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

Issue 30 - Evidence

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 9:05 a.m. to examine the state of the health care system in Canada.

Senator Michael Kirby (Chairman) in the Chair.

[English]

The Chairman: Senators, we are here to get reaction to our "Issues and Options" paper, which, as I think people know, was released about a month ago. We have a series of witnesses today in Winnipeg as we start visiting every province over the next four weeks.

Our first witness is Professor Linda West from the Asper School of Business at the University of Manitoba. Thank you for delivering your paper to us. Our hope is that you will begin with a summary of your comments and we will inevitably have a variety of questions that we would like to ask. Thank you for taking the time to be with us this morning.

Ms Linda West, Professor, Asper School of Business, University of Manitoba: It is my privilege and honour to be here.

I also quite enjoyed a trip to France this summer. It is difficult to go and do research in another country. I would like to introduce you to what I want to speak about through a real family. I would like to tell you about Jean-Luc and Maria. They are a couple in their early forties with two young children. Jean Luc and Maria live in Grenoble, a city in the French Alps that services approximately 600,000 people.

Jean Luc runs a small hotel and Maria teaches at a public school. They are both active in the community.

When asked about the health care system in France, they tell you it is good. Maria gave birth in a private centre. She, like every other woman in France who gives birth, was guaranteed three days of hospitalization. Jean-Luc had surgery on his knee a few months ago in a private clinic. He did not have to wait for a family physician. He did not have to wait for a specialist. He did not have to wait for his test, and finally, he did not have to wait for his surgery. On the day he arrived for his surgery, everybody knew his name and the clinic was furnished like a home, not a hospital. This made him feel very comfortable. He was discharged at 6:00 p.m. and the physiotherapist was available the next day. The repeated visits to the physiotherapist seemed to be key in ensuring both his physical recovery and reassuring him that that recovery was progressing normally.

During the interview, it was revealed that Jean-Luc's mother was recovering from cancer. About two years ago, she started to have some abdominal pain. One morning she woke up and found it difficult to get out of bed, so she decided to do something about it. Within minutes, her family physician arrived at her home. The physician was very concerned, phoned for an ambulance for Jean Luc's mother, and met her at the hospital.

On that same day, Jean-Luc's mother saw a specialist, received numerous tests, including a scan, and the next day had bowel surgery. All follow-up treatments were immediately available.

The World Health Organization has ranked France's health system as number one out of a 190 countries they surveyed. Judging took into consideration five criteria: one, the overall level of health within the population; two, health inequities within the population; three, the health system's responsiveness; four, how well the various economic groups are served; and lastly, the distribution of costs. In this survey, Canada ranked thirtieth.

One of the key conclusions of the World Health Organization ranking is that spending copious amounts of money does not ensure success. The U.S. Health system, for example, consumes a higher proportion of the gross domestic product than any other country, but ranks only thirty-seventh and leaves approximately one-third of its population uninsured or underinsured. The United Kingdom spends much less of its GDP on health services and ranks eighteenth. However, it is plagued with several problems, including very long waiting lists and dissatisfaction from both patients and providers.

France has chosen a middle path. The French health care system is based on a national, universal and compulsory health insurance system linked to employment and financed by employers and employees, creating a purchaser-provider separation. The government has created a framework for health care in which the public and private hospitals co-exist to provide the population with easy access to the required treatment.

Within this framework, both public and private hospitals are subject to government approval for their location, development and major medical equipment investments. For each medical specialty, there is a bed-to-population ratio that has a direct impact on what is approved.

Citizens have almost total freedom to choose between private and public health care systems without referral. Accreditation and evaluation watchdogs are independent of the government. Waiting lists are rare.

The French system is fair to poor French citizens, who pay only 26 per cent out of their pocket. Our system is more costly at $200 per person per year, and on average, we pay 30 per cent out of our pocket for additional insurance.

France has a higher disability-adjusted life expectancy than does Canada. In Canada it is 72 years and in France it is 73.1. Life expectancy is fairly similar, with the women in France living longer than our women, but living without disability for a year and a bit longer.

The public-private mix in financing and provision of health care in France rests on the principle of pluralism, that is, the encouragement of organizational diversity, whether it is complementary, competitive, or both.

The Director General of Health, Lucien Abenhaim, is certain that this mix, this flexibility, is the reason that France is able to provide more services at a lower cost than Canada. I would like to point out that Lucien has dual citizenship. He lives both in Canada and in France, and therefore his ability to compare the two systems is very credible.

It is not insignificant that France is part of Europe. There has been a strong history of sharing information and strategies, and according to the World Health Organization, all of the top five rated countries are in Europe.

The European vision of health for all people, established in 1984, calls for a radical shift of focus, from implicit values to clear ethical frameworks, from inputs to health care to outcomes in terms of health status, from inward looking to outward reaching, from bureaucratic administration to strategic guidance and support, from control and regulation to consensus and accountability. I think that you can see that in the year 2000, Europe has moved quite a long way along that continuum and is seeing significant success.

The Chairman: Thank you very much.

Our second witness, before we turn to questions to both members of the panel, is Mr. Peter Holle.

Mr. Peter Holle, President, Frontier Centre for Public Policy: Thank you for the opportunity to share some thoughts on the future of Canada's medicare system. We share the public's desire to preserve and extend the present health care system, one based on a principle of publicly funded, universal access. Today I will speak about two different models that are successfully operating in two countries.

The first model, in Sweden, has been undergoing refinement and improvements since 1991. The Swedes have managed to improve their health system by adopting something called the "purchaser-provider split." Regional governments, primarily the Greater Council of Stockholm, have separated the purchasing of services from their provision. This has effectively ended the monopoly on service provision enjoyed by the public sector for years. As a purchaser, the government seeks bids for providing services from both public and private providers. The resulting competitive framework has produced substantial productivity gains that have reduced delivery costs while increasing the quality of services.

The Stockholm regional government sold its largest emergency hospital to a private corporation in 1991 and has used its lower delivery costs as a benchmark for comparing costs in competing public hospitals. The private facility delivers services for 15 to 20 per cent less than public facilities. The remaining six public hospitals have now been converted into publicly owned corporate entities. It is only a matter of time before more are sold to the private sector.

Health care unions, particularly the nurses' union, support the transition to the competitive model. They have discovered that they have more market power when more than one buyer is seeking to purchase their services. Nurses are buying into private clinics as employee-owners and are participating in the redesign of the workplace to improve efficiency. These gains have been split between, one, the purchasing government, and two, health care providers, in the form of higher salaries or a better working environment. Between 1995 and 1999, this competitive dynamic allowed nurses to raise their pay by 26 per cent, the highest rate of salary increase in the country.

The model of competing private and public suppliers within a publicly funded framework has produced dramatic efficiency gains. Whereas the public health care monopoly in each province has weak incentives to innovate and become more efficient, the Swedish model has delivered savings of 10 to 50 per cent for various services. Hence I will sum up the main lesson from Sweden, particularly the Stockholm area: Competition occurring within a publicly funded model can produce a win-win situation that benefits both service providers in health care and consumers.

To sum up the emerging purchaser-provider split model in Sweden: One, the government requests bids for services from competing public and private suppliers. It does not favour either sector; it is neutral. Two, ownership of facilities is irrelevant; the most innovative and efficient supplier, public or private, provides the service. Three, user fees have been charged for all visits to health care facilities/providers since 1970. Low income and chronically ill people are exempt. These fees are seen as an effective mechanism for discouraging frivolous use of the system. Four, sophisticated costing and waiting list information is being developed to make quality decisions possible. Waiting list times for different procedures and facilities are posted on the Internet. Consumers have this information, which gives them the ability to bypass facilities with long waiting lists.

I have attached several background materials provided by Johan Hjertqvist, who is a health reform expert advising the Stockholm government and a member of the Frontier Centre's policy advisory board.

I close my remarks on Sweden by noting that Tony Blair's Labour government in Britain is closely following the competitive purchaser-provider split model in Stockholm, with an eye to adopting it.

The second model I would like to highlight to the committee has given Singapore one of the best-ranked health systems in the world. It extends the purchaser-provider split model to its ultimate limit. The policy framework completely separates the delivery of services from their financing. The government's role is to require consumers to save funds for purchasing health care services in medical savings accounts. Most services are private, with the remaining public hospitals in the process of being privatized. There are no waiting lists. Only 2.7 per cent of GDP is spent directly by government on health care. The government facilitates services to consumers who do not have the ability to maintain a sufficient medical savings account.

The Frontier Centre has proposed a model similar to the highly successful Singapore MSA model. Here is how it would work. At the beginning of each fiscal year, health authorities would deposit each citizen's share of the medicare budget into a dedicated bank account in that person's name. Each account holder would gain access to those funds through an electronic debit card. Withdrawals from the account would be allowed only to pay for health care services. Minor, non-catastrophic events requiring a visit to a clinic or doctor would be paid by direct electronic debit from the individual's MSA. Individuals would cover themselves against catastrophic events by purchasing insurance from competing companies. Money not spent would be rolled over and left to accumulate tax-free over the account holder's lifetime, until the fund reached some predetermined amount sufficient to create an income stream that would cover future medical emergencies. Ownership of the funds belongs to the consumer and his or her estate. Special cases, such as the small minority who run out of funds or have special needs, are accommodated separately with extra government assistance.

Under this model, consumers would be able to choose between a diverse range of health care providers, including private and public facilities. The government would reverse decades of policy that have created large, inefficient government service providers. Health care facilities would be turned back into employee-owned organizations, insurance companies, and charitable organizations like the Grey Nuns and the Salvation Army.

The end of the service delivery monopoly is the key reform in either the Swedish or the Singapore model outlined here. The debate about private versus public provision is, in our opinion, a red herring. The real drivers of excellence, innovation and consumer sensitivity, offer citizen consumers the ability to choose within a framework that offers competing service delivery alternatives. Both models described here do that, while preserving the Canadian ideal of public financing and universal access.

The Chairman: I want to ask the two of you a question that really picks up on Mr. Holle's comments on the Swedish example. My memory of this issue is a little vague, so you are going to have to help me.

As I understand it, there were three privately owned clinics that operated in Winnipeg through most of the nineties, and maybe even part of the eighties, and then subsequently, part of the federal cash contribution for medicare was held back, essentially as a penalty, because these clinics were charging user fees. Then somewhere in 1998, 1999, the provincial government started purchasing the services from the clinics, so that in a sense they were not treating private patients any more. I believe that some time in the last couple of years, one of them was actually bought by the provincial government.

My question to you is, how much of that history is accurate, and can you tell us a little about the history before the government started to pay for the services? It seems to me that the original three clinics were very much like the Swedish model that Mr. Holle was talking about. If I am completely wrong, feel free to tell me. I am just going on the basis of a vague recollection. Could you both comment on that?

Ms West: Your recollection is very good, in that there were three surgical clinics in Manitoba. The reality is, as most physicians' clinics are actually private, we pay fee-for-service for virtually all of the services in the province.

The Chairman: They were owned by doctors?

Ms West: Yes, all three of the surgical facilities were owned by physicians. The interesting thing is, the facilities that were charging what were called "facility fees," which tended to be a little bit larger, in the $60, $80, $150, $200, $500 range, were penalized by the federal government. The province was penalized. There was a clawback of transfer monies.

Therefore the government of the day decided to pay those directly, avoid the clawbacks by the federal government, and clean up its act as far as the Canada Health Act goes. The federal government turned a completely blind eye to a vast number of what are called "tray fees" that tend to be $10, $20, $30, $40, $70, and those still go on today. They are alive and well in Manitoba, as in most provinces.

The Chairman: I have never heard the term. What is a tray fee?

Ms West: A tray fee is charged for sutures and smaller equipment, and maybe scopes, because there is a lot of scoping done in Manitoba in private clinics. It is really interesting to see where the lines got drawn in all of this, what got penalized by the federal government and what did not, and then how people have reacted to it. Now that facility fees are clearly illegal, the number of tray fees is growing, because they were left alone.

Senator Pépin: Could you give me an example? Let's say I am a patient going to see a surgeon. Do I have to pay the tray fee at my first visit, or every time I visit the office, or how does it work?

Ms West: Every time you use it, yes, that is right. One of the times when patients are regularly charged user fees, additional fees, whatever you want to call them, is when they are being scoped, both from the top and from the bottom. If the doctors do it in their private offices, there is often what is called a "tray fee." Those are really quite alive and well.

Senator Pépin: There is a kind of fee in Quebec, and maybe my colleague, Senator Morin, can correct me, whereby when we go to see the eye doctor, we have to pay, I do not know if it is $20 or $30. Is it for similar kinds of services?

Ms West: It is a very similar kind of service. Frankly, the health care system would not work any other way. If the physicians were not able to charge you for that, it would push all of these patients into hospitals or outpatient clinics and we could not handle the volume. There has to be some way of paying for these. There is no fee-for-service method right at this stage, so the physicians charge the patients.

The Chairman: It is a fee for service with a different name?

Ms West: Yes, it is a user fee with a different name.

The Chairman: It is a user fee. Mr. Holle, I did not mean to get sidetracked, but this is, to me, a very interesting example of what exists out there that, sitting in the ivory towers of Ottawa, you do not necessarily hear about.

Mr. Holle: I think what is more interesting, and I am not aware if the committee realizes this, is that Manitoba spends the most in Canada on health care per capita. We are 20 per cent above the Canadian average. If you add in the kind of back-door user fees here, plus a system that for a have-not province we could say is technically overfunded, I think it confirms that you can throw lots of money at it, but, as in the experience in Manitoba, it is not being improved at all. I think there is evidence that waiting lists are not shrinking.

Ms West: If I could add to that, we have seen a 22 per cent increase in our overall health care budget over a two-year period, a totally unsustainable amount. That makes us, on a per capita basis, number one in Canada for spending money on health care. In spite of that, we have waiting lists that the Fraser Institute - and frankly, I do not often quote the Fraser Institute but we have no other information - says are going from 5.9 to 9.4 weeks on average. On a wide range of services, our waits have not quite doubled, but have gone up about 40 per cent.

The Chairman: In spite of that increase, as I recall from data that I think was published in B.C., the money has not gone to the front-line workers, because your nurses are among the lowest paid in the country still; is that correct?

Ms West: Yes. We did get up to eighth after the last settlement. We were third from the top, sort of thing.

The Chairman: Third best.

Ms West: Third best, yes, but settlement after settlement has been higher than what we achieved, so no, the money is not going to the nurses. The medical group has also seen a substantial increase. I think the GPs got an 18.4 per cent increase, but every other settlement since then has made that seem pale by comparison. A lot of the corrective actions that were taken are being overrun at this stage.

Senator Morin: Where does the extra money go?

Ms West: Frankly, we have one heck of a big bureaucracy. If you want my opinion, we have one wonderful, big bureaucracy that has a lot of ability to leak money.

If you want to run a good bureaucracy, create something simple and straightforward. Go to McDonald's; they have a wonderful bureaucracy. You make the hamburgers the same way, the straw goes inside the serviette and it gets handed out the window in identical fashion. You can bureaucratize that. You cannot bureaucratize a technically difficult, ever-changing world.

I can give you an example. A group of nurses wanted to change a form because they had made an error, recognized it, and did not want it to happen to any other patient. So they got together, created a new form, took it to the head nurse, and 100 per cent of the nurses said it was okay. They were not allowed to put it into play, but the head nurse was going to take it on to the next committee.

The next committee, which was within the hospital, looked at it and everybody agreed, but they could not put it into play at that stage. They had to take it on to the regional health authority program. At that stage, it took two or three months before the committee looked at it and approved it because there was a mini crisis in the health care system. Then there was the forms committee, then there was the purchasing committee, then there was the purchasing order, and then it was purchased. They got it a year and a half after the main event, and by then the form was obsolete. They have a new piece of equipment.

That story plays itself out over and over and over in health care systems. You cannot run big, monolithic bureaucracies and achieve success. In fact, the World Health Organization suggests that once you have about 1,000 beds, and long before you hit 2,000, you become dysfunctional. We have created these big regional health authorities that have single hospitals within them almost that large, six or seven other hospitals, and all sorts of programs and home care and all of the rest. You have these huge bureaucracies that just seem to be spinning their wheels.

Mr. Holle: If I could just make a quick point. We need to distinguish between resource reforms and structural reform. In the Canadian system, there has been a bias toward resource reforms, that is, we need to put more resources into the system. I think Manitoba is probably the best example of lots of spending without achieving great results. We need to look at structural reform, how we deliver the system. I think, again, if you look at France or Sweden or these other models, they do have an element of choice and competition. I think Linda and I would say that is probably the way the system needs to go.

Senator Morin: I have one more question. If we take the major sectors here, and I do not want to push this too far, but hospitals, physician fees, drugs, home care, where does Manitoba spend more than the average? Bureaucracy is the same the world over; we have all been through the form story. Where do you spend more? Is it on hospitals, doctors, drugs or home care?

Ms West: A big part goes right into the hospitals in the acute care sector. In fact, our average length of stay in Winnipeg is 20 per cent greater than the Canadian average, which is a big, big cost driver. It tends to push all of those other things. We have seen a significant increase in our drug costs.

Once again, I would like to point to the French model, because they got control of their drug costs and a whole range of medical technologies through consensus conferences. This province is thinking of hiring 10 or 12 pharmacists to go out and suggest to physicians that they should not order this and they should not order that and they should not order something else. It is not being well received by either the physicians or the pharmacists.

What France does, instead of trying to create those kinds of situations, is have a conference. They have technical people who gather all of the research together. Then they invite in doctors, nurses, pharmacists, physiotherapists, chiropractors, whichever group is appropriate for that conference, from all over the country, and they come up with one solution. They do not get away from the conference until they have found solutions, and seven days later, they have a commitment to have that written up and disseminated. It is on the Internet. That will then suggest what is the most effective, efficient way of dealing with a wide range of problems, whether it be low back pain, or where drugs can be substituted for gastric surgery, those kinds of things. They have already reviewed a long list of things.

In doing that, they have not only had great health outcomes, their costs have been reduced by an average of 5 per cent. That is achieved by putting the people who know the health care system the best in the same room and having them hammer it out. At the end of that time, they have something that they can print out for everyone else and it has great credibility. It does not then have to be repeated hospital by hospital, and regional health by regional health authority.

Mr. Holle: We spend too much on management. We spend too much on infrastructure. There are many rural hospitals that are underutilized. I think that for certain services in the system, household services and so on, there is strong evidence that above-market wages are being paid. I would throw that in.

Senator Morin: I will ask my questions of both of you, if you want to take notes, and then you can answer.

Professor West, I know the French system very well and I think it is unfortunate that of the various countries that our committee has studied, France was not one of them. Of course, all health care distribution and delivery systems are based on history. France has a long history of social security, and naturally their social security insurance also covers disability insurance and a pension plan. It is part of the same system. I do not see how we could move into that.

In addition, what you call "private insurance" is private up to a point, but everybody has this private insurance, except for the unemployed and some self-employed or other groups, for example, certain farmers and so forth. I do not know the exact figure, but a very large majority, I would say around 90 per cent of the French, are covered by this so-called "private insurance."

Ms West: Where they are not, the government picks up the cost.

Senator Morin: It is no longer really private insurance like in the other countries.

Ms West: It does not look very different from our taxes.

Senator Morin: No, but I am saying that in Britain, for example, they have private insurance, but it covers 1 per cent of the population. In other countries, it is less than 1 per cent. So it is not really private insurance. The third point is, these private clinics really only do minor surgery and obstetrics. They do not provide major services.

Ms West: Open heart surgery?

Senator Morin: There are very few outside of Paris that do that. There are two or three in Paris, but otherwise I think they tend to stick to minor surgery.

Ms West: It tends to be the more minor surgery, and we would be promoting orthopaedic surgery. In some areas, 80 per cent or 90 per cent of knee and hip replacements are done by the private sector.

Senator Morin: You know that the private clinics are currently having financial difficulties because the present government is less supportive of them than in the past.

In any case, I think it is an interesting model, and you are right that there is a high level of satisfaction among the population. As far as equipment is concerned, here we are near the bottom of the list of OECD countries, while France is well equipped.

Coming back to Sweden, I think the purchaser-provider split is really the way to go. I think you are quite right in saying that.

Now I had the impression that a new party came to power in Sweden over the last year. I believe they reversed a little of this trend towards private clinics, and that there are none outside Sweden. When we say "private," they are really "not for profit." There is a big difference here. In North America, all of our hospitals are private really, but they are not for profit. I think Sweden is moving toward private but not for profit, which is really what we have. When we see "private" here, we mean for profit. We have to be careful. I think Sweden is moving towards private but not for profit. For example, employee-owned hospitals would be not-for-profit organizations.

Mr. Holle: In Sweden, there is a distinction between the central government and the regional governments. Health care generally is at the regional level. For example, the City of Stockholm, the Greater Council of Stockholm, has been aggressive in innovating and trying to improve the system. I think it is a Social Democrat government in Sweden at the central level that has been uncomfortable with the idea of a competitive model, and it has passed some sort of legislation that has effectively put the sale of the hospitals on hold. My sources there see it as a temporary phenomenon, and the fact that all of the hospitals are being set up as corporate entities means that over the medium term, you will probably see more sales.

I think when we talk about profit versus non-profit, we need to remember that the Swedes do figure on something called the "cost of capital." If you have money tied up in a facility that could earn 5 per cent in a bank, that is a cost.

We make the mistake in Canada of saying, for example, that the public sector can deliver services for less cost, but we do not figure in things like cost of capital, taxes and all that the private suppliers must put into their price. When you do an apples-to-apples comparison, often you will find that indeed the private suppliers can be cheaper than the public ones.

We do not have that information in Canada, so we are unfortunately stuck with a lot of political arguments - private sector good or bad, public sector good or bad. I think the philosophy in Sweden is that competition is better than a monopoly, and the private versus public thing is very secondary.

I think that debate would fly in the Canadian context. We are not pushing an American-style system. I think we need to get away from the discussion that focusses excessively on privatization. What is important is competitive delivery with the right incentives for different suppliers, and if a public facility can do it at lower costs, then all power to that facility; they get the business.

Senator Morin: I fully agree with your last statement.

