Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology

Issue 20 - Evidence

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 11:04 a.m. to examine the state of the health care system in Canada.

Senator Marjory LeBreton (Deputy Chairman) in the Chair.

[English]

The Deputy Chairman: Honourable senators, our witness this morning is Mr. Graham Scott, who is known to many of us in many capacities, myself included. I once worked for him in the office of the Honourable Robert Stanfield. Mr. Scott is here today to speak to us on our study of the health care system in Canada. He is speaking to us from his experience as a former provincial deputy minister of health.

Mr. Scott, please proceed.

Mr. Graham Scott, Former Deputy Minister of Health, Province of Ontario: Thank you, honourable senators. I am honoured to have the opportunity to share with you some of my thoughts with regard to the status of health care in Canada. I have had the privilege of reading some of the testimony to your committee by some distinguished guests and I wish to endorse every single word in the opening statement of Mr. Tom Kent. I thought it was thoughtful and straightforward. The subject matter that he covered reflected most of my views.

Obviously, a great deal has occurred since I submitted my presentation in June. That said, I do not think most of the presentation has been meaningfully altered by those events. My experience in both the federal and provincial jurisdictions tells me that both jurisdictions definitely have a legitimate role to play in health care policy, and it is essential that they work effectively together.

I do not wish to address the political wins and losses arising from the federal-provincial agreement this month, but it is worthwhile to consider what impact that agreement has on the road to finding a solution to the principal problems confronting health care in Canada. The agreement will provide the provinces with much-needed cash to address a build-up of problems over the last half of the previous decade. My fear, however, is that the money will flow to immediate political pressure points in the system and not address the longer term problems required to fully rebuild public confidence and ensure that the system is focused on its goals. To better understand that, one need only look at the media today and note that substantial pressure has already arisen from providers, demanding that they get immediate attention as a result of this transfer of cash.

The providers themselves are quite capable of swallowing up all that money overnight if caution is not utilized. In my most optimistic moments, my scenario is that the provinces will at least use some of the money to grease the skids on reforms to improve the system in areas such as technology and alternate payment plans. I do not believe, however, the agreement will do anything to improve the state of federal-provincial relations except to introduce a quieter period for a short time. I believe the only answer is to tie the federal government and the provinces together in their commitment so that they share a common interest in the system's success and can agree to advance some reforms together. If the federal commitment was tied to system costs and performance as suggested by Mr. Kent, then it is possible that they would have enough in common to work together on reforms. Until there is a mutual incentive to solve problems, the most difficult ones will not be addressed.

The most crucial issue at the moment in the health care system, of which the public is not fully aware, is the shortage of human resources and professional human resources within the health care system. All the money in the world cannot produce doctors in one, two or three years and cannot produce more nurses in one, two or three years and cannot produce radiation technology to deal with the problem. I predict that the provinces will find themselves in a great deal of difficulty, money notwithstanding, in very short order.

Money will support current systems, but one must bear in mind that many of the current systems do not work well. In reinforcing, for example, some of the existing professional payment systems, they may stifle reform.

The challenge that lies ahead is to avoid the apparently simple solutions that some propose, which would make matters considerably worse. I wish you well in developing a report that will address the debate and, hopefully, bring it toward a constructive solution.

Senator Robertson: Thank you for coming here this morning, Mr. Scott. I have been looking forward to your presentation. I read over your printed comments a few times. In your overview of the last agreement between the federal and provincial governments, you suggested that money will support the current system. I suggest to you that this is not correct. It is the small provinces that really get hit. In my province, the last financial agreement gives us funds for two weeks of health care and that is all. The rest of the time it is a downhill run. We are nervous about that. The other small provinces are in the same position. We do not have the money to change the system. What comes first? We must change the system, but we must have money to keep operating and money to change the system. It will be a difficult time, in particular, for the smaller provinces. It will be a disaster for the small provinces.

I wrote a few notes during your presentation. I agree with you about the family physicians. On page 7 you speak to the issue of family physicians moving to office practice and the momentum to move fees away from hospital practice to office practices. You note how this growing tendency has negatively influenced hospital operations, both urban and rural. You argue that this tendency has further threatened the quality of primary care medicine by separating many family physicians from the learning environment found in the hospital setting.

One could not disagree with what you say. However, I should like to know your recommendation to solve that problem given a large body of thought that believes there should only be rooms in the hospital for those who are extremely ill and whose lives are in danger of an invasive process. These people believe that everything else should be done in the community or in the workplace, which keeps the family practitioner out there.

Do you have a solution to that problem that we all recognize? The reality is that our hospitals, as we know them, will increasingly have room for specialists.

Mr. Scott: You could look at the problem on two levels. In the urban centres with the teaching hospitals, and particularly those that do more complex secondary and tertiary care, it is quite true that most of the physicians working permanently in the hospital will be specialists. I do not think that this would prevent affiliation arrangements between family doctors and the hospital. Some of the teaching hospitals and larger community hospitals in the cities do have a family practice unit, and sometimes quite a large family practice unit, that can coordinate with a speciality care service that is provided.

