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

Issue 31 - Evidence

SASKATOON, Tuesday, October 16, 2001

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 9:02 a.m. to examine the state of the health care system in Canada.

Senator Michael Kirby (Chairman) in the Chair.

[English]

The Chairman: We are delighted to be in Saskatoon on the first day of winter. It has been cold in the East, but not quite this cold. However, I went for a good walk this morning and the weather was terrific out there.

Our first two witnesses this morning are June Blau, President of the Saskatchewan Registered Nurses Association; and Bob Layne, Vice-President of Planning and Public Relations, Western Region, for the Victorian Order of Nurses.

We are delighted to have the two of you with us. I know you have given us some submissions. We would like you to take a few minutes at the beginning to hit the highlights, and then we will proceed to ask you questions.

Ms June Blau, President, Saskatchewan Registered Nurses' Association: Good morning, ladies and gentlemen. I too am delighted that the committee was willing to rearrange its schedule so I could come early this morning; that was most helpful. Thank you, also, for the opportunity to speak today on behalf of the nurses of Saskatchewan.

You read my mind; as I was driving up this morning from Regina, I thought, okay, hit the highlights, hit the high spots, and then we will talk later. That works for me.

The Chairman: I must tell you, probably 20 years ago now, the first time I visited Saskatchewan, I actually drove the other way, but I deliberately went through the Qu'Appelle Valley, which was a longer drive. It was about this time of year, this time of day, when the feeling of fall was just perfect. You had a good day for driving down, at least.

Ms Blau: We did indeed. I want to tell you first a little about our association. It is included in the submission that we presented to you, so I will hit the high spots. We represent roughly9,000 registered nurses, all the registered nurses in the province. We really commend the committee on the approach that you have taken and the thoroughness with which you have dealt with this topic so far. We are encouraged by the thoroughness of the process and we want you to know that. We see that your focus is on the public, and we share that focus.

Our association was established by provincial legislation in 1917. We are both the regulatory body and the professional association for the nurses of the province. Our standards are set out in the act and our mandate is to maintain and uphold those standards. Our vision is of registered nurses as partners in an informed, healthy society. Our mission is competent, caring nursing for the people of Saskatchewan.

We believe in a citizen-centred approach to health care. We believe that citizen involvement needs to occur at every level of decision making. We also acknowledge the fundamental compo nents of health - peace, shelter, education, food, income - that you have detailed in your report. Within that, we want to highlight three things that we think are integral to the survival of Canada's health care system.

The first is a primary health care delivery model. The second is stability and quality as changes occur over time. The third is health human resource management, which has been sort of seat-of-the-pants management up to this point, and needs to be much more carefully considered.

Having said that, I will go to the last page of our submission and look with you at the recommendations. It is actually page 7, if you are following along.

We think there is some urgency to the need for change, but at the same time, we need to be concerned with maintaining stability while that change is happening. We are urging our provincial government not to procrastinate any longer. We want to see change occur, but we want to see planned change, with people involved at the levels that the changes are occurring.

We advocate a strong, comprehensive primary health care system as the cornerstone of an overall health strategy for Saskatchewan, and we also recommend that for Canada.

We recommend that centres of excellence for primary health care be established by operationalizing two primary health care demonstration projects here in the province, one rural and one urban, by the spring of 2002. We want particular attention to be paid to Aboriginal and women's health, as those are vulnerable groups in our population. We note with pleasure that you have spent some time considering Aboriginal health, and we certainly support that.

A national health quality council should be established with strong citizen representation. There are a number of ways to look at that kind of council. You can consider some citizen participation and a lot of health care providers included in it. Or you can use the approach of a citizen committee or council, with the provider groups and others as advisers to that council. We are leaving you with those two notions of how that might work best. It needs to be accountable to the Government of Canada and to the people of Canada. I believe you have said those are your beliefs as well.

The committee has recognized that nurses are integral to a quality primary health care system and has acknowledged the crisis in our nursing human resources and other health human resources. You have identified some short-term strategies to address the above-mentioned points, including healthy, safe workplaces; the tools needed to provide quality nursing care; facilitation of a work-family balance and work interesting enough to attract nurses.

However, though the SRNA is supportive of these recommen dations, we feel that these alone are inadequate to meet the goal of recruiting and retaining nurses. More specific, concrete solutions, as opposed to dependence upon the intrinsic rewards of the profession, are mandatory to meet the urgency of this situation.

As we see it, the solution must include increasing the number of funded nursing seats in educational programs across Canada. That number has dropped from 10,000 in 1990 to 4,000.

The Chairman: What do you mean by a "funded nursing seat"?

Ms Blau: Seats that are provided in universities.I am speaking of the number of training positions, the number of education positions.

The Chairman: Are you saying that nursing schools limit the number of people they can take in?

Ms Blau: Yes. They limit it on the basis of the funding that is provided for education.

Senator Pépin: For students?

Ms Blau: For students. We are limited in Saskatchewan right now to 260 seats; we need at least 400. The Province of British Columbia, for example, has only ever trained 50 per cent or less of their needs because they rely on recruitment from other provinces. Consequently, we train and they use, and that has been the philosophy ever since I became a nurse.

The Chairman: I am sorry to sidetrack you. I just wanted to make sure I understood the idea.

Ms Blau: It is good to do that.

There is the issue of tuition support for nursing students. We are finding that nursing students are often not sequential students, so do not have the same access to student loan programs that young, coming-out-of-high-school students do.

I had a student approach me recently to say that she had been denied access to further student loans for tuition and books - this was a loan, this was something she was prepared to repay - on the basis that she was married and had other options. Like she should go and work at McDonald's after school. She was married and had a family. It was also suggested that maybe she could get a legal separation and then she would qualify for a further student loan.

The Chairman: I should not laugh.

Ms Blau: Well, if you do not laugh you will cry. That is where we are at with this.

We need support for mentoring programs for students intheir transition from school to workplace and concomitant compensation - boy, there is a mouthful - for experienced nurses in the mentoring role. One of the particulars in there is support for mentoring Aboriginal students. We have a very good peer-support program here in Saskatoon, the Native Access Program to Nursing, that has just worked phenomenally well and is associated with the University of Saskatchewan College of Nursing. We are supporting getting a similar one started in Regina.

We recommend funding for quality workplace programs to establish quality workplace environments. This is related to "magnet hospitals," which is a patented term in the United States. Those are facilities that are able to attract and retain nurses and, perhaps by the same token, other health care providers, as a result of which, they also provide very good patient outcomes. When quality workplaces attract and keep good people, the outcome for the clients is superior.

The SRNA is currently sponsoring, with funding from the provincial government, a quality workplace pilot project in Moose Jaw. We are starting with one of the medical units there. There has been a tremendous response from the people involved. We have a partnership with the Health Services Utilization and Research Commission to develop our assessment tool. We are helping the unit to put a program in place that is based on its needs. It starts out by identifying what they are doing that is good, and what they are doing that needs some work. Then they identify how to improve. We are working on that and looking for more project sites to be established.

Financial support to the nursing profession must be competitive with professionals in other sectors, and the same is true for professional development and continuous learning.

We are confident that the government will continue to demonstrate the required leadership in rejuvenating our national health care system, keeping foremost in mind the needs of the citizens.

Mr. Bob Layne, Vice-President, Planning and Public Relations (Western Region) Victorian Order of Nurses:I welcome the opportunity to make a presentation to this group. We will focus on some of the general ideas identified in the report and then add an additional comment that we feel should be included in it.

VON Canada supports the following options that the Standing Senate Committee on Social Affairs, Science and Technology is considering at this time and strongly urges their inclusion in the final document.

The first is a national home care program for Canadians to be assured of receiving a consistent and appropriate level of care in their homes when it is needed. The second is a commitment from the federal government of funding for information systems that extend into the community and home care sector to allow for reliable and timely patient-client information. This technology will improve continuity and quality of care across the continuum, increasing efficiencies and reducing costs to the overall health care system. The third is an increase in federal funding for research targeted at the community sector of the Canadian health care system. The fourth is a federal commitment to develop programs and policies that recognize and support informal caregivers. Family, friends and neighbours currently provide the bulk of the care to loved ones in the community.

These issues are clearly defined in our written submission of May 2001 to the committee. We are certainly prepared to speak about them today, but you should have the documentation already available.

On behalf of VON Canada, today I would like to highlight one issue that was not noted in the "Issues and Options" report, that is, provincial and federal recognition of the value of not-for-profit organizations working within and/or in support of the health care system. VON raises this issue on behalf of all non-profit agencies across Canada that offer charitable support services and programs to those who cannot afford fee-for-service programs, are not eligible for government funded programs, or need health care or support services that are non-existent within the current govern ment mandate.

This year is the International Year of the Volunteer, and volunteers worldwide are being honoured and recognized for their immense contribution to society. VON strongly believes that the large volunteer component in the health care system in Canada must be formally supported. VON recommends that all levels of government throughout Canada recognize the value of not-for- profit organizations through policies that support, encourage and provide incentives for collaboration, cooperation and partnering with volunteer agencies.

This brings to an end our brief, five-minute introduction that we were requested to provide. I would like to bring two other people to the table for the question-and-answer part. They are Brenda Smith, board chair of the Prairie branch; and Lois Clark, executive director of the North-Central Saskatchewan branch.

The Chairman: That is fine.

For the witnesses and the audience, let me introduce my colleagues, and you will soon discover that I am the one person who does not know anything about the health care system.

Senator Lucie Pépin, on my left, has been in politics for a long time, but her profession is nursing.

Next to her is Senator Yves Morin from Quebec, a former dean of medicine at Laval University.

On my right is Senator Wilbert Keon, who has just stopped practicing cardiac surgery, but is still chief executive officer of the Ottawa Heart Institute.

I am the one with no health care credentials. That is why I am up here, I guess.

Senator Pépin: I am very happy to welcome you all. If you look at me, you will realize that nursing gets you anywhere you want to go.

Listening to you, and to other nurses, I realize that if we are studying improvements to the health care system, we have to do something for nursing. I think it is so important, because you are the backbone of the health system.

I want to be sure I understand what you were saying about the nursing seats. These are the nursing students. Now where do they study - in school, in university? They are not doing their nursing courses in a hospital, like I did?

Ms Blau: No.

Senator Pépin: When you speak about insufficient nursing seats, do you mean those nursing students? Or did Imisunderstand?

Ms Blau: In our province, and similarly elsewhere, universities have a certain number of spaces for students. Over the last10 years, some decisions were made - at what level is not clear to us - to reduce funding for education for nurses.

Senator Pépin: Who want to specialize?

Ms Blau: No, these are basic students. Our numbers dropped from something over 300 to 260. Other provinces have dropped more than half. At the beginning, a seat guarantees you a spot when you graduate. We are graduating 6,000 fewer nurses now per year than in 1990. That is the outcome, but the reason for it is a decrease in funding for nursing education programs

The Chairman: You said 6,000?

Ms Blau: A 6,000 decrease. It has gone from 10,000 graduating in 1990 to 4,000 last year.

Senator Pépin: It is unbelievable.

Ms Blau: The Canadian Nurses Association has those statistics and they would be available to you from them.

Senator Pépin: It seems there is a big problem. When I listen to you, I see that if you want to become a nurse, you have to have a seat at a university, unlike my generation, and maybe some of your generation, where we had to study nursing in the hospital and apply what we were learning. We had two hours of courses every day, and after that we were at the hospital. I was thinking that if we returned to a similar system, at least we would have more nurses.

We were also a team with the doctors and we all were working together. Currently, when you see how the work is divided, you realize the approach is quite different. As you mentioned, we are very well aware of the issues of quality of the workplace and the amount of work available.

We are proposing making some recommendations, but let us say we are looking at different ways of proposing a solution. I do not know if you have had the time to have a look at the report, where we say maybe the nurses would be part of the team, and the practitioner nurse would be welcoming the patient and finding out what kind of care the patient needs, what kind of doctor is required, things like that. Do you see the nurses' work going in that direction, or how would you organize it?

Ms Blau: Yes, we very much see that, and I go back to your analogy of us working as a team. I too graduated from a hospital school of nursing, and in those days hospitals were practically the only place nurses worked, other than a few in public health.

Nursing is very different today, and I think a return to those schools of nursing is less of an answer than a health sciences education facility, where nurses, doctors, psychiatric nurses, social workers and pharmacists could take core courses that are common to all of those disciplines - the life sciences, those kinds of things.

Senator Pépin: We have the same thing in Quebec.

Ms Blau: We need to have people educated together, so that when they need to work together, they will know how. They will each know what the other has learned, and they will also know what each is capable of. That is very much what we are espousing, and we think it needs to start at the educational level, at the university level.

It also needs to carry through into primary health care teams, where nurses, doctors, social workers, nutritionists and everybody are working together, and the person who sees the patient in the community is the one who can best meet those needs. In many cases a nurse will be doing the triaging, but in a wellness or a primary health care model, it may well be the social worker or somebody who can help with financing who is the first contact. Financial health often dictates other kinds of health. We are on the same track with that one.

Senator Pépin: Also, the patient will feel much more comfortable, knowing that all those people are looking after him or her.

You mentioned that nurses are aging and that they are exhausted. If you wanted to attract young persons to nursing, how would you do it?

Ms Blau: Senator Pépin, in Saskatchewan we have no problem. We turned away 170 qualified applicants because we did not have the spaces for them. Some of them went to Alberta; some of them could not get spaces anywhere. Some of them may go into something else, and then we have lost them to nursing. It is very sad, because they would potentially have been 170 nurses in three-and-a-half years time.

Senator Pépin: Yes, because we know how much we need them. You are very lucky, because I know other provinces would really like to be in the position of having to refuse potential student nurses. Young women do not go into nursing any more. I know of at least one province that has a big problem.

Ms Blau: We are not having a problem here at the moment, and have not had in the past. We may have had one or two years where we were close, where we had the necessary number of applicants but not many more. However, in the last two or three years, we have turned away qualified applicants because there were no spaces for them.

With hospitals decreasing in size too, and the numbers of hospitals in Saskatchewan diminishing, we have had a problem with clinical placements. For nurses to get their practical experience has become something of an issue, and we have had to become quite creative in dealing with that practical matter.

Senator Pépin: The other witnesses, who are working with the VON, what is your major difficulty? Is it funding? Do you have enough instruments? What is your major difficulty that you would like us to address?

Mr. Layne: Perhaps I could just make an initial comment, and then my colleagues can participate as well. Our difficulty out there is the same as June has identified, that is, the need for large numbers of qualified health care workers, and quite frankly, it is not just at the nursing level; it pervades the whole structure. Clearly, we see that situation worsening significantly over the next few years, with the demographic and cultural changes that we are all aware of in the Canadian system. We will have to have more human resources.

In addition, I think there has to be some strategic redesign, with better information systems and better utilization of current resources. Your report speaks about the reforms that you are looking at. Well clearly, we strongly support the need for a more integrated team approach throughout the entire health care system. Certainly there is need for more resources; I do not think anybody can argue with that. However, there is a very significant advantage to be garnered from bringing together the different players out there, and getting physicians working with the nurses, working with the pharmacists, everyone in the health care system. We believe that would be a significant improvement in the use of the resources currently available.

Senator Pépin: You are moving in the right direction.

Senator Morin: Ms Blau, there is no doubt that the nursing profession is at the heart of any reform anyone wishes to make to the health care delivery system in this country. Both the Fyke commission, and the Clair commission in Quebec recommended, for example, the use of primary care teams. I am more familiar with the Quebec scene. Everybody was in favour of doing that, but to everybody's surprise, there was quite an important financial cost associated with it initially. There is the cost of recruiting nurses and setting up these teams and so forth.

Have you had any experience with the financial aspect? If you want to do these things well, you have to have a good team. What are the costs involved in setting it up? I know you have had pilot projects here in Saskatchewan. Do you have an idea of how expensive it is for a given community to move from a fee-for-service system to a health-care-team system, including the nurses and the nursing profession? That is my first question.

My second question is related. Last year, a Canadian study showed that there is a major problem with workplace quality for nurses in hospitals from coast to coast. I think this is one of the major reasons why the nursing profession has dissipated over the years. Here again, do we have an idea of how expensive it would be to fix it?

I know that various reforms have been recommended. You talked about the "magnet" centres in the U.S. Do we have any idea of the cost, for example, of a given hospital of 500 beds moving from one system to the other? Is that a very expensive proposition, or is it just a matter of rearranging?

I know that one of the major reasons why nurses are moving to the U.S., in addition to salary difference, is workplace conditions and the possibility of further education while they are working. That is one of the reasons that were given to us by the Canadian Nursing Association in Ottawa.

I have so many questions because I think the nursing issue is so important here.

I was struck by the out-migration of nurses you experience. Am I right that it is 285 nurses a year? That is a large number for the province of Saskatchewan. Now are these nurses leaving mainly for reasons of salary, or working conditions? Is there another reason? I know most of them are going to Alberta, and some of them are going to the U.S., according to what you have stated. Is the reason for that the salary scale? If it is, should we consider a Canadian scale? We will have nurses moving from one province to the other according to where conditions are better, and I do not think we can do any long-term planning if we just continue that way.

Finally, I would like to deal with the Aboriginal health situation. This is, to my mind, the current major issue in Canadian health care. Senator Kirby, our chairman, keeps repeating that the Aboriginal health situation is a national disgrace, and we certainly should do something about it. We have discussed the situation, but it is difficult to get a handle on what we should do. Of course we should improve housing, economic and living conditions. How ever, it is difficult to get a handle on this within the health care delivery system.

I think Saskatchewan is in a very special position here, because this province has the highest Native population proportionately, and if I am correct, in a number of years, they will be the majority. Therefore, for this province, it is a very special issue.

I also feel that the nursing profession is at the heart of the solution. It is obvious that a cardiac surgeon cannot deal with this, and nor can a past dean of medicine. I think it is the nursing profession that is really at the heart of the solution to that problem. I do not know exactly what that solution is. In a way, it is a plea for you people, the nursing profession here in Saskatchewan, dealing with the problem. You are not sitting in an office in Ottawa, you are right in the middle of it. This is where the solution should come from.

You cannot do it today, of course, but as everybody is grappling with this very serious problem at the national level, I think maybe you people can come up with a solution from the grassroots. I hope that you will consider that, and later, send your ideas on the subject to the committee while we are working on our final report.

I am sorry I was a little long-winded, but it does show the interest I have in this cause.

Mr. Layne, I just have one more, quick question here. I think your point on voluntary organizations is very important. I do not know if Senator Keon has had the same experience, but I tried setting up a number of volunteer groups when I was in another life, in clinical work, and I had all sorts of problems with the unions: "Who is this volunteer taking our work?" I really had serious problems and had to curtail some of the volunteer work that was being done on the floor with patients because of union pressure. They were quite upset about this.

This may be a minor point, but I was wondering if this were true only in Quebec, where perhaps our unions are more aggressive than they are elsewhere.

I fully support the idea of helping the voluntary agencies; there is no doubt about that. I was wondering if you could suggest practical methods by which we could help you, and which we could recommend in our report on a national basis.

Ms Blau: I will have to get a refresher on the questions. I wrote two of them down. I will start with the rural and Aboriginal one.