The Chairman: Just let me make one comment on cost of capital. The fact that that is not taken into account in the health care system in Canada is not unique to that system. The only place that I know of in government in which the cost of capital gets taken into account is when they are considering whether to buy an office building or lease it. In that case, they do what I would call a "standard financial analysis," which as you put it is "apples and apples," but I do not know of any other examples. I just want to be clear that the failure to do that is not unique to the health care system. I am not arguing that is right, I am just saying that is the fact.

Mr. Holle: No, no. Countries like Great Britain, Australia, New Zealand, now all require their public sector operations to do that, and that is where you are getting a much more sophisticated analysis of public policy.

Manitoba is notorious. We have politicians running around saying we have the lowest power prices in Canada, and it is a miracle and a function of public ownership. Well, if you figure out that Hydro does not pay any dividends or taxes and all of that, what you actually have is a subsidy that is creating the illusion of lower prices. Again, that is one of the reasons that in Manitoba, in my opinion, the public policy debate is pretty mediocre.

Senator Keon: Professor West, first of all I want to compliment you on a very splendid presentation, very accurate. There were a couple of truly interesting areas on which I would like you to comment.

The first thing that has fascinated me about the system in France, and to a lesser degree the other EC countries now, is that they are in fact using a population health basis for all of their decision making. In fact, they are constantly monitoring the population health of various groups, and when they see something out of whack, they are putting the necessary people together to come up with a solution to that particular problem. I do believe that, more than any other single thing that they have been doing, this is the key to their success. It is a voice in the wilderness. I have been using every opportunity to say that until we get to this in Canada, we are not going to solve our problems, regardless of what we do.

The second very interesting phenomenon in France is the public health issue. Whether through good luck or management or whatever, they have had a low incidence of cardiovascular disease that is causing the major economic burden here in Canada and in the U.S., Finland, Ireland and some other countries.

Twenty-five years ago, Dr. Fraser Mustard from McMaster used to preach the wine gospel - you have seen his lectures over and over and over - that the French were saving a fortune simply by drinking lots of red wine. I think there is a component of truth to that, but as we know, alcohol causes other problems.

I want you to comment on those two areas, because I do think they skew the figures a little, and that when you come down to the economics of the system and the way it works, it may not be as perfect as you think.

If you, Mr. Chairman, and the committee will forgive me an anecdote, I have just retired as head of heart surgery at the Ottawa Heart Institute, and the man who replaced me is from France. He came to Canada because he was not happy with the French system. I just want to make the point that not everybody there is happy, just as we are not all happy here. I do want to have you truly expand on this concept of constant monitoring of population health as a nation, as a group, as a region, and putting in place the necessary mechanisms to deal with the areas that are out of sync.

Ms West: You are right, they do have a long history that was re-strengthened in the mid 90's with the creation of a new group called ANAES to undertake the accreditation-evaluation process with total independence from government, and in fact, it makes recommendations that the governments of the day do not necessarily like. They are responsible for accreditation, like our system, except all those accreditations are actually made public, so the public knows how well the local hospital is doing. They are evaluating new technology. For example, they came out with the recommendation that there should be one MRI for every 240,000 people. The government got grumpy about that, but they bucked up and actually are paying for that, plus the upkeep and refreshing of that system.

This umbrella organization is also responsible for the consensus conferences. A consensus conference could be held on cardiovascular disease that could look at all of the newest information, all of the new drugs, what they should be teaching, both in prevention and health promotion, and eventually in curative techniques. You have all of the skills within the room, and then those recommendations go out to the general public. It seems extremely effective and extremely credible to the people of that country. I do not think that that can be underestimated, that when you put the bright lights of the country within one room, you often come up with more effective, efficient ways of dealing with things, of making sure that that sector of the population or that disease is looked after.

The cardiovascular disease is quite interesting. You are right that credit has been given to olive oil and wine, but we are also seeing the level of fat consumption dropping quite rapidly. Their consumption levels were above ours, but now they are starting to slide below us. They seem to take information about health promotion much more seriously than Canadians do, and actually change their lifestyle. They change their lifestyle according to some of the recommendations, which we seem to have a very difficult time convincing people to do. I am not saying that they do it easily, but they seem to do it more effectively than Canadians do.

The satisfaction survey on the public hospital in Grenoble demonstrated that people were 91 per cent satisfied or very satisfied with the care. They want to improve on communication. Satisfaction with that dropped down to 80 per cent. Some Canadian studies have only demonstrated satisfaction percentages in the 50's on communication with patients about their health care and related matters. They were not happy with their food either, but I am not sure what you do about institutional food. From a patient's point of view, the health care system seems to work. They are afraid of tomorrow, of the additional cost that might be a result of the baby boomers of that country. We interviewed a lot of people and really pushed them to find out what the difficulties were, and they were small in comparison to what you would find here. They would say that the private care was better because it was more personalized than the public, but they trusted the public system enormously and they knew it had to be there for the big health care problems. It was really interesting.

We pushed them on waiting lists, because interview after interview, we heard that there was no waiting list. We said, "Come on, you have to have some waiting list. One gentleman said, "Well, there is for that Parkinson's disease surgery that we invented in this country, and they have Arafat on the list for that, and for some minor eye surgery," but nothing like we have in this country.

Senator Pépin: I would like to speak about the nursing situation. We know that for many years, let us say maybe 10 years, nurses have been overworked and demoralized and patients have not been happy. Let us say that we could propose better working conditions, flexible, family-friendly hours, more available technology, better organization and distribution, a better salary, and most of all, respect. Is there any other proposal that we could make to improve the nursing situation, so that at least they will feel comfortable and happy in doing their job?

I believe that they are really paying the price of health care restructuring, that they are the ones who are being left aside, and right now they are so exhausted that they can hardly speak for themselves. How could we organize it better?

Ms West: First, I would attack the respect issue. I would actually give people a say. Front-line people should be allowed to make decisions that only affect their unit or division, and get on and correct problems. I think that nurses and other front-line people know where the bottlenecks are, they know how to attack them, and if you were to give them a voice, they would actually be able to make a lot of those changes. We have got to devolve some of the decision-making power to the unit level, to the hospital level. It all has to be defined. I am not saying you give away all this power without establishing a framework. Wherever you privatize, wherever you make a system change, you create a framework that allows all of that to occur safely.

As for working hours, one great difficulty is the fact that nurses cannot get full-time jobs. We have a huge nursing shortage here in this province, and only 35 per cent can get full-time work. I can tell you, from teaching and from talking to soon-to-be graduates, that they are going to leave. They are not going to graduate and go into part-time work and be happy about it. They are going to go to another province, another state where about 70 per cent of positions are full time, which seems to be about right for women. There are going to be a few women wanting to have children, and, nearing retirement, to be able to tone down their lives, but the vast majority want full-time jobs, and 35 per cent just does not cut it.

In the U.S., some Australian states, and several of the European countries they have created full-time positions for weekends. You work three 12-hour shifts and get full-time benefits and wages, but that allows two to three other people to have reasonable schedules, where they get every other weekend off. That seems to be a really big innovation, creating shift flows, when I talk to people from other countries.

You have to remunerate adequately. It has to be internally and externally fair, but I think that there needs to be the possibility of additional remuneration. They do not, for example, allow additional remuneration for working in the North, or in some of the very high-end ICUs, CCUs, and all those places where they cannot recruit people. The nurses have additional education, additional responsibility, and they should be remunerated for those kinds of things. We have full-time positions unfilled in some of those really high-tech, difficult places, because why would you go there when you are going to have to put in a lot more heart and soul. Nurses put heart and soul into everything, but you have to put in even more effort and you are going to have to be more technically capable.

Senator Pépin: Do you have anything to add, Mr. Holle?

Mr. Holle: I think we could probably say that the unions have to do something as well here. In fact, there is a big divide between the older nurses and the younger ones over scheduling and so on, and I think it is also a labour issue. In fact, there are nurses officially working part-time who work lots of overtime. The official wage is $35,000, and we can run around saying that we have the lowest salaries, but at the end of the day, you are making $70,000 because you are working a lot of overtime. I think that is one reason why Manitoba has the least number of full-time workers. There is a bit of labour politics going on here that we need to understand.

Senator Keon: Mr. Holle, you threw out a very interesting idea at the end of your presentation, the concept of the consumer account. I was thinking that the analogy that I, at least, am familiar with is the British clinics that receive their account for the year and have so much cash to spend on their patient population base.

Again, anecdotally, I happen to have a daughter who is a doctor over there, married to a doctor, and I get an opportunity now and then to grill them on the system. I have asked them how this works and they say, "Well, it works great for the first half of the year, until the money runs out." Then the problem is that the distribution of services becomes rather unfair.

Now, if we bring that down to the private patient account, it certainly would be a very ingenious way of introducing accountability into the system, and there is no question that we need to do that in Canada. However, how would you deal with the fact that families, for example, or individuals might skimp on their accounts for fear of over-utilization?

Mr. Holle: I think the evidence in Singapore is that on all of the indicators, of lifespan and so on, they score very highly. I guess the evidence is there in Singapore that the system is delivering good services.

I think you touched on the problem of cherry picking at the beginning, and there are a few ways of dealing with that. You might require that the insurance companies, for example, cannot just pick the youngest, most healthy people, that they have to take a cross-section of the population.

I would also say that generally, the proportion of the population with special problems is quite small, and we could then design a special policy for that 5 per cent or whatever, or we might even just take them into the public system where they are taken care of by the government. However, the vast majority of people, the middle class and so on, can benefit by being intelligent with their health care dollar. If you do not smoke, your insurance gets reduced, et cetera; or we could arrange it so that if you join an exercise club, you can deduct that from your health care account, so it gives the government another policy lever to encourage good behaviour.

Our problem is we have a lowest-common-denominator system where we are trying to handle all of these diverse groups in one system, and it just does not work very well. We have evidence of that.

I found it interesting that China looked around at health care systems a few years ago, concluded that ours was not the system to run with, and ended up going with a medical savings account system, where the goal of the policy is to make sure that the people have resources to take care of themselves, but they just laugh at the idea of politicians running sophisticated service businesses.

I think our problem here in Canada is that our politicians are trying to do too much. We had a big fiasco here with kitchens a few years ago - and it actually defeated the last government - where the government minister was involved in the technology of centralized kitchens and all of that, and that was really not an issue for the politician. Let the system look at nitty-gritty issues like that.

I think the MSA model, because it creates a separation between the politician and the system, actually helps the politician, but it also delivers a better outcome for everybody else.

The Chairman: Can I just ask one follow-up question on that? As you know, the Clair Commission in Quebec in effect proposed that kind of medical savings account model for long-term care. They proposed that people would be required to put aside a certain amount of money on an annual basis, which would then ultimately be drawn down for long-term care.

I think I know the answer, but my question was going to be, do you see the medical savings account in Canada applied to the entire health care system, or starting with just a specific part of it, such as home care or long-term care?

Mr. Holle: I think politically, you would want to introduce it as an option, a parallel system. I think that going the whole way, of course, is the ultimate answer. I think the politics of it are difficult, but I see it being introduced much as RSPs were to supplement CPP. Most people, at least of my generation, do not expect much from CPP. The RSP is where we are going to find our pensions.

The Chairman: By the way, I should tell both the audience and our witnesses, one of the reasons for the knowledgeable questions that you are getting is that three senators with me today have all spent very large chunks of their life in the system. Senator Pépin was a nurse, Senator Morin was dean of medicine at Laval, and Senator Keon, although, as he modestly said, stepped down from doing cardiac surgery on October 1, is still the head of the Ottawa Heart Institute. They carry me along, and the knowledge base among my three colleagues is really quite outstanding.

Professor West, I have one last question for you. If you had to identify just two or three things that make the French system better than the Canadian, what would they be?

Ms West: I would say having some sort of competition, being able to peg your price, knowing what a knee replacement costs, knowing what a hip replacement costs. I presented France because it is number one according to the World Health Organization, but I am not sure that they are actually as dynamic as Catalonia in Spain. That province has moved further on the payer-provider separation, is getting very dramatic results from that, and is starting to significantly separate its information and stats from the rest of the country.

I think it is important in France that there are three different groups. The government is setting up rules, the evaluation and accreditation group is providing a backbone of technical and health care information, and then the insurance companies, whether we call them private or employee supported, are absolutely mandatory, and are just like our MPI.

In fact, I do not know how much you know about our MPI insurance.

The Chairman: What does MPI stand for?

Ms West: Manitoba Public Insurance. We all have to pay for car insurance into one system so that we are all covered, but then you have the choice of whichever private garage you want. That creates ability to make choices, where the people sort of drive the volume and competition makes sure there is not a surplus in one kind of care and deficits in others that create the long waiting lists. That is where competition really is much more effective. The bureaucrats will never predict the right number of heart, knee, hip and eye surgeries and set the system up. The more we micro manage the system, the worse it gets.

I suggest that we move away from that to a system of either real competition, private and public, or quasi-competition, so that we do not have those inaccuracies in volumes and the queuing lists that really control our costs.

The Chairman: Professor West, this list that you gave us is clearly the index to a book. Is that a finished book or one you are still working on? I know you gave us chapter eight, in addition to the index. I am just curious, where is the rest?

Ms West: The rest of the book is being peer reviewed and I will get the results this week. It is available at this stage only in identical format to chapter eight, which is really my first cut of the book. It is to be published by January.

The Chairman: If we wanted to get an advance copy, particularly looking at your section E on a stable, sustainable health care system, would you would be willing to give us, at least unofficially, some of those chapters if we specifically wanted them?

Ms West: In fact, you can have the identical format to what has been given to the peer reviewers. The publisher has it and can now produce it. I have had a few copies produced in the peer review style.

The Chairman: That would be helpful. We will chat with you about that off-line.

Senators, our next group of witnesses is from the Western Canadian Task Force on Health Research and Economic Development, so we are quite sharply switching topics.

The next witness is Dr. Henry Friesen. He is recognized around the world and in Canada as a researcher in medicine.

By the way, congratulations. You became a Companion of the Order of Canada in the last couple of weeks, I believe, which is an honour bestowed on very few Canadians.

I first met Dr. Friesen when he was heading the Medical Research Council. He then went on to chair the original group that lead to the CIHR, and is still, I believe, the chair of Genome Canada. His record, both inside this country and outside, and particularly in the technology area, is quite outstanding. We are delighted to have you with us today, sir.

I understand you have distributed a handout. Perhaps just for the purposes of our record and our Hansard reporters, it would be useful if you would identify your colleagues and proceed with your presentation, and we will then turn to questions. Thank you for coming.

Dr. Henry Friesen, Team Leader, Western Canadian Task Force on Health Research and Economic Development: It is a pleasure, and an opportunity for us to express our gratitude to you all for meeting with me and my colleagues from the Western Canada initiative on health innovations.

May I introduce on my immediate left, Dr. Aubrey Tingle, president of the Michael Smith Fund at UBC. He is a professor of pediatrics and has a long history of involvement in health research. On my right is Dr. John Foerster, director of St. Boniface Health General Hospital Research Centre. On my far left is Chuck Laflèche, president of Momentum Healthware. We are here as members of the task force commissioned by the Honourable Ron Duhamel to address the future of health research and economic development in Western Canada. The initiative was undertaken to explore the opportunities that might present themselves for Western Canada to become a platform or a launch pad for economic development and opportunity. The consensus reached was that if we correctly positioned the Western Canadian health care enterprise and institutions, it would be possible to envisage health research, innovation and commercialization as an opportunity for major economic development.

I wish to link our efforts with the thrust of your report and make a number of observations, because I believe the major emphasis of our work is largely absent in the options you lay out. I believe it is important to recognize, as we do and hope to persuade you, that in addition to the output of knowledge and its application to the health care system and health of Canadians directly, there is another possible opportunity to apply that knowledge, gained from investment in research, to the development of products, services and management skills.

Let me make the point in another way; over the next decade, Canada will spend a trillion dollars on its health care system, and it spent 600 billion to 700 billion over the previous decade. I ask myself, and you, how many brand names and services have been generated through those multi-billions of dollars of public investment? I am hard pressed to identify a single product. Indeed, I come to the sad conclusion that the only product that Canadians would recognize immediately is Pablum. That was a 1930s' development. What other new products and developments have been generated by this huge public investment?

We maintain that we are in a knowledge-based economy. Where is the Canadian knowledge of the management of its health care system bundled and made available as expertise to the world? For example, in the engineering field, just one company, SNC-Lavalin, has a 4-billion-dollar enterprise in its pipeline. There is nothing close to that kind of opportunity and activity in the health care system.

We pride ourselves on having the know-how and the management skills. At which annual meetings are hospital boards and CEOs normally expected to report on products and services that have been generated by their institutions and sold around the world?

It is not too dissimilar, I maintain, to what was true in the 70s and the 80s in the universities, where education, training and research was the expected norm, but too often, regrettably, the resulting products and developments were financed by American capital and Canadian researchers were lured to the United States. We would then buy back these products and services at inflated prices, and still do. The balance-of-payments deficit in this field is now approaching $8 billion and growing. I do not think that is good public policy, and this is one of the issues that we wish to address in our report, to say we can do better, we should do better, we must do better. However, it will require a cultural shift in our thinking and in our approach.

Therefore, when you say in your report that one of the key federal roles is in supporting research, we heartily agree. The investment should be at an internationally competitive level. We believe that strategies and policies should be put in place to capture the knowledge generated by public investment in a way that has not been done in the past. In addition to investing in research, there is an opportunity, in our view, to see the Canadian experience - indeed, this huge asset that is our health care system - as a platform or opportunity for economic development.

The last point I would make, and I think you refer to it in your report on the issue of regional disparities, is that we recognize the asymmetry across the country and in the western region, particularly Manitoba and Saskatchewan, and we agree with your conclusion that a massive structural change undertaken all at once is not likely the right way to proceed. However, we will recommend strongly that the real innovations will come from taking advantage, in a sense, of natural experiments by various health authorities in various health care settings with a whole series of innovative programs in research and evaluation. My colleague, Dr. Aubrey Tingle, will speak to you about some of the possible priorities and approaches.

Dr. Aubrey Tingle, Western Canadian Task Force on Health Research and Economic Development: Over the last six months, we have developed a process to engage the thought leaders in Western Canada. We have undertaken a series of workshops in each of the Western provinces involving the front-line health service workers, academic leaders, research institute heads, technology-transfer authorities in the universities, industry leaders and public policy leaders.

These workshops posed the challenge of how to approach bringing an industrial strategy to the health care system. The consensus that was developed, and outlined in the deck that you have received, is that the key strategy is the development of a series of managed networks that will focus on particular regions of the health care system. Dr. Foerster will describe how that could be carried out.

It was felt that bringing provinces together to look at and manage networks would achieve critical mass. It is based on a group of interested provinces that are keen to work together, and it really would form a pilot project for evaluation of new strategies for health care delivery and their possible commercial or industrial outcomes. That network was a key. It would be phased in and strategically selected.

The second part of that strategy is the development of some key technologies that underpin the health informatics and bio- informatics areas in particular, and Chuck Laflèche will discuss this further.

The final one is the development - and we heard this clearly from the technology people - of venture capital and other industrial partners. We have to do a better job of seamlessly managing commercial output from our universities, our teaching hospitals, our research institutes and the health care system.

The consensus that came out of this process, with over 300 participants strongly supporting it, was to develop an integrated Western Canadian network targeted at bringing innovation to the health care system and achieving commercial realization of the advantages that that would bring.

I will turn it over to John Foerster to illustrate some of the ways in which this could occur.

Dr. John Foerster, Western Canadian Task Force on Health Research and Economic Development: In support of the previous presentations, I wish to re-emphasize and illustrate how a consortium of the health authorities, the universities, the research centres, industry and venture capital pools in the four Western provinces could energize many of the initiatives that are included in your preliminary report.

For instance, there is a tremendous emphasis on the restructuring of our health care system, on changes in how care is delivered, including primary care, different payment systems, salary capitation versus fee for service, and many others. Due to political pressures, often very far-reaching changes will be made that are not evidence based. Those of us who are involved in the health care system are always encouraged to make evidence-based patient care decisions. I am afraid that the changes that are often recommended, and acted upon, are not evidence based. They reflect the particular positions of individuals, of groups, of parties and so on. I would submit that Western Canada would be optimally positioned to address many of these issues through research and test comparisons. If we were given a chance to do that, I am sure we could develop a system that would answer many, many of these questions.

The fact that this will take a long time is often raised. We have been engaged in changes to the health care system since the 60s. We have worked for four decades and still are dealing with the same conundrum of decision making that is not appropriately evidence based.

The second item that you addressed is access to technology, which is a hot political issue, yet we need to remind ourselves, especially as physicians, that superior health care or superior health correlates much better with education, with jobs, with income and other measures of social well-being than with access to tertiary care or technology.

The last time I looked, the United States probably had 10 times as many MRIs on a per-capita basis as we do in Canada, and often, this technology offers greater benefits to the providers than to the users. Why not base the need for technology on evidence, rather than on consumerism? I applaud your emphasis on output rather than input on page 7 of your report, and suggest that the West could provide much helpful evidence in this regard. We could explore that later in greater detail.

Third, we are already making contributions in the areas of rural and Aboriginal health that will greatly assist in the delivery of services. For instance, we have engaged in Winnipeg in a major project to digitize radiological information to the point where, in the very near future, we will no longer look at these black and white X-rays on a view box. All of this information, whether it has to do with ordinary X-rays or ultrasound or CTs or MRIs, is going to be digitized. We have developed, in conjunction with the Manitoba telephone system and other industrial partners, a way of transmitting that information relatively cheaply over great distances. Thus, someone working in Thompson or in Churchill or, in fact, in a larger Aboriginal community, could be taking X-rays or ultrasounds and transmitting that information to a radiologist who might even be at home on call. The radiologist could view these findings on a computer screen, give an immediate report back, and even direct interventional medicine through the use of this technology. In our view, refinement and extension of services through research and involvement of the private sector holds very much promise.

We also envisage a special emphasis in the Western consortium on health issues specific to Aboriginal peoples, including the high incidence of diseases like diabetes and infectious diseases on the one hand, and the low incidence of other diseases such as Alzheimer's on the other. I might add that the Aboriginal communities are very keen to get involved in the latter. They are excited about the possibility of making a positive contribution to the rest of society, rather than always having their defects and problems categorized and investigated.