The current problem is not just a question of privileges in the hospital. I do not think that full privileges are needed. There needs to be a relationship, a confidence, that exists between the practitioners in the field and the hospital. Some relationship is necessary. I think that is one way.

The situation is most serious in the smaller communities, those with a population of 10,000 to 15,000. In the urban growth areas like southern Ontario, a number of doctors will no longer have anything to do with the hospital, period. They do not maintain a relationship or a regular knowledge of what is happening at the hospital because they believe that the time they spend at the hospital costs them money. In those circumstances, hospitals are becoming more and more understaffed and the family doctors who are voluntarily working in those hospitals are coming under more and more pressure. Therefore, service is getting worse.

In under-serviced areas, the situation is exacerbated even further. With the doctor shortage, perhaps one in four or one in five doctors who are now standing on call are questioning why they need to stand on call anymore. They believe that they could go into practice in another community, not stand on call, and roll things through on a fee-for-service basis. That threatens the entire system.

I will make a final point, which is one that bothers me and many miss, regarding family doctors practising on their own without consulting with their colleagues in a hospital setting. In the northern under-serviced areas, doctors do consult because they must consult each other due to the nature of the problems that they face. However, it is worse in the cities because doctors are becoming more and more the victims of scripts from pharmaceutical companies and others. These companies are telling physicians how to practise medicine because they are not interacting with their colleagues. If you do not interact with your colleagues, you cannot maintain your skills over a period of time.

Senator Robertson: I appreciate that the pressure is always financial and that the family practitioner is encouraged to keep his or her patients who require family medicine. I do not know the current costs; years ago we had a firm figure. It cost seven and one-half times more for the patient to go to the outpatient section of a hospital rather than the family doctor's office. The difference in cost causes concern.

I agree that there must be communication. There must be an opportunity for absorbing knowledge. However, I am not sure that most hospitals, even in the small communities, will be there much longer. Their services really can be done elsewhere in the community. Treating people in the hospital is the most expensive approach. People can be treated other than through the hospital.

People do not need to go to hospital to receive treatment. Most of the family physicians and many of the specialists are of this opinion. Patients can be treated outside of the hospital. We want to end this "hotel hospital" impression.

In Atlantic Canada, you could walk through a hospital on any day and see that 30 per cent or 40 per cent of the patients occupying beds could be treated elsewhere. We must change that.

This begs the following question: What should the doctors do? How do they join with their specialist colleagues to maintain their motivation to improve and not run their practice based on the information that the drug peddlers leave at the door?

Mr. Scott: I would add that there are different ways of doing this. One way is for the hospital to establish a group practice in conjunction with the hospital operations. Many of the "non-emergency" emergency visitors could be streamed through that system.

Another way is to have good community practices, with good affiliation arrangements with the hospital. That approach would cover the educational side as well. However, that requires an alternate funding program. When that type of arrangement is in place, there is a notable difference.

From my experience in northern and rural Ontario, I would rather attend one of their overly stressed family doctors than a doctor in Scarborough or Mississauga in a sole practice. The doctors in the remote area work well together. They realize that their patients do not want to travel 250 miles because the local doctor may have never seen a certain mould before. Therefore, the rural doctors go to an extra level to learn things. We do not do enough as a system to support physicians, particularly from academic health science centres.

I am totally convinced that fee for service should not be abolished.I believe that the answer lies in solid group practice arrangements.

Senator Michael Kirby (Chairman) in the Chair.

The Chairman: Mr. Scott, I apologize for being late.

Senator Keon: I came back to Canada when medicare came into force and have had a glorious life practising in this system. It is ideal for a doctor; there is no question about that. I had the great pleasure of working for a salary and was never concerned about what I made in a given day. My decisions were divorced from that kind of stress.

However, when I was young, I said over and over again at the Medical Research Council and everywhere else I pontificated that Canada needs a surgeon general who will report once each year on the state of the health of our nation -- where the gaps are, what we are doing wrong, and where we must correct things -- so that our aboriginal peoples and these "pockets" of terrible health services can be quickly responded to and corrected. I learned that this will never happen in the Canadian mosaic because it is politically unacceptable.

In talking with our chairman when the idea was spawned for this committee, I asked if he thought we would ever reach the stage where we could provide an annual report on the health of the nation -- its strengths and weaknesses and where the problems are -- and if that would ever be politically acceptable. I am not sure if he answered me; I think he is too smart for that. However, I would appreciate a response to that question if you would care to stick your neck out.

Mr. Scott: My answer to that is actually positive because I am a great believer in annual reports. For example, I believe that government agencies -- the independent ones -- should put out a report on the state of their organization. There should be an expectation around it. In this case, I believe it would be useful and might help to some degree, but I do not know that it would specifically help federal-provincial relations because both the federal government and the provinces could take their own angle on the reports and continue the war.

I think there would be some value, but I do not think that it would go to the root of solving federal-provincial issues, unless it was in conjunction with something else.

