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

Issue 14 - Evidence

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OTTAWA, Thursday, May 17, 2001

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 11:05 a.m. to examine the state of the health care system in Canada.

Senator Michael Kirby (Chairman) in the Chair.

[English]

The Chairman: Honourable senators, we are here to continue our discussion of the state of the health care system in Canada. We are delighted to have with us the panel of witnesses that will deal with the home care issue, which has come up indirectly many times during our discussions. We are delighted to hear the views of the Canadian Home Care Association, the Canadian Association for Community Care and the Victorian Order of Nurses. Thank you all for coming.

Speaking first will be Ms Nadine Henningsen, Executive Director of the Canadian Home Care Association.

Ms Nadine Henningsen, Executive Director, Canadian Home Care Association: Honourable senators, I would like to introduce my colleague, Ms Evans, the Treasurer of the Canadian Home Care Association. I would like to thank you for the invitation to present today.

Our association is composed of policy planners, administrators, service providers, researchers and educators in the home and community care field. The brief entitled "Strengthening Home Care, a Call for Action" will serve as the basis for my presentation. This document was developed through a consensus process with our membership and governing board. It expresses the views of the Canadian Home Care Association as a collective voice for home and community care across Canada.

It is important to begin my presentation with a clarification of a term that I will be using quite frequently. In home and community care we refer to the patient as the "client." That is an important distinction to make before I begin my presentation.

During the past 15 years, home and community care services have been widely recognized as essential elements in an integrated health service system. This recognition has been reinforced by a steady increase in public home care spending from 1.2 per cent of the total health care expenditures in 1980-81 to approximately 4 per cent in 1997-98. Home care is the program that plans in-home support, monitors -

The Chairman: For clarification, you keep using the term "home and community care." Are they different, or the same? If you are going to explain later, that is fine. We have always used the term home care, so we do not know the term "community care."

Ms Henningsen: Home care is the program that plans in-home supports. It monitors and evaluates clients' needs, provides nursing services, helps with activities of daily living and provides homemaking or offers assistance to enable independent living. Home care programs work with other services, including community support services. This is where the community care comes into the picture.

Community support services could include meals on wheels, day centres, respite care and volunteer services. Home care also works with acute care hospitals, palliative care and respite facilities, long-term care services, mental health services and independent living programs - all to assist the client in the home and community.

Home care accomplishes three main objectives. First, home care substitutes for traditional hospital and long-term care facilities. Home care maintains and supports independent living, which allows Canadians to live in their home environment rather than in more costly institutions. Home care serves a preventative function by supporting quality of life and helping to prevent deterioration and by providing brief but intensive interventions in a client's home.

What forces are driving the demand for home and community care? I would like to touch on four key forces that are driving the demand. First is the rapidly growing elderly population. In the 1989-89 national population health survey, 12 per cent of seniors reported receiving publicly funded home care services. More and more seniors are demanding choice, and this will be reinforced with the aging boomer population.

The second force is pressures facing informal caregivers. Most informal caregivers are women who support their family members and who must often manage simultaneously responsibility for aging parents, for their own children and full-time paid work. The combination of pressures can lead to not only stress-related illness and loss of work time for the caregiver, but can also increase the risk of neglect and mistreatment of the care recipient.

The third driving force is the advances in technology. Medical advances have increased life expectancy, decreased the length of hospital stays and have resulted in more outpatient services. Conditions that previously required hospitalization - for example pain control - can now be managed at home. Advances in treatment protocols and accessibility to high-tech equipment make palliative care in the home a real option for Canadians.

The fourth driving force is hospital bed reductions. The trend is now towards shorter hospital stays, early discharge and the use of outpatient procedures. This results in more reliance upon community services. Home care is critical to sustaining a hospital system with fewer beds.

What are the benefits of a strengthened home and community care system? A strengthened home and community care will result in the following outcomes.

First, it will enable the health care system as a whole to operate more cost-efficiently. Second, it will reduce the pressure on acute care beds and emergency rooms by providing medical interventions in alternate settings and using hospital resources only when they are needed. Third, it will reduce the demand for long-term beds by providing a viable choice for aging Canadians to maintain their independence and dignity in their own homes and community. Fourth, it will help support family caregivers and sustain their commitment.

What do we need to do to strengthen the home and community care system? The membership of the Canadian Home Care Association believes that the federal, provincial and territorial governments have a strong role in strengthening the home and community care system by achieving national standards, through investment in services, human resources and necessary infrastructure.

To this end, we recommend working towards the achievement of three key objectives. First, the development of national standards for home and community care. National standards for quality and provision of home and community care services will ensure both an effective Canadian health care system and equitable treatment of Canadians in all parts of our country. The method by which these standards are incorporated into national legislation may be debated, but the time for debate about the importance of the standards has passed. This is a very important role for the national, provincial and territorial governments.

The second objective is the enhancement of human resources that are the basis of home and community care programs with improved training and retention strategies. The shortage of nurses, home support workers and therapists is critical in some regions across Canada. While these personnel shortages are part of a larger picture of scarcity of health workers, they are often exacerbated in home care by lower wages and benefits than those paid to workers in hospital and care facilities. Both the wages and supply of community workers are a serious challenge. We must provide compensation that is competitive with care facilities and hospitals. Ongoing professional training must become a priority to ensure that the highest standards of care are maintained. We must continue to investigate the most effective working relationships with the health care team, including the primary care physician and other components of the health care system.

The third objective is the improvement of the infrastructure of home and community care. The Canadian Home Care Association membership recognizes that we cannot simply pour new health care resources into the same old silos in the same proportions. Health care renewal should aim for a sustainable health care system for all Canadians, no matter where their care is provided. Often home supports can be provided at fewer costs than new hospital beds. It is imperative that we build the basic infrastructure of home and community care so that services are accessible, properly managed and available. We must invest to increase the quality and quantity of home care services. We must also ensure that there is a capacity to support people of all ages with many different needs.

The Canadian Home Care Association believes that it is important to invest our money, our skills and our time to achieve these three objectives - national standards, human resources and infrastructure. We must work together to build a system that will ensure that Canadians receive the most appropriate care by the most appropriate provider in the most appropriate setting. A strong home and community care system will help realize this goal. Thank you.

The Chairman: Dr. Alexander, could you explain at the beginning, how your organization differs from the CHCA?

Dr. Taylor Alexander, President and Chief Executive Officer, Canadian Association for Community Care: Perhaps, I might describe scope of activities of our two organizations and the scope of home and community care. Home and community care touches not only home-based services but services provided in the community. For our organization, those include services within long-term care institutional settings as well. Our membership base reflects the long-term care sector. We are a national voice for that sector as well.

