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

Issue 19 - Evidence (9:00 a.m. session)

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OTTAWA, Thursday, June 7, 2001

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 9:07 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 learn what we can about the Swedish health care system. Our witness this morning is Lars Elinderson, a member of the Committee on Health and Welfare of the Swedish Parliament.

Mr. Elinderson, as has been explained to you, we are really trying to look at what reforms, if any, should be taken with respect to the Canadian health care system. We are trying to understand how the models of health care delivery in some other jurisdictions are handled and how they are structured. We would like you to begin by making some comments on your system, and then my colleagues and I will be delighted to ask you some questions. Thank you for taking the time to be with us.

Mr. Lars Elinderson, Deputy Member, Committee on Health and Welfare, Swedish Parliament: Mr. Chairman, I should like to present myself. I have been a member of the Swedish Parliament since 1998. Before that, I was a county commissioner in the county of Skaraborg for 12 years and mayor of Falköping for seven years. In that respect, I have all the different levels of the health and medical system in Sweden in focus.

This Swedish system is a formally decentralized system, as you have written in one of your comments, but in real life it is not so. I should like to take a few minutes to explain the main elements of the Swedish model.

All health and medical care is under the same act, the Swedish Health and Medical Care Act. The law regulates that all health care and medical services should be available to everyone. It dictates that the counties are responsible for funding and providing health care and medical service - the whole scale from preventative action and primary health care to highly specialized care.

In that sense, the Swedish model is a highly decentralized system. However, at the same time, it is necessary to stress the fact that each county not only has the obligation to fund but also to provide health care and medical services. This means that we have 21 regional monopolies in the area of medical services and health. Virtually all health care and medical services are provided by government-operated units, primary care centres and hospitals.

The funding is normally based on a fixed budget system. All professionals, both in the hospitals and in the primary care centres, are paid by the county government on a fixed salary basis.

In most counties, the patients need referral from a GP to visit a hospital, except for emergencies, of course. The doctor is normally not able to refer a patient to hospitals outside a county. Most of the regulations in the specific counties follow national recommendations and agreements between individual counties on the one hand, and between the Federation of County Councils and the government on the other hand.

I think this will give you the main structure of the Swedish health system.

The Chairman: Thank you. Health care is very broadly defined in your case. It includes all drug care and physiotherapy and that kind of thing. It is an all-encompassing definition. Is that right?

Mr. Elinderson: That is right. The individual doctor makes the judgment of what different medical service or care is needed for the individual patient. All aspects are considered in his judgment.

The Chairman: Can you explain to us in some detail how your user fees work? As I understand it, for every procedure you pay some modest user fee. I would like to get some details on how that works for two specific areas. What do you do for low-income welfare patients? How do they pay the user fee? There has been an argument advanced by opponents of user fees in Canada, but the argument is also used elsewhere, that for low-income workers, people who are low-income but not on welfare, a user fee amounts to a deterrent such that they will not seek medical help when they actually need it. Can you comment on those sets of issues surrounding the user fee question?

Mr. Elinderson: First, I should like to stress the fact that we have a maximum annual fee for each individual. You are not obligated to pay all your visits if you are in need of regular visits to a doctor. Nine hundred crowns per year is the maximum fee for each individual. That would equal something like $150 Canadian, I think. It is a reasonable maximum fee for a person with continuous need of medical care or assistance.

Children under the age of 18 pay no fee at all. This is decided by the individual local counties, so it can be different in some counties, but the majority of the counties have no fee at all for children under the age of 18.

The fees are somewhat higher in the hospitals. In the hospital, for an individual visit, it would equal about $40 Canadian. In the primary health care centres, the fee would be, in most cases, $20 Canadian. This is because the aim is to make the patient choose a less expensive and acceptable level of care in the individual situation.

People on social welfare can be paid for by the local government, which is the provider of the social welfare, for their medical needs.