Senator Keon: I agree with the issues that you and Senator Robertson addressed. One of the hopes for a solution to the integration of our resources, in a reasonable way, lies in the electronic world. If we can reach the point where a patient gets one electrocardiogram each year instead of 10 or one X-ray per year instead of 10, and if we can reach the point where we have a good electronic record that the patient owns and that follows the patient, it would help to deal with the privacy issues. I think that many of the problems we have had in trying to integrate primary care into secondary, tertiary and quaternary care would disappear. Would you comment on that? I spent a great deal of time with the various agencies, as well as the minister's committee, trying to get the health highway up and running. Bureaucratic stalls should not be a part of it.

Mr. Scott: I am a big booster of health information technology, but the state of health information is so bad that it is difficult to make an intelligent decision. When people debate that we cannot afford this system any longer, they may indeed be right, if they are projecting into the future the way this system currently operates.

My argument is that before we throw away the principles in this system, we should first be sure we are running the system properly and efficiently; but, we cannot do that because of our appalling lack of knowledge. For example, 16 years ago, when I was deputy minister, we regularly put submissions before cabinet requesting upgrades to the computer system. Each year, the bill became demonstrably bigger and each year the cabinet said, "Next year." In Ontario, we have experienced governments of all political stripes since that time and not one of them has modernized that system. As a consequence, while the system still adequately pays physicians, tonnes of information are collected that the government does not know what to do with. Ontario is not unique in these circumstances.

Until we have an electronic patient record, for example, and exchange information effectively, we will not have many efficiencies in the system. I predict that it will be a miracle if any of the money in this federal-provincial agreement leaks into any kind of coordinated information technology.

The Chairman: That last comment is fairly disconcerting.

Senator Kennedy: A branch of my own family, living in Orangeville, Ontario, has personally experienced the shortage of family physicians. To find a family physician for a growing family, you need to know someone who knows a doctor. Doctors are so overworked and so few in number that you might not find a family physician otherwise. If that situation exists in many other communities, it is no wonder the emergency departments are overflowing -- people may not have any alternatives.

How do we medically accredit people with medical experience who come from other countries? The other day I listened to an interview with a doctor who came from another country five years ago. He is still not accredited in Canada. I do not know if there is a large pool of such doctors, but if there are people who have qualifications from elsewhere, perhaps it should not take so long to bring them up to our standards and methods. Do we deal with that issue or do we adopt almost a closed-door policy?

Mr. Scott: It is a pretty thorny question, and I will not pretend to be particularly knowledgeable about it. In the large urban areas we have a large number of physicians who were fully qualified in their native countries before coming to Canada. They run up against the standards that are established and applied to many of the Western countries, but not all of them. Canadian standards are not exactly Canadian -- they are also American and British -- so it is relatively easy to adjust between those.

I do not know how much of it is an adherence to standards and how much is protectionism. I would have thought that protectionism was much less than it was.

There is another problem. Assuming that the assessment is performed by a royal college, or equivalent, and a doctor from country X requires one year or one and one-half years to upgrade, where will the doctor get that upgrading? The inflexibilities of the academic health sciences centres are fairly serious at the moment. In the small rural communities and the under-serviced areas, we find that the doctors tend to develop a special interest, or special knowledge, or even a certificate in some area. One of the doctors may prefer to take an interest in obstetrics and prefer to do most of the births in the community. The other doctors may agree, provided there is an appropriate arrangement. Others will say that they would like to do more surgery.

There are upgrading programs available, but it is difficult to get a spot anywhere. That is a big problem in the medical schools, as well. It is not just a question of upgrading, but rather how and where the upgrading is to be done.

Senator Banks: I am from Alberta, and I am sure you are aware of some of the provincial government attitudes with respect to addressing these problems. I will ask you to comment on these attitudes and the likelihood that privatizing the provision of some services might be a way to improve the system, but I will ask you a larger question first.

The system, which everyone is trying to save, maintain, or improve, is almost mythical, one in which all Canadians have equal access to publicly provided health care. In the largest sense, and in your experience, can we afford such a system? Can we actually have this "thing" to which we would all aspire? Can we afford a universal public health system that covers all of the services that most of us think about? Are we after an impossible goal?

Mr. Scott: I do not believe that we are after an impossible goal. I believe that we can afford it -- we have been able to afford it. When I look at the system today, I see duplication and waste. I am talking about a family physician who sees 50 patients each day -- that is waste. In order to see that many patients in one day, many will be seen and referred to a specialist, when the family physician probably could have handled the matter, but not in an optimum way in relation to the fee schedule.

The standard complaint concerns repeated or duplicated treatment, such as everyone's comment about how often they have had their blood taken for the same reason. This references Dr. Keon's comment that there is no proper transfer of information, so treatment is repeated. These problems have long since been solved in industry through technology. This middle-level technology does not exist in the health care area.

Can I give you a guarantee that we can afford universal health care with full accessibility? I cannot give you that guarantee. When I look at the system and the way it currently operates, I do not believe that you ever receive savings from the system -- the money requirement never comes down. It will take a fair amount of political courage at the federal and provincial levels to let that happen. It is more of a pragmatic political question.

In a practice sense, I believe the system is quite sustainable, but some of the political decisions that must be made are difficult. If $100 million is spent to upgrade the OHIP system in Ontario, that does not cure one patient in the short term. However, if there is an announcement expanding the emergency wings in six community hospitals in southwestern Ontario, that is worth many seats. That is where the trade-off is, as far as I am concerned.

