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

Issue 32 - Evidence

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EDMONTON, Wednesday, October 17, 2001

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 8:31 a.m. to examine the state of the health care system in Canada.

Senator Michael Kirby (Chairman) in the Chair.

[English]

The Chairman: First, Mr. Mazankowski is appearing today as the chair of the Premier's Advisory Council on Health in the Province of Alberta. We are delighted to have you here, and some are old friends of yours from the minister's office, and some were old friends of yours, indeed, in the House of Commons.

I know you have an opening statement, and we would be delighted to ask you questions. Thank you very much.

Hon. Don Mazankowski, Chair, Premier's Advisory Council on Health (Alberta): Thank you very much, Mr. Chairman and senators. It is a pleasure to be here before you. I have with me Ms Peggy Garritty, who is helping me and the other members of the council in trying to document many of the things that we have heard and things we would be in a position to propose.

Let me begin, Mr. Chairman, by congratulating all the members of this very important committee on the ongoing and excellent work that you are undertaking. At least, from the work that I have examined so far - and I think this view is shared by others - I believe you are providing an objective, comprehensive and factual overview of the state of the health care system in Canada and identifying a number of the major issues and possible policy options.

We like the manner in which you are proposing various policy options on a non-etiological basis, and it is encouraging to note that no option is foreclosed. I think that is the kind of honest debate that we need to have on this issue. It is a very important issue.

I think that the work that you are doing will contribute very positively to advancing the national debate because it is an important debate that affects the lives of all Canadians. Volume 4 in particular, I think, provides an excellent framework from which to launch the more thoughtful and comprehensive debate.

Like all other provinces, Alberta is seized with the issue of health care. It has been the subject of many studies, many initiatives and various attempts to overcome the issues of the day.

In an attempt to help define the kind of health care system that will be needed in the future, the Premier established an advisory council to provide strategic advice to him and his cabinet, and the government, on the further enhancement of quality health services for Albertans, and particularly the continuing sustainability of the publicly funded system.

You will see attached to the statement that has been handed out, the Premier's terms of reference, the initial announcement on January 31, which named myself as the chair, and the other members of the committee announced on August 18 together with a little summary of their backgrounds. You can refer to that in looking at the people who make up the committee.

We started our work just a little over a year ago. We have met with a broad base of stakeholders, groups and individuals to listen to their views, and we have heard a lot and we have all learned a lot. It is a complex system.

As a starting point, we began by defining what we wanted to achieve with our health care system. We prepared context papers on things like waiting issues, shortage of health professionals, sustainability, cost drivers, Albertans' opinions on the use of the health care system, is the health care system balanced, and basically, how the system works. Those documents will be accompanying our reports to the Premier. It is a form of backgrounder.

We started out describing the goal we wanted to see set for Alberta in this way: a sustainable health system that is a partnership between users and providers, that continues to evolve and improve, and results in better health outcomes for Albertans; a system that is research and evidence based, has the right incentives, and is a model for Canada and the world.

Then we set out to define each of the words that make up that mission: "sustainable" means that the system has sufficient resources, both dollars and people; the resources available to respond to various forces that drive changes and increase costs, and plans in place to ensure that there are adequate resources to support Alberta's health care system.

Then we described what we meant by "the health care system," what we mean by "evolve and improve," what we mean when we say "better health outcomes," what we mean by "research and evidence based," what we mean when we say "we need to have the right incentives," and what we mean when we say "we want to be a model for Canada and the world."

Much of the work that we have engaged in is focused on three critical issues: namely, the sustainability of the publicly funded health system; improving and ensuring access to quality health care services; and how we could best improve the health status of Albertans.

Let me just deal briefly with those three issues, and sustainability first and foremost. There are a number of threats that we see to the sustainability of the health care system. We say that the continuing escalation of health care costs without a clear funding plan, the consequent impact on federal and provincial treasuries, and the crowding out of other important spending priorities creates an unstable climate. These all affect the confidence in and performance of the health care system.

We outline current spending trends, noting that health spending in Alberta has increased from $3.9 billion in 1995-1996 to over $6.4 billion in 2001-2002, a 64 per cent increase. If you add in capital costs, the total expenditure on health care in the Province of Alberta this fiscal year is $7 billion.

That works out to $20 million per day. In 1990-1991, Alberta spent 24 per cent of its budget on health and 76 per cent on other programs. In 2000-2001, about a third is being spent on health and 65 per cent on other government programs.

Alberta, given its economic base, can only sustain the current spending trends if its economy remains strong and provincial revenues stay high. As most of you know, we do have a volatile economy, heavily dependent upon our natural resources. If prices level off or decline, it makes it very difficult to manage this responsibility.

If you look at the bottom of page 4, you will note that our current budget is based on a $5 mcf for natural gas, and you all know it is currently considerably below $3. Each 10-cent drop or variation in the price of natural gas, that is, 10 cents per mcf, results in an impact of $142 million on the provincial budget. Likewise in the case of oil, every dollar of price variation per barrel has an impact of $153 million on the provincial budget. You can see the volatility of price has an important effect.

Alberta, like other jurisdictions, has seen its health expenditures rise significantly over the last 10 years, and looking ahead, we foresee, if current trends continue, that our health care budget will be consuming up to 50 per cent of our provincial budget by 2008.

In trying to assess that, you look at cost drivers and factors that drive up health care costs, and we think that the provincial and territorial ministers did an excellent job of categorizing those factors that contribute to health care costs. I will not comment on that further, but we are using that as a reference guide. Clearly, they place them into three categories: basic cost drivers, cost accelerators, and the impact of system change, all of which will tend to drive costs up.

Let me just deal briefly with accessibility. Here in Alberta, as in most provinces, accessibility is the number one concern. People worry that they will not get the health services they need when they need them, and waiting times for some procedures are lengthy, in spite of government efforts to target funding to reduce waiting times. We have backgrounded that material for you to some extent.

Clearly, if there is one thing Albertans should be able to expect from their health system, it is access to health care service when they need it. Access should be available on equitable terms, and that is at the heart of what we expect from our health care system. However, too often, it is not what Albertans get, in spite of significant and growing investments.

Therefore, given the desire for better access and the escalation of health care costs, we must extract the maximum value from every dollar we spend, and we must find ways to diversify the revenue base to support health care so that people can get equitable care on a timely basis.

Let me just turn briefly to the section on improving the health status of Albertans. This is, essentially, the very foundation and core of the work of our report. Our advisory council believes that the promotion of good health, wellness, disease prevention and healthy lifestyles is fundamental to a strategy for health care reforms for the future. As we work through this, we intend to spend a fair amount of time and put a great deal of emphasis on this particular issue.

In terms of our approach, we divided our group up to look at five different areas. Number 1 - and this is how our first report will evolve; it will be based upon the work that we have done in these five particular areas - how do we enable people in communities to take more responsibility for their own health? Number 2, how can we best organize and deliver health services? Number 3, how can we ensure an adequate supply and the best use of health providers? Number 4, how do we pay for these health services? Number 5, how can we get the outcomes we want and ensure continuous improvements in the system?

As I said, these studies and the work on this is based, to a large extent, upon the evidence of our findings and upon the context papers, which we have outlined, that provide a picture of the state of affairs in the health care system in Alberta.

Now, let me just conclude by talking about some of the major considerations that are underway.

As you know, Mr. Chairman, our committee is continuing its work. We have not completed our first cut at identifying issues and suggesting solutions. What I am saying here today outlines approaches and directions that we are following as a result of the consensus that is developing. However, by no means have we concluded our work, and we are at a very critical stage of defining with more clarity, some clear options based upon the findings.

Let me just say this. Some of our major considerations and key themes that are emerging include: First of all, our report will not be about a quick fix. We are looking at the best ways to sustain the system over the longer term, and not necessarily to reduce cost in the short term. As a matter of fact, some of the things that we see as curing some of the problems that we have identified may, in fact, cost more money to begin with, in terms of putting in the system changes that will evolve.

Second, we need to extract maximum value for every dollar spent on health care; that is critical. However, those measures alone will not be sufficient to match the increasing demand on the health care system.

Third, we must look at diversifying the revenue stream. The burden on the tax base is getting too large, and as I said, by 2008, 2010, it could consume half of all the spending in Alberta. Therefore, we believe it is time to explore other ideas and look at their impacts, things like medical savings accounts, co-payments, deductibles, private or supplementary insurance, taxable benefits, et cetera, and look at them in a very objective and unbiased way.

Fourth, government spending on health cannot be allowed to crowd out spending on other essential services like education, infrastructure, or security.

Fifth, we believe the answer does not lie in rationing health care services. People are concerned about access, and rightly so. We believe that all Albertans should have access to the very best health care when they need it, and it should be available to everyone on equitable terms.

We also believe that it is time to think carefully about what should be covered by medicare. We believe the system was never designed to cover all aspects of health care services, but people have come to expect that it will, and at no cost to the individual.

Furthermore, I know that you, Mr. Chairman, as do I and many members of my committee, believe that you cannot regulate anything to perfection. We believe it is time to open up the system, take the shackles off, and allow health authorities to experiment, to try new ideas to see what works and what does not.

We see the health system, as it is presently constituted, as a monopoly, where government serves as insurer, provider and evaluator. We say it is time to "unbundle" the system, separate some of the functions, set clear roles and introduce more competition and choice into the system.

Next, if we are going to have regional health authorities, and we believe the concept is good, then it is time to give them the tools and the mandate to do their job and hold them accountable. We see a gap in their ability to carry out their mandate.

We see examples of interference, and we see examples of where they have the responsibility, but they really do not have the tools and the mechanisms to carry it out.

Next, we believe that we need an innovative blend of public and private health services, and in that connection, Mr. Chairman, we cannot single out any one of these things in attempting to cure any of the problems. We are looking at a package here, and we cannot cherry pick. Our sense is that in reforming the system and trying to make it work better, these things all have to be done, albeit maybe incrementally in some cases, as a package, because cherry picking will only exacerbate the problem.

Therefore, if we unbundle, if we create a system that is more patient oriented, that gives the patient more choice, we can encourage the development of an innovative blend of public and private health services. We can start with encouraging more contracts between health authorities and a wide range of public and private providers.

We can set standards and make sure that they are met. We can assess outcomes and costs, and we should not let the fear of private medicine get in the way of opportunities to improve capacity and provide better access to care. We do not believe that you should differentiate.

Finally, we do not have to choose between the status quo and an American-style health care system. We can and we must create our own alternative, one that preserves the best of what we have, but is also sustainable for the future. Then again, to reiterate the very foundation, we must encourage people to take more responsibility for their own health and find the best way of helping people to stay healthy through promotion, prevention and protection, and healthy lifestyles.

Mr. Chairman, as I said, the work that we are engaged in is important, and our task is not to present a quick fix. We appreciate very much the number of ideas and options outlined in your report. As I said before, this kind of debate will certainly stimulate and advance the national debate.

I have been asked whether medicare is dead, and my reply is a strong and definite "no." However, that does not mean that we are immune to change or that it is not time to redefine what we mean by "medicare" in the 21st century.

It is time for Canadians to embrace the debate, put all of the ideas on the table, preserve what is essential, avoid rejecting ideas out of hand, and be willing to experiment and give new approaches a try. Only with this kind of open discussion can we take the required actions to sustain Canada's health system today, and in the future.

We have been challenged, Mr. Chairman, to be bold in our recommendations, and while I am not in a position to outline any specific recommendations today, I can offer this: I think it is fair to say that our report will live up to the challenge of being bold and different.

Mr. Chairman, I must say I am sorry that I did not have translated copies of my presentation. It was my fault. I was travelling and did not get to it.

The Chairman: Knowing your schedule, we appreciate your being with us, and may I say that from our point of view, it is delightful to know that there are kindred spirits with similar views to those expressed by the people around this table.

You commented on the need for experimentation - and I realize this is outside your mandate, so I will volunteer this comment. Clarity requires that the Canada Health Act be changed, at least to allow pilot projects, experiments, whatever you want to call them, that violate the existing terms and conditions of the act. One of the problems with the Canada Health Act is that it does not allow even pilot projects.

I realize that is in our bailiwick, in a sense, not yours. I just want to tell that there has certainly been some discussion.

You can read that between the lines in Volume 4. We understand that, at the very least, allowing some experimentation would be required.

Senator LeBreton: I must say that I agree with Jeff Simpson. I do not often agree with Jeff Simpson, but I did when he said, knowing Maz, Albertans should expect short on theory, long on no-nonsense advice, and quite likely, a few startling ideas. I think that was a good forerunner to what we can expect.

Mr. Mazankowski: Senator, we have been trying to cool expectations.

Senator LeBreton: Well, you have a reputation to live up to. I have a couple of questions, and they are not necessarily related. On the whole issue of accessibility and waiting times, of course, a lot of people look to Alberta because of its resource-based economy. People assume that if Alberta can get it together, that is a kind of beacon light.

Have you compared Alberta, in your studies, with other jurisdictions, other provinces in terms of accessibility and waiting times?

Mr. Mazankowski: Yes. We have, to some extent, in our context paper, and that will be provided as background. Alberta has addressed this issue and is very cognizant of it. I think some improvements are being made, but there are still areas where the waiting times are considered to be too long, particularly for CAT scans, MRIs and things of that nature.

There has been improvement, but there are a number of cases where the waiting times are not acceptable.

Ms Garritty did most of this work.

Ms Peggy Garritty, Premier's Advisory Council on Health (Alberta): It is difficult to make comparisons. We have some information, as I think other provinces do. However, it is difficult to compare waiting times because there are no standard definitions and no standard processes for how people on waiting lists are managed. It is very difficult to do.

Mr. Mazankowski: Also, there is a lack of data. We do not have the database to measure outcomes, quality, and many of these other things. First and foremost, in this age of high-tech, we find that the medical care system is way behind on that front.

That will probably create additional expenditure, but it is a must if we are ever to get a handle on how to measure outcomes, how to apply the evidence-based research and how to identify the problems with respect to waiting and accessibility. We do not have that database, and I think you will probably find that is the case right across the country.

Senator LeBreton: Yes. I think the Canadian public assumes in this age of high-tech that there is instant sharing of not only data, but also information when a person from one part of the country happens to become ill in another, and that is not necessarily the case. It certainly calls into question the accessibility section of the principles of the Canada Health Act.

You discussed community care or the regional health authorities. Are there any examples presently in Alberta of where some regional health authority or community care is working?

Mr. Mazankowski: Yes. Indeed there are a couple. One that has been much referred to provincially, and even nationally, is the Edmonton North East Community Health Centre experiment, which is working quite well and making some very major breakthroughs. There is another one in the Calgary area, the Crowfoot Family Practice.

The problem with pilot projects is there is so much surveillance and so much accountability placed on everything they do, they do not really have the freedom to manoeuvre. Also, the funding is always a bit of a problem. I think it tempers the innovative and creative spirit to some extent.

The ideas are good, and we are hopeful about the experiment in Edmonton, which is, I think, working very well. Obviously you will be meeting with the CEOs of the capital and Calgary regions. I think they will be able to comment on that.

Those are the only two of significance. There is also one in Bassano that was developed under the auspices of that particular regional authority. However, the progress and the evolution of these things are not as rapid and fully developed as I think we expected.

Maybe we are expecting too much, but I think they need more freedom to experiment. They need fewer shackles on their funding, and I think that is frustrating to people as they go through this.

I know that in the Crowfoot case, it was only through the dedication of the professionals that they were carrying on, because they were working for a lot less money than they were before. If the medical professionals end up making considerably less than the current fee for service, you know the experiment will fail.

The answer to your question is yes, there are a few, but the jury is still out on their success. We are going to have to be more all encompassing in our support, or we will not reap the benefit of that sort of initiative.

Senator LeBreton: You said in your opening remarks, "Let them do their job."

Mr. Mazankowski: That is right. The regional health authority concept has pros and cons, but it is a structure in place. I think it works very well in a number of areas, but I think that they are somewhat hampered by the fact that they do not have full control over their destiny.

Senator LeBreton: I ask the question because in our study so far, a lot of attention has been paid to remote and rural areas, and certainly a model like this, with nurse practitioners, might be the answer for those areas.

I am going back to reading this piece from Jeff Simpson, in which he talked about the need for health care inspiration. "Alberta is your beacon." He also talked about the courage of Bill 11, which, of course, became such a political football.

Are you monitoring the effects of Bill 11 in your studies? How is it impacting on the deliberations in which you are trying to come up with these solutions?

Mr. Mazankowski: I think it is fair to say that most of the evidence we have heard so far is that it has not made much difference.

Senator LeBreton: Positive or negative?

Mr. Mazankowski: Positive or negative. Things that were being done before are being done to date. If anything, perhaps there are a few more restrictions.

Senator LeBreton: Can you elaborate?

Mr. Mazankowski: Well, apparently the regulatory process is probably more cumbersome than it was before. I think that that is really what they are referring to.

Senator Morin: Thank you very much, Mr. Mazankowski, for coming and giving us the extremely interesting report. I think you have the right approach in considering all options, studying them, and then coming up with a solution based on the best available evidence.

I think you outlined the problem very well. I am always surprised when we hear witnesses state, as we have, that our system does not require extra funding. I want to quote one sentence in your report that I think is very important:

Demands from health care will increase and cost more...not because people use the system frivolously...but because we are on a relentless pursuit of new knowledge, new treatments...

I think you really hit the nail on the head there. As you know, many countries, including Britain, Sweden and others in Europe, are considering what we call the "payer-provider split." You alluded to the fact that right now, we have a single payer, single provider, and as you stated, a single evaluator. You also considered the possibility of having, for example, a single payer but several providers, bringing competition into the system. I would you like to expand on this, if possible.

Finally, I hope, Mr. Chair, that we will have more opportunities for exchange of information between the council and our committee. I think we are both considering the same problem from different angles. I very much appreciate your coming this morning.

Mr. Mazankowski: Your assumption is right. I think we would like to see several providers. We would like to see a more patient-oriented system in which the patient has greater freedom of choice and the providers have greater latitude.

We would like to see a system without differentiation, where the money follows the patient, rather than having to tap into this pool of funds over which everybody has to squabble to get their share. It is like any form of regulation. It is very difficult to regulate and refine with any degree of accuracy.

Under the alternative arrangement, the money will flow with the patients to where they get the best service, best quality and best outcomes. We think that if we can relax the system and allow for greater innovation and creativity, we will see all sorts of new approaches that we believe would be healthy for the system.