Senator Morin: Is that the difference between home care and community care? I do not think the chair's question was answered there. Is that the only difference?

Dr. Alexander: There are different ways of understanding this issue. Home care is traditionally seen as care provided in the person's home. We talk in terms of home and community care because it is very common for persons who receive home care to also go out into the community into day hospitals and various support programs to receive care at the same time in their local communities.

In addition there is the next step, which is long-term institutional care - which is the other part of the continuum. I hope that I have answered your question.

The Chairman: We customarily do the questions at the end, but I am trying to understand the context. Do either or both of your organizations include private sector providers as well as public.

Dr. Alexander: Both.

Ms Henningsen: Both.

The Chairman: Both of you have private and public sector providers as members. The owner of the delivery system is not an issue for you people.

Dr. Alexander: No.

[Translation]

Honourable senators, it is a great pleasure for me to represent our board here today and to have this opportunity to share with you a few thoughts on home care in Canada.

[English]

The Canadian Association for Community Care is a national non-profit bilingual association formed in 1995 by the merger of Home Support Canada and the Canadian Long Term Care Association. Our guiding principle is the commitment to providing a strong national voice for the community care sector, which includes home-based care, facility based long-term care, and community support programs such as meal services. Our mission is to promote the development of a range of high-quality, flexible, responsive and accessible community care services within a continuum of care.

I would like to address a number of key issues to which our association has been deeply committed over the past few years. We would like to make some suggestions for federal action in moving ahead.

Formal home and community care services are fairly recent developments in the Canadian health care system and have evolved primarily in the last 25 years or so. In some jurisdictions, their development is even more recent. National data on the sector are very weak, but according to a 1999 report by Statistics Canada, about 613,000 Canadians received care through provincial home care programs. Of this total, about 400,000 were seniors, representing about 12 per cent of all seniors.

More than three million Canadians - mostly women - provide unpaid care to ill family members in the home. They provide that care often at great personal and financial hardship to themselves. Yet, home care programs rely heavily upon the vital support provided by this vast number of devoted family caregivers and would be unable to function without it.

On the other hand, there are very few effective support services and incentives in place to assist these dedicated caregivers, an issue that demands urgent and creative solutions and service delivery. Immediate changes are required in the tax system and employment polices among others areas.

Overall, the sector is characterized by lower wages and benefits than provided by hospitals, especially for paraprofessionals who, in some provinces, earn roughly the minimum wage. As there are no national standards, there is a "patchwork quilt" of programs across the country. Often important services are either not covered or only partially covered, causing great inequities among jurisdictions. Indeed, according to Health Canada, about 20 per cent of family caregivers reported that their loved ones did without services because they could not afford them.

Home and community care are not insured services under the Canada Health Act. This has created a parallel, two-tiered system in Canada. Often home care clients are surprised that must pay out of pocket for their care.

Only about 4 per cent of all public expenditures on health is devoted to home care, amounting to just $2.1 billion per annum. Financial expenditure data are also sparse and when available, they omit paraprofessionals who provide most of the care in the home. At the same time, there are wide variations among the provinces and territories regarding the proportion of public spending on home care, hence there are disparities in the provision and scope of services across the country.

CACC believes that the federal government has a key role to play in promoting the development of an equitable, sustainable home and community care program across the country.

The next section about which I would like to talk is titled "Medicare's Unfinished Business, a National Home and Community Care Program." As I noted earlier, there are no national standards for home and community care. The sector is not covered under the principles of the Canada Health Act. This glaring item of unfinished business on the national policy agenda has created a U.S.-style two-tiered health care system in the sphere of home and community care.

Often essential services such as pharmaceuticals are covered by medicare while persons are in hospital, but not when they return home. This places their health at risk if they cannot afford these treatments.

Home support services, which are vital to maintaining independence, are frequently only partially covered, if at all, by public programs. Again, this undermines independence and drives up costs due to avoidable hospital admissions.

Canadians living in the so-called "have-not" provinces should not be further disadvantaged and put at risk if their province lacks the funds to provide home and community services that are comparable to more affluent jurisdictions.

There is an urgent need for a federal/provincial/territorial agreement on a "core basket" of essential home and community care services to which the principles of the Canada Health Act would apply. These insured services must include, at the minimum, paraprofessional home support, nursing, social work, physiotherapy, occupational therapy, palliative care, prescription pharmaceuticals, respite and case management. Moreover, there must be flexibility to ensure that the mix of such services is required to support independence is readily available without the barriers of excessive bureaucratic red tape or other policy restrictions.

I will move to the recommendation that we would like to make because we have been asked this morning to comment on the federal government's role. I will frame my comments in terms of a recommendation on this particular issue.

CACC recommends that the federal government work with the provinces and territories to reach agreement on a core basket of home and community care services. As well, they should develop national standards for the provision and administration of these services based on the principles contained in the Canada Health Act. Finally, they should undertake the necessary financial analysis to establish appropriate federal contribution levels to support these services. Funds should be made available as soon as possible and targeted for home and community care spending by the provinces and territories, which should be held accountable for their appropriate allocation.

The next point I would like to comment on, senators, is human resources - the challenge of recruitment, retention and training. As my colleague has mentioned, there is a growing national crisis in the supply, distribution, recruitment and retention of staff in home and community care programs. Years of health care reform, nursing layoffs, low wages, difficult working conditions, poor training and greater complexity of care have made the sector an increasingly unattractive work environment.

Most home care is provided by paraprofessionals, virtually all of whom are female. Many paraprofessionals are recent immigrants with low education who speak English as a second language. Many home care workers are subject to various forms of abuse in client's homes but many provide service after hours without pay to assure that the clients receive the support that they need.

The wide disparities in wages and benefits across the country draw workers to areas of higher pay creating even worse shortages in areas with low wages, such as some Atlantic provinces. The dearth of workers in Canada is forcing some agencies to recruit workers from overseas from developing countries, which can strain the supply of workers in those countries as well.

Without adequate numbers of trained staff, home care programs are unable to fulfil their mandates and the independence of clients is threatened, further adding to pressures on the acute care system.

I would like to make recommendations with regard to human resources. CACC recommends that the federal government work closely with the provinces and territories to develop a national home and community care human resources strategy that will help ensure an adequate supply and distribution of appropriately trained home and community care workers across Canada.