Senator Banks: We are being softened up in our part of the world to accept that we will have a health system, but services and provisions will be carved out of it. The health system, to the extent that it remains universal and accessible, will offer fewer kinds of treatment. Is that not necessary if the political will can be found to make the systemic changes that must be made?

Mr. Scott: Some adjustments like that are probably worthwhile. There are old procedures and practices that we probably should not be paying for any more. Some people will argue that much of the cosmetic surgery, for example, should not be paid for any longer and should not be a priority. While there is room for reform in that area, that is not the place to start. No one should expect that reform will yield anything like the kind of results that I believe we want to accomplish within the system.

I draw a distinction between private health care and the involvement of the private sector in health care. Close to 40 per cent of our private health care money now goes to private sector delivery systems. Thus, I am not opposed to the private sector being more involved in health care, but the policy control must remain at the public level, not in the hands of the private deliverers.

The Chairman: Mr. Scott, in response to Senator Banks, you said two or three times that the system is sustainable provided the political will exists to address the difficult questions. The illustrative example you used was putting money into an electronic information system rather than into emergency room development. Can you give us a few other examples of what you would call the really tough political questions that need to be answered?

Mr. Scott: I think the biggest problems occur when dealing with providers and changing the environment around which these providers work. I talked about alternative funding plans.

The Chairman: When you say "providers," is that a code word for physicians?

Mr. Scott: It is broader than that -- it encompasses nurses and other paramedical personnel as well.

We have working groups in place in a number of the teaching hospitals and in a few of the large community hospitals. Instead of the traditional hierarchy where the physician was in charge, the physician is now part of a team that involves nurses, technicians, and so on. The different teams do different work, which improves the environment considerably.

There is enormous opposition to the broadening of that kind of exercise, which begins to manifest itself even when we get into alternate payment plan, or APPs. It seems to me that to have a good community alternate payment plan -- an ultimate funding mechanism -- we ought not to be providing just for the doctors but also for the nurses in all professional categories. There is still much institutional opposition to that idea. In fact, it is not unusual for the government to suggest that it is unwilling to take that plan on when it has so many other related issues that require solutions, such as negotiating current fee schedules or remuneration structures.

The Chairman: In essence, your concern is that when there is a crisis, we will deal with it and not worry about taking steps toward a long-term solution that might help to avoid a future recurrence of that crisis.

Mr. Scott: Yes. That is why I felt that while it is a simple answer, it is a difficult solution to implement. The reason is that if a province were to spend that money on information technology with no immediate payback and, as a result, the public were to become upset by this, would a federal government defend the provincial government's spending actions or would they simply say, "We gave them the money and they should be able to manage it effectively to solve the problem"? Some sense of joint accountability must be achieved or those problems will not be eliminated, especially on the eve of an election.

The Chairman: Politics is the art of shifting the blame, and if you can leave everyone with someone else to whom they can shift it or shift it into some other form that is hard to pin down, that is always helpful.

Mr. Scott: This has been the high art of health care. Because of the cuts the federal government made in the mid-1990s as part of its strategy to deal with the debt and the deficit, for the first time in my memory the public began to conclude that maybe the federal government did have an impact on the quality of what was being delivered at the provincial level. While the provinces still carry the bulk of the credit and the blame for things that go right or wrong in the health care system, I think the federal government will find it harder and harder to be as aloof as it used to be when it could simply say "You are not doing the right things." If that happens, maybe that will bring them together. When I was involved with environment issues, I saw a fair amount of cooperation federally and provincially on the issue of acid rain, for example.

The Chairman: The public blamed each government equally.

Mr. Scott: Yes.

The Chairman: In health care, they have been much less inclined to do that to date.

Senator Banks: There is a third element to which you have referred -- and I am sure there are fifty elements -- namely, institutional resistance. I presume that would include the institution of a hospital and the hospital's management as well as the hospital district, or however it is done from province to province. It also involves the professions, does it not? Can the medical profession be convinced, subsumed or co-opted into going along with the systemic changes that must be made in order to fix the problem?

Community health systems have been tried in Ontario and in Quebec, and there was great resistance to them on the part of physicians in particular. How can you see that we might break that resistance down?

Mr. Scott: The recent Ontario Medical Association- Government of Ontario agreement on payment of fees opened the door in a big way to alternate payment plans. Five years ago the Ontario Medical Association would have said no, a thousand times no. They then moved to a position where they would consider the plan, but it had to be good and it had to include these payment plans. They are now acting as partners with the government in the design and structuring of these programs. That will advance it.

Most professions can be dealt with one on one, but it is a complex thing to do. When I was deputy minister in 1984, the then minister established a review of the health professions legislation in Ontario to bring some order out of the chaos about the borderlines between all the professional groups. The ministry started off with everyone from dental assistants, hygienists, denturists, and so on, to figure out whether they should have independent governance, what role they should have, what regulatory powers they should have, and so on. That process began in 1984 and legislation was passed in 1995. If you really believe that the borders have been sorted out, then you can spend some time explaining it to me.

The reality is that everyone steps on the hand of the person on the ladder behind them within the health care system.