Senator Keon: That was a truly interesting presentation, Mr. Mazankowski. In fact, you seemed to encompass almost every health system that exists. I am going to come back to what Senator Morin raised, because I think this requires a tremendous amount of thought and may be the key to everything, and perhaps most of all, to relieving the anxiety produced in Canadian citizens when we tamper with the health care system. I think many Canadian citizens are afraid that they will lose their "universal insurance," so to speak, and face catastrophic costs from illness.

The idea of separating out the insurer or the payer, and the provider and the evaluator, I think is something that all of us have to spend a lot of time thinking about. I was also interested to hear you throw out the concept of a medical savings account, which would increase accountability with the insurer. However, whatever mix we develop, whether we use a European mix or not, people are assured they are covered one way or another, but can accept some responsibility for it according to what they can pay. Then the uncoupling would allow the system to glean efficiencies with providers. I am afraid one of the traps we have fallen into is that we produced some systems so big that we do not know how to manage them after we get them up and running, and it might get us out from under some of those problems.

The evaluator is probably the most important component of all, and it is interesting that Marc Lalonde, in his report a number of years ago, emphasized that if a universal health program is to be successful, then it will have to be done on the basis of population health, with continuous evaluation of the population health of the region, the province, the country, whatever units we want to look at, and with appropriate feedback and adjustments to deal with the problems we discover.

Then I would suggest that since we do currently have the regional authorities, it would seem to me that that concept could be layered on top of the regional authority, and indeed could be implemented without too much in the way of headaches as compared to some of the other systems we are looking at.

You already answered Senator Morin's question about uncoupling insurance and the provider, but I would like you to expand on where you see the evaluator coming from. Is this going to be an Alberta evaluator? Is this going to be an independent evaluator, where you would, perhaps, contract with a Canadian firm or maybe an American firm or maybe a European firm to come in and evaluate your various units and give you the information you want? Would it give you the flexibility to change evaluators every couple of years if they were not doing their job, instead of being stuck with some bureaucratic invention within the province? Have you had time to reflect on that, sir?

Mr. Mazankowski: Yes. We have thought about this. We see two areas that we believe require very close monitoring, and of course, this is assuming that we get the kind of database in place that is needed for evaluation. You cannot measure outcomes if you do not have the data. That is the first premise.

We know that Sweden has taken action on accessibility. We are looking at whether, in fact, we can define accessibility as adequately, or whether we can establish a set of standards or provide information on a Web site as to what kind of waiting lists there are in what areas and where they are the most critical.

We really believe that in order to address that issue, we have to put something in place to monitor and to highlight that. Maybe it is in the form of a health commissioner, a health ombudsman or something of that nature, and the same thing applies to quality and outcomes.

We are looking at various mechanisms, and we will probably advance some suggestions on that front too. We are also toying with the idea of invoking change, and we are not talking about a revolution here; we are talking about incremental change, done in a practical and pragmatic way.

We may very well need something like a health commissioner to oversee and drive the process and make sure that it moves forward, but also to act as a kind of ombudsman if anyone is falling through the cracks and being denied service because of the reforms. That would be for a limited time.

We have not yet considered the structure, to whom that person would report, whether it would be for a fixed period and whether it would be contracted out. I think, Senator Keon, to make this work, we need to do two things: We want to ensure that it progresses in a fair and equitable way and that no one is hurt by the change or falls between the cracks; and at the end of the day, we want to measure whether our outcomes were positive, negative, or neutral.

I appreciate your comments. You will have the RHA CEOs here. You will be able to get a good idea from them about what can be done in a practical way to advance some of the broader payer-provider issues to which we refer.

Senator Keon: I would also like to hear your thoughts on information systems, because you are quite far advanced compared to most parts of the country. You have people who are known locally and nationally with various working groups. I have spent quite a number of years myself on these various committees, and my feeling is that we have never been able to get the system up because we have been putting the emphasis on the wrong end.

We have been talking about big, bureaucratic systems, and that raises all kinds of anxieties in our citizens about privacy and related issues. I believe that we have to come at this from the other end, so that every citizen in Canada will have a health card, which is their health record, and that is their responsibility. The technocrats can put in the necessary firewalls. If people want to protect their privacy, they simply carry the card with them.

Have you had time to look at this and where are you going in that direction?

Mr. Mazankowski: Alberta is progressing in that area, but probably not as rapidly as is necessary. We are talking about the need for a health card. Of course, there is controversy over what types of information that card would access. Obviously, we need that kind of system to do the things that we should and we expect to do, such as monitoring outcomes, accessibility and waiting lists.

We will be very forthright in moving forward on this front, because it will be pretty central to the issues that we will be advancing.

On the question of making things too big, our committee has seen many problems arising out of the command-control kind of operation we have had in our health care system. As I said, you cannot regulate everything to perfection.

I think that is also part of the reason for the shortage of health professionals. The command-control system has let us down. We are talking about freeing it up, just unbundling and allowing the initiative and the creative spirit of those in the medical profession, those on the administrative end, and those who want to make the system work better, to get on with things. We think this is a great opportunity.

Senator Roche: I want to say, Mr. Chairman, that Mr. Mazankowski's service to Canada and Alberta over many years has been outstanding.

The Chairman: Absolutely.

Senator Roche: We are fortunate, I think, to have him in the role he is occupying now on the Premier's Advisory Council on Health.

The brief that he has brought before us this morning is very clear and helpful. There are a couple of points I would like to expand on a little.

First, I am struck by the projection that Alberta's spending on health, now consuming a third of the government's budget, is on track to become 50 per cent, and this will inevitably squeeze out other necessary programs such as education. Something must be done about this. I am concerned that the amount of money available for health seems to be so directly tied to the international prices for oil and gas. I am just making a marginal comment on that.

What I am getting to is Don Mazankowski's assessment that medicare will have to change, as will our understanding of it. I took from that that an innovative blend of public and private sourcing for health care will have to become a new characteristic of medicare. Am I correct that there is not enough money in the public system to pay for the escalating costs of health care in the 21st century, that new sources will have to be found, and that private funding will have to complement what we have always understood, through medicare, as being public funding?

Mr. Mazankowski: Theoretically, there probably is enough money in the public system to fund it. You just raise taxes. We are drawing attention to the question, what is the magic figure? Is it 50 per cent? Is it 60 per cent? Should it be 30 per cent or 35?

We sense that the burden of taxation on Albertans and Canadians is almost at the breaking point, and that there may very well be more cost-effective ways of doing things if you experiment and try new things.

We just do not believe that throwing more money at the problem will necessarily result in better health care outcomes.There are ways and means to achieve better health outcomes and better quality, and in a more cost-effective way.

We are saying that Canadians, or Albertans, have to take on more responsibility for their own health in terms of living healthier lifestyles, and this is very fundamental to everything we are going say. This is really the first tenet.Albertans need to take more responsibility for their own health in terms of protection, promotion and prevention and leading healthier lifestyles, and Alberta Health and Wellness has to be very much a part of that. It goes right into the education system. That is first and foremost.

Secondly, I think with the advances in new medicine and new technology, access to which can prolong life and improve lifestyles but are very costly, we need to find ways and means to deliver that service and pay for it, rather than saying, "Look, that service is available but we cannot afford it. You cannot have it."

Jurisdictions are forced to live within a budget, and so they ration the health care services to fit that budget. As a group, we are saying we do not like that approach, and what are the alternatives to that? Are there ways and means whereby we can rebalance the payment structure?

Maybe there are things now covered under medicare, under the definition of "comprehensiveness," that an individual can take more responsibility for, but we then broaden the scope at the top end. Those are the kinds of things that we have to discuss. It is a combination.

You will not fix a system simply by trying to extract better cost-efficiencies and reducing administrative costs. Some who have evaluated the health care system in their individual provinces and in other jurisdictions have suggested that that is the answer. We do not see that as the answer. We see that as part of the solution. We want to make sure that we get good value for the dollars that are being spent, but we believe that it has to go beyond that.

Senator Roche: The point you made about people taking more responsibility for their own health is well taken. We have heard this before, and I think the committee is pretty convinced that this is an important element going into the future.

The question of more responsibility, though, also raises the question of patients paying for a certain amount of their own health care. It gets into the controversial aspect of user fees. I sense your hesitancy about making any definitive statement on user fees.

Let me call on your political background to ask you, if user fees were to become necessary or a desired instrument for finding more money for the system, how would this be sold politically to a sceptical public? How could such a system be made more politically palatable, in your view?

Mr. Mazankowski: Mr. Chairman, Senator Roche, I am not a politician, so I will not give you a political answer, but I will give you my personal viewpoint. I do not like user fees. I think there are other, more effective ways. Once in a while, we go back and read the last speech Tommy Douglas made in the legislature, where he indicated that he felt that individuals should pay something towards support of the health care system. There was always the assumption that there would be some form of payment made, and that it would have a psychological impact if nothing else. If we really want to go back to the basics of the medicare system, all we have to do is read Tommy's Douglas's last speech in the House. I have the quote here, from 1961, if you would like me to present it.

Having said that, things are evolving in such a way that if we want to save the system - and our group wants to save medicare; we want to save the system - we have to make it work. We sense that many people fear this continual talk about sustainability and whether the system will be around in the future.

The greatest fear in the minds of a lot of people is this: Will the system be there when I need it? That is the lack of confidence that exists in the system.

We want to try to deal with that. We would like to advance something that provides a framework for sustainability, fairness and equitability, and that allows you to receive the best and the latest treatment. However, there may have to be some kind of sharing of costs; that is also fair and equitable.

We are not there yet, but as I said, we may not be bold, but we will be different. And I should say that our report will be to the Premier, and it will be up to him and his colleagues to decide whether our report is worthy of consideration or fit for the trashcan.

The council that he has established is of a permanent nature. Our appointment is for a two-year period, and after that, he can appoint new members, reappoint some of the existing ones, or a combination of both.

Our mandate is to report to the Premier, and we are to look beyond the issues of today. We are to look beyond the year 2005, 2010, to see what kind of system we need to respond to the challenges on the horizon.

The Chairman: Just to echo your Tommy Douglas history, as we indicated in our first report, when medicare was first debated in Ottawa, there was a suggestion that there be an element of patient pay; not user fee, but patient pay.

We have always used the term "patient pay," because it means that patients might pay somewhere in the system, as, by the way, all Albertans now do. You call it a "premium," but it is an element of patient pay.

The problem with user fees, as you correctly identify, is that payment at the time of service is highly questionable for many reasons. However, the notion that the patients ought to make a contribution was certainly part of the original federal debate back in the early 1960s. I will get your Tommy Douglas quote, because there will be a number of occasions where it will be very useful for me to use. I will tell you that I found one from Tom Kent on the Liberal side that was equally effective from my point of view.

Mr. Mazankowski: I have some good friends over in the NDP who did this research for me.

Senator Pépin: Mr. Mazankowski, it is always a pleasure to see you.

I come from Quebec, where we have a very severe shortage of nurses. As we have been travelling across the country, we have been told that many nurses are coming here to Alberta to work. There must be good working conditions. You must have something special here.

In your study or in your approach, how do you see the work of nurses in the delivery of care? Do you see them as practitioners, partners, team players, or people doing paperwork, because as you mentioned, you a want partnership between user and provider. I do not know if you have had time to look at nursing.

Mr. Mazankowski: Indeed we have. We see them very much in a professional mode. There are issues between physicians and nurses in terms of their working arrangements that have to be overcome, and we would certainly like to see that resolved. We will be saying something about that.

Senator Pépin: Would you be able to facilitate the process?

Mr. Mazankowski: Absolutely, and we see potential here for partnerships between the various medical professions to provide a broad range of services in established enterprises. We have had some excellent presentations from the nursing profession, and we have also had some excellent presentations from the physicians, and they basically agree. However, for some reason or another, they have had difficulty in coming together to resolve the problem. Someone will have to do that.

On the broader question of the shortage of nurses, again, I think it is a product of our command-control system. We try to predict what will be needed out there, and we do not do a very good job of it.

Senator Pépin: I will be watching for the report.

The Chairman: Thank you very much for taking the time to be with us. In closing, just to echo Senator Morin's comment, I think an informal meeting between some of your colleagues and some members of this committee would be very useful. You and I can perhaps have a chat soon about how we might do that.

Colleagues, our next witness is the Honourable Edward Picco, the Minister of Health and Social Services for the Territory of Nunavut.

Thank you very much for coming, Mr. Picco. I know on our original schedule, we had you and Mr. Mazankowski at the same time. However, we have always given ministers the privilege of appearing on their own.

We are delighted that you are here. I know you have given us a handout. If you would proceed with your opening statement, we would then be delighted to ask you a series of questions.

Thank you, by the way, for coming all the way from Iqaluit. We appreciate your being here.

Hon. Edward Picco, Minister of Health & Social Services (Nunavut): Mr. Chairman, I think it is important to bring today to this standing Senate committee some very frightening statistics, and a very disturbing outlook on health care and health provision in the northern part of Canada and also for the Aboriginal populations across Canada in rural areas.

I think Mr. Mazankowski hit the nail right on the head when he said that the health status of people in general depends on their socio-economic status. That is the major determinant of health, and I think Nunavut graphically demonstrates that.

Mr. Chairman, I am very pleased to be here today to appear before the committee as the longest-serving health minister in Canada, in either the provinces or territories. I have had the unique opportunity to be at the table during the CHST debates and so on and so forth.

I would like to begin by telling you about the health status of the people of Nunavut. It is very poor in comparison to the rest of Canada. Approximately 85 per cent of our population is Inuit, making Nunavut the only jurisdiction in the country that is endeavouring to meet the urgent health care needs of an overwhelmingly Aboriginal population.

Now, the context for the provision of health services has many challenges in Northern Canada; it begins with our children. This is a very shocking and disturbing picture. Several weeks ago, the National Post, The Globe and Mail, and CBC Newsworld covered a recent study of our Inuit children in Baffin Island, where I live, by Dr. Anna Banerji of the B.C. Children's Hospital.

That disturbing report shows over 484 admissions per 1,000 children with lung infections in Baffin Island. It was 50 times higher than the Canadian national average of 10 admissions. Indeed, there are only a very select few of developing countries, third world countries, which even come close to this status.

That is not well known in the country, and it is not acceptable. Our smoking rates are the highest in the country, and are especially worrisome amongst our young people, who are developing lifelong addictions. Seven out of ten 19-year-olds smoke.

The unemployment rate in Nunavut is over 20 per cent, which compares with the annual Canadian rate of 8 per cent. The average annual income among 85 per cent of our population is well below the Canadian average. Again, it goes back to what Mr. Mazankowski said about the socio-economic factors and health determinants.

Mr. Chairman, I think it is also important to highlight overcrowding in Nunavut because of our housing situation. I am also the minister responsible for homelessness. In Nunavut, if you understand homelessness, you use two terms: one is "relative homelessness," and the other one is "absolute homelessness."

Absolute homelessness refers to the people you see on the streets in your larger cities. Relative homelessness is what we have in Nunavut, where 22 people live in a two-bedroom house, and people have to sleep in closets, on the floor, and in shifts on foam mattresses.

When you are in an environment like that, Mr. Chairman, when you have colds, the flu, pneumonia, and you are not getting enough to eat, of course your health status goes down. This is happening right now in Canada.

Although I appreciate some of the comments that I heard earlier this morning, and after having an opportunity to actually read your report, I believe we really need to refocus on a national level on what we are doing on health care expenditures, especially in northern regions, Labrador, and the rural areas of the country.

As you stated in your interim report, Mr. Chairman, Aboriginal people accept a broad concept of health that encompasses not only the spiritual, but also the physical, mental and emotional aspects of the individual. People's social, cultural, physical, economic and political environments also influence the state of their health. I think that is what we are trying to say today.

Mr. Chairman, we must improve our social conditions, invest in health, and provide health care at acceptable levels, comparable to those available to Canadians living in other parts of the country.

Mr. Mazankowski talked about access. If you are living in downtown Edmonton or Ottawa, maybe you cannot decide if you will go to Doctor A or Doctor B or Doctor C. That seems pretty strange when you are living in Northern Canada and do not have that option. You have the option of going to a nurse, and you might only see a doctor once every three or four months. However, I think we can be optimistic, Mr. Chairman.

I just want to talk a little about the cost of health care. Mr. Mazankowski touched on it earlier. Every meeting that I have been to as a health minister, it always comes back to cost.

Health care costs in Nunavut are extremely high. We provide services to about 30,000 people who occupy one-fifth of Canada's entire landmass. Nunavut spans three times zones, as you know, Mr. Chairman. The remoteness and vastness of the territory impact greatly on our health care costs. We have a very complex health care system that is delivered in three official languages: English, French and Inuktitut.

Much of our acute care is provided in southern cities. There is a network of boarding houses in order for our patients to receive care in the South. For example, right here in Edmonton, I believe 70 patients are today receiving health care from the Edmonton health services network. I also run boarding homes in Churchill, Winnipeg, Montreal, Yellowknife, Iqaluit and Ottawa.

The boarding homes in the South must provide transportation, translation and country/traditional foods to people who may be making the trip. Let me give you an example. Would a person here, for example, a mother or a father, like to send their daughter from Montreal, let's say, to Edmonton 2,000 miles away, by herself at 18 to have a first baby? Would you like to do that? No, you would not.

In the north, we have to send our children 2,000 miles away, sometimes by themselves, to receive health care in Toronto or Ottawa or Edmonton. Here in Edmonton where we are today, we have patients who have travelled for two days from communities of 300, 400, 500 people, and where their first language is not English.

I only have one hospital in all of Nunavut - one. It was built 40 years ago. I really get passionate about the issue because I have lived in Nunavut for 20 years. My wife is from Nunavut. My three children were born there. They speak their language. Some of the things that we are seeing are not acceptable, and of course, as a politician - you guys having some familiarity with politics - you know that you have to answer to it.

It is very disturbing. Let me give you a parallel. For someone travelling from, say, Igloolik, a remote community off the west coast of Baffin Island, to Ottawa, would be something like one of you going to Japan for health care. When you arrive in Japan, you are in a strange culture. You would not be able to read or understand the language. Television is in Japanese; the papers are in Japanese.

You would not necessarily know what to do or where to go, and you are sick. You would be there for chemotherapy or radiation therapy and so on. As uncomfortable as that may be, it would probably be several times more difficult for an Inuit person whose first language is neither English nor French.

For example, the patient arrives here in Edmonton, or Ottawa or Montreal. You can imagine being sick in bed, you are getting chemotherapy and you have lost all your hair. Maybe for two hours a day, someone will come along who can speak your language and talk to you and ask if you want a glass of water and so on. However, after that, you are alone. Would you get well very quickly?

You are 2,000 miles away from home, and we do not have the luxury, Mr. Chairman, to fly family members with you.What usually happens, if you are a unilingual person, is that we fly one escort with you, but that might not be your wife, because she might not speak English. It might be a child, a friend or a neighbour.