The Chairman: Let me pursue your view that the user should have a market signal, in effect, that says to him, "If you have a choice, we want you to choose one that is the cheaper of the options." Does that sometimes lead them to make a choice that is not medically good? In an attempt to save money, do they deny themselves service that they really ought to have at the more expensive level?

Mr. Elinderson: I do not think so. I think the overall tradition in Sweden, when you get sick, is to go to the hospital. We do not have a strong tradition of using your GP when you get ill. You turn to the hospital. The idea of this different fees is that you should make a judgment as to whether you need a hospital or if you can seek the service or the care at the local health centre instead. If you really need the specialized treatment or specialized care, you will choose to go to the hospital.

Senator Callbeck: I have a few questions on the funding. The national government gives the money to the councils. How is it determined how much money they will give them? Is it solely based on the number of people who live in that area, or are there other factors involved?

Mr. Elinderson: Approximately 60 per cent of the funding is by local taxes, or, rather, by county taxes. A proportional income tax, about 10 per cent of the income, is funding for medical care and medical services. The other 40 per cent is provided by the national government, and that includes the medicine and pharmacy part of it. I think that the pharmaceutical costs are is about half, or about 20 per cent of the total cost of the health system. The larger portion of the funding is county proportional income tax.

Senator Callbeck: Of that 40 per cent that comes from the national government, how do they determine how much goes to each county?

Mr. Elinderson: Most of the money is distributed by way of demography and the numbers of people living in the county. It is a rather rough way of distributing the money. However, some portions of the national money are specifically delivered in relation to certain objects, following agreements between the Federation of County Councils and the government, to develop systems such as child care or things like that. They have agreements, and the money follows the agreements. The largest portion of the national money is distributed by way of demographics and the numbers of people living in the area.

Senator Callbeck: Is that attached to the GDP? How does the national government decide whether they will increase that? Is it tied to anything?

Mr. Elinderson: No, not really. It is a matter of political debate. There is always a lack of money for the health sector, so the government tries to negotiate a certain figure. For example, this spring there was a negotiation process between the county councils and the government for special arrangements to shorten the waiting lists, so they paid a sum of money to the county councils for different actions to shorten the waiting lists. The largest portion is distributed by way of demographics.

Senator Callbeck: With respect to the 40 per cent contributed by the national government, do they follow up on that to see how it is spent, or do they just hand over the money and that is it?

Mr. Elinderson: Not really. The political responsibility is on the counties. The counties are elected every four years, for the same period as the government. Normally, the political majority in the majority of the counties is the same as in the national government. There is discussion between the different levels, but the responsibility is on the county level.

Senator Callbeck: Thank you.

Senator LeBreton: I have a question about private health insurance. I understand that you also have private health care insurance. I am wondering how it is utilized and how it integrates with the public health care system?

Mr. Elinderson: We have a very short tradition of private insurance in the health system because the public health system is supposed to cover everything for all individuals. Because of difficulties with accessibility, waiting lists and things like that, some people - I think about 120,000 people in Sweden now - have bought private insurance to have quick access to hospitals when they need it. Most of that insurance is paid for by their companies or their employers. The growing rate of the number of insured, or people on private health insurance, is some 80 per cent or something like that now. It is growing very fast due to the normal waiting lists and the problems within the system today.

Senator LeBreton: How is that impacting on the general public that relies on the public health system in terms of waiting lists?

Mr. Elinderson: This will create criticism towards the system. This is already creating criticism towards the system. Because we have a tradition of being treated equally, it is not accepted by all people that you can buy yourself ahead of the queue, so to speak.

Senator LeBreton: An article in one of our national papers early in May dealt with the Stockholm regional health board. It talked about the long waiting lists. I guess it is only in Stockholm, according to this article, but they decided to experiment with public funding for private services in the early 1990s. The largest health council in the most socialist of Western European nation, according to the newspaper, began contracting out. They claim in this article that the costs for lab and x-ray services fell by nearly 50 per cent. Is this just happening in Stockholm? Are people watching this? Will it seriously impact on the universality of the health care system for Swedish citizens?