Senator Cohen: I wanted to talk about New Brunswick's extramural hospital, which Senator Robertson initiated when she was minister of health, and how effective that instrument is as a separate institution. I was twice the recipient of the care of that hospital. I had surgery in Nova Scotia and then returned to Saint John, never having to see a surgeon again because of the nurses at the extramural hospital. They were so efficient and so caring and were in constant contact with the doctor in Halifax. My care was excellent and efficient. This innovative hospital is still in existence in New Brunswick. Why is an institution like the extramural hospital not considered by governments across the country? I know there is a lack of nurses, but we have not grown with this concept.

Mr. Scott: I do not know a great deal about the extramural hospital, but the problem goes back to the issue of billing authority. I will get into trouble for saying this, but things such as well-baby visits probably do not need to be done by doctors at all. Many doctors do not even like doing them, but they pay not badly in the fee schedule. It is happy moment for a doctor to see a healthy, happy baby as opposed to all the other problems they see on a daily basis. I have had doctors in rural areas tell me that they do deliveries so that they will be able to have the fee schedule payment for well-baby visits for the next three years. As long as we are driving well-educated doctors down into a fee schedule to practise in areas that do not challenge them, we are making life less interesting for most doctors. They are "A" personalities and they are looking for a challenge. Not only are we not making proper use of our doctors, but that is filtering down to the nurses. Nurses cannot perform certain duties because if they do, they will become a threat to the income made by doctors.

The Ontario Medical Association has been struggling to change the fee schedule for some time and put it on a value base, but the OMA is a political association and must deal with its internal politics. The moment you try to change the entitlements, they are probably much less flexible than most elected governments.

Senator LeBreton: Would the answer be to radically restructure the fee schedule to force that kind of situation, or would doctors not agree? Would it not be in their best interest to restructure a fee schedule so that they receive a higher fee for the serious work they do and a lower fee for work such as the well-baby visits? Would that not force the system into responding to these issues?

Mr. Scott: The Ontario Medical Association has been trying to do that among their members for several years now. Every year, the report is to come out the next year. I am sure they will get a report out, but it probably will not do a great deal. It is difficult for them, and I am not being critical. Over the years, when the Ontario government negotiated with the OMA, it did not change the fee schedule. It said, "You received X number of billions last year and you will get X number of billions plus $400 million this year." The physicians sat down and adjusted the money across the fee schedule.

If family doctors had said they had been getting short shrift since the last agreement and the psychiatrists were making a killing, then more of that $400 million would go into fee schedule items that family practitioners would use more often and less, or maybe none, to psychiatrists. The orthopaedic doctors may have then been upset, feeling they did not get enough money, and their fees would have been adjusted the next time around.

It is a terribly political exercise. Ontario governments have never wanted to touch it with a 10-foot pole because they have not had the expertise. They know that all they can do is get into trouble. The poor OMA has the same problem politically. In fact, one of the sections -- the radiologists, I believe -- has sued the OMA over their handling of this kind of matter. That is why my solution tends to push more away from fee for service.

In community clinics -- and there is good evidence of this -- physicians tend to do the things they want to do and work out arrangements with their colleagues. As a result, when they go to hire another physician to join their group, they know exactly what they are looking for and what to do. Work then becomes more pleasurable. There is no reason for it to be less rewarding because it is not driven by a series of artificial items and time.

From a patient's point of view, if you have a complex series of problems and one or two consultations a year before you run outside of the 20 minutes, that will not do you much good.

Senator Fairbairn: In much of what Mr. Scott has said, and particularly in the last conversation, an interminable circle appears to be impeding progress on so many fronts, whether it is service or the income that people make. The question is this: How do we break through that circle? We are working at a certain political level, but in listening to you talk, we hear that there is equally as vibrant a political level within the professional groups themselves.

That is more of a comment than a question because I do not believe you have the answer; I am not sure anyone does. However, clearly it is a major part of the larger issue when we are talking about quality and the availability of human resources. There is an impediment to new thinking entering the system right now because of all of the structures that have been in place for a long time. I suppose some critics would also say that this includes the Canada Health Act.

Senator Banks asked a question that I will also ask. What are your thoughts on the situation in the province of Alberta with the new law that has yet to be played out? Does this new law, Bill C-11, concern you in your views of the relationship between private sector involvement and delivery of service? Do you have a concern about that legislation, as it now has come into law?

Mr. Scott: I will begin by saying that I am not an expert on the legislation. I certainly was not of the opinion that it breached the Canada Health Act, but I would like to see if it can work. I am somewhat skeptical that this structure will prove to be more efficient. We always have problems measuring efficiency between government and the private sector and who counts what. However, I have some hesitation in believing that this initiative will turn out to be more efficient.

On the other hand, I believe that one ought to at least test these things and see if these delivery systems work better. My understanding of that system is that the government still has political control, so if it does not work then the government can stop it.

That is one of the problems. We must do more experimentation. I do not claim to know enough to say whether that is the right experiment or not. I would be reluctant just to say no or that it cannot be tried.

Senator Fairbairn: One of my questions is in relation to the system of control, which will not really be tested until there is a breach in the way that system operates. That has been the concern all along. Once it gets rolling, it will take on a life of its own. The interesting point will be the degree of control that can be maintained. I wanted to raise that point because it is troublesome to many people on both sides of the issue.