Medical travel to southern referral centres alone results in costs of about $1,000 per capita per year. Medical travel now costs about $30 million a year and represents almost one-fifth of the total expenditure of my health department, which is about $150 million.

Due to our remote location, costs are especially high for medical emergency evacuations. For example, when someone is injured in an accident in a remote community and requires hospital care, they are sent out on a medivac flight that can cost anywhere from $12,000 to $25,000. If you go into premature labour and are living in a small community, I would have to send a plane to bring you out. And when I send that plane, of course I would have to have a nurse and other people available to help. It is very expensive.

The costs are going up currently because of salaries. Costs for recruitment, retention, salaries and benefits, housing and transportation are higher in Nunavut than anywhere else in Canada. Nurses provide primary health care in 90 per cent of my communities.

Therefore, if you get sick in one of my communities other than Iqaluit, your first contact with a medical professional would be with a nurse. These nurses practice in very remote communities, several of which do not have computers or access to the Internet.

These nurses carry a heavy workload with very significant responsibilities. They must be able to diagnose, treat, prescribe medications and monitor very ill people. The per-visit cost to see a nurse in Nunavut, of course, is much higher than to see a physician in the South.

We have done quite a few things to try to change the health care system in the two-and-a-half years since Nunavut came into existence. We have just implemented a costly labour market supplement to support recruitment, but even this is having limited results. I cannot find the health care professionals in Canada to work in Nunavut.

I am now recruiting Australian nurses. Last year, I brought in 12; I am looking at about 22 this year, because I need an undetermined number of nurses who will work in a community for two or three years. To Canadian nurses, I offer a $24,000 signing bonus on top of a minimum salary of between Can $60,000 to Can $80,000 to work in Nunavut. I still cannot find enough.

Senator Morin: Senator Pépin would know. She is a nurse.

Mr. Picco: Yes. I still have a hard time contracting those health care professionals. The retention of our staff is a constant issue. The frequent turnover and relocation of staff adds even to the basic input cost of my service delivery, and the situation can only worsen as the nation and the world face an acute shortage of nurses.

We also have a very aged, outdated health infrastructure in many communities. For example, as I said earlier, the territory's only hospital is in Iqaluit. It is almost 40 years old and is obsolete.

What that means, Mr. Chairman - and our colleague, Senator Pépin, would understand - is that the hallways, the corridors, are not wide enough to accommodate the new gurneys and hospital stretchers that are in use today.

I cannot have modern IV equipment because the corridors in the hospital will not accommodate that. Even the supplies and services to support our care significantly add to the cost. Many items used in the North are twice as expensive as in the South.

The current system also faces further cost pressures as our population grows. Our birth rate is the highest in the country. As the population ages, of course, we have more pressure on us to deliver services.

Mr. Chairman, I think the health care system in Nunavut cannot be sustained at its current funding level. Since we were entrusted with the responsibility of governing our territory, I believe that the Government of Nunavut has demonstrated a deep commitment to responsible fiscal management.

However, Mr. Chairman, Nunavut requires unique fiscal considerations and ongoing and creative partnerships with our federal government to be successful.

Canadians expect health care to be provided by our governments, and it is very important that Canadian health care systems remain single-tiered and publicly funded to ensure equal, and I think what is key here, Mr. Chairman, fair access to health care for everyone. There should not be better access for the rich, for the educated, for the urban.

Mr. Chairman, many Canadians, as Mr. Mazankowski said earlier and following on from Tommy Douglas's legacy, believe that medicare is a birthright, and that all governments must collectively share the responsibility for the provision of health care.

Nunavut's government has taken aggressive measures to improve the efficiency and the quality of our services while streamlining the system. We have implemented quality-control measures that did not previously exist. We had three health boards that we disbanded to eliminate the bureaucracy and the duplication.

I had a health board in the Western Arctic that was trying to hire nurses. I had a health board in the Eastern Arctic that was trying to hire nurses, and they were competing against each other. We eliminated them, at some political cost to us.

We are developing community-based services, many in partnership with our federal government, and these will increase community capacities in important areas like home care. We are also attempting to establish urgently needed infrastructure. The recent approval of a CHIPP proposal is bringing telehealth to another 10 remote Nunavut communities. I have signed off on a recent agreement with the state of New South Wales in Australia for telehealth medicine. We have also signed an agreement with the Government of Newfoundland and Labrador on telehealth.

The federal government is soon to roll out a Health Canada primary health care program. We have been practicing primary health care and health care reform for years and would expand on the model to deliver effective, community-based, integrated health care. Nunavut is also working with the federal government and the other territories to establish a wellness framework that will involve Inuit and First Nations in health planning issues.

Mr. Chairman, we have a problem. The current health status of the Inuit is unacceptable. You yourself have said it is a "national disgrace." Steps need to be taken to address this national disgrace. We cannot solve the problem alone, and we now have to ask the question, what are we going to do about it? The federal government has a longstanding and special relationship with Inuit.

We believe the federal government has fiscal, historical and constitutional responsibilities to our Aboriginal people throughout Canada. This, of course, includes the Inuit of Nunavut.

Mr. Chairman, I have also previously stated that Inuit expect levels of health care that are comparable with other Canadians. To achieve this, we need resources from the Government of Canada. We would strongly recommend that the Government of Canada accept and discharge its responsibility for the 85 per cent of the population of Nunavut who are Inuit.

In turn, we are willing and eager to work collaboratively with the Government of Canada to address the health care concerns of Nunavut. Those who might suggest, Mr. Chairman, that we are already doing a lot and spending too much in Northern Canada, should be reminded that whatever the federal government and Nunavut is spending now, and whatever we are doing now, is not enough; the statistics make that clear.

The deplorable health statistics speak for themselves. If I may, Mr. Chairman - I know it is late - I will go to the overhead of selected health status data. I think it should be attached to your report. I believe you have this.

Just as an example, on page 4, you will see, under communicable diseases, the rates for tuberculosis. You will see that the Nunavut average yearly infection rate for tuberculosis is 92 cases per 100,000. The national rate in Canada is 6.6 cases. The Nunavut rate is over 13 times the Canadian rate and trending up. I recently read an article in The Globe and Mail about a case of TB in Don Mills somewhere, and the Ontario health people were going crazy to isolate it and so on and so forth. We have TB being diagnosed every day in Nunavut. It is not acceptable. I have had to dedicate new resources and a specialist nurse to it.

If you move forward in the handout, you will see something on substance abuse and addictions, which are health challenges for Aboriginal Canadians. It is not a graph, but rather some stats. We have no alcohol and drug treatment centre in Nunavut. We have no access to Health Canada's alcohol and drug rehabilitation program, and no access to mental health services through the NIHB.

On page 8 you will see "Diabetes in Alaska." Why are we talking about Alaska? Well, Alaskan Inuit have a similar genetic heritage but longer experience with the western lifestyle than we have in Northern Canada.

The prevalence of diabetes among Inuit in Alaska has almost tripled in 15 years, going from nothing to almost national rates, with no sign of abating. Mr. Chairman, we are starting to see a disturbing trend in diabetes among the Aboriginal population in Northern Canada.

Mr. Chairman, if you continue, on page 12 - and I apologize that the pages are not numbered - there is just one more slide that I would like to bring to your attention, on children in care.

Approximately 1.9 per cent of Nunavut youth are in care. In Canada as a whole, it is only 0.67 per cent. Our rate is almost triple that of the rest of Canada, and we are still developing community support networks and other options.

The next page shows family violence and shelter admissions. Nunavut has the highest shelter admission rates in Canada at 66 per 1,000 women. There are only 4 per 1,000 in Canada. Our rate is 16 times higher than the national average. The admission rate for our children, Mr. Chairman, is 54 per 1,000, which is nine times the national rate.

Mr. Chairman, I very much wanted to come to Edmonton today. I just left Ottawa yesterday, where I had meetings with several of our federal partners, ministers, on some of the infrastructure requirements for Nunavut.

I will return to Ottawa this afternoon and then back to Nunavut. It is a two-day trip to get here. I think it was worthwhile to be able to explain to the committee some of the issues that we are dealing with and hopefully answer some of your questions on some of the information that you received here today.

The Chairman: Thank you for, to put it mildly, very graphic and moving testimony.

I wonder if I could ask you to clarify an issue which has crossed the minds of several of us. One of your recommendations states:

That there be a consolidation and integration of the plethora of federal programs now being offered by several federal departments so that there is a unity of purpose and a critical mass of resources to actually make a difference.

I have two questions: Can you indicate to me what programs you are talking about? Secondly, we asked a witness yesterday, I think it was, when dealing with the First Nations issues south of 60, whether it would make sense to move the Aboriginal health portion of the Department of Health over to the Department of Indian and Northern Affairs. Do you have any views on that?

Mr. Picco: I met with Minister Nault, who is the Minister for Indian and Northern Affairs, two days ago. We did not discuss that. However, that is what we are trying to allude to here. Under Health Canada, there are several programs for Aboriginal Canadians. I could give you an example from the CHST funding. When we signed the agreement - and I was there - for $4.2 billion of extra CHST funding, when Nunavut extrapolates the figures out of that, it only gets $1.3 million.

Because 85 per cent of our population is Inuit, we are linked in with other First Nations monies, and those monies are tied mostly to Indians who are on or off reserve, and not to Inuit north of 60.

Our funding from the federal government comes in one lump sum because we are a territory. They give us $530 million. Then on top of that, we have other agreements. For example, from the NIHB, which is the uninsured health benefits program that the government uses to pay for Aboriginal health costs, and which is a Health Canada program, I get $10.8 million for hospital and physician services.

It costs me $17 million to run that hospital in Nunavut. The plethora of programs in one department, another department, administration costs, and so on, make it very difficult to know how to access all the programs. I do not know if that makes it a little clearer.

The Chairman: That does make sense.

Senator Morin: As we have stated, we often talk about this issue within the committee. There is no doubt that Aboriginal health is our priority. Personally, I think that Canada will be judged by the way it solves this horrendous problem. This is not in the third world; this is right in our own backyard. I would like to ask you a difficult question, and I think you alluded, with reason, to the determinants of health, which is an important issue.

Now suppose that, in order to improve the health status of the 30,000 citizens of Nunavut, we gave you $1 billion, but you had to choose either to put it into social and economic determinants, including education - you could not put it into both - or into improving the health care services by building a new hospital and recruiting personnel. Which way would you go? I know it is not easy, but you cannot choose both.

Mr. Picco: If I could sit in my ministerial chair, I could say that it is a hypothetical question and I do not have to answer it, and be ruled out of order. However, since we are not in that formal setting, I will try to answer your question. I would suggest to you, Senator, that as the Minister of Health and Social Services, as minister responsible for the homelessness, I would put money into housing.

In 1993, the federal government withdrew from social housing in rural and Aboriginal communities and in Northern Canada. If I could illustrate the point, I was recently in a community called Pond Inlet. It has over 500 students in school from age 6 to 16. In 10 years, they will be graduating. How will we find 500 houses or 250 houses or 100 houses in Pond Inlet for these students? Every community in Nunavut is the same.

Since the federal government withdrew from social housing construction, we have fallen behind. When you have 15, 18 people living in a three-bedroom house, it leads to family violence, the spread of tuberculosis and so on and so forth.

Mr. Chairman, and if I may be so bold as to say, as the longest-serving health minister in the country, I think we have missed the point here. I think Mr. Mazankowski hit it. Mr. Mazankowski said we needed to focus on the preventive side of medicine, which is exactly what you just said, Senator Morin.

For example, Aboriginals make up only, I think it is 10 per cent or 12 per cent of the Canadian population, but account for 35 or 40 per cent of the health care costs. The federal government and provinces could reinvest in those communities and start putting in healthy housing. When you build a house in the community, you create a job, because somebody has to build it.

Do you bring 15 guys from Newfoundland and send them to Pond Inlet to work, or do you hire people locally? You are creating economic opportunity, you are doing trades training, and you are providing a home. That is where the reinvestment should be, Mr. Chairman.

Senator LeBreton: I must say that that was a very compelling presentation. And when we call it a "national disaster," we are understating the problem. I have another issue to discuss, but on the issue of housing, if you were to start now and develop a critical path, how do we get to a situation where there are actual facilities in the North to deal with - as you mentioned - a young woman of 18 being sent 2,000 miles away? I cannot imagine that.

How do we then follow a critical path where we can start putting facilities in place, utilizing telehealth more efficiently? I suppose it is the typical hypothetical question, but what is next? How do you get those hospitals built that can handle the gurneys and the new technologies, and does it require more than just money?

Mr. Picco: I wish I could spend some more time with you today. I would formally invite the committee to come to Nunavut and actually hold a hearing outside of the urban centres in Southern Canada. I think it would be an eye-opener. We are currently in the process of trying to renew our federal infrastructure, and I do not want to go back to 1988, when the federal government transferred health care to the territories. At that time, that included building new facilities.

The hospital in Iqaluit, for example, was built in 1962, when the population of Iqaluit was 980 and it served the Baffin region population of 3,280. The population of Iqaluit today is 6,200; the Baffin is almost 20,000. It is the only hospital I have in the whole territory. I am trying to rebuild it. It will cost $30 million to $40 million.

I have met with my federal partner several times to find resources to do that. At the same time, if I could have a regional hospital facility, a smaller cottage hospital in Rankin Inlet and one in Cambridge Bay, I could save about 40 per cent on medical travel expenses. Directly north of Winnipeg is a community called Rankin Inlet. It is the regional centre for eight or nine of my communities.

Every patient there who needs to have a baby delivered would have to go to Winnipeg. In the Western Arctic, directly north of Edmonton, you have to go to Yellowknife or Edmonton. If I could have a small cottage facility to just deliver babies, do tonsillectomies, et cetera, I would save about 40 per cent of those health care costs, but I need money to build those facilities.

We figure it would take about $100 million to actually do something with the Baffin hospital, replace it and build two cottage hospitals in Rankin and Cambridge Bay. We have not had any luck yet in accessing funds to do that. We are trying.

Senator LeBreton: I was interested to hear, when we were talking about nurses and nurse practitioners, you talking about going to Australia to recruit nurses, because when we did teleconferencing with Australia, we learned that they have a similar situation. The health care system is very similar, and they have a similar disaster situation with their Aboriginals. I am curious about whether these nurses whom you are recruiting from Australia have experience working with the Aboriginal population there. Are those the nurses you are going after? Why Australia?

Mr. Picco: I would go to the Philippines. I would go to any country in the world to hire staff if I could find them. There is a pandemic shortage of nurses across Canada and in North America. When you go to St. John's to recruit, you are up against Connecticut, Rhode Island. Edmonton is up against California. It is a national problem. Therefore, at the federal, provincial and territorial health ministers' meetings, we are looking at a national human resource strategy.

We are going to Australia because they do have familiarity with Aboriginal peoples. They also work in the outback, and since they are licensed practical nurses, they can deliver babies. They can deliver a lot of the primary health care that we need on the ground.

At the same time, two years ago, we started the first Aboriginal nursing program in Canada in Nunavut. We are affiliated with Dalhousie, and when the Inuit women graduate from that program, they will have a degree. They will be able to nurse in Edmonton or Iqaluit. However, I needed some support from our federal partner, and did not get any. It is costing me about $1 million a year to run that program for approximately seven students.

The only way that I can fill the need is to train local people to take those jobs, but it will take 5, 10, 15 years to start turning out those numbers.

Senator LeBreton: Has Dalhousie not discontinued that program?

Mr. Picco: No. I am running the program. I started it as the Minister of Health in 1999.

Senator LeBreton: It is still ongoing?

Mr. Picco: It is on the go right now, yes, and because our educational levels are a little lower, I have to, in some cases, have students upgrade for about a year in sciences and math to be able to complete the program.

Senator Pépin: I have visited your hospital. I went three times over the years, and I have to agree that it is really a culture shock when you go there and see the needs.

My last question concerns your recommendation:

That the Government of Canada support increased access to training programs in the South for Inuit students by funding places in medical schools, nursing schools, and allied health professional training programs.

When you say that it costs you a fortune to train nurses, do you mean that the federal government should pay for nursing places at the university? Could you elaborate a little on that?

Mr. Picco: It is very difficult to leave Northern Canada and go to school 2,000 miles away, but there are a lot of people from Nunavut who have graduated and been very successful, although not in the medical professional field. We only have one Inuit nurse, I believe, working right now in Nunavut. We were hoping that the federal government would allocate different seats to Northerners to finish their studies and be able to graduate.

Conversely, if Senator Roche would like to go to school, the federal government could say, "We will pay for your education for four years, you will go to Nunavut and work there for five years, and then we will write your debt clean." I think that would be another opportunity for us to get some of the staff that we need in northern and rural remote areas of the country. That could apply not just to Nunavut, but also to the Northwest Territories, Yukon, Labrador and Northern Quebec. That was the idea there.

Senator Roche: Minister, thank you for the trouble you have taken to come to this committee, and I tell you that your brief, your words, the passion that you brought with these figures - these outrageous figures - have not fallen on deaf ears.

Mr. Chairman, you remember that representatives of the Aboriginal community appeared before us in Ottawa and gave us the same figures. There was a sense of outrage on the committee, and I want to repeat today the outrage that I feel as a Canadian that people in our country are treated this way. Anyway, outrage is not enough.

Is not the problem deeper, minister, than realigning the existing programs, or even adding a few new programs or a new hospital? I suppose some of that is helpful, but is there not an attitudinal problem on the part of Canadians or on the part of the federal government?

What has been done about the recommendations of the Royal Commission on Aboriginal Peoples, which produced a lot of material aimed at bringing Aboriginal peoples into a more integral role in Canadian society? That report is sitting on the shelf.

We might make some good recommendations, Mr. Chairman, but how are we going to keep our report from sitting on the shelf? What have you got to say to us in this respect?

Senator Morin: You do not know our chairman.

Senator Roche: Well, more power to him if he can keep it off the shelf.

Mr. Picco: If he can keep it off the shelf, then I will recruit him for Nunavut.

I have to say, in all sincerity, that having served in the Northwest Territories legislative assembly and now in the Nunavut legislative assembly, I have some experience in meeting with different federal partners and so on. Having been in politics for over 20 years, I have met many of our national leaders, and they are sincere. I would suggest to you that Mr. Rock, who is my federal counterpart, has always been very open to helping alleviate our situation in Nunavut.

However, there is a malaise when you are dealing with northern areas of Canada, when you are looking at a per-capita funding of about $24,000 per person. Then people say, "They are getting enough money." I ask you, if I were a country, would I be able to apply, based on my conditions, to CIDA and get money? Probably. It would love for CIDA to come and build me a hospital.

