant lack of diversity within leadership ranks.</p>
<h2>Bold and ambitious visions</h2>
<p>Perhaps most pressing is the lack of incentives and available budgets for leaders to build bold and ambitious visions for health-care organizations.</p>
<p>Bureaucratic institutional systems leave leaders with little autonomy and encourage them to make incremental low-risk changes instead. Priority allocations go to first-line health services, often forgoing “nice to have” items such as leadership development for employees.</p>
<p>While no one can predict the future, we call for action to cultivate environments within the health system for emerging leaders to develop.</p>
<p>For our part, McMaster University’s Health Leadership Academy will use the results of this research to update and adjust our <a href="https://healthleadershipacademy.ca/education/emerging-health-leaders/emerging-health-leaders-application/">leadership development programs</a> — to better prepare leaders to navigate the disruptive forces ahead.</p>
<p>As budgets shrink, resources are constrained and patient needs sharply increase, the development of effective leaders is anything but “nice to have.” In fact, leadership development in health care has never been more important.</p><img src="https://counter.theconversation.com/content/116331/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rick Hackett does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In an era of rapid technological advance, devastating climate change, increasing inequality and a steadily aging society, health-care leadership development is vital.Rick Hackett, Canada Research Chair, Organizational Behaviour & Human Performance, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1043082018-11-12T22:10:35Z2018-11-12T22:10:35ZDementia’s hidden darkness: Violence and domestic abuse<figure><img src="https://images.theconversation.com/files/244400/original/file-20181107-74754-4c1byl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Dementia patients are often the perpetrators and often the victims of abuse. Research also shows that a medical history of head injury can more than double the risk of developing Alzheimer's disease in some populations, even after many years.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Every week in my neurology clinic, I see patients and their families who are dealing with the realities of dementia. Of the many people I encounter, these three stories highlight a growing health issue that I feel is neglected — the complex relationship between dementia and domestic violence. </p>
<p>The first is a story of confusion:</p>
<blockquote>
<p>“Dad is a nice guy, always has been. But now, because of the Alzheimer’s, he’s confused most of the time — and Mom isn’t coping. She doesn’t know what to do and she is frustrated. It started with her twisting his arm to get him to do things, but now she even hits him sometimes.”</p>
</blockquote>
<p>The second is a story of public safety: </p>
<blockquote>
<p>“The dementia has changed him — he’s not the same man I fell in love with and married so many years ago. He gets suspicious and angry a lot. He screams at me, he yells at our son, he shouts at the postman. He has even punched the caregiver who comes to help him bathe. I suppose we can cope, but I’m worried. We have two shotguns and a rifle in our basement — what do you think I should do with them?”</p>
</blockquote>
<p>The third is a scene of abuse: </p>
<blockquote>
<p>“I got divorced a long time ago because he used to hit me … a lot. He would get drunk every Saturday night and beat me up. He even knocked me out cold, probably five or six times. I haven’t seen him in more than 30 years, but I still feel that he is hurting me. Do you think all of these beatings caused my dementia? Did that bastard cause my dementia?”</p>
</blockquote>
<p>These stories are united by a common theme: the complex relationship between dementia and domestic violence. Today, both are commonplace. <a href="https://www.alz.org/media/HomeOffice/Facts%20and%20Figures/facts-and-figures.pdf">One in 10 people over 65 years of age in the United States have dementia</a>, typically Alzheimer’s disease (AD), and about one in four women and one in seven men in the U.S. <a href="https://www.cdc.gov/violenceprevention/pdf/nisvs_executive_summary-a.pdf">experience severe physical abuse by an intimate partner</a> at some point during their life. </p>
<p>Alarmingly, evidence now suggests that there may be a complex but definitive link between dementia and domestic abuse. Notably, <a href="https://doi.org/10.1159/000093894">one case-control study</a> that I carried out with colleagues shows that spousal abuse could be associated with the development of Alzheimer’s. </p>
<h2>Caregiver abuse</h2>
<p>Abuse of older people is not a new problem. Elder abuse is a growing concern on a societal level, with <a href="https://www.cbc.ca/news/canada/elder-abuse-a-growing-dilemma-in-an-aging-population-1.1050233">more seniors reporting incidents of abuse and violence</a>. The abuser may be a partner, a relative, a friend or a paid caregiver. </p>