Another situation bothers me. You come from a province of large rural areas and huge distances between small communities. I come from a province that has two major centres and then there is the rest of the province. I do not wish to discount my own city, which is the third largest, but there is quite a difference in population.

What do we do when even electronic assistance cannot be of a great deal of help to a small community that simply -- and this is happening -- cannot attract a doctor? We do not have a process in this country to address that problem.

My colleague mentioned the process of accrediting people coming from outside of Canada. This is undoubtedly an area where there is a great deal of frustration at the length of time it takes to certify qualified people or for them to gain access to the required upgrading. They sometimes give up altogether. In many cases, people with skills would probably find it acceptable to go to a smaller community but cannot do so because of these difficulties.

Mr. Scott, what can we do in areas of the country that have a shortage of doctors simply because their income demands cannot be met or there is a lack of services for their families? It is happening in Canada and in my part of Canada. Desperate communities that are far enough away from Lethbridge, and certainly Calgary or Edmonton, simply do not have physician health care or are on the verge of losing it. For example, a doctor may have been hard at it for 40 years and simply cannot continue working. It is a fearful thing that no one wants to come into these areas.

Mr. Scott: In 1995, I delivered a full report to the Rae government on that subject. In 1993, not only were physicians leaving under-serviced areas in fairly large numbers, but those who were staying were demanding supplementary income to provide on-call services at the hospitals. I went on quite an extensive tour of the province and talked to doctors in all those communities, following which I produced a report that I believe contained some of the answers.

First, when I looked at the overall remuneration, those doctors were not doing badly -- that is, of course, because they were working 24 hours a day, seven days a week.

Generally speaking, doctors wanting more money was more a manifestation of anger and frustration about their working conditions than the fact that they may have wanted more money. It may have been exacerbated by seeing their classmates in Missassauga working nine to five and sending everyone to emergency after five o'clock, when most people come home from work and want to see a doctor.

The answer lies entirely in lifestyle. You will find Toronto-born-and-bred physicians who are happily ensconced in Pickle Lake, Red Lake and Rainy River. They will move for the lifestyle, but they do not have an opportunity to experience the lifestyle they went there to get.

That is the reason that I first became enthusiastic for an alternative payment plan. Sioux Lookout and Dryden had stability in physician services, yet conditions were the same as other communities. The physicians there put together a group practice. They had an arrangement whereby they cooperated on their fee-for-service earnings. They had separate but collegial practices. They divided the responsibilities among themselves. They found life more enjoyable and therefore had fewer turnovers. When they went out to recruit, they had greater success recruiting. An APP makes it better because you can do the things you want to do in cooperation with the other doctors in the community. You would not be penalized because your interest is in mental health and not in well babies, which pay better in certain parts of the fee schedule.

Senator Fairbairn: You are presuming that there are other doctors in the community.

Mr. Scott: Yes. In a community that has a hospital, we cannot expect to maintain any stability in physician services if we have less than five doctors. It is iffy with five doctors or six doctors. However, if all of the conditions are right, if there is some understanding in the community, and if we make greater use of nurse practitioners and others, perhaps we could sustain some stability in the community. It could not happen with fewer than five doctors.

The most energetic young doctors get burned out after two or three years. The iron horses tend to drive away new doctors because the iron horses tend to be dominant independent operators.

I do not have a simple answer for situations when there are fewer than five doctors. I did suggest that they look at something like a military service concept and move doctors around, stationing them in different communities for a certain period of time. One or two doctors with a good, solid, nurse practitioner backup could be well-placed.

There is no easy answer for those communities with only a few doctors. We could make it more palatable with electronic backup, but we will never have a good relationship between an isolated community of 1,200 and one doctor. It is just too hard on the doctor, even when the public tries to be understanding. It is hard to be understanding if a new baby is screaming in the middle of the night. It may be nothing, but we do not know that.

Senator Fairbairn: With all the other services that have been chipped away over the years in small communities, it becomes a survival-of-community issue at some point.

Mr. Scott: We could look at industries such as pulp and paper and some mining facilities. They are now looking carefully at whether their marginal operations will continue because they cannot get employees due to the lack of medical services in the area.

Senator Fairbairn: It might be useful, Mr. Chairman, if we could get a copy of the report.

Senator Cohen: I wanted to ask you about the Canada Health Act, if you think that the criteria are still important. Do you believe anything should be added to it, such as sustainability? I would like your personal opinion on the act as it stands today in view of what is happening across the country.

Mr. Scott: My last experience was in the negotiations leading up to the Canada Health Act. They were quite colourful. I was looking through Monique Bégin's testimony to see what she had said.

I do not have a problem with the Canada Health Act. I have a problem with the environment that has been created around it and a problem with the act being used as a blunt instrument by the federal government to make themselves champions of health care. That is my only complaint about the act.

I agree with earlier testimony that the act is an icon and should be left alone. My view is that we do not need to change the Canada Health Act to fix things up.

I constantly hear that the open-ended nature of medical services should be defined. I cannot think of a more destructive exercise. The principles are fine.