Senator Morin: The first one is the cost of the primary care.

Ms Blau: The cost of the primary care team, yes.

Senator Morin: Not precisely, but whether you have an approximate idea of the cost of improving the quality of the workplace for nurses in a given hospital.

Ms Blau: I do not have an answer to the question of cost. We have community clinics in the province that function rather like the community health centres in Quebec, the CLSCs, where there are multi-disciplinary teams working with a population base. We have a small project in which a physician and an advanced practice nurse work together and then draw on resources from surrounding communities. It will not be possible in Saskatchewan to have a primary health care team in more than a few central locations, and then we will have to find innovative ways of getting them out to the population in the more rural areas. It will take us some time.

I think you are probably correct that it will likely cost more at the beginning. Any time you reorganize the way people do things, inefficiencies are created, and those cost money. However, I think the outcome will be physician retention, will be nurse retention, and will be better community services. I think some of those will happen immediately. The quality will probably go up more than we might expect, even in the short term, and in the long term, it will really prove to be effective.

Some of the things that would improve workplace quality, we believe will not cost any money at all. A change in attitudes towards nurses would help a great deal. I want to go back to your out-migration comments. One of the differences in the U.S. is an attitude of respect for nurses and nursing that is not common in Canada. Nurses are not respected by their colleagues from other disciplines, which creates a major problem. You become like the mother who is always there, and not appreciated until she is gone.

Senator Pépin: And has to look after everyone.

Ms Blau: What we are seeing now is, "Oh, my goodness, we have to fix the nurses' situation now, because we did not notice them before this happened." Some of the things will not cost a lot of money; it is a question of recognition and respect.

Some of the things will cost money, such as professional development, with the use of replacements for nurses taking time away from the workplace to further their education, so that they know their colleagues will not be running flat out in order to get the work done.

We need opportunities for advancement that are mentored. We do not have in nursing what medicine, perhaps, has had all along.

We do not have the dollars at the end of the two-week pay period that other professions have had, and that is a major problem. It will cost money to build a quality workplace. It will take a national strategy to keep nurses from jumping from one provincial bucket to another.

I think the predominant factor right now in the movement of our graduating students is financial. They are coming out of school with student loans, and they want to pay those off as quickly as possible and get on with their lives. It is also more complex than that; there are other factors.

We find that when our nurses move to the U.S., some of them stay because they like the environment, but some of them come back because they do not like the cost implications for patients. They are very uncomfortable with having to document every item of supplies that they use for patients.

Senator Pépin: Just like in a lawyer's office.

Ms Blau: They spend more time doing paperwork than patient care. That has covered three of them, I think.

As an association, we are very aware of the Aboriginal health issue. We are lobbying the provincial government and the universities for a centre of excellence for rural and Aboriginal health. One of the things we need from the federal government, because this will benefit all of Canada, is some funding for research. We need to know what this problem is. We know we have a problem; we do not know the nuances yet. We need some research dollars to discover those. If we can get something started here, where the universities and the provincial government are interested, that research and its outcomes can probably be applied to the rest of Canada.

Senator Pépin: Do many nurses sit on the boards of directors of the hospitals? A few years ago, maybe eight, I spoke to nurses and doctors and recommended that a nurse should sit on the board, because if you decide to make cuts in one department and reorganize the hospital in a certain way, but there is no nurse to tell you about the impact, you will make mistakes. I have to admit, there were very few nurses appointed to the boards of directors. I was wondering if you are wiser in this part of the country and appoint nurses to the boards of directors of hospitals.

Ms Blau: We are not wiser. In some instances, nurses have put their names forward. We have elected boards in Saskatchewan now and some nurses have been willing to run. However, they are a very small minority.

Our association would prefer that the medical advisory committee, which has such power at the district level, be replaced with a professional advisory committee representing all of the professional groups working in that district. Then the medical people would have their input, but nursing, social work, physiotherapy, pharmacy, all of those disciplines which have such a small voice now - we think it is bad in nursing, but some of those others have even less of a voice - would have theirs also. I believe that is what Ontario's legislation provides for. They got rid of the medical advisory committee and established a professional advisory committee that encompasses all of the professions. I cannot tell you how that is working, or that it is working, but we think it would be an interesting way to go, rather than having special-interest groups represented on a board of directors that really ought to represent the owners, the public.

Senator Pépin: I really did not express myself very well. I think it is something similar to what you have described.

Ms Blau: Similar, okay. Yes, we support that.

Mr. Layne: Senator Morin, I would like to answer your second question first, on practical methods to help volunteer organiz ations, and then I can respond to the other question.

I think that there are many practical things that can be done and that can evolve over time. However, I think the very first step that has to be taken is the recognition of the value of these organizations to the current health care system. Then, everybody would want to listen to their opinions.

Currently, when an issue arises, there is sporadic discussion amongst these various organizations - some of it makes it to the media, some does not - but there is no legitimate, formal mechanism by which these people can report to the public system. I think what you are doing here is very, very positive, and your activities serve a very valuable role at the strategic level. However, beyond that, we need some sort of ongoing, daily recognition of the value of these organizations. By that I mean that there should be formal mechanisms by which these organizations can speak to the public health care system.

As Senator Pépin identified, decisions are made about nursing in the institutional sector without any input from nurses. Decisions are made about the whole health care system, how to structure, centralize and redesign it, without any input from these organizations. Sometimes they gain sporadic input, but for the most part, there is no legitimate mechanism that allows organizations like ours to speak on these issues. It should not be a formal mechanism like this one, which occurs every few years; it should be on an ongoing, everyday process when these organizations are going through their decision making.

For example, we have seen the authorities across the country taking over nursing care through their own delivery systems - and that may be a fine system, we will not comment negatively or positively on it. However, the comment we would like to make is that there was no consultation. I think in many places, those decisions were just made, and they may have been for very good reasons, but the input was not there.

Senator Pépin: They are business decisions and they do not take into consideration that we are also dealing with people.

Mr. Layne: That is right, and there are a lot of people affected, so it is very important to have that dialogue. For example, our organization has 15,000 volunteers and 8,000 staff, and we are just one of many. There are tens of thousands of organizations out there that have knowledge and could give input. It is really essential to develop a structure in which they can feed that information through in a constructive fashion on an everyday basis.

Senator Keon: I think this is one of the most important issues that the health care system in Canada has to grapple with over the next short while.

I will start with you, Ms Blau, and the question of primary care, why we just have not been able to put this together. In the last few years, every province has had a royal commission or the equivalent, and they have all recommended that we devolve the system out of the large, central institutions and build primary care, but we have not been able to do it. Whether we are using regionalization or some other model, we somehow have not been able to do it. My own perception is that the failure has been based on our inability to devolve authority and to devolve care. We have not been able to devolve care out of the large institutions into home care, and in trying to organize the home care system, we have not been able to devolve authority to it. Consequently, as Senator Morin has said, the models that we have designed have been simply too expensive and have died of inanition.

I will put a very difficult question on your plate. I know that in the medical profession, there has been tremendous resistance to abandoning fee for service - I will come to home care with you, Mr. Layne, later - and I do not think a primary care model can be developed if the physicians on the team are practicing on a fee-for-service basis. I do not see how it can possibly work.

I would like to hear what you have to say, and I understand that is not an easy issue for you.

There is no question that there is a tremendous shortage of nursing personnel, but when we look at the health economics of the system, I think both physicians and nurses have to be prepared to provide more leadership and devolve much of the actual hands-on work. I think this could be accomplished - and I will come to Mr. Layne about this later, because he raised it - with good information and communication systems. I will talk about that with you, Mr. Layne, but I will leave it for now.

I would really like to hear your comments on the design of a primary care model that would have a fully integrated medical team, with appropriate salaries for physicians and nurses, and with other health care professionals who could perform much of the service at a much, much lower cost, the physicians and nurses providing the leadership.

I will take it a step further. I think the educational programs have to be redesigned to fit into these new systems. We perpetuated a terrible mistake in medicine for a number of years when we educated our primary care physicians in tertiary care hospitals, and about 75 per cent of what they learned was useless. We are gradually overcoming that and getting them out into the community, but we have not gone far enough yet.

It seems to me that nursing has to take the leadership role in primary care, just as medicine, I think, will have to continue to take the leadership role in medical science. Therefore, it seems to me that you have to fit your educational programs with your health care delivery program.

After that bit of ranting, let me hear what you have to say about the design of a primary care model with a fully integrated, salaried team. Let me hear what you have to say about the personnel necessary for a successful team. Then let me hear what you have to say about the education of new personnel to refurbish that team.

Ms Blau: I will start with education first, because I agree with you that we have to educate people for the role that they will play when they are at work. That, in large part, sets the expectations for what they will do. On the other hand, we have to have some changes in the system, because if you put the education system in there and create expectations that are so much different from what they meet in the workplace, we will just set up endless frustration, because the rest of the world will not have caught up with us.

We differentiate between primary care and primary health care. We use the World Health Organization's definition of primary health care that includes social, economic, and all other aspects; that is, optimal health, not just the absence of disease.

We think we should have excellence in primary care, where all the five principles of the Canada Health Act apply to people who are ill. However, we need to go farther up the river than that, and make sure that our environment, our social system, our economic system, all of those things, enable people to be self-reliant about their everyday health.

A primary health care team could be part of that, because many of the things that nurses already do are to teach people how to stay well. Many of the things that doctors already do are to advise people how to stay well. We just do not have a sufficient connection with them because we are sitting in a doctor's office in Regina or Saskatoon, and the people are in Meadow Lake. We need to get that group, whatever it will look like, into the community where people live.

I think there are two reasons why we have failed. One of them is that the medical profession is tremendously powerful, and people will back off when a doctor speaks. I am not saying that other than factually; it is just the way it is.

Second, we have not done community development. We have not gone to the people - we have done it to them instead of facilitating them doing it for themselves, and that is a big failure. I have watched the Saskatchewan government do precisely that.

The Department of Health thinks they are doing a great job in setting up these primary health care centres; they are really not, because they have done it to the community instead of going out there and facilitating the community doing it for themselves. It is a big failing. People are not going to work well in a system that has been imposed on them. There are some people who might want that, but the vast majority of people want to participate in this development: "This is what we need in our community, this is why we need it, and this is how much it will cost. Now we have all of these things that we want, we have this much money, so these are the options that are most important to us, this is where we will start and this is how we will build it." Those are the two failings.

Doctors are very powerful and do not want to abandon the fee-for-service system. They are afraid that we will shortchange them. I do not think anybody realizes how many hours doctors put in per week. I have a daughter who is a family physician, so I am probably more aware than anybody. If and when we put physicians on salary, it will be a very good salary, as it ought to be.

We ought to be recognizing nurses in a similar way. We have to get rid of the hierarchy; doctors are not better than nurses, nurses are not better than LPNs or RPNs, and RPNs are not better than aides. This is not a hierarchy; this is a team. Each profession has some things that only it can do, each has areas of overlap, and we need to work in a team that takes advantage of all of those resources in the best way possible and achieve the efficiencies that come with that. What we have now is everybody working in silos, and with diseases in silos, instead of looking at health as a big picture.

Now, have I come anywhere near answering your question?

Senator Keon: You have done pretty well. I will move over to Mr. Layne - I may come back to you - because I want to consider the other piece of the puzzle.

I will take you directly to the issues that you raised about information and communication systems, and I will pontificate a little to lead you on.

In my other life, I am currently working with Science and Industry towards the design of a health card, just like a bank card, that all Canadians will carry. It will be their health record, and they will own it, control it, release what they want to release, and withhold what they want to keep private. I do not think we will ever have a successful information and communication system until we get there. I think our dismal failure in information and communication systems, as Ms Blau has just said, is that we have been trying to tell people what they need, rather than treating them as free citizens who want to control their own information, privacy, destiny and so forth.

That is technologically possible. Also technologically possible, and really quite cheap, is a communications systems for both image and voice that would allow an organization like the VON to communicate with all of the patients on its list on an ongoing basis.

Also approaching very rapidly are little sensors, chips and monitors that will give you most of the vital information about biochemistry, hemo-dynamics and so forth on a patient.

The technology has unfolded; we have not been able to put it together. We are trying to be too grandiose. I have spent a few years of my life on one of the federal committees talking about "the big picture," which has not happened. It is sitting on a shelf, and it will not happen because it is too big.

However, an organization like the VON could easily, if you could convince somebody to give you the funding and found the right consultants, have a system in place that would be a health record, and an information and communication system, for all your patients.

Let me take you further. If you had that in place, your nurses would not have to visit every patient every day, but you would have to establish another category of health professional who might have to visit your patients every day. It might be a homemaker or it might be a physiotherapist; I do not know who it might be, but you could coordinate that from a central station.

I want to hear all three of you comment on this. Then I want to go back to Ms Blau, if the chairman will let me.

The Chairman: I know we are over time, but we will continue because this is so fascinating. I want time to ask a question, too.

Mr. Layne: I think you raise some very good points, Senator Keon. The technology exists. Pieces of it are available throughout the economy, and certainly it is a question of integrating it and doing something useful with it.

Our organization would be very much interested in participat ing in projects such as you indicated, where we would be able to collect the information on a client, have an internal health care record and communicate with our staff. Certainly, we have looked at that on a very specific basis in many cases. One of the issues, and I think the hurdles, that we would have to face is that that process would have to be legitimate within the larger context. Time and time again, we institute a system, somebody else institutes another one, somebody else institutes another one, the three are not the same and you start all over again.

The other part of the argument is, if you take a really high-level look at the system, sometimes it is just too high, you are way up in the air and do not see the details, and nothing really comes out of that.

I would like to suggest an integration of both levels. What I mean by that is to take the high-level direction that a commission like this, that government at the national level, can take, and set some very high-level, broad parameters. You do not solve all the problems, but just set the parameters and identify expectations at different levels. Then you pass that down to organizations, for example, such as the VON, and we would participate in that process. We would know that what we were doing was consistent with the big picture, and if and when the details are all worked out, that there is a legitimate process for passing it along.

Where these things die, quite often, there is not that process of recognition. When you come back to the table and say, "You know what, folks, we have a system that works," somebody says, "Well mine is better." That kind of issue comes up.

I think leadership by the national government would be very helpful in identifying the broad, general parameters that have to be met by any pilot projects, and then farming them out to organizations such as ours, and many others across the country.

Senator Keon: Ms Blau, I am convinced that the servers can be designed to technologically integrate the information now. If such a system were to be designed, and you were king of the world in Saskatchewan, designing the primary care piece, what personnel would you put into that system?

Ms Blau: That is a good question. For sure I would put in nurses, but you would know that, because I am biased. However, I also know that nurses are the circulatory system. They are the nervous system of any health care system. They are currently sufficiently educated in wellness that they do a good job of that, as well as of care of the sick.

Nurses are central to it, and I believe they are probably the best level at which to assess the client's needs and determine whether that is for a social worker, a physiotherapist or a counsellor. There are all of the people that we normally think of, and then there are financial advisers, there is the rural or the urban municipality that deals with the environment and with the health hazards. All of us are aware of water quality now, where we never had to be aware of it that much before. I grew up on a farm where we tested our water every year, so water safety is something I grew up with, but then did not have to think about for many years.

The central people on the team would be nurses, or in a small place, one nurse, with access to a physician for medical care and to other health care providers for other health care needs. They would also need the ability to make referrals to financial people, and to deal with the rural or the urban municipality on environmental issues. It would be much broader than what we currently think of as care of the sick.

I think nurses are central to the piece, and depending on the situation, they need access to others.

Senator Keon: I realize that was rather unfair, but I think it is a fascinating area and one which we all have to address.

The Chairman: When my wife was trained as a nurse and, I suspect, when Senator Pépin was trained as a nurse, it was in hospitals, as opposed to going to university. I suspect, by the way, that that was also true in your case. Over several years, a number of the provincial nursing associations have moved to the position that in order to quality as an RN, you must have a university degree.

My question really follows on from Senator Keon's question about training people to the level that they really need. You yourself said you have CNAs, and then you have another level, then you have RNs, then you have nurse practitioners and so on. Frankly, by the way, the number of university positions that have been cut over 10 years is 60,000, which is roughly the number of nurses that the country is currently short - just as an interesting observation. Provincial governments brought the problem on themselves. By the way, they also cut down on the number of enrolments at medical schools, so you were not alone.

My question is, how do people like us, who are trying to make recommendations on the human resource side, make them in a way that does not cause people to be overly qualified? Do all nurses need to have a university degree? For instance, there is a current experiment run by the Edmonton Regional Health Authority - which we will hear about tomorrow - in which they are undertaking to train, I believe it is 1,000 nurses or1,200 nurses in an 18-month intensive program entirely in a hospital. Thus returning to where we were 30 or 40 years ago. Believe me, as an ex-academic, I am not the slightest bit opposed to education, but I think we need to ask ourselves how much education do people generally need in order to do specific jobs, and as you said yourself, there can be gradations within those jobs.

How do we get a handle on that question?

Ms Blau: You cannot reduce nursing to a series of tasks, and that is why it needs a broad university education.

About 90 per cent of our current patients were educated in a university. There are very few people these days who do not have at least an undergraduate degree. If we went back to that, they would be cared for by somebody who has been educated in a task-oriented fashion, and who may not have the broad problem-solving and knowledge-of-life skills that a university education develops.

Our association looked very carefully at what the current needs are. Going back to the future, hospitals have changed, medicine has changed, medications are more complex, and people need that integrated assessment of their psychosocial as well as their physical needs. If you reduce nursing to just performing tasks, then you take away the ability to decide that the task you are doing is the one that should be done. Nursing is much bigger than that. Nursing is looking at the patient, the family, and the situation and saying, "These are the factors that I need to take into consideration, and on that basis I will talk to the patient about taking this particular course of action."

We have had experience in Saskatchewan with nurses who took a two-year, technically oriented program, and having worked beside both them and the nurses who are educated at the baccalaureate level, I would not ever want us to go back to that. They are good on tasks, but they do not put the big picture together nearly as quickly. They will develop that ability, but it will take them five years, whereas a university-educated nurse may be a little short on tasks, but she has the broad thinking skills and the broad problem-solving skills.

The Chairman: That says to me you see a nurse in what Senator Keon called the "leadership role," with the CNAs, or whoever, doing what you would call the "tasks." That is the model you see?

Ms Blau: Not necessarily, because while the nurse is doing the task, she is also doing the assessment and the big-picture thinking. It is not a question of the nurse sitting at the desk and directing the foot soldiers. It is a question of the nurse being out there in the hands-on work.

We learn far more from our hands than we do from our eyes. Our hands, our eyes, our noses, our innards, we trust them all, because they give us the whole picture of the patient and the situation.

Nurses must get better at delegating tasks that can be delegated, and doing that appropriately, but I do not see nurses only in leadership roles and directing the care. I see nurses as being involved too, so it needs to be both.

Senator Pépin: You mentioned life skills, and maybe I misunderstood because of the language, but for me, life skills do not come from being solitaire, you have to be working with people. Is there a minimum age for becoming a nurse now?

Ms Blau: I do not believe that there is a minimum age to enter an education program, no.

Senator Pépin: We had to be 18 to begin training.