That is a shocking statement to make, but it is a true statement. I do not think there has been an abdication of responsibility by our federal partner. They have been there for us. However, we need to move the political spectrum in Canada to look at the less fortunate in our communities.

I should also point out, Senator Kirby, that we should look at the potential wealth in Northern Canada. The only two diamond mines currently operating in North America are in the Northwest Territories. That has turned the whole economy around there. There is an opportunity for oil and gas exploration.

An investment in Northern Canada, Mr. Chairman, has economic benefits in the South. Every time you build a house, you have to buy the lumber from Montreal or Edmonton.

Every time you buy a piece of medical equipment, it comes from a company in the South. In every investment you are making, the money does not go into some black hole or to the planet Krypton. The money stays in Canada, and I think that is where we should be looking at reinvestment for Canadians. I hope that helps answer your question.

Senator Roche: I think the Chairman probably needs to move on. I would like to keep the discussion going, but I think we will have to stop there.

The Chairman: I think we will find a way to do that.

Senator Keon: Mr. Minister, like Senator Pépin, I have been in your hospital in Iqaluit and in some of your outreach clinics. It is my impression that your problem is of such magnitude that what is needed is a special, focused program. I am familiar with many of the innovative things you have done in the way of telehealth, the rotation of medical practitioners and nursing practitioners and this kind of thing, and I am aware of your frustrations over your inability to retain manpower and so forth.

I do not think the problem will be solved without a total commitment on the part of the federal government, and which department does not matter. There has to be a total commitment on the part of the federal government to a special program to put the resources in place to deal with this horrendous problem that you have on your plate. I mean capital expenditure to give you proper facilities, proper housing and so forth. I mean a personnel support program that can give you young doctors out of the medical schools to get invaluable experience up there through reasonable rotations, and the same with nurses and nurse practitioners.

Most of all, I think what is very much needed is a special category of health professional for which you could draw on some of your own personnel, and perhaps preparation of some special personnel in the rest of Canada whom you could retain up there, because I am quite familiar with your retention problems too.

I will be recommending to my colleagues that our report recommend a targeted program specifically for the North to overcome a situation that is now totally unacceptable.

Mr. Chairman: Any last comments you would like to make?

Mr. Picco: Yes. Again, I appreciate the indulgence of the committee, and I am not here to make political brownie points. We do not have political parties in Nunavut. You run, and you represent your riding. I came today for the opportunity to let another group of people know what we are going through.

Senator Keon made a good point. Mr. Chairman, in the East, you have ACOA, which is an infrastructure program for Atlantic Canada. In B.C, you have a program. You have Western Economic Diversification here in the West. Quebec has something, and Northern Ontario has FedNorth. Every region of the country has either an economic development program or some other separate pot of money.

We do not have anything like that in Nunavut or Northern Canada. If we had a program like ACOA, then I could say, "Can I get an extra $22 million for a new hospital? Can I get $15 million for housing?" We do not have that opportunity, Mr. Chairman.

The Chairman: Thank you very much for coming. We really appreciate it, and we look forward to keeping in touch with you as we go down the road.

Senators, I think our next two witnesses are known to a number of us. Sheila Weatherill is the president and CEO of what is now called the Capital Health Authority, formerly the Capital Region Health Authority, and Mr. Jack Davis is the CEO of the Calgary Health Region.

Welcome to your town. As you can appreciate, we are running slightly late this morning.

I must say, as representatives of urban regional health authorities, your problems are somewhat different from those that Minister Picco just described. It is really quite incredible.

We will begin with Sheila Weatherill. I must say this, because Senator Pépin is a nurse and my wife is a nurse - and in case you do not know, Senator Pépin, - Sheila has clearly achieved the highest-ranking administrative position of any nurse in the country, since she runs a program of about one and a half billion dollars.

In spite of all the comments we hear about nurses sometimes being kept down, we are delighted to see that you have justifiably risen to the top. We are also delighted to have you here.

Ms Sheila Weatherill, President and CEO, Capital Health Authority: We are both very pleased to be here, and thank you for your warm words about my background as a nurse. It is something I have valued for many years. Jack and I have talked about how we would proceed, and with your permission, Jack will go first and then I am going to follow. We will give you a lot of time for questions.

Mr. Jack Davis, CEO, Calgary Health Region: It is an honour to be able to present here today and always an honour to share the stage with my good colleague from Edmonton, Sheila Weatherill, with whom I have enjoyed a long working relationship through my time in government and with the Calgary Health Region.

We have collaborated on the written material, and the Calgary Health Region will not be submitting anything separate from that submitted by Capital.

I just have a few opening comments, and then I will turn it over to Sheila, who generally does a better job of presenting these issues than I do. I would like to start out by saying that in my opinion, the health system is of tremendous value to Canadians. Clearly, there are many very dedicated people working in the system, including physicians, nurses, other providers and managers.

For those of you who do not know my background, I was the provincial deputy minister for transportation for a while. Whenever we built a new interchange or put in a new highway component, we never heard anything about the cost. It was always considered of great value and a great asset to the community, whether it promoted economic development or just allowed people to move around more quickly and more freely.

For some reason, we seem to have lost that attitude in terms of the health system, and people are focused on the costs. They see it as a cost issue and do not look for the value in the system. I think there is tremendous value. The issues facing the system, which clearly you have identified in your report, include ensuring effectiveness, the cost and the financing

However, I think there has been a disproportionate focus on the efficiency side of the system. In Alberta, and I know in many other parts of the country, there have been tremendous efficiency gains in the system through regionalization, and I do want to applaud the courage of the government in moving forward with that a number of years ago. We have seen tremendous productivity gains.

In Calgary, for example, we are operating with slightly more hospital beds today than in 1994, we have 165,000 more people in the city, and I think we have a better health system.

We have been able to manage most of the expansion services and programs in the community. We have large home care and continuing care programs, and with integration and better management of the system, we have been able to make the best use of resources. Our administrative costs are now at less than 4 per cent of our total budget, and for an organization of 17,000 people spending $1.5 billion, that is extraordinary.

No private sector company anywhere on the planet would spend less than 4 per cent of its operating budget on administration. Furthermore, most of those companies would tell you that the strength of their organization starts with the quality of their leadership and their management, and they would not be interested in decimating that as a way of improving performance.

I had an interesting chat with someone the other day about oil and gas companies and what makes a good one. He said that there are only two things you need to look at. First, you look at the quality of the leadership and management; secondly, you look at the quality of their assets in the ground.

There has been an out-of-proportion focus on the productivity side, and while I think there are more productivity gains to be made, I think we need to be careful in assuming that that is the magic fix for all these system and cost issues. I am certainly a big fan of evidence-based practice, a big supporter of the Western Canada Waiting List Project, and Dr. Noseworthy asked me to again flag that.

We need to aggressively pursue that 1 to 2 per cent a year productivity gain and we will do that. My commitment to our board is that we will do that every year.

However, when you put that 1 to 2 per cent productivity gain against a growing and aging population, the development of new treatments, new technologies, the rising cost of pharmaceuticals, and the increasing value that the system is bringing to people in life expectancy and quality of life, clearly, that is not going to get us there.

In your document, you ask about the role for the federal government in the national health arena. In reviewing your paper, I was certainly struck, first and foremost, by the notion that the federal government should participate financially in the health system through stable funding. I think that is absolutely critical. During my days in government, I was never successful in convincing my federal colleagues that "stable funding" for health meant funding indexed to population growth, aging and inflation.

That was always disappointing, because I think that there has to be recognition of the fundamental cost drivers in the system, and that seems to be absent. That is a key area where there has to be a long-term commitment, jointly shared by provinces and the federal government. That is part of the answer. Another part of the answer is the productivity improvement I talked about, and in a moment, I will talk about what I think the other components might be.

Another key role for the federal government is information technology infrastructure. We have talked about that. We need to execute on that better. We need to execute on it in a greater, more comprehensive fashion, as opposed to funding a myriad of pilot projects all over the country that will never aggregate into a critical mass that will be useful.

Another key role for the federal government is providing leadership in the very area that your committee is taking on, Senator, which is strategic leadership, looking at where the system needs to go and what the issues are that face us.

There does need to be a recognition, however, that the health system has changed fundamentally in the last few years for some of the reasons I have mentioned. The system is now largely populated by a workforce of very specialized individuals who are well paid and in demand throughout North America.

Our capacity to deliver new and innovative treatments is expanding every day. There are considerable costs to those initiatives, and there is public expectation, as I have said, that they will be able to access those types of treatments at about the same rate as people accessing services in a very successful health management organization in the U.S.

We need to look at all of the options on efficiency and productivity, from better management to better use of information technology. My friend Heather Smith, the president of the United Nurses of Alberta, and I just had a little debate on the use of the private sector on the delivery side. Maybe we need to look at all of those things in trying to pick up efficiency gains.

Those will not, in and of themselves, be enough to adequately finance the system in a way that I think Canadians would want it financed. We are encouraged to hear that Don Mazankowski's committee is looking at other ways of financing the system, such as health spending accounts, insurance, and ways of engaging the patient as a consumer.

We would support a thorough review of those options. We have not been able to move forward on some of them, with all governments in Canada, including the federal government, focusing on tax reductions, paying down debts and managing deficits. I cannot see how the system will be adequately financed in the future, and I think we could lose some of the very real gains we have made in the system over the last years.

Ms Weatherill: I am going to get into somewhat more specific responses to the questions that were posed.I wanted to start off with what I know has become the usual Alberta commercial for what we have achieved in health care, and we were pleased to have Jeffrey Simpson from The Globe and Mail here last week. He says that if you need health care inspiration, use Alberta for your beacon. We have included that article.

Just to echo Jack's comments, you have produced a great document. We would recommend it be required reading for government and health leaders. My overarching comment, as I begin to get into the detail, is, as Jack has already framed so well, that change is needed if our system is to be financially sustainable, and there is not one magic fix or one easy solution. If there were an easy solution, we would have found it by now.

We will give you a brief, thumbnail sketch of Capital Health, and you can just "ditto" that for Calgary. The two regions are very similar, and the only ones here in Alberta with the primary responsibility for the province's academic mission of training men and women in the health sciences professions.

Like all regions in Alberta, the two big urban regions were created through the amalgamation of, in our case, nine former health and hospital boards. It happened extraordinarily quickly, and we do not think about it very often now because it took place five years ago. I too would just like to acknowledge our government for that courageous move, because we now describe ourselves as "fully integrated," doing everything from looking after immunizing babies right up to heart transplants. We are also regionalized, and we are academic regions, as I mentioned.

In our case, we provide a lot of service to the North, and in Calgary's case, a lot of service beyond Calgary to Southern B.C., and even, in some cases, to Americans. Here is the map of the province, and it shows Region 10, which is our region. The number of regions, just as in other provinces that have been regionalized, is controversial. Reducing the number of regions, in and of itself, is not a big cost saver. A lot of emphasis has been focused on how many regions is the right number, and again, that is not a solution to the more complex problem of financial sustainability.

There are a lot of metrics on the next page on the size of the system. Just to add to Jack's comments about the number of beds in the two urban areas, I believe both of our areas have the fewest number of beds per population of any system in Canada, largely because we have been able to, any day of the week, go into our database and find out, for example, that 8,000 people had received a home care service in our region. Therefore, we are very large systems, each with one medical staff - a big advantage - and we are very large employers.

I wanted to just focus for a moment on the academic mission that we share, because when we think about opportunities for financial sustainability, we often do not remember, or need to be reminded, that in addition to caring for people who are ill or injured and promoting health, we also have a very important responsibility to train future generations of health sciences professionals.

That does need to be a guidepost as we think about the relative portions of for-profit and public services in a single-payer system. It is a very important issue for us, and sometimes causes us to do things in a way that, to the public, may appear less efficient or somewhat more cumbersome or bureaucratic.

The George Bernard Shaw quote included in this material is important, and we want to congratulate this committee again for encouraging people to think about what change is needed.

Moving on, then, into responding to your specific highlights and questions, first of all, we wholeheartedly agree that our health system is not contemporary.

People get their pizza free if it is not delivered in 45 minutes or 60 minutes or whatever. No wonder that when they come to our emergency departments, they are so puzzled at why they have to wait, or even more profoundly, why more services are not accessible in a contemporary way using the Internet and other, very readily available methods.

That is a profound societal issue that we hear about all the time. The health system is back somewhere in the 1960s in a user-friendly sense, and so it is no wonder the public is unhappy about it.

There has been a lot of focus in your reports, those of Ken Fyke and the Quebec report, on the need for primary care reform. We agree, and there are many pilot projects underway. It is a slow process. I personally would advocate a more standardized framework that would see us moving primary care reform ahead faster.

However, in addition to that, and going back to the system being user friendly, Canadians do sincerely want to take responsibility for their own health, but we have not given them the simplest of tools with which to do that. There are a number of very good pilot projects in Alberta that are trying to encourage people to pick up the telephone and get advice, so they do not have to phone their physician for an appointment or go to the emergency department.

I will not repeat Jack's comments here, but the dramatic scope of the changes to our health system means, quite frankly, that it just does not fit with the existing legislation. Our province, and our organizations individually, very much urge a non-ideological and reasoned debate. The public is way ahead of us here, and I think you need to be talking to them about this, not just people like Jack and myself.

We hear from the Alberta public frequently, "Why is the debate so slow? Why have we not started it?" Why are we not just getting on with asking the public what size of health system do they want, what is the right size, and how it should it be paid for?

There is a lot of focus in Chapter 7 on waiting times, which is an important area, and again I echo Jack's comments on the wait list work that is underway.

There are real problems with waiting times in some areas, but not all, and we are seriously in need of a more standardized approach for dealing with wait lists using better clinical data, and there are many reasons why we have not been able to move faster on that.

I remember that five years ago, I thought, well, that will be easy to fix. We are a region now. However, there are a lot of reasons, which Dr. Keon here would be able to tell us about, why it is not easy to grab the wait lists away from individual practitioners and manage those centrally.

A more important concept, from my point of view, is that the focus that the public has put on some of the wait areas, like MRIs and joint replacement surgery, has actually caused us to pay insufficient attention to waiting times in some very important areas such as mental health, and other clinical areas that do not get quite the same profile.

In Chapter 8, you asked for our advice on the mix of for-profit and public services, and this whole very controversial area of how many tiers do we need and should the public be able to pay for services.

I know this has been a cause for much debate, and we talked with our own unions and providers about this at length, but we have a mix of for-profit and public providers. From my point of view, because they fall within our current oversight responsibility within the health authority, the mix has worked. There have been some real advantages to having that mix.

One reason we have to pay a different type of attention to the proportions in the mix in both the Calgary and the Capital region is we also have this important responsibility for education and research. We have to take that into account as we ensure that we have the right training and academic environment.

As to whether two tiers is the right thing, the Alberta public tells us they just want to be asked that, and sooner rather than later.

There has been a lot of discussion on efficiency, and Jack said it all. All the effort that we can put into improving efficiency is not going to be enough to solve the problem. We need an approach that causes us to make fundamental changes in the health system and look at new financing options, as well as the ongoing pursuit of efficiency.

In Alberta, we have talked a lot about other sources of financing, just in response to Chapter 8, and Edmonton and Calgary are jointly working on financing sources that already exist within the current legislation. None of it is easy, and all of it requires some public discussion. We agree on the national drug formulary - simple response.

I want to spend a few minutes on Chapter 8, on the matter of home care, and I spent a few years of my earlier career in home care. We have had a publicly funded, very comprehensive home care program in Alberta since 1978. In fact I was working in government when the home care program was set up. It can be a valuable support for early discharge and for avoiding permanent institutional care for disabled and older people, and I would encourage you to look at the Alberta experience in detail when deciding on or recommending the possibility of a national home care program. It is complex, and maybe more so than it appears on the surface. I think personally that tax credits and EI benefits for caregivers should be explored.

I am going to stop there, because I wanted to leave you enough time for questions, just glancing at my watch. In the next few pages, we have given you our response to the specific chapters, but I have covered the major points that I wanted to cover.

The Chairman: Can you send us or something on how the home care model in Alberta, or at least in your two regions, works? That would be helpful.

If the Canada Health Act included the notion that there could be pilot projects, experimental programs, whatever you want to call them, that violated the provisions of the act, are there things you would be doing on an experimental basis that you cannot currently do?

Mr. Davis: I think there are obviously things that need to be looked at and explored. As Sheila said, we are looking at some of the revenue opportunities that are within the legislation, but we need more than just experiments. There needs to be a more comprehensive look at some of the options and alternatives. Then we need to fit the experiments within that to road test some of these ideas.

I would not want to see us road testing a bunch of ideas on an ad hoc basis. There has to be a larger policy framework for the options that we look at.

The Chairman: Right. However, I am asking, are there options? I am trying to understand the extent to which the Canada Health Act is constraining innovation.

Mr. Davis: The Canada Health Act is an issue, but a lot of the services we provide now in the community are outside of the Canada Health Act. We do have a lot of legislative flexibility there. Do we have the policy direction and can we engage the public? As to should we be looking at an insurance-based model as opposed to just a tax-funded model to pay for some of the services, or should we be looking at an individual user-pay model, I do agree with some of Don Mazankowski's comments about the difficulties around individual user pay.

I think there are some alternatives as to how the system is financed, and the issue of giving more consumer power to the individual is important. However, we need to be careful that we do not do what we have been doing over the last 10 years, which is launch a plethora of what I consider fairly small pilot projects that are time and energy consuming to manage, and at the end of the day, we are not sure what to do with the results.

Ms Weatherill: Just to give you a specific example, senator, what would be our province's policy on having young families pay for prenatal classes? If you were to look across Canada, you would find no standard approach to that. It is a very tiny cost in the system, but we do not even standardize that provincially. We probably do not even standardize that within our own health authority. However, that would be fully within our ability to change.

In an environment where there has been so much discussion - and we welcome the discussion on the topic - the random, shotgun approach to making changes is not a good way to go. I continue to say that we need to ask the public how they feel. Maybe they would really be interested in buying insurance for certain sorts of services. We do not know because we have not asked them.

Senator Keon: I have to congratulate you and your province for having the courage to undertake what you have undertaken, and we are all going to learn a great deal from you. There are two things: Last time I was out here, you were expending about four-fifths per capita of the national average on health care, and frankly, your outcomes are better than anywhere else. Does that still apply?

Mr. Davis: I think we have moved to near the top, and there are a couple of reasons for that. One, I believe that the government took a position, supported certainly by all health authorities, that we needed to move our compensation rates for physicians, nurses and other health care providers closer to the Ontario and B.C. levels, just to help us recruit and retain individuals.