The strategy should include provisions to enable the provinces to support the training and skill development, particularly of paraprofessionals; and enable agencies to offer adequate wages and benefits that will allow them to recruit and retain staff and prevent their loss to the institutional care sector or to other sectors.

We have touched earlier on care for the caregivers, the informal family caregivers who provide this support at great personal cost - both emotionally, physically, and even financially. I mentioned earlier that there are at least three million of such individuals in Canada, ranging in age from teens to seniors.

I will not go into the details on the background. I think that the issue is well understood. We know the scope of the problem and we know that there are very few supports available in the country.

Our association recently did a study. We found that informal caregivers required four main types of support - information and advice, time for themselves, psychosocial support and advocacy on their behalf. None of these is a high cost intervention. Yet, the benefit would be real if we had these supports in place.

We recommend that the federal government work closely with the provinces and territories to develop a national respite strategy, which means giving people time off from their care giving so that they can recuperate and have a personal life and some recreation. This strategy should be aimed at supporting family caregivers. Respite services should be included in the core basket of insured services within a national home and community care program. The strategy should consider a wide variety of financial mechanisms to support caregivers, especially the tax system, employment policies, the employment insurance system, and the pension system as well as direct payments.

Finally, I was asked to offer a few comments on the issue of palliative care. In that regard I have consulted with the Canadian Palliative Care Association and I would like to offer some thoughts around the issue of palliative care in home care in Canada.

According to the Canadian Palliative Care Association, about 225,000 persons die in Canada each year. In 1997, an Angus Reid poll found that about 80 per cent of Canadians prefer to die at home. However, this is often not possible because of the lack of home-based palliative care services. Such services vary across the country; rural and remote areas are particularly under serviced. Overall, only about 10 per cent of Canadians have access to palliative care services.

There is also a widespread lack of adequate pain management often because patients and families simply cannot afford the drugs to control the pain. This tragic situation results in unnecessary suffering for persons who are ill. Moreover, because seniors often suffer from multiple health problems, including dementia, pain may be difficult to locate. Pain may be difficult to locate and difficult to treat.

I have consulted some of the literature on this issue, and I would like to offer a couple of thoughts around the notions of what are central to optimal end-of-life care. One notable report that was recently released by Fisher et al. noted that three underlying themes are central to optimal end-of-life care: comfort, communication and support. Again, these are not high cost, high-tech interventions.

The elements of a good death are defined as being pain free, operating at the highest possible level of functioning, resolving long-standing conflicts, satisfying final wishes and relinquishing control over care to significant others.

CACC recommends that palliative care services and pharmaceuticals be included within the core basket of insured services within a national home and community care program to ensure that death with dignity is available nationally.

The Chairman: Thank you both for excellent, thought-provoking presentations. We will go on to the next presenter, please.

Ms Diane McLeod, Vice-President, Policy, Planning and Government Relations, Central Region, Victorian Order of Nurses for Canada: Honourable senators, I have with me Dr. Bill Gekowski, who is a member of our national board and the chair of our advocacy committee.

VON, a national registered charity and not-for-profit organization has been caring for people in the community since 1897. VON nurses were there to care for those who contracted influenza during the pandemic of 1918-19 when more than 50,000 Canadians died and many more became gravely ill.

Programs such maternity care, well baby clinics, school health care programs and home care programs were all started by VON. When VON began there were four branches, in Halifax, Montreal, Toronto and Ottawa. Today, VON has 67 branches serving the health care needs of Canadians in some 1,300 community this is nine provinces.

This morning I will be bringing to you the perspective of a provider agency for home care and community care.

Visiting nursing continue continues to be our central service, but we recognize that nursing alone is not enough to keep people at home. Good support services are an essential component of community services and for more than a century VON has been developing innovative programs to respond to the needs of people in the communities we serve.

The Chairman: May I ask that you hit the highlights rather than read a 15-page brief? I would like to have more time for questions.

Ms McLeod: That would be fine. I will go on to say that we offer many other services besides our professional nursing services, including "meals on wheels," food care clinics and respite care. Many of our programs are delivered to the most vulnerable in our society - those who cannot afford them. These programs are made possible through a very large workforce of volunteers. We have 15,000 of them across the country. We also work with 8,000 health care professionals.

As we begin this new century, the need for community-based services is rising as more and more people are being discharged early from hospital and receiving care at home in order to avoid hospitalization. You have heard the needs outlined by my colleagues, so I will not go into that in detail.

This morning I would like to touch upon six issues with you. My colleagues have touched upon some of them, but I would like to bring our perspective to them.

Certainly we want to bring to your attention the need for national standards. Home care, to say the least, has become a bit of a hodgepodge of services across the country. Each province has its own idea of what is required. These are ideas are governed by provincial views of how these needs will be met.

Every province and almost every region has its own set of standards and approaches to responding to these needs and this makes the service provided to Canadians very inconsistent. VON believes that there must be national standards and that these standards must be established in collaboration and cooperation with all levels of government, health care providers and ordinary citizens throughout the country. Without these standards, there is really no hope of having a unified health care program in the community sector.

There is definitely a need for improved information systems. As was mentioned earlier, there is little statistical information in the community sector to help in decision making critical to the effect of delivery of care.

At the present time, we basically have a paper-based system. This not only causes enormous inefficiencies and extra cost but also, perhaps more importantly leads, to an inadequate capacity to assess quality of services. Unlike the institutional sector, governments across Canada have not made a significant investment in development of an information system for home care.

VON believes that a national investment must be made in information systems. This should be given priority in the future if services provided in the community are to become part of an integrated system. At the moment, we function very much in silos with the community sector being a low priority.

We certainly need improved human resources practices. This is an extremely important issue for VON as a provider agency. The essence of quality within the community is the strength and skill level of the individual nurses, home care workers and therapists who interact and provide services to clients.

At the present time, there are significant problems with respect to human resources. There are shortages, as I know you are well aware, and significant wage disparity issues. Workplaces are ambiguous and difficult for these people.

With respect to nurses, everyone understands and is aware of the shortage. In the community sector, particularly in Ontario as a result of managed competition and wage disparity, there is an acute problem with respect to nursing. In Ontario, in some circumstances, community nurses are being paid as much as 25 per cent less than their counterparts who work in institutions. This is making it impossible for us to recruit and retain the quality of staff that we require to deliver the care that is necessary in the community.

In other parts of Canada, the situation is better. Where nurses are working in a regional health authority model, they have more regular work conditions and standardized pay. This is not a consistent problem across the country, but nonetheless it exists.