Ms Blau: Right, but we also could not be married, and if we got married while we were being trained, we got kicked out. There are a lot of things I do not want to go back to.

The Chairman: By the way, now that you mention it, my wife lost two classmates who got married while they were in the course.

Senator Pépin: So as long as they have finished their college education?

Ms Blau: They have to have completed grade 12 in Saskatchewan, yes.

The Chairman: Mr. Layne, you commented on the desirability of a home care program, and there is no question that that is an option we put into our report. We also discussed the possibility of a national pharmacare program. However, we sort of narrowed that option down to what I would call a "bite-sized piece." That was essentially dealing with the fact that there are a number of people, even people with drug plans, by the way, for whom the cost of drugs gets to the point where it is truly prohibitive. We called it "catastrophic" in the report. We had a bite-sized piece there that said maybe you begin there, with a national program for the catastrophic level. For one thing, we do not want to take over from all the employer-sponsored programs. They are doing very well.

We did not have enough information to be quite as specific on the home care side. You may not have the answer today, but if you could talk to your colleagues across the country and give us some help on this, it would be useful.

If one were to say one wanted to deal with the "catastrophic" end of home care - and Senator Keon is fond of pointing out that that applies very much to end-of-life care in many cases - what is the bite-sized piece that we could begin with that might start us down the road to some eventual national program? At least it would deal with those awful situations in which people are becoming destitute and bankrupt and so on as a result of having to pay out-of-hospital costs, particularly toward the end of their lives.

I would love to hear your comments now, but perhaps you might take it back to your national organization and say we really need help with what the first, most important step would be if we were to look at trying to ease the home-care burdens for Canadians. As I say, particularly those toward the end of their lives.

Mr. Layne: Clearly, we support the concept of developing bite-sized pieces. We talked about it earlier in response to your comment, Senator Keon, that if the pieces are too large, it just does not happen.

We have certainly talked about home care as an organization, because we see a lot of need for that. There is a need for a national palliative care program. There are individuals out there who, in the last decades of life, and in the last few weeks or sometimes months or days, are having a very difficult time. It is a most difficult time for them, their families and their connections within their networks. In many cases, the programs out there are not the best. It is piecemeal. It used to happen exclusively in institutions. Thank God we are moving away from that, although very slowly. People do not live their lives in institutions, they live their lives in their homes, and many people we see express the desire to be at home in the last few days or hours of their lives.

I think if we could leave one suggestion at this table - and certainly, we will discuss it further - it is that we feel there is a need for a national palliative care program. Clearly, we would be prepared to pilot that in partnership with the Canadian Home Care Association, the Canadian Palliative Care Association, and other organizations out there that are connected with that client group. I think that that would be a very positive first step.

Our organization has reviewed it and feels that that is a very doable project. I think it would have a significant impact on evolving perceptions of health care. A lot of the population has heard a lot of debate on it over the years, but now they are waiting to see what will develop that will really have an effect. We believe that a national palliative care program would do exactly that.

Senator Pépin: I do not know if you are aware of it, but there is a new secretariat on palliative care in Ottawa. It published a report. Could I send you a copy so you can tell us what you think about it?

Mr. Layne: Please do.

Senator Pépin: We have a new secretariat, and every year, we will be updating all our recommendations. I will send you a copy of the report, because it is very important.

Senator Morin: I think it is important for the people in Ottawa to look at this, but I also strongly urge your organization to look at it. If you are to recommend a national program on palliative care, which I strongly support, you should consider the financial aspects. The problem is there are so many recommendations for programs, and we have no idea how much they cost. I strongly urge you to go ahead, but also to consider the financial component: what you would save, or what extra resources would be necessary. I think this is very important and that your organization is the ideal one to do that. You are the ideal organization to look at the Aboriginal health problem.

The Chairman: One of the points that I was getting at was that there is a difference, in my view, between a national program and a universal program. A national program would mean it is available everywhere; a universal program would mean it is available to all Canadians. The reason I talked about a bite-sized program is that I do not think you begin with a program that suddenly applies to all Canadians; it applies to all Canadians who really need the help.

Where you would be of real help to us is in giving us some insight into how we define who really needs the help, and who can largely finance it on their own. It is not just an on-off switch. Some people might get the entire program for nothing and some people might pay the entire costs themselves, and then there might be some kind of a sliding scale for those in between. You would have a much better, on-the-ground feel for how one could define those "layers," if you want, than we would from just sitting looking at macro income data, which is basically all we have. Any help your organization could give us would be really appreciated.

May I say thank you to the witnesses. I know we went way beyond the allotted time.

Do you want to make one last comment? You looked like you were about to.

Mr. Layne: We never answered Senator Morin's question about unions.

Senator Morin: I thought you did not want to touch that.

Ms Brenda Smith, National Board Member, Saskatchewan Representative, Victorian Order of Nurses: I wanted to comment on that because I am the provincial representative on the board for VON, but I am a also a nurse and I work in geriatrics.

We had a problem with volunteers, and I think it is important to consult with the unions and get the feedback before you begin - and maybe you did that. We have a big volunteer organization in our building, and it is more a question of deciding what jobs they can do, with the staff being so stretched now that they do not have enough time to do everything. I think if you do that - and I think it has to be ongoing - then they are not quite as opposed to the volunteers; they accept them. It does not work if you just decide all of a sudden that they are going to do these jobs - that is what we found. I think with the nurses and everyone else being so short of time, there are jobs that the volunteers can do, working with the families especially, and the kinds of things that the nurses are not able to do right now. That might be the key to it, really.

The Chairman: May I thank all of you for coming. As you can tell, we really appreciated your testimony.

Our next witness is Ms Kathleen Storrie, Vice-President, Community Health Services (Saskatoon) Association. With her is Ms Ingrid Larson, Director, Member Relations Director.

We also have with us Dr. John Bury, who is appearing as an individual. He is a retired physician here in Saskatchewan and, ad I understand it, he was instrumental in getting a number of community clinics and other facilities started. He has been involved in the health care reform movement in Saskatchewan for a long time.

I would welcome all of you. Ms Storrie, we will begin with you and then turn to Dr. Bury. As you know, we are not short of questions.

Ms Kathleen Storrie, Vice-President, Community Health Services (Saskatoon) Association: Thank you very much for this opportunity to present to this Senate committee.

I would just add that Dr. Bury was a physician at the community clinic that I am representing for 22 years. He was head of the medical group for seven years. If it is agreeable to senators, if Ingrid and I feel that we are not entirely competent to answer a question, perhaps we could co-opt Dr. Bury as another of witnesses, even though he will be making his presentation as an individual when his turn comes.

Unfortunately, our administrator, Mr. Patrick LaPointe, could not be here this morning. He is in Regina meeting with the provincial cabinet. Mr. LaPointe is also Chairman of the Canadian Alliance of Community Health Centre Organizations, so I am sure he would have been of great assistance to the committee. However, that is the way it works.

From our brief you will see that we deal with four major areas. To save time, I will summarize those points. I hope you can follow as I go along. As I make my remarks, I will try to clarify where I am in the brief.

As an association, we support a comprehensive, publicly- funded health care system that is accessible to all Canadians, and we have real concerns about a two-tiered system. We oppose a two-tiered system, and I have cited some of the reasons for that. Essentially, we see for-profit systems as being inherently more expensive. There are other negative effects of a two-tiered system, which I am sure you are aware of, such the administrative costs being higher, the problems with waiting lists, and so on.

We are not sure about the suggestion to give the public sector equal time in the case of a two-tiered system. We believe there are other ways to consider, if you are concerned about the use of resources, and we think integrated multi-disciplinary primary care is one way that that can happen.

We make a point, which is often overlooked, about the cost to the public purse of the subsidy to private insurance plans. I am referring to the third dot under 1.a. of my brief. When employers pay for health insurance on behalf of the employees, the expense is tax deductible and it is not taxable to employees. In fact, we are forgoing tax revenue amounting to about $3 billion to $4 billion annually. I am simply pointing out that we have a major public subsidy to private insurance which is not always taken into account.

I have the impression - and this is my personal opinion - that this Senate committee is quite pessimistic about what can be done to make the publicly-funded system more efficient. My question is: Is my impression of this pessimism well-founded? It seems you may be relying on the profit motive to make the system more effective and to reduce the overuse of resources. Yet, if that were the result, one would wonder why the American system is so much more expensive than ours.

We believe there are some answers to the systemic problems we face. For example, at the bottom of that page 1, I deal with long waiting lists. Although I did not read all of them, I saw no reference in your reports to the fact that long waiting lists may not be due to lack of resources but, rather, they may be the result of systemic problems.

On page 2 we move to refocusing. We would commend your recognition of the fact that we must refocus our system to a more holistic model, supporting the health of all Canadians.

We then move to primary care. We were delighted to hear the nurses, who spoke earlier, dealing with this subject. Possibly much of what we have here is redundant, but we still want to make our points. We are pleased that the federal government is devoting $800 million to primary care reform. We note that your committee does, indeed, very much support primary health care with delivery by multi-disciplinary teams of professionals.

Our Saskatoon clinic has been involved in this kind of work for almost 40 years here in the province. The clinic opened its door in July 1962. We serve about 25,000 patients. We also have a clinic on the east side and on the west side, which is an area with a largely Aboriginal population.

Our brief then lists the characteristics of the Saskatoon Community Clinic. We stress community development, and we involve our patients and our members in decision making. As you run your eyes down this list, you will see that we are non-profit, community based, we form strong partnerships with our users and providers, and we have a multi-disciplinary approach to care. All members of our staff are salaried employees. We respond to needs 24 hours a day, seven days a week, and we are very much involved in partnerships with other health organizations. We work with other organizations in other sectors.

We strongly recommend this model, as described in our brief.

We noted the mention of the community clinic model in your report, but we did not see it in the context of cost saving. This is a point that we want to make. In fact, in the early 1980s Saskatchewan Health did research the cost to the public purse of 200 fee-for-service urban doctors compared to the cost of community clinics. The report was put together in 1983. For political reasons, it was not made available to the public for several years.

This research found that the clinics, on average, cost17 per cent less than private physicians, in terms of lower prescription costs, the lower use of services, and lower levels of hospitalization of patients.

Saskatchewan Health continues to monitor the differential costs: the costs of community clinics on the one hand, and the costs of private practice on the other. The clinics are still more effective, even though we have many professionals on staff and we have a global budget. The differentials are not as great because, generally, hospitalization costs have gone down, so that makes a difference to the cost of the private practice doctors. The numbers of people sent to hospitals has gone down and, I think I am correct in saying, the length of stays in hospital have been shortened.

We also believe, for many reasons, the multi-disciplinary approach is much more sustainable. One reason is that our salaried professionals spend much more time with patients and, therefore, they can deal with their social and emotional needs. For example, they can refer patients to social workers if there are social needs; and to a nutritionist, if there is a nutritional issue. The nurses discussed this with you earlier.

We are also very conscious of accountability. We emphasize outcome indicators, patient-care protocols and external evalu ations.

In November, 1997 the Saskatoon clinic was the first community clinic in Canada to be accredited by the Canadian Council on Health Services. We are very proud of that. The accreditation was renewed just this year for another three-year period.

Again, we strongly recommend that the federal government support this model.

We agree with an expansion of publicly funded health care services, particularly home care, palliative care, and the cost of prescription drugs.

We were unable to get your chapter 8, so we cannot comment in detail about the options that you suggest therein, but from reading the interim report we concluded that we certainly would support a national pharmacare initiative and a national home care program.

Our staff continuously deal with real problems in this area. For example, with respect to prescription drugs, we know that people end up in hospital simply because they cannot afford certain drugs. Palliative care is also a major issue - and it is particularly a major issue for me - and I was glad to hear the nurses address that issue earlier.

Turning to page 4, I will now deal with population health. Our association is a strong advocate in the community on many health and social issues. We see our clinic as a model or a way in which the social determinants of health are, in fact, addressed. Particularly on the west side, we have many programs that attempt to deal with issues our clients face. As you see from our brief, we have groups who do all sorts of work. We have an advocacy group which deals with renter' rights. We have community kitchens and all kinds of support programs, especially for diabetic patients. We also have parenting and parent support classes, as well as prenatal groups.

Our Aboriginal people have been able to develop leadership. For example, we have an Elders group. The grandmothers play a major part in that.

We consider the west side to be a really good model of a primary care facility that provides a tremendous amount of support to the Aboriginal people and people in general in that area. It works well in trying to help with the leadership of the people themselves.

Our other recommendations, essentially, support your remarks on health protection, health promotion and wellness as outlined in your report.

We do a great deal of work in the area of health promotion. Our health promotion unit is involved in all kinds of programs, such as anti-smoking programs and others. We will expand on those if you wish.

With regard to the federal government's role as it relates to Aboriginal peoples, we make some fairly straightforward recom mendations about strategies, particularly with respect to coordina tion. We see this cooperative, multi-disciplinary kind of approach being very well suited to Aboriginal values and the way Aboriginal people themselves like to operate.

Finally, on page 5, we recommend that the federal government re-enter the whole area of social housing. Personally, I thought it was a total disaster when the federal government exited that area. Most of the provinces followed that example. We have paid a major, price for the lack of federal and provincial involvement in social housing.

Dr. John Bury, individual presentation: Honourable senators, my presentation will be quite different.

The Chairman: We have always found it easier to hear both presentations and then ask questions of everybody at once.

Dr. Bury: Since the royal commission in 1964, we have held multiple provincial inquiries, we have had this inquiry, there have been amendments to the Canada Health Act, and there is the present Commission on the Future of Health Service in Canada, chaired by Mr. Roy Romanow. It seems to me that what is lacking is that we have never directly challenged the medical profession to seriously consider its own behaviour and the way that it carries out medical care.

We have talked about the evidence of inappropriate, wasteful, ineffectual medicine, and you have suggested that even correcting that would not be sufficient to make up the deficiency in funding and, therefore, as is suggested in your report, you are seeking sources of other funds. That suggests and supports a public view that is being promoted, and that is that the only solution is putting more money into the system. In times of an economic recession when we have external threats to our society, governments have to spend their money on something else. It seems to me this is a particularly appropriate time for everybody in the health system to look at what they do and what effect that has on the cost of medical care.

Although I am a strong supporter of what you call "the spectrum of services," as are exemplified in the primary health care proposals of the Fyke commission, and as you talk about in your report, you must face the fact that a very large part, if not the majority of the costs of health care, are generated by what doctors do. They are the engine that drives the machine.

The modern expansion of technology adds to that. Technology brought with it the desire to use it when it appeared that it would have a beneficial effect, but after a time we have found that technology did not always solve the problems. In the meantime, we have expended great amounts of money on technology.

I will give you a very simple example. When we introduced fetal monitoring into obstetrics, there was a huge increase in Caesarean sections. It went up as high as 20 to 30 per cent in some institutions. We did not really understand the technology. Now we have realized that we can appropriately use that technology better and Caesarean section rates have come down to closer to what they were before that new technology came in. It was thought to be an improvement but, in fact, it was detrimental to many women who had Caesarean sections they did not really need. That is a very simple example. Technology is a demanding mistress.

I believe it is now time for the serious consideration of this issue by the medical profession itself. I feel as if the captain of the ship, which commands this great ship of medical care, has been relegated to a small dinghy being towed, and looking resentfully at the stern of the good ship "Government Commission." I believe that has gone on and that we never got the profession to come on side. Now is the time to do that, because I believe there is enough goodwill and understanding in the profession, and a lot of work has already been done, to have an opportunity for physicians to ask: "Is what we do always appropriate? Can we do better? Are there some things we are not doing which we should be doing, and are there some things which we should be doing which we have stopped doing?" If the doctors are not part of the solution they will remain part of the problem.

That is all I have to say. If you would include that in your report and, then perhaps some other body, perhaps the Commis sion on the Future of Health Care in Canada could take it up.

Senator Morin: The work you have been doing is extremely interesting. The recognition of the work of your clinic has done travelled as far as Quebec City. I would parallel your work with what is being done by the CLSCs in Quebec. That is why we know so much about your work.

Your report is most interesting. It is clear; you make no compromise; and that is perfect.

My first question is: Is there a country which, in your mind, could serve, in part, as a model for Canada? You recommend a number of changes. I realize that no models can be totally similar, since there are differences, historical, cultural and so forth, but is there a country that you would think could serve as a model for Canada as we consider these changes?

My second question relates to recommending a universal, totally government-supported system. Some people might object to this and see dangers in it because it would be a monopoly. There are some disadvantages in having a monopoly. In Sweden, Britain, France and many other countries, there is a move to what they call an internal market in which they have competition between the various providers, with a single government payer. The advantage of that is that there is competition between various providers, which could be either all government providers or a mix of private and government. Would you have any objection to that?

On the subject of waiting lists, I am not in any way promoting the American system, but have you made a study of the waiting lists in the U.S.? I know the American public would not tolerate a 24-hour wait in any system. It is not strictly a matter of organization, I believe it is also a matter of resources. That is my point.

Are your clinics set up with a capitation system? Are you responsible for a given community with a gate-keeping system? I believe the basis of a primary care team and program has to deal with capitation, a given community or number, and responsibility for the total service. Are you functioning in that way? From what I hear that is not the case.

Of course, you are aware of the HMO backlash in the U.S. where all the physicians were salaried. There is evidence of under-usage. The Bill of Rights, which is now before Congress and has been approved, addresses the under-usage of services in HMOs, where the physicians are salaried, and where they, for various reasons, did not propose the list of services that were to be available to patients. There is a distinct problem there.

Finally, I would like to address the Aboriginal health problem. I am very much aware of the fact that this is a national disgrace, and I know this province deals with the problem more than any other. One of your recommendations is that we should ensure Aboriginal health. The federal government is spending$7.3 billion a year on Aboriginal health, plus what the provinces are paying. That means that Aboriginals are receiving by far the highest per capita health funding in Canada, and probably in the world. I do not think the problem lies in inadequate resources; in fact, there may be too many resources. I will not get into that. Have you any solutions to this problem?

As a last quick question: In 1983 the differential was17 per cent between fee-for-service physicians and salaried physicians. What is the difference now? You said that the differential was going down.

Ms Storrie: As to your first question, I must point out that I am not a health specialist, I am a volunteer on a community board; I am a sociologist; and I have studied the health system when I was teaching, and I continue to study it. I think the senators here probably know more about the international situation than I do.

I do not know of any country that I would say is a model. I understand that New Zealand had a very efficient, well-run health system, which was publicly funded. Then they made a severe, 180-degree turn and went into a highly privatized model and there were all kinds of consequences, not only in terms of health but also in terms of the other social aspects of their society.

Frankly, I think that Canada has been doing extremely well, compared to most other nations, in addressing our problems. I think our problems are largely systemic, and that they relate to the kinds of issues Dr. Bury has addressed.

On the issue of monopoly versus competition, it is my understanding that there have been some pretty severe negative consequences of competition between hospitals. For example, in Britain hospitals are spending huge amounts of money on the latest technology because the hospital down the road has done that. Hospitals, and I suppose other health units as well, end up being generators of funds rather than the users of funds. That is a private enterprise model that simply does not fit health which, in my view, should be publicly funded. It should not be treated as a commodity.

