Hall reviews Canada's health care insurance programs, not "medicare" D.A. GEEKIE
"As one of the fathers of medicare, he is obviously one of the best qualified to conduct the review." "It is ridiculous. It's like asking an architect or contractor to write a critique on his own building." "Emmett Hall has proven he is one of Canada's outstanding names for decades. His abilities, insight, administrative acumen, his social conscience and integrity, his record of performance during the past 50 years have few peers. But, at 81 years of age, is he up to such a monumental task?"
Former Supreme Court Judge EmmeLt Hall, appointed to review Canada's health insurance program, is not likely to be surprised, unduly flattered or disturbed by such comment. In many cases the words may be slightly different from those he heard in the early '60s as chairman of the royal commission that resulted in medicare, but the tune will be the same. Rumour has it that he will recognize the toll that passing years have exacted on him and conduct much of his task at his home in Saskatoon, letting the delegations come to him. No doubt the eminent gentleman will face problems while completing his review but limited time - 6 months - is not likely to be one of them. He will work hard, guided by his interpretation of the terms of reference and without undue attention to the calendar or the bureaucrats. If anyone has any doubt regarding his being his own man we respectfully refer them to his report on Canada's railway operations.
Mr. Hall may deny any paternal responsibility for medicare, but there is no doubt that he was one of the chief architects of its current structure. It is important to remember that the blueprints that his royal commission submitted for government financed and operated medical care insurance were largely a redesign of the prepaid voluntary program that already existed, and that medical care insurance was built on top of the hospital insurance infrastructure. Hall's current assignment does not ask him to review medical care
insurance or medicare as it is perceived by the public, politicians and government in 1979, but Canada's health care insurance programs. Mr. Hall will be asked to review medicare "as it ought to be in the not too distant future". For the majority of the population that means full access to all aspects of quality health service. Also important is that while Mr. Hall may have been the architect, his original plans were altered from province to province and they have been subjected to almost continual revision. In some provinces he may have difficulty recognizing the appendages to, or even the basis of, his original plans. Under the circumstances it might be wise for all concerned, to reread
1266 CMA JOURNAL/NOVEMBER 3, 1979/VOL. 121
the Hall Royal Commission Report on Health Services. Minister of National Health and Welfare David Crombie picked two quotations of note from the report. The first outlined the primary objectives of the commission: As we examined the hundreds of briefs with their thousands of recommendations we were impressed with the fact that the field of health services illustrates, perhaps better than any other, the paradox of our age, which is, of course, the enormous gap between our scientific knowledge and skills on the one hand, and our organizational and financial arrangements to apply them to the needs of people, on the other. What the Commission recommends is that in Canada this gap be closed, that as a nation we now take the necessary legislative, organizational and financial decisions to make all the fruits of the health sciences available to all our residents without hindrance of any kind. The second was described by Mr. Crombie as the commission s "Health Charter for Canadians": The achievement of the highest possible health standards for all our people must become a primary objective of national policy and a cohesive factor contributing to national unity, involving individual and community responsibilities and actions. This objective can best be achieved through a comprehensive, universal Health Services Programme for the Canadian people IMPLEMENTED in accordance with Canada's evolving constitutional arrangements; BASED upon freedom of choice and upon free and self-governing professions; continued on page 1303
OTTAWA FILE continued from page 1266 Brief Prescribing Information