With respect to home support workers there is currently a significant set of problems across the country from coast to coast. As a result of low wages, inadequate training and insufficient support systems, there are situations where unskilled and unsupervised workers are delivering complex care.

VON is collaborating with other health care organizations and Human Resources Development Canada to undertake a study and analysis of this issue. We believe firmly that initiatives must be undertaken to address the issue of wage disparity for nurses and home support workers, workplace conditions for all staff who work in the community, as well as training needs for the community.

There is a need for policies to support not-for-profit organizations. Over the past 25 years, it appears that many provincial governments have developed policies and processes to effectively undermine and reduce the presence of not-for-profit organizations, such as the VON in our communities. These policies seem to be driven by the need for efficiencies and for control of services, and the mistaken idea that governments have a greater capacity to directly deliver services than not-for-profit organizations.

Over the years, VON has been pushed out of communities in this country by regional health authorities or provincial governments that have made the decision to take services in-house. The additional benefits that VON brings to the community are lost in this process. Many governments seem to be unmindful of this. Through the network of 15,000 volunteers that I mentioned earlier, VON is able to provide charitable programs to respond to individual health and social needs of Canadian that are not currently being met through government-funded programs. Each time a government policy limits the capacity of a volunteer organization to grow, it also reduces the organization's capacity to respond to emerging needs in the community.

We believe that all levels of government throughout Canada must revisit their approach to responding to needs within their communities. They should also provide encouragement and support rather than disincentives for not-for-profit organizations.

We feel that there is a definite need for research in this area. I mentioned earlier, as did my colleagues, the lack of statistical evidence and quantitative and qualitative analysis of what is happening in the community. To develop best practices and acquire new knowledge regarding delivery of care, society must make a commitment to investing in research.

At the present time, the majority of research funding goes to established organizations such as hospitals and universities. We strongly recommend that the Standing Senate Committee on Social Affairs, Science and Technology seriously consider including in this report recommendations regarding the need to target research for the community sector.

There is need for recognition and support of informal caregivers. I think that this statement has been made strongly by my colleagues. VON supports this. We see over and over again informal caregivers being pressured by the lack of services in the community and no supports for them. It is a critical situation that needs to be addressed for chronologically ill, disabled or dying clients.

In conclusion, there are recommendations put forth in this paper, most of which I have touched on. There is a need for national standards and a need for investment in information systems in the community to help us to communicate with the institutional sector and with each other for the purposes of improving client care. We need to have a leadership role taken, if at all possible, by the federal government in looking at the human resource issues of training and addressing the issue of wage disparity.

We would like very much to see that the creation of policies to support not-for-profit charitable organizations be examined. Without government understanding and recognition of the importance of supporting not-for-profit organizations, these organizations will continue to be under enormous stress and will be at risk of dying out.

The need for research in the community sector cannot be stated more emphatically. Again, we recommend that the federal government make a commitment to develop programs and policies that recognize and support the important and integral role of informal caregivers within the Canadian health care system.

The Chairman: I thank all of you for your interesting presentations.

Senator Morin: This is a very important issue. It is a shame that Minister Rock's plan fell through a year ago. As you know, the federal government was supportive of this. It is the provinces that shot down that plan. We would be in a completely different situation today if Minister Rock's plan had been put into effect.

It is interesting to note that molecular genetics leads to home care. Mr. Chairman, you remember the discussion that we had yesterday about the importance of having some scientific basis. We see that this morning.

Both your organizations have represent public not-for-profit and proprietary - which I suppose is a euphemism for profit - organizations. I would be interested in your views. Is there a place for each type of organization? If so, what is that place?

I note that in your document you mentioned considerations of social values and efficiency. I was wondering if you were thinking more of one type of care than the other.

My other question deals with the great the great variance in home care across the provinces. You touched on this topic, Dr. Alexander. It is not homogeneous at all. My own province, Quebec, is doing extremely poorly. We are spending far less than the national average. Maybe you could comment on this great variance briefly. Of course, you cannot give us a detailed picture, but a rough outline would be helpful.

Ms McLeod, I strongly support your position that research is needed in this field. CIHR was created a year ago exactly with supporting health services research in mind.

There is a program called the "Community Alliance Program." I strongly urge you to meet with Dr. Bernstein, the president of that organization. After you have met him, if you are not satisfied, give me a call.

These fields need research for good evidence-based decision-making. I strongly urge you to meet with Dr. Bernstein. You will have no problem getting an appointment. If you do, give me a call.

Ms Henningsen: To address the question of the not-for-profit and the for-profit or proprietary involvement in home and community care, the Canadian Home Care Association feels that there is a strong and productive role for both types. We believe that it should be from a service delivery point of view. It should be the best provider who can provide high quality care at the bedside. We do not believe that profit status or not-for-profit status should play a role in the decision of choosing the service provider.

We also strongly believe in the private-public partnerships that would partner government organizations with possibly for-profit private organizations. We see a big benefit of this in the research and development area. One of the challenges of home and community care is that there are a significant number of private organizations - for example, equipment suppliers - that are continually putting money into research development. They have some really nifty products out that would improve the quality of life for the client. However, there is so much red tape for these private organizations to have their product approved by government and the administrative bodies that the products never reach the client.

We believe in putting together the government administrative role and the private, for-profit or not-for-profit, companies as a partnership to benefit the client at the bedside.

The Chairman: At the beginning of your response, you said it does not matter whether it is public or private, whichever provides the best care. "Best" is obviously a value-weighted term. Would you help me? Does "best" that mean most efficient? What are the criteria by which you say someone is better than another one?

Ms Henningsen: There are a number of different ways that you could evaluate the best care. Certainly many different home care programs across Canada have different evaluation tools. To determine the best care, one would look at the best-qualified, trained and supported home care workers, whether they are the nurses or the home support workers. One would examine the organization that will be providing services and determine how they hire, how they review and check qualifications, and how they train and support their caregivers.

There is also the need for administrative support. We would wonder if we were driving costs out of the administrative level and putting it into the home care workers at the client? We advocate that we abolish the administrative roles other than those that support the home care worker or the client. That is where we need to put the emphasis.

Dr. Alexander: Our association is committed to developing resources and training materials that support high quality practice in the sector. That is one of our main activities.

The issue of public versus private does not enter into that debate for us. Our concern is about overall quality of care and supporting the sector in being able to do its job.

We are aware that the sector has a tremendous need for high quality training materials, resource materials and various kinds of supports that will enable them to do their job better. That is a main activity with which we are involved.