It is always a puzzle to me that when we try to do something that Ontario is doing, we get criticized for it. That has pushed up our costs. The government has also reinvested in some key areas that perhaps suffered a little during regionalization and the budget reductions. We do need to recognize that Albertans have high expectations of their public services generally, whether health care or infrastructure.

I would say that the results are there to show that this investment has paid off. We have seen the outstanding results that the Capital Health Authority has achieved in national surveys, and we are moving up in Calgary, so we are very pleased with the results.

Senator Keon: I think your home-care programs are definitely models that we should all be looking at. The gaps that exist in some of the other programs do not seem as common in yours.

Would you be kind enough to lead me through, for example, a cancer patient who has been through the active treatment system and is referred to the home care system, how that is managed, and how the interface is managed if the patient needs to go back into the active treatment system. Are there any gaps in financial coverage from the time the patient is flipped into the home care system until, unfortunately, he or she expires?

Ms Weatherill: I wish I could tell you that there were no gaps and that it was a perfect system. It is getting better. In particular, we take pride in the palliative home-care program that is now in place in both the major cities and beginning to become more visible in the rural communities.

Home-care staff are present in our hospital facilities and also in the treatment facilities where patients go for oncology therapy.

In Alberta, there is a provincial cancer board that operates some of the services, and some are operated by our health authorities. There are also outreach clinics for oncology in some of the more remote areas.

There are jurisdictional issues here, but in fact, because we are a small province population wise, even though we are big geographically, by and large, that has been sorted out.

Patients going back and forth between hospital admissions, in and out of hospital, and on and off home care, is, generally speaking, well managed from a case management point of view. Similarly, the patient moving in and out of the cancer facility is generally well managed, due to improving information systems, which is the key.

The degree of home care service is based on what the family is able to provide. However, when the patient becomes terminally ill, then a different level of home care kicks in, with additional advice, palliative care advice, provided to the family physician.

It is very comprehensive, but not perfect. Senator Carstairs was here a few weeks ago and spent some time with our palliative care program. It is something we take pride in, and although there are opportunities for improvement, I would say it is probably better than we might see in other areas.

Senator Keon: If I could just draw you on a little more, if a patient, for example, leaves an active treatment centre, requires home care and then gets somewhat better and appears to be in a prolonged period of relief or remission, but still requires some kind of nursing or custodial care, how is that managed financially?

Ms Weatherill: Depending on the amount of support needed, which again is linked back to what the family is able to provide, in our region - there is some variation throughout the province, but not much - that service is provided without cost to the individual.

If the patient required help with housecleaning, not with getting in and out of the bathtub or personal support, but actual cleaning of the house, then a small fee is charged, but actually, that rarely happens.

Senator Keon: What about some of the nursing home facilities that a patient might want access to? What coverage applies to them?

Ms Weatherill: The maximum cost right now, although this is under review, to an individual per day in our long-term care system is under $30, which is currently, we believe, the lowest in the country.

Senator Pépin: Does that include medication?

Ms Weatherill: It includes medication. It is rated as, as we describe it, "long-term care nursing home auxiliary hospital system."

Senator Morin: Thank you very much for coming and for your comments. There is no doubt that both the Capital and Calgary Health Authorities are Canadian success stories. I was at an international meeting not very long ago where it was described in some detail as a model in questions coming from foreign visitors, and it is certainly a very interesting enterprise.

You are not responsible for pharmaceuticals, physician fees or union negotiations for salaried personnel. I was wondering whether those are areas that you would like to move into or not.

Mr. Davis: On the pharmaceutical side, in Alberta, there is a fairly generously sponsored subsidy to the Blue Cross pharmaceutical program for seniors in the community.

Senator Morin: Your regional authority does not have authority on pharmaceuticals?

Mr. Davis: Right.

Senator Morin: That is what I meant.

Mr. Davis: I do not feel that we have to control everything, but this debate has gone on since regionalization - should the physicians be part of regionalization, should all the pharmaceutical costs be included. There are pros and cons, and it goes back to the efficiency argument. Do you get more efficiencies and do you align incentives better? Maybe you do, but there are a lot of disruptions in that kind of change.

My perspective would be, as long as, from a policy point of view, we are coordinated with these programs, that is really our key.

Senator Morin: For example, for physician fees and also union negotiations, there is some advantage, of course, to having it more regionalized. I am not saying it is easy, but that might be considered.

Mr. Davis: The regions collectively undertake most of our union negotiations. We work together on it, and by and large, we have had a good process for working with the unions and have been able to resolve most issues.

The physician issue is an interesting one, and of course there have been experiments with different models all over the planet, from physician fund-holding to salaried physicians, to the fee-for-service model we have, and all have their pros and cons.

We are starting to see more movement of physicians voluntarily into either teams on the primary care side, or into a kind of contract model on the specialist side.

There is some evolution there, but it is not moving quickly.

Ms Weatherill: You did focus many paragraphs in your report on fee for service. In and of itself, fee for service is not all bad, in our opinion. I believe strongly that there needs to be a variety of payment systems for physicians. For some types of physicians, fee for service is a very good method of payment.

Senator Morin: My second question deals with the issue of stable funding from the federal government. Of course, that is an ideal situation. However, we have no guarantee that any government will give us stable funding. All provinces have both cut and increased their health care budgets at various times, and there is no guarantee that in the future, the federal government, for political reasons or because of economic conditions, will not change its funding. It is very difficult for governments.

Privately, I can decide that every year, I will pay $1,000 on my dental health insurance. That is my decision, and that will be stable. However, when it comes to government, it is very difficult to have any guarantee that there will be stable funding in the future.

My next question has to do with the multiple-payer situation that would result if we introduced private health insurance in addition to the government payer system.

In the U.S., and in other countries where they have multiple payers, it would appear that this increases administrative costs - in the private system you have to count the number of pills and the cost of aspirin and so forth - and also regulation.

I am not all that impressed by the dangers of a monopoly under a single-payer system. I do not see the advantage of competition. I think the private insurance system is quite similar to the government system. They have the same advantages and disadvantages. I am not sure that competition would increase. I think this situation is quite different, and I think you have done very well as providers.

I think multiple providers are excellent. My last question is, what is your opinion of the private clinics that have been created under Bill 11? That was an interesting experiment, and I think that you might have an opinion on that.

Mr. Davis: Let me start. I would like to challenge your comment about governments not being able to provide stable funding, if that is permissible, Mr. Chairman. We hear this a lot, and it has been the history of health funding and other social program funding. When times have been good, generally it has increased; and when times are not as good, it has decreased. I think governments have a responsibility, first of all, to determine what the funding framework for health care will be and what their participation in it will be.

Our governments make their debt payments regularly. When the fiscal situation tightens up, I do not hear them saying, "The economy is not quite so good. We think we will pay you 10 per cent less."It just does not happen.

There has to be some political will and some political responsibility engendered around these large social programs that has not been there in the past. We need to understand the benefits of them; we need to understand how they will be funded. If there is to be a mix of funding sources, that is fine. The government has to participate in a realistic, responsible and consistent way.

They cannot be all over the map, because one thing that is really hurting the Canadian health care system from a planning point of view is that it is "stop and go." There has been a lot of stop and go over recent years. No wonder providers are disillusioned. People are trying to manage their lives around their careers. It is a very difficult to do, and very difficult to plan the system. It is also very confusing for the public.

To some extent, the different levels of government are trying to point the finger at each other, rather than coming together on how to really make it work for the benefit of all.

I do not think we should let federal or provincial governments off the hook, nor should regional health authorities on the delivery side of the system be let off the hook from working together.

Ms Weatherill: Just to add to Jack's perspective - because I totally agree - and to use the earlier analogy of highways and interchanges, if we have less government revenue or if the economic situation is not as positive, we can agree to pave fewer roads, and people can understand that. However, they really have a very difficult time understanding why they have to wait so much longer to have a procedure done, or even more catastrophic, why they perhaps experience a less positive health outcome because they did not get a test in time.

I say governments need to decide what level their funding will be, and then provide an environment in which the shortfall can be made up in a predictable way.

Senator Morin: It should be both levels of government.

Ms Weatherill: Indeed. Both levels, absolutely. The whipsawing between the levels is not helpful to us.

On the question of private clinics, I think we are into our second full year with the new legislation. And speaking from our own experience in Capital Health, it has allowed us to provide better oversight of clinics that were in place.

It provided additional rigour in monitoring and supervision, and follow-up if there were difficulties. It allowed us to create expectations about the academic mission that I spoke of earlier, such as what type of teaching requirements would the private clinics need to participate in.

By and large, there has not been a dramatic change in the volume or type of services that the clinics are providing.

From a practical, purely administrative point of view, it has taken additional effort to implement the new bill. I do not think that providers are particularly unhappy with the change. It has not been a big deal, and we are providing better oversight of the clinics.

There have been no dramatic shift of work from hospitals out to clinics and no initiation of overnight stays in either city, I believe. Dare I say that it has been a bit of a non-event?

The Chairman: It is always dangerous in public policy; however, we like the prediction.

Senator LeBreton: I am very interested in the home care, because there is not a lot of uniformity across the country. I think Alberta is probably way ahead.

Ms Weatherill: If I could make a comment on home care, something incredibly near and dear to my heart, and I would just like to compliment the Province of Manitoba for having done a lot of the very fine groundwork for how we understand home care in the Canadian context. Much of what we have done in Alberta was based on the experience in Manitoba.

However, I would caution you that it is not the solution to everyone's problems. Most older people - and I have been through this with both sets of parents now - do prefer to stay in their own homes as long as possible. Most people actually prefer to get out of hospital quickly too, if they can get good support at home.Much of the time, it is the right thing, but not all the time.

It is not one size fits all and it is not going to fix everything - our long experience in Alberta has shown that. I know there are colleagues of mine in the audience today who have had a lot of experience with home care. We have members from our community health councils here today, and they would tell you that the home care system in Alberta is still far from perfect, especially from the coordination point of view.

That is why, when I answered earlier, I said there is still lots of work to be done. However, it is relatively comprehensive. I looked at our database yesterday because I had a feeling you would ask questions about home care. We have a couple of children on home care who are incredibly well cared for at home, but it is very expensive and a huge responsibility for their family, even with this tremendous support. It is not the perfect solution for all families.

Senator LeBreton: Home care does fall to the women of the family a lot of the time, so I would be very interested in that.

However, Mr. Davis, on the issue of stable funding, some of us, you may recall, advocated a sixth condition for health care, and that was stable, permanent, long-term funding. It seems to make eminent sense to index it to population growth, aging and inflation.

I am just wondering why that has not happened. It seems to be one of those simple, common sense approaches that get overlooked.

Mr. Davis: We do have a funding formula in Alberta that allocates on that basis, but the federal government does not - and again, I do not want to be critical of my federal colleagues, because they are wrestling with a myriad of complex fiscal and policy issues.

The Chairman: Just so you are clear, a lot of us around this table, in fact, I think all of us around the table, are often critical of our federal government.

Mr. Davis: In that case, I will say that this has not resonated with the federal government. Quite frankly, a little less than 70 cents of every personal income tax dollar raised in Alberta goes to Ottawa.

It is the same argument that municipalities use effectively with provincial governments, "You raise most of the provincial revenue. Our tax base is not large enough to support the infrastructure development we need in our communities."

It is absolutely true with health care. The federal government is the major tax "receiver," if I can put it that way, in the country, and health care is the major social program. From the person on the street's perspective, it seems silly that the two levels of government cannot put together a proper funding balance based on the revenues they receive and the importance of the program.

Now, I am not necessarily advocating that all of this should come out of the tax base. I do think we need to start exploring other ways that put consumer power into the hands of the patient and produce properly aligned incentives.

A lot of the difficulties in the health care system in Canada today could be avoided if the federal government funded their contribution in an open, transparent and sensible way. In Alberta, health care is 33 per cent of the budget. I believe in some other provinces it is now approaching 50 per cent.

In good times, equalization payments pick that up. However, when the economy tightens up, that money may not be there, and that is going to put those provinces in a deficit position.

Now the Prime Minister and the premiers meet once every two years for dinner and decide that a certain amount of money will be allocated from the federal government on the basis of which nobody can understand. All of this allocation, of course, is over a significant number of years, so it sounds like a huge amount of money in the short term, but it really is not.

That is not going to get the job done of managing a $60-billion-a-year enterprise through ten provinces and two territories in an organized, professional way.

Senator LeBreton: I actually made a note of your comment about viewing the patient as a consumer, and I think it is something we should bear in mind. There is not enough of that.

Senator Roche: Mr. Chairman, would you permit me, as an Albertan, to say how proud I am of these two great health leaders? No wonder Jeffrey Simpson was impressed. We came out here and found that these elite Easterners were also coming here to find out what has been done in the West.

Mr. Davis and Ms Weatherill, I want to pursue this question of stable funding. I think it is at the heart of what we are really trying to do here.

Mr. Davis, when you made your opening presentation this morning, your last statement, if I heard you correctly, was that you could not see how the system can be adequately financed. You have been elaborating on this a little.

Could you just take me through what, from your experience, you think is the proper funding balance between federal government and provincial government? Are you saying that we may not be able to depend entirely on the tax base for funding health care in the 21st century, with all the expansions that we have been noting?

In addition to that, what is the right proportion between the tax base and private funding? Can you take me through some of your thinking?

Mr. Davis: I do not want to sound like a tax expert. I have former colleagues in the Ministry of Finance who would probably say, "He is the last guy who should be talking about this." However, just generally, I think there are a few things that governments have to look at.

Clearly, governments want to hold general income taxes at current levels or reduce them, and that has a lot to do with international competitiveness and all kinds of things. That does seem to be the prevailing opinion of all of the provinces and the federal government, irrespective of political stripe.

We have not really looked seriously at dedicated taxes in this country. The United States uses them; a lot of European countries do. The interstate highway system has been built with dedicated fuel taxes. Is there a problem with a dedicated health tax? I am not sure there is. I think we let corporations off the hook on health in this country in a spectacular way.

Health care is a huge cost to every corporation in the United States. They like their personal income tax rate; they like their corporate income tax rate. However, $5,000 of the cost of every automobile rolling off the assembly line in Detroit is for health care.

We might be able to do something on the dedicated tax side. I do believe firmly, though, in putting consumer power in the hands of patients. That means government dollars follow the patients, or, where there is an insurance method, they participate. When you pay, you have more power. When you do not, you have less.

That is a brief overview of where more tax money might be found on the consumer side. As to the relative split between the federal and provincial governments, I do not know what the right number is, but again, this is the major social program in Canada. There are huge socio-economic benefits to our health care system.

Governments need to recognize that and to participate extensively in funding and providing the policy direction framework. That is not to say that there should not be consumer participation.

The federal government, as the major revenue generator in the country, cannot evade this. On the other hand, a lot of the provinces would say, "Look, we do not want the federal government any more involved in health care policy than they already are." I think provinces have to say, "We do need to start working as a national team on health care, because it does differentiate us as Canadians."

Why not make this the best it can be, rather than fighting amongst ourselves over who will carry the can for it not working? To me, that is the huge disappointment in what I have seen in the last few years, notwithstanding that a number of jurisdictions have made some very good progress.

I think the federal government has also tried to do some things, but we do not see this national team effort on health that there could and should be.

Ms Weatherill: A lot of effort is put into holding personal taxes down, and I agree with Jack about the corporate side too. However, at the same time we are doing that, we are withholding choice from the users of the system. That is the argument that I am starting to hear, and people are losing patience quickly when they wait so long for some things.

I am surprised that there has been no discussion with the public. What does the public want to do about this? Maybe they do want to pay more tax. Maybe they do want a dedicated tax. Maybe they would prefer that over some other methods of financing the health system.

I have been very puzzled, since this became more of a public discussion, about why the public has not been asked a focused question, rather than people like us.

Senator Roche: Are you thinking that maybe we ought to recommend a dedicated corporate tax?

Mr. Davis: We must try to come at this from the value proposition. The health system brings huge value to all elements of society, including corporate Canada. I do not think we should let corporate Canada off the hook as we lower corporate taxes. We should be asking, "How do you want to participate in this?"

There is no magic source of revenue. It will come from individuals or companies, whether through taxation or insurance. Large employers, in particular, need to recognize the very significant benefit of the health system.

The Chairman: I was in Nova Scotia when medicare began there in 1968. There had been no provincial sales tax until then. They introduced a provincial sales tax, but they did not call it that; they called it a "health services tax."

This practice has long since disappeared, but for the first five or six years, the money went into a separate account and was essentially an earmarked tax. The accounting was strictly for health care expenditures, and I do not think that was unique to Nova Scotia at the time. I think a couple of other provinces did this too.

You may not know the answer to my last question, but you may be able to tell us where to find the answer. When we look at the percentage of the population who have drug plans, all of the Western provinces, with the exception of Alberta, are at 100 per cent. Alberta is at 83 per cent.

Drug insurance is available to everybody through your provincially subsidized Blue Cross plan. Do you have any idea why Alberta would be unique, in the sense that a significant portion of the population has not taken advantage of subscribing to a drug plan? If they cannot get it through their employer, there is the Blue Cross one. You can sign up as an individual. Is there some unique reason? Do we know who those people are?

Mr. Davis: I would have to have a look at that.

The Chairman: It is more a matter of curiosity to me than anything else, because it may tell us something about what a drug plan ought to look like if we were to ultimately move to a national program. Obviously there is consumer choice. You do not have to sign up for the Blue Cross program, and it would be interesting to know why people do, and in particular, the demographics of that.

Mr. Davis: They may have signed up with another plan, though.

The Chairman: No. We have data on the percentage of Albertans who do not belong to a plan. We know one is available, and yet 17 per cent do not have any drug plan. I am just curious as to why people have not taken advantage of it.

Ms Weatherill: I do not know. We will find out.

Mr. Davis: I think it is worth looking at the WCB model, and you have probably done that as you travelled across the country. We talk about whether we have two-tier health care in Alberta or Canada right now. Clearly, there are multi-tiers, and in workers' compensation, both employers and individuals participate.They also participate in the health care portion in most provinces.

The Chairman: All kinds of people in the health care system, and policy-makers in particular, were stunned by our comment in our report that, in a sense, WCB operates as a second tier in every province. They get priority on waiting lists. In some provinces, they actually have acute care beds held in reserve for them.

In most provinces where doctors' incomes are capped, fee for service to WCB patients is not counted under the cap. Therefore, a parallel system clearly exists, and I think your point is, what, if anything, can we learn from WCB? It is an interesting question. We were shocked to learn that this was going on and nobody knew about it.

Senator Morin: Everybody should be part of the WCB.