On the subject of waiting lists, I do know something about some of the work that has been done in the United States. I am sure some of that information will be available to you. They made a major effort to change the whole way in which waiting lists were managed. They introduced a lot more coordination and cooperation, and the waiting lists improved immensely. That was particularly so as it related to those programs in the United States that are non-profit.

I am afraid I cannot comment on that question of salaried physicians under-using the system. I am sure Dr. Bury could speak to this. I would have thought that, if that is the case, then it is very much a matter of peer pressure, peer education, protocols and so on being put into place.

The great thing about a salary, as far as I am concerned as the vice-president of this clinic, is that it would simply take the pressure off doctors to generate all kinds of tests and services, and to have patients return for follow-up visits. Our doctors do not do that. If a problem is indicated as a result of a test, the doctor will phone the patient. If there is no problem then they do not phone. That, as far as most of the patients are concerned, is acceptable. Perhaps Ingrid will want to comment on this. Is that acceptable?

Ms Ingrid Larson, Member Relations Director, Community Health Services (Saskatoon) Association: Yes.

Ms Storrie: That is the clear understanding. Of course, it does mean that when you get a phone call from your doctor, then that is something to be concerned about. On the other hand, it is an enormous saving of time and effort.

I am aware of the huge expenditure for Aboriginal people. It simple speaks to me, though, of the fundamental problems which, of course, you know all about. It is a matter of social determinants. The levels of poverty, of community disorganiz ation, addictions and so forth, are at the root of the difficulties of Aboriginal people.

I do think the notion of a collectivity, of a cooperative on the reserves and in the urban areas where Aboriginal people predominate, would be one way of helping Aboriginal people. You can, then, involve them in the decision making, and in education programs and so forth.

Perhaps Ingrid would like to say more about that.

Senator Morin: You did not answer the capitation question.

Ms Storrie: Sorry, I missed that. Our doctors are on salary and we are not funded on a geographic basis. We simply treat whoever wants to come to our clinic. Therefore, our patients are spread all over the city.

Do you want to say something more about the west side clinic at all?

Ms Larson: In terms of our experience at the west side clinic where we primarily see an urban Aboriginal clientele, the issues we deal with are social determinants of health issues. There, our nurses do community outreach and community development work. They are very well aware that the issues facing that community are far more than physical health issues. We then work on issues related to housing, nutrition, and all the related issues that have a substantial impact on people's well-being. It is not just about health when it comes to serving that population group. It involves some very complex issues, all of which have to be addressed.

Ms Storrie: I agree with the nurses that they are absolutely essential, in fact, critical. They can do so much very good work in this multi-disciplinary kind of way.

As an ex-social worker I perhaps a bias in that I think social workers are a fairly unsung group in the medical area. I trained as a medical social worker at the University of London before I became a sociologist. Social workers do an enormous amount of invisible, preventive, constructive work. As a medical social worker I know I made an enormous difference. I was able to put patients in touch with all the community resources that would help them to develop a real plan to deal with their issues. That applies particularly in the area of palliative care. Very often the social worker is the person holding the situation together.

Dr. Bury: May I say something about HMOs?

The Chairman: Yes.

Dr. Bury: Some physicians from America have talked to us about problems with HMOs. If an HMO is dependant on an insurance company, and that insurance company to make a profit for its shareholders, there is an inherent pressure to reduce services. That seems to be one of the most determinant reasons that that has occurred.

Senator Morin: If I might interrupt. Let us talk about the largest one, Kaiser Permanente, for example, which is not for profit. The profit element does not enter into it.

Dr. Bury: Are you asking: Has that affected them?

Senator Morin: Yes. Whether there is the under-use of service is a subjective decision. I think there may be an anti-HMO backlash. An American witness told us that the HMO system is going down, that it is now not the preferential provider system. The reason the HMO system, both for-profit and not-for-profit, is being discarded in the U.S. is that there is a sense, by the patients, of under-use of services under that system. That is the main reason for all this legislation and regulation. I realize that American patients are not Canadian patients. I realise it is a different population. This is the main reason why you have all this legislation and regulation. I am just raising this as a possibility.

Of course there is a problem with over-use on the basis of fee-for-service, but you must realize that there is the possibility of under-use under a salaried system. I am not saying it is the case in your clinic, I am merely raising this as an alternative.

Dr. Bury: I had a small private practice in England. Those patients got treated much less well than my ordinary patients because I felt guilty about charging another guinea if I made another house call. I have worked on capitation; and I have worked on a salary. There is no perfect system. We do not put capitation fees on doctors, nurses and many professionals. We do not pay fireman for the number of fires they put out. Of course, there are always lazy people in any system. I do not believe that doctors are any different from the rest of society. I think they will do an honest job for an honest day's pay, if they are given the opportunity.

However, inherent in the fee-for-item-of-service system, to make your money you have to do something. That has certainly led to certain abuses. There is nothing perfect about it.

Senator Morin: I fully agree with that, Dr. Bury.

Senator Keon: Ms Storrie, I noticed in your brief when you address population health you emphasize three key areas: health protection, prevention and wellness. Since the Lalonde report came out, I have held the view that the secret to the provision of optimal health for Canadians, as well as optimal health care, lies in continuous monitoring of population health with appropriate feedback and mechanisms to deal with the problems in the area of population health.

There is, however, a fourth undertaking in population health, and that is the elimination of disease entities that are interfering with population health, that can be targeted and dealt with on an effective basis. We have a history in Canada, for example, of doing that with tuberculosis. I admit we got lucky and found a couple of good antibiotics along the way, but the way we built the sanitaria and so forth was also very effective. I think the way we have dealt with AIDS has been very effective also.

Would you comment on that? I think there is a missing link. Whatever entity looks at it, whether it be regional, provincial, national or, indeed, a community health unit, they must look at the areas that are interfering with the health of the population and correct those. I fully endorse the three things you suggest, but the fourth one is missing.

There is another missing link, and that is home care. I think that the main failing in our system, is the gaps in our system. It does not matter whether care it is organized regionally or provincially. While your community clinic is truly commendable and has done wonderful work, I believe the missing link is that home care is not integrated into your clinic.

Would you comment on that?

Dr. Bury, I am looking forward to an interesting discussion with you a bit later.

Ms Storrie: In terms of the focus on specific diseases, I would have categorized that as coming under health protection because the first thing to do is to seek to prevent people from contracting a disease in the first place. I agree with you. Perhaps there should be a specific focus on that.

I am not an expert in population health. I know there are some very active units at the University of Saskatchewan deal with that, and it would have been interesting to have heard them on this particular point. I am old enough now to remember TB. I was a medical social worker in London, Ontario. When I arrived there I was all peachy-keen, like a new broom, and I was appalled to find there was no social housing in London, Ontario. The assumption was it was not needed; while it really was needed. As a group of social workers, one of the major arguments we made for subsidized housing was the fact that TB was still around. The whole question of social housing and other ways in which we support the health of the people involves a major strategy.

We could draw upon the expertise of volunteer groups such as the Arthritis Society and the Lung Association when addressing how these particular diseases should be handled. Maybe that is area needs more attention.

Moving on to the issue of home care, I would point out that our administrator, Patrick LaPointe, was one of the founding members of home care in the province. As I remember it, a volunteer group, a non-government organization started pointing out the need for home care.

This matter has been in the hands of the provincial government and also, of course, the district health officers. We work with them. However, as far as I know, it is not a service that we could have undertaken. We work on a global budget and we have to negotiate with the Department of Health about what we do and what we do not do.

I agree with you, that the gaps or the lack of integration in home care is a very serious matter. That is an area into which we need to put more resources.

John, do you have any comments about what I have said?

Dr. Bury: Both Regina and Saskatoon had some home care services in the 1960s. It was a mental health home care service in Saskatoon. In Regina it was a general nursing service run by the Victorian Order of Nurses on contract to the provincial government. It was never taken into our field, partly because it had started and from that date forward it was seen, in this province, as being part of the health system that should be dealt with in the future and it now is, in fact, a responsibility. As you know, in this particular health district quite a considerable of money has been transferred and they have saved on bed days to home care. We do have a service here. It is not as good as it should be, but it is here, and it is run by the district health system.

We never felt it was our responsibility to do that, although a lot of doctors used to do home care. Nurses used to visit, and other health workers or technicians would to homes and take samples. That happens right up to this moment. However, we have never actually provided home care services, domestic services, and so on.

Senator Keon: It seems to me that one of the major problems has been confusion between integration and ownership. Integra tion is not ownership. Integration is cooperation. To many people, integration has meant ownership. When we discuss with you the gaps and the fact that you are not addressing home care, the connotation should not be that this is your responsibility. Your responsibility is to work with home care, whoever is providing it, so that, between you, you provide the population health that is necessary to impact on the health of the population you serve.

Ms Storrie: My understanding is exactly that. Our doctors take responsibility for their patients when they need home care. That also applies to social workers and others.

Ms Larson: Other professionals such as occupational therapists will also get involved in what we call the coordinated assessment unit, which is the unit in the Saskatoon district that deals with home care.

All of our health care workers either advocate for home care or help in the placement of people into the home care system.

Senator Keon: Dr. Bury, let us talk about the medical profession. I am very proud of my profession, and have had a wonderful career as a doctor. I just hung that hat up a couple of weeks ago, and I am now an administrator and a senator.

I have felt very badly that our profession has not made the contribution it is capable of making. I have served on virtually every arm of our profession along the way, including the Medical Research Council, the Royal College of Physicians and Surgeons and provincial associations.

I do not know why physicians have been reluctant to come forward and pontificate on the overall problem of the health of our nation, of our province, of our community. Why do you think that is so?

Dr. Bury: I do not really know.

I will give you a bit of English history about family practice which goes back to the 1950s, 1960s and 1970s. At the beginning of the health service there was a feeling that doctors were getting paid too much, yet they were always asking for more money. Then the British Medical Association started talking about the responsibility of providing good care, and became public advocates for good medical care and a good health service. Suddenly, the attitude changed. It can be done. It switched. I am not quite sure why, but Britain certainly hung back until it realized that they did have a responsibility to help design a National Health Service.

Currently, the perception in the community in Canada is that doctors get too much money, and so on and so forth. However, I think the relationship between doctors and patients is still very good in spite of the fact that there is all this awful hawking your patients around to the cheapest hospital to get more money for your own practice so you can buy something else. I find it a rather awful situation.

I do not know, Dr. Keon, why we have not been involved. I have never been part of "the profession" and I tend to be, as a professional, on the outside. We had a rather stormy relationship with "the profession" at the community clinic. One of the reasons for that was that we were the first group practice in Saskatoon. We actually had physicians, specialists and general practitioners, working together. They held that against us. Of course, we were in favour of medicare at the time other doctors were not. We were salaried employees. That idea of a primary health care system was resisted. I have always been looking at this from the outside.

I have been involved with doctors who have carefully tried to examine the system. When I was a doctor at the City Hospital I remember being involved in two studies. One I particularly remember was related to the fact that we had a lot of patients falling out of bed. An internist and myself were on the Quality Care Committee. We did a study which found that the patients who had taken lots of hypnotics fell out of bed, and those who had not taken them did not fall out of bed. After we published our findings it was no surprise that hypnotic prescriptions were limited and people stopped falling out of bed. Doctors can examine what they do and make changes.

I do know that visiting pharmacological professors go around to district medical societies, and we published bulletins of what seems to be the inappropriate use of certain medications. There was a response to that.

However, we have never collectively participated in this type of activity as professionals.

I think when doctors are faced with facts of this nature they will change.

I made this presentation because I thought we should ask the doctors to look at themselves. I think we should challenge them at this time. They are still looking out at what is happening. I know that they feel they are being manipulated by the commissions. They are manipulated by the administrators. We talked about this earlier today. Voltaire's Bastards is a reality in health care as it is everywhere else in society.

Senator Keon: Let me address another issue, although Senator Morin has already mentioned it. It seems we keep dealing with "either/or" when it comes dealing with physician remuneration. My own feeling is that we should be looking at a continuum of systems with alternate payment plans of various kinds that fit given situations and avoid the black-and-white statements sicj as, "Physicians should be salaried," or "Physicians should be fee-for-service," or whatever. What is your view of that?

Dr. Bury: I liked what you said before when you were talking to the nurses. You said that a salary fits the model for primary health centres much better than fee-for-item-of-service payments.

I think for specialist care, the fee-for-item-of-service might well still be appropriate under a much more watchful eye.

I believe, however, that we do need salaried chiefs of staff in our hospitals. When I worked in University Hospital, we had a very good chief of obstetrics who monitored what we did and kept our noses to the grindstone. That was a great experience. We had a very good pediatrician in City Hospital, an old, conven tional pediatrician who watched what physicians did to their patients like a hawk. If he thought you were out of step he would tell you. If you felt you could justify doing something, then you would have an interesting clinical debate. I think those types of positions should be salaried.

Senator Pépin: The nurses told us that doctors are the "big bosses," and that they do not like to be challenged. They certainly do not consider themselves to be on the same footing with the nurses. Will they accept being put on salary and perhaps adopting a new role? Do you think that they will adapt to sharing responsibility, or do you think it will take a new generation of doctors?

Dr. Bury: I do not know anything about the Canadian system of medical education because I was educated in Britain. However, I did learn that the nurses were absolutely critical to my way of life as an intern or resident. If I did not get on with the sister on the ward, I was dead in the water.

Furthermore, when we did rounds with our chiefs, we always had the chief, the resident, the intern, sister, and a social worker. As medical students we were part of a team, and that is what the chiefs preferred. In fact, in the hospital I worked in, the only person who could discharge a patient was the intern. Lord Brain - I happened to be Russell Brain's intern - could not discharge his own patients because he was not there every day. We had a hierarchical system and in that hierarchical system we had a degree of cooperation, each person knowing his or her role.

Senator Pépin: I have to admit, I my training was based on the same approach. We always worked as a team with the doctor and the social worker, so I understand what you are describing.

Ms Storrie, one of your recommendations is to ensure that Aboriginal people have good health services. Senator Morin spoke about the amount of money that the provincial and federal governments are giving to them. Do you believe that we are taking the right approach? How come it is so difficult to have them involved even with all the money we put in? Should we change our approach?

Ms Storrie: I am not an expert in this area, but from observing as much as I have, from reading, and from talking to many Aboriginal women at the university, I have the impression that they hold many of the keys to the situation. Unfortunately, like it or not, some of the Aboriginal chiefs are patriarchal. That is not to condemn all Aboriginal men, that is just to say that some of them are patriarchal. Women have to struggle to get their point of view across. They are certainly very well aware of the needs of their communities and I think that support to Aboriginal women's groups is one way communities can go.

As I said, at the west side clinic they certainly draw on the experience of, and there is some stature for, Aboriginal Elder women. That is where the west side clinic works well. That is one way to go.

Rather than adopting a community development model, I think we should adopt this collective kind of a model where there is integration in that you work with the people, you do not act as the superiors. You involve them in decision making and you listen to what they have to say.

A great deal of education has to be done, of course, with FAS and so on. It is really a scandal. The same thing with spina bifida. Spina bifida, I understand is 80 per cent preventable, but you have to get folic acid into those young women even before they get pregnant. That is the sort of very practical approach that I think the women could take hold of and run with if they were given the opportunity.

Senator Pépin: I agree. I know that when they have difficult situations to deal with they always share their emotions and feelings in healing groups. That is what is needed as a part of health care. We may even adopt the same system.

You mentioned a grandmothers' group. What is that?

Ms Larson: Kathy referred to the Aboriginal grandmothers' group. We also have programs directed to the more middle-class, seniors population in Saskatoon. However, our Aboriginal grandmothers' project is directed to Aboriginal elders.

Senator Morin: Ms Larson, I understand you are working with the Aboriginal population. If you have a few minutes and you could send us in writing a few recommendations, it would help us a lot. As I said earlier, this is a subject that we do not have a handle on. We want to hear from people like you who work in the field with these populations and who have concrete recommenda tions. We have heard from the official organizations and Health Canada and all these people, but we have not heard from people who are, on a daily basis, working with these people in the field.

Ms Larson: I would do it, though, in consultation with the health care workers who are working directly with them. We would be happy to do that.

Senator Morin: As long as they are not bureaucrats.

Ms Larson: No, they are doctors, nurses, nutritionists and social workers.

The Chairman: In other words, real people.

Ms Larson: We also have volunteer groups with whom we could consult.

The Chairman: I intended to ask a similar question, so I will add slightly to that. You said something that intrigued me. You said that at the west side clinic you deal with social housing and a variety of other things. Are you saying that you deal not just with health, but that you also deal with the determinants of health?

Ms Larson: Absolutely.

The Chairman: How, from a federal policy standpoint, recognizing the obligation that the federal government has vis-à-vis Aboriginals, can we deal with Aboriginal housing needs?

Senator Morin has said a couple of times, as we say in the report, that the status of Aboriginal health is so shocking that, if most Canadians knew about it, they would be unbelievably embarrassed. Yet, at the same time, the federal Department of Indian Affairs and Northern Development, DIAND, tells us, with some considerable pride, that they have reached the point where 57 per cent of the housing on reserves is now standard. In other words, only 43 per cent is substandard. There is a reason to be proud, because it is an improvement, I guess. However, is it surprising that we have a health problem when 43 per cent of the housing is substandard?

You are the first person we have talked to who appears to be attempting to integrate those. Can you offer any practical, on-the-ground suggestions as to how we might do that? Forget about the fact that it would probably require some reorganization in Ottawa. We can tackle that problem. We need to know what the structure needs to look like to be able to do exactly what you do.

Perhaps you could think about that for the next month or so and send us as detailed a set of recommendations as you can. We would appreciate that.

Ms Larson: We would be very happy to do that.

The Chairman: May I thank all of you for coming. That was a very interesting discussion.

Senators, we have one last witness before lunch, Mr. Stephen Foley, President of the Health Care Council, Canadian Union of Public Employees, CUPE, in Saskatchewan.

As you are leaving, I just want to say that you are the first witnesses we have had who are genuinely looking at the broad issue as opposed to the health issue, the housing issue, or something else.

Ms. Larson: It is all integrated into our organization.

The Chairman: That is exactly why it is awesome.

Mr. Foley, we have your brief, as you know. We would like to focus most of our time on questions, so if you can touch on the highlights of your brief, we will turn to questions.

Mr. Stephen Foley, President, Health Care Council,Canadian Union of Public Employees (CUPE) Saskatchewan: First, I would like to thank you for this opportunity to appear before you this morning. I will quickly introduce the people with me. The CUPE Health Care Council in Saskatchewan represents approximately 14,000 health care workers. With me is a national representative of CUPE, Mr. John Welden; and Mr. Tom Graham, President of the CUPE Saskatchewan Division which represents about 23,000 CUPE health care workers in the province.

To save time, we will make some short introductory remarks and then open the discussion for questions.

As you are probably aware, the Canadian Union of Public Employees, CUPE, is the largest health care union in Canada, with close to 480,000 members. In Saskatchewan, CUPE represents approximately 23,000 public sector workers. Of those 23,000 public sector workers 14,000 are frontline health care workers.