<p>Most abuse tends to take place in the privacy and supposed safety of the home — and so it’s typically a hidden problem. Yet, anywhere between <a href="https://doi.org/10.1093/ageing/afm194">five to 20 per cent of seniors globally may be physically abused, while up to 55 per cent may be abused in other ways</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/244413/original/file-20181107-74754-w7m92u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/244413/original/file-20181107-74754-w7m92u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/244413/original/file-20181107-74754-w7m92u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/244413/original/file-20181107-74754-w7m92u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/244413/original/file-20181107-74754-w7m92u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/244413/original/file-20181107-74754-w7m92u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/244413/original/file-20181107-74754-w7m92u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Needing help with simple everyday tasks can be a huge blow to the sense of self and pride of someone dealing with dementia.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Patients with dementia are especially vulnerable to this disturbing trend. Unsurprisingly, caring for patients with dementia requires time and patience and, as with any advanced medical care, practice. </p>
<p>Dealing with dementia’s intellectual impairments can be especially challenging for unprepared caregivers and family members, and this frustration can sometimes lead to abuse.</p>
<h2>Violent mood swings</h2>
<p>Conversely, sometimes the person with dementia is the initiator of the violence rather than the recipient. The onset of dementia is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3345875/">known to coincide with the development of aggressive and angry tendencies</a>. One study found that <a href="https://www.ncbi.nlm.nih.gov/pubmed/18258723">almost 20 per cent</a> of new dementia patients have behaved aggressively towards caregivers, including loved ones they’ve known for years. </p>
<p>It’s not hard to understand why. In the early phases of the disease, patients are acutely aware of the changes happening to their memories and thoughts and regularly feel overwhelmed. As the disease progresses, they may need help dressing, bathing or performing simple everyday activities, which they have done for themselves, without help, for all of their lives. </p>
<p>This can be devastating to a person’s pride or sense of self; sometimes these emotions can manifest as unusually aggressive or hostile behaviour. Dementia can also trigger violent mood swings and outbursts. At times, these can be extreme; a patient may seem perfectly fine one moment, then be screaming and overtly physical the next. </p>
<p>As yet, it’s a mystery as to why these outbursts occur. But it is possible that changes in the brain’s neurochemistry may destabilize moods and cause more violent emotions.</p>
<h2>‘Punch drunk’</h2>
<p>Finally, there is the possibility that abuse that occurred decades ago could be contributing to the onset of dementia today. There has been much debate as to whether head trauma can lead to dementia or Alzheimer’s disease later in life. </p>
<p>Typically, associations have been vague, and it seemed unlikely that trauma from years ago, with no other apparent effects, could somehow lead to dementia. But we now appreciate that <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5221805/">head trauma can be a major risk factor for dementia and Alzheimer’s</a>. In fact, as far back as 1928, the term <a href="https://jamanetwork.com/journals/jama/article-abstract/260461">“punch drunk”</a> was introduced to describe a disorder of progressive dementia that was first seen in boxers. </p>
<p>This was later called “dementia pugilistica” and is known today as <a href="https://www.alz.org/alzheimers-dementia/what-is-dementia/related_conditions/chronic-traumatic-encephalopathy-(cte)">chronic traumatic encephalopathy (CTE)</a>. Recent research suggests that concussions and other <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5835563/">traumatic brain injuries may increase the early brain pathologies that lead to the development of Alzheimer’s later on</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/244414/original/file-20181107-74763-ttksee.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/244414/original/file-20181107-74763-ttksee.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/244414/original/file-20181107-74763-ttksee.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/244414/original/file-20181107-74763-ttksee.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/244414/original/file-20181107-74763-ttksee.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/244414/original/file-20181107-74763-ttksee.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/244414/original/file-20181107-74763-ttksee.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">‘Punch drunk’ was a term used to describe the behaviour of boxers who had suffered repeated severe blows to the head.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Also, a medical history of <a href="http://dx.doi.org/10.1136/jnnp.74.7.857">head injury can more than double the risk</a> of developing Alzheimer’s disease in some populations, even after many years.</p>
<p>With the <a href="http://apps.who.int/iris/bitstream/handle/10665/112325/WHO_RHR_14.11_eng.pdf?sequence=1">World Health Organization estimating that up to 30 per cent of women worldwide have experienced violence from an intimate partner</a>, the global burden of domestic abuse on Alzheimer’s may be a critical factor.</p>
<h2>A call to action</h2>
<p>Despite its obvious significance, this dementia and domestic violence overlap remains under-recognized and incompletely understood. It’s not a new problem, but because it tends to be conveniently ignored, it has yet to garner proper scientific scrutiny.</p>