The issue becomes a moot point if we look at the development of a national home and community care program. Public administration and public funding come into play. The public-private dimension takes on a different colour at that point. We are advocating for a national home and community care program in an attempt to resolve this issue.

As you well know, physicians in our country are virtually private practitioners paid by public funding. Hospitals are private institutions paid by public funding. The way we have as a country dealt with that in terms of physicians and hospital care is through the principles of the Canada Health Act, which really transcends that issue very well.

Ms Henningsen: It is important to look at the case management function in home care when you are looking at the profit / not-for-profit debate. Home and community care is unique in this case management function. The case manager does an assessment, and determines the level of care that the client needs and the services required. The case manager manages the ongoing care plan basically.

The CHCA believes that this case management function should be a government, publicly administered role. The case managers are the drivers or the controllers. The service providers, whether they are equipment or nurses, are following this controlled case management plan. That is unique to home and community care. That is not the situation in a hospital.

The Chairman: What is your rationale for that? I understand you to say that the case manager should be public sector and it does not matter whether the deliverer is public or private. What is the rationale for the case manager being in the public sector?

Ms Henningsen: We would like to be included in the national home care program. We must have a level of transparency and accountability that would be easier to manage and to be able to report if this function were managed through public administration.

Senator Morin: I would like to have Ms McLeod's opinion on where case management should rest, whether it should be public or private. I realize that a national home care program is the ideal situation. It was suggested a year ago, and was shot down. We could come back year after year. The provinces would apparently shoot it down again. They want uncommitted funds. It is as clear as that. They said it a year ago. They will say it again. This morning in The Globe and Mail, Ontario came out on that. We could recommend it, but we must be realistic.

If we do not have a national home care program, what is the next best thing? Is there a place for both private and not private?

Ms McLeod, your comments were somewhat different from what we just heard concerning the role of the government in case management decision-making.

Ms McLeod: It is an interesting question. I know the Ontario system the best. I will qualify my answer as being applicable in Ontario. The case manager role in the system is as Ms Henningsen described.

I think that their role is essential in the more complex cases. However, in cases where there is a professional in the home - a nurse, a physiotherapist, or an occupational therapist - the ongoing management of the plan of care could well be done by that professional in the home.

There is an issue of accountability of which we must not lose track. These are public dollars. We are being paid those dollars as a provider organization, and we need to be accountable to someone. At the moment, that is the case management position. There is nothing wrong with that need for accountability.

I am not really sure whether the case manager should be a public or private employee. They certainly are publicly funded at the moment, and they should likely stay that way.

They are accountable for the dollars spent within the system of the current home care programs. We, as providers, are accountable for reporting to them and ensuring that the dollars are spent appropriately to achieve the objectives of the plan of care. In that sense, it is a very cooperative arrangement. I am not sure if I have totally addressed your question.

Senator Robertson: On the subject of case management, I would like for you to share your knowledge about some of the difficulties with case management. In a number of jurisdictions, a case manager is involved before a senior is transferred to an appropriate nursing home or special care home. The case manager frustrates the other professionals often. The other professionals are ready to move a patient. They will not take the physician's recommendations until this primary care person is consulted. I do not know whether it is because there are not enough case management workers, but there is a delay.

What is your opinion about the professional requirements of a case manager? How can we increase the efficiency of case managers working with the health workers who have been treating the patient up to that point of transfer? That seems to be a stumbling block.

Ms Henningsen: It is interesting that you mention that the case manager is causing a delay. Case managers, at least in theory, play a critical role in the smooth running of home and community care.

One of the challenges in the system is that Ontario is the only province that actually has standard case management criteria. No other province has that. A person could be a case manager without certain qualifications. There would be no training program.

If you lived in New Brunswick, you could be a case manager merely by choosing to be. In Ontario, you would need certain qualifications. You would have needed to undertake a specific training program in order to understand the case management role.

The case management role is critical to smooth and seamless transition of the client. In the instance that you mentioned where a person is looking at either long-term care or different community supports, the case manager fills a need and assists in finding the correct match of need and service available. However, there is much work to be done in the case management area.

Senator Robertson: I appreciate that because I do believe that the qualification and training of the case manager is extremely important for a smooth transfer.

Senator LeBreton: When the general public hears terms like "home care" and "community care," they would be able to relate to community care. I think that people see community care in the clinics and places where they can go.

However, do you think that the entire term and expectations around home care are widely misunderstood? As a matter of fact, people do not even give much thought to home care until they are confronted with the need for the services. Would all of you comment on that?

We have an aging population. The need for home care will become more acute. How do we assist the public to become more knowledgeable on the topic? I am sure that if you were to go out on the street and ask, people would recognize your organization, the VON, because VON has been around for a long time. How do we bring the issue of home care forward in people's minds? How would you deal with that?

Dr. Alexander: There are a number of issues that come up around that. One issue is the prevailing misunderstanding that home care is covered by medicare. People are surprised when they must start paying direct for these services. They are also surprised when they find out that there are too few staff and too few case managers to help coordinate care.

The individual must then act as the case manager in that situation. There are a number of unpleasant surprises that could happen with home care because of the kinds of the crises that we are addressing this morning.

On the other hand, numerous polls have shown that there is tremendous national support for home care and for a national home and community care program. In that sense, the general public is ahead of the political process. There is a heartfelt commitment within the general public to providing care in the home. I mentioned earlier my comments around palliative care that 80 per cent of persons would prefer to die at home.

As a result of the weaknesses within the current system that we have described this morning, many home care arrangements are not possible. That can create frustrations in the public mind.

Ms Henningsen: I would like to add to Dr. Alexander's comments. Senator, you are quite right. Canadians do not think about home care until they are in the middle of it. It happened to me, and I am the executive director of the CHCA. I had not considered that it would require such a high energy to bring my husband home.

There are a number of different areas in which we could support the Canadian public when they do find themselves in a crisis. They would be looking for quick simple answers. The case management role is critical. Case managers provide a lifeline for people in that crisis situation. A person seeking assistance would be quickly connected with a case manager, either through a community access centre or through the hospital.

Family physicians have shown a willingness and an interest in understanding home care. We need to spend some time and investment to help to teach physicians learn more and introduce the concept of home care to their patients. For seniors especially, what a physician says and does is very important to them. They will follow that physician's suggestions. If a physician could educate patients on the options of a home and community care program, it would help to ease some of the anxiety.

Ms McLeod: If someone finds themselves within the context of the community care access centres, they would have the link into the care system. It is an expanded role from the previous home care programs in Ontario whereby a case manager can help an individual access the services that are required. A case manager would also manage an application to a long-term health care facility. The case manager role has certainly brought those services together. If there is care required in the home, it would be a co-ordinated effort. That is excellent.