As frontline health care workers, we have a strong interest in the direction of our health care system. As you are probably aware our province has just recently completed a review of the health care system. That review was done by Kenneth Fyke. Our provincial health care council has spoken in favour of the general recommendations of the Fyke report, primarily because of its emphasis on the development of a primary health care model. We will talk a little bit more about that.

A national review of health care and the role the federal government plays, however, provides us with an ongoing chance or an opening to discuss health care issues on a much broader level. We believe that the federal government must have a strong role in the financing of various aspects of health care and in the protection of the system from increasing privatization.

In general, we support the five roles of the federal government identified by the Senate committee, and we would suggest two additional roles be added to those. One would be the enforcement of the Canada Health Act; and the other would be to act as a protector of public health care from the international trade agreements.

Provincial governments can be innovators, as was the case with Saskatchewan being the birthplace of medicare. Similarly, provincial governments directions can undermine our national health care system, as Alberta has done, in our minds, with the introduction of legislation that encourages private clinics.

The federal government's role as an enforcer of the five principles of the Canada Health Act is critical in light of certain provinces' ideological promotion of privatization.

Furthermore, with the recent acceleration of international trade agreements, it is imperative that the federal government excludes our public health care system and protects it from any possible threats of the trade agreements.

Our submission today will briefly outline our concerns and recommendations for a national health care system.

The recommendations laid out here today to this Senate committee in our submission, do not provide an in-depth response to the detailed report prepared by the Senate Committee on Social Affairs, Science and Technology. Instead, we have grouped our recommendations into four broad areas, with several recommen dations within each area. Our recommendations do respond to the options presented in your report, but they are not in the same order.

Mr. John Welden, Health Care Coordinator, Health Care Council, Canadian Union of Public Employees (CUPE) Saskatchewan: Recommendation number one is that the federal government must strengthen medicare by expanding the scope and number of health services covered by a public health care system. This would include, but not limit it to, the development of a national home care program; the creation of a national pharmacare program; and an increase in the public delivery of long-term care.

Recommendation number two is to reduce the level of privatization in health care and ensure that any future privatiz ation is rejected. We firmly believe that the cost-effectiveness of the public care system is far better than the cost-effectiveness of a private system, as well as a public-private system mix.

Recommendation number three is that the federal government exclude health care from all trade agreements.

Recommendation number four is that the federal government fund and support primary health care reform initiatives. This would include the elimination of the fee-for-service remuneration for physicians and place physicians on salary. However, other alternatives can be considered at well. As well, that the federal government support the creation of multi-disciplinary teams of health care providers, improve working conditions for health care providers, and enhance the role of health care providers in the health care system. The final paragraph of that recommendation is that the federal government implement economic and social policies that improve the health status of Canadians in general.

Mr. Tom Graham, President, Canadian Union of Public Employees (CUPE) Saskatchewan: Health care in Canada is one of our most cherished social programs, if not the most cherished. I believe it sets us apart from most of the rest of the world.

The five principles of the Canada Health Act embody the foundation of the public health care system. We see many threats out there to our public system, and we would urge this committee to categorically reject privatization options as we believe they will further endanger our public medicare system.

The interim report suggests privatization options, such as the contracting out of health services to private, for-profit facilities; setting up some medical savings accounts; user fees; health care premiums; tax credits; and private-public partnership initiatives with prescription drugs. We reject all of these. We believe that any solution that further drives down the cost to the individual and the community, as opposed to us as a whole, is the wrong way to go.

We would also stress our concerns over health care and the trade agreements we are facing in the world today, and we would urge this committee to include any of the implications of trade agreements into the final report.

The Chairman: May I just say to the three of you, thank you for raising the trade agreement question. It is one that, frankly, as you pointed out, we did not focus on, and it is one that, certainly in my understanding of it, is fuzzy as to exactly its implications. Bringing that to our attention is helpful to us.

Senator Morin: This is the first time this subject has been raised. Perhaps you could share with us any further information you have on this. It is an important issue.

What is interesting about your very detailed report is that there is no doubt about where you stand. There is no doubt that you support a one-payer, one-provider system, government supported and government controlled.

What is your position concerning dental care insurance? Do you think it should be government supported as it is in other countries? What about optometric care insurance? Should we follow the British example?

What about the matter of non-prescription drugs? As you know, the trend in North America and also in Europe, is that more and more drugs are moving from the category of prescription drugs to the category of non-prescription drugs. As the Canadian public becomes better informed on the costs of drugs, I believe the trend will be towards moving to the non-prescription system.

Finally, what is your position concerning natural health products? For many Canadians that is an essential part of their health care. As you know the costs for Canadians of natural health products has been increasing, much more than prescription drugs. That cost is increasing by more than 20 per cent a year. Since we are a culturally diverse country, a large part of our population considers this to be their primary health care system. I am thinking of Chinese medicine. We must respect that. Should the government be part of that as it is for what we call "western medicine"? That is my first question.

The second question has to do with the fact that, in Europe, there are many social democrat governments. Some of them that have been generally far more on the left than the governments we have had in Canada. I am thinking of the Scandinavian countries and Germany for example. Why has none of those countries that have social programs that are far "more progressive," to use that expression, than those we have in Canada, gone the way you are recommending? I am thinking primarily of Sweden. You are recommending that there be one payer, one provider, and that it be government supported and totally government controlled. There is no talk in those countries, even from those parties that are on the left, of moving in that direction.

Mr. Welden: I will deal with your first question in inverse order first, so that we can talk about the different products that you mentioned.

Should naturopathic products be covered by the Canada Health Act and subsequently covered by the provincial health acts? Our answer is: to a certain extent.

At one time there were no physicians and no dentists. If you needed a tooth pulled you went to the barber and, if he happened to have a pair of pliers and a chair, he pulled your tooth. If you needed some help with a disease you went to the local witch doctor or whomever for help. Over time, we developed a refined form of health care.

We have also found, as technology has increased and understanding of disease and wellness has increased, that we do not have all the answers. Notwithstanding that, some people do claim to have an answer. It creates a conflict between the paradigms. Medical professionals may take the view: "I should know all the answers because of all this technology, but I do not; and this person has the answer but I do not want to recognize it."

There has to be a melding of the two thought patterns into a single health care process. That would mean that certain parts of the naturopathic discipline should be brought under the health care system and should be governed by the rules and regulations. I also believe that the focus should be on health care and wellness rather than on who is right and who is wrong.

That is a big job because some people, quite frankly, a great many people, are very entrenched in their own areas. If we are to step over the bounds of dealing with health care in its general scope and disease in its broadest scope, if we do not work towards the melding of those two systems, then people will abandon one or the other and suffer as a consequence.

I believe certain areas should be covered, including, quite frankly, the products. I think there are many products out there that may claim to cure a whole spectrum of illnesses while at the same time the patient suffers. For example, in Saskatoon there was a child who had bone cancer and, despite all the cries of the medical profession, the parents leaned towards the naturopathic system, to a certain extent. That does not mean that was either a good or a bad choice. The problem is that the two systems were in conflict and, as a result, after several court cases and a whole bunch of other legal procedures, the child expired. Had the two systems been better melded, there may have been a better result.

I will turn to the subject of prescription drugs. This is one of the fastest, highest-growing costs in the health care industry. The across-the-counter corporations are now offering all sorts of advantageous prescriptions to the North American public. Since we are a consuming public, if a pill will cure a cold then we will buy that pill. If I can purchase that pill off the shelf without a prescription from a physician, then I have the ability to treat myself. You throw in the Internet and the World Wide Web and people are diagnosing and treating themselves.

I think there has to be a process to put, not a stop to it, but at least to slow down and take a second look at some of the products that are being offered out there and why they are being offered.

One of the questions I am often asked is, "How come nobody can find a cure for the cold?" It is a multi-billion-dollar industry, and if you found a cure, it would come to a standstill.

Senator Morin: Excuse me, you are talking about regulation, and that is a different matter. I am talking about financial support. Did I understand you to say that, as far as natural health products are concerned, you are in favour of control? I fully agree with that. In addition, should there be some form of financial support for these products?

Mr. Welden: Yes.

Senator Morin: Are you saying the same thing with respect to non-prescription drugs?

Mr. Welden: No. I think with non-prescription drugs, if I want to buy an Aspirin then I should have the ability to buy that Aspirin. Should the government pay for that? No. We do not we agree with that concept. I think we are more concerned about the regulation of those products versus the purchasing of the products.

Prescription drugs is a completely different area. We believe that some government support should be provided in that area.

Senator Morin: What about dental and optometric services?

Mr. Welden: Saskatchewan was one of the places that had a school-based dental plan. During the Devine era it was cancelled. It was based more on ideology than providing practical services. That program was acclaimed worldwide. It has been put into place in some European and other countries, and it has been shown to save health care costs in general. I believe that. Should the full scope or spectrum be covered, financed by the government? My response to that is: no, not necessarily. Should we be setting up programs, such as a school-based program for dental health, which affect our children's health? Yes, I think the government should be actively involved in that because it promotes health as an adult.

Senator Morin: Why would you not go the whole way? Britain has dental insurance for the whole population, and also have an optometric plan for glasses that is covered by the government? Why are you not in favour of that?

Mr. Welden: It is not that I am not in favour of it. It is a matter of: Is the government prepared to start putting higher regulations on those industries, as well? When you decide that you will fund an industry, are you prepared, politically, to put into place those regulations necessary to regulate that industry?

Senator Morin: I think the dental profession is already well regulated, although there may be problems. However, there is no problem with the regulations there.

Mr. Welden: I would tend to disagree with you.

Senator Morin: Let us say we regulate the dental profession. Would you go all the way and have public funding for that?

Mr. Welden: Yes.

Senator Morin: Same thing for optometric?

Mr. Welden: Same thing for optometric, yes.

Senator Morin: My other question dealt with European countries.

Mr. Welden: Why have they not done it?

Senator Morin: Yes. These are social democrat countries which are very advanced, and far more progressive, than Canada as far as social programs are concerned. We have never had a social democrat government in this country. None of those countries has recommended what you are recommending this morning.

Mr. Welden: Prior to 1962, there was no medicare. Nobody had recommended it. In fact, nobody had talked about it. Innovation comes from people with new ideas and new concepts. Perhaps they have not thought of it. I cannot give you the reasoning because I am not from one those countries.

Is it a left-wing agenda? I do not think it is a left- or a right-wing agenda. I think it is an agenda of: Do you put people in front of profits? If that is left wing, then I guess you would look at it as a left-wing agenda. Does it have to be a social democrat government that does that? I do not think it has to be a social democratic government that does that. I think it has to be a government that cares about its people more than it does about the corporation and the corporate agenda.

Just because nobody has done it before, does not mean it should not be done. If the present system does not work, then what parts of it can you fix? What parts of it are important to fix in order to get it to work? Do you simply change it to something that you know does not work as well? People can espouse all they want about the American system, but it does not work quite that well.

Senator Morin: I agree with that.

Mr. Welden: If that does not work, then maybe we have to look at something completely different. That is what we are suggesting.

Senator Morin: Thank you very much. You are very clear.

Senator Pépin: I am coming from another direction. Let me be the devil's advocate here. One of your recommendations is the development of multi-disciplinary teams as health care providers. You say, and I agree, that multi-disciplinary teams are essential to the primary care model.

I know that you are a very strong syndicate. I come from a province where the unions are very strong. I agree with the recommendation. I also support the way you support workers such as nurses. I always supported the nurses when they were on strike to have better conditions of work.

From your perspective as a union, if we have all those people working together, how will you organize that, and how will you be able to ensure that they are all working in good conditions? As it is, they work in smaller teams. I am sure you have thought of how you will do it. Will it be easy for all of those people to work together - the bosses, the leaders, and the workers?

Mr. Welden: I am a nurse by profession and in all my nursing career I was a CUPE member. I was not a member of SUN, which is the organization or the union that represents nurses in this province.

In the area that I worked in, the union represented everybody except the administrator. If there was a physician, that physician was represented. If there was a psychiatrist or a psychologist, they, too, were represented. It was an all-inclusive bargaining unit.

It was not until I became a CUPE representative and started working in the health care area that I realized that there was a hierarchy in health. I had never realized before, that there were physicians, and then nurses, and then technologists, and then the rest of the unwashed. I cannot understand it. I cannot understand how a system has set itself up on a basis of education and functionality and superiority. It is no wonder it does not work.

In the place that I worked before, no one of us considered ourselves any higher than the person that we were working beside. That person might have been a dietary aide, a housekeeper or a psychologist. When we had a unit meeting they were all involved. If the unit was not cleaned properly it affected the health of the residents. If the dietary areas were not functioning properly it affected the health of the residents. If the rest of the team was not cognizant of that or part of that, it affected the health of the residents.

One of the changes that has to be made in health care to make it function better and to treat the health of the patients, the consumers, the residents, is that teams have to put this hierarchy aside and start to function together on a more equal basis. No one part of the health care team can stand on its own. Without a cook, meals are not served. Ever discipline is an integral part of the whole. However, we have to incorporate coordination. How that is to be done is the million-dollar question.

Senator Pépin: I am sure you have been thinking that. You have the union on one side and the administration on the other. You will be very powerful.

Senator Keon: I also want to thank you for appearing before us.

Mr. Welden, you presented an interesting concept that has been presented over and over again, and that is that comprehensiveness should be extended to include the entire spectrum of health care and be paid for by government. I believe that is what you said.

Of course, as you know, currently the funding of health care is about 70 per cent government and about 30 per cent private. It is consuming about 8.5 per cent of our GDP. Other people have proposed this and when I have asked them what the financial implications of this will be, their responses boil down to the fact that the implementation of this will push funding up to about 12 per cent of GDP and doubling current government funding.

Do you think that would be politically acceptable in Canada?

Mr. Welden: If it is done right, yes. I do not think you can just turn around and say that the Canadian population, through its tax dollars to government, will suddenly take over health care and fund it completely. There has to be a complete analysis of the health care system and a true definition of what health care is. If you ask 30 million Canadians the question: What do you think health care is? You will probably get 30 million different answers. What we are trying to espouse is that health care is not a system unto its own. It has become more than just a visit to the hospital or a visit to the doctor.

To use an example, in Saskatchewan 40 per cent of the people using the food bank in Regina are children. If you do not solve that problem, you will not solve the problems that they experience in the health care area.

When we talk about a comprehensive health care system that is fully funded, we also talk about the fact that you have to deal with the health care status of the nation, which is even more comprehensive.

Can it be accomplished overnight? I do not think it can be. Can it be accomplished at all? I think it can be. The one thing that separates us from the rest of North America is the fact that we do take care of our neighbours. We are concerned with our neighbours. It is a matter of political willingness, and I think the population will follow on that. I do not know if I answered your question.

Senator Keon: No, you did not. I do not blame you for not answering it. I think if you asked it of me I would not answer it either.

It is a very interesting phenomenon. People keep advocating this blanket solution and it would be interesting just to lay it out and have somebody run on a political ticket that says: I will increase health care funding to 12 per cent of the GDP and I will double government funding in health care.

Mr. Foley: If would refer you to the first paragraph on page 6 where we deal with the cost comparison between Canada and the United States.

Having said that, Tom is prepared to take a stab at your question. If John would not answer it, Tom might.

Mr. Graham: I believe it is politically possible to sell just what you said. When we talk about health care, we talk about the government not being able to afford to fully fund health care. We then say it will have to be handed over to private hands. People will get health care one way or the other. They will sell their house, or they will go to the bank and borrow money. If they are forced to go to a private clinic, for example, an American-style clinic, they will do what they have to do to pay for that service.

I think the selling point is to start explaining it. It seems to us that there is a lack of logic here. We cannot afford to pay for health care, so we say that we will privatise. We will put it into the private sector. Who, then, are the people paying in the private sector?

I think that point has to be made a little more honestly. The point is that, as individual citizens in this country, we pay the bill. Do we pay it collectively; or do we hope we do not get sick and then declare bankruptcy when we do, because there is no public system?

We understand that health care costs are the number one cause of bankruptcy in the United States. People fall ill and they do not have the appropriate insurance. They sell their house, they go into debt, and they end up bankrupt.

I think the message has to be delivered a little more clearly. It is politically possible, to say that you do have to pay a little more taxes. There are not too many people who would not pay house insurance in the hope that their house will never succumb to fire, or something like that. Of course people would pay that. You may never need it but you pay it because it is easier to pay $600 a year in house insurance than $100,000 for a new house because you had no insurance.

I think we view the taxes we pay towards health care, certainly, as insurance premiums. Maybe that is the political answer.

Yes, I believe it is possible. It is not possible as it is being addressed now with Bill 11 in Alberta. If the message is made clear that consumers will pay for it one way or the other, then why not do it cooperatively, it should be politically saleable.

Mr. Welden: I would be prepared to run on that if you could find a party that would be prepared to put that forward.

The Chairman: I thank all of you for coming. We appreciate you taking the time to be with us. We are hearing from several of your colleagues, as you can imagine, as we travel across the country.

Honourable senators, our next witness is Ms Jodi Blackwell, Research and Operations Director of the Saskatoon Chamber of Commerce. We are delighted to hear from a business group.

I would ask you to introduce your two colleagues, hit the highlights of your statement, and then we will be delighted to chat with you.

Mr. Kent Smith-Windsor, Executive Director, Saskatoon and District Chamber of Commerce: Mr. Chairman, if you will allow me, I shall do the introductions. Then, with your permission, I shall step away to another media conference. However, I shall be back probably in time for the question and answer session.

Before I introduce my colleagues, let me thank you, on behalf of our organization, for the opportunity to present to your committee today.

Let me first introduce Mr. Dave Dutchak, who is President of the Saskatoon and District Chamber of Commerce, our CEO, an elected official. In his everyday life, Mr. Dutchak, aside from committing significant personal time and resources to the chamber movement, is in the health petitioning field relating to M.D. Ambulance.

Next, let me introduce Ms Jodi Blackwell, our Research and Operations Director. Her presentation forms the basis of a piece of work that the chamber has invested about three years in, where we are talking about changing the mind set concerning health care opportunities in this country. Thank you very much.

Ms Jodi Blackwell, Research and Operations Director, Saskatoon and District Chamber of Commerce: First of all I would like to echo Mr. Smith-Windsor`s remarks, thanking you for the opportunity to address your committee and to share with you some of the ideas, efforts and aspirations of the Saskatoon and District Chamber of Commerce in this area.

First, we would like to commend you on your efforts to raise the level of debate around the issue in your examination of the Canadian health care system. As you are very well aware, I am sure, Saskatchewan citizens are very passionate about this issue, so it is close to our hearts.

As indicated in our submission, our chamber recognized the significant opportunities facing us in the area of health research and brought together a group of dedicated, passionate and innovative people from a variety of backgrounds. Working together, we realized a need to develop a dynamic model based on strategic partnerships to encourage a change-friendly culture to allow strategies to be developed to take advantage of the remarkable opportunities in a world of rapidly changing health care technology and the explosion of health knowledge.

We in Canada are faced with a tremendous opportunity and must take the lead to aspire, once again, to be world leaders in the health sector.

We are also faced with a very important choice - and we do have a choice in this area: We can either be a consumer of medical research, medical services and medical opportunities, and with that comes the corresponding expenses, or we can be a producer of these same medical services, research and opportu nities. With that come the corresponding benefits and profits. It is up to us to make this decision and the time is now to move. In the global arena, speed really does matter.