Adverse [email protected] The following adverse reactions have been reported with ANAFRANIL or other tricyclic antidepressants: Central Nervous System Effects: drowsiness, fatigue, insomnia, extra-pyramidal effects such as tremor Antidepressant and ataxia. headache, anorexia and convulsions. IndIcations and Clinical Uses Peripheral neuropathy has also been reported with ANAFRANIL (clomipramine hydrochloride) is mditricyclic cornpounds. cated in the drug treatment of depressive illness, Behavioural Effects: agitation, excitement, hypomania including manic depressive psychosis, depressed or manic episodes, activation of psychosis, confusion, phase, and involutional melancholia. ANAFRANIL disturbed concentration, visual hallucinations. appears to have a mild sedative effect which may be Autonomic Nervous System Effects: dr,r mouth, helpful in alleviating the anxiety component often blurred vision, difficulty with accommodation, accompanying depression. ANAFRANIL also appears constipation, paralytic ileus, disturbances of micturito be of some value as an adjunct in the management tion, excessive sweating, nausea and vomiting. of manifestations of agitated depression which some- Cardiovascular Effects: hypotension, particularly times exacerbate obsessive-compulsive neurosis. orthostatic hypotension with associated vertigo, Contralndlcations tachycardia, syncope, arrhythmia, asystole, EKO ANAFRANIL should not be given in conjunction with changes (including flattening or inversion of T wave) or within fourteen days of treatment with a monoand disturbances in cardiac conduction. amine oxidase inhibitor. Combined therapy of this Haematological and Other 2bxic Effects: agranulotype could lead to the appearance of serious hypercytosis has been reported; it represents a hypertensive crises and death may occur sensitivity reaction. Eosinophilla may also occur. ANAFRANIL is contraindicated in patients with Obstructive jaundice, allergic skin reactions, photoexisting liver damage and should not be administered sensitization, occasional disturbances of appetite, to patients with a history of blood dyscrasias. abdominal pain, changes in libido, and weight gain. ANAFRANIL is contraindicated in patients who have Dosage sad Adinlaistrati@a shown hypersensitivity to the drug. Except in Elderly Patients and Adolescents: 25 mg ANAFRANIL is contraindicated in patients with 3 times daily initially, increase up to 150 mg daily, glaucoma, as the condition may be aggravated due or more, as required. to the atropine-like effects of the drug. Dosage in excess of 200 mg daily is not usually Use in Pregnancy: recommended for office patients. Occasionally in The safety of use in pre.ant women has not been more severe hospitalized patients, dosages up to established. Therefore, . should not be 300mg may be required. administered to women of childbearing potential, In Elderly Patients and Adolescents: 20 to 30 mg daily, particularly during the first trimester of pregnancy, increased by 10 mg daily, if necessary, .epending unless, in the opinion of the physician, the expected on tolerance and response. benefit to the patient outweighs the potential risk Availability to the fetus. ANAFRANIL is available as a: Warnings 1. Sugar-coated 10 mg pale yellow triangular tablet The following warnings apply to ANAFRANIL and with the GEIGY monogram printed in brown ink other tricycic antidepressant agents: on one side and identification code DK on the Tricycic agents may lower the convulsive threshold other side. and should, therefore, be used with caution in Sugar-coated 25 mg pale yellow round tablet with 2. patients with convulsive disorders. the Geigy logo printed in brown ink on one side. Electrocardiographic studies suggest that Bottles of 50 and 500 tablets. Protect from heat and ANAFRANIL should not be used in the presence of moisture. pronounced cardiac or circulatory failure, recent Product monograph supplied on request. myocardial infarction or ischaemic heart disease. ANAFRANIL also has a hypotensive action which may be detrimental in these circumstances. The drug should, therefore, be used with caution in References: patients who are susceptible to hypotensive episodes. 1. Rompel, H.: Med. Proc. P. 26fi31-636, Dec. 23,1967. Z McMillin, W.P.: J. hit. Med. Res., 3, (SuppL 1) 36-46,1975. Thcycic agents may produce urinary retention and should be used with caution in patients with urinary pathology, particularly in the presence of prostatic hypertrophy. Particularly in the elderly and in hospitalized patients the tricycic antidepressants may give rise to paralytic ileus and therefore appropriate measures should be taken if constipation occurs. ANAFRANIL should be kept in a safe place, well out of the reach of children. Precautions In seriously depressed patients the possibility of sulcide should be borne in mind and may persist until significant remission occurs. Therefore, these patients should be carefully supervised during treatment with ANAFRANU.