Fourth, I would like to address the creation of economic spinoffs and stabilization of health care costs through innovation. Our report indicates that we would like to see the creation of 50 new companies per year that would eventually generate significant economic spinoffs in the West. Some people might say that this is a pipe dream of some sort. I will remind you that in Manitoba, as a result of work at the universities in particular, we have created 13 companies in the last few years, eight of them at St. Boniface General Hospital Research Centre alone. We are a relatively small institution. We have approximately 45 principal investigators and a total staff of about 280. Our current overall budget is only about $20 million a year.

I will just illustrate this with a few examples. The first one actually comes from an investigator by the name of Dr. Shoo Lee, who is working in British Columbia. He was part of a group that has discovered that health care costs could be significantly reduced in the newborn nursery if mothers who are going to give birth under difficult circumstances were given a one-day dose of steroids. This has resulted in tremendous changes. In fact, it can reduce health care costs in newborn intensive care nurseries by something like 20 per cent.

The problem is instituting changes like that. In a recent review, Dr. Shoo Lee discovered that the institution of these changes, which are already evidence based, across Canada varies between 17 and 75 per cent. Thus we are facing another problem, and that is how to institute changes that have already been recommended on the basis of evidence-based studies.

Let me illustrate, then, a few additional matters having to do with health care costs. For instance, there is the problem of restenosis, wherein when people have their coronary arteries expanded by balloon angioplasty or reconnected through bypass surgery, the chance of these things closing off again is very great. On the balloon angioplasties, if the patient has diabetes, the chance of these arteries clogging up again within a year is almost 100 per cent. If you do not have diabetes it is still very substantial, probably 25 per cent per year or maybe even higher. Researchers here in Winnipeg have discovered a substance that, when applied either to the inside or the outside of vessels, in animal studies that are very close to what we encounter in the human situation, completely prevents this process of restenosis. We call this the "Dick Cheney solution." Dick Cheney has already had four or five re-dos, and you can imagine the cost implications of something like this. We have applied for permission to conduct human studies in phase-one trials, and if it holds true, I think it will bring about major savings in health care costs.

The Chairman: I am concerned about the time because I want to make sure that we have time to ask questions.

Dr. Foerster: Let me just close with one additional example, the treatment of diabetes. One of our researchers has discovered a substance, a plant product that, both in type 1 and type 2 diabetes, has the capacity to normalize blood sugars in animal systems for a long period of time. This is a single pill taken at 3-week to 15-week intervals. Again, if this were put into clinical practice, after the additional studies and so on, it would generate tremendous savings in health care costs. We could bring other information to bear on this, but I will stop here.

Mr. Chuck Laflèche, Western Canadian Task Force on Health Research and Economic Development: You all have a copy of my presentation. I will go through it quickly because I know we are short on time.

I think it is a microcosm of not only what Dr. Friesen's task force is trying to accomplish from an economic development perspective, but it also relates to the message in chapter 10, Volume Four of your report that speaks to what we need to do from an IT perspective in terms of delivering health care.

This is in its infancy, we are a month away from finalizing the costs and the potential funders, but what we are proposing is a private-public partnership that involves four Western Canadian IT companies. These companies are: Sierra from Victoria, which is probably well-known from a health care consulting perspective; Momentum Healthware, here in Winnipeg; and, Fifth Dimension and IW Technologies, both based in Edmonton.

On page two of your handout, you will see an analysis of the current situation from an IT perspective. It outlines recent developments such as the CIHR roadmap, the National Health infrastructure blueprint that was agreed to by the Council of Deputy Ministers, and finally the EHR - the electronic health record for the delivery of health care, and in spring of 2001, the $500 million commitment with the establishment of the health infoway.

The electronic health record is essentially a patient-based health record that we think is the fundamental cornerstone in terms of accessing data and producing evidence-based material.

On pages four and five, we provide a motherhood statement on what are we trying to accomplish. In chapter 10 of your report, you mention that the half billion dollars is only a start. Some people have said it will cost $5 billion to $6 billion to produce what you are seeing here. You can see the before and after pictures here and it shows that we have a way to go. We are recommending a very small slice of this figure.

If you turn to page seven of the presentation, you will see an overview of what we consider continuing care. It is a dangerous term, but we view it as long-term care, home care, some post-acute care as well, and rehabilitation.

On page 8, we state why we think it is important. The impact that the aging population will have on this sector is obviously very large. Currently the population over age 65 accounts for about 45 per cent of hospital patient days and it is estimated that this figure will double by 2021. Obviously it should be important for policy-makers and for funders.

On page 9 - because this is a Western Canadian initiative and we are working alongside Western Diversification - there is a microcosm of what is continuing care in the west. It includes 770 continuing care facilities, 400 home care authorities, and roughly 20 per cent of regional spending, which is probably representative of the national figure. The current situation is no different than what is stated in your report. There is little information to support decision-making and little accountability for those decisions. There are a lot of stovepipe systems out there, with very little integration between the systems. I do not think that is new to anybody.

On page 11, we have set out our proposed solution. We are proposing a Pan Western initiative that would fully automate this segment of the health care market.

Page 12, again, one of our people uses the term "blazingly slow." If we do not have this type of system, if we do not have the buy-in from the funders and from the parties, it will be blazingly slow, because, frankly, it is not happening fast enough. As a company, we have attracted $20 million in Manitoba investment. Our projected sales are two or three years behind because the system is just not happening fast enough, even though everybody wants to automate.

We have a provided an overview of the project on page 13. The Western Canada Continuing Care Electronic Health Record, WCCCEHR is a multi-jurisdictional project focussed on the development of an electronic health record in the continuing care sector in the west.

Page 14 is just a graphical overview. What does this mean? This is access in the system with handheld devices. Mention was made, I believe by Senator Pépin, regarding the pressure on nurses to deliver care and lack of time. We think the use of systems like this can free them up to give better care.

You may have heard of the MDS Assessment System sweeping the country. We are doing pilots in Nova Scotia, and B.C.; we sold one in Saskatchewan. We would recommend it at the front end to properly assess people for home care or long-term care. We also recommend a fully automated clinical system under the hood that will drive quality indicators, things like use of restraints, use of drugs, drug interactions.

This assessment tool is in 26 countries. We are the first company in the world to develop the home care assessment tool with these researchers. We are working with the Government of England through a related company and we are getting a lot of interest in the U.S. as well. We have not announced this publicly because we are in the final negotiations, but we have been selected by Extendi-care in the U.S. - a 169-facility chain for our system, and we went up against 50 vendors. So there is an example of what Dr. Friesen is talking about. When you invest 20 million Canadian dollars and you can then go and beat out 49 U.S. vendors, it is very gratifying.

On page 15, there is an explanation of what we will get. We would get 770 long-term care facilities fully automated, with 2,279 home care assessment workers using fully automated handheld devices and common tools to assess people and move them through the system.

We show the benefits on page 16. Among other things, this system will improve equity of access to the continuing care sector, strengthen case coordination, support management and continuing care sectors, and provide standardization. It would provide a model for Canada.

On page 17, we explain how it would accelerate the implementation of a comprehensive electronic health record in Canada. The number $6 billion was brought out. We think we can do this for less than $100 million.

To accomplish this, it will take leadership and commitment. We are currently determining the qualitative and quantitative costs and benefits of delivering this initiative and the potential sources of funding.

Finally, on page 20, we show the connection between what your committee is doing and what Dr. Friesen is doing. This would establish a Western Canadian continuing care-managed network that will improve service delivery and measure the improvement in health outcomes. This system would provide the infrastructure required to greatly improve evidence-based decision-making, which is important for service providers, funders, policy makers and researchers. With the involvement of the four Western Canadian companies, the initiative is a very strong economic development driver. Thanks for your time.

The Chairman: I have a couple of questions for clarification. Is the Western Canada CCEHR an actual pilot project, is it an idea, or is it at the other extreme, moving ahead to full implementation?

Mr. Laflèche: It is somewhere between. We are formally presenting to Western Diversification a proposal within about a month.

The Chairman: Presenting to whom?

Mr. Laflèche: To Western Diversification, the plan is we are getting buy-in from the four provinces and we will then make a formal request to the federal government.

The Chairman: Dr. Friesen, is this Continuing Care EHR part of your proposal, or effectively an illustrative example of the kind of thing that can be done?

Dr. Friesen: It is the latter. It is a splendid example, and that is why we invited Mr. Laflèche here.

The Chairman: I have two specific questions. Your proposal, as I read it, asks that Western Diversification put in the order of $265 million up front, and that the provinces would make a contribution - a bit of cash - but largely R&D tax credits and other tax changes. As you indicate in your chart, there would then be a series of cash flows from increased economic activity back to the governments.

Have you had discussions about your proposal either with the federal government and/or any of the provinces that you can actually talk about? I realize you may be having confidential discussions with them.

Dr. Friesen: We certainly have had discussions with federal officials, as we have with you, indicating the scope and nature of the idea and to elicit a response, a reaction to it. As Dr. Tingle pointed out, as part of the initial process, the provincial ministries of health and economic development were all invited and participated to varying degrees. The economic development departments participated quite fulsomely, the health departments less so. This reinforces the point that it is not good public policy to see the health and economic policy developments, thrusts and perspectives so often being at polar opposites on the same issue. In the end it is not beneficial to the Canadian development, either for health or for economic policy.

I believe there is general endorsement of the validity of the idea. There is surprise, as I observed in some of the responses to my mention of Pablum, that it is the last great Canadian product that is out there on the market? That is a bit of an embarrassment, if it is so. Quite clearly, there are other molecules and developments, but none that are selling around the world and immediately recognized like Coca Cola. It is just not there.

Perhaps, I can invite Dr. Tingle to talk about the provincial response because he has been closer to that.

Dr. Tingle: In private discussions it has been very clear is that the health service ministries are so consumed with day-to-day crisis intervention that the ability to plan ahead has not been part of their ongoing activities. The notion of linking the health services side with the industry side has not even entered their lexicon. To illustrate my point, I recall a discussion with one provincial deputy health minister. I asked who the deputy minister for industry was. He was unfamiliar with the name of the individual. The strategic approach that we are taking is to work with Western Diversification as the lead investor to develop the managed network proposals, and then involve the provinces directly by using the provincial health care facilities in a combined fashion as a pilot initiative.

The Chairman: In one of the handouts that you gave us, Dr. Friesen, one of the costs that you had to the four Western Provinces, you have labelled relaxed reference pricing in formularies. Since a lot of the discussion we have had around our table would move to what I would call "tighter" reference pricing in formularies, can you explain what you mean by that?

Dr. Friesen: The point is that health and economic policies need to be more tightly integrated. If you look at simply the cost of drugs as a sole indicator as the input, we are saying we should look at the variety of outputs as well. If, in fact, some of the more innovative drugs are more cost effective, then although the initial price may appear high, if patients in fact no longer need to be hospitalized or require less medical attention over the shorter and longer terms, the cost benefit may be in favour of that more expensive innovative drug. If the analysis focusses simply on the cost of drugs, that is ineffective.

The Chairman: I am glad I asked you the question because that is not the way I read that one line.

Dr. Friesen: In looking at the overall drug policy for the country, it is important to recognize whatever changes are made, if we want the multinational pharmaceutical industries to look upon Canada as an attractive place to invest, the business climate and the economic opportunities must be available to them. Any discussions on drug pricing must look at the opportunity for eliciting - and ultimately gaining - substantially more R&D investment in this country. We are not getting our fair share from the multinationals. I think there is a quid pro quo argument that could be made for greater investment, provided that the business environment is right.

Senator Morin: I would also like to thank my good friend, Dr. Friesen, for coming. In addition to all of these awards, I should also say that he has an honorary degree from my own university, Laval University. I also thank him for his eloquent remarks in relation to health and economics, because I think that important point is not well enough recognized.

Dr. Foerster also made a very important statement in relation to the dangers of having changes to our health care delivery system that are not evidence based. Surprisingly, this is as true for academics as it is for politicians: Everybody seems to look at this from an ideological point of view, including the academics in the field.

Mr. Laflèche has dealt extensively with the information system. That is a very important issue. The American Institute of Medicine has just published Crossing the Quality Chasm, a book on the quality of health care. One of their recommendations is the elimination of handwritten clinical data by the end of the decade. In stating that, they also say that we should not underestimate the difficulties of applying health information systems to health care. They say it is costly, difficult, and there will be much resistance to it. I was interested to see that the $6 billion comes from CIHI. I am surprised to see that you could bring it down. Was it $250 million?

Mr. Laflèche: This is only for our piece of it.

Senator Morin: That is only for Western Canada?

Mr. Laflèche: Exactly.

Senator Morin: Before I pass to a question to Dr. Friesen, I would like Mr. Laflèche to tell us what system was actually sold to the American corporation?

Mr. Laflèche: It was an MBS assessment tool that is being used in the 50 States and in 18,000 nursing homes, and a clinical tool, an electronic chart, a paperless chart.

Senator Morin: I had the opportunity, Dr. Friesen, of reading the report. I think the full report deals, of course, with a number of managed networks and clusters of centres of excellence that would be dealing with the research, and there is a large sector on commercialization. My question deals also with what Senator Kirby has suggested. You have a statement here under commercialization that intrigued me: "Put the bio-pharmaceutical industry on a level regulatory playing field," and later you say there are regulatory barriers.

What specifically did you have in mind? There is much talk about increasing the regulation of the drug industry. You have read the premier's press release from St. John's two weeks ago where, far from removing the barriers, they want to increase them. What exactly do you have in mind here?

Dr. Friesen: Some of the regulatory machinery to address particularly developments in biotechnology and bioengineering are really from another era. When you look at the variety of products that are in the pipeline for assessment, you ask, "is a machinery for efficient, speedy, timely approval available in Canada compared to other jurisdictions?" That is one issue. This is an important issue, because that will determine to some degree where some of the clinical trial studies will take place. If, in fact, there are barriers in Canada relative to other jurisdictions - U.K. as an example - where phase one clinical trials essentially can be done within a 24-hour approval process compared with Canada where it is a month or two. Is that the sort of barrier to which we are referring?

In terms of the patenting regime, are we current? Do we in fact have a patenting regime that is comparable to other industrialized countries, to make sure that our intellectual property protection is equivalent?

We want to ensure that the business and the commercialization opportunities are on a level playing field, so that in the global economy in which we compete, Canada has an equal and a fair opportunity to make its case.

Senator Morin: Am I correct in saying that you are in favour of a more favourable environment for the bio-pharmaceutical industry as a leverage for health research and development?

Dr. Friesen: Yes, that is correct.

Senator Morin: From my view, that is a very important statement, Mr. Chairman.

The Chairman: Just to expand slightly on that point, you are in favour of it not only as a driver for research, but the key point of your document is a driver ultimately for the creation of spin-off private sector operations that in turn ultimately become employers? It is not research for research's sake - not that that is a bad thing - but it is research with an ultimate economic development focus?

Dr. Friesen: Yes, and improved health care delivery. Perhaps Dr. Tingle will speak to that issue. I think it is clear that individuals who are part of protocol management, as part of a managed network, have in the end a superior health care system available to them.

Dr. Tingle: I would like to expand on the example that Dr. Foerster talked about - that is a model that Dr. Shoo Lee has done. Dr. Shoo Lee is a pediatrician from Singapore originally, who did a Ph.D. in Health Economics at Harvard. When he came back to Canada, he set up a network of all of the neonatal intensive care units in Canada on a single database system.

The Chairman: Country-wide?

Dr. Tingle: Country wide in this example. With this network, he can now look at every neonatal centre in Canada and look at their outcomes relative to each other. He can look at predictive values for looking at cost effectiveness of outcomes. He has been approached to join the insurance industry and reinsurance industries in the United States, because they are looking at the cost effectiveness of care and risk that they assume in taking a small premature infant on as a health insurance risk. So he has spun out two companies that are looking at marketing the capacity of making decisions in the neonatal intensive care network for Canada.

He did this with an initial $1-million operating grant, and has had great difficulty in funding it because this is no longer classical research. He is addressing questions such as "How do we improve the health care system?" "How do we do cost benefit analysis in the health care system?" "How do we do quality improvement at each of the partner institutions that have a neonatal intensive care unit?"

The Chairman: When someone wants to pursue an idea that has gone beyond basic research into the application and implementation end go in this country, where would he go? As I inferred from what you said, Dr. Tingle, that kind of study does not meet the tests of the classical old research councils or the CIHR. Where do you go for that?

Dr. Tingle: We have already lost half of our team from this unit to the United States. We have highlighted it as a key part of the strategy, because we feel that it is a missing part of the Canadian framework.

The Chairman: I assume that the missing part, as you call it, is not unique to this particular study, the problem is that there is a gap in funding efforts. If this was a private sector you would call it "venture capital," but it is the gap between taking the output of primary research, basic research, and actually implementing it?

Dr. Tingle; I will illustrate it. In British Columbia the health care budget is $9 billion. The proportion of that spent on quality improvement or quality evaluation is virtually zero. The health care delivery side of the system is not supported.

The Chairman: Not supported because they are so short of funds for other things that it just does not get to the top of the pile?

Dr. Tingle: Absolutely correct.

Senator Keon: I will direct my comments and then the question to you, Dr. Friesen, but I would like all of you to respond to it. This is a fascinating field. Why have we not been able to do better than we have? I recall very well, as you do, Dr. Friesen, when you became president of the Medical Research Council, we were essentially dealing with two solitudes: the basic scientific community of Canada and the industrial complex. Eventually, some bonds grew and became established. In reality I think there has been tremendous progress with the creation of CIHR, CFI, the provincial agencies and a number of other philanthropic organizations and public corporations that are looking at venture capital and the rest.

It seems to me that the bridge we have not been able to cross is getting the large health industrial corporations to change their operational frame of mind and getting them to locate their people in our universities and our institutions, make substantial long-term investments in research chairs, and de-emphasize their preoccupation with patents and this kind of thing, which has driven them commercially and is their life's blood.

I know that you have spent the last number of years dedicated to the creation of a milieu where this would occur. There has been real progress - there is no question about that. However, when we look at the industrial giants - the pharmaceuticals, the device corporations, the health technology companies - and the biggest one of all is the health provider organizations - the HMOs and the large health corporations that are now international. We still have not been able to put together the intellectual resources of our country to do something positive for most of these people.

For example, the HMOs, or the large international health care provider corporations, blow all kinds of money funding things that are doing no good at all. They do not fund things that are doing a lot of good because they do not have appropriate outcome research and they do not have appropriate epidemiological research.

It seems to me that the bridge that we have to cross, more than government investment, is to get our scientific intellectual community to convince the global industrial complex to switch 180 degrees and stop investing in their own fortresses and invest in our institutions. I have no idea how to do that. I know we are making progress and I know you have been trying to do that, but I would like to hear comments from everybody.

Dr. Friesen: Senator Keon, you have touched at the heart of the matter. In the end, behavioural changes in this sector demand kind of a cultural, attitudinal shift, fundamentally and deeply. We saw that as part of the exercise. I think the health care providers and those who manage them have been absorbed - and so they should be - on delivering health care. That is their mandate; that is their mission. If there are others out there in the industry economic portfolios, they are busy doing their thing, and the boundaries of that perspective do not intersect with the health care system. So you have these two world views of what is possible and who is responsible for the various arenas.

I agree entirely that there is progress. Yet, I would note still that if you asked how much time - this is not even product and service development - federal and provincial deputy ministers of health devote to the subject of research. Unless the last few meetings have changed, it has been very little, if any.

I used to needle my colleagues about this oversight - that if the driver of innovation is research, why is the subject not preoccupying them? I believe that this should be a federal role.

I am deviating a little bit from answering your question precisely. I think the federal role is to articulate the vision for Canada's health care system - broadly and in an inspired way. No one has; no one is. We are busy talking about the process, mechanics and structures; in a sense we are moving toward a bureaucratic description of what our health care system should be about. I believe that Canada's "brand" should be our health care system.

The issues that we are raising concern economic development, innovation and products. If we choose to, we can develop the most excellent products and services, which we can then sell around the world and get a return on this investment to continuously improve, through innovations, our health care system. Sometimes I think we see our health care system like a poorly performing student that occasionally has a pass, and we all celebrate the pass saying that is victory. That is a far cry from my view of my vision for Canada's health care system.

There is so much opportunity if we get it right. I would urge your committee to articulate that vision of the grand opportunity. That, in my view, is what this committee's report might choose to address.

I will turn the rest of the answers over to my colleagues who will be more specific.

Dr. Tingle: I will just follow through on the example that I used to illustrate the dilemma we are facing. If you go to the universities and ask, is quality improvement in the health care system an academic enterprise; the answer is, no, it is not. If you go to the hospitals or the health care ministries and ask if research and quality improvement is a health care issue; the answer is, no, it is research. You have a cultural dynamic inhibits the area. Yet, Dr. Shoo Lee went to Kaiser Permanente, said that he had a system that could change the way we deliver health to a specific population. Kaiser Permanente has co-patented this system with Dr. Shoo Lee and is right there at the table, keen and interested.

A journey of a thousand miles begins with a single step. You have to create some type of pilot system to begin to look at this in selected areas of high priority and develop the new cultural paradigm among health and industry and academia and service professions as to how can we carry this out.

That has been part of the strategy behind the initiative that we have been proposing. You must start somewhere. You must do it in a pilot system. You must get enough centres working together to form a critical mass and change the dynamic that we have been stuck with for a variety of reasons over the last several decades.

Dr. Foerster: To the answer your question about involvement of big pharmaceuticals and other companies of that type more specifically, these individuals unfortunately are currently not interested in anything that is not almost completely a sure thing. What is lacking in many parts of Canada is money to take it from what MRC, CIHR to what can be sold to industry. For that we need venture capital pools. In the east they are much better developed. In Western Canada, we are just starting to develop some in Manitoba, and they have helped us to take some of these things forward, but there is a big lack there.

One of our researchers here developed an excellent innovative new way of treating cancer. He could not get enough venture capital pool here to take that idea forward. He went elsewhere. His company is now valued at $60 million on the stock market. Another physician here developed an excellent way of improving respirators for intensive care units. He could not get enough venture capital money here in order take that further and had to go to the United States. Everything is now being done down there, the manufacturer, the benefits that accrue from these kinds of industrial development. I see that as a missing link between what universities do, what industry is interested in, the in between piece.

The Chairman: Dr. Foerster, for clarification, when you used the word "here," did you mean here in Manitoba or here in Western Canada or here in Canada?

Dr. Foerster: Specifically, Manitoba for those two examples.