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Read more:
<a href="https://theconversation.com/traumatic-brain-injury-the-unseen-impact-of-domestic-violence-92730">Traumatic brain injury: The unseen impact of domestic violence</a>
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<p>The growing prevalence of both dementia and domestic violence is worrisome. We need to appreciate the clear relationship between Alzheimer’s and domestic violence. </p>
<p>As science grapples with these uncomfortable questions over the years to come, stopping the spread of domestic violence seems like an obvious, and feasible first step.</p>
<p>Dementia is more than just three stories or some ambiguous science; it is a call to action.</p><img src="https://counter.theconversation.com/content/104308/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Donald Weaver does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>From aggressive patients with Alzheimer’s to frustrated caregivers, dementia is increasingly entwined with violence in private homes and residential facilities.Donald Weaver, Professor of Chemistry and Director of Krembil Research Institute, University Health Network, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/826742017-09-24T23:12:55Z2017-09-24T23:12:55ZHow healthy is the Canadian health-care system?<figure><img src="https://images.theconversation.com/files/183665/original/file-20170828-1612-bhj9um.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Our rapidly aging society will place even greater pressure on the already expensive and mediocre Canadian health-care system.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p><em>This article is part of our global series about health systems, examining different health care systems all over the world. Read the other articles in the series <a href="https://theconversation.com/au/topics/global-health-systems-series-43434">here</a>.</em></p>
<p>Canada’s health-care system is a point of Canadian pride. We hold it up as a defining national characteristic and an example of what makes us different from Americans. The system has been supported in its current form, more or less, by parties of all political stripes — for nearly 50 years.</p>
<p>Our team at the Queen’s University School of Policy Studies <em>Health Policy Council</em> is a team of seasoned and accomplished health-care leaders in health economics, clinical practice, education, research and health policy. We study, teach and comment on <a href="http://www.queensu.ca/connect/policyblog/">health policy</a> and the health-care system from multiple perspectives.</p>
<p>While highly regarded, Canada’s health-care system is expensive and faces several challenges. These challenges will only be exacerbated by the changing health landscape in an aging society. Strong leadership is needed to propel the system forward into a sustainable health future. </p>
<h2>A national health insurance model</h2>
<p>The roots of Canada’s system lie in Saskatchewan, when then-premier Tommy Douglas’s left-leaning Co-operative Commonwealth Federation (CCF) government first established a <a href="https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-care-system/canada.html">provincial health insurance program</a>. This covered universal hospital (in 1947) and then doctors’ costs (in 1962). The costs were shared 50/50 with the federal government for hospitals beginning in 1957 and for doctors in 1968. </p>
<p>This new model inspired fierce opposition from physicians and insurance groups but proved extremely popular with the people of Saskatchewan and elsewhere. Throughout the 1960s, successive provincial and territorial governments adopted the “Saskatchewan model” and in 1972 the Yukon Territory was the last sub-national jurisdiction to adopt it. </p>
<hr>
<p><em><strong>Read this article in French: <a href="https://theconversation.com/systeme-de-sante-canadien-un-bilan-en-demi-teinte-83899">Système de santé canadien : un bilan en demi-teinte</a></strong></em></p>
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<p>In 1968, the National Medical Care Insurance Act was implemented, in which the federal government agreed to contribute 50 per cent toward the cost of provincial insurance plans. In 1984 the <a href="https://lop.parl.ca/content/lop/researchpublications/944-e.htm#chistoricaltxt">Canada Health Act</a> outlawed the direct billing of patients supplementary to insurance payments to physicians.</p>
<p>The <a href="https://www.med.uottawa.ca/sim/data/Canada_Health_Act.htm">five core principles</a> of the Canadian system were now established: universality (all citizens are covered), comprehensiveness (all medically essential hospital and doctors’ services), portability (among all provinces and territories), public administration (of publicly funded insurance) and accessibility. </p>
<p>For the last 50 years, Canada’s health-care system has remained essentially unchanged despite numerous pressures.</p>
<h2>Long wait times</h2>
<p>The quality of the Canadian health-care system has been called into question, however, for several consecutive years now by the U.S.-based <a href="http://www.commonwealthfund.org">Commonwealth Fund</a>. This is a highly respected, non-partisan organization that annually ranks the health-care systems of 11 nations. Canada has finished either ninth or 10th now for several years running. </p>