The public administration provisions allow one to use the private sector if that may be constructive, provided that the responsibility remains with the public. My only reservation would have been if the act had said that only the government could be involved in day-to-day administration. I would have said that that was wrong. That is not my interpretation of the act, so I am comfortable with it.

Senator Robertson: Mr. Scott, we have had a lot of frustration at this table since we started this exercise with the system. There is an anxiousness to improve, but we seem to run into walls all the time. Suppose that you had a clean slate and that we did not have medicare, but you did have the knowledge that you have now. What would be five or six component parts if you were to redesign the system, without worry about all the political ramifications and the professional commotion? What would you start with?

Mr. Scott: I would start with an integrated system. These artificial distinctions between home care and hospitals are ridiculous. We have them and we have them in spades. I think that is the first place I would start.

I would say that the whole system is a continuum, a patient-based continuum. We would not have the situation we have now with hospitals putting people into home care but hiring all of the nurses out of home care. We should not have those kinds of contradictions. We would need an integrated system.

I would also look at the relationship between the primary provider groups. Nurses deserve and ought to have more status in accordance with their qualifications. They should be seen as parts of teams rather than as adjuncts or add-ons to teams.

Notwithstanding all that I have said about alternative payment plans, I would not require all physicians to be in an alternate payment plan. There is probably room for some reformed fee for service, but not at the primary level. I am totally opposed to it at the primary level. I do not think it could work meaningfully in most cases. There may be cases where I am wrong, but I am prepared to be flexible.

Doctors, like everyone else, are driven by different incentives. There are brilliant doctors who work long hours and do not earn much because they prefer the academic environment. There are doctors who like to be paid a lot and lawyers who like to be paid a lot. There must be flexibility. No one system fits all.

Some interesting studies were done 10 years ago in the United States, and I think that they still stand. We cannot fit all physicians into one box and expect the system to work.

Although not many people thought of it, instituting fee for service put physicians in a box. Most of the doctors I talk to would like to get out of fee for service. They cannot get out of fee for service as they have the same fear that each of us has about changing jobs or being demoted or promoted. The physicians have legitimate concerns about change, as do we all, and we must find ways to address that fear.

A key to addressing it would be to get it right the first time. I have a philosophy that anything you have right now will not be right 10 years or 15 years from now.

Senator Robertson: Thank you for that. I think that this committee must look at what is going on with all these things.

I have one more question. It is not meant to be a political question.

You have worked for a variety of governments in one capacity or another and you have political convictions. Some of us get the feeling that you would have the federal government provide an increased ratio of funding. We know that it dropped to 50 per cent from where it is today. It would be easier during negotiations to be on a friendlier basis with the provinces if there were a methodology whereby the federal government could get recognition, no matter the political stripe.

If the federal government provides more money, how does the public know that it is giving money? Does the public really know if the government is contributing a certain percentage? How do we fully recognize the contribution of the federal government? If we could find a nice way of doing that, more money would be available.

Mr. Scott: I do not think I can say much about that. I agree with it, but we must first bear down on the incredible barrier of distrust. I can think of many existing programs in this country where federal and provincial ministers and municipal people get together to cut ribbons and do all sorts of things.

There is no reason this cannot happen in health care. However, it will be slow and it will take the effort of several leaders. I understand the need for credit. I do not have a problem with that. I can see why any federal government would want recognition if it were to pour in money. I suppose that there will be credit in the recent deal because the federal government will be at ribbon-cutting ceremonies for new MRI machines. There should be more of that because it keeps the parties together.

No matter how well intended the federal government is in saying that there are great sums of money earmarked for home care, for example, that resonates very well with the provinces. Each province is at a different level in regard to home care. They see a home care program that might be different.

I do not mean to jump to conclusions. This is a natural environment that occurs.

A province may say that it does not need money for home care but rather for emergency wards. That escalates the environment into maximum negative. We have seen that. I think that there is no fault entirely on any one side. However, unfortunately it is the tradition, and it will take leadership to break through that tradition. Perhaps the answer lies in the suggestion that Tom Kent made about entering into a permanent commitment, in exchange for which the provinces get the guarantee that they will be protected within certain parameters, in exchange for which the federal government is given a more active area for which it can take credit.

Senator Robertson: It would be very expensive, but perhaps each family should receive a statement of the health benefits they accrue during the year. The statement could indicate that 50 per cent of the cost is borne by the province and 50 per cent by the federal government.

The Chairman: One of the interesting things I found in reading the paper you sent us before you testified today is how well incentives have worked with physicians. You noted that if a particular behaviour pattern is desired, give them the fee schedule and they will figure out how to maximize their self-interest with respect to the fee schedule. I do not say that negatively. That is exactly what human beings ought to do.

I found that rather encouraging. I am thinking of your suggestion that more family practitioners ought to have their offices open in the evening and that they be paid differently if they see someone after five o'clock. If we were to do that, we would find a lot of practitioners open in the evening.

You talked about incentives in the context of physicians. The medical system consists of both patients and physicians. Has anyone looked at the various ways of putting incentives, or disincentives, into the patient side of the system to encourage a different form of behaviour by patients?