The Chairman: By the way, I do not know if this is good news or bad news, but the venture capital problem is not unique to Manitoba, it is true in the whole country and not just in the health care sector. If you look at creative ideas that require venture capital in a whole variety of areas, the amount of venture capital available in Canada is very small. Canadian investors - which is what venture capitalists are - have a tendency to be far more cautious and far more risk adverse than is the case, particularly in the U.S. and increasingly, in parts of Europe. I do not know if that makes you feel good or bad, but you are not alone.

Dr. Foerster: On the other hand, there are positive changes and I see them as part of the development we have just presented. For instance, individuals in Manitoba and Saskatchewan have recently created a Life Sciences Fund, which already has $45 million committed and which is seen as topping out at about $90 million.

Change is happening. However, people with vision such as Dr. Friesen and others who are presenting this report need to come forward with ideas that excite all of these different sectors, including private industry and the universities.

The Chairman: It is also true that venture capital is much less likely to come from government. This is in part because of the nature of politics. Any venture capital fund is obviously going to have a number of failures in hopes that it has the odd success. Yet in a political climate - politics being what it is - the issue will be the failures and not the successes in spite of the fact that the fund may make money. There is a huge resistance.

I go way back to the early regional development days when they did not call it venture capital. If you go back to the early days of ARDA and DREE and all of those other acronyms, the media and opposition parties focussed on the failures and not the successes. Government is deeply reluctant to get into that area.

Dr. Foerster: We are not looking for that.

The Chairman: No, I know that.

Senator Morin: Mr. Chair, I would like to be on the record as saying that I had the opportunity of reading this in detail and that I am in support of this project. The three main elements of bringing the health and economic communities together, bringing about health services innovation, and finally of developing bio-tech commercialization, are very important.

There is an opportunity for the west here to be a trailblazer for the country. Eventually, after this has started out here as a pilot project, the rest of the country could follow the lead here. So I am very much in favour of that.

The Chairman: May I thank all of you for coming. We appreciate you taking the time to be with us. I am sure, Dr. Friesen, you will keep us up-to-date as how things go along.

The next witness is Bill Bryant, Chair of the Council of Chairs, Regional Health Authorities of Manitoba.

I have a copy of your statement. Can you begin first by, you have been here so you know what our format is, if you can begin by introducing your colleagues for purposes of our Hansard reporters, and then I am not sure whether you or Mr. Beresford is doing the opening statement, but whoever is, if you could then do the opening statement and we would be delighted to ask you questions.

Mr. Bill Bryant, Chair, Council of Chairs, Regional Health Authorities of Manitoba: The Regional Health Authorities or RHAs of Manitoba, as representatives of health system managers and trustees, appreciate the opportunity to appear before you today.

We are pleased to be here representing the RHAs of Manitoba. My name is Bill Bryant and I am the Chair of the Board of Southwestman RHA and Chair of the Council of Chairs of the RHAs. With me I have Kevin Beresford, CEO of the Interlake Region and Chair of the Council of CEOs of the RHAs. Also with us is Mr. Randy Lock, Executive Director of the Regional Health Authorities of Manitoba.

As you may know, Manitoba has 12 regional health authorities, consisting of 10 in northern and rural Manitoba, one in Brandon and one in Winnipeg. Collectively, we represent the health system in Manitoba with the exception of Cancer Care Manitoba and the Addictions Foundation of Manitoba.

The RHAs are responsible for the direction, operation, coordination and provision of the full continuum of the health services. The continuum includes acute and long-term care facilities as well as community, mental health, public health and ambulance services.

Our mission is foster the development of an efficient and effective interregional health care system that meets the needs of all Manitobans.

As a Manitoba member of the Canadian Health Care Association, RHAM has been very involved in the work of CHA in preparing policy briefs on a variety of issues from which we will be drawing on today.

Let us begin by saying that it is our opinion that the system of health care that we have today is not sustainable in its current form into the future. The need for change is real and immediate. The bigger question of how we make the required changes is the real challenge, as there does appear to be a consensus forming as to what changes are required.

Mr. Kevin Beresford, Chair, Council of CEOs, Regional Health Authorities of Manitoba: Before we can undertake dramatic and sustainable reconfiguration of the system, which we believe is needed, a stable and on-going funding framework must be assured. Some of the basic infrastructures of our health care system have suffered serious erosion over the past decade as a result of "stop and go" funding methodologies by both federal and provincial governments. Therefore, one of the first priorities must be a significant and sustained federal cash commitment to restore stability to the existing health care system and ultimately renew confidence in the health care system.

There is also an urgent need for the federal government to explicitly commit to an annual escalator to be applied to this funding commitment. A cash floor at $19.8 billion will just meet existing needs to ensure roughly comparable services and health outcomes within Manitoba and across Canada. The annual escalator will provide some assurances that long-term sustainability of our health care system in the face of economic growth, changing demographics and other factors, will be possible. Although it would be preferred that these funding commitments come in the form of the CHST cash payments, it is recognized that alternate funding mechanisms may be considered. These would, of necessity, need to be negotiated between the varying levels of government, but should not delay the flow of cash that is immediately needed.

It is recognized that with increased funding there will be a need for increased accountability as well. This accountability framework should be based upon a common set of objectives and standards for our health care system. The focus of accountability should not be on provincial and territorial governments being accountable to federal government for tracking of dollars. Rather, the primary focus should be that all levels of government and regional health authorities should be accountable to Manitobans and Canadians with focus on performance measures and health outcomes. These are the elements that the public expects to have reported and are the elements that will ensure that what we are doing is making a difference to the well being of our communities.

For accountability mechanisms to be effective however, reliable data is needed. Integrated health information systems are essential components of effective accountability mechanisms. While the Canadian Institute for Health Information is funded to do, and is providing, valuable work, unless the system on the ground provides reliable data derived from compatible systems, we will not achieve our objectives of measurements. We would encourage the federal government to direct funding towards the development, implementation and ongoing support of health information technology to achieve these specific objectives.

Much has been said of late with regard to the need for expanded privatization within the Canadian health care system. It is our view that a publicly administered health care system, as envisioned in the Canada Health Act, can and does work and should be maintained. If there is a role for private providers, it should be based on specific contracts to provide a defined set of services. These contracts should be coordinated through the publicly administered system to ensure that Canada maintains one system with one set of objectives and outcomes. To do otherwise leads to confusion, competition and, ultimately, gaps in service. In the end, there is only one source of funds - the public - and therefore there should only be one controller of the provision of services.

We have attempted to focus our presentation on only a couple of aspects of the changing health care environment in which we find ourselves. We wish the Standing Senate Committee on Social Affairs, Science and Technology much success in your deliberations, and thank you for the opportunity to meet. We will be pleased to answer any questions that members may have of us on these topics or any others. Thank you.

The Chairman: Thank you for your succinct presentation. Can I ask you a couple of questions that relate to your second and third last paragraphs? They flow out of some evidence that we heard at the beginning. Were you here when Professor West and Mr. Holle were here? They were our first witnesses. I will have to give you a bit of background.

I am puzzled by your statement that the focus of accountability should not be on provincial and territory governments being accountable to the federal government for the tracking of dollars. How do you square that view with the view that the federal government has some obligation, it seems to me, to account to the people who elect the federal government for the spending of federal funds?

I will give you a very concrete example. In the September 2000 conference there were two major announcements, $800 million for pilot projects in primary care. That money can be accounted for because the federal government has to approve the pilot projects. A billion dollars was approved for equipment that was described as imaging equipment and MRIs - that sort of thing. The federal government gave the money out, but it has absolutely no idea where it went. I do not understand how the federal government can simultaneously say "we are going to give money for X" and yet not actually be able to know if the money was spent on X. It might just as well have announced it was going to give a billion dollars, because that is its knowledge base.

Having been also in the provinces, I understand why the provinces do not want it. I am not suggesting this should be popular with the provinces. I am only puzzled as to why an organization like yours should take the view that that level of accountability should not be required.

Mr. Beresford: I am certainly in agreement with your comments in relation to the accountability of tracking the dollars. More succinctly, our position would be that the primary focus does not necessarily always have to be related to the dollars, but we certainly have to have a major focus on accountability of the outcomes.

The Chairman: I agree with that. It is only when they announce a targeted program, they have to know if the targeted funds are really spent on the targeted program.

Can I just get to the central point? In the second last paragraph you say two things, which seem a little bit inconsistent. If there is a role for private providers, it should be based on specific contracts to provide a defined set of services. I understand that. That is the case that still exists with two of the private clinics in Manitoba; is that right? Am I right on that score? Subsequently at the end I will come back and ask you about those.

You then say, "to do otherwise leads to confusion, competition..." The interesting thing is our first two witnesses stressed the benefits of competition - even if the competition was between two publicly owned facilities. That is, the public/private was not the issue that our first two witnesses were talking about. They were talking about experience in Sweden, France and elsewhere, where an element of competition between two providers - both who might be owned by the public sector - was in fact helpful. I want to know why you are opposed to competition, or if you are equating competition with private ownership, because they are two separate issues.

Mr. Randy Lock, Executive Director, Regional Health Authorities of Manitoba: When we are talking competition in this particular case, we are talking competition going to the public. The public becomes extremely confused when there are public and private providers of comparable service. There is no dispute that competition - whether between two public entities or otherwise - drives us to a better level of service, a better level of care provision. What we want to ensure here is that the public is aware that there is a basic standard expectation. The way to assure them of that is to have the publicly administered system providing the entry point into that system, into one system and one system alone. Within that system there can be streams. Those streams can be varying public providers or a combination of public and provider. Our statement here is not to say that there is no room in the system for private providers. It is simply to say that if there are to be private providers, they should be working within the system and not in direct competition with the system in that they take certain services that the public system needs access to as well, if they want to provide the full care continuum.

The Chairman: That piece I understand, the first sentence. You people are in the perfect position to try to address this question. Let us make the assumption that every facility is publicly owned. Experience elsewhere in the world would suggest that if consumers have a choice, if they can go to institution A or clinic A or clinic B - and to some extent each clinic wants to maximize its volume, hence they are in competition with each other - that that improves the quality of service entirely independent of who owns the facilities. This is what the first two speakers those of us around the table think of by "competition." I am still not certain whether you think that is okay or not okay.

Mr. Lock: Certainly competition is okay and certainly competition does work as you have described. The other side of competition is that there are certain services that can be provided more easily, more readily than other components of service.

The Chairman: Give me a "for instance."

Mr. Lock: It is relatively straightforward to provide appendectomies. It is not quite as straightforward to do public health services; it may not be as straightforward to provide tertiary care services, and yet those are integral to a provision of a continuum of services that we in Manitoba and across Canada value. We must ensure that in that competitive environment the full continuum continues to be provided, rather than going after those areas that are easily delivered to the public at the expense of losing other services that are equally as important, yet not as easily delivered.

The Chairman: We now have competition for cataracts or laser eye surgery or whatever; you might have an element of competition for simple orthopaedic things - and so forth. However, you wouldn't have it for open-heart surgery, for example.

Senator Morin: I had the same remark concerning the competition. I am not clear why you are opposed to competition between a private provider and a public provider if it is all done under a single payer. There is a divorce between provider and the payer here that is manager that all European countries are getting at. I think it is effective, and I do not want to get into that. I also was impressed by your sentence, "to do otherwise leads to competition." For me competition is the best stimulus here.

With respect to funding, your statement says that there should be a significant and sustained federal cash commitment and so forth. A year ago, September 11, 2000, there was a $23-billion cash infusion in the system. How much more should the federal government give? Should it be $23 billion a year, or what limit is there on it?

Mr. Lock: I think a significant portion, or at least a portion of that $23 billion was targeted one-time funding as opposed to assured baseline funding into the future. As an organization or group of organizations trying to run a business here, we do not know from year to year what our cash flow is going to be. We are in an awkward position in that we are dependent on employees in the system to provide services. Those employees need to be paid to provide those services, and yet we do not have an assured cash flow one year to the next.

Historically provincial budgets have come down into the current year of operations for our businesses. We do not know what our funding support will look like. The argument that we are putting forward is that we need a committed amount of baseline funding. That committed amount should be predictable. Then we can make plans as to how we will conduct the operations of our entities in advance of the actual year beginning in which we are operating.

Senator Morin: The disadvantage of government spending as compared to private is that the government has political priorities. In private funding I have my dental insurance; I spend $1,200 a year and I have my policy year after year, so that is stable. For me it is a priority. Yet for the government, there are other priorities, based on political ideology. One government will spend more. There are other issues. We are faced with security issues right now, and for any Canadian that may be more important that health care spending. Therefore, if you are in a government spending environment that you can expect stable funding. That is both the advantage and disadvantage of the system.

Mr. Lock: I think that is the environment that leads us to deal with the day-to-day hot issue as opposed to the longer term plan for the health care system, which is what I believe the public is calling for. What does the basic system provide us and will we be assured that it will be there next week, next month, next year if and when we need it? In the absence of us being able to assure them of some basic level of service, based on some predictable level of funding, then they believe the system is falling apart. Every day that they open their papers they find that there is something else going on in the health care system that they were not aware of and were not planning for. What we are asking for is the ability to have some baseline that we can anticipate.

Senator Morin: You know that many people, it was stated in the Canadian Forum of Health and it is still stated by well-known people here in Winnipeg, Dr. Noralou Roos, maintain that there is enough money in the system. This afternoon she will appear as a witness, and I am sure that what she will tell us there is enough money in the system. How do you react to that? I am sure you have heard of her work and what she is doing.

Mr. Lock: Yes, we are certainly aware of Dr. Roos and her work.

We maintain, both at our regional level and through the Canadian Health Care Association, that the baseline needs to be assured. The baseline as it stands today does not reflect the $23 billion to which you referred. There is specific targeted funding in that $23 billion, and the actual floor that can be assured is less than the $23 billion.

Senator Morin: Many people maintain that whatever increase of funding we put in the system goes immediately into increased salaries of the workforce. The Fraser Institute maintains that the salary levels of those workers in the health care system are far higher than in the private. I am not referring to nurses and physicians, I am referring to electricians and plumbers and kitchen staff, and so forth. They give specific examples of that. This appears to be true. We have had illegal strikes from coast to coast over the last year. In several cases the unions appear to have been stronger than the governments, and there have been large increases in salaries.

There appears to be a spiral: As we put more money into the system, it immediately goes into increased salaries, and 80 per cent of the money that we invest in health care goes into salaries. There appears to be no end to that. The reason for that is because it is a monopoly. If there were five or six different corporations giving the same service, if there is a strike in corporation A, the four other corporations would go on. These arguments have been made. How do you react to that?

Mr. Bryant: I do not dispute your percentage in terms of salaries. We are faced with that all of the time. The competition for employees is tremendous. It is an ongoing battle at the regional level. I can speak for all of the Regional Health Authorities in Manitoba; it is an ongoing battle in terms of trying to maintain some kind of a level playing field in the provinces. It is a continuous battle, not only for our nurses but also for physicians. So it is a problem. I do not know if you can comment on that, Mr. Beresford, in terms of your role as a CEO?

Mr. Beresford: I am in agreement and certainly would not challenge your percentage in relation to salaries because I know that to be very true. I also agree with your comment that the minute there are more dollars injected into the system, there are more people with their hands out in respect to the labour component of health care.

In relation to the dollars that are in the system, I feel the system has been focussed on the illness model, the curative areas of health care. Speaking from experience within my region, we have not been able to turn the corner as far as looking at the expanded needs, the aging population, the growing population, in order to put money into health promotion and disease prevention. I see that as being of very significant and critical importance. If there are earmarked dollars being spent within this province, within this country, they should be directed to that component.

It is not an easily quantifiable saving over a projected period, and we have all had difficulty in convincing our provincial government in some cases that for X number of dollars spent at the front end, there would be substantial savings at the end. However, to turn the corner in this province and in this country, there is a substantive need for an infusion of money to look at health promotion and disease prevention initiatives.

Senator Keon: Mr. Bryant, you made a statement that is almost trite now, and that is the system is not sustainable. I believe every provincial Minister of Health is saying the same thing. The question is, "how can we work to a system that would become sustainable."

The Canadian public - particularly the older people - are frightened of going back to what was there before the system came in the 1960s. In other words, where illness meant bankruptcy in a lot of situations. Consequently they are being very defensive of any kind of change. Yet we have to admit there are systems around the world that are functioning a lot better than ours now, particularly in Europe. They are all based on some kind of financial security for the individual, the patient, but the providers are a public/private mix with some reasonable competition.

Again there was a trite example raised again this morning about mandatory auto insurance, which works fine. If there is mandatory auto insurance in a province, that is fine, nobody is out-of-pocket after an accident. However, do not have the government funding all of the auto collision shops or you would have a disaster on your hands. It is probably a little unreasonable to compare health care delivery to automotive repairs, but there is some sort of analogy there.

Somehow we have to grope and find a way of getting the message across to the Canadian public that we have to do something about this, because the conundrum that we are in is that 30 per cent of health care services are now private, 70 per cent are public. The scary thing is that at end-of-life situations people are not protected at all. People are going to be facing bankruptcy in end-of-life situations with chronic care, home care, and so forth.

The other thing is the good drugs. They are usually not covered in the formularies. The best drugs for hypertension are not covered. If you want to take Cozaar, you go out and buy it, otherwise you get a prescription that is paid by the pharmacy for one of the run of the mill drugs that is covered.

So, I want to give you a minute to reflect and then I would like you to be daring and suggest how we are going to get out of this. We have to be daring. Before very long we have to provide a report and we have to make some recommendations, and we are trying to draw these out of you people that are coming before us.

Mr. Bryant: "Innovative" is a good word, because it is going to take some innovation. I can speak from a regional basis, a small rural western Manitoba region, because I have been the chair of that board since regionalization was introduced into Manitoba. We have been through quite a growing stage in our development, and we are faced with the sustainable part of this equation on a daily basis.

In the past we have had to change the focus of the small acute care facility because we were unable to recruit a physician to it, so we were no longer able to offer emergency room services or acute admissions. But we did change the focus of that facility. It is still there and it is still functioning. In fact, the use of the beds in that facility is higher now than it was before, because we are using it as a mid-point for people waiting placement for personal care home beds, et cetera, so they are in that facility versus being in another acute care facility.

So where we can, we are working towards being innovative and maintaining or trying to maintain that sustainability. We have been pleasantly surprised with people in our communities when we have gathered together some of the major stakeholders, some our local politicians, to discuss what is the future for health care in our region and the sustainability aspect of it. We have come away from those sessions with the impression that the people are aware. They know that the current situation cannot last forever, that change is necessary and it becomes more evident every day.

Tomorrow evening, I will be attending a public meeting in another community where, because of a nursing shortage issue, we are going to have to change the focus of that facility until we can correct the system or correct the issue by hiring into that position.

So we are very aware of the necessity of change. I think the people are ready for change. I am quite optimistic that with the right leadership it could happen.

Senator Keon: Do you think that people are ready for provision of services by private enterprise?

Mr. Bryant: I am not sure how honestly I can answer that question because I have never really talked to people about that. I know that there is provision of private service within our region basically because we cannot or are not able to recruit occupational therapists or physiotherapists. Private clinics have set up in our region and people are using them to avoid travelling long distances and being on long waiting lists.

The Chairman: Would any of the other panel members care to venture into that minefield?

Mr. Beresford: I certainly have my opinions in relation to innovation of the system and potentially how we can save dollars within the system. I do not want to appear derogatory towards physicians, who are valuable parts of the health care system, but I feel that they are certainly the major drivers. They significantly control the expenditures within the health care system in relation to ordering diagnostic tests, using our facilities, and prescribing drugs.

In addition to supporting health promotion and disease prevention, I am a strong proponent of primary health care, community health centres, and appropriate access to appropriate caregivers within the system. When a person is presenting within a system, that person should be put in touch with the appropriate provider that would be easily accessible. This would be preferable to that first contact being with the physician, because I think it would stem and alleviate a lot of the costs.

The Chairman: I understand your comments about providers, or doctors. I agree with what you said. However, would not any rational human being put into the system that now exists do that? In other words, your statement implies that what is wrong is that the incentives in the system are all wrong. Therefore, government seems to have a tendency - and a lot of us, including me, have been in senior positions in government - to want to be critical of people who respond in a totally rational fashion to a system that the government has established which has clearly some irrational elements. My question to you is, given your criticism with which I agree, why do you not change the incentives for the doctors so they do not follow the behaviour that they do?

That is a tough governmental question, because that now says you have to actually accept the responsibility. I also understand politics is the art of shifting the blame, that is a situation with which I am long familiar. Why do we not change the system then? That, frankly, is what got this committee on to this issue in the first place?

Mr. Beresford: Yes, there are a number of methodologies to do that. The most obvious one, which I do not think has been successful, is in relation to the method of remuneration to physicians - to decrease what I would call a competitive environment within the health care industry. That is certainly one opportunity.

In relation to your statements previous to that, one of the issues that we face is public perception, relating to whom the public sees as the gatekeeper to the health care system.

There are many attitudinal differences in a region such as mine. I would like to give you a brief description of this region. It commences at the perimeter highway of Winnipeg and goes right to the 53rd parallel. Within that region we have 30,000 square kilometres. We have an urban environment that would be the southern area of the region because of the accessibility of Winnipeg and some of the larger communities. We have a very rural environment and a very remote environment.

The Chairman: Do you include Brandon?

Mr. Beresford: No, basically between the lakes, Lake Manitoba and Lake Winnipeg.

From what we have seen in our dialogue with various communities is that people who have less accessibility or less stability in relation to health services are very willing to accept the community health models or the primary delivery. The closer or greater your accessibility to the urban centres, the greater the public demands. It is difficult to determine how we would turn that corner in changing public perception as far as primary care and how we can be innovative in changing the system. However, I think that given the few success stories out there, that we will slowly turn the corner. In our region, we have a great deal of community support in relation to that.

Senator Keon: Mr. Beresford, I should like to pursue that with you, because I have a lot of experience with the problems with physicians, the remuneration. I was a professor and chairman of surgery for 16 years and had to deal with full-time contracts. I am the CEO of an institution where the physicians are salaried. Some of our research endeavours, for example, were heavily into telehealth, where there is absolutely no mechanism for physician remuneration. The only reason we could do it out of our institution was that it did not affect the physician's incomes. So I believe that there is room for a lot of positive change here, if it is done in the right way.