The article mentioned St. George's Hospital in Stockholm now being run by a private company, and that they have reduced costs by 30 per cent. Is this happening all over Sweden? How is this infusion of the private system impacting on the public system? There are some similarities to what is happening here in Canada.

Mr. Elinderson: The political majority in most counties are socialists or left wing today. They are not in favour of the changes taking place in Stockholm, for example. Two major regions are trying to develop the health system by contracting private companies and private health providers. This is the main debate today. I think the effect in the rest of the country would be similar to what happened in Stockholm: We would be more productive within our system if we contracted privately to other providers.

You have to consider that all the hospitals except two in Sweden are actually operated by the county governments. This has created a lack of productivity within the system.

Senator LeBreton: You talked about the 21 regional monopolies, and Senator Callbeck asked about the 40 per cent funding by the federal government. How do you maintain standards? Are there different standards from one county to another? How do you ensure that there is the same kind of universality of standards across the 21 counties?

Mr. Elinderson: The difference in standards is not very big between the different counties because they all try to make a formula or standardize the systems between themselves. There are agreements between the individual counties and between the Federation of County Councils and the government.

Senator LeBreton: Thank you very much.

The Chairman: I would ask you to go back to the question Senator LeBreton asked you. You said that all but two of the hospitals in Sweden are owned by the county councils, and that they are, in that sense, not terribly efficient. Why are the ones not owned by the county councils more efficient? What is it that makes them that way? Is it the management style? Is there competition between the hospitals? What is generating the increased efficiency?

Mr. Elinderson: We have a long tradition in Sweden of publicly run or operated facilities. Also, boards are populated by politicians, not professional doctors or lawyers and other people who normally staff boards. I think that this has created a culture that is not very moderating for raising the productivity. That is the first point.

Second, the individual hospitals are not paid for performance. They have a fixed-budget system. All the staff, the medical professionals, are paid within the fixed salary system. This would not give any incentive for high productivity. These are two of the explanations.

The Chairman: In the ones managed by the private sector, are the doctors not on salary? Are they paid a fee for service or something like that?

Mr. Elinderson: They have more incentives like salaries and things like that. Not totally, but more. They have smaller organizations. The counties are really huge organizations. For example, in this region where I live, there are 45,000 employees within the health system. It is very hard to manage a big organization like that. The privately-run hospitals are relatively small organizations, and they can be more cost efficient.

The Chairman: Do you think that if you went to privately run, very large general hospitals, you would not get the same efficiencies?

Mr. Elinderson: I think so. We would have an incredible rise in efficiency and productivity if we split the county organization into separate parts.

The Chairman: Thank you.

Senator Morin: I should like to carry on with this private care issue. I also read recently that the proportion of health care costs in Sweden that comes from private sources is increasing. It is now 16 per cent, and the percentage is increasing every year. Would you care to comment on that?

Mr. Elinderson: Ten per cent out of the 16 per cent includes the fee the patients pay for the public sector. About 6 per cent of the total health sector is actually operated by private doctors and private hospitals, or private physiotherapists and things like that, and most of that is also funded by public money. The rate is less than 6 per cent, I would say.

Senator Morin: Coming back to total health costs, what proportion of GDP does Sweden put to health costs, and has there been an increase? We have figures, but they stop at 1999 and 1998. Here in North America, there has been a major increase in health costs over the last two or three years. Have you had the same phenomenon in Sweden?

Mr. Elinderson: Not really. We have had, in the last five to ten years, a drop out from the public sector. Many doctors and nurses leave the system and try to work in vacancies. They go to Norway for shorter or longer periods; they work in the pharmaceutical industry; they go to Saudi Arabia. A rather large proportion of the publicly employed doctors, nurses, physiotherapists and so forth have left the system in the last five, six or ten years because of the budget reductions and because of the bureaucracy and the problems within the public sector. I do not think we have had an increase in the number of doctors working within the system. Rather, I think we probably have a decrease in the number of doctors working within the system.

Senator Morin: How did Sweden succeed in keeping the costs down? Most other countries' costs are increasing. Is that because the number of doctors has been decreasing? Is that why the costs are less?