Senator Marjory LeBreton (Deputy Chairman) in the Chair.

The Deputy Chairman: The chairman will be not available for the next two sets of witnesses. I am going to introduce our witnesses, and we will add one more person to the table, not for the purpose of making a presentation, but to answer questions after.

I would like to welcome Pat Fredrickson, president of the Canadian Practical Nurses Association; Dr. Donna Wilson, from the University of Alberta, Faculty of Nursing; Elisabeth Ballermann, Health Sciences Association of Alberta; and Sharon Richardson, Alberta Association of Registered Nurses. We are also inviting to the table, Heather Smith, who is president of the United Nurses of Alberta.

Ms Pat Fredrickson, President, Canadian Practical Nurses Association: Good morning to everyone. I am pleased to be here as president of the Canadian Practical Nurses Association. As a committee, you have the unenviable task of taking a structure that you describe as "19th century" and trying to move it into the 21st century.

In your interim report, you have identified two human resource issues that clearly require the attention of all governments, federal, provincial and territorial. Those issues are, how to make the best use of the full spectrum of differently qualified health professionals so that the full range of abilities of each is productively employed, and how to recruit, train and retain an adequate supply of health care professionals who can adapt to the changing health care needs of the Canadian population.

The health human resource issue is a major one. It is not only unlikely that there will be a "quick fix," as you say, to the human resource problems, we would venture to say it is next to impossible. The system and the attitudes did not develop overnight, nor will they disappear any time soon. The human resource needs will be increasingly impacted by the changing demographics in our country, including an increasing aging population and a declining birth rate. In any profession, trade or occupation, there are shortages of workers across the country.

Nursing, by virtue of the sheer numbers, will be especially hard hit. The Canadian Nurses Association projects the shortage of registered nurses will be anywhere from 59,000 to 113,000 by the year 2011. However, we will not have to wait that long to see the need for nurses. There are already shortages right across the country. This underscores the urgent need for Canada's health care system to more effectively utilize the health care workforce to its full potential.

Licensed practical nurses are a part of the solution to the nursing crisis. LPNs are both a practical and cost-effective way of alleviating the shortage of nurses and averting an even more serious nursing crisis. We would strongly support a move away from the hierarchical way of thinking to your assumption that each profession has its particular strengths, and these all need to be properly valued and deployed.

Just as the registered nurse's education and scope of practice has expanded in recent years, so has that of the LPN. The LPN education has moved from skill-based training to knowledge-based education. The LPN's role and scope of practice has evolved to assume many competencies once only performed by the RN. The national nursing competency project, completed in 1996, identified that the competencies of the LPN overlap with those of the RN from 50 to 70 per cent.

In many provinces in the last couple of years, provincial legislation has removed barriers and moved away from the premise that LPNs work under the direction of a registered nurse towards the notion that, based on their knowledge, they work within their defined scope of practice.

Yet the LPN remains wilfully underutilized. Examples in this country of where the knowledge and skills of LPNs are used to their full scope of practice are few and far between. In Ontario, the practical nurses in the community practice in an autonomous role as full members of the health care team, utilizing all of their knowledge and skills.

They also have supervisory or managerial roles in long-term care, yet in acute care, face barriers that restrict or eliminate their roles. The greatest underutilization is also where there is the greatest shortage of registered nurses. The biggest barrier to the utilization of the LPN is in the facilities, where the unions protect the turf of the registered nurse through restrictive collective agreements.

Our goal as licensed practical nurses is not to replace the registered nurse, but to seek due respect in a complementary role for the knowledge and skills that we bring to the health care system.

You asked what role the federal government will have in the development of a national human resource plan. You may be encouraged to know that the federal government will have a huge role as the primary funder of the national nursing sector study announced last week by the Human Resources minister. This study will provide labour market information to address the current and future supply of the three nursing groups.

It will conduct a comprehensive analysis of the long-term human resource issues and challenges facing the nursing occupational groups in each of the main employment sectors. It will examine the application of nursing knowledge, skill and competencies of the three regulated nursing occupational groups within the context of the health needs of the population, and provide necessary information and recommendations to support the development and implementation of a Canada-wide, integrated human resource strategy.

While studies are important, nothing will change without leadership, a willingness to change the way we do business and our attitudes, and a willingness to recognize that there is enough room, and need, for everyone in the system. Today, because of nursing shortages, all nurses are overworked, and RNs particularly are required to work mandatory overtime, while LPNs are underutilized.

This precludes the effective utilization of both groups, reducing their morale, making both professions less attractive and further exacerbating the nursing supply crisis. Comprehensive utilization of practical nurses would ensure LPNs continue to enter and remain in the nursing workforce, recognize the potential of each professional group, and permit each group to work within that potential to improve health team relationships and enable far more cost-effective care, as well as attracting practitioners to and encouraging them to remain in the nursing professions.

On the other hand, a diminished LPN presence would result in increased costs in hiring additional RNs and an underutilized RN population, which would further prohibit RNs from maximizing their potential and contribute to the diminished role of the current nursing workforce.

The CPNA has seen much convincing evidence that maximum utilization of the LPN improves nursing staff morale and addresses the current shortages of both RNs and LPNs, as well as improving cost efficiencies in the health care system. Our brief contains several examples of the effects of full LPN utilization, and we would strongly urge you to support that position as part of a solution to the nursing crisis. I thank you for the opportunity to appear before you.

Dr. Donna Wilson, Faculty of Nursing, University of Alberta: Good morning, and a particular thank you to all of you for coming to Edmonton. It is a beautiful city and I hope you enjoy it. I hope you can get out for a nice walk and take in some of our sights.

Senator Morin: We will do that right away.

Dr. Wilson: I will keep to my short time here. As you no doubt know, I am a registered nurse. I have brought a brief that I will be going through step by step. I am here because I am a researcher. I am a professor at the University of Alberta and also a staff nurse. I try to work one day a week to keep my hand in so that I know what is really happening in health care. Over the last 10 years in particular, I have been hearing a lot of concern, and saw it in your report, about how to improve health services, particularly health services utilization. How do we get a "better bang for a buck," you might say, or how do we use the resources that we have more wisely?

It is of interest to me as a researcher that there has been some attention paid to who are the high users of the health care system, in particular, dying people or the terminally ill, and certainly the elderly, who often fit into that category.

I have undertaken four studies and a fifth one is in progress. The first one that I will talk about briefly is an analysis of Statistics Canada mortality data. I have data on deaths going back to 1950, so I can look at age of death, where people are dying and what have you.

Interestingly enough, this was the cheapest data that I have had to purchase. This only cost me $5,000, and I received a grant from the NHRDP that enabled me to afford it.

The second study that I will be reporting on looked at data on all deaths in Alberta hospitals over a five-year period. That was not that expensive for me to purchase as a researcher. It was only about $10,000, and two grants later, I was able to receive that data.

The third was a self-funded study in which I asked senior citizens who had looked after dying people about their preferences for end-of-life care. I followed that up with a second self-funded study looking at how long people need help before they pass away, and the fifth study, which is ongoing, is looking at 12 years of long-term care data, which, by the way, has been collected but never analyzed before. I was required to pay $40,000 to access that data, and the funding for that came from an Alberta Heritage Fund grant.

Just as a little, quick aside, I am now planning to purchase $80,000 of Alberta health data to look at the shift to ambulatory and home care in this province, and I am asking the Canadian Institutes of Health Research for that funding.

If I can turn to page 2 of my brief, I would like to talk about what I found when I looked at Statistics Canada mortality data. In many ways, the graph says it all. There was a continuous rise in the number of people using hospitals for end-of-life care up until 1994. More profound is the fact that since 1994, there has been a decline every year in the use of hospitals for end-of-life care. In some ways, graphs and statistics can be very misleading.

The graph on page 3 shows the shift from hospitals. Using hospitals for end-of-life care actually began back in 1982 - fully 20 years ago - in Saskatchewan, and each province followed suit. I know of no national program that tried to make this happen, but it did. This was a very slow but certain trend.

Looking at where people are passing away today, the shift has been to private homes or to seniors' residences, to multi-dwelling places. By the way, those findings were published.

The second study, using Alberta Health and Wellness in-patient hospital data, also produced some quite astounding results, in my opinion. One of the main findings was that less than half of all the deaths in Alberta over a five-year period took place in a hospital. These are very interesting data, and much different from the myth about high utilization of hospitals.

The second amazing finding was that during their final hospital stay before death, 52 per cent received nothing other than nursing care - no procedures, no treatments, no chemotherapy and no surgery.

The third key finding was that in the five years before people passed away in hospital, most were admitted very infrequently and were not commonly treated. I have included a number of graphs there showing that the most common pattern was that people were admitted only once in five years. In other words, they only came in at the time of death.

On page 5, I have again included a graph to emphasize that very little is done in the last five years of life and that only a few people are high users. In fact, I was able to identify, as did another study a few years ago, that less than 4 per cent of people could be considered high users in the five years before they pass away.

These were people who were admitted frequently to hospital, stayed in for a long period of time, or had many procedures done.

When I looked into the people who were in for long periods of time, I found that they were actually long-term care residents transferred to hospital. In fact, they were not in hospital any longer than anyone else.

The study looked at who were these high users and why were they high users. It had nothing to do with age, nothing to do with gender, and certainly nothing to do with the type of illness.

The only factor that influenced utilization was whether people lived in a rural or urban setting. In fact, 78 per cent of the high users were rural residents. These people were almost all admitted to a very small hospital, were cared for by a general practitioner for the most part, and had the same procedures performed over and over again.

I would like to suggest that one solution to this issue would be a nursing case manager to look at these people.

The Deputy Chairman: Dr. Wilson, could I ask you, since we really want some time for questioning, to go to your recommendations and highlight those?

Dr. Wilson: Thank you. I will do so.

The other studies are again just filling in some of the information about dependency when people are terminally ill. The recommendations arise out of the fact that I know there is very little analysis of what is called "administrative data," the hospital data, long-term care data and what have you. There are a number of barriers for researchers to accessing that data.

The second recommendation is to enable research to evaluate the decentralization of health care planning, control and delivery. Certainly regionalization has not helped to address the situation of these high users, and I have had other issues with regionalization in Alberta.

The third point is that I believe there is a need for programs such as nursing case management to identify the few people who are high users of health services and assist them in achieving a better state of health and less reliance on the small local hospitals.

Ms Elisabeth Ballermann, President, Health Sciences Association of Alberta: On behalf of the Health Sciences Association of Alberta, I would like to thank to the committee for this opportunity to appear before you.

The Health Sciences Association of Alberta is a labour union that represents over 12,000 health care workers in Alberta. The vast majority of these people are in our paramedical technical and paramedical professional bargaining units. These are the men and women who perform a large array of diagnostic and non-surgical therapeutic procedures. Your report, I believe, generally refers to them as "other health care professionals." For the purpose of this presentation, I shall refer to them as "allied health workers" or "allied health professionals."

My comments will focus on the question of recruitment and retention of these allied health workers.

The first issue that arises for our membership - and according to our colleagues across the country this is not restricted to Alberta - is the invisibility of these allied health workers. Much attention is given to nurses and physicians. The general public thinks of nurses and doctors; the media, policy makers and governments, while somewhat more informed, also tend to focus on nurses and physicians. However, it is clear that the allied health workers are an indispensable part of the health care system.

An example of this invisibility can be found in a recent Global TV segment on the shortage of nurses in the capital health region. The program talked about a need for 400 nurses, which represents approximately 6 per cent of the total nursing population. As an afterthought, the reporter also said, "By the way, they are also looking for 65 diagnostic imaging technologists." We represent all of the diagnostic imaging technologists employed by the capital health region, and the figure 65 represents close to a 20 per cent shortage among that discipline. We have a great deal of data related to nurses and physicians, data related to quality of work life, demographics and workforce situations.

The issues of allied health workers must also be addressed. Our written presentation lists over 20 disciplines that are experiencing significant shortages, and the list is not exhaustive. All of the factors noted in the committee's report in relation to nursing are equally relevant to allied health workers, whether they be workload, lifestyle issues, shift work, the need for continuing education, and leadership and advancement.

The second issue that deals with these people is the rising educational requirements. Many of the disciplines that we represent are facing an increasing need for educational preparation. For example, where the Michener Institute in Ontario once offered a two-year program for diagnostic imaging technologists it now offers a five-year program, because of the expansion of technology. Physical therapy in Alberta and across the country is moving to a master's level preparation for entry to clinical practice. These rising expectations will be reflected in the remuneration expectations of the graduates.

Nursing settlements have resulted in situations where nursing graduates from a two-year program are earning as much or more than physical therapists or occupational therapists, both of which require a B.A.

A more extreme case here in Alberta involves combined laboratory x-ray technologists who work in the rural area. They are required to complete a two-year program. The top pay rate differential for a graduate from a two-year nursing program as compared to these technologists is over $9 an hour. This is a huge inequity for these technologists.

To raise the educational levels without adjusting the relative pay levels will, in our opinion, provide a disincentive to young people in choosing health care in these professions. It also creates unnecessary tension between the professions.

It also raises the question of the educational institutions themselves. Decisions made in one province affect what happens in other provinces. Ontario decided that its radiation therapists should be trained in university as opposed to the institutions. At one time, Ontario produced more than 70 graduates per year. By changing the program, there was a three-year lag time - in other words, for three years there were no graduates coming out of Ontario. This very directly contributed to a significant shortage of radiation therapists, the result of which patients had to go to the United States for treatment. That shortage was, in our view, a very significant factor in large wage increases for radiation therapists here in Alberta.

This brings us to the issue of funding. We fully agree with the committee's position that health care funding must be stable. The cuts to health care in the mid-1990s were followed by significant increases; however, often one-time infusions have not dealt with the continuing operating costs. Even now, we are hearing of contemplated cuts arriving on the heels of a sudden announcement by our provincial government. These roller coaster lay offs and shortages have a very negative effect on the health care system. They create havoc in staffing the increased workloads, and they damage morale. It also leads to the robbing-Peter-to-pay-Paul syndrome, as we call it. Provinces compete with each other for these skilled professionals, an action that exacerbates inequities between the provinces contributes to a rise in health care costs.

Funding cuts have also been felt in the education of allied health professionals. The mid-1990s saw a substantial reduction in enrolments. For example, with respect to laboratory technologists, between 1987 and 1997 the number of graduates decreased by 42 per cent, at a time when our population is growing and the number of tests that are being done is also growing.

Let me now turn to the increasing level of privatization. We have heard a lot about the private sector taking up some of the slack, that we may be able to reduce costs. With respect, we beg to differ. What we have seen among some of our members, those who have private-sector options, is a brain drain, not south of the border, necessarily - although that is a factor - not from one province to another, but from the public system to the private system. People are leaving for similar pay levels but significantly better working conditions - for example, no shift work, no on-call work, no overtime. We have not seen a concomitant decrease in the demands on the public sector.

This leads us, then, to the four options that we recommend with regard to this issue for the federal government. We fully endorse a national long-term health human resources planning strategy involving all provinces and all levels of government, advanced education sectors, professional and regulatory bodies as well as labour organizations. Interprovincial mobility means that we have a national labour market for allied health workers, and it should treated as such.

There has been a great deal of discussion this morning about stable funding. We feel this is crucial, for both health and advanced education, as the supply of professionals and recruitment and retention are directly affected by both. There is little point in spending a lot of money on a health human resources strategy, if the strategy is not backed by stable funding for those who graduate from the programs.

We also advocate for a communications strategy to address the invisibility of allied health workers. We must ensure that all health professions become attractive career choices for young people and that allied health professions are seen as an integral part of the system.

Our final recommendation deals with the limits on the growth of privatization. We suggest that this recommendation is more than an ideological perspective. We have experienced the effects on the public health care system, and we would argue that the growth of for-profit medicine has resulted in a brain drain from the public system and is a significant driver in the cost of providing health care.

Ms Sharon, Richardson, President, Alberta Association of Registered Nurses: Thank you for the opportunity to comment on the committee's report.

Having been asked to make brief opening remarks for five to seven minutes followed by an opportunity for responding to questions, I have chosen to offer comment on chapter 11, health human resources. First, however, let me offer a brief background on the Alberta Association of Registered Nurses, colloquially referred to as the "AARN."

The AARN has been the professional association and regulatory body for registered nurses in Alberta since 1916. The AARN manages two key responsibilities: first, regulating the practice of RNs to ensure that Albertans receive safe and competent nursing care; and second, promoting excellence in the practice of nursing. The AARN also advocates for a high-quality, cost-efficient health care system that makes the best use of the knowledge and skills of workers.

The AARN endorses the committee's identification of two human resource issues that clearly require the attention of all governments. The first is how to recruit, train, and retain an adequate supply of health care professionals who can adapt to the changing health and health care needs of the Canadian population.

The AARN believes there is an immediate crisis in health human resources in Alberta, particularly with regard to the situation faced by RNs. In Alberta, fully 28 per cent of RNs are over the age of 50. Given that this 28 per cent might reasonably be expected to begin retiring in significant numbers over the next few years, there will obviously be increasing demand for new graduates just to maintain the Alberta RN labour force, and that labour force currently is slightly more than 24,000. Also noteworthy is that 46 per cent of the current Alberta RN labour force is between 35 and 50 years of age and only 23 per cent are between 26 and 35 years of age.

Despite the increased demand for RNs during the past two years, there has been a progressive decline in registrants from other Canadian jurisdictions and no increase in the number of RNs graduating from RN Alberta educational programs. There were 578 RN graduates in 1998, a decline to 475 in 1999, and a slight increase to 544 in 2000. Clearly, one of the significant implications of the mature age of the Alberta RN labour force, coupled with the reduction in transfer registrations from other Canadian jurisdictions and the decreased number of RN graduates in recent years, is demand for dramatically increased number of new RN graduates from Alberta educational programs.

The AARN acknowledges that significant salary increases recently negotiated by the United Nurses of Alberta for about 75 per cent of the province's RN labour force and increasing flexibility of educational programs leading to entry to practice will enhance recruitment to the nursing profession. The AARN believes, however, that recruitment could be enhanced further by governments providing tuition support via taxes or grants. Many RN students rely on loans for a significant proportion of their tuition and expenses and often enter the labour market with very large outstanding educational debts. Tuition support through taxes or grants could go a long way in lightening graduates' debt burdens at a time when they are attempting to establish their professional careers.

The second human resource issue identified by the committee as requiring the attention of all governments is how to make the best use of the full spectrum of differently qualified health professionals. The AARN concurs that primary health care reform is essential if Canadians are to rationalize the use of health human resources. Primary health care is defined as the first level of care, usually the first point of contact that people have with the health care system. The AARN concurs that primary health care services need to be coordinated, accessible to all consumers, provided by health professionals who have the right skills to meet the needs of individuals in the communities, and accountable to local citizens through community governance. Further, the AARN agrees that multidisciplinary teamwork is a vital part of primary care.