There are regions in Canada, and certainly the northern regions I suspect of Manitoba, where fee-for-service just does not work. It is not possible. You need teams of people, and they have to be remunerated in a reasonable fashion. A physician would not spend his morning teleconferencing if he is not going to be paid, if he is on a fee-for-service system. I think that governments have to accept the responsibility for not initiating some of those changes.

I am fully aware of the criticisms aimed at physicians and so forth, and some of them are justified, some of them are not. I do not believe that we can stand still any longer, particularly in rural health. Government simply has to come out and say, well, we are going to provide a funding formula that will cover all of the health professionals in this area, and we will cover their relationships, the integration of the teams that will manage this area and so forth. If that were done it would overcome a lot of the debate that exists now. I would like to hear your comments because you are very much into this.

Mr. Beresford: Well, I certainly agree with what you have said. I am a firm believer that there has to be a remuneration model that does foster teamwork within the health care system. We have made some strides within this province in respect to salaried and contract physicians. We have made some strides in relation to telehealth, where I believe that is now inclusive within fee guides. I agree that there has to be a cooperative dialogue with physicians and associations representing physicians to come up with some innovative planning.

One of the potential downfalls is the relationship between the professional associations and the funding agency. If that bridge can be overcome, there are many areas in which we can see innovative ways of remuneration that will foster teamwork within the health care system.

Senator Pépin: You have said that people are demanding and expect to have the same kinds of services available in the city. You also suggest an alternative distribution of health services whereby the doctor would be part of a team including nurses, pharmacists and so forth and that salaries would cover a full year of services. You suggest that a nurse would be making referrals to the appropriate doctor or specialist. Do you believe that the doctor would be ready to accept that kind of an innovation?

Mr. Beresford: Physicians in my region have been receptive to that, and those who are most receptive are those who are on a contract or salary basis. They do not see the competition from other health care providers and they feel very much one of the team.

Senator Pépin: So we have to look into that.

The Chairman: Can I ask one last question? You may be the wrong people to ask, but perhaps you can send us in the right direction. We would like to understand as much as we can about the history of three private clinics that operated for a considerable amount of time in the 1980s and early 1990s. We would like to know how well they worked or did not work, what the public reaction was and all of that. Subsequently, we would like to know, when the when the government began funding all of the patient services that they performed, whether that worked or did not work, what the change was.

My understanding is that the government has now actually bought the bricks and mortar of one of the three. I would love to understand the policy rationale for that, because I do not understand how owning new bricks and mortar changes anything - particularly since there are two other ones still out there that are not being done.

Any light that you can shed on this would be helpful to us because a lot of people will argue a lot of things about parallel clinics and other things. In fact, in Manitoba here we have a real live experiment for a while. Where can we get the most up-to-date comprehensive piece of analysis on that?

Mr. Lock: The best people to talk to would be the Winnipeg Regional Health Authority, which is one of our member organizations. The CEO there is Dr. Brian Postl, and certainly he would be well aware of both the history and the current arrangements that are going on with those clinics.

The Chairman: Were all three in Winnipeg?

Mr. Lock: Certainly the one that you refer to, the most current one, where the bricks and mortar have been purchased is a Winnipeg example. There is at least one other example within Winnipeg. The third one I am not sure.

The Chairman: There is also one that has been built, but not licensed and doing business.

Mr. Lock: That is also in Winnipeg.

The Chairman: So the source we would go to is the Winnipeg Regional Health Authority?

Mr. Lock: Yes.

The Chairman: We will do that. I thank all three of you for coming. We appreciate your taking the time to be with us today. It is important that we talk to not just people who have done research, but people who are actually running institutions like you are. We know how busy you are, so we appreciate you taking the time from your schedule to come and be with us today. Thank you.

The committee adjourned.

The committee resumed

The Chairman: Honourable senators, our first witness this afternoon is Dr. Noralou Roos from the Manitoba Centre for Health Policy and Evaluation. Madeline Boscoe, Advocacy Coordinator for the Women's Health Clinic for Manitoba, will follow Dr. Roos.

Please proceed, Dr. Roos.

Dr. Noralou Roos, Manitoba Centre for Health Policy and Evaluation: Mr. Chairman, this is my first experience making such a presentation, and I am honoured to do so.

I would start by commending several aspects of this report. I think your objectives make sense. Your proposed options for reducing the costs of prescription drugs make sense. Your support for research and development and the use of health information is commendable. The call for a report which is "factual and non-ideological" is exactly what this country needs.

My concern, and it is a very serious one, is that what I have read to date, particularly your Volume Four, fails to deliver a report which is factual and non-ideological. Chapters 6 and 7 in this report have many serious failings.

I have outlined in my brief three particular areas of problems. One, the evidence does not support the committee's proposal that private funding approaches are needed to address the problem of timely access to care. Two, evidence does not support the committee's assumption that more money is needed in the health care system. Three, a factual review of private funding mechanisms is not provided.

The problem as I see it with this version of the report is that the committee is making the assumption that any new option must be preferable to the current system, and that the problems are horrendous, despite evidence which you present in earlier volumes to the contrary. This means you then have an executive summary that uncritically assesses a variety of options, and the whole report results in an unbalanced and inaccurate review of the evidence on private sector involvement.

My recommendation is that you work with some of the national organizations that you have identified. The Canadian Institutes of Health Research, the Canadian Health Services Research Foundation, the Institutes of Population Health are all organizations which could provide you with a thoughtful, evidence-based review of your findings and your options and the degree to which they flow from the evidence.

I will elaborate on the areas of the report with which I have some difficulty. You identify waiting lists as a key problem. Nobody will disagree with you that this is clearly an issue that is in the public's eye. The options that you suggest focus on private sector alternatives.

The Canadian Health Services Research Foundation is an organization to which you could go to review the evidence in this area. The current Chairman of the Board, Dr. Arnold Naimark, is our University President and former Dean of the Faculty. Dr. Matthew Spence and Dr. Michel Bureau, who were founding board members of this institute, have published a series of "mythbusters" in which they specifically looked at evidence about waiting times and private sector involvement. One of their essays, which I mention in my brief, specifically reviews the evidence which disproves the myth that a parallel private system would reduce waiting times in the public system. They identify this as a myth. The evidence simply does not support this.

Today, you asked a question about the effect of having private clinics in Manitoba where individuals could jump the queue. You were referred to Dr. Brian Postl, who is the chair of my advisory committee. He is a very thoughtful individual who is head of the WRHA. I believe he would refer you to our report. We looked at how waiting times for cataract surgery varied according to whether an individual was being operated on by a surgeon who operated only in the public sector, or by a surgeon who operated in a private clinic as well as in the public sector. We found that individuals who were operated on by somebody who only operated in the public sector had much shorter waiting times than individuals who were operated on by somebody who worked in both a private clinic and the public sector hospital.

This finding was also made in Alberta after their consumers' association completed a survey. They had someone phone to ask how long he would have to wait for certain surgical procedures. It was also found in England that having a parallel private system does not reduce waiting times in the public sector. The evidence suggests it increases it.

The assumption that more money is needed and, hence, we have to turn to private sector alternatives, also is not founded on strong evidence. Clearly the Americans spend more on the health care sector. They spend more privately, and they spend more publicly. More money does not buy more health care for Americans.

Our surgical rate overall is higher than that of Americans. We have more physician contacts per person than Americans. We spend more days in hospital than Americans. As to quality of care, there is absolutely no consistent evidence that their much higher expenditures buy higher quality care than we get in Canada. In fact, the evidence is very mixed. In certain areas, it appears that Canadians receive higher quality care. Certainly, the evidence is clear that Canadians are healthier than Americans, despite the very large amount of money being spent on the American health care system.

Finally, your review of private versus public funding mechanisms is quite unbalanced. In this volume you cite evidence on medical savings accounts from four different organizations. I searched a Web site to find the opinions that these organizations bring to the health care sector, and I concluded that they are all committed to undermining the public system. If you look at peer reviewed evidence on medical savings accounts as practised in the U.S., where they have attempted to run some evaluations, or at the evidence collected in Singapore, you will see that the evidence does not suggest that these would be an attractive alternative for Canada.

The Canadian system is, in fact, efficient. The American private insurance bureaucracy absorbs from 10 to 15 per cent of what Americans spend on the health care system. That is one of the reasons it is so expensive.

In summary, you have not delivered a factual, non-ideological report, and I am very concerned because your objectives are absolutely on target.I strongly urge you to take steps to remedy the current problems with the report.

Ms Madeline Boscoe, Advocacy Coordinator, Women's Health Clinic: Thank you very much for the opportunity to make this presentation today. I am a nurse by training and a long-time employee of the Women's Health Clinic here in Winnipeg. I thought I should mention that, because I am a paid staff person although I represent here today the thoughts and remarks -

The Chairman: I apologize for interrupting you, Ms Boscoe, but are you going to read the nine pages of your brief?

Ms Boscoe: No, I am not. I believe in psychic transfer, that is, e-mail of the brain.

The Chairman: We will certainly use that.

Ms Boscoe: I will highlight a few areas of concern. I put the report together since I thought you might want to hear arguments.

The Chairman: That is fine.

Ms Boscoe: Initially, we had no intention of making a presentation because our issues are very focused. Dr. Roos well illustrated our significant concerns regarding certain parts of the report. However, we have wholehearted enthusiasm for other parts of the report.

I spent the summer with my mother-in-law in New York trying, and I use the word "trying," to manage her care through a hip replacement surgery. As a worker in our system, I was overwhelmed with the number of interactions with administrative and gatekeeping staff and the number of financial transactions that had to be completed. Often there would be the sending or receiving of cheques for as little as $4 which would be co-payments. There would be a reimbursement system and deductibles. It was a very complicated system. I intended to bring the paper with me, because it was such a great piece of art, but I did not schlep it down here. It is no wonder to me that their administrative costs are so out of line. It is with great trepidation that I think of us trying to model that system in the future.

We are here because we strongly believe that health care reform is a women's issue. We have been working and organizing a network here in Manitoba since 1993. Women are, as you know, the majority of care recipients and of those who provide care, both paid and unpaid, in this country.

In many ways, we believe that the care and experience of women in health care and healthy public policy is illustrative of what is occurring in society. We are in many ways the canary in the coal mine.

I would note, however, that our use of health care services is higher primarily due to our reproductive role; and as with men, the burden of ill health is connected to income levels. This is of significant concern to women, as poverty is increasingly becoming "feminized." It is anticipated that about 50 per cent of single women over the age of 65 will live in poverty. We know that because of unequal work force participation, low wages, part-time work, time taken out of the work force for caregiving either of children or family members, women have less access to pension benefits, benefit plans, et cetera, dental service plans, unlike their male counterparts.

The issue of privatization is of very important to women, and that is why we are here today. We have completed an enormous project looking at the impact of health status, poverty, and women here in Manitoba; and looking at some of the health service utilization data that Dr. Roos' department has done. I will leave a copy of this for you since I referred to it in my presentation. Unfortunately, I did not bring 25 copies.

We are very interested in the consequences of health care reform on women. Our observation is that, primarily, health care reform to date has consisted of privatization and off-loading from the public system to informal caregiving and private systems where the burden is unequally met.

Women have been conscripted into unpaid health care work as hospitals have changed their discharge patterns, and it is because of that that I think issues like home care are of big import to us.

We strongly support your vision of a new model of primary care. In fact, my agency is a good living and breathing example of the kinds of things you envision in your report. That being said, I must say that the initial language in section 5, which talks about health care as a service industry, was alienating to the volunteers, clients and staff within our agency. However, on further reflection, we know that your vision is one that we share.

We have had a 20-year experience here at Women's Health Clinic in a model of care that puts community and clients at the centre of the decision-making process and, in fact, we often make jokes that our clients are our bosses in very real ways. Our board members are made up of members of the community and our clients. Therefore, we see unique kinds of service models based on needs. For example, we have been running a teen drop-in clinic for about 18 years. Our counselling staff is made up of volunteer women who are aged 18 to 24. Our staff members have purple hair and the music is that clinic is louder than you could ever bear to listen to. There is no waiting. It is a drop-in clinic. A client can be accompanied by 10 friends. It is all very informal. Those teenagers have told us that they want health care services to be accountable and to be useful.

I have provided you with both our annual report and a copy of what we call our model of care, which outlines how we build programs and interact with our clients. I am delighted to report we have received the Commonwealth Award For Excellence for this. We all worked very hard on this, so it is nice to see that it has been recognized in an international arena.

We have 18 EFTs. We have a budget of over $1 million dollars. We have doctors, nurse practitioners, midwives, counsellors, social workers and about 240 volunteers doing counselling, education in schools, public speaking, organizing committees, and so on. We are actively linked to our community, and we develop programs that they are reflective of community needs.

We also have an active policy and advocacy department. I am the staff person with that job. This allows us to organize on issues such as reproductive and genetic technologies, eating disorders in young women, and the restructuring of the Health Protection Branch. We hope to see more about the community health centre model in your report because we think it is a useful model, and one that has not been celebrated enough in Canada.

I am not going to replicate the comments Noralou made around the fee for service system and the issue of user payments, other than to say that we are particularly concerned about the inequities in the regular part of our social system. Those things can have an unfair effect on women, especially senior women who will shortly be the bulk of seniors. My report does go into some of the myths to which Noralou alluded.

I also wanted to commend you on your vision of a national pharmacare program. We think it is critical. We would suggest that you look at developing a consumer drug and device information system to parallel that. I think we are past the stage of relying on pharmaceutical company created package inserts.

I am very active on the Steering Committee of the Canadian Health Network, which has primarily been concerned putting on line health information in the areas of prevention and wellness. We know that Canadians are looking for unbiased information.

We should introduce disincentives for pharmaceutical advertising and educational activities in physicians' practices. To go along with this, we should develop an adverse drug reaction reporting system that actively recruits and involves consumers.

We very much appreciated your comments about health promotion and population health. We think this is critical, and are delighted with the idea of a commissioner in health impact assessments. We hope these concepts will be enshrined in an act of Parliament. As a matter of fact, the joke around our place is: Since we do health impact assessments for the environment, how come we do not do them for people?

We would also like to see programs that increase and support citizens' self help groups, mutual support groups, and action groups on health. One of our concerns since the federal cutbacks - and it is not alluded to in your report - is that many consumer community groups, such as those people who deal with breast cancer and endometriosis, those who take antipoverty action, and those who offer stopping smoking support have lost their infrastructure as Health Canada's health promotion and education programs have been cutback. As a result, many of those groups are starting to partner with the pharmaceutical industry in a way that we do not have any control over. Accountability and transparency is important for our volunteer community, as it is for everyone else.

There has been a reshaping of citizen agendas as a result of some of these partnerships. The landscape of citizen groups in the area of health are predominantly now ones of diseases and disease treatment. Groups that are involved in wellness and health promotion do not have a similar partnership. This will, I think, skewer the debate on what makes an effective health system. I will stop there.

The Chairman: Before turning to Senators Keon and Morin, I just want to address a couple of points you make, because I think you may have missed the point in Volume Four, in essence. Quoting from your paper, and you repeated it in your testimony, you state:

Evidence does not support the Committee's proposal that private funding approaches are needed to address the problem of timely access to care.

Our report does not contain a proposal. Our report contains a series of options. It contains options from the far right and the far left and everywhere in the middle. I am troubled if you read the paper as containing a proposal when we were explicit that we were not going to put forward a proposal, that what we were going to do was put options out there.

Let me make just two other comments and I will gladly hear your response. In the material you gave us, you state that the evidence that there are long waiting lists for most procedures is flimsy. Again, I do not think that is what we said. I believe that what we said is that the major concern for Canadians about the health care system is the length of waiting lists. That seems to me an irrefutable statement, given all the public opinion polling that has gone on and all of the comments that have been made. In your paper you say that it takes 40 days for varicose vein surgery and 50 days for a tonsillectomy. You describe the waiting lines in terms of days, though 120 days is approximately four months. Our view of the waiting line issue is that there is not much doubt that the public perceives that to be the biggest problem, and that if you are involved in public policy, it is important to address issues like that.

Having said that, I think your idea of a nationalized waiting list procedure is a terrific idea, and we should talk about that.

You also make the comment that evidence does not support the committee's assumption that more money is needed. I think what we say in the report is that all kinds of experts are demanding more money. We very clearly said that there are two schools of thought on that. One school says that more money is not needed; and one school says more money is needed.

Our view was that if we are going to begin by looking at the issue of funding, given how long it takes to make any change in this system, that it would be important to begin a public debate on the question of what happens if more money is needed. Then we go on talk about the need, as Ms Boscoe just pointed out, to expand the system to include catastrophic drug coverage and catastrophic home care coverage. Clearly, they require more money from somewhere. I do not think we made a judgment. Our view was that you must begin to discuss the question of what happens if more money is needed, as opposed to accepting the first school of thought, which is the categorical judgment that no money is needed.

Finally, I cannot resist teasing you about this since your suggestion was that our position was ideological. In the handout you gave us, all of your comparisons were between Canada and the U.S. I think we are very clear in the paper that the U.S. position, that argument, is the classic bipolar view of the world, which I would have thought academics would not do. However, there is a perception in the world that there is the Canadian model and the U.S. model and nothing in between. In fact, I do not think there was any significant reference to U.S. data in the report. We have deliberately talked about European models that meet the Canadian objective of universality and a variety of other models.

I understand why you used the U.S. data to make your point. However, by using that, you may be as ideological on one side as you think our report is on the other. I just leave that with you.

Before I call on Senator Keon, you may want to respond.

Dr. Roos: Perhaps the problem you have with your report is that it may be difficult for all of us to deal with any issue in a non-ideological fashion.

The centre that I work for was founded under a Conservative government. We are celebrating 10 years of work under four Ministers of Health. We now have a NDP government. I am firmly convinced that the system needs evidence-based approaches to these issues.

The Chairman: We would completely agree with you on that.

Dr. Roos: I only came to this because I received a phone call asking me to make this presentation to your committee. At that point I took a look at the report. I, frankly, was very concerned. I think the disadvantage you have is that you are seen to be coming out of the private sector. Your connection with Extendicare raises all sorts of flags for people. I believe that, as chair of this committee, you have to bend over backwards.

The Chairman: Just so you are clear, this is a unanimous report of 14 people.

Dr. Roos: Absolutely.

The Chairman: By the way, two medical people are on the panel with me today.

Dr. Roos: However, as we were discussing in the hall, people are disagreeing with one another. What people are concerned about is the uncritical presentation of a preponderance of options which suggest that private sector funding has to be the way to go. You may not see that in your report, but I have discussed this with scientists across the country and I have asked them to read the report and to tell me if I am wrong.

As I said, people find a number of aspects of the report to be very positive, but the general tone to the effect that we have a crisis, we need to meet it with finding wider sources of funds and the private sector seems to be the only place to go, permeates your current report. That is not only my perception, this is widely perceived as being a major problem.

The Chairman: That was not our problem.

Senator Keon: Dr. Roos, I have the greatest admiration for your work and the work of your organization. I believe that the conundrum facing the Canadian community at large is not whether we must put more or less money into the system, it is how we can solve the distribution problem and how can we break the log jam. We have a system that I believe most Canadians are terrified to give up. They do not want a system whereby they might go bankrupt from treating an illness. They see that happening in some other parts of the world. Our system was fundamentally designed to fund hospitals and doctors, and that system has grown like topsy.

We now have the most rapid rate of growth in end-of-life care, and in drug care, and in both it is becoming pay as you go. If you want good drugs, you pay for them out of your pocket. If you want to provide end-of- life care for mom or dad at a standard that is acceptable to you, you will eventually pay for it out of your pocket, though you might get some of it up front, but not much.

The real conundrum here is how society will address this situation from A to Z? The reality is that government is paying about 70 per cent of the bill and the private citizen in one form or another is paying about 30 per cent. Should there be a mechanism for redistribution so that physician and hospital costs are carried at the same rate as end-of-life situations and drug costs? Alternatively, to get out of the conundrum does one add more financing so that end-of-life situations and drug costs are fully covered? Can you propose a solution to this?

Dr. Roos: I think the solutions are in the evidence. You said that if you want the good drugs, you have to pay for them.

The Chairman: Just so we are clear, I think he said that as a statement of fact, it was not a proposal. Senator Keon is making a truthful statement, and that is that most provincial formularies do not cover some of the most effective drugs precisely because they are expensive. That was not a proposal. I want to be very clear that you are distinguishing that statement from a proposal. He is simply stating the truth, as best we know it, in every province in Canada. I am sure he can give you some specific drug illustrations if you want.

Dr. Roos: I am coming from the perspective which understands that there are many situations where what we are told is the good drug, the drug which we have to have is in conflict with the evidence about what is an equally effective, much cheaper drug. The other day Michael Rachlis said that, for hypertension, he was taking a drug which costs, I am not sure if it was five cents a day or 50 cents a day, as opposed to a drug which costs $5 a day. Certainly, there is that information out there.

I think there is a line in the report to the effect that, if you have enough money and you want best quality care now, you should go to the States. That is what Canadians do. The number of Canadians who do travel to the States for medical care is very small. That is true even of the wealthiest Canadians.

When you look at end-of-life care, nursing home and home care services -

Senator Keon: If I may interrupt you, I agree that the number of people who travel to America for care is very small. However, those who do go are very wealthy. I have witnessed that first-hand. If patients require endoscopy under general anesthesia, they simply go south.

Dr. Roos: I know. My family is American. They all live in the States. I can give you an example of terrible care delivered to both my father and my mother-in-law. When you examine the data, as group researchers in British Columbia and Ontario have done and count how many people actually go to the States, you do not find that the numbers are anything more than extraordinarily small. It is not the wealthy or the highest income groups that are going to the States. I think you need to incorporate the evidence into this report in order to understand how big a problem it is.

Senator Keon: I would debate that with you very strongly. I have seen no evidence to indicate that wealthy people do not go to America for care.

I am not in favour of the American health care system. I worked in it before I came back to Canada 32 years ago. I have never regretted coming back to Canada. I think our system is wonderful.

However, that is not my point. The point I was trying to make is that we no longer have an equal distribution of funding in the Canadian health care system. We have to find a way of having an equal distribution of funding. How are we to approach that?

Dr. Roos: When I was on the Prime Minister's health forum, we were very concerned about rising drug costs. What was recommended was essentially a pharmacare program to bring drug costs under a single-payer system. That is the most likely way to achieve high quality care at low cost. I think that approach still makes lots of sense.