Mr. Elinderson: Most counties work within a fixed budget system. It is only a matter of political decision. You decide to reduce the budget, and the hospitals and the counties have to deal with that. They will have to slim the organization. The major explanation is that the counties and the government reduce the funding.

Senator Morin: Are the health care services affected?

Mr. Elinderson: Yes. We have had longer waiting lists and other problems such as vacancies.

Senator Morin: There has been a program of internal competition which is called, I think, the "purchaser-provider split." How effective has that been?

Mr. Elinderson: It is not a model that actually looks the same everywhere they have tried it. The idea was to separate the funding and leave the fixed budget system to a more market economy type of system where at least parts of the funding could be distributed through a fee-for-service system. In some respects, during a short period, it led to a rise in productivity in some parts of the country, but I do not think it made a big difference.

Senator Morin: Thank you very much.

Senator Pépin: You mentioned that you do not pay for health care for children. Until what age does that apply? Does that also include eye care and dental care?

Mr. Elinderson: Dental care is included, but it is not in the health care system. Another act regulates that, but we have the same system for dental care. Dental care is provided free for children up to the age of 18. Medical care and health care are also provided for free up to the age of 18.

Senator Pépin: You said that the number of doctors is decreasing. They are publicly paid. How are the salaries of doctors negotiated? Are doctors satisfied or happy with their remuneration? That could be one of the reasons why the number of doctors is decreasing.

Mr. Elinderson: The number of doctors within the system is decreasing. I think we have an increasing number of doctors in total, but a growing number most of them do choose not to have positions within the public health system. They take vacancies instead. When the hospitals cannot fill their positions, they try to hire in for shorter periods. There are many doctors who go around the country and are paid for shorter periods. They work for two or three months in each hospital. In that way, the hospitals have to follow the market. They need to pay people to have them come and work with them. It is a way for doctors to get paid better.

The salaries are negotiated on the national level between the Federation of County Councils and the doctors' association through normal salary negotiations between the parties. Most counties follow that agreement. The same goes for the rest of the health sector such nurses' salaries, physiotherapists' salaries and others. We have a very flat salary structure in Sweden. Few countries have lower levels of salaries for doctors than we have in Sweden. It is very popular for Swedish doctors to go abroad for longer or shorter periods to work.

Senator Pépin: We have seen that in some provinces. We are beginning to have a similar problem.

Are the doctors involved in decisions regarding the health care system? Can they be part of the decision-making procedure? If the government wants to make a decision regarding a special treatment or regarding a budget, are the doctors involved somewhere in the system? Do they have an impact?

Mr. Elinderson: Not formally, of course. It is a matter of political decision. However, in reality, the doctors have a great impact. They are representatives, more or less, for the sector towards the politicians. You have a word for it in English. They have the general opinion on their side, and they can use -

Senator Pépin: Public opinion.

Mr. Elinderson: They are pressure groups on the political system. However, formally, it is a matter of political decision.

Senator Pépin: Do you have similar difficulties with nurses? How are the nurses organized or paid? Is it a similar system, and are they happy with their work?

Mr. Elinderson: It is quite similar. We have a national negotiating process for salaries and other parts of the job. Of course, the nurses as a group are not as strong as the doctors. If I said that doctors are not well paid in Sweden compared to other countries, that would go for nurses as well.

Senator Pépin: Thank you very much.

Senator Graham: I want to go back to your response to a question asked by Senator Callbeck with respect to the formula for paying health care insurance in Sweden. You talked about percentages. I just want to review those so we have them clearly. You said 60 per cent is funded by local taxes and 40 per cent by the national government, which is 100 per cent. Then you said there was 10 per cent paid by medical care. That is 110 per cent. I am more interested in the accuracy of the percentages paid by the national government and the local councils.

Mr. Elinderson: To be accurate, the public funding of the health system is 40 per cent and the national government is 60 per cent, county taxes, but 10 per cent of the total costs are private fees. I think that private fees to the health sector totally is 10 per cent, but if you look at hospital care in particular, it would be 5 or 6 per cent; health care outside of hospitals would be 14 or 15 per cent, or something like that.