Through the efforts of the Saskatoon chamber's health opportunities committee, under the leadership of Mr. Dutchak, we have been successful in raising awareness and debate on a variety of health-related issues.

The committee's main purpose is "to educate and promote opportunities for business services, education, research and development in health services and their role..." for Saskatoon.

One tool we have used to achieve this goal is the 2020 Health Vision Conference. We first introduced this conference last year; the second annual conference will be hosted November 19 and 20 here in Saskatoon. We are offering a full agenda of local, national and international speakers who will be highlighting opportunities for economic development within the health sector.

I have brought with me some information regarding the conference. I believe an invitation has been extended to members of this committee to attend the upcoming conference, and we would very much like to see you there.

With respect to the health care opportunities committee, the committee itself is comprised of individuals from our chamber of commerce, Saskatoon District Health, the University of Saskatchewan, the Regional Economic Development Authority and local business. They are pursuing opportunities to develop new partnership models. We are looking for models that are adaptable and dynamic and models that will benefit Canadians now and into the future.

In seeking new partnership models, we have made great strides in developing mutually beneficial relationships with our Aborig inal community. Saskatchewan is faced with a major opportunity with its growing Aboriginal population, and we are committed to work with Aboriginal people and organizations to ensure they enjoy a healthy, bright future in our province.

We will work with the Aboriginal leaders in their quest to be included in the developing of health provision systems for their people.

We at the chamber feel very strongly that a changeable structure to accommodate health care partnerships will be the foundation upon which strong relationships will be built. We must provide the leadership that recognizes the changing health delivery system and take advantage of the many opportunities presented. This will not occur through continuing to increase funding; we must aspire to change.

In order to achieve this lofty yet, in our opinion, obtainable goal, we must work together. Together we are stronger.

Our recommendation is the creation of a policy framework that encourages and supports strong partnerships both inside and outside current systems. We must respect the support by Canadians for publicly funded health care; however, at the same time, we must be proactive, not reactive, in our approach.

We must have the courage to move ahead and create more adaptable models, ones that have the capacity to change with the dramatic growth in health knowledge that is facing us.

We will take any questions.

The Chairman: I shall begin; I have two questions. One is a sort of fact-based question; the other is a question of interpreta tion.

We had a very interesting presentation yesterday by a Dr. Friesen, who has been chairing a committee on behalf of the minister responsible for Western Economic Diversification. Are you plugged into that process? Are you part of the group?

Ms Blackwell: We actually came from a meeting just this morning. We have a very informal group of people who are very passionate about this issue, including people from WD - how would we explain it?

Mr. Smith-Windsor: Our informal group is very much involved in the Friesen model. In fact, Jodi is doing some work to narrate the discussions that are ongoing in Saskatoon.

One of the decision points we are dealing with is that, while there is a very exciting opportunity to build a node of strong research networks, if I can use that term, across Western Canada, it does require the patience to establish those relationships. In the context of speed being of the essence, part of the work that this informal group is dealing with is how Saskatoon structures itself as being partner friendly and ready when others are ready.

We have already started on some of this work, and I suspect that Jodi will be authoring a fair bit of it.

The Chairman: Is it a fair conclusion that you are more than a little supportive of what Dr. Friesen is doing? We are just trying to get feedback. We had a terrific presentation from him. You are one of the groups that I presume he wants to be supportive. Are you supportive of what he is doing?

Mr. Smith-Windsor: Perhaps I can ask Mr. Dutchak to answer, with his own level of enthusiasm.

Mr. Dave Dutchak, President, Saskatoon and District Chamber of Commerce: I attended a conference last fall of which WD was one of the co-sponsors, the Kansai Conference, with a health networking process. Kobe, Japan has become very aggressive in creating a medical health park and collaborating, as Kent has mentioned, in the elements of research, clinical, and business industry. Those three elements are quarterbacking our process. Our vision is that there are many opportunities that can be offered worldwide, opportunities that others have on their radar screen that can be executed, and that health care is an economic element, not only a function of protecting and serving our people.

Mr. Smith-Windsor: Yes, we are wildly enthusiastic.

The Chairman: "Partnerships" is the buzzword of the first decade of this century, and it is used in a variety of contexts. I notice that you have used the word in several places. You have talked about health care partnerships; you have talked about a partner-based vision.

Can you translate that from a semi-slogan into something that I can operationalize in my mind?

Mr. Smith-Windsor: There is a living example that is now under negotiation between Saskatoon District Health and the medical college of the University of Saskatchewan. Similar relationships are being explored in Calgary and Edmonton, and they are now starting to talk about how they might expand beyond that.

Those are very fragmentary discussions. What we are trying to demonstrate is something that business brings to the table, understanding collaborative relationships. We are exploring how to find mutual benefit.

I think that is the ingredient we bring to the table. I have given you one example. There are several.

The Chairman: When you do that, somebody has to be in charge. Is the business side in charge, is the academic side in charge, or is the community clinic in charge?

Mr. Smith-Windsor: Everybody wins. There is no team captain because everybody has a role to play.

Think of a symphony, for example - however, we do not have a conductor. We just know that we want to make music. We know that the trombones take the lead from time to time, and then the violins take the lead. What know that the chairs have to be arranged properly, and that not everyone can be the star all the time.

I consider our role to be that of a stage manager. The health opportunities committee is, in fact, within the structure of the Saskatoon and District Chamber of Commerce, but I consider ourselves as being a stage manager rather than a team captain.

Mr. Dutchak: Three years ago, when M.D. Ambulance became involved -

The Chairman: Let me just interrupt you for a moment. Your company provides ambulance service to the Saskatoon Regional Health Authority; right?

Mr. Dutchak: To the Saskatoon Health District, yes, on a contract basis. So that partnership culture, and understanding where a partnership has to be mutually beneficial to be successful and to exist is, I think, what was brought to the table when I started with the chamber of commerce.

The process right now - this is a great question because it is a very virtual culture right now. The partnership culture is growing in a way that is quite innocent and quite healthy.

Does the partnership have to have more structure at some point in time? Maybe, maybe not. However, the three entities, at their highest level, including the president of the university, have come together to say, "Let us create this thing." It is still a "thing," because we are still in the process of defining it.

We want to create world-class health services. We want to be open for business. Living within the context of the Canada Health Act, we want to see health as an economic driver, not only as an element to protect and to support our people where and when we can.

That is our mission and we will seek ideas from across the world to help achieve that, to determine how we can be involved in that equation. As a result of the virtual relationship I talked about, some really good stuff is happening, and we are respectful of that culture.

Senator Morin: I have been through your document, which talks about the health care opportunities committee and some clear objectives, but as far as I can understand you still do not have specific programs you can talk about. Am I right in saying that?

Before you answer, let me put my second question.

We were all impressed by Mr. Friesen's presentation. I was familiar with his work because he had sent me information about setting up centres of excellence throughout Western Canada, doing not only basic research but running clinical trials and research on health care systems, to be sure that health care delivery is improving - placing a great emphasis, and with reason, on a health information systems, which is one of the most serious problems we are facing now in our health care system.

If in Western Canada there is a big push for that, the rest of the country will certainly profit, accenting the commercialization of all the discoveries and innovations that are made.

What I cannot understand is why you do not push in the same direction, the direction of Mr. Friesen's work, instead of going a different way. This appears to me to be such an exciting program, one that will profit all of Western Canada as well as the rest of the country. It will be a trailblazer and will be a model for the rest of the country. The issues that were highlighted to us yesterday are issues that the rest of the country is facing. No one is addressing them currently as clearly and as decisively as the group we heard yesterday morning.

Mr. Smith-Windsor: With regard to the work of the Friesen initiative, we have been intimately involved and have tried to champion the relationships. There is another word that is used frequently, and that is "silos." Building porous silos is something that businesses are good at; sometimes institutions are not.

We have helped them have a culture that allows them to deal with groundbreaking experiments in structure. The hypothesis is how do we build a world-class health care system within the constructs of a Canada Health Act in a dramatically changing world relating to technology and expectations of Canadians on health? Therefore, yes, the Friesen model is an important one.

We have some specific examples. With the support of the federal government and the provincial government, some great leadership from the University of Saskatchewan, I can point to the synchrotron initiative. Our very first health conference resulted in a memorandum of understanding between the SPring-8 synchro tron in Kobe and the University of Saskatchewan CLS piece. The significance of this is that there are three nodes that are aspiring to deal with medical imaging potential within the synchrotron - one in Japan, one in Grenoble, France, and one here in Saskatoon.

The SPring-8 people came here because of the health opportunities conference that was convened under our leadership. The people from Grenoble came here because a week later; they could not attend the original conference. That is a significant opportunity.

We are now exploring relationships in England, in a similar opportunity. This is a territory that we can own for North America, should we choose to do so. That is just one piece.

Mr. Dutchak is very Canadian - he is not very good at boasting. He was in Kobe because he was dealing with leading-edge technology in terms of emergency measures response on wireless technology for health protocols. He was exploring potential partnerships to deal with that technology.

We were in a meeting yesterday afternoon with TRLabs to talk about a project that might transfer into Asia. These are global opportunities that we are trying to pursue. However, the world moves quickly and as such the Asian opportunity will not wait for Saskatoon or Saskatchewan or the considered opinions around the Friesen group to be decided upon to pursue the opportunity.

If we wait for the structures to emerge, many of these opportunities will be presented to someone else.

Senator Morin: The examples you cite are very important; too bad they could not have been part of the report. I had the impression this was all theory, so I am pleased to see it.

The synchrotron issue is very important. Incidentally, Canada is extremely weak in the area of imaging and that type of technology. There is almost nothing happening in that area in Canada. Therefore, I am quite excited to see that you are taking the lead here, with reason. I am very happy to see that Saskatoon is taking the lead here.

In your written presentation, under "Part III: Partnering with the Aboriginal Community," do you have anything specific on that issue?

Mr. Smith-Windsor: Build trust. You are looking for something specific, but the relationships are really basic.

Our first vice-president is a gentleman by the name of Lester Lafond, who has been involved in the chamber for many, many years. Mr. Lafond took huge risks to reach outside of his community and into our business community. He has been involved, along with a gentleman by the name of Ron Kocsis, from Kocsis Transport, who is also on our board of directors, in the establishment of the Saskatoon Aboriginal employment and business opportunities partnership. We hate the name, but it describes what they do.

Those types if relationships have to be established. You hear about aspirations to use some of the health incidences in the Aboriginal community to do research. How have we talked about the aspirations of the Aboriginal community in terms of how they will be involved in those health systems?

Mr. Dutchak has worked hard to structure relationships on safety in training protocols in a groundbreaking partnership between himself and the Saskatoon Tribal Council. It all builds on trust.

Mr. Dutchak: Following our conference last year, there was an announcement in our community to establish a health centre and nephrology services. On the renal research and transplant side, by far the majority of renal issues and transplants are in Aboriginal communities. Hence, as we build this world centre of excellence in the different disciplines, the renal component can be a worldwide leader in that research and in the Aboriginal community.

Once the train is heading in a particular direction, as partners who are on that train, opportunities to load it with what has to be shipped to wherever can occur. However, if the partners are not it is not possible to capitalize on those opportunities. That is what we have started since our conference. The work we have done locally is to nurture projects and announcements like this.

Senator Keon: Mr. Dutchak, I noticed in passing that you used the expression "health park." Were you referring to a health sciences park or a health sciences industrial park of the nature that I think we first saw around Oxford and Cambridge in England - they have also grown in America, and there are a few of them in Canada - where fundamentally the scientists of the medical schools and hospitals link up with industrial partners in the business communities that provide these industrial parks to move products out to market and so forth?

Was this the contribution to the sort of western health science alliance that you were thinking about? I am just trying to read where you are coming from here.

Mr. Dutchak: I shall begin, and then my colleague can add to what I have said.

The two things we must focus on is the courage to move ahead on the health file and understand the brand. What are the elements of the health brand that can present worldwide opportunities, to give people solutions from Canada, from Saskatchewan, from Saskatoon?

The dispositions of cultures and health parks are integral elements to becoming worldwide. When the outside looks in and says, "Do you have all the players on the team and the culture to make those things happen?" we have to be able to say yes. We cannot have a minor-league mindset.

That concept is something that we have talked about as recently as this morning. We do have the courage to try to sight what that might mean for our community, a part of the Canadian scene. We have not totally defined that yet, but we will aggressively move to try to do that in a partnership element.

Mr. Smith-Windsor: When our chamber got involved in talking about health, we were involved in a redevelopment of our strategic plan as a chamber of commerce, acknowledging that the world is rapidly changing and that we had better determine how to change fast, too.

The challenge that was presented to our group was that if we were in Baltimore we would be talking about Johns Hopkins University Hospital as a key economic driver. Because we are in a publicly funded health care system, we in the business community have tended to focus on the cost side of this rather than exploring the opportunities. Is a research park, an integrated health science centre, part of the opportunity mix? Absolutely. However, it is not the only answer.

We see some significant opportunities in Saskatoon that build on pieces like the synchrotron, such as the Veterinary Infectious Disease Organization, actual real-life functioning nutriceutical companies that are making profits in this community. Twenty years out, we see convergence being a significant opportunity for Saskatoon.

We want to be a knowledge nexus point in the 21st century. If that requires a building, so be it.

Senator Keon: Probably the greatest success story in this whole field of industrial medicine is in Minnesota, and they did it without an industrial park. It just became a sprawling industrial medical complex. Hence, I do not know that industrial parks are necessary, and they certainly have not all been successful either.

Mr. Dutchak: At last year's conference, Dr. Cal Stiller andDr. Bernstein talked to us about positioning ourselves to be part of a network nationally. Canada still has the opportunity to lead the world, opportunities as once existed in the 1960s.

This year, there will be speakers from the Medical Alley and from the Mayo Clinic at our conference talking to us about the elements of a world-class health centre, talking to us about collaborating with national partners, our neighbours.

The Chairman: As I hear you, other than effectively encouraging the federal government to get the Friesen proposal off the ground, not at the usual bureaucratic pace but a significantly faster one, there is nothing specifically by way of changing federal policy that you need. You really have the on-the-ground catalyst; you say it has to be run locally, which makes sense. It has to be big enough to cover more than one province, as you say, but the reality is that you are not really looking for anything from the federal government, other than down the road if WD gets involved in helping to do the infrastructure of a multi-province organization. There is nothing specific that you need from the federal government; is that right? Is that a fair reading?

Mr. Smith-Windsor: We recognize that the rate of change in this field will be almost unfathomable, so all structures in the future should be designed around the principle that they have to be malleable and dynamic, not rigid. I think that is an operating principle. Certainly, the Friesen model thinks about that. How does one stimulate resilient partnerships? The answer is this: You have to have flexible limbs amongst people rather than rigid structures.

Senator Morin: If there is one area in which the federal government can help, I think it is in research. As you know, the medical college's share of federal funding is not what it should be - there is no doubt about that - and it is not among the top earners of funding. That is a euphemism.

As you know, there is a regional difference in programs. Certain federal programs, such as CIHR, have a good regional component; others, such as CFI, do not. The Canada Research Chairs program is in the middle. Coming from Quebec City, I am a strong supporter of regional programs. Perhaps the government could help in the research area by having stronger regional programs. Saskatoon would certainly benefit from that.

Mr. Smith-Windsor: The best collaborators will win this. Regional imperatives across this country from a nation-building perspective are important, and we should not lose sight of those, but we have to think in terms of those who can adapt to other cultures, opportunities in Asia and Japan.

One of the key strengths of Canadians is their more accommodating style of negotiating than that of our good friends to the South. We have to capture that opportunity. If that means cross-regional or inter-regional or solely regional pieces, wonder ful. However, if we think solely in terms of Canada we are really selling ourselves short as to opportunity.

Mr. Dutchak: I think Canada, the partners, governments, federal and provincial, must view the area of health as being a cup half full, not half empty, costing a lot of money and spending being out of control. We have not dealt with the aging population yet, technology, drugs, et cetera. Japan, for example, has empowered its communities: "Get ready to offer solutions, and we will support you." They are getting R&D support, to assist them to be ready to offer health solutions.

The government must say that Canada can become worldwide leading partners in health delivery models, in research, and we will support that initiative. We need that support, that culture of saying, "Go do it." I saw it in Japan, where they have the largest synchrotron in the world. In fact, they have one the size of ours, a little brother to their big one. When they are signing MOUs with us on medical imaging, we are onto something. If we do not capitalize on that opportunity, we will miss out. That is just one example.

The government has to send the message that we can do this. It has to say, "Let's offer worldwide solutions; let's be ready and open for business." We need to have those benefits come back to our communities, both financially and clinically, and through research, as well, of course.

The Chairman: In closing, may I just ask a layman's question, for the record? What does a synchrotron do?

Mr. Smith-Windsor: It is a very good microscope.

The Chairman: Thank you. That is the level of technical competence I can grasp.

Senator Morin: It is the only one in the country. Are there 10 in the world?

Mr. Smith-Windsor: There are about four of this generation. There are several synchrotrons, but as each new technology evolves we are dealing with second generation, third generation, and fourth generation.

Senator Morin: It is a very unique and very powerful instrument. It is quite exciting that it should be in Saskatoon.

The Chairman: Is it up and operating?

Mr. Smith-Windsor: It will be, as of 2004. They are already exploring partnerships. Speed does matter in this business. People in Japan are experimenting with tabletop models of synchrotrons for medical imaging purposes.

Mr. Dutchak: The synchrotron will replace the MRI, as the MRI replaced the CAT scan.

Senator Morin: But more expensive.

Mr. Dutchak: Of course. However, that is where that new generation is heading, and we have it. I am sure this committee would love - and I can provide the ambulance to do it - to get over to our university for a tour.

Mr. Smith-Windsor: That is only one dimension of this. This imaging piece represents one of 40 opportunities from the synchrotron, each of them being leading edge. We did not talk about the nanotechnology piece. There is a definite thrust relating to protein crystallography that will create the designer drugs of the future.

The health applications are mind-boggling, and you are still only talking about 10 per cent of the potential of this "really good microscope."

Mr. Dutchak: Sony - and I forget the other one that was there.

Mr. Smith-Windsor: Kawasaki has one.

Mr. Dutchak: Sony was doing the testing in Japan when I was there, from the commercial side. Therefore, besides health, it has wider applications.

The Chairman: Thank you for being here. I must say that your enthusiasm is wonderfully infectious. Good luck.

Mr. Dutchak: I want to say that on the way back from the Canadian Chamber of Commerce AGM, we read one of your articles in the paper there and it was quite refreshing to hear the content of what was discussed that day with our colleagues across Canada.

The Chairman: Thank you very much.

Senators, our next panel consists of Ms Sherry McKinnon, who is the Executive Director of the Arthritis Society of Saskatchewan, and Randy Goulden, representing the Canadian Parks and Recreation Association.

Ms Sherry McKinnon, Executive Director, Arthritis Society of Saskatchewan: First, on behalf of the Arthritis Society, I would like to acknowledge our appreciation and thank you for allowing me to be here today to express my comments.