<p>One challenge for Canadian health care is access. Most Canadians have timely access to world-class care for urgent and emergent problems like heart attacks, strokes and cancer care. But for many less urgent problems they typically wait as long as many months or even years. </p>
<p>Patients who require hip or knee replacements, shoulder or ankle surgery, cataract surgery or a visit with a specialist for a consultation often wait <a href="http://www.waittimealliance.ca">far longer than is recommended</a>. Many seniors who are not acutely ill also wait in hospitals for assignment to a long-term care facility, for months and, on occasion, years. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/184382/original/file-20170901-27291-139epe4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/184382/original/file-20170901-27291-139epe4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=415&fit=crop&dpr=1 600w, https://images.theconversation.com/files/184382/original/file-20170901-27291-139epe4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=415&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/184382/original/file-20170901-27291-139epe4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=415&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/184382/original/file-20170901-27291-139epe4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=521&fit=crop&dpr=1 754w, https://images.theconversation.com/files/184382/original/file-20170901-27291-139epe4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=521&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/184382/original/file-20170901-27291-139epe4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=521&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Canada ranks 9th out of 11 countries in The Commonwealth Fund ‘Mirror, Mirror 2017’ report.</span>
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<p>And it’s not just accessibility that is the problem. Against measures of effectiveness, safety, coordination, equity, efficiency and patient-centredness, the Canadian system is ranked by the Commonwealth Fund as <a href="http://www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-international-comparisons-2017">mediocre at best</a>. We have an expensive system of health care that is clearly under-performing.</p>
<h2>A landscape of chronic disease</h2>
<p>How is it that Canada has gone from a world leader to a middle- (or maybe even a bottom-) of-the-pack performer? </p>
<p>Canada and Canadians have changed, but our health-care system has not adapted. In the 1960s, health-care needs were largely for the treatment of acute disease and injuries. The hospital and doctor model was well-suited to this reality. </p>
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<img alt="" src="https://images.theconversation.com/files/183666/original/file-20170828-1542-1elm9qe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/183666/original/file-20170828-1542-1elm9qe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/183666/original/file-20170828-1542-1elm9qe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/183666/original/file-20170828-1542-1elm9qe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/183666/original/file-20170828-1542-1elm9qe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/183666/original/file-20170828-1542-1elm9qe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/183666/original/file-20170828-1542-1elm9qe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Medical care offered in homes can be more efficient and comfortable than hospital visits.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Today, however, the health-care landscape is increasingly one of chronic disease. Diabetes, dementia, heart failure, chronic lung disease and other chronic conditions characterize the health-care profiles of many Canadian seniors.</p>
<p>Hospitals are still needed, to be sure. But increasingly, the population needs community-based solutions. We need to “de-hospitalize” the system to some degree so that we can offer care to Canadians in homes or community venues. Expensive hospitals are no place for seniors with chronic diseases.</p>
<p>Another major challenge for Canadian health care is the narrow scope of services covered by provincial insurance plans. “Comprehensiveness” of coverage, in fact, applies only to physician and hospital services. For many other important services, including dental care, out-of-hospital pharmaceuticals, long-term care, physiotherapy, some homecare services and many others, coverage is provided by a mixture of private and public insurance and out-of-pocket payments beyond the reach of many low-income Canadians. </p>
<p>And this is to say nothing of the <a href="https://www.cma.ca/En/Pages/health-equity.aspx">social determinants of health</a>, like nutrition security, housing and income. None of these have ever been considered a part of the health-care “system,” even though they are just as important to Canadians’ health as doctors and hospital services are.</p>
<h2>Aging population, increasing costs</h2>
<p>Canada’s health-care system is subject to numerous pressures. </p>
<p>First of all, successive federal governments have been effectively reducing their cash contributions since the late 1970s when tax points were transferred to the provinces and territories. Many worry that if the federal share continues to decline as projected, it will become increasingly difficult to achieve national standards. The federal government may also lose the moral authority to enforce the Canada Health Act.</p>