Senator Graham: What percentage of the people purchase private insurance?

Mr. Elinderson: Less than 3 or 4 per cent; probably about 2 or 3 per cent.

Senator Graham: What is the view of the Swedish people, the population at large, with respect to the user charges? Are they generally acceped?

Mr. Elinderson: They are accepted. We had a debate some years ago when children had to pay fees, too. We had a debate on that. There has not really been any question to reduce or take away the fees for grown-ups. We have always had them, and they are accepted. It is not really a very high cost. The ceiling on an annual basis is 900 Swedish crowns. We also have strongly subsidized pharmacies.

Senator Graham: What is the income threshold at which these user charges begin to apply?

Mr. Elinderson: The charges apply to all citizens except for children.

Senator Graham: Would someone be denied care -

Mr. Elinderson: No.

Senator Graham: - under any circumstances if they could not pay user charges at the point of service?

Mr. Elinderson: There are situations, of course, when people do not have any money or a credit card on them when they come to the hospital, and the hospital has to charge afterwards, but that does not happen very often. You know if you are going to the hospital or to the doctor that you have to have the 100 crowns or 200 crowns, depending on if you go to the hospital or to a general practitioner. Normally, most people have 100 crowns or 200 crowns when they go there. Sometimes it happens that you do not, and then the government has to charge it afterwards. Most people actually pay it.

Senator Graham: How much emphasis is placed on preventative health care programs in Sweden?

Mr. Elinderson: Not very much within the health sector, but we have a rather large preventative agenda within the local community municipality sector that is cooperating with the health sector. I cannot say compared to other countries, but in the health sector, the counties have a rather low proportion of preventative medicine.

Senator Graham: Finally, has Sweden invested in tele-health activities?

Mr. Elinderson: We have in some parts of Sweden, but we have not come as far as you have in parts of Canada. I had the opportunity to visit Alberta last September. We have the techniques, of course, but we do not have as much experience yet. In the remote parts of the country where we have about the same problems you have, this is growing.

Senator Graham: Thank you.

Senator Pépin: I have another question regarding the population over 65 years old. I believe that in Sweden you have a large population group who are elderly. I read somewhere it was close to 17 per cent. In Canada, we have 12 per cent. How is your country able to cope with this situation? It seems the responsibility for housing elderly persons is being given to the municipality. Does it help to have fewer people in the hospital beds? We know that when people are old, very often we have them in hospital and they occupy those beds.

How does the system work? Do you have any provision for the future, or advice on how we should cope with and address that problem?

Mr. Elinderson: We are lucky enough to be out of the wars. We can see in the demographics that all of the people who were in the war are growing old now. We have a larger proportion of people over 65 years of age than most countries, or at least most European and North American countries. I think that the Swedish population is one of the oldest in Europe, and in the industrialized world.

This is not, of course, a very big problem for us. We had a change in responsibility some eight or nine years ago as far as medical care for old people is concerned. The local municipality now has responsibility both for the medical care, the normal day-to-day medical care, and the housing and social care of old people. There are regulations that the municipalities have a responsibility to take the old people from the hospitals when they have been medically treated and do not need further medical treatment at the hospitals. This has led to a major increase in the number of employees, service houses, old people's homes and things like that in municipalities. That is working rather well in most parts of the country.

We try to create systems that enable people to stay in their ordinary homes and have their services in their normal homes as long as possible. This is working very well in some municipalities, but we also have a rather large proportion of old people living in nursing homes.

Senator Pépin: As you say, you have a system that allows the elderly to live in their own houses. You must have doctors making house calls.

Mr. Elinderson: Yes, especially district nurses, but not so much doctors. If a person needs more qualified medical care, that person must go to the local medical centre or the hospital. The district nurses, the physiotherapists and other persons provide most of the care.

Senator Pépin: Thank you very much.