Today, I would like to briefly outline some of the issues surrounding arthritis, which are the following: the fact that arthritis is a costly and serious disease; the importance of early diagnosis and education, and the implementation of a disease-coping and management program; access to medical professionals who treat arthritis; and access to and cost of medications.

To start, I would like to provide some information on arthritis. Today, more than 4 million Canadians have one of the100 different forms of arthritis. Prevalence rates of people affected by osteoarthritis are 1 in 10 individuals, resulting in2.930 thousand individuals in Canada having that form of arthritis. Rheumatoid arthritis affects 1 in 100 individuals, resulting in 819,000 Canadians having this form of arthritis. Juvenile arthritis affects 1 in 1,000, resulting in 6,300 children suffering from arthritis.

Arthritis is the third most frequent reason for prescription drug use in Canada. In 1992, Canadian doctors wrote nearly 29 million prescriptions for arthritis medications. Arthritis is the second most frequent reason for non-prescription drug use. Arthritis is one of the most frequent reasons for consulting a doctor in Canada. Arthritis is the most common cause of disability in Canada

Arthritis and musculoskeletal diseases are ranked second among the four most costly illnesses in Canada, just slightly behind cardiovascular disease and well ahead of costs associated with cancer and injuries. Arthritis and other musculoskeletal diseases cost $17.8 billion.

Arthritis is a serious problem and a growing one. Arthritis ranks high as a cause of illness, disability and health care use. The incidence of arthritis in Canada's aging population is poised to become a health care issue of critical importance.

Honourable senators, it is time to stop treating arthritis as just an ache or a pain and make it an important part of the health care agenda.

The Arthritis Society recognizes the importance of early diagnosis, treatment and implementation of a disease-management program and the major impact they have on the function and quality of life for people with arthritis. Much of joint damage in rheumatoid arthritis occurs in the first two years of the onset of the disease, which is why early diagnosis and treatment is critical. These factors can help prevent irreparable damage and major economic loss.

The Chairman: Rather than read verbatim all the next five or six pages, can you sort of hit the highlights, because I want to make sure we have time to ask you questions.

Ms McKinnon: Sure.

The health care system needs to recognize the importance of early diagnosis for arthritis.

Maybe I will just read the next couple of paragraphs because I think they actually summarize a lot of what I would like to say.

The Arthritis Society would like to see a health care system that no longer sends individuals home not knowing what kind of arthritis they have, and tells them there is nothing they can do. We would like to see a system where the primary health care workers utilize a proactive and integrated approach that provides the patient with the information and supportive services required to become an active participant in disease management.

I cannot emphasize the importance of changing the attitude of primary health care providers. They are on the front lines and play a key role in early diagnosis of the disease. We must convince these workers that arthritis is serious and that an aggressive approach is required.

Educating patients with arthritis to take responsibility for their disease management is vital. Given that the number of individuals with arthritis is expected to double over the next 20 years, we must pay to fix the problem now, or pay later.

A key point with arthritis is that early diagnosis plays an important part in the result of the disease. Early detection allows a patient to be put on a disease-management program. This is to the patient's benefit. We know that the deterioration of joints can be prevented if people are educated about their disease and implement an early disease-management program.

It is important to change the philosophy in health care right now, which is that it is just an ache or a pain and we will deal with arthritis when it becomes serious later on. It is important for us to recognize that something can be done now.

With respect to specialized services, for example, hip replace ment surgery, in Saskatchewan there is currently a 61-week waiting list.

We need to train more specialists that treat arthritis - rheumatologists, orthopaedic surgeons, occupational therapists, physiotherapists. The average age of a rheumatologist in Canada is 50, so we will face attrition in that specialty. Canada is producing about 10 rheumatologists a year. We know between now 2031, the number of individuals with arthritis will double. Hence, Canadians will need access to individuals that treat arthritis.

On the topic of medications, Canadians must have access to the new treatments and medications for arthritis. They prevent joint injury and economic loss, and they reduce health care costs because they help individuals enjoy and maintain a good quality of life.

I also want to talk about the Arthritis Society. The society has been in Saskatchewan since 1949. Our mandate is threefold, as follows: to find a cure for arthritis; to help individuals with arthritis now, today, and their families, and to put in place prevention programs to make individuals aware of the association between arthritis and, let us say, sports injuries.

In our program offerings, we have an arthritis self-management program. We offer arthritis exercise programs. We offer a help line and an information and referral service, lender libraries, support groups, and a Web site. We have over 60 pamphlets, because there are 100 different forms of arthritis. Our pamphlets talk about the different types of arthritis, about coping techniques and about medications.

The Arthritis Society is not government-funded. Our society is 100 per cent publicly funded; we are supported by the people of Saskatchewan.

The Chairman: Thank you. I think you have covered all your main points, as I read your brief.

Ms Randy Goulden, President, Canadian Parks and Recreation Association: Let me begin this afternoon by commending this committee on the impressive work you have done to date. On behalf of the Canadian Parks and Recreation Association, I would like to thank you for this opportunity to have a dialogue this afternoon.

The Canadian Parks and Recreation Association is the national voice for a very vibrant grassroots network. We lead through partnerships. We connect people who build healthy, active communities, and we influence the everyday lives of all Canadians.

CPRA exists to build healthy communities and to enhance the quality of life and environments for all Canadians through collaboration with our members and our partners.

To this end, CPRA builds and nurtures partnerships, and we advocate recreation as essential to individual, family and community health and well-being. We communicate and advocate the benefit and value of parks and recreation, and we respond to the diverse and changing needs of our members.

Recreation in Canada has a dedicated volunteer community- based delivery system that has strong linkages to CPRA through our shared values and membership.CPRA plays a key leadership role in this system as a national link between Canadian communities and the leisure field, and is the collective voice for recreation and parks in Canada.

Of particular note is CPRA's partnership with our 13 provincial and territorial recreation and park associations and our shared 3,200 members who are directors, managers and programmers of parks and recreation departments and are key leaders in the education, private and voluntary sectors.

CPRA is also very proud of our strategic initiatives and alliances with the Coalition for Active Living, National Children's Alliance, Voluntary Sector Initiative, the Federation of Canadian Municipalities, Active Living for Canadians with a Disability and the National Crime Prevention Centre.

In the executive summary of your report, "Volume Four: Issues and Options," you cite five distinct roles for the federal government in health and health care. For this presentation, we would like to concentrate and focus on the population health role, as this area is directly linked to our mandate.

The federal government indicates that a good health care system is only one of the numerous factors that keep Canadians healthy. The population health model, supported by the federal government, is another key part of our health care system that keeps Canadians and their communities healthy and vibrant.

CPRA is a strong proponent of the population health approach. We believe that all Canadians, regardless of their age, gender, ability, where they live or their socio-economic status, should have equal opportunities to quality and safe recreation, leisure and active living pursuits. Canadians who work or volunteer and participate in the fields of recreation, sports, fitness, arts, culture or parks have known that the activity or program in which they participate is but a means to a larger end.

CPRA, our members and our partners are very focussed on the impact and benefits that an active lifestyle can offer all Canadians. These benefits have been documented in a publication we commissioned, to be developed with our provincial and territorial partners, entitled "The Benefits Catalogue." I have brought with me today an English and French copy of "The Benefits Catalogue" for the committee's information and review, and have given them to the clerk. More can be made available from our CPRA national office upon request.

"The Benefits Catalogue" provides research from Canada and around the world that states clearly the impact that participating in recreation, sports, fitness, arts and culture, parks and other safe therapeutic leisure pursuits has on individuals and communities. The catalogue discusses four main benefit areas that lifestyles and environments perpetuate - the personal, the social, the economic and the environmental benefits. This catalogue takes the best research available about the work that our field can do for the health of individuals, families, communities, economies and the environment, and packages this information around 44 benefit or outcome statements.

These 44 statements are structured around eight key messages and were developed with the population health approach in mind. They are as follows: Recreation and active living are essential to personal health, a key determinant of health status; recreation is key to balanced human development, helping Canadians to reach their potential; recreation and parks are essential to the quality of life; recreation reduces self-destructive and anti-social behaviour; recreation and parks build strong families and healthy commu nities; pay now or pay more later because recreation reduces health care, social service and police and justice costs; recreation and parks are significant economic generators in your commu nities; and parks, open spaces and natural areas are essential to ecological survival.

The vast amount of health outcomes and evidence backing these aforementioned benefit statements advocates the importance and measurability of healthy lifestyles and environments and can be used when addressing, and by, key decision and policy makers.

The Chairman: Can I suggest that you not read the three examples, because we can do that ourselves as fast as you can read them.

Ms Goulden: "The Benefits Catalogue" also offers evidence that more specifically addresses the disturbing trends as cited in section 12.2 of your report. Because it offers measurable evidence, such as statistics and facts about the impacts of recreation and leisure lifestyles, this tool can assist decision makers to develop programs and policies that will be meaningful to Canadians and their communities.

We strongly believe in engaging those who will ultimately benefit from policies and programs to be involved in their development. Practitioners in the parks and recreation sector are leaders in this community development approach to policy, program and service development and delivery. We are also very skilled at mobilizing and motivating Canadians to be active and to lead healthy lives, and we are networked in every community across Canada.

Ultimately, the parks and recreation sector and allied networks are providing a catalyst for change in the way we view healthy individuals and communities. The benefits catalogue is one key tool that CPRA and our allies are using to reposition, promote and provide services that go beyond traditional health care services. The work that we do is being recognized more and more as truly essential for the improved health of all our Canadians.

We believe that the outcomes as stated in "The Benefits Catalogue" support our conviction that recreation and physical activity is a prime contributor to the healthy development of Canadians. However, in today's society there are many personal, social and economic factors that prevent many Canadians, especially children and youth, from realizing the many benefits of participation.

CPRA encourages this committee and the federal government to continue to explore the population health approach and the impact that physical activity and recreation has on the prevention and management of diseases and illnesses.

We advocate that the federal government make a significant investment to support the provision of these types of essential services for Canadians.

The existing federal and provincial health care infrastructure for the provision of health care is, indeed, very complex. However, we believe and have evidence, as presented in "The Benefits Catalogue," that investing in this approach would mean significant reductions to federal and provincial health care costs and the improved health status of Canadians. We encourage the federal government to recognize the necessity for a preventative approach to health care.

CPRA advocates for the distribution of dollars that would result in increased resources to preventative health delivery systems, which would include the parks and recreation sector.

The work of our sector is one means and the CPRA's "Benefits Catalogue" is one tool that could offer the government a starting point for research that would support and thrust forward the population health approach, especially in the eyes of those responsible for measuring health care outcomes.

CPRA is currently working with its partners to prepare a more comprehensive brief. We look forward to submitting it in the coming weeks. In the meantime, should you require any additional information, please contact our national office.

On behalf of the Canadian Parks and Recreation Association, I thank the members for affording me this opportunity to speak to you this afternoon.

Senator Morin: I would like to address my questions toMs McKinnon. As far as I know, you are the first voluntary health organization that we have met. This presents us a good opportunity to congratulate, of course, the Arthritis Society, but also to recognize the extraordinary work that the voluntary organizations have been doing in this country.

These are truly typical and quite unique Canadian success stories. I realize that there are voluntary organizations in other countries, but the combination of health research support, of education and of care is truly Canadian. What is also truly Canadian is the hundreds of thousands of volunteers throughout the country in all these organizations that have been giving their time, their money, to these organizations. It is important for us to recognize that. I do not know if we will recognize it again in our report, but I think we should recognize it.

I have a couple of questions, one dealing specifically with the arthritis issue. You said that the waiting time for a hip replacement in this province is 61 weeks, a little over a year. How does that compare with the waiting time in other provinces, and what do you think - of course, the optimal waiting time is nil - is a reasonable waiting time? What should we be aiming at, to give us a handle on this?

My other question deals with voluntary health organizations in general. I know it may be unfair to ask you this, but because you are the only one we have met you are supporting the brunt of my questions here.

As you know, this is a federal survey; we are not dealing with provincial issues. In that regard, how do you think the federal government can help in supporting the various voluntary organizations? If you do not have an answer immediately, you can forward it in writing. I realize that your organization is a provincial one and that it may not be easy for you to answer this, but I am posing the question because to date we have not heard from any voluntary organizations, organizations that are so important to the Canadian health system. I do not think it is fair that we should not have heard from them. We do have a number of recommendations but - unless you are prepared to give them right away - what could the federal government do to help these organizations do their extraordinary work in this country?

Ms McKinnon: The waiting list in Saskatchewan is 61 weeks, the longest in Canada. It is double the second worst province, and I suspect that that is because of the resources.

It is difficult to say what the average waiting time should be. It would depend on the seriousness of the condition, as to the priority an individual is given for surgery. The waiting time definitely should be a lot less than 61 weeks.

Individuals who are waiting for surgery are frequently in pain; some suffer economic loss and risk damaging other joints that try to compensate for the weakness in the one joint. What often happens is that once an individual who has been waiting for a hip replacement gets a new hip a knee replacement then becomes necessary.

The Arthritis Society does not want to function in isolation. We want to work with government agencies and with the health care system. Our programs and services blend well. We want to be part of the solution. In that sense, many services our organization offers can be of benefit to the health care system. An example is our Web site, which offers valuable information. We do not want to work in isolation.

How voluntary organizations can help in the long run is something that I would probably want to think about and could submit at a future date.

Senator Morin: And vice versa, how the federal government can help voluntary organizations do their extraordinary work.

Ms McKinnon: Arthritis needs to be brought to the forefront. We need to take a proactive approach to the disease, recognize that it is not just an ache and pain. What is an ache and pain now will come back into the health care system later and costs a lot of dollars. The best treatment for arthritis is early diagnosis. I cannot emphasize that enough. In that sense, arthritis must move to the front of the health care agenda. The philosophy of the federal government must be to put emphasis on the disease, even in the research dollars that are allocated. Ultimately, if better treatments are found, if we can find a cure, the cost savings will be enormous.

The Chairman: Can you tell us which province offers the shortest wait for hip replacement surgery? Even if you cannot recall the province, can you recall the waiting time?

Ms McKinnon: I think it is in the range of between 25 and 30 weeks.

The Chairman: Hence, most of the provinces are grouped together in roughly a six-month waiting period, except in your case, which is double that.

Senator Pépin: You said that people discover too late that they are suffering from arthritis. Is lack of education and a lack of prevention programs responsible for that? Or is lack of early diagnosis responsible? You also referred to a shortage of rheumatologists. Why are people finding out too late that they have arthritis? Is there another reason?

Ms McKinnon: Part of the reason relates to education. We need to educate people on the warning signs of arthritis. As well, we must emphasize with the primary health care workers the importance of early diagnosis of arthritis. I have often heard of people being sent home and told that the pain they are complaining about is just arthritis. They are not told what kind of arthritis they have; they are just told that it is arthritis, go home.

I would like to see those individuals referred to the Arthritis Society so that we can educate them and give them some coping techniques. They could attend a self-management program; they can access information on pain control and on exercises. We can provide them some disease management techniques andinformation about protecting their joints.

In the package we gave you, there is information on a sports body basics program we offer in Saskatchewan. Through that program, we are trying to educate young athletes, coaches and parents about joint injury in sports. There is an association between injuries not being properly treated and a higher risk of arthritis later on in life. It is important that we put that education out there to the public.

We want to educate people about the warning signs of arthritis. In that way, people can speak to their doctors and get an early diagnosis. We can teach people about prevention, even in the workplace, and help those who do have the disease maintain their quality of life.

Senator Pépin: In your written presentation, you say that family physicians earn more than rheumatologists. That surprises me. Why are rheumatologists, who are specialists, earning less?

Ms Joy Tappin, Board Member, Arthritis Society of Saskatchewan: I believe that rheumatologists are not only physicians but also counsellors. By the time they do a diagnosis and then counsel an individual with respect to exercise programs, educate the patient and so on, they have spent a fair amount of time. General practitioners often do not spend as much time with a patient. Often, they only have to do a quick exam and write a prescription. Hence, a GP can see many more patients in a day than a rheumatologist can.

Senator Pépin: They are paid by the number of services they perform; correct?

Ms Tappin: That is right. A rheumatologist is not like a physician or a surgeon who may get thousands of dollars for a one-hour procedure. A rheumatologist is many things, acounsellor, a physician, a diagnostic person. Then there is the follow-up. Treating arthritis takes a lot of time. Patients keep coming back and saying, "I am in pain. You simply must do something about the pain." The rheumatologist then prescribes medication. I speak from experience. I have arthritis and it takes a lot of time for a rheumatologist to deal with just one patient.

Senator Pépin: I understand. You will see that one of our proposals was for physicians to be on salary. Perhaps that would solve some of the problems for rheumatologists.

Ms Goulden, I think what you say is very important regarding parks and recreation, and since the larger part of our population is approaching the sedentary age exercise and recreation will be very important. If I understood you, you would like the government to take into consideration an association like yours. You are teaching prevention, in a way. It is one way to teach prevention and to educate people about what they have to do if they do not want to be aged and sick.

It is the first time that I have seen an organization like yours present a brief on better health. It could form part of the prevention aspect that we would like to do with our report.

Ms Goulden: Thank you very much for your recognition on that. We are also very strong advocates of the role that we play with our youth, who are the citizens of the future. With the obesity that we see in our youth now, along with the trend toward increased smoking among youth, we feel we have a real role to play in creating awareness of a healthy, active lifestyle among our youth, a lifestyle choice that will, in the long run, reduce the costs of health care.

Senator Keon: Ms Goulden, I commend you for coming here. You represent a very important dimension in health. There is a real need for a closer integration of your activities and the health activities, particularly in the public health sector. I will not ask you any questions because I agree with your brief; I will leave it at that.

Ms McKinnon, I think arthritis represents a classic problem that we have in Canada of a disease that is a huge economic burden and is not being targeted. My own serendipitous experience with patients who have arthritis really makes me feel that they really do not get the attention they deserve.

I would hope that your organization could find a way to come together with government authorities and streamline diagnostic facilities, streamline therapeutic facilities, so that people are getting optimal therapy - particularly primary and secondary preventive facilities and counselling. People who could extend their joint function for years and years are not doing it because they are not properly educated.

With a concerted attack, the management of this disease could be drastically improved. It would relieve the economic burden in Canada, too.

I commend you for what you are doing. The volunteer and philanthropic organizations do tremendous work in every area.

Ms McKinnon: Thank you very much. I agree with your comments that arthritis needs to be targeted. There needs to be a more proactive approach in the health care system as well as working together with the non-profits and ourselves in the area of education, the power of education and the empowerment of the patient in self-management. Those actions would play atremendous role in easing the burden on the health care system and within the community at large.

Again, thank you very much for allowing me to be here.

The Chairman: May I thank all of you. I appreciate your taking the time to be with us today.

Senators, our last witness today is Mr. Gerald Morin, President of the Métis National Council.

Mr. Morin, you have written a very interesting brief, which I have just had the pleasure of reading. You have responded very directly toward the end to the very specific question we asked you, which is this: Give us some advice on what we ought to do to get the federal government to respond adequately to your needs. Hence, I would ask you to hit the highlights but with a particular focus on your response to our question.

Let me just ask you one question, to which you can ad lib an answer at the end.