However, that is not consistent across the country. It is also not consistent at the level of the individual. If a person is not eligible for services through the CCAC, then that person is left on their own. The word "hodgepodge" seems somewhat negative, but I did use that word in my submission. There are many community services that are excellent, but where does one begin? It is quite complex if a case manager is not there to help walk through it. It can be frustrating and frightening; the payer is unknown. It could be that the individual would be the payer. There is much variation in that regard across the country.

Senator LeBreton: That is an excellent lead-in to my next question. Dr. Alexander mentioned in his brief that home and community care are not insured under the Canada Health Act. Some people require long-term palliative care and cannot afford it. They are left in other institutions, if the family cannot afford to pay for the long-term care. What happens to these people?

Furthermore, what is the cost to the health care system? It must be that many thousands of people are left in hospitals because their families cannot afford to pay for long-term care at some private facility. What is the cost to the system? Where do these people go? What happens to them?

Dr. Alexander: I do not know if it has ever been costed out nationally. There have been numerous studies done on the problem of what is called pejoratively "the bed blocker" in acute-care hospitals. That situation arises after an acute episode of treatment has been completed and there are too few long-term care beds in the local community, or inadequate home support services in that community, to enable the person to be discharged. The person languishes in an acute care bed at a phenomenal cost to the system. This practice is totally inefficient and provides a totally inappropriate level of care. Bed blocking occurs because the other supports were never put into place.

I come back to my comments about the two-tiered U.S. style health system that exists in home and community care. Each province has its own policies with regard to how they manage patients' finances in long-term care. Very often, patients are required to spend all of their personal assets when they enter into a long-term care facility. The province may then give them a small comfort allowance on which to subsist after that point.

The other issue, which runs parallel to your comment, Senator LeBreton, is the impact on the home care sector when sicker and sicker patients are being discharged earlier and earlier into the community. Home care, which was designed to support people not only in an acute phase but over a long period of time, is being required to shift increasing resources into what is called "acute care substitution." In other words, it is like the hospital at home with all of the high-tech and high cost resources that go into that.

Fewer resources are available to provide the long-term care component of home care - the care that continues over time in the home. We have perverse incentives driving the system currently, which need to be resolved.

Senator LeBreton: You are absolutely right. It is a two-tier system.

Senator Graham: My congratulations to the three organizations here. As Canadians, we are proud of the service that you provide to Canadians. I have one quick question.

I am curious with respect to the VON. You say that you have services in nine provinces. Which province is not represented?

Ms McLeod: Prince Edward Island.

Senator Graham: That surprises me.

The Chairman: I am stunned.

Senator Graham: We have heard your representation of the need for analysis. Is there any kind of analysis that would indicate the savings in the home care bed as opposed to the acute care bed to which Senator LeBreton has referred?

Dr. Alexander: There has been a series of excellent studies that were funded by the Health Transition Fund and carried out by Hollander Analytical Services and the University of Victoria.

Those studies have shown conclusively that care in the home is by and large considerably less expensive than care in an acute care centre. The debate raged for many years around whether it was or was not more costly.

There was also an excellent study out of Saskatchewan not too long ago that indicated the extent of cost savings by providing care in the home versus care in the hospital. I would be happy to provide you with references.

Senator Morin: We have that in the material that was submitted to us this morning.

The Chairman: As I understand it, we made some modest effort to get one of those studies of which you speak. For some reason, we did not obtain it. If we could receive a copy from you, we would appreciate it.

Senator Morin: Those figures are here in a presentation.

The Chairman: Perhaps later, we could talk to you about how to get that information.

Ms Henningsen: The Hollander Group study funded by the Health Transition Fund is exciting. The study had approximately 16 or 17 sub-studies that looked at the cost-effectiveness of home care in different regions across Canada. It is quite comprehensive.

Senator Graham: Will we be provided the hard numbers, Mr. Chairman?

The Chairman: Yes, we will.

Senator Graham: What kind of training do home care workers receive?

Ms Henningsen: In which province do you live?

Senator Graham: Nova Scotia. You were talking about having national standards. Let's talk about it.

Ms Henningsen: Unfortunately, there is no set training program for home support workers. The training requirements depend on the policy of each province, which is why I jokingly asked your province.

Some provinces have set criteria. Ontario has a stringent training program. I believe that it is a three-year program for a home support worker. In Nova Scotia, a training curriculum is currently being designed. They do not seem to have instituted it yet. In Saskatchewan, there is no training program for home support workers. It is managed by the service agency.

Senator Graham: A person who is a resident in a long-term care facility pays according to his or her ability to pay. Is that correct?

Dr. Alexander: It varies, again, from province to province.

The Chairman: The answer is yes, you pay according to your ability. However, the rules for what is deemed to be your ability and, therefore how much you pay, are different in every province.

Senator Graham: Therefore, some people could go to a long-term facility free of charge if they could not afford the fee. The provincial government supports the cost. Other people, with assets, are drained of their assets in order to receive the same care.

If a person has some resources, they used for the services that are provided to all Canadians, wherever they happen to live. You are saying also that the type of services available varies from province to province.

Ms Henningsen: Yes, and from region to region. If you lived in the Ottawa-Carleton region, you could have access to different services than if you lived in the Mississauga region. It varies within provinces, too.

Senator Graham: Dr. Alexander, one of your eight recommendations states:

...develop national standards for the provision and administration of these services based on the principles contained in the Canada Health Act, and undertake the necessary financial analysis to establish appropriate federal contribution levels to support the services.

You want the federal government to pay for the analysis, which I think is quite appropriate.

Senator Morin: And for the care.

Senator Graham: Once they pay for the analysis, they are automatically co-opted.

Senator Morin: This is Minister Rock's plan.

Senator Graham: Would you like to comment on that further or elaborate on your recommendation?

Dr. Alexander: I would like to begin my comments by returning to the point about national standards. There are many kinds of national standards. There are, for example, the standards that have been developed by the Canadian Council on Health Services on accreditation for home care and long-term care. Those standards do exist. Long-term care facilities and home care programs across the country are being accredited as we speak. More are coming on board all the time. Those standards relate primarily to program administration and organization of the program, et cetera.

There are standards with regard to training. Those standards are not in place across the country. There are no national training standards for home care workers. They will occur within individual provinces; each province is different. Some provinces financially support them; some do not. Sometimes home care certificate workers must pay for their own training out of their wages, which is an impossible burden to carry.