I happen to have had some experience in emergency wards in the past several weeks. To be blunt, I am amazed at the number of people in emergency wards who ought not to not be there. The result is that a number of people who clearly need to be treated more quickly do not receive treatment quickly because there is a backlog. I am not sure that I would agree with the person on the trauma unit who ranks them. I am not criticizing that person.

Surely we need to put more obligations on patients to use the system efficiently, as well as placing that responsibility on physicians. As physicians respond well to incentives, perhaps patients would as well because that is a human reaction. Has anyone looked at the various ways of doing that in Canada or anywhere else?

Senator Banks: In Alberta, it is user fees.

The Chairman: That is one model. Tom Kent proposed a different one that was interesting. He proposed that at the end of the year an individual would get a T4 slip equal to the value of health care services they had consumed in that year, up to a fixed amount. I believe that he mentioned $5,000.

I do not know how good an incentive that would be. It is a means test after the fact. The poor would not pay because they do not pay income tax. The user-fee model is a before-use disincentive system.

Surely, someone in this world must be looking at how to get patients to respond or use the system better than they are using the system currently.

Mr. Scott: I am not an expert on that. By and large, I would say that efforts have been placed on disincentives. Some studies indicate that people would adjust with some training so that they would be comfortable with a nurse practitioner. They will not so readily say that they are not being well served unless seeing a doctor. We still do not have that type of system in place to properly help people to develop this broader confidence or a better sense of where they could go to be treated in the system.

There is some work out there, but I am not an expert on it. There are reports saying that some of this work can be pushed down, but it must be done in an educated manner so people can be confident.

The Chairman: It is not an avenue that you would say is a dead-end street.

Mr. Scott: No.

Senator Kennedy: There is the issue of people going to emergency wards because they do not have any other place to go. They do not have family doctors.

On the home care issue, I want to mention one experience I have had that shows how valuable that service can be. My sister was at my house recovering from heart surgery when she had a stroke and wound up back in the hospital. She was there for a week. When she returned to us, a speech therapist, a physiotherapist and an occupational therapist came once a week. That service was invaluable. My sister was lucky that she could come to our family because care was there. However, other care was provided that would have normally been provided in a hospital. She was with us for three months. One could not put a dollar value on that home care because it was invaluable. How does one teach someone to speak again and to use their hands again? They were absolutely super, and we did not know that this service existed until it was there when we needed it.

Mr. Scott: Home care is not balanced. In some cases, like your example, it works incredibly well and makes the case for integration. In other cases, it does not work at all. Instead, the poor patient finds himself or herself bounced back and forth between hospital and home care for treatment.

I should like to end on a positive, personal note because many people are worried about the state of our system. You had a negative observation about your experience, Mr. Chairman.

I was last in Ottawa at the end of May, but I want to be clear that I am not blaming Ottawa for this experience. I felt stomach pains going back on the aircraft. I went to my office and felt progressively worse. I decided to check myself into the emergency ward at a Toronto hospital.

I did have a complaint that it took a bit of time to get me to the triage. From the triage, I was taken in immediately and went through a battery of tests. I had a complex acute appendectomy, complex in the respect that it was not easily identifiable. The operation was completed. I was at home in less than 24 hours, and that is with a major incision. Sometimes the system works extremely well.

I must tell you that although I am a former deputy minister and know the president of the hospital, to this day the president of the hospital does not know that I was there. No one I knew saw me. I came in off the street, and because it was an acute situation, I was handled extremely well by the system.

The Chairman: In that positive note, thank you very much for your testimony today, Mr. Scott.

Honourable senators, I have two items of business before we adjourn. Technically, I need two motions. The first motion is to approve the terms of reference on the Subcommittee on Veteran's Affairs, which requires approval of the committee. It is a paragraph and one-half long. The subcommittee approves it unanimously, I am happy to take the motion. Thank you.

The second matter is that I must give notice to have a motion put through the Senate related to Bill C-6. Bill C-6, you will recall, was the famous privatization bill where we had a modest disagreement with the minister, and, ultimately, he came to understand our point of view. In that discussion we did indicate that we would keep a watching brief on how the negotiations were going between the various parts of the health care system and the government in terms of how the Privacy Act will impact on the health care sector.

I think it would be useful to have an update because of some things that I understand to be occurring. Technically, I cannot do that unless I have a motion referring the matter back to the Senate. If you are in agreement, I would be happy to put a motion today.

Senator Robertson: Was the agreement not that they will back to us?

The Chairman: We agreed that if the issue is not resolved in two years, then the existing act goes into effect.

Senator Robertson: That is right.

The Chairman: We said that we would be prepared to help in the negotiations if they got bogged down. Other Senate committees have done that. My sense is that this issue is getting a little bogged down because it is not totally clear to me that all parts of the bureaucracy and the industry are of one accord as to what needs to be done. I think that some modest leverage might be helpful, but I cannot get the committee do this until it is approved.

Senator Robertson: Approved.

The Chairman: Thank you very much.

On Monday, you will receive from the clerk the draft report on phase one of these hearings. I caution you to please watch the confidentiality of the report. We do not need the problems that some other committees have had with respect to leaked documents.

The committee adjourned.