The Alberta RN labour force is well positioned to engage in primary health care reform. A particular attribute is the proportion of Alberta RNs with baccalaureate or higher degrees. In 2000, 8,275 Alberta RNs, or slightly more than one third of all registered nurses, held a baccalaureate or higher degree. Of these, the overwhelming majority, almost 80 per cent, were employed in delivering direct care to clients in hospital and community settings. Baccalaureate education facilitates RNs who are knowledgeable and skilled in health promotion and disease prevention as well as assessment and care of ill individuals. Since 1997, the number of new RNs entering practice in Alberta with a baccalaureate degree has been four times greater than the number entering with a diploma. Increased government funding of baccalaureate nursing programs leading to entry to RN practice is an important option for increasing the proportion of the RN labour force especially amenable to practising in a primary health care mode.

Thank you for the opportunity to speak to you about options to promote recruitment to RN nursing practice and implementation of a primary health care delivery strategy.

The Deputy Chairman: Ms Richardson, you referred to the statistics, and we have heard many references as we have moved across the country, to the age of RNs.

Senator Morin: I have a number of questions. I would like to start with you, Ms Fredrickson. Is there any variability between the provinces and the utilization of practical nurses? Is there any provinces wherein you feel the utilization of practical nurses is more efficient and could be conserved as a model for other provinces? It does vary from province to province; correct?

Ms Fredrickson: It does vary from province to province. In fact, I can tell you that it varies from hospital to hospital, even from unit to unit within a hospital. In terms of an overall provincial model for utilization, I would probably have to point to Nova Scotia. Because of the serious shortage of nurses in Nova Scotia, they are establishing a province-wide model. It is still in the implementation stage, however; after being piloted in one region, the model is now moving to a provincial level.

Senator Morin: Dr. Wilson, thank you very much for coming. As far as I know, you are the first researcher we have heard here. It is a bit curious that we have not had other researchers before the committee as witnesses, or even comments from other researchers. If we were dealing with cancer or heart disease, we would be hearing from hundreds of researchers, who would passionately be telling us about their research. They would be eager to share their point of view with us. We are dealing with health services, a very important issue, and the academic experts in this field have been remarkably silent. We have heard from practitioners, from professional associations, from administrators, from politicians; the number of witnesses has been overwhelming, and we are pleased with it.

What is missing here is the testimony from the academic experts and the research community. You are the only exception to this point; we may hear from some of them later, but to this point we are not hearing from them. They are out there, but they are not here.

Finally, Ms Ballermann, your comments respecting private health care interested me. You know the field much better than I do. Do you have any concerns about the quality of care in the private radiology clinics? Or do you feel they are more expensive, not less efficient, because they are funded by government, of course?

You also referred to private-sector competition with respect to pharmacy services. Do you think pharmacies should be government-owned? I do not understand what you mean. Do you mean they should be under government control?

Ms Ballermann: With regard to the radiology clinics, I am not sure I am qualified to comment on issues of quality. I would refer you to the professional bodies for that.

Nevertheless, we hear anecdotally from some of our members who work in both sectors - the ultrasound technologists, for example - that the time they have allotted to an exam in the private sector is substantially less than what they would have allotted in the public sector. It certainly raises the question of quality, but I could not authoritatively say that it is a quality issue.

The question tends to be the utilization and the total cost of bringing that up. From the radiology point of view, the concern is mostly about the brain drain out of the public system.

Senator Morin: I understand that point, but what I am trying to get from you is whether private radiology clinics are more expensive.

Your opinion is that there is less time spent per patient in private radiology clinics than there is in hospitals.

Ms Ballermann: I want to be very clear that I am not making that as a general statement. We have had anecdotal evidence that that is in fact the case with some exams.

I am not privy, nor is anyone, to the exact cost of each exam the private system provides, so I could not authoritatively talk about the cost per exam. Unlike the surgical facilities that now have to report their contracts publicly, the diagnostic facilities are not covered.

Our concern is the drain of people out of the public system without a corresponding decrease in demand on the public system.

With regard to your next concern, we are not suggesting that retail pharmacies should come under government control. We know that that is a longstanding issue. However, we would advocate for a national formulary, a national pharmacare program, which we believe would have the effect of reducing the amount of private participation in the health care system.

Public-sector pharmacists earn somewhere over $30 an hour. They are seeing advertisements for $50 an hour to come work at the superstore. The dramatic difference in pay is not enough to keep pharmacists in the hospitals, where, while their work is more interesting, the workloads are extreme.

If you were to speak to Mr. Davis or Ms Weatherill, they would tell you that they are having significant difficulties in recruiting and retaining pharmacists. As a union, we will be looking for wages that stay competitive, because that is our job for our members; nevertheless, that is a significant cost-driver to the system, as a whole.

The Deputy Chairman: Did you want to comment, Dr. Wilson, on the Senator Morin's statement with respect to lack of evidence by researchers?

Dr. Wilson: I have not been aware of who has been testifying before the committee, but it is a shame that more researchers have not been here.

However, there are very few researchers who can access this data. Unfortunately, when there is a charge of $40,000 or $80,000, a researcher has to get grant to cover that. As well, a distinct skill set is required. Hence, there are few researchers who really delve into this, and few will in the future with these kinds of barriers.

In terms of privatization, Alberta Health, over the last year, privatized their databases, the data that flows into them from long-term care facilities and hospitals. Last year, the data I wanted would have costs me $40,000. This year, that data cost $80,000. It is exactly double, because it is a private company now that is charging for that.

This limits to a great extent where a researcher goes to access this data. I do not have those funds myself. I need a very large grant to access this kind of data, and there is a great deal of competition for grant funds these days. Even with more money going into research, it is becoming more difficult for a researcher to get his or her hands on those research dollars. Getting a successful grant proposal together is a lot of work. This is a crucial issue.

How can a researcher operate without data? One cannot operate on myths or on the basis of how things worked 10 years ago. Our health system has changed quickly, and there is a lack of data describing these changes or identifying what they are and their impact.

The Deputy Chairman: That is a very good point.

Senator Pépin: Ms Fredrickson, if I understood correctly, there is a slight difficulty between your association, which represents LPNs, and RNs. What is the difference between the two in terms of years of study?

Ms Fredrickson: It varies across the country. It ranges from a one-year minimum to a two-year program, which Ontario is now putting in place. In Quebec, the program is, I believe, two years, but it is delivered in a different manner.

Senator Pépin: Thank you. I thought it was standardized across the country.

Has there been any proposal about how you could work together? There have been many suggestions about teamwork, about doctor, nurses and allied health worker all working together. How do you see your association working closely with the RN?

Ms Fredrickson: If there were articulated education, the collegiality and the teamwork would start right there, in the education program. A far better understanding would develop on the part of registered nurses about what the practical nurse education involves. In other words, if there were a continuum of education it would go a long way towards alleviating some of the problems that are there now.

Senator Pépin: You say that LPNs are underutilized. You say, and I quote, the following:

The greatest underutilization of the LPN is also where there is the greatest shortage of nurses.

How did you come to be in that situation? I realize a difficult exists between the two associations, and I do not think we can resolve it; nevertheless, it is important to work towards the day the two will be able to work together.

Ms Fredrickson: It goes back to where the practical nurse came from. The occupation arose from a shortage of registered nurses post-WWII. It was an assistive role. However, the practical nurse has moved beyond that in many jurisdictions. Granted, in some they have not and in others they still carry the title "nursing assistant." Therefore, the role varies.

Nevertheless, overall there has been a very significant increase in the education of the practical nurse. It has moved into a knowledge-based education rather than the skills-based education it was, and part of that message has never been delivered to a lot of people.

The Deputy Chairman: Ms Richardson or Ms Smith, did you want to comment on that?

Ms Heather Smith, President, United Nurses of Alberta: There are questions around supply of licensed practical nurses as well. I do not think it is necessarily a matter of non-utilization in certain areas of the province here. It is my understanding that the undersupply of LPNs is even greater than the undersupply of RNs.

Hence, I just did not agree with the nature of the comment.

Ms Fredrickson: One of my other hats is that I am the executive director of the regulatory body for LPNs in this province. As such, I can tell you that in this province alone we went from 8,600 LPNs in 1986 to 4,300 two years ago.

The Deputy Chairman: Where did they go?

Ms Fredrickson: They were laid off; they were eliminated from the system. There were no jobs for LPNs so no one was going into the profession. Our numbers are now starting to increase, but that will take a long time. Along with the AERN, we have a very significant population who will be leaving the workforce for retirement within the next 10 years.

Ms Richardson: One of the things that all nursing categories are struggling with in this province right now is directly attributable to the dramatic reduction in funding of health care services that took place in the mid-1990s and was euphemistically referred to as "restructuring." One third of all registered nurse positions were cut between 1993 and 1995. We lost four years of graduands from 1994 through 1998. Those people had to leave the province to get jobs. They will not be back.

The numbers Ms Fredrickson is referring to were also affected by the dramatic cuts in the health care delivery system. Hence, when she shares with you the information about the dramatic decrease in numbers of LPNs in the mid-1990s, that decrease is associated, in my opinion, with the "restructuring."

It is very difficult, once the number of jobs has been reduced - and you are dealing with a more mature cadre of workers in whatever category - to promote that particular occupational group.

The other comment I have is that this province did not close its hospital-based diploma nursing programs until 1995. Hence, one of the things that happened - and prior to 1995, two thirds of all of our graduates entering practice as RNs came from the four hospital-based diploma programs - is that those students were used for service. It does not matter how you cut it, they were there on the roster somewhere in their two-and-a-half or three-year program.

We have a particular history in this province about student labour that lasted longer than most other provinces, and this is also a factor in relation to the LPN situation. When you have a student labour force, even if it is only used partially, it reduces the demand for the LPN category because they have been, by employers, used interchangeably.

Hence, the situation is very difficult for the category that we call LPN at this point in time.

Senator Pépin: I know that Quebec is facing a similar situation. During restructuring, many nurses were laid off. Currently, there is a shortage; however, the nurses are gone and will not come back. So I know what you are talking about.

Dr. Wilson, I am interested in what you said about home care, nursing homes, and the statistics about the numbers of people using hospitals. You said that 78 per cent were rural residents. It would appear that well-structured home care will become a necessity, as well as palliative care.

We did a study last year on palliative care, and every year we will try to update it. I intend to read your study; it is very important. As Senator Morin mentioned, you are the first researcher to give us information of the type you presented here.

Ms Ballermann, you spoke about salary differences among allied health workers. If we look at the teamwork option, the issue of salary differences will have to be - what I am trying to say is that the unions will have a lot to do with that.

Ms Ballermann: Absolutely. It is our job to negotiate for adequate salaries for our union members. The reality is that the sheer numbers of our membership has not given us the clout. We congratulate our nursing colleagues, because we have been able to capitalize on some of their gains over the years, but we have not in other areas.

The sheer numbers makes a big difference as to the bargaining power that we hold and our governments' - and this is primarily provincial governments - treatment of the bargaining situation. We look at other jurisdictions with a great deal of trepidation. We have seen in British Columbia, for example, where the government, I believe, has created a very difficult situation, one that has caused a lot of tension between different disciplines, by giving a very significant increase in salary to nurses, a less significant salary increase to a large number of the allied health professions and what can would only be called an insult to about 35 per cent of their allied health workers. If that is reflective of the relative value our governments - we can talk about the Regional Health Authorities having the roles, but the funding comes from the governments - place on these workers, then the government sets up a situation of real morale problems. When young people look at these professions and ask themselves, "What am I going to be able relative to my education," the choice becomes much easier, because that kind of a differential cannot be justified.

Senator Pépin: Ms Richardson, you talked about the percentage of nurses who are between 35 and 50 years old. You also said that, to encourage nursing as a profession, a tax relief or grant could be introduced. Tell me more about that. Do you mean that by subsidizing their education we will be able to get more nurses?

Do you believe that that would entice people into the profession, regardless of the working conditions and the reported lack of respect? Explain that to me a little bit more.

Ms Richardson: I was referring to additional financial assistance for tuition and other expenses. I will give you specific examples of students with whom I have had contact. Some of them are graduating with loans of up to $20,000.

One of the things we are trying to do in nursing - and we have been quite successful at this - is to recruit people when they know that jobs are available. There is not a shortage of applicants for educational seats; there is a shortage of educational seats.

Every single educational agency that offers a pre-licensure program in this province has got at least four qualified applicants for every seat that they can provide. One of the challenges for a number of students - and I am not saying all, but it is a significant proportion - is paying for their educational experience. They have to pay their tuition; they have to pay for their books. Many of them have to pay additional living costs, although we do have transfer programs at regional colleges to facilitate students remaining in their geographic locale.

What I have suggested is a method of assistance for individual students, not the educational programs per se, but for the individual students, possibly tax credits, possibly increased grants, so that they would not be facing such horrendous loans in some cases.

Also, if we wish to attract more mature individuals, and this is an increasing proportion of the recruits to nursing, they very often have dependents. They are not the cadre that we were recruiting into nursing 15 years ago, certainly not 20 years ago.

Senator Pépin: My next question: What is the average age of those recruits?

Ms Richardson: I cannot give you the statistics off the top of my head; I am not sure we are even collecting them. We do know that there is an increasing proportion of what we loosely refer to as mature students, hypothetically 25 and over; there is an increasing number who are 30 and 35. We are dealing here with people who sometimes are recycling from other careers. Some may have spouses, some may have dependents in the form of children, and we are getting some who have parents who are dependents.

Hence, the age spectrum of recruits into nursing is much greater. Their socio-economic characteristics are considerably different; and, on average, as the Canadian Nurses Association has also pointed out, because we are recruiting a larger proportion of more mature people, their occupational life span will be shorter.

Senator Pépin: Ms Fredrickson, do you face this same problem?

Ms Fredrickson: The average age of our students here in Alberta is 29.5 years. Therefore, it certainly is very similar.

Senator Keon: Thank you all for attending here and for taking the time to present on behalf of your relevant constituencies. It is interesting to experience the interface between all of the health disciplines, including the disciplines you represent in medicine and nursing, to be aware that each one is groping for its place in the sun in the overall system. The other interesting thing is that each health discipline seems to be lengthening its training and increasing its educational aspirations. Certainly, this is true in medicine, and I think it applies to every health discipline.

Paradoxically, the overall human resources in health care are just not there anymore, as long as we are depending on the government. I have often thought it would be enormously interesting if one could put the 35 to 40 health disciplines in a big room with appropriate representation and have a think-tank on where the appropriate place of each one of them in the overall system is. That would be a very difficult exercise, because there would be no agreement. I appreciate the enormous responsibility that each one of you as a leader has to your own discipline, to see that your discipline is properly taken care of.

Nonetheless, in the overall scheme of things, somewhere along the line, we will have to find some sort of solution to this, instead of continuing to approach it serendipitously and by letting each discipline find its place in the overall system as we go along.

I am going to ask each one of you to comment on that. I do not particularly care which side of the table goes first, but I would like to hear your comment.

Ms Richardson: I would be delighted to respond to that, Senator Keon. I quite concur. I think the time has long passed when individual disciplines can just be left on their own without any interface either with the health care delivery system or their collegial disciplines. I would caution against any kind of imposed hierarchy, and I would suggest that it would start out as a hierarchy. However, I do concur that it would be very useful to approach the problem from a practical perspective.

If we look, for example, at one section of the health care labour force - and I will use the term "nursing," small "n," and incorporate not only registered nurses but LPNs into that category. We have never sat back in this country, in my opinion, nor to my knowledge in any province in any significant way, and said, "How best can we utilize these categories?" In fact, we have had a situation where there has been dramatic fluctuation in recruitment, in retention and in utilization of these categories.

Ms Fredrickson has spoken eloquently to the variation in the use of what we refer to as the LPN category across the country. Why?

Hence, I would endorse your overall intent.

Dr. Wilson: I will just address another concern that feeds into this, that of regionalization. The regions in Alberta were not given control of payment for physicians. That was the one thing that was left out. How can you plan - you can certainly plan for pharmacy and nurses and what have you - when your doctors who are the cost drivers are outside of that system? That is all I will say.

Ms Ballermann: Certainly, there are some elements of turf protection. I think any of us would be dishonest if we were to deny that that is an aspect of our health care system today. Nevertheless, we have seen some very successful team approaches. For example, I am a physical therapist. My home base is the Glenrose Hospital here in Edmonton, where they have had a number of self-directed teams. I hasten to add that I am not doing active clinical practice at the moment. In any event, they have had self-directed teams, where the professionals come together. There will be the nurse, the physiotherapist, the occupational therapist, the recreation therapist, perhaps a pharmacist, working together to plan the care of a specific patient; and the physicians, of course, are there as well.

There is still the hierarchy of the physician at the top of the heap. I do not see, quite frankly, anywhere in the near future that that is likely to change. However, within the context of some of these self-directed teams, we have had some very good successes.

We had an interesting situation in that very institution where the hierarchy had disappeared within the various disciplines. My physiotherapy colleagues were saying, "We do not rely on anyone to supervise us, per se. We are empowered to make various decisions." To save money, however, the region decided that a hierarchy system must be re-established, because of this additional responsibility that people had to be self-directed. They were being paid at a higher level. "We have just declassified a whole bunch of people to a lower level - re-established a hierarchy," the region said. That has been tremendously frustrating for our members.

Ms Fredrickson: In my presentation, I did talk about the national nursing sector study. One of the mandates of that study is to look at the nursing knowledge, skills and competencies of the three regulated nursing groups, which is the registered nurse, the registered psychiatric nurse in the four western provinces, and the licensed practical nurse.

There is some hope that, if we get into a room, we will be able to discuss where the roles of each should be - where one will end and the other will continue - and what the knowledge and competency should be of each individual practitioner. I have hope that that will happen.

However, before you look at putting it into practice, the education system has to be foremost in terms of looking at how we train people, because there are silos in the education system, not just in practice. The silos start there, and then they continue into practice.

Ms Smith: Just a couple of comments. In terms of turf protection and human health resources, one thing that is not mentioned in my reading of the report is the whole other group of providers, the unregulated. What you have here are the representatives of the regulated health care providers. Unfortunately, for a variety of reasons, one of the greatest issues confronting our health care system, particularly in long-term care, is the massive use of unskilled, which I think brings us back to the issue of public administration and, with that, public accountability in terms of our system.