With regard to the national standards to which I referred in the recommendation, those would be standards around the provision of the core services. Those standards should weave together the principles from the Canada Health Act to support those services. Those are the standards with which we are familiar as a country. They are defensible.

The analysis comment was made because at this point no one knows what it would cost. Numbers were floated at Minister Rock's policy conference in 1998 in Halifax. One of the commentators suggested that $1 billion might kick-start a national home care program. Maybe it would, maybe it would not. It is a number. Someone must do the hard thinking. The only way in which we could do that analysis is if we have some agreement on what would or would not be covered and to what level it would be covered.

One follows the other in my mind. We must reach that agreement first.

To return to a comment that Senator Morin made earlier on the notion of a national program and the political difficulty. I am sensitive to that problem. At the same time, the provisions of the Social Union Framework Agreement do not require unanimous consent of all the provinces and territories in order for the federal government to mount a program.

There is some political manoeuvring room here. At their health accord last September, the first ministers agreed to put home care on the national agenda. I think that there are options here that can be pursued in terms of moving ahead.

Senator LeBreton: To do that study, they also would need to look at the savings realized by people receiving home care.

Senator Robertson: You have been the most refreshing group of witnesses that we have had. I applaud your presentation.

Senator LeBreton: Were you here for the nurses yesterday? They were very good, too.

Senator Robertson: Many of my questions were answered by your presentations. I do have other questions.

Thank goodness people are now talking about tearing down the silos. Government departments, unfortunately, have a habit of building barriers around their programs and clutching them to their breast as if their life depended on maintaining what they have been doing forever, which is somewhat tiresome. Sometimes silos must be torn down within departments. We might think about that in the future.

Speech therapy is directed towards children in schools or senior citizens who have had a stroke. These services are available in large centres. However, we have a diverse population.

It is important that staff members be shared to gain more value. For instance, speech therapists in a less populated area would not necessarily work with only children or only seniors; they would work with both. The therapists could be shared and we would save some tax dollars. We must look at this.

I would like to know if you have experienced different modes of financing the health system. Canadians consider the health system to encompass everything about which we have been talking. Unfortunately, we must work to get it financed. I thoroughly agree.

Have you seen experiences in the country where the funding of health services is done vertically by the department of health? In other words, dollar comes down from the department to the hospital, from the department to the nursing homes, from the department to public health, and from the department to mental health.

I know that there are some models where a block of funding is given to an umbrella group in a region or zone. The people on the board of the umbrella group could determine the greatest needs.

Is that a better system for funding, in your experience, than this vertical process? Have you examined the effect of those two processes, the vertical and the umbrella?

Dr. Alexander: I personally have not seen any evaluation studies. I believe that when the Quebec health care system went through its reform process a number of years ago, following the Castonguay-Nepveu commission, that was one of the shifts that they moved towards with their regional boards.

The model, at least on paper, looks good. It is a democratically based model that empowers communities to allocate resources and target them to health status at the same time and to raise the health status by funding. It is a model well worth study. An evaluation protocol for that should be developed. The other models are the more traditional models.

Again, the comment reflects back to the comments that were raised in your paper around the notion of the population health approach to health care funding. We know that the health services component is not the only one that improves population health. I sense that that is the direction in which you are going with this.

Senator Robertson: Senator Morin may be able to help us gain some information on that. I know that some other jurisdictions have tried that approach, and they may have models of this. I do not know how successful they have been.

I would now like to open the territory somewhat wider. If you do not have anything on this, perhaps you might advise us where we would look.

Dr. Alexander, you mentioned that you had a research department. Would your research department know of any country that integrates all the components of the health care system and ageing benefits?

I was watching some sophisticated witnesses one night. I believe that they were from Singapore. Their old-age benefits are integrated with their other health benefits. It seemed that there might be an element there that could help us. Have you knowledge of any such elements?

Dr. Alexander: I personally do not, but I would be happy to look into that for you.

Senator Robertson: There are other countries as well, but Singapore comes to mind first.

Ms Henningsen: I might have access for you. Recently, I did a presentation at a conference in Budapest, Hungary. While there, I met a colleague from Germany who described an interesting funding method whereby they included an insurance product for nursing care, for old-age benefits, for unemployment insurance and for worker's compensation. They all went under the umbrella of the insurance. I do not want to go into any details, because I am not conversant on it, but I can send you the papers.

Senator Robertson: I believe that Austria has something similar. There is much happening elsewhere. From what we have heard from witnesses thus far, there seems to be a general expression that our delivery system is out-dated. It is time to give it a good shake and redesign the delivery of our services.

I thank you for your excellent presentations.

Senator Cordy: This is a follow-up to Senator LeBreton's question on the public's misconceptions about home care. Dr. Alexander, you spoke about the financial aspect of home care.

There is another misconception about home care: many people believe that when someone is released from the hospital they will receive a home care worker, if not full-time, certainly for a high percentage of the time. They become distraught when they realize that the home care worker will come for one hour per day, or perhaps just three times per week. Suddenly, the family is in a dilemma, because often situations like this occur rapidly. In many cases, there has been no time to prepare for such a situation.

Dr. Alexander, one of your recommendations was that the federal government make allowances for respite care. However, Dr. Armstrong was here from the Women's Centres of Excellence in Health Care. She made the point that in most cases, the caregivers in the home are women. In some cases, the women have chosen to be the caregiver; in other cases, the responsibility is simply thrust upon them.

There is a need for more than just respite care; there is a need for family support. Sometimes people who need the care are going home to an abusive situation or perhaps they are just not able to deal with it. Did you consider any of these things when you looked at the issue of respite care, or that particular recommendation?

Dr. Alexander: We certainly did. Thank you for your question. I would draw a distinction between "respite care," which is a service that is usually provided, or traditionally has been provided, to the ill individual versus "respite," which is time off, or a break from caregiving. My comments are directed toward the latter.

The study that we undertook in 1998 and completed was a landmark study. We found, as we went across the country, that very few home care programs were targeting the needs of the caregiver in the home, or the person who was coming in to the home help the ill individual.

We really had no idea how to respond appropriately to them, in many cases. One of the contributions this study made to new knowledge was to suggest various ways in which "the system" could respond more appropriately to these individuals' needs. Again, they need not be high-cost kinds of strategies to give people a break, or some time off. I would be happy to share our report with you, which outlines that in great detail.

The Chairman: Dr. Alexander, in your paper you spoke about ideas for using the tax system as an incentive. Do you actually have any specific proposals in that respect? If you do, I would appreciate reviewing them.