<p>A second challenge has been the increasing cost of universal hospital insurance. As economic growth has waxed and waned over time, governments have increased their health budgets at different rates. In 2016, total spending on health amounted to approximately <a href="https://www.cihi.ca/en/nhex2016-topic1">11.1 per cent</a> of the GDP (gross domestic product); in 1975, it was about <a href="http://evidencenetwork.ca/costs-and-spending/costs1">7 per cent</a> of GDP. </p>
<p>Overall, total spending on health care in Canada <a href="http://worthwhile.typepad.com/.a/6a00d83451688169e201b7c6fd426b970b-pi">now amounts to</a> over $6,000 (US$4,790) per citizen. Compared to comparably developed countries, Canada’s health-care system is definitely <a href="https://blogs.wsj.com/economics/2013/07/23/u-s-health-spending-one-of-these-things-not-like-others/">on the expensive side</a>. </p>
<p>Canada’s aging population will apply additional pressure to the health-care system over the next few years as the Baby Boom generation enters their senior years. In 2014, for the first time in our history, there were <a href="http://www.statcan.gc.ca/daily-quotidien/150929/cg150929b004-eng.png">more seniors than children</a> in Canada.</p>
<p>The fact that more Canadians are living longer and healthier than ever before is surely a towering achievement for our society, but it presents some economic challenges. On average, <a href="http://www.andrewweavermla.ca/wp-content/uploads/2015/01/HealthSpend.jpg">it costs more</a> to provide health care for older people. </p>
<p>In addition, some provinces (the Atlantic provinces, Quebec and British Columbia in particular) are <a href="http://www.statcan.gc.ca/daily-quotidien/150929/cg150929b004-eng.png">aging faster</a> than the others. This means that these provinces, some of which face the prospects of very modest economic growth, will be even more challenged to keep up with increasing health costs in the coming years.</p>
<h2>Actions we can take now</h2>
<p>The failure of our system to adapt to Canadians’ changing needs has left us with a very expensive health-care system that delivers mediocre results. Canadians should have a health-care system that is truly worthy of their confidence and trust. There are four clear steps that could be taken to achieve this:</p>
<h2><em>1. Integration and innovation</em></h2>
<p>Health-care stakeholders in Canada still function in silos. Hospitals, primary care, social care, home care and long-term care all function as entities unto themselves. There is poor information sharing and a general failure to serve common patients in a coordinated way. Ensuring that the patient is at the centre — regardless of where or by whom they are being served — will lead to better, safer, more effective and less expensive care. Investments in information systems will be key to the success of these efforts.</p>
<h2><em>2. Enhanced accountability</em></h2>
<p>Those who serve Canadians for their health-care needs need to transition to accountability models focused on outcomes rather than outputs. Quality and effectiveness should be rewarded rather than the amount of service provided. Alignment of professional, patient and system goals ensures that everyone is pulling their oars in the same direction.</p>
<h2><em>3. Broaden the definition of comprehensiveness</em></h2>
<p>We know many factors influence the health of Canadians in addition to doctors’ care and hospitals. So why does our “universal” health-care system limit its coverage to doctors’ and hospital services? A plan that seeks health equity would distribute its public investment across a broader range of services. A push for universal pharmacare, for example, is currently under way in Canada. Better integration of health and social services would also serve to address more effectively the social determinants of health.</p>
<h2><em>4. Bold leadership</em></h2>
<p>Bold leadership from both government and the health sector is essential to bridge the gaps and break down the barriers that have entrenched the status quo. Canadians need to accept that seeking improvements and change does not mean sacrificing the noble ideals on which our system was founded. On the contrary, we must change to honour and maintain those ideals. Our leaders should not be afraid to set aspirational goals.</p><img src="https://counter.theconversation.com/content/82674/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chris Simpson is a past president of the Canadian Medical Association and has served as their spokesperson on numerous health policy issues. He is also a member of the National Speakers' Bureau and speaks on health policy issues at meetings of NGOs, associations, societies, universities, and other organizations.</span></em></p><p class="fine-print"><em><span>David M.C. Walker, Don Drummond, Duncan Sinclair, and Ruth Wilson do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Bold leadership is needed to adapt Canada’s expensive and mediocre health-care system for an aging population struggling with chronic disease.Chris Simpson, Professor of Medicine and Vice-Dean (Clinical), School of Medicine, Queen's University, OntarioDavid M.C. Walker, Stauffer-Dunning Chair and Executive Director, Queen's School of Policy Studies, Queen's University, OntarioDon Drummond, Stauffer-Dunning Fellow in Global Public Policy and Adjunct Professor at the School of Policy Studies, Queen's University, OntarioDuncan Sinclair, Professor of Health Services and Policy Research, Queen's University, OntarioRuth Wilson, Professor of Family Medicine, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.