The Chairman: I should like to return to the issue of waiting lines. As I understand it, about 10 years ago that was a very hot political issue in Sweden. It is currently a hot political issue in Canada.

As I understand it, your national government introduced a guarantee to the citizens that waiting lines would be capped at three months for certain things, three weeks for something else, and so on. I can understand how a national government could pass that policy, but I have no idea how they could make it work.

What happened as a result of the so-called waiting line guarantee? From a practical standpoint, what actually made it work?

Mr. Elinderson: The former national government introduced the waiting line guarantee. The main components of the guarantee was that, as a patient, you were guaranteed that if the county in which you lived could not provide you with the service you needed within three months, you could have the money to go to a private hospital, private provider of medical services, or a hospital in another county. This created a situation of competition among counties, hospitals and private providers of medical services that raised the productivity dramatically within some years only. The problem was that this guarantee was restricted to only 12 or 13 different diagnoses, those that had the longest waiting lists. Some of the problems were transferred over to other diagnosis and other parts of the system.

As a whole, the main effect was that we had a dramatic raise in productivity, because the doctors and the hospitals were paid more than through the fixed budget system for their contribution. If a patient could have medical service within the county, he was guaranteed that the county would pay to meet those needs in another hospital or another county.

The Chairman: In effect, the county hospital then saw the danger that it would lose income?

Mr. Elinderson: Yes.

The Chairman: They then increased productivity to meet the waiting line targets. That is the behavioural response.

Mr. Elinderson: Yes.

The Chairman: How did the government decide the amount to pay for someone who did not meet the waiting line list in time, and therefore had to go somewhere else? For instance, was a patient given a certain amount of money and could then shop around for a hip replacement, for example, or did he go and get the hip replacement somewhere else and send the county the bill?

Mr. Elinderson: The latter is the way in which it was done. If I remember correctly, there was a price list on the national level. They introduced a list of reasonable prices or costs for each individual treatment. The counties were obliged to pay through that list. The hospital that treated the patient sent the bill to the other county.

The Chairman: Are the waiting line guarantees still in effect?

Mr. Elinderson: No. The government in power today did not like the system. They are not in favour of a market system in the health care system, so they tried to find other ways to solve the problems. They abandoned this system. One of the effects was that the waiting lists were much longer within a short period of time.

The Chairman: That is a terrific case study. You introduce an element of competition and the waiting lines decline; you remove the element of competition and the waiting lines almost immediately increase again. Is that right?

Mr. Elinderson: That is my opinion, but of course representatives of the government would argue the opposite.

The Chairman: We understand that. It does seem to me that the length of the waiting line ought to be reasonably factual. There are people on it or there are not.

Mr. Elinderson: Yes. I think that the results of the period with the guarantee is that the general opinion has another view on this matter. I think that they are in favour of reintroducing that system.

The Chairman: Will there be political pressure on the government to lower the waiting lines? Will they go back to the old system?

Mr. Elinderson: I do not think the government we have today will reintroduce it, but I hope that such a thing will be possible after the elections next year.

Senator Pépin: It seems we have a similar solution. Coming back to health services for the elderly, is there any cost for a patient who needs those services when they are in special houses for the elderly, and what is the cost to have that service? Let us say they have a visit from a nurse or physiotherapist. Is there a price they have to pay to get those services?

Mr. Elinderson: The costs of elderly care, including the medical care for elderly people, is considerably higher than normal health care because it contains a broader range of different services: housing, social services, counselling, medical treatment and things like that. The costs are considerably higher.

There is a big debate in Sweden now on how to change the system. It is accessible for all Swedes. If you do not have any money, the municipality provides the service anyway, but depending on how much money you have and how high a pension you have, you have to pay a part of the cost by yourself. This is a very demoralizing system because some people think that they have to spend all their money before they get old because, if they do not have any money at all, most services will be free. There is a debate now on how to create incentives for people to pay for their own services without creating these inequalities between those who have saved and those who have spent.

Senator Pépin: It could be pro rata of their income.