Dr. Alexander: I wish we had some specific proposals. I regret to say that we have none. Obviously, we believe that it is an area that is worth mining at this point.

The Chairman: My second question arises from your responses to Senators Morin and Graham. Senator Morin made the point that a national program is a difficult, if not impossible, political sell. Senator Graham spoke about the means of funding. For example, the way that people pay if they are in a nursing home or long-term care home, in the sense that they pay somewhat according to their means.

Additionally, all three of you spoke about the principles of the Canada Health Act. I would like to know how firmly you are behind the principles of the Canada Health Act? The kind of program that works in nursing homes, in which you pay according to your needs does not meet the principles of the Canada Health Act. That does not mean it is not a bad program.

What is your reaction to a home care program where an individual would pay on the same basis as one would pay for long-term care, which is an amount based on the individual's resources? What is your reaction to Senator Graham's idea extended to home care, which places it outside the Canada Health Act?

If it is so difficult to sell a national home care program, would it be possible to define the parameters of a program targeted - at least initially - only at palliative care? The politics of selling a national palliative care program are much better than the notion of a full, wide open home care program, which is difficult to provide to people. Is it possible to know when the home care provided genuinely meets the test of palliative care? Those are two ideas, and I would like all three of you to give me your reactions to each.

Dr. Alexander: With regard to the issue of using a home care model similar to that used in long-term care, I do not see how that would move us forward very far. We are still creating a barrier to care. Study after study has shown that when people are aware that they have to pay for care, they tend not to access that care. The last thing we want is for people to be discouraged from seeking care at a vulnerable moment in their lives.

The second issue has to do with the level of care that they require. If they do the mental arithmetic and decide they can not necessarily afford it, then a self-selection process occurs.

We are creating barriers to care, rather than encouraging people to obtain the care when they need it. I, personally, do not see that entrenching a two-tier approach to long-term care in the home care system would solve many of the problems.

I do not know the political dynamics of palliative care. Any targeted funding seems to be difficult for the provinces to accept. The question would have to be on the levels of funding, the extent of funding and the federal, if you will, intrusion into the provincial jurisdiction around it.

The dynamics are the same. Whether the provinces will find it any more comfortable or not, I simply do not know. Certainly, palliative care has an emotional appeal and there is a strong need for it in Canada. That may be the entrée at the provincial level, but it is a judgment call at this time. I would personally prefer to see it as part of a comprehensive program.

The Chairman: We all would prefer that. If a comprehensive program is not possible, then what is the first step? I am asking whether palliative care is a reasonable first step.

Senator Morin: It is not the most expensive part of home care. The most expensive part is what you call acute care.

Senator Robertson: If you started with one, though, would you not just be enforcing the silo?

The Chairman: That is why I put it forth. I had not thought about it before today. Ms Henningsen, do you have any comments?

Ms Henningsen: In regards to the payments for home care services, the CHCA does not advocate such strong adherence to the Canada Health Act. We believe that a shared responsibility for home and community care is needed.

We believe that education of the public and planning for home care requirements will allow the Canadian public to be able to receive services in their home. Let me give you an example of that.

There are now programs available that have long-term care insurance. We certainly know that we are all ageing. We know that we prefer to be at home; we do not want to be in an institution. Therefore, we should start to plan for that now. We advocate for a shared responsibility.

There is a model in Manitoba where the home care programs are permitted to spend for home care services up to the amount that it would cost to have someone in a long-term care institution. Basically, they are saying that a certain amount of funding exists for each client whether they are in a long-term care institution or in home care.

By understanding better the costs of having someone in a long-term care institution versus someone in the home, we will be able to set a bottom line of what the public funding needs to encompass. I do not think that it is realistic to look at publicly funding everything. Health care is too comprehensive. We do not want our taxes raised any more. That is from the funding source.

In regard to palliative care, as Dr. Alexander mentioned, it is an emotional issue. It is certainly one that involves a high intensity of care. From a system point of view, acute care substitution is the quickest and easiest way to see the value of home care, because you could compare it to a hospital bed. You do not want to limit yourself with just the acute care or the palliative care.

A national home care program will not happen. However, there should be a national base of standards. What should home care include? It should include end-of-life care, long-term care, and acute care. We could then talk about which services should be included.

We could give that to the provinces as a goal to work towards. We have given ourselves that as a target to work towards.

Currently, every province describes home care and community care differently. We are one of our own worst enemies because we describe it differently from province to province. If we could have one common definition and one goal to work towards, we would see progress.

Ms McLeod: In terms of the issue of what is affordable, I share Dr. Alexander's concern that if there is a cost to these services, many will not access them. The deterioration of health would continue. The patient would end up in a long-term care facility or in the hospital. There is a real risk there.

We are more concerned with equability of the services. That should be a standardized level of services across the country. Thus, a home support worker in Ontario would have the same qualifications as her counterpart in Newfoundland or Quebec.

The Chairman: The basket of services and the level of training would be comparable.

Ms McLeod: That would be a very important issue.

On your question of the palliative program, it would be quite difficult to judge when an individual reaches the level of requiring palliative care.

The Chairman: That is the reason for my question.

Ms McLeod: That is a tough question to answer. I am not sure that we have the definition at the moment, although it is an interesting prospect to have one.

The Chairman: We talked about palliative care, and I did not know how you decided when someone moved from being a sick patient to being a palliative care patient. I assume that is a judgment call by the physician..

Thank all of you for coming. They have been terrific presentations.

Senators, I have one announcement for you, and I need one quick motion.

The quick motion regards the subcommittee that we structured a while ago. We must formally put five committee members on that subcommittee, although it is understood that we will then be substituting members of the committee off for other people when we do it.

I would like a motion that Senators LeBreton, Cook, Cordy, Robertson, and myself go on the subcommittee and that the subcommittee have the ability to manage its finances under section 32 and 34 of the Senate Act. Is that agreed?

Hon. Senators: Agreed.

The Chairman: May I remind you that next week the Senate will not be sitting, so we do not meet. On Monday, May 28, 2001 and the following two Mondays, we have videoconferences. They start at 9:00 p.m. because of the time change to Europe.

I ask that you be on time, please. The witnesses in Europe will be on time. They will be held in 257 East Block. We will tell your offices.

On the May 30, 2001 we will have a lengthy session because we have agreed to look at the entire Aboriginal health issue in one sitting. On May 31, 2001, we have several panels on rural health.

Thank you very much for coming.

The committee adjourned.

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