Given the focus in your brief on the need to deal with the determinants of health, not just health itself - you call them the root causes not just the symptoms - is there an argument to be made that, in terms of the federal government's role, the area Aboriginal health ought to be in the same department as all the other Aboriginal services, as opposed to being in the Health Department? I just ask the question; I do not know the answer.

At some point, I would like your thoughts on that.

Mr. Gerald Morin, President, Métis National Council: All right, Mr. Chairman.

With me is Mr. Don Fidler, the new health coordinator at the Métis National Council. He will be assisting me this afternoon with the presentation.

I will highlight some of the major points that we have in our brief, which you have in front of you.

First, thank you for giving us this opportunity, once again, to appear before you. I want to commend you for your efforts. We reviewed the recommendations in your report, based on presenta tions at previous hearings, including presentations from ourselves. We are happy to see that you have taken a strong position in terms of advocating for the health of Aboriginal Canadians, as well as pointing out that, with respect to the Métis, there has to be Métis-specific solutions. You also note that our people exist in a jurisdictional limbo, where the federal government will not take responsibility for the Métis as they do with other Aboriginal people.

Discrimination occurs in a variety of areas. We can talk about the entire area of addressing rights and land claims and so on, which goes to your question in terms of the point of holistically addressing all of these issues. It affects us in that area but it also affects us in terms of not being able to receive programs and services. We are not able to access billions of dollars of programs and services that are available to First Nations and Inuit people.

It makes it very difficult for us. In my report, I touched upon how the federal government has been unable to come to grips with the Métis reality in Canada. For all intents and purposes, from a legal perspective, in the view of all governments sinceConfederation, the Métis people do not exist in this country. We have no rights, and the federal government has no responsibility to address our issues. It is in that kind of jurisdictional and legal framework that governments in Canada have operated, so we are neither here nor there.

On the rights front, we are not able to establish land and resource bases; we are not able to access resources, in order to pursue a way of life and create economic development and prosperity for our communities. That, in itself, creates a lot of problems in terms of that framework that I talk about.

Let me now move to programs and services. The federal government delivers programs and services in many areas. There is health care, there is economic development, there are justice-related issues - the entire area of human activity, because we are a nation of people with the right of self-government. As a result of that denial, we are not able to access any of these programs and services.

If you look at our situation, I think more Métis-specific research has to be established. Part of the problem is not being able to access those kinds of resources. Generally speaking, we exist in the same poverty, the same social and economic circumstances that other Aboriginal people find themselves in; yet, because of discrimination and lack of recognition, we are not able to access anything from governments in Canada, whether related to rights or jurisdiction or programs and services, to tackle these very serious issues amongst our people and our communi ties. A lot of the issues, problems and challenges faced by Aboriginal people in general manifest themselves in the area of health. Statistics indicate a high rate of HIV, hepatitis C, homelessness, family breakdowns, poverty, low levels of educa tion, and so on. I could go on and on. In all those areas, our people are affected in the same way, but we are not able to address these issues.

That is why, in our presentation - and I am glad you touched on it in your report; you urge the federal government to tackle these issues and to ensure that there is equity of access for our people, urge the government to address health-related issues. You point out also the need for a broad response by the federal government, to ensure that these other issues get addressed. If only one department is getting it right, say, for the sake of argument, Health Canada - which they are not - and other departments are not following suit, then only the surface would be getting scratched. The government would not be tackling the problem head-on. It would be like throwing money to the wind, because, ultimately, it would not be achieving solutions for our people.

I think there is a lot of goodwill. Certainly, I am very pleased with your report. In the past three or four years, there is growing support and understanding for our position amongst different sectors in the federal government. There is a growing recognition that we are here, that our issues are legitimate and that they must be dealt with.

A lot of the solutions are there. Canadian taxpayers spent $60 million studying all Aboriginal people through the Royal Commission on Aboriginal Peoples. The commission's report encompasses recommendations and solutions that, if the federal government were to implement, would go a long way in addressing these issues that I point out.

Over the years, I have made many presentations to both levels of government. Sometimes it is discouraging because it does not seem like we are making enough progress.

Some good reports have been written. I point out, for example, the report that was done on Aboriginal veterans by the Senate a couple of years ago. That report made awesome recommendations in terms of addressing the issues of Aboriginal veterans who went to fight for our country. It was tabled, and then it was shelved and is collecting dust. The federal government does not really seem to be responding in a meaningful way to any of those issues.

The same could happen here. We could make all the right arguments and a wonderful report could be written establishing all of the rationales and arguments for why this must be done and that must be done. However, if the people in power do not listen and do not make policy changes, and if there is no leadership and no political will, then sometimes we get the impression that we are simply spinning our wheels.

I do not pretend that this committee, whose mandate it is to explore health-related issues in Canada, can necessarily find all the solutions or implement those changes. However, somewhere along the line somebody has to say this: "Look, it is time for change; it is time to come to grips with these issues. Here are our recommendations. We spent this or that amount of money on the report. Here is what we are saying. Let's do it. Let's demonstrate political will and make those changes."

We have been dealing with Ralph Goodale, the federal Métis interlocutor. He has been doing a reasonably good job. He has certainly been doing his part within the federal government. In many ways, too, he faces a lot of the same barriers and constraints that myself and other Métis leaders face in terms of convincing cabinet, the Prime Minister's Office, all the powers within the federal government, including the bureaucracy, which has a lot of power. Certainly, the Department of Justice lawyers and their opinions carry a lot of weight with the federal government.

The question is this: How do we bring about that change? I pointed out to you in my earlier presentation, a few months ago, that we are working on a Métis Nation agenda. It addresses two streams of issues. On the one hand, it addresses the program, service delivery and equity of access for our people to many of the issues we are talking about here in Health Canada. It also addresses the more difficult questions of Métis rights, legal rights and jurisdictional issues.

We are finding it a little bit frustrating breaking down the barriers, particularly as it relates to the federal government legally recognizing that we exist as a people, that our rights are affirmed in the Constitution of Canada, that there has to be processes where we can have constructive negotiations to begin implement ing these rights. Perhaps we may have underestimated to some extent how difficult it will be to overcome those barriers. I think that is what we are finding.

Our written brief contains a lot of facts and good arguments. A number of figures and data are included. Again, I think ultimately it comes down to leadership and political will.

In this particular area, since you have the mandate of addressing health - and I did point this out to Ralph Goodale in our last meeting - there are a number of departments that have moved a bit. For example, Human Resources Development Canada, for the last six or seven years, has devolved a fair amount of dollars to our five member organizations in the Prairie provinces, Ontario and B.C. to address training and employment issues in our communities. I think we get, collectively, maybe, anywhere from $40 million to $50 million dollars a year.

That is a significant breakthrough, when you compare that to the history that I described to you. This is encouraging. It has its challenges and there are ongoing issues, but we try to work them out and we are generally successful in delivering those programs to our people.

Other departments, especially since the federal government responded in "Gathering Strength," have been moving a little, but not to the extent of HRDC. We actually have a national accord through the MNC with HRDC to devolve those programs and services to our member organizations in the area of training and employment. Some other line departments have moved a bit.

Health Canada is probably - if we were to issue a report card, Health Canada would be at the bottom in terms of where they rank in their response to Métis people. We are having difficulty getting a meeting with the minister to address these issues. I have not met with him for at least three years, I think. In terms of diabetes, several millions dollars were made available for Aboriginal people.

The Chairman: In your report, you explain the numerous committees that you are sitting on.

Mr. Morin: Absolutely.

The Chairman: They are all dominated by Health Canada.

Mr. Morin: We get $100,000 a year to address this issue. We do not get the $5 billion a year from Indian Affairs to hire core staff to do research in the area of health. We get $100,000, and out of that we pay the salary and travel expenses of an individual. I am sure the diabetes problems in our communities are just as great as they are for First Nations and Inuit people. If your report influenced Health Canada to begin responding to our people, then that would represent some progress.

The Chairman: It is at a hearing like this when I hear you talk extemporaneously that I understand. There should be no doubt in anyone's mind about the value of a hearing like this. We can always read the report; it is your extemporaneous comments that are very useful, however.

Before I turn to Senator Morin, can I ask you just to clarify one thing. With respect to your memorandum of agreement with HRDC, you said something about five members. Could you please explain that further.

Mr. Morin: The Métis National Council is made up of five provincial member organizations.

The Chairman: That is what you mean by the five. Okay.

Do you have any idea why it was you have been able to negotiate an agreement with HRDC? Were there problems with a particular minister at one time, or was it that you had a particularly sympathetic regional ADM?

Mr. Morin: That is a really good question. Actually, I am not sure about that. All I can relate to you is my own personal experience. These discussions actually started when the Tories were in power in the 1980s. I forget the minister at the time, but we began discussions in the 1980s. I am not sure the department was called HRDC then.

The Chairman: It would have been Manpower and Immigra tion, maybe.

Mr. Morin: Nevertheless, we began discussions back then about the whole idea of devolving training and employment programming to Aboriginal people. There was a very pan-Abori ginal board in place. We struggled just to ensure amongst Aboriginal people that the Métis had fair representation in that process and a fair amount of the resources. That was a struggle in itself. However, we were successful in that.

In the 1990s, there was devolution of these training programs to various Aboriginal organizations across the country, First Nations, Métis and Inuit. That existed for several years and then, I think in 1995, the MNC signed - I cannot remember its name - a national accord on human resource development with HRDC, formalizing the arrangements in which HRDC devolved those training and employment dollars to the MNC and its member organizations.

That expired in 1999, and we signed another similar accord, which is in existence until 2004. We are beginning work on negotiating a new accord when this one expires in 2004.

There is always an ongoing struggle. We have heardunofficially, for example, that some people within the federal government are saying that HRDC should never have entered into this kind of an accord with the Métis, that our expectations have been raised. Some argue that a precedent has been set, admitting federal jurisdiction, that the federal government has allowed the Métis to make the argument that it does have federal jurisdiction. Some say that the federal government's longstanding legal and jurisdictional position has been jeopardized with regard to the Métis. There is actually advice being given to the effect that these agreements should not be renegotiated with the Métis as of 2004 because of that longstanding position.

I want to point out one other thing, which I know it is not strictly within your mandate but which indicates some of the problems. I talked about the report of the Royal Commission on Aboriginal Peoples, a comprehensive report that delved into every aspect of Aboriginal life in Canada, including ours. The report was comprehensive, including about 440 recommendations. They dedicated one entire chapter to the Métis in which there were some very, very positive recommendations.

In January 1998, the federal government responded in a written document called "Gathering Strength." As well, additional commitments were made verbally and publicly by federal ministers, Ralph Goodale and so on. Hence, there were verbal and written commitments. The federal government has implemented a number of those commitments.

Let me give you an example. The Métis Nation represents at least 300,000 people in Canada, I would say. We are the Métis National Council, and we advocate for our people nationally and internationally. Prior to "Gathering Strength," we were getting about $250,000 a year in core funding to run our head office in Ottawa to represent the interests of the Métis Nation in Canada. One of the commitments in "Gathering Strength" was the increase of core funding, so that Aboriginal organizations would have a greater capacity to represent their people. Hence, our core funding was increased from $250,000 to $450,000.

In the overall scheme of things, this is a small issue, but it is a very important one to us, because the capacity to represent our people is ultimately very important in terms of advocating for their interests, et cetera. We heard just a few days ago that the commitment in "Gathering Strength" will expire on March 31 and that Heritage Canada does not intend to go to Treasury Board or cabinet, whoever is responsible, to seek a renewal of this increased level of core funding.

Therefore, if the increased funding is not renewed, our core funding will drop from $450,000 to $250,000. I suppose the federal government can argue that it has fulfilled its "Gathering Strength" commitment of increasing core funding to Aboriginal organizations, which would only have lasted for three years.

This is discouraging. Quite frankly, what is happening in terms of global and international affairs affects us. People are beginning to realize that more so than before. As a result of the events of September 11, there are increased pressures now to spend on security and national defence issues. In times like this, Canadians tend to be less sympathetic to the plight of Aboriginal people and certain other domestic concerns.

Hence, it is fair to say, and certainly in my travels and from the discussions that I have had with our people, there is a lot of concern out there. Our expectations were raised. We gathered a lot of momentum, and we are hoping that we will continue to go in that direction. Nevertheless, there is a lot of concern that perhaps we may lose that momentum.

Senator Morin: Thank you very much, Mr. Morin, for attending here again to address a very important problem.

You did not answer Senator Kirby's question concerning whether the health services of Aboriginals should move from Health Canada to Indian Affairs. I think that is a very important issue; it is important that it be answered. There are several arguments there to be made in favour of that.

The second point is dealing with research. You state here, you underscore the statement, that research is very important in dealing with Aboriginal health. You say the following: "Research should arise out of the needs of the Aboriginal community and with their full cooperation and acquiescence."

You might not remember, but I think when you were here, a presentation from the Institute of Aboriginal Peoples' Health. The director is Jeff Reading, himself a Mohawk Indian. I believe their advisory committee consists of a majority of Aboriginal people. It is well-funded - maybe not sufficiently funded, and that is another issue; maybe we could consider giving it more funding. By the way, their work, their reports, the minutes of their meetings are on the Web. They can be accessed through the CIHR Web site.

From what I read, it seems to be a totally Aboriginal committee. They have a strategic plan, which has been initiated, as far as I can see, by Aboriginal people. Perhaps you will fault with that. If you do, I would be very much interested in knowing what your reaction is to it.

Many people were hoping that this would be really an answer to the problem you have raised in your document.

Mr. Morin: With respect to the earlier question that was asked by Senator Kirby, for us, that would not be a solution, because the Indian Affairs and Northern Development strictly has the mandate of dealing with First Nations and Inuit people in Canada, primarily First Nations people on reserve. First Nations people off reserve complain that they are not being serviced adequately, and they are being discriminated against as well. DIAND's mandate is strictly to address the issues of First Nations and Inuit people in Canada. Of the $5 billion a year, plus, that goes to the department, none is available to Métis people. Hence, that would not solve it for us.

Because of the historical policy of non-recognition of our people by the government, it does not have the capacity nor has not it created any institutional change to be able to address our issues adequately. That is a big problem.

I think, Senator Morin, you were talking about the National Aboriginal Health Association?

Senator Morin: No. I was referring to the Canadian Institutes of Health Research. Within the Canadian Institutes of Health Research, there is the Institute of Aboriginal Peoples' Health. When you presented to us the last time, immediately after you there was a presentation by Dr. Jeff Reading, who is a well-known researcher. As I said, he is a Mohawk Indian. He gave a very good presentation on the status of Aboriginal health. The institute is conducting health research in the area of Aboriginal health. They are well-funded. The majority of the people at that institute are Aboriginal. If you go to www.cihr.ca, you will see a list of the institutes. You can access the Institute of Aboriginal Peoples' Health there.

Dr. Reading is very available. I have phoned him on several occasions. He will be very pleased to meet with you personally.

The Chairman: I think that would be a good idea.

Senator Pépin: I have to tell you that the Métis have a very outspoken person in the Senate. For two years, Senator Chalifoux, who is a Métis, has advocated for the Métis people. She has an office in Morinville, Alberta.

Senator Morin: A very good name.

Senator Pépin: Senator Chalifoux speaks for her people.

As you said, you do not have access to research and things like that. I was not present for your first presentation, but I must agree, I support Senator Morin, that the federal government really has to do something.

It is quite interesting that you have not had a meeting in three years with the Minister of Health.

Mr. Morin: Well, we are still trying.

Senator Pépin: We may be able to help you on that one.

Mr. Morin: If you do not mind.

I would now ask my colleague, Mr. Fidler, if he has anything to add.

Mr. Don Fidler, Director, Health Care, Métis National Council: I thank you, as well, for the opportunity to appear. The issue of research is an important one, and, yes, there are some sectors that are doing research, and particularly in Aboriginal health. Our problem is that still, in terms of the needs, a lot of the research dollars are going to the academic community. A lot of the direction of research is directed, essentially, by Health Canada. There still is very little attention paid to us, as to what type of research is needed. There is not much attention paid to the question of building capacity in research. We are dealing with a widely dispersed community, and I think you would have to agree that if we are to have a chance of addressing the health needs of Aboriginal Canadians, it is Aboriginal Canadians who will have the opportunity to do that. In order to do that one needs to be able to gather the information. More often than not, one has to gather the information at the community level.

Because of the nature of research in Canada, which more or less is determined by bureaucracies that set the limits of research, such that it is academics from mainstream universities that get bulk of it. For example, SSHRC is directing a lot of research in Canada. Community-based researchers oftentimes are shut out. SSHRC did start a program, under what they call CURA, which essentially is a community-based research program. It is showing some promise. We need to be able to find ways to access research dollars, so that we can look at the needs of our people from our point of view. We need, as well, to be able to build capacity. In order to do that, partnerships must be created with local communities and researchers so that research is not vested or in the ownership of those who do it but research belongs to the people that the researchers are working with.

One of the major problems we as Aboriginal peoples have experienced is that we have lived a fish-bowl existence as far as research goes. A lot of people have made a lot of money. Also, the academic credentials of the researchers are based upon the research that they have done with Aboriginal peoples but very little of it has come back to ourselves. I think that we need to start looking at a different way of doing research. We have to look at the notion that perhaps meaningful research is not necessarily the purview of academics but that community-based people also should have the capacity to be able to look at the questions that are important to them.

Senator Keon: I will not ask you a question, Mr. Morin. Your presentation was very clear. You have my complete understanding and support. I can assure that we, as a committee, will give some real time to your predicament. I wish you well and hope that you see some daylight soon. If there is anything that I can do as an individual or as a member of this committee or as a member of the Senate at any time, I would like to.

Mr. Morin: Thank you.

The Chairman: I want to thank you for attending here. As our report indicates, we were substantially influenced by your previous presentations.

Mr. Morin: Yes.

The Chairman: Just to pick up on Senator Keon's point. Some of us who have been around the Aboriginal issue for a long time, 20 years in my case, understand the dilemma that the Métis have always had, frankly, and would be delighted to do whatever we can to push it, not just on this front but on other fronts. You are quite right, the federal government has a policy in some sense of non-acknowledgement, but having been involved in the constitu tional negotiations you were acknowledged. It is an are-you-or- aren't-you kind of situation.

Therefore, anything we can do to help push those issues, please let us know. Just call us personally; we would be delighted to help.

Mr. Fidler: I just wanted to respond to a previous question relative to Health Canada. One of the great problems we have with Health Canada is that Health Canada's official position is that they have no mandate to be able to deliver services to anyone other than First Nations and Inuit. Hence, in any discussion that we have with them, in terms of accessing even something that may come close to equitable delivery of services, their official reaction always is that they have no way of being able to do that because they have not been given the mandate to do that.

The Chairman: We will undertake to investigate that question. I am not surprised that that is the position, but it is inconsistent with some government positions vis-à-vis the Métis on other questions. It is the inconsistency that makes it very hard to read.

Mr. Morin: I just want to say in closing that I thank you very much. This has been our second presentation to this committee. I can tell from your report that you listened to us the first time. We like the report and the recommendations. I thank you very much for hearing from us, and I hope your next report will have some impact on the federal government. I wish you well in your work.

The Chairman: Thank you. We will keep pushing.

The committee adjourned.