Senator Keon: Where would the money come from to do that?

Dr. Roos: There is no clear evidence that it is not going to be cheaper to do that over the next 10 years than it will be to pursue any of the other options you have suggested. Certainly, the Canadian system, in fact every system, has been much better at controlling costs than the U.S. system has been. Drug costs is your best example of where you have strong, private sector participation.

Senator Keon: If I understand you correctly, you are saying that we have to glean efficiencies in the system to cover the areas that we are not funding at the present time. Is that your opinion?

Dr. Roos: I am suggesting that in the pharmacare area particularly there are opportunities for funding. If we move to a national system, which has been recommended by many groups, just as with the medical system, that it is a much better and much more efficient system than the alternatives which you are suggesting. That is what the evidence suggests.

Senator Keon: How did you interpret the alternative I am suggesting? Would you comment on that?

Dr. Roos: What alternative you are suggesting?

Senator Keon: Yes.

Dr. Roos: I see your whole report as suggesting that a continued single-payer driven system, and increasing the number of opportunities for user fees and for private sector alternatives are the options. You have developed those options very clearly in your executive summary as a desirable way to go to control consumer demand and to provide more money in the system.

Senator Keon: Mr. Chairman, I believe our witness can add so much to our discussion that I hope you will allow me to debate with her for a few minutes.

The Chairman: Certainly.

Senator Keon: I am on the public record as saying that the Canadian health care system does not need more money, and that that is not our big problem. Our problem is a maldistribution of money and efficiency of spending. When cornered in a debate, I do not know what to suggest to solve the drug problem and I do not know what to suggest to solve the end-of-life care situation without thinking about more money. I would appreciate it if someone would give me a argument that I can use the next time I an cornered.

The Chairman: We will give Dr. Roos a moment to reflect on that.

Ms Boscoe: The National Working Group on Women and Health Protection, has been considering drugs and drug utilization. I brought for you a report from an international group of physicians called the "No Free Lunch" group.

This group is trying to look at sane and rationale approaches to drug utilization in medical practice. "No Free Lunch" refers to the enormous amounts of money that pharmaceutical companies spend on alleged physician education. I use the work "alleged" because I do not believe that that is true, even though I know they will argue that they are never influenced by the free lunches, the trips and the free packages of drugs. If we look at the Celebrex example and the way it was introduced into the Canadian economy, we will recognize one absolute savings right off the bat. If we had a national formulary and we had had a national evidence-based discussion of that drug, we would have saved enough money to pay for all of our drugs for a long time.

I would propose, and I am not an economist, that these companies should not be allowed to write-off the costs of providing these "free lunches," and that profound disincentives to do this be established through taxation. That money could easily be, and should be, redirected to a pharmacare program, and that you could follow up on some of the suggestions in my brief.

I grew up with the Royal Commission on the Status of Women, the Hastings Report on Healthcare, and the vision of the Canadian public working together to solve problems. That vision has dissipated, and we are working from our worst paranoid fantasy.

I read your report, Senator Kirby, in a very similar way. I read it not because it was not couched in possibilities, but because it was on the agenda at all. I take very seriously as a Canadian the things that we say are on our agenda, and the things we will not allow. It seems that is not to be considered. I see people my age being a group of line jumpers and people who are terrified that the community will not be there for them. We have a responsibility to turn that around, not just for ourselves, but for our children and the generations that come after us. There are possibilities, but it means taking on some of the big interests in our system and reclaiming them. I particularly used the example of taxation.

The Women's Health Clinic exists as a model. We did it inside the system. We did it with hard discussions with our community and debate with consumers. Our clients do not use drugs that are advertised. They have a discussion with us, and they tend to choose cheaper, older, well-proven drugs and systems. If they need interventions, they wait. They are cautious. These things not only protect the financial savings of our system but, ironically, they also improve the health and well-being of patients.

I would ask you to consider the use of fetal monitoring equipment, and the decision to perform lumpectomies, where preferable, instead of mastectomies. These changes come from the input of an educated, involved community. Often, we do not give the Canadian public the space or enough credit to be able to be involved in this debate.

Tax the rich. That is my suggestion.

The Chairman: Dr. Roos, do you want to make any comments to Senator Keon?

Dr. Roos: I am not sure that I have much to add. Everybody is looking for the magic solution and there is none. Politically, there are some very difficult shoals to be negotiated.

What I would bring to this committee is the comment: Let's make sure we understand the evidence. As to your report, I think your frustration is in some sense reflected in the whole variety of options available. Where is this report directing that attention be paid? My concern is that this is not evidence based. It is playing into this ideological debate around the private sector being the saviour of a system that is failing, and I do not think the system is failing.

Senator Keon: No, I do not think so. I agree with you.

Dr. Roos: That is my concern.

Senator Keon: Thank you, Dr. Roos. I enjoyed our discussion. It was most enlightening, and I carefully listened to what you had to say.

Senator Morin: I would also thank Dr. Roos for appearing before our committee. She is a good friend of mine. I would point out that she is a director at the Manitoba Centre for Health Policy and Evaluation. Next week at the OECD meeting in Ottawa, that centre, with Dr. Roos director, will be receiving a very prestigious award, the annual award of the Canadian Health Services Research Foundation. That is an annual award given once a year to the organization and its director that has done most to improve the quality of health care delivery in the country. I think it is quite appropriate that she go along with what Senator Keon said earlier on.

One of the reasons, Mr. Chairman, that Dr. Roos refers so often to the American system is that she is an example of the reverse brain drain. She is an American who moved to Canada and is now a Canadian. We are very happy about that. Obviously, she knows the American system as few people do.

My first question relates to the American system. What is your opinion as to the advantage of the American systems that have a co-existence of health care delivery in the public system and health care delivery in the for-profit private care system? Do you have any evidence of the quality of health care delivered in both systems? Do you have any opinion on that?

Dr. Roos: As to quality of care, I do not have any firm evidence on contrast, but there are New York Times anecdotal examples of surgeons, who have contracts with a for-profit hospital, sending 20 of their patients for prostatectomy with no prior examination.

In terms of quality, however, I do not know of a comparative study. I found intriguing the studies that suggest private hospitals are no more efficient than public hospitals. In fact, a New England Journal of Medicine article compared the efficiencies, cost per patient in public hospitals versus private hospitals. One would expect there to be at least a 10 to 15 per cent profit factor in the private hospitals, and that maybe accounts for the fact that there is no difference. I then read the fine print in the article, and found that profit had been excluded from the comparison, so one was not more efficient than the other, but the private hospitals were more expensive.

Senator Morin: My second question relates to what Senator Keon was saying earlier. In the Canadian system, at least for hospitals and physicians, we have a single payer and we have a single provider, that is, it is government provided. In the Canadian system which do you think is more important, the single-payer aspect or the single-provider aspect? I know you will probably defend both, but which would you choose if you had a choice?

Dr. Roos: In Manitoba, we have single payer, and we have nursing homes which are operated both by for-profit organizations and by public, not-for-profit organizations. The government decides how many homes they are going to have and sets standards for inspection, et cetera. That seems to be a model which, in the nursing home sector here, has been reasonably effective. I think the single payer is the most important piece of the system.

I recently saw the Auditor General's report in the newspaper where concern was expressed about having a single payer. However, I would point out that you have private clinics and that surgeons run the regional health authorities. There is no monitoring of the referrals to private clinics. I think things are getting very messy. This is being picked up on. I think the single payer is absolutely critical.

The Chairman: Now I am confused. In response to Senator Morin's question, your observation was that there is a part of the health care sector, nursing homes, in which there are some private providers and some public providers. You essentially said that that seems to be working very well.

As I read your report and listened to your earlier comments on the private sector, if that works in nursing homes, why would it not work in clinics or in hospitals? I buy into your single-payer theory. I am not arguing the single-payer question. That makes absolute sense to me. I am trying to understand your response to Senator Morin, in light of all your other comments about the evils of private care.

By the way, can you be precise? You have used the word, "private" in two or three different contexts, and I want to make sure there is a consistency. Does "private" mean provider? All doctors, I think you would agree, are private sector providers. I am trying to understand precisely what "private" means to you, so that we can then know how to interpret some of your comments.

If it works in one part of the health care sector, would it work in clinics? Would it work in hospitals?

Dr. Roos: I was trying to respond to Senator Morin's specific question: was I aware, and what did I see as most important. I was trying to think of an example of private sector involvement which seems to be working reasonably.

The Chairman: Can that be extrapolated to apply to other parts of the health care delivery system, assuming you are a single payer?

Dr. Roos: From my understanding of the evidence on the private clinics and surgical clinics, and how they worked in Manitoba, with tray fees and surgeons being able to operate in both sectors, there is good evidence that that does not work well.

With regard to user fees, my reaction to your report is no so much an ideological one. I am not saying that private sector care is forever awful. My reaction is to specific examples in your report which collectively involve more private sector type alternatives around medical savings accounts, around user fees.

The Chairman: What does "private sector" mean in the phrase as you are using it? I am puzzled.

Dr. Roos: Bringing in more private funding.

The Chairman: Funding by individuals?

Dr. Roos: In terms of the private sector, private sector clinics are set up.

The Chairman: I am confused. Senator Stratton, go ahead.

Senator Stratton: Dr. Roos, thank you for coming, and thank you, Madeline, for coming.

I am not an expert in this field. As a matter of fact, I am not a regular member of this committee, but because it is being held here in Winnipeg, I thought it important that I attend to find out what Manitobans were thinking.

I am also an advocate of our Canadian health care system, but as we all know, we have some fairly serious problems. I know many pilot projects have been tried in the health care sector, as there have been in other fields.

I recall visiting my daughter in Calgary, a right wing province, as we all know, and she is a worker. She deals with rehabilitation of injured workers for a fairly large company. Her area of responsibility covers Alberta and British Columbia. Of course, her first priority is to make sure the injured worker gets proper care and gets back to work as quickly as possible. I was amazed when she told me that her employer, a private sector company, a publicly traded company, goes directly to private clinics for diagnosis and treatment of their injured workers. That is because the diagnosis time and treatment time is shortened not by days but by as much as four to six weeks. It brings an injured worker back to a healthy position and back to work in a much shorter period of time.

Ever since she told me that, it has really bothered me, because I feel that perhaps the private sector, meaning publicly traded companies or private companies, should be providing this for their injured workers. If it speeds up their recovery and gets them back to work quicker, why not? Surely we should be willing to try such experimentation. If it seems to be working for her particular company, then why should we not try it?

I admit that this is hearsay evidence. I have no concrete evidence. I can only rely on what she has told me. I see no reason for her to stretch the truth, as it were.

Ms Boscoe: I could use the example of my own agency in that we run a specialized service in the public system. I think of our agency as being part of the public system, though incorporated as a not-for-profit organization. Our funding comes from a single payer, except for a few donations. I can confidently say that, if you have an unplanned pregnancy, we can see you within two to three days, unlike a regular doctor, because our system is set up to deliver those specialized services.

Although I am not an expert in evaluation, my experience with some of the workers' clinics in other parts of the country they have to do with the grouping of individuals whose mandate and mission is to serve that population. I do not think it is particularly because it is for profit.

The for-profit question raises other problems that we have talked about already today. The concept of specializing and having committed staff who take up special issues I think is a good one. It is difficult for all of us all to be generalists. As you know, here in Manitoba we had the horrible experience of not being specialized enough in pediatric cardiac surgery. We know it is important to specialize. I think those models can work.

Dr. Roos: How do we do a better job of getting people who need surgery, who need a diagnostic test to that test when they need it? My recommendation is to do, as we do in Manitoba with MRI screening, which is one of the most costly screening procedures. We have a wonderful head of radiology who has developed a series of criteria which ensure that people who need that test first, get it first. Waiting times are very short. If it is an elective situation, that is, if it does not meet an evidence-based assessment of when a test will make a difference to that patient, then doctors are not encouraged, in fact, they are not allowed to refer. Therefore, waiting times are kept short.

In contrast to other areas where there is no organized screening of patients, waiting times and waiting lists can grow completely out of proportion. When you analyse the indications of patients on those lists, you will realize that we should be organizing it better, and that we could do it cheaper. We are doing things that we should not be doing.

Senator Stratton: Would you not be willing to allow private sector companies to go to private sector clinics to have their injured workers treated, if the example in Alberta is true, and I think it is - I do not think my daughter would fib to me - and use that as a pilot project to determine whether that would relieve the system of a tremendous burden? The insurance companies that insure these workers, including the workers' compensation boards, are quite willing and prepared to do that. Why would we not try that?

Dr. Roos: I think you are making the assumption about health care that health is a commodity similar to other things we buy. It is different.

Calgary is a major centre for private care in Alberta, but waiting times for cataract surgery in Calgary are much longer than any other area of the province. Having more private clinics does not reduce the waiting time.

With private clinics you have increased advertising, you have demand generation, and you create a bigger problem for individuals who are using the public sector than they had when they started out. I am afraid there is good evidence that that is not a solution which anybody who understands how the system will work under those circumstances would want.

Senator Stratton: You would not be willing to try it even as a pilot project.

Dr. Roos: There have been pilot projects that have evaluated this type of access to care.

Senator Stratton: I am talking specifically about injured workers. I am talking about the private sector becoming involved to get those people back to work much earlier than they are now. Why not?

Dr. Roos: I am suggesting you create city-wide, evidence-based waiting times for all procedures. That will solve your problem.

In the case of Ontario where you have a cardiac care network, thoughtful physicians have looked at the waits and at the types of patients waiting for those procedures and they, as I understand it, have been very effective in encouraging the government to put more funding into an area where they have demonstrated that more services are necessary.

I would like to see evidence that what is going on in the system now cannot be directly improved, with access also being directly improved.

The Chairman: I would add an aside on the subject of workers' compensation boards. I cannot deal with the Alberta example, and I do not know the details of Manitoba, but I know most of the other provinces. Workers' compensation boards generally operate the only two-tiered system allowed under the Canadian Health Act, in the sense that, if you are injured under the Workers' Compensation Act, you immediately go to front of the line. In some provinces they actually have acute care beds set aside for workers' compensation patients. Indeed, in provinces that cap physicians' fees, fees that physicians receive for treating workers' compensation patients are not included in the cap.

I have never gotten into this discussion with governments of certain political stripes, but it would be interesting to understand how they squared the position in their province on workers' compensation with the position stated more generally.

Senator Pépin: Ms Boscoe, I would welcome you and congratulate you on the wonderful work you have been doing at the Women's Health Clinic. You have been involved in that for many years. We now have many other women's health clinics across the country, and I think that is a positive step forward. I am glad you took this opportunity to make your presentation to this committee.

Does your clinic deal with the prevention of illness as well as the treatment of illness? I apologize for missing part of your presentation. When I came into the room you were speaking about young women with coloured hair who play loud music. What work does your clinic do?

Ms Boscoe: I have given you a copy of our annual report.

Our philosophy is very much one of health promotion and population health, and we see the care that we provide to women as a continuum. We do not provide surgical beds or anything like that. It is all primary care and ambulatory care. I might also add, though, that our philosophy is one of trying to put back or to normalize. That is much of what we do. For example, people with sexually transmitted diseases could go simply consult our doctor, but because we are committed to encouraging people to think that reproductive health is a normal part of life, they are offered an opportunity to meet with our volunteer counsellors. That gives them an opportunity to sit and talk for two or three hours about their lives. They get a lot of health education and information. Sometimes they do not even see a doctor or a nurse, because that information is enough is adequate for them. It is very much health promotion and education, and it is a primary care interaction.

The same situation applies to our disordered eating and weight preoccupation. We see a lot of young women who, in a psychiatric diagnosis, would be considered to be bulimic, but because we try not to deal with things as a pathology and to interfere with the power control discussions that are going on, we talk about disordered eating and weight preoccupation and bring those women into dialogue with women who are involved in cyclical dieting and other kinds of behaviour. They are not seen as pathogenic. We try to do things differently.

Senator Pépin: What is the average age of the women you see?

Ms Boscoe: Their ages vary from 12 to about 70. We see women of all ages. We have to turn away about 1,000 women a month. They want to see us but they cannot. They come in to see our volunteer counsellors. I am not just talking about women having consultations with our doctors. I believe Canadian women and men are hungry for a new alternative, that they are not dependent on doctors, and that they do not need to see clinical nurse specialists.

Senator Pépin: It sounds like good teamwork.

Ms Boscoe: Our people just love it.

Senator Pépin: Earlier you said that some women who ask for a consultation at your clinic decide not to go ahead with an intervention.

Ms Boscoe: Yes.

Senator Pépin: What kind of intervention are you speaking of?

Ms Boscoe: For example, we have run a large menopause and mature women's education program. Instead of women seeing our physicians in a one-to-one consultation, once every two months we run a menopause clinic where women can talk to our educators and learn everything they want to learn about menopause. Many women do not know if they should fill their prescriptions for hormone replacement therapy. They are unsure about whether they should be taking that medication. We take them through everything. We talk about what they should do if they want to be well when they are old. We talk about pension plans. We talk to them about the pros and cons of hormone replacement therapy, and the need for education.

On review with our doctors, we find that most of those women do not need hormone replacement therapy as much they need an exercise program. They need a place to talk about aging and wellness and what it is going to be like for them as 70 year olds. Once that information is given to them, medical interventions are not as necessary.

Similarly, with fetal monitoring equipment during pregnancy, our midwives are very good at alternative pain management, the need for movement in pregnancy, and how to be assertive enough in the hospital so they do not put you in bed.

Am I helping you here?

Senator Pépin: Yes. I understand you to say that you are educating them about what to do so that they will not suffer from hot flashes.

Ms Boscoe: Yes.

Senator Pépin: We all know that home care is essential. Are the individuals most involved in home care women?

Ms Boscoe: Absolutely.

Senator Pépin: You mentioned that there is a need for financial support to provide for informal caregiving, and we will consider that. Currently these people receive no income. They quit their jobs, and they have no other income. When they want to resume their jobs, often their job is no longer available, and they cannot find another one.

Ms Boscoe: I totally agree that we should address that. A wage or some other way of supporting family members has been raised with the disability community. Women are at home with disabled children who need a lot of care. In fact, women have quit their jobs to do this. They struggle with the decision of whether to stay in the paid sector, where they have some benefits and some pension, or hire somebody to provide care.

This is a good example of a population health approach that needs interdepartmental planning. It is also a taxation issue or an income supplement issue. It is not often raised in health delivery circles.

When we do roll out home care, we need to think of a system that reflects the spectrum of health home care needs. As I mentioned earlier in my brief, many women are picking up nursing services because of early discharge, and they are doing that because many are nurses, and because there is a natural assumption that they will figure it out when they get home, whatever it is. It causes a lot of anxiety and concern, and people are afraid to leave their providers alone, which is why we think family leave programs, in the form of legislation, should be put into place. Many unions are negotiating these things for workers, but too often that means those most vulnerable, those who are not in unionized positions, have no protection.

Senator Pépin: Over a year ago, a Senate committee, chaired by Senator Carstairs, published a report on palliative care. One of the recommendations of that committee was that we look after those persons who leave their jobs to look after a family member. Hopefully we can address that issue.

Ms Boscoe: I am there for you.

Senator Pépin: Thank you very much.

The Chairman: May I thank the two of you for coming. It has been a most fascinating hour and one-quarter.

Our next witness is Dr. Paul Henteleff, Chair of the Advocacy Committee of Hospice and Palliative Care Manitoba.

Dr. Henteleff, for the purposes of our Hansard reporters, could you please identify the other two people with you and then proceed to your opening statement.

Dr. Paul Henteleff, Chair, Advocacy Committee, Hospice and Palliative Care Manitoba: Thank you for the opportunity to be here. The presentation that we are circulating identifies all the members of our delegation.

I think it is quite obvious that this is Margaret Clarke, our executive director, and Dr. John Bond, a member of the Advocacy Committee. Some opportunities are more equal than others.

I would just like to make sure that we identify that Hospice and Palliative Care Manitoba is a volunteer-based charitable association that champions and promotes the availability and accessibility of quality end-of-life care and bereavement services for all Manitobans. We do this through processes of education, information, advocacy, and support to service delivery.

We have a staff of nine that is a paid staff and a volunteer component of 400 participants. Our budget is $300,000 annually, and we operate with no government support.

The vision that we have is that these services throughout Manitoba will be comprehensive, coordinated, accessible, and of the highest quality for individuals, for their family members and the friends who are with them when there is a terminal illness or bereavement.

Given the quite short notice to prepare for this meeting, we will be rather brief and have not been able to prepare supporting documents.

We intend to focus particularly on chapter 8, which has within it proposals regarding the provision of prescription drugs and of home care, and there are some proposals in relation to home caregivers. Our perspective will be from that of palliative care.

Before we get into that, though, we have some general observations that are less specific. Our sense is that funding considerations have dominated the discussion in the paper as it is in its present form. We realize that increasing costs of health care have precipitated some of the review, but from our preference the discussion should begin with firm establishments of principles, and then working out how much can you afford to do to meet those principles.

More specifically, we are struck that the term "medical necessity" is a principle in the Canada Health Act, and note with agreement that chapter 8.2.1 demonstrates that the principle appears to have very limited useful application. We believe that a process to make medical necessity applicable is needed to define medical necessity. If that cannot be done, some other principle or criteria has to be worked out to decide what is and what is not included in coverage under the Canada Health Act.

I would just like to go aside from our written material at this point and note that the previous presenters gave some very clear examples of individual instances in which a system of prioritization was established in order to deal with problems of waiting lists. It would appear that there are limited examples of medical necessity being worked out with criteria that are effective and beneficial, and we think that should be expanded.

To go back to the paper that we have submitted, the document has a strong focus on consumers of a service industry, and our sense is that this may not be compatible with the term medical necessity. In what other example of consumerism is there an external judge of necessity? I think that intrinsic conflict between the two principles has to be taken into consideration.

Again, on the general questions of the whole paper, we are struck that we found no reference to one of the usual principles that is stated, that is, the free choice of provider. That principle is not referred to at any point that we could identify.

The particular areas that we wanted to cover are, first, prescription drugs and subsequently, home care. We are very pleased to see that attention is being given to recognizing that drug costs can be a burden. The principle of a national drug formulary with the associated research appears to us to be a very positive step, one that we are pleased to see.