% and hospitalization or concomitant electro-convulsive therapy may be required. Activation of latent schizophrenia or aggravation of existing psychotic manifestations in schizophrenic patients may occur; patients with manic-depressive tendencies may experience hypomanic or manic shifts; and hyperactive or agitated patients may become over-stimulated. A reduction in dose or discontinuation of ANAFRANIL should be considered under these circumstances. Since ANAFRANIL may produce sedation, particularly during the initial phase of therapy, patients should be cautioned about the danger of engaging in activities requiring mental alertness, judgment and physical coordination. It should be borne in mind that ANAFRANIL may block the pharmacological effects of hypotensive drugs, such as guanethidme and similar agents. Caution should be observed in prescribing ANAFRANIL in hyperthyroid patients or in patients receiving thyroid medication conjointly. Transient cardiac arrhythmias have occurred in rare instances in patients who have been receiving other tricycic compounds concomitantly with thyroid medication. Obstructive jaundice and bone marrow depression with agranulocytosis have been reported. Periodic blood cell counts and liver function tests are recommended in patients receiving treatment with Dorval, Quebec ANAFRANIL over prolonged periods. H9S1B1 G-9003
Anafranfl®
[.J Geigy
FINANCED through prepayment arrangements; ACCOMPLISHED through the full cooperation of the general public, the health professions, voluntarj agencies, all political parties and governments, federal, provincial and municipal; DIRECTED towards the most effective use of the nation's health resources to attain the highest possible levels of physical and mental wellbeing. While the detailed terms of reference and method of operation of the Hall review were not finalized at the time this report was prepared, Mr. Hall will be asked to: * consider the current status of public health insurance programs in Canada; e consider the extent to which the goals set forth in the "Charter of Health for Canadians" proposed by the Royal Commission on Health Services is being achieved; * examine the extent to which the principles of portability, reasonable access, universal coverage, comprehensive coverage, public administration, reasonable compensation and uniform terms and conditions are being achieved; * consider the nature and extent of necessary revisions to the federal Hospital Insurance and Diagnostic Services Act and the Medical Care Act and related legislation; * consider other means by which public authorities may best comply with the principles referred to above. Mr. Hall has been requested to: * examine and review available data; * consult with federal and provincial ministers of health and social services and their officials; * consult with health professionals, consumers' and health institutions; * consult with associations representing consumers, health professionals and institutions; * consult more broadly as nec-
essary.E
CMA JOURNAL/NOVEMBER 3, 1979/VOL. 121
1303
"As one of the fathers of medicare, he is obviously one of the best qualified to conduct the review." "It is ridiculous. It's like asking an architect or contractor to write a critique on his own building." "Emmett Hall has proven he is one of Canada's outstanding names for decades. His abilities, insight, administrative acumen, his social conscience and integrity, his record of performance during the past 50 years have few peers. But, at 81 years of age, is he up to such a monumental task?"
Former Supreme Court Judge EmmeLt Hall, appointed to review Canada's health insurance program, is not likely to be surprised, unduly flattered or disturbed by such comment. In many cases the words may be slightly different from those he heard in the early '60s as chairman of the royal commission that resulted in medicare, but the tune will be the same. Rumour has it that he will recognize the toll that passing years have exacted on him and conduct much of his task at his home in Saskatoon, letting the delegations come to him. No doubt the eminent gentleman will face problems while completing his review but limited time - 6 months - is not likely to be one of them. He will work hard, guided by his interpretation of the terms of reference and without undue attention to the calendar or the bureaucrats. If anyone has any doubt regarding his being his own man we respectfully refer them to his report on Canada's railway operations.