Mr. Elinderson: Yes.

Senator Pépin: Also, on a different matter, do you have electronic medical charts or records? Is there legislation regarding the confidentiality of those charts and who can get the information in your medical chart?

Mr. Elinderson: It is only the people who treat you medically, the doctors and nurses, and not any doctor or nurse, but the doctors to whom you are referred or the doctor in charge of you as a patient. The confidentiality or secrecy is guaranteed. Only the doctor or the other professionals who treat the patient or the professionals consulted according to the patient's needs can read their files.

Senator Pépin: Does that mean you are already using electronic patient records?

Mr. Elinderson: Yes. I am not sure how it works in Canada, but there has been reluctance to use IT in this respect. Slowly, they have found technical means to secure the patient's integrity. In some parts, they use technology to communicate, but I am not sure we have developed the systems very far.

The Chairman: I should like to go back to the issue of the experiments in Stockholm with respect to contracting out. As I understand it, they did two basically different things: First, the hospital was managed by a private sector company and a private sector board, so at a management level it was private sector. Did they also essentially contract out various services that might have historically been done in the hospital? For example, did they decide that they would no longer do magnetic resonance imaging, MRIs but would contract that out, for example, to some private sector facility near the hospital? What did they really contract out, or was the change only because they brought in a different management team?

Mr. Elinderson: I think the major change was that they brought in different management. The hospital, the buildings and some of the equipment are still owned by the county and rented by the private company that has run the hospitals for, I think, 10 years. Most of the services and care provided at that hospital are exactly the same type of care and the same spectrum of care that was there before the private company took over the hospital.

The Chairman: Have there been any studies done on patient satisfaction or dissatisfaction with the system? People in Canada who would be opposed to that type of model would say that the patients will receive less quality care in order that the private sector owners can make a profit. I am curious as to whether any customer satisfaction studies or patient satisfaction studies have been done.

Mr. Elinderson: Both employee satisfaction surveys and customer-patient studies both show an increase in satisfaction. I have visited the hospital possibly ten times, and when you visit that hospital, it has a totally different atmosphere than it had previously, and it is also different from most other hospitals. We have hospitals professionally run by the government too, but it is a totally different atmosphere. If you discuss this with the employees, the nurses and the doctors, there is no doubt that all of the ones whom I have spoken with, at least, are very satisfied with the change.

This idea is spreading throughout the country. They have no problem in recruiting new doctors, nurses, physiotherapists or other medical people at all, or management people, while every other hospital in the country has great problems.In fact, they have people on waiting lists to start working there. I think that we will have a large debate on the change in the coming year till next year's election, and I think that that example will affect the debate all over the country.

Senator Morin: This is very interesting. Has this interesting experience been published? Can we read the figures on this, or is this too recent?

Mr. Elinderson: I think there are publications that discuss these surveys. I am not sure, but I think I have read some things besides the newspaper reports. I have read some memos on that. I am sure that I can manage to find some interesting material. I am not sure whether it is in English, but it would be possible to find people to translate that material.

Senator Morin: I would appreciate very much receiving that material. What have been the reactions of the unions and the employees to this?

Mr. Elinderson: The first reaction was one of reluctance, so to speak, but the experiences from this example have changed some. The doctors and nurses have been in favour of the changes. They are actually advocating changes to the whole system. The greater number of employees in the hospitals or health system - the assistant nurses and other professionals, except for the specialized medical professionals - have traditionally been left wing politically, and they have opposed such changes.

I believe that there is a change. They had their annual conference two weeks ago, where there was a first-time debate on this issue. The majority is still opposed to these changes, but an increasing number of union officials are in favour of the changes.

Senator Morin: Thank you. I appreciate your comments and I am impressed by your knowledge of your health system.

Mr. Elinderson: Thank you.

The Chairman: On behalf of the committee, I thank you for taking the time to appear before us via modern technology. If you are able to obtain the material that Senator Morin spoke to you about, we would appreciate it.

Mr. Elinderson: It has been my pleasure.

The committee adjourned.

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