We have some concern that although a national drug buying agency sounds like a valuable proposal for the efficiencies it may simply elaborate the amount of bureaucracy needed to operate it and thus may lose whatever benefits its buying power could give. We do not know about the certainty of that; we just raise the question.

It is difficult to evaluate the various drug plan options with the limited time we had at our disposal. However, we would like to point out that, in the case of people with terminal illness, any plan to reduce the financial burden must be effective immediately. A plan based on tax credits is not useful, because it is delayed into a subsequent year, at which point the potential beneficiary may not even be alive.

Any plan based on deductibles has similar limitations. From our experience in Manitoba, since the deductible for the pharmacare program is based on the previous year's income, and since terminal illness is commonly associated with inability to work and loss of income, the promised benefits from that method of relating the costs of drug care would be delayed until too late.

The report does recognize the powerful effect of drug advertising on doctors' prescribing practices. We support the proposal that the ban on public drug advertising be maintained.

There is also the powerful effect of pharmaceutical company representatives on physician prescribing practices. We raise the following question: Could this form of promotion be forbidden? Doctors are prevented from working outside medicare to a large extent. Why not prevent pharmaceutical information from being provided to doctors other than through scientific journals? I would add that we have very severely restricted advertising and promotion of tobacco products because they are not good for health. Our view would be that the promotion of the latest and most expensive drugs, with the effect that it has on prescribing practices, is harmful to health care rather than to health, although it may be that as well.

Back to the report, there is no suggestion in the report of reconsidering the kind of patent protection that has been introduced relative to generic drugs. There was a time within the memory of everybody at this table when generic drugs were a far greater help to consumers than they are now.

Finally, under pharmacare, we would like to say that we had a little bit of uncertainty about the term "catastrophic drug costs." We think what is probably meant by that term is that the cost becomes catastrophic to the buyer.

The Chairman: That is what we meant.

Dr. Henteleff: But it could not be read with certainty that it did not mean catastrophic illness.

The Chairman: I am pleased that you raised that point. It is the sort of thing that is useful to us, such that when we write other reports we make ourselves clear.

Dr. Henteleff: We are also not sure who defines catastrophe, or catastrophic. One of the concerns around palliative care, hospice care, is who is formally identified as being in the terminal phase of an illness and receiving hospice or palliative care in order to qualify for any special benefits that might be attributable to the terminal phase of illness.

Further along that line, and apart from the paper, with respect to the numerous references in previous presentation about end-of-life care, it was not at all clear to me whether the discussion about the cost of drugs and medical care for end-of-life care was formal palliative care or whether it was the extremely high cost of drugs for care at the end-of-life that fails to save life - in other words, that there can be very high costs for health care that fail to produce the results and the person dies. That is not palliative care.

So, when referring to end-of-life care, I wish to highlight the importance of distinguishing between the last year of life, to take an arbitrary term, and the terminal phase of illness treated with palliative care. I think that distinction has to be clarified and maintained.

I would now like to move on to the question of home care. Generally, we are very pleased to see attention given to home care and to informal caregiver support. We support the development of a national home care program. For individuals who are dying, home is often and very commonly where they would prefer to be if they feel secure and if the family is supported in the caregiving role. At present, those with the financial means are better able to achieve this goal by using private services. For many, care at home is not possible.

There are proposals in the document that we received about caregiver financial support and respite. These could be very useful. Hospice and Palliative Care Manitoba together with our provincial wing of the Canadian Palliative Care Association is advocating for income protection for family caregivers. Family caregivers who take time away from work to care for a dying relative are indeed saving money to the health care system as it actually exists; however, frequently they bear undue financial hardship, a term used in the national health program. Canadian health care policy has tried to avoid undue financial hardship.

There are several aspects about home care and caregiver support that appear to have received no mention in the document to date that we would like to draw to your attention. The first, which was drawn to your attention earlier, is that caregivers need job protection should they miss work. Both British Columbia and Quebec have limited provisions to protect individuals who must care for a family member. Saskatchewan appears to be the only province that provides significant leave to meet family caregiver responsibilities. In that example, it is 12 weeks in a 52-week period. We suggest that the federal government could set an example to all provinces and employers by providing such provisions for its own employees.

The second point we would like to make is that home care workers, at least in Manitoba, who are not professionals, have no legal protection and are by policy excluded from aspects of care that would be perfectly legal for a non-professional family member to give. An example that we will draw to your attention, and there may be many others, is a patient who is experiencing excess saliva and difficulty swallowing it, the benefits of having those secretions sucked from the mouth. That procedure is absolutely forbidden for a non-professional caregiver. Family members can do it but an outside person cannot. The policy is set by home care services to protect the agency from any possibility of the formal caregiver from outside getting into legal difficulties.

Another aspect of care that is very commonplace is the giving of medications. A family member is allowed to pull medications out of a box, put it in the patient's hand, put it in their mouth, put it on a spoon, feed it to them. At least in Manitoba, a caregiver from the home care program is not allowed to handle medications in any form whatever, unless the caregiver is a professional. This puts a drastic limitation on the usefulness of non-family member caregivers for providing home care support.

The third point we would like to make is that there are potential family caregivers who may not live in the same province as the patient. Taking a sick relative for care across a provincial border can be problematic, since home care, whatever it may be in one province, is not in any way portable to another province. This could be dealt with either by making portable the care that is provided to the particular patient or by having the host province responsible for respite care in terminal illness for the caregiving family.

As everyone in this room knows, families today are scattered. This is a consideration. We have no exact measure of the extent of it, but the care coordinators that we are in touch with throughout the province have brought this to our attention, that it does provide problems that they see.

The fourth point we would like to make is that respite for caregivers for dying family members needs to be considered more broadly than is done in any of the material that you have accumulated in the report to date. It has to be able to respond more quickly and on an emergency basis for several reasons. The report already recognizes, and we congratulate you for that, that the informal caregiver risks burnout. A service that does not provide respite until burnout occurs is really occurring too late, because there is going to be great reluctance about resuming caregiving after an episode like that.

However, scheduling preventative respite also has risks involved with it. There are risks of unexpected incapacity for the caregiver, that is, the arrangements to provide care during the interval between respite is at risk of being lost if the caregiver, commonly another member of the family, often frail themselves, may be unable to continue, may get an intercurrent illness that makes it impossible for them. It also quite common that a caregiver has more than one family member for whom he or she may feel responsible, and other members of the family may require care and overburden unexpectedly the caregiver who is looking after somebody at home between respites. So a system that is able to respond more quickly and on an emergency basis is needed.

We would like to make an observation, but not a recommendation, that it is a common assumption when home care is seen as substituting for institutional care that it is at a lower cost. It depends entirely on how much service is being provided. If you need to put shifts of workers into a home on a one-on-one basis, that is not as efficient a provision of service as it is in an institution where one shift of care workers looks after several patients or clients. So it depends on the number of paid caregivers and the amount of time they work.

We would also point out that we have earlier, as other people have, recommended that there be financial support to informal caregivers. If that were introduced, again, the cost of home care would be higher than experienced to date.

In conclusion then, with the short notice we have had, we express appreciation for being able to address this committee. We have not been able to submit our ideas in two languages. We have not been able to support them with documents. We have not been able to make a list of recommendations. However, our report is so short that by crossing out a few lines it becomes a list of recommendations.

The Chairman: May I just make the observation that your options on home care are very creative and helpful.

I wish to ask you a question of clarification. You say there appears to be no reference to the consumer's free choice of caregiver. There is no question, we would automatically assume that there would be free choice of caregiver, as there is now, but if that is not clear, we would be happy to emphasize that.

Dr. Henteleff: It is very hard to provide free choice of caregiver with a 24-7 service. Twenty-four seven comes out of your documents. There is no individual caregiver who is available 24 hour a day, seven days a week, 365 days of the year.

The Chairman: Then I am glad you clarified it, because that is not what I thought you meant by the sentence.

When you say strong focus on consumers of a service industry is not compatible with medical necessity, can you explain to me what you mean by that? I just did not understand it; I am not disagreeing with it necessarily.

Dr. Henteleff: What we meant by that is that if a system of medical necessity is in effect, it is operational, it has got categories and rules. It means that when I have a headache and think that I should have a MRI, somebody else can say, sorry, consumer, you cannot buy that because we do not regard it as medically necessity. What other consumer is told by the seller that he cannot buy that?

The Chairman: Now I understand your point.

Senator Keon: Dr. Henteleff, does that last statement contravene the Bill of Rights? Do you think the Bill of Rights gives us the right to choose who delivers our health care and so forth?

Dr. Henteleff: I think the Canada Health Act gives universal rights to that which is available, so I do not see any contravention.

Senator Keon: Fair enough. We have had a little debate about that, but we were I would say at best in the confusion state, so I will not carry it any further.

I do want to bring you back to comment, on a slightly broader basis, if you would, on this whole situation of people, older people usually, but in the last few years of their life, that I referred to earlier as end-of-life situations, who are subjected to a panacea of accommodations, drug coverage systems, and sometimes non-systems, sometimes accommodations such as nursing and custodial care that they can pay for, if they are terminally ill and defined as terminally ill, and if they are lucky they get palliative care. It is an area that in my latter years as a medical practitioner concerned me a great deal, that is, when patients were being discharged from hospital, frequently there simply was totally inappropriate resources to cover them from thereon in down the road.

Let`s take, for example, drug coverage plans. Depending on what part of Canada you live in, you might have 100 per cent drug coverage in your drug plan or you might have 65 per cent, and the delistings are growing all the time across the country. Of course, there is no overall comprehensive plan for taking care of Canadian citizens who can no longer take care of themselves. I would like to hear your comment on that. I realize your presentation was on a much narrower scope, but I would like to hear your comment on it anyway.

Dr. Henteleff: I will speak here on my own behalf, because the organization did not prepare an answer to that question. Our presentation does say that the "medical necessity" should be defined. There is no difficulty in pointing to areas where people appear to have needs and get into great difficulties receiving service or paying for service. If we can point to problems like that, surely we can think of solutions. And then we have to decide, when we have a description of an ideal service, what can we afford and how we can pay for it.

I am aware of other countries where taxation is considerably heavier than ours in which many of these needs can be met. There seems to be an assumption in Canada that that is not the case, that increased taxation for the services we say we want is out of the question. I find that an impossible proposition, one that I am sure I share with a number of others across the country. How do you get everything you want for less than you are prepared to pay?

The Chairman: You are right; that is the classic political conundrum.

Dr. Henteleff: The point I am making is that our group believes that there could be policies - there are certainly a number of principles set down for the Canada Health Act that have won widespread appeal internally in the country and admiration externally. We have seen modest examples of how to put medical necessity - I would hope that that could get enlarged into health care necessity - into a definition that can be operationalized. If we could see an overall proposal that required that kind of a system, it would be very reassuring before the tax man comes.

Senator Pépin: Dr. Henteleff, on page 4, you say that the caregiver needs job protection, and you speak about British Columbia, Quebec and Saskatchewan. Is what you are proposing with respect to palliative care similar to the concept of maternity leave? Is what you are suggesting vis-à-vis job protection for caregivers similar to maternity leave protection?

Dr. Henteleff: Yes. However, we are aware that that falls under provincial labour law, or some category like that. Therefore, our suggestion is quite specific that the federal government could set an example.

Senator Pépin: You are saying that the federal government could start with its own employees.

You also said that home care workers who are not professionals need legal protection. I believe that also falls under provincial legislation.

Dr. Henteleff: Probably.

Dr. John Bond, Member, Advocacy Committee, Hospice and Palliative Care Manitoba: If a national home care program were set up, perhaps the protective legislation could be introduced at that point.

Senator Pépin: Could you elaborate on the concept of home care not being portable, where a potential family caregiver does not reside in the same province as the patient.

Ms Margaret Clarke, Executive Director, Hospice and Palliative Care Manitoba: Under the current situation, home care is a provincially arranged program, so I suppose it comes back to a national home care program that would allow portability from one province to another.

Senator Pépin: Similar to the palliative care committee's recommendation?

Ms Clarke: Yes, I think that is where this recommendation comes from.

The Chairman: Just to add to that, the issue is not limited to home care; it also involves, for example, nursing home care. In my own case, my mother is in a nursing home in another province. My siblings and I looked at the question of moving her closer to some of us, which we may end up doing. First of all, it is hard to get on a waiting list in another province; secondly, a significant amount of the cost must be borne by the family during a transition period. So, I am not disagreeing; I am simply reinforcing it to say it is not simply a home care problem. The reality is that for the frail, elderly, as well as palliative care issues, there is now the issue of portability.

Ms Clarke: If one looks at how Canadian families are scattered far across this country, how families live in the 21st century, that demographic must be taken into consideration by the health care system.

The Chairman: It is an issue that I have never thought about, in general, so I am delighted you raised it.

Senator Pépin: We now have a secretariat for palliative care and will be able to follow it very closely.

Under home care, your fourth point concerns respite care for caregivers. How would you organize that?

Dr. Henteleff: It is an administrative question.

Senator Pépin: How do you see it?

Dr. Henteleff: First, you need a policy statement that says it has to be put in place, it has to be looked after. How it comes into effect then becomes an administrative question.

There would have to be an estimate of the frequency and duration of such episodes, and then there would have to be beds available to match the estimate, or facilities that match the estimate, whether it be institutional facilities that take over, or home care services that will come in and take over. The proposal has to deal with a problem, an ideal solution. It would be costly, of course, but there is no point pretending that a band-aid will solve the pressure that exists for caregivers at the present time.

Senator Pépin: Do you have anything to add?

Dr. Bond: Dr. Henteleff refers to the cost of respite care, but who knows what the extra costs would be if one does not respond in that case? We look at the cost to put the person there to provide the respite; however, without respite, what is the long-term cost to the health care system if there is a breakdown? In fact, it may be more expensive not to put them in for the long run than to put them in for the short run.

Senator Morin: I congratulate Dr. Henteleff and his colleagues for his work on a very difficult and very neglected field, the field of palliative care. We know where Senator Carstairs got her inspiration now.

I am interested in the matter of burden of drug costs in palliative care. I am not an expert, far from it. Are you an MD, Dr. Henteleff?

Dr. Henteleff: Yes.

Senator Morin: I was under the impression that drugs in palliative care were not an important cost factor, generally, the minimum amount. On the contrary, pain relievers are very important, things like that, but as you know, they are not very expensive and one would not give the latest expensive drug in that environment, unless I am mistaken. As I say, I am far from being an expert here.

Dr. Henteleff: In principle, I agree with you. Unfortunately, the pressure of pharmaceutical representation on medical practice is such that there seems to be nowadays a great preference for quite costly alternatives.

I vividly remember the first time I heard about a palliative care program for people at home that consisted of a continuous infusion of medication. At the time, it involved an outlay of something in the neighbourhood of $1,000 for a piece of equipment to continuously inject medication into the patient. It required the purchase of soluble medication of sufficient refinement to be given directly into the body rather than through the intestine.

If that is what palliative care means in practice, without any standards, then the cost of palliative care and symptom control becomes very expensive. In practice, the stories we hear are that the cost of drugs for care at home can be catastrophic.

Senator Morin: Using that system, perhaps. However, the type of care you would prescribe would not be necessarily costly, or by those who know the field, it would not be major. I am not an expert here and stand to be corrected, but the impression is that, on the contrary, you want to have the minimum.

Dr. Henteleff: I appreciate your flattering remarks about my practice compared to what may be general practice. From what I hear from people in the field - I am no longer in practice - particularly from those who are looking after family members and who are providers of home care services, there is a problem.

Ms Clarke: May I just add to that? I am not a clinician either, but I know that in the present day palliative care has become a much more highly specialized field, and the ability to control symptoms has really improved a lot in the last number of years. There is really encouraging research ongoing, so that palliative care is indeed a very active form of care and treatment in order to keep the patient comfortable. It frequently involves the use of multiple medications, because of the myriad of symptoms that may need to be controlled, and sometimes the side effects of one medication require the administration of another medication.

Indeed, the cost of drugs and the issue of drugs is becoming I think even more important in palliative care. Yes, I know that there are certainly some palliative care physicians who are persuaded that infusion pumps or the most expensive medication might be the best one, but I also know some very fine palliative care physicians who carefully weigh the cost benefit of any given medication and try very hard to choose the most economical one.

Senator Pépin: Dr. Henteleff, you mentioned when speaking about medication that there was a time when generic drugs were of more help to consumers than now. What do you mean by this?

Dr. Henteleff: The pharmaceutical companies are able to protect patents for a much longer period of time now. In the past, what had been proprietary drugs became generic drugs in a much shorter period of time.

The Chairman: I would like to ask you one last question; you may want to think about it and send us a note on it. When you look across to various jurisdictions, either in Canada, the U.S., Europe or whatever, is there any one place that you think has a noticeably better approach to palliative care from an overall policy standpoint than anywhere else? Or is it such an embryonic field, in terms of people focusing on it, that there is no one place that you would point to as being a terrific model?

Dr. Henteleff: From what I know, the British lead the field in this by at least a decade and they have quite a good system. It is a combination of private and National Health Service, so it is a divided system.

I believe the Australians have the most universal, uniform system that exists, and it coincides with recognizing palliative care as a specialty. So there is a status question that is involved. It has to do not just with status of those who are consultants, but it has to do with the extent to which health care workers are exposed to training, which is available in a very limited way to the generality of health care workers in Canada at the present time.

Ms Clarke: I would add - and I am not arguing with Dr. Henteleff's comments - that Canada is identified as a leader in hospice palliative care in the world.

The Chairman: In spite of the gaps that we are talking about?

Ms Clarke: In spite of the gaps that we are talking about.

The Chairman: I do not know whether that is encouraging or discouraging. On that note, may I thank all of you for attending here. The committee appreciates you taking the time to be with us.

Senators, our final panel this afternoon consists of Mr. Paul Moist from CUPE, the Canadian Union of Public Employees, and Mr. Daniel Boucher, who is the Chief Executive Officer of the Societé franco-manitobaine.

May I remind you that it has been the policy of most if not all Senate committees that at the end of the formal witness stage anyone in the audience who wants to make a five-minute statement may do so, with no questions from us.

We will begin with Mr. Boucher, followed by the CUPE representatives and then questions from senators.

[Translation]

Mr. Daniel Boucher, Chief Executive Officer, Société franco-manitobaine: Honourable senators, I want to welcome you to Manitoba and thank you for this very important initiative in the debate on health care services in Canada. I will mostly be speaking about the experience of the Franco-Manitoban community and of the challenges we face in the area of health care.

The Société franco-manitobaine has existed officially since 1968, but the defence of the French language in Manitoba began in 1916 with the Association de l'éducation des Canadiens français du Manitoba. The SFM is the official organizational advocate of the Franco-Manitoban community. It sees to the development of this community and does advocacy work to ensure that its rights are fully respected. With its partners, it plans and facilitates the overall development of the community, and promotes it.

In 1966 there were approximately 49,100 people with French as their mother tongue in the Franco-Manitoban community. Those francophones represented 4.5 per cent of the total population of the province.

Franco-Manitoban women and men are to be found throughout Manitoba. The greatest concentration of francophones is found in the metropolitan region of Winnipeg, clustered in the area that used to be the old city of Saint-Boniface. Other francophones live in cities and villages to the southeast and southwest of Saint-Boniface such as Saint-Lazare, Somerset, Notre-Dame-de-Lourdes, Saint-Claude, Saint-Pierre-Jolys, Sainte-Anne-des-Chênes, to name only those.

Their distribution follows the course of the Rouge and Assiniboine rivers, where francophones in Manitoba first settled. Sainte-Rose-du-Lac and Saint-Laurent make up the rare francophone enclaves in the north of the province. Sainte-Rose-du-Lac was the native village of the late, lamented Senator Molgat, a great defender of our community whom we miss enormously. The vast majority of francophones, about 90 per cent, are clustered in or around a two-hour, or less, radius of Winnipeg.

Francophones constitute a large proportion, that is, more than 25 per cent, of the population of about 15 cities and villages, a fact which has contributed to the dynamic character of French life in our province.

I want to speak first about certain determining factors that have an influence on the state of health care in our province. Essentially, we have noted that the francophones of our community have had less schooling. This obviously contributes to the health of the population. It means that it is absolutely essential for our communities to work on improving the state of health care. This is an extremely important area.

The accessibility of health services in one's language is inherently much more than a mark of respect for the culture of the service-user. It can sometimes be an essential element in improving health conditions and in encouraging the population to claim responsibility for its own health. Overall, the scientific literature allows us to conclude that the language barrier decreases the probability of seeking health care for preventive purposes, while it has a slight influence on the probability of seeking health care for treatment of acute health problems. The language barrier does however seem to increase the time between consultation and conclusion; it has an effect on the probability of ordering diagnostic tests, and may thus have an effect on the probability of erroneous diagnoses and the prescription of inappropriate treatment; has a greater influence on the quality of service where good communication is essential, for instance, in the provision of mental health services; diminishes the probability of compliance with treatment; and appears to reduce the satisfaction expressed by service-users with regard to the health care services they receive. These are very important points.

The accessibility of health care services has two generic forms. It mostly consists in a relationship with a health professional, and the information one receives through, for example, brochures, videos, printed matter, etc.

We feel that access to health care can be facilitated in many ways. Potential initiatives can be grouped under five broad headings: a meeting place where people can work together to find collective solutions to offer services in French to our population; technology - today's technological means would help us a great deal-training, which is extremely important; we have a training problem not only in the francophone community but throughout our communities and among professionals; and the availability of information for people. These are all very important points.

We consider that the initiatives grouped under these five headings should receive support in the near future. These are strategies developed at the national level by a national committee on services in French co-chaired by the Department of Health and a representative from our communities. We feel it is absolutely essential to make a start and take some action in these areas.

We want to emphasize the accessibility and quality of services. We feel it is absolutely essential that our communities have access to quality services. Health care services are fundamental in the relationship one has with someone else, in the sense that when you are sick, when you don't feel well, it is absolutely essential that you feel comfortable. Feeling comfortable in our own language is to us absolutely essential in the area of health care services. At the national level, the level of services in French is insufficient. We are of the opinion that there should be a national strategy in that regard. We are at this time working in close co-operation with the Province of Manitoba. In fact, our community has very good relations with the Province of Manitoba and we have made great progress in the areas of health and social services. We still have a great deal to do, but we hope that the examples set in our province and the progress we hope to make over the next few years will be a model for all of Canada, because it is very important, we feel, that we evolve in this sector.