Mr. Hall may deny any paternal responsibility for medicare, but there is no doubt that he was one of the chief architects of its current structure. It is important to remember that the blueprints that his royal commission submitted for government financed and operated medical care insurance were largely a redesign of the prepaid voluntary program that already existed, and that medical care insurance was built on top of the hospital insurance infrastructure. Hall's current assignment does not ask him to review medical care
insurance or medicare as it is perceived by the public, politicians and government in 1979, but Canada's health care insurance programs. Mr. Hall will be asked to review medicare "as it ought to be in the not too distant future". For the majority of the population that means full access to all aspects of quality health service. Also important is that while Mr. Hall may have been the architect, his original plans were altered from province to province and they have been subjected to almost continual revision. In some provinces he may have difficulty recognizing the appendages to, or even the basis of, his original plans. Under the circumstances it might be wise for all concerned, to reread
1266 CMA JOURNAL/NOVEMBER 3, 1979/VOL. 121
the Hall Royal Commission Report on Health Services. Minister of National Health and Welfare David Crombie picked two quotations of note from the report. The first outlined the primary objectives of the commission: As we examined the hundreds of briefs with their thousands of recommendations we were impressed with the fact that the field of health services illustrates, perhaps better than any other, the paradox of our age, which is, of course, the enormous gap between our scientific knowledge and skills on the one hand, and our organizational and financial arrangements to apply them to the needs of people, on the other. What the Commission recommends is that in Canada this gap be closed, that as a nation we now take the necessary legislative, organizational and financial decisions to make all the fruits of the health sciences available to all our residents without hindrance of any kind. The second was described by Mr. Crombie as the commission s "Health Charter for Canadians": The achievement of the highest possible health standards for all our people must become a primary objective of national policy and a cohesive factor contributing to national unity, involving individual and community responsibilities and actions. This objective can best be achieved through a comprehensive, universal Health Services Programme for the Canadian people IMPLEMENTED in accordance with Canada's evolving constitutional arrangements; BASED upon freedom of choice and upon free and self-governing professions; continued on page 1303
OTTAWA FILE continued from page 1266 Brief Prescribing Information
Adverse [email protected] The following adverse reactions have been reported with ANAFRANIL or other tricyclic antidepressants: Central Nervous System Effects: drowsiness, fatigue, insomnia, extra-pyramidal effects such as tremor Antidepressant and ataxia. headache, anorexia and convulsions. IndIcations and Clinical Uses Peripheral neuropathy has also been reported with ANAFRANIL (clomipramine hydrochloride) is mditricyclic cornpounds. cated in the drug treatment of depressive illness, Behavioural Effects: agitation, excitement, hypomania including manic depressive psychosis, depressed or manic episodes, activation of psychosis, confusion, phase, and involutional melancholia. ANAFRANIL disturbed concentration, visual hallucinations. appears to have a mild sedative effect which may be Autonomic Nervous System Effects: dr,r mouth, helpful in alleviating the anxiety component often blurred vision, difficulty with accommodation, accompanying depression. ANAFRANIL also appears constipation, paralytic ileus, disturbances of micturito be of some value as an adjunct in the management tion, excessive sweating, nausea and vomiting. of manifestations of agitated depression which some- Cardiovascular Effects: hypotension, particularly times exacerbate obsessive-compulsive neurosis. orthostatic hypotension with associated vertigo, Contralndlcations tachycardia, syncope, arrhythmia, asystole, EKO ANAFRANIL should not be given in conjunction with changes (including flattening or inversion of T wave) or within fourteen days of treatment with a monoand disturbances in cardiac conduction. amine oxidase inhibitor. Combined therapy of this Haematological and Other 2bxic Effects: agranulotype could lead to the appearance of serious hypercytosis has been reported; it represents a hypertensive crises and death may occur sensitivity reaction. Eosinophilla may also occur. ANAFRANIL is contraindicated in patients with Obstructive jaundice, allergic skin reactions, photoexisting liver damage and should not be administered sensitization, occasional disturbances of appetite, to patients with a history of blood dyscrasias. abdominal pain, changes in libido, and weight gain. ANAFRANIL is contraindicated in patients who have Dosage sad Adinlaistrati@a shown hypersensitivity to the drug. Except in Elderly Patients and Adolescents: 25 mg ANAFRANIL is contraindicated in patients with 3 times daily initially, increase up to 150 mg daily, glaucoma, as the condition may be aggravated due or more, as required. to the atropine-like effects of the drug. Dosage in excess of 200 mg daily is not usually