Not only is health the most precious possession anyone can have, but the vitality of francophone in Acadian communities is also driven by the health of those populations. For its importance at the individual level as well as for its collective role, the health dossier must be a major preoccupation for all government authorities, federal as well as provincial, for all institutions concerned, in the fields of health and education, as well as for all francophone communities in a minority situation.

In Manitoba, we have already set up a 16-person council to guide our actions and strategies in the area of health and social services. We are preparing a very concrete draft action plan which will be discussed by the council and by the health and social services sector in the coming months. We are counting on you to convey our message to the Canadian government and more particularly to Health Canada, because without their support, it will be very difficult to implement our action plans in our communities.

This matter is all the more important in that being able to communicate in the language of the service-user can be an essential component of the health care service that is provided. It is for this reason, in fact, that several francophone communities have set up health care services in French. Several current experiences even prove that it is possible to offer quality health care services to sometimes sparse francophone populations and to develop effective approaches that make it possible to meet the diverse needs of the communities.

We are counting on you a great deal as far as this effective approach is concerned, if you intend to redesign the system or overhaul it in depth. The challenge of increasing accessibility to health care services in French will only be met if government authorities have the will to do so, health institutions are committed to this goal, and francophone communities are mobilized.

[English]

The Chairman: Thank you very much, Mr. Boucher.

Mr. Paul Moist, President, Canadian Union of Public Employees in Manitoba (CUPE): Mr. Chairman, members of the committee, I work for CUPE here in Manitoba. With me is Ms Lorraine Sigurdson, our health care coordinator in the province.

We have here in the province of Manitoba about 10,000 health care support workers and about 150,000 around the country. We will keep to your prescribed time limit and just jump around to a couple of issues.

At the bottom of page 1 of our written presentation, we relate the three main themes we want to talk about. Mr. Chairman, I regret that we are not saying more on chapter 11, the health human resources questions you put forward. I will tell you that here in Winnipeg, in addition to nursing shortages, health care support, we are short 600 certified nursing assistants, not to mention elsewhere in the province.

We have had discussions with governments of all political stripes over the last decades. There are huge governance issues in health care that you might ask questions about. We may send you a note on chapter 11.

The Chairman: That would be very helpful.

Mr. Moist: With respect to quality of health care delivery, we have had different experiences here in Manitoba. We had a failed experience with our Winnipeg hospitals food system under something that was known as the Urban Shared Services Corporation. We have had to revamp and restructure that plan and get rid of the U.S. consultant that was brought in to run the system.

At page 2, we cite a 1996 U.S. study that talks about preventable hospitalization rates two to four times higher in areas with "poor" zip codes than in areas with "wealthier" zip codes. However, in Canada, preventable hospitalization rates were less likely to vary by income, which we believe is a commentary on the nature of our system versus that of the U.S.

With respect to waiting lists, there is an argument that a parallel private for-profit health care system would decrease waiting lists in both the for-profit health care system and the public non-profit system. We think this argument is flawed and we source the Manitoba Centre for Health Policy and Evaluation that found that cataract patients here in Manitoba had to wait about four months longer for a doctor who worked in both systems as opposed to patients being served by a doctor who only worked in the public non-profit system. Those waiting periods of 7 to 10 weeks versus 14 to 23 weeks are cited by those authors.

We also quote from an Alberta study where the argument was made that private and for-profit health care organizations will mean two waiting lists, as physicians work for both the for-profit and non-profit sectors. The private for-profit list will consist of patients who will pay additional user fees and/or require the least costly equipment, while the public non-profit list will consist of the low-income basic medicare patient.

Mr. Chairman, on page 4, under the heading "Sustainability of the Canadian Health Care System including options for Funding," here in Manitoba we prefer to talk about modernization as opposed to privatization as what we think is needed for health care reform. We cite the federal-provincial health ministers in September 1998 identifying the need for primary health care reform, an integrated health care system between primary, acute care, long-term care and home care, where physicians receive salaries, as being preferable. Your chapter 11 comments on that vis-à-vis an option for physician payment.

Under the guise of modernization here last year, our provincial government purchased the previously for-profit Pan Am sports clinic, as it is commonly known, and brought it into the not-for-profit realm. It is an example of how non-profit and public health care delivery can change and reform to meet today's demands and standards. We think that is a success story in a change initiative here in our community.

There are other community health clinics - they are listed in our written brief - in our community. Funding for these health clinics must be appropriate in order for overall health care savings to occur, which is part of our theme that we need an integrated approach to considering the whole health care system, as opposed to simply dealing with the hospital setting, as important as it is.

We had a debate, Mr. Chairman, in this community a number of years ago regarding Manitoba's public home care system. We have a publicly funded, publicly run home care system. Everyone in this province has access to home care if they need it, and it is publicly run, meaning one central administration.

In the mid-19902, there was an experiment to offer a privately delivered home care system. That venture did not last, by virtue of worker, quite frankly, and patient complaints, and the firm left our province towards the end of the 1990s.

Manitoba, not unlike some other provinces, has been a net recipient of equalization and other forms of transfer from our federal government. The creation of Canada Health and Social Transfer payments have hit provinces like Manitoba, Saskatchewan and Atlantic Canada very hard. We give you some figures there.

For Manitoba, one of the most important federal-provincial issues is the issue of equalization and transfers. We cannot have a conversation in Manitoba about the role of federal government in funding or assisting with health care without talking about the whole ambit of federal-provincial transfers vis-à-vis Manitoba.

Finally, Mr. Chairman, in our submission, private health care costs more than public health care. For-profit U.S. health care costs are increasing at a faster rate than Canadian non-profit health care costs. We cite a study from the OECD that gives the figures, expressed in U.S. dollars, between our two countries.

In the U.S., there are four main factors that increase health care costs: no cost control, profits and executive remuneration, administration and overhead, and fraud, corruption, and lack of accountability. In 1995, overall administrative costs for the health care system in U.S. was about $995.00 a person. In Canada, expressed in the same U.S. dollars, it is about $248 a person.

In conclusion, we think quality health care means public and non-profit health care. Health care is not a commodity. We also do not mean the status quo; we mean modernization of the kind of examples I have suggested. All of the statistics on the last page of our submission are sourced with the appropriate citation.

The Chairman: Before turning to Senator Morin, I would like to ask you to clarify something. At page 5 of your written presentation, there is a section entitled "Other Manitoba Community Health Clinics." It would be helpful if you explained exactly what a community health clinic is.

I will tell you why I ask the question. The last sentence in that paragraph says:

A Saskatoon clinic found that overall costs were 17 per cent lower for patients attending the Saskatoon clinic than for those treated in the fee-for-service system.

What confuses me is the fee-for-service system. Is that not how they are paid in a clinic? Maybe I do not understand what the clinic is. Could you tell us what it is?

Ms Lorraine Sigurdson, Health Care Coordinator, Canadian Union of Public Employees in Manitoba (CUPE): For the community health clinics that exist in Winnipeg that are listed there, all but one, the physicians are on salary. The community health clinics are clinics where doctors are employees, and they provide a full range of services. It depends on the community health clinic.

For example, the Women's Health Centre provides service to women. Mount Carmel Clinic is an inner-city clinic that provides doctors appointments, dentists appointments, as well as some social services.

The Chairman: Social workers, counselling.

Ms Sigurdson: Yes, but not as extensive as the models in Quebec.

The Chairman: Along the same line?

Ms Sigurdson: Yes.

The Chairman: The cost savings then presumably come from what we have called in the report primary care reform?

Ms Sigurdson: Yes.

The Chairman: In the sense that it is salary capitation, whatever the form is, but it is not a fee-for-service at the primary level; is that right?

Ms Sigurdson: That is right.

The Chairman: It is not universally true, because you have listed some here, so I guess some of the primary care in Manitoba is provided that way and some is not; is that right?

Ms Sigurdson: These community health clinics are for specific communities.

The Chairman: Geographic communities?

Ms Sigurdson: Mount Carmel Clinic, as I listed before, is in a poor area of the City. Women's Health Centre is a women's health clinic. Village Klinic is a service to patients with AIDs. Not every person in the province would be able to go to a community health clinic because there are not enough of them.

The Chairman: Is there an attempt being made to take that concept and apply it elsewhere in the province, for example, so that a suburb of Winnipeg, St. Boniface, say, would have one or two or three, or something like that?

Ms Sigurdson: There is an process underway within the Winnipeg Regional Health Authority for access centres, but it is not clear how the physicians will be funded, whether they will be salaried or under fee-for-service. The idea of the access centres is to take away some of the pressure on emergency rooms.

The Chairman: The clinics are open seven days a week, 24 hours a day?

Ms Sigurdson: Not yet, not these community health clinics. What is being looked at is how the access centres could relieve - for example, not having to go to an emergency clinic to have a finger stitched.

The Chairman: There is a lot of evidence that the way to solve the emergency room problem is the 24-hour-a-day clinic.

Ms Sigurdson: Right. These are in process; there is no access centre that is open yet.

[Translation]

Senator Morin: I want to congratulate and thank Mr. Boucher for the cause he advocates, a cause that is also championed by myself and other senators. I would have two questions for him.

The first concerns the message you would like us to convey to Health Canada. I would like you to tell us specifically what message you would like us to take to Health Canada.

On page 7 of your report, you refer to obstacles. Could you elaborate a bit on the scarcity of bilingual personnel? What is the real situation with regard to bilingual personnel in the province of Manitoba? What are the union constraints? What sort of will exists in this regard at the administrative level, although you do say that there has been a great deal of improvement in your relations with the province.

Mr. Boucher: As far as Health Canada is concerned, it would be important to help us with networking for professionals and other people who work in the health care area throughout our communities. There are some distances to be bridged. I think we have to find ways of co-ordinating our efforts and effective means of service delivery.

As you know, in a system where population levels, the critical mass, is not always present, you have to work to find solutions, you have to be creative. We have been doing precisely that for a long time. We are beginning to have a handle on how to go about being creative. We would like Health Canada to support us at that level, to help us help them deliver services to the province.

The obstacles at this level constitute a real problem. There are two ways of finding personnel: you can train and you can recruit. A nursing program has just been started up at the Collège universitaire de Saint-Boniface, a development that is very positive for our community. We work in co-operation with stakeholders throughout Canada in the area of training, including the university of Ottawa. These are positive developments. There are a lot of challenges. There is a scarcity everywhere. Obviously, this is a big problem for us.

With regard to union constraints, I won't spend a lot of time on that topic. The system has been in place for a long time and everyone works within a system; however, when you want to propose something different, because of the configuration of our community it is very difficult to work within majority systems, and I use the term in its broad sense. I am not at all pointing a finger toward unions, because that is not the point. The point is that they work within a particular system, there are a large number of people who work at other levels, and we have to find ways of making all of this more flexible, in order to take into consideration the minority that needs services. It is in that context that union constraints might be raised. We do not talk about confrontation, because there is no confrontation.

[English]

Senator Morin: I have a question for Mr. Moist. I read your very interesting report. At page 8 of your report, you are opposed to contracting out services, if I understand correctly. I understand you may have an argument with private clinics, and I think some of the references that you pointed out, the quality of care and efficiency of care in for-profit compared to not-for-profit are well known. However, you say that contracting out cleaning work has been responsible for superbugs. What about contracting out kitchen work, groundwork, laundry, and so forth? That surprised me a bit.

Mr. Moist: I would not make that argument on behalf of each and every contracting situation, but we sourced that comment as it relates to that particular experience. I think it is much more of a broad notion we are trying to impart to you and your colleagues.

If we give up major control over the management of any portion of the health care system, it will be that much harder to reform. The earlier question about movement into different types of clinics and all that, if we are going to move in to provide clinics to ease pressure on our hospitals here in Manitoba - we are not going to emulate the success story here of putting doctors on very competitive salaries, but by putting them on salary, we are going to get out of the gates in the wrong way for what those clinics are attempting to do, to provide services to people before they need services in our hospital.

I am making an analogy to your direct question that I do not think we should be relinquishing control, and I do think you give up control to manage a system.

We notice in CUPE at all levels of government, not just in health care, that we are moving away from two- and three-year contracts, we are into 10- and 20-year contracts. With respect to the shared kitchen services for Winnipeg's nine hospitals, despite the fact that the experiment has been bad, it is a 20-year deal. We cannot deconstruct that building and start reconstructing kitchens in those hospitals.

If we were sitting here 10 years ago, we might be talking about a two-year contract or a three-year contract to clean floors in this hospital. The private sector is not interested in bidding for two or three more years. When you make that decision, be aware that you are making it for a long period of time, and it is going to impact negatively, in our view, on your ability to make change within that system, which is about the only constant of the last decade, the desire to make change.

[Translation]

Senator Pépin: Mr. Boucher, this disorganization, the supply of services, the low visibility of francophone professionals and the unavailability of francophone professionals only serve to make the situation worse. You mentioned that you had trouble recruiting personnel. Is the scarcity of professionals the reason for this difficulty, or is there another reason?

Mr. Boucher: Senator Pépin, I will give you an example. Two years ago, we opened the St. Boniface Health Centre. It was an urban centre in an area where there was a need for services in French. We had been asking for this for a long time and the province had decided to fund the Health Centre. This centre has an extraordinary potential. There is a two to three month waiting list because we cannot find enough professionals to staff it. It is very difficult to find a francophone professional to provide health care services, and the St. Boniface Health Centre operates in French. It offers services in both official languages, but it is a francophone centre. They managed to recruit three physicians, but they need six or seven. Our biggest problem is that we lose our physicians, they go elsewhere. Of course, when you need health care, you need it immediately.

We believe we have to find ways of helping each other in Canada, especially in the area of training, of exchanges with Quebec and New Brunswick. We have to work together to find ways of reaching people, of recruiting people everywhere. We must also promote careers in the health care field in our educational institutions, because we do not do that enough, and not enough value is attributed to these careers. We believe we really have to emphasize the value of the services provided by the people who do this type of work.

Senator Pépin: You mentioned that there were an increasing number of francophones who go on to university. I was very happy to hear that. There is a fairly large increase to be noted.

I know that in New Brunswick there will be a meeting during the first weekend in November to discuss French services. I was pleased to hear your comments, because we are going to be able to network with the other francophone communities from other provinces.

Mr. Boucher: I hope to see you in New Brunswick, because this is a very important meeting that will be attended by about 200 stakeholders from the health care field, and we hope to at least begin to find some very concrete solutions to the challenge we face.

[English]

The Chairman: I have two short questions. Under the section, "Manitoba Public Home Care," you say - and I will just read the sentence.

Everyone has access to home care, if they need it...

Is that factually true? I ask only because everywhere else we go in the country we are told that of the shortage of home care paid by the state seems to be huge. Is there something unique about Manitoba?

Ms Sigurdson: Well, I think our reference was probably to the fact that no one had to pay for home care.

The Chairman: Okay.

Ms Sigurdson: I think we would be optimistic to say that there were never any waiting lines or waiting time.

The Chairman: You are where most people are, which is that there is a need problem.

Ms Sigurdson: There is still a problem with people accessing the system, but people do not have to pay for it, I guess that is the context.

The Chairman: That is fine.

When you talk about the cost savings resulting from the government's purchase of the Pan Am clinic, correct me if I am wrong, but as I understand it, prior to the purchase, in year two or three prior to the purchase, all the patients going through the clinic were covered paid by Manitoba medicare. Hence, in a sense, changing the ownership of the building does not change the operating cost, because the same patients are being seen and the coverage is the same after the purchase as it was prior to the government purchasing the building. I am trying to understand where changing the landlord results in any significant amount of cost savings. I do not understand the economics of it. That is what is puzzling me.

Mr. Moist: That statement you made is true in part, but also offered previously at the clinic were -

The Chairman: Farther back in history?

Mr. Moist: No. I have had personal experience at the clinic with my own knees being scoped and being offered next week's service versus my knees being scoped in the health care system.

The Chairman: Let us take a scenario where the building was owned either by the government or someone in the private sector but where, in either scenario, the patients were covered by medicare, do you have a view that that is likely to save the government a lot of money?

Ms Sigurdson: My understanding of the situation is, first of all, there is going to be an expansion of services at the Pan Am clinic. Secondly, there will be less reliance on services being performed in hospitals because it is going to expand the capacity. If I need an arthroscopy, I am much less likely to end up in the hospital - not that I would have to stay overnight in a hospital, but there are some procedures that are still being done in hospitals that previously could not be done at the Pan Am clinic, so it will expand the range of out-patient services.

The Chairman: Presumably they could have expanded the clinic and still have the patient's costs paid by the government, even if the government did not own the building?

Ms Sigurdson: Except that all of the money keeps going back into the public system now, right?

The Chairman: I am just simply trying to understand the economics of it. I absolutely understand your issue about the days, which Mr. Moist pointed out, where you could pay extra and move up the system. I am trying to understand, frankly, why anybody cares whether the government owns the building or not? I mean, you just do a straight piece of financial analysis.

For instance, the government does not own most of its office buildings these days. The government gets somebody to build a building and then does a lease-back arrangement of some kind. Why do you not do that for health care? What makes health care buildings different?

Ms Sigurdson: When you are looking at space for health care, you are not just looking at space, you are looking at equipment, you are looking at all kinds of things that go along with it. The Department of Finance can probably move in here tomorrow; they would just have to bring their computers and their desks. However, it is a bit more complicated when you are looking at the kind of equipment that is necessary to put in a medical clinic.

The Chairman: Thank you all for coming. I appreciate you taking the time to be with us.

Senators, Mr. Barry Shtatleman, a walk-on, wishes to make a statement.

As you know, Mr. Shtatleman, our policy is that you have five minutes to make your presentation. There will be no comments from the panel.

I notice you have been here for awhile. Thank you very much for coming. Go ahead, sir, whenever you are ready.

Mr. Barry Shtatleman: Thank you very much. I appreciate your kindness.

On August 13 of this year, the Winnipeg Free Press printed excerpts from a survey out of Montreal conducted by Leger Marketing. Mr. Leger said that the poll and other studies suggest a shift in Canadian's concerns toward giving more attention to collective values. The report said that Canadians are less preoccupied about the deficit or the debt and most preoccupied about social values. Please understand this survey was made long before -

The Chairman: September 11?

Mr. Shtatleman: The survey was conducted long before even the possibility of a downturn in the economy, so I would suggest that this would be even more pertinent today.

Canadians generally have a strong egalitarian conviction. Indeed, universal health care is considered intrinsic to democracy, and Canadians see their health care system as something precious that somehow identifies them in some inexplicable way.

Poll after poll indicate that Canadians do not mind being taxed in order to have that quality of health delivery that they believe they have a right to, and deservedly so.

According to Statistics Canada, during the Mulroney Conservative era, approximately $30 billion was removed from the health delivery system in Canada as a result of the great deficit that occurred at that time, even though we had removed so much money from health care in order to balance the books. God knows why they would do that, but they did it. Paul Martin was forced to remove a further $6 billion before restoring a portion of it last year. It is a wonder that our medicare system even survived at all, frankly.

So here we are today, even after last year's cash infusion of $23 billion over five years to health care in Canada, the federal government only covers about 14 percent of health costs. That is still well below the pre-cutback days of 1994 and 1995 when Ottawa picked up about 18 percent of the provinces' health care costs. So, we have a bruised system, but one that is still going strong in spite of all the attacks.

The interim report that your committee released on September 17 said the Canada Health Act should be updated to allow for more private medicine and predicted a Charter of Rights challenge related to access to health care within the next few years, no doubt from American health insurance corporations and those who have long sought dreams of investing in private health care.

Interestingly enough, the Journal of the American Medical Association in 1999 published findings of an exhaustive 10-year study of private for-profit market medicine in the United States. The bottom line is that it is a total disaster. That is all there is to it.

There are those who talk about private health care in other jurisdictions. Let's look at those that may be successful. Let's look at Sweden, at Australia, at France. Look in the mirror.

Let's look at Alberta for a moment, with their disastrous for-profit eye clinics. After all, is it not reasonable to expect investor profits to take precedence over quality health care? Would you have Canadians believe otherwise? If you do, I have a bridge I would like to sell you.

The United States provides a window into this private health care future. The prestigious New England Journal of Medicine reported in August 1999 that for decades studies have shown that private for-profit hospitals are 3 to 11 percent more expensive than not-for-profit hospitals. The drive for profit is compromising the quality of care. The number of uninsured persons is increasing. Costs are escalating and spiralling out of control rapidly, not to mention the billions of dollars of fraud taking place in the United States at this very minute, with no controls over it. Thank you very much.

Australia, amongst other nations, provides a further window into the failure of a private health system operating alongside a publicly funded one - which became the impetus for changes to their health care system. Over the past decade or so, however, state governments began to allow profit-making health care companies to bid to take over public hospitals. The difference was to be that the privatized public hospital would operate more efficiently. Just how this was supposed to happen was never made clear. Government simply assumed that private enterprise would be more cost effective in all fields and that privatized hospitals would provide more bang for the medicare buck. How wrong they were.

First, the privatization of Australia's health care has not achieved one of the major benefits that proponents promised. It has not eased pressure on the public system. In fact, waiting lists in public hospitals are longer than ever. The more specialists who work in the private tier, the less time they have to work in the public one.

As well, privatization does not save money. Australia's federal government has been forced to subsidize the private health industry to the tune of $2.2 billion a year just to keep going. Politically and financially, Australia's privatization attempt of health care has been a stunning disaster.

We do not have time for me to give you further research that I have done, empirical evidence, not opinion like the Fraser Institute.

I would add one more thing. You will find this very interesting. Charles Baillie, Chief Executive Officer of the TD Bank, devoted a whole speech a little over year ago to the topic of public healthcare in Canada, preserving a competitive advantage. Mr. Baillie chose the topic because, as he said, he believes it is high time that those in the private sector went on the record to make the case that Canada's public health care system is an economic asset, not a burden, an asset that today more than ever our country dare not lose. I agree and so do most Canadians, frankly.

The Chairman: Thank you, sir, for your comment and for your well-researched effort. We appreciate you taking the time to be here today.

Mr. Shtatleman: I wish I had the time to give you the research on other countries. It would be an eye-opener.

The Chairman: Thank you, again, and thank you to the people who have been sitting patiently in the audience all day. We appreciate you taking the time to be with us.

The committee adjourned.