Use in Pregnancy: recommended for office patients. Occasionally in The safety of use in pre.ant women has not been more severe hospitalized patients, dosages up to established. Therefore, . should not be 300mg may be required. administered to women of childbearing potential, In Elderly Patients and Adolescents: 20 to 30 mg daily, particularly during the first trimester of pregnancy, increased by 10 mg daily, if necessary, .epending unless, in the opinion of the physician, the expected on tolerance and response. benefit to the patient outweighs the potential risk Availability to the fetus. ANAFRANIL is available as a: Warnings 1. Sugar-coated 10 mg pale yellow triangular tablet The following warnings apply to ANAFRANIL and with the GEIGY monogram printed in brown ink other tricycic antidepressant agents: on one side and identification code DK on the Tricycic agents may lower the convulsive threshold other side. and should, therefore, be used with caution in Sugar-coated 25 mg pale yellow round tablet with 2. patients with convulsive disorders. the Geigy logo printed in brown ink on one side. Electrocardiographic studies suggest that Bottles of 50 and 500 tablets. Protect from heat and ANAFRANIL should not be used in the presence of moisture. pronounced cardiac or circulatory failure, recent Product monograph supplied on request. myocardial infarction or ischaemic heart disease. ANAFRANIL also has a hypotensive action which may be detrimental in these circumstances. The drug should, therefore, be used with caution in References: patients who are susceptible to hypotensive episodes. 1. Rompel, H.: Med. Proc. P. 26fi31-636, Dec. 23,1967. Z McMillin, W.P.: J. hit. Med. Res., 3, (SuppL 1) 36-46,1975. Thcycic agents may produce urinary retention and should be used with caution in patients with urinary pathology, particularly in the presence of prostatic hypertrophy. Particularly in the elderly and in hospitalized patients the tricycic antidepressants may give rise to paralytic ileus and therefore appropriate measures should be taken if constipation occurs. ANAFRANIL should be kept in a safe place, well out of the reach of children. Precautions In seriously depressed patients the possibility of sulcide should be borne in mind and may persist until significant remission occurs. Therefore, these patients should be carefully supervised during treatment with ANAFRANU.% and hospitalization or concomitant electro-convulsive therapy may be required. Activation of latent schizophrenia or aggravation of existing psychotic manifestations in schizophrenic patients may occur; patients with manic-depressive tendencies may experience hypomanic or manic shifts; and hyperactive or agitated patients may become over-stimulated. A reduction in dose or discontinuation of ANAFRANIL should be considered under these circumstances. Since ANAFRANIL may produce sedation, particularly during the initial phase of therapy, patients should be cautioned about the danger of engaging in activities requiring mental alertness, judgment and physical coordination. It should be borne in mind that ANAFRANIL may block the pharmacological effects of hypotensive drugs, such as guanethidme and similar agents. Caution should be observed in prescribing ANAFRANIL in hyperthyroid patients or in patients receiving thyroid medication conjointly. Transient cardiac arrhythmias have occurred in rare instances in patients who have been receiving other tricycic compounds concomitantly with thyroid medication. Obstructive jaundice and bone marrow depression with agranulocytosis have been reported. Periodic blood cell counts and liver function tests are recommended in patients receiving treatment with Dorval, Quebec ANAFRANIL over prolonged periods. H9S1B1 G-9003
Anafranfl®
[.J Geigy
FINANCED through prepayment arrangements; ACCOMPLISHED through the full cooperation of the general public, the health professions, voluntarj agencies, all political parties and governments, federal, provincial and municipal; DIRECTED towards the most effective use of the nation's health resources to attain the highest possible levels of physical and mental wellbeing. While the detailed terms of reference and method of operation of the Hall review were not finalized at the time this report was prepared, Mr. Hall will be asked to: * consider the current status of public health insurance programs in Canada; e consider the extent to which the goals set forth in the "Charter of Health for Canadians" proposed by the Royal Commission on Health Services is being achieved; * examine the extent to which the principles of portability, reasonable access, universal coverage, comprehensive coverage, public administration, reasonable compensation and uniform terms and conditions are being achieved; * consider the nature and extent of necessary revisions to the federal Hospital Insurance and Diagnostic Services Act and the Medical Care Act and related legislation; * consider other means by which public authorities may best comply with the principles referred to above. Mr. Hall has been requested to: * examine and review available data; * consult with federal and provincial ministers of health and social services and their officials; * consult with health professionals, consumers' and health institutions; * consult with associations representing consumers, health professionals and institutions; * consult more broadly as nec-
essary.E
CMA JOURNAL/NOVEMBER 3, 1979/VOL. 121
1303