Also in terms of turf protection and getting all of the providers in a room to duke it out, as it were, one of the significant barriers to that is a simple lack of confidence, which creates a type of paralysis and, in fact, accentuates and makes turf protection an even bigger problem for us. Until we are giving clear signals of confidence in our health care system, and I would say confidence in our public health care system and confidence in the delivery of public health services, there will be an ongoing problem with workers being unwilling to share or to look at alternatives because of the basic economics they are facing and the determinants of their own health.

The Deputy Chairman: I wish to thank every one of the witnesses. The presentations have been very interesting and useful. We have a lot of reading in front of us, in order to properly incorporate this into our study.

The committee recessed.

Upon resuming.

Senator Michael Kirby (Chairman) in the Chair.

The Chairman: Senators, let us begin. Our first witnesses this afternoon are Christine Burdett, the provincial chair of Friends of Medicare, and Kevin Taft, who is the co-author of a book that has just been circulated.

Thank you very much for attending here today. Ms Burdett, can I ask you to begin, and then we will turn to Mr. Taft. Following that, we will have our usual round of questions and answers.

Ms Christine Burdett, Provincial Chair, Friends of Medicare: I should first like to introduce my colleague, Tammy Horne, who is an independent researcher with Friends of Medicare.

Thank you, honourable senators, for giving us this opportunity to present our case in support of medicare.

The term "evidence-based" has become the buzzword in health care. Indeed, I have heard it from your own committee on occasion. If we talk about evidence-based decision making in health care, we have no choice but to acknowledge the overwhelming weight of evidence in support of medicare, evidence that indicates that publicly funded, publicly administered and publicly provided health care is more cost effective, as well as being more compassionate and just.

I could sit here for my entire presentation and cite title after title of peer-reviewed research that supports public health care. I am not going to do that. Indeed, I do not need to do that. You can just read the bibliography in Mr. Taft's book.

I know that you are as aware as I am of the incredible weight of evidence in support of medicare compared with the lack of evidence in support of private for-profit care. For-profit hospitals have higher costs than not-for-profit hospitals and public hospitals, which are operated on a non-profit basis.

In instances where total patient costs are similar as between for-profit and not-for-profit hospitals, the similarity is achieved by having longer lengths of stay to offset higher daily costs in for-profit facilities. That comes from Ettner and Herman, which was published in the Journal of Health Economics.

During the Bill-11 debate here in Alberta, Friends of Medicare and groups like us, as well as concerned citizens, provided study after study in support of medicare, and our government was reliably informed and sought evidence to the contrary without any success.

Your committee has looked at various schemes for reducing the cost of medicare, and it seems, in reading some of your reports, that you may have bought into the fallacy, popular in some quarters, that medicare is not sustainable.

When will we stop framing the medicare debate in terms of public versus private, user fees and medical savings accounts and start talking about real changes, changes that can improve medicare without putting it at risk.

When we look at saving money on health care, we should be looking at reducing the overall cost to individuals, not just reducing the cost to government. That would mean looking at a national pharmacare program to reduce drug costs, which have risen far more sharply than any other costs in health care. It would mean implementing salaries for physicians rather than fee for service, using nurse practitioners and multidisciplinary teams, which would not only reduce costs but also lead to better health care.

Much can still be done to develop best practices and information-based treatments and diagnostics. If we are willing to accept a truly difficult task, we must look at the cost in terms of both money and dignity surrounding end-of-life issues.

Why is it so difficult to accept the simple truth that reducing the cost of health care to government is not the same as reducing the cost of health care to individuals? In fact, the tendency is to the opposite.

In the time given, it is not possible to cover all of the evidence in support of medicare, nor is it possible to sum up the importance of medicare to Canadians. Unfortunately, fewer of us remember what it was like before medicare.

About 16 years ago, my husband was ill with the flu. On Boxing Day, he was admitted to intensive care; he came out at Easter. Although the flu occurs commonly in the population, my husband was in intensive care for three long months. I spent many a sleepless night at his bedside, willing him to live, worried about being left to raise two young sons and threatening him with the most dire consequences I could think of if he left me. Never once, however, did I worry about how I would pay for the almost $500,000 his care cost.

I compare that to a memory from Arthur W. Fletcher of Hythe, Alberta. "The biggest difficulty with the hospital was that payment for the bill had to be made before the patient was admitted. If you had no money available, you had better stay home. One mother died on the hospital steps while her husband was at the desk pleading to have her admitted."

Lillian Laakso of Ottawa said, in part, the following: "When my father was a young man, he worked in the mines in Sudbury, Ontario. He injured his arm somehow, and it became infected. His arm was swollen, and he even had a fever. The nuns at St. Josephs Hospital refused to treat him because he owned no property in town. He walked back to his boarding house, and his landlord walked back to the hospital with him. Then he was treated."

I would like to close with a quote from Dr. Walley Temple, Chief of the Division of Surgical Oncology and Professor with the Departments of Oncology and Surgery with the Faculty of Medicine at the University of Calgary and the Tom Baker Cancer Centre, President of the World Federation of Surgical Oncology Societies and editor-in-chief of the Journal of Surgical Oncology.

Dr. Temple in April 2000 at a rally in Edmonton, where he said, in part, the following: "Some aspects of our humanity are not for commerce - not blood, not organs, not children and not medicine."

Mr. Kevin Taft, Member of the Legislative Assembly of Alberta: Honourable senators, let me say at the outset that Ms Burdett and I in no way coordinated our presentations, but they will overlap certainly in tone and direction.

Let me begin by just briefly running through my qualifications. In 1973, I was appointed by the Lougheed government and served nine years on a cabinet committee reviewing and monitoring the health care system in Alberta. I served on a second cabinet- appointed provincial task force reviewing the nursing home system in the province. I have worked in the Alberta Hospital Association and in private practice as a consultant. I have a Ph.D. in business. Currently, I am a MLA in Alberta; I am the Liberal health critic.

When I was asked to make a presentation here, I was told I should address my remarks to Volume Four: Issues and Options. In that regard, it is important to note that health care is not a commodity like any other. It is an example of market failure. Health care is widely regarded by health economists to be a product not suited for the marketplace.

That understanding must underlie any health-care delivery approach. I notice in the report that you refer to the four patient-oriented principles of the Canada Health Act but left out the one concerning public administration. I do not know what to make of that. My reading of the evidence is that if we shift away from a publicly administered system, we will see inefficiencies increase, costs rise and a host of other problems. My notes, which have been circulated to you, cite a couple of small examples. The research is clear that a publicly administered system has enormous gains in efficiency over a privately market-driven system.

There were some comments in the report on contracting out for clinical services such as surgeries or other clinical services, and I know there were some questions about that this morning. Contracting out clinical services is very different from contracting out services such as dietary services or laundry services, say. There is a different kind of relationship between a patient and a caregiver than between a purchaser and a supplier. If laundry services are contracted out, that may save money; it may not. Nevertheless, the relationship between the buyer and the seller is essentially that - it is a commercial relationship. The buyer, in this example, a laundry department, can determine exactly the quality and the quantity to be purchased.

Conversely, when I go to my physician with a medical problem - cloudy vision, a pain in my chest, chronic headaches, a lump in my breast, or whatever - I am entering a relationship of trust. I need my doctor's help. The physician has a professional responsibility, in effect, to place the patient's interest above that of himself or herself. The interest of the patient prevails over everything.

That relationship is fundamental differently from marketplace relationships; in fact, it could not be more different. People entering a commercial relationship are under an obligation to place their interests first. As an example, the slogan at McDonald's is, "We do it all for you." Actually, they do not; they do it all to maximize their profits, and great for them. In many cases, it works well; in health care, it does not.

Hence, if we move to contracting out clinical services, the patient, who needs to be able to trust the physician, will be in a relationship with a physician who is connected, say, to organization that may trade on the Toronto Stock Exchange and, thus, has a duty to maximize the profit. When that occurs, the normal checks and balances of the marketplace break down and all kinds of problems arise.

The evidence actually confirms that perspective. For example, if you look at the Gimbel Eye Centre Web site, you will see that that clinic is charging in excess of $2,000 per eye for a procedure that is done routinely in the public system for between $700 to $900 an eye, including the surgeon's fees.

I would refer you to the letters I have attached to my notes. Two of these letters were obtained through freedom for information requests. The letters make clear the efficiencies of public provision of surgical services, in this case, eye surgery, over for-profit provision. Please take the time to read these letters. They illustrate some of the fundamental problems that we are dealing with here.

I should also point out that despite intense public pressure during the Bill-11 debates the Klein government was never able to produce evidence that showed that contracting out surgical services would save money.

It is possible to work to gain efficiencies within the public system. I would, for example, use examples from Edmonton, where particular units have been developed within the public system. Within the public system in Edmonton, there is a major eye surgery unit that easily outperforms any private system in the country. The same is also true for orthopaedic and various other services. It is possible, therefore, to specialize and gain the efficiencies of specialization within a public system.

Your report also contains a number of references to encouraging competition. This is not a new idea. This is an idea that has been studied extensively in the U.S.

I would refer you to some quotations at the bottom of page 28 and page 29 of this book. Ironically, the evidence suggests that the greater the competition among hospitals the lower the efficiencies and the higher the costs. How does that happen, you might ask?

Imagine for a moment that the four major Edmonton hospitals were competing with one another. There would have to be four neonatal intensive care units, four pediatrics wards, four obstetrics departments, four of everything, including CEOs and administrative structures. Instead, we have one region that allocates its resources. Obstetrics is the specialty in one area, burns in another, intensive care in another; the result is that they operate with great efficiencies.

At page 3 of my written brief there are some suggestions for solutions. I should like to run through those quickly.

The first one, which is important - I cannot drive this principle hard enough - is that we formally have to acknowledge that health care is not a market commodity. The evidence for that is overwhelming. Although I like the market and have worked in the free market, it does not work for everything.

We need to commit to stable funding for health care. I would suggest to you that the current level of funding in Alberta for hospitals and physicians is probably adequate, if it were held stable for several years and allowed, of course, for adjustments for inflation and population growth.

We need to move forward to reduce market forces in health care delivery. Drug costs have soared in the last several years. It is not a coincidence that the pharmaceutical industry is one where market forces prevail. We need greater evaluation programs. We need a national public home care system, a national health care labour force plan and national regulations enforced through federal agreements to control conflicts of interest in the health care system.

The Chairman: By the way, you should know that it was Senator Roche who strongly urged us to invite you to come here today, so you can decide afterwards if you want to blame him or thank him.

Let me just clarify a couple of points. We separated out the public administration principle from the others because the other four principles are patient driven; the public administration principle is the means of achieving the objectives. We talk about the administration one later on. We also did that in Volume One. It is clearly a principle of a different kind, which is the rationale for doing that.

With respect to your comments regarding the Gimbel Eye Clinic, which is a private clinic - and correct me if I am wrong - I thought their specialty was laser eye surgery, which is not covered under medicare. I may be wrong, but that has always been my impression. Am I wrong on that?

Mr. Taft: They provide a range of eye surgeries.

The Chairman: Not just laser surgery?

Mr. Taft: Not just laser surgery, no. One of the most common procedures is cataract surgery. They also do something called a "refractive lensectomy," which, in terms of procedure, is identical to cataract surgery. That procedure, for which they charge in excess of $2,000 per eye, is done routinely in the public system. It is done dozens of times every day in the public system for, depending on the source of the information, $300 to $500 in facility costs and another $400 in surgeon's fees.

The Chairman: It would appear that the hospital system has difficulty determining the actual cost of procedures. Our group reached that conclusion, after speaking to several witnesses. The industry is information-intensive. The information systems in the health care system are unbelievably poor.

I am not arguing with your numbers; I am just curious to how you got them. I understand how you get the $400. Whatever the doctor is paid he is paid, but how did you get the other costs?

Mr. Taft: Those costs are based on internal information. They were provided by an ophthalmologist who works within the system.

I will give you another example. At a small hospital northeast of Edmonton in Lamont, where they do a lot of cataract surgery, the Board asked management to break down the full cost of that surgery, right down to the electricity.

The Chairman: Cost of capital, the whole thing.

Mr. Taft: Yes. Management did that, and the figure they came up with was just over $200.

The Chairman: That helps, because it is surprising how few hospitals can provide that kind of information.

Senator Morin: The fact that you are defending medicare is admirable. Medicare is one of the most treasured institutions in the country. You will find very little disagreement with that here.

Of course, the problem is costs. Ms Burdett, the example you provided of your husband's illness was very revealing. The story of the man being denied care because he did not have the resources is a story we have all heard. I remember a time when patients who did not have sufficient resources were just turned away from hospitals. Nobody wants to go back to those days.

Ms Burdett, the fact that your husband was in intensive care from Christmas to Easter with health costs in excess of half a million dollars is revealing. No individual Canadian can pay that. It is a very good example.

At the time, had pharmacare been in place and had there been salaried physicians and nursing practitioners, would that have brought down the cost at all?

Ms Burdett: I think it would have reduced the cost. It is difficult, until you try these things, to know exactly how much it would have reduced the costs. There are several different models of how physicians are paid, and none of them is perfect. Arguments can be made against any of them.

However, when if we look at the fee-for-service method of payment, what we are doing to physicians is turning them into conveyer belts. General practitioners are being given so little for an office visit that, if they want to cover overhead expenses and make a decent living -

Senator Morin: I was referring to your husband's stay in intensive care, where, by the way, the great majority of physicians are salaried.

Ms Burdett: The majority of physicians are salaried; the specialists are not. They still bill on a fee-for-service basis, even if they are seeing someone in the hospital, in Alberta at least.

I know my husband's cost of his care because, at that time, the Alberta health department send out an annual billing statement. There were extensive consultations because the doctors did not know what was ailing my husband. The doctors examined a whole host of possibilities that might have been the cause of his illness; however, the final consideration was that he had influenza B - which incidentally, children get rather than adults usually, and I have used that against him many times since.

However, to answer your question, yes, I do think that in my husband's case costs would have been reduced had the criteria you mentioned been in place. I think in many other cases they can reduce the costs significantly.

Senator Morin: Mr. Taft, when you refer to clinical services where do you draw the line? For example, are you opposed to private radiology clinics? Can you give me a few examples.

Mr. Taft: Yes.

Senator Morin: There are physician groups who own buildings. Physicians often build their own building and share the expenses. These are sometimes referred to as private clinics. Do you extend your objection to private clinics, too?

Mr. Taft: It is important from an economic perspective to separate out a physician in private practice who is paid on a fee-for-service basis from a group of physicians who are, say, working at an HMO in the United States or in Canada at, say, a surgical centre. A physician in private practice working on a fee-for-service basis is paid by the service he performs. If he does not work, he does not get paid; the more he works, the more he gets paid.

On the other hand, a group of investors putting money into, say, a surgical hospital is hoping to live off their capital. The difference in economic terms between wages and capital is fundamental and profound, as you may well understand.

At present, my most serious concern is that, as we open up the health care system to capital, to the interests of venture capital, we are bringing in a whole different set of economic forces than we have right now.

Senator Morin: In other words, your objection is to the for-profit clinic?

Mr. Taft: That is right.

Senator Morin: Let's talk about the Mayo Clinic. In your opinion, would it be more efficient if it were not a privately owned institution?

Mr. Taft: I am not going to comment on the Mayo Clinic. I do not know the Mayo Clinic.

Senator Morin: It is an example of a privately owned institution.

Mr. Taft: Yes. However, it is not something I know a lot about, so I am not going to comment.

If we were to look at private eye surgery centres in Alberta, clearly they are not as efficient -

Senator Morin: You are giving an example of poor quality of care, whether it is private or public.

Mr. Taft: No.

Senator Morin: They are doing surgery under another name, and they are charging more. That is unacceptable, whether it is a private clinic or a public clinic. What you are describing is ethically unacceptable. It has nothing to do with whether the clinic is a private one or a public one.

When a patient is being overcharged and deceived, that is not ethical.

Mr. Taft: Let me refer you to a letter dated October 1 to Mr. Gary Mar, the Minister of Health for Alberta. You have a copy, if you wish to look at it.

In the second paragraph of that letter, the first sentence reads as follows:

Currently the Active Treatment Center Operating Theatre at the Royal Alexandra Hospital outperforms efficiency at any private center in the Nation...

The letter goes on, in the third paragraph, to describe, with dollar examples, the order of magnitude of efficiency here.

As Ms Burdett said, the evidence suggesting that publicly delivered health care services are more efficient than market driven ones is simply overwhelming. If you want me to provide a 12-inch stack of studies endorsing that, I would be happy to do so.

Senator Morin: I am not necessarily in opposition to what you are saying. I am just trying to understand what you are saying.

Mr. Taft: The marketplace works really well; do not misunderstand me. I am not ideologically opposed to the market. I am delighted with all the things marketplaces provide. Markets have their limits, and those limits can usually be identified through both theory and evidence, and it is very clear that health care is one of those limits.

Senator Keon: Mr. Taft, why do you think people support private clinics if an alternative in a public clinic at a cheaper rate is available?

Mr. Taft: There could be any number of reasons for that. One of the things I did not raise in my comments, but which alarms me, is the suggestion that we might want to expand the opportunity for physicians to work both in the public system and in the private system. I would have taken the opposite view, which is that physicians need to choose one or the other, but not both. Again, the evidence is quite clear on that.

Let's look at a physician who is are working in both the public and the private systems. If that physician can make more money in the private system, he or she will tend to steer patients toward that system. There is a study out of Manitoba that confirms these findings. There is a lot of evidence for that out of the NHS in Britain.

Hence, patients might indicate a preference for the private system because that is where their physicians are telling them they ought to go. As I said, there is plenty of evidence for that.

Senator Keon: I am sure that is one reason. However, if we look at some of the wealthy patients from Eastern Canada who use American facilities, it is not because they cannot have rapid access to facilities in Canada. There seems to be some other motivation. I do not know what it is; I was wondering if you had researched it.

Mr. Taft: I have not researched that specifically, and I do not suppose I will ever be in that position. However, if those people want to go to a private hospital, one that is completely outside of the medicare system, more power to them; that is fine. If we start encouraging physicians to work both sides of the fence, we will weaken the public system and increase our problems, I think.

Ms Burdett: It would like to jump in here, if I may. I think part of the reason those people choose to go to private clinics is for the frills. Take the Shouldice Clinic in Toronto, for example. It concentrates mainly on hernias. We hear a lot about it, as an example of a private hospital that works in Canada. The hernia operations that are done at the Shouldice Clinic that keep people in the hospital for three or four days are done on an out-patient basis, that is, day surgery, almost everywhere else, and this is a saving to the health care system. If a person wants to spend three or four days at a luxury clinic, then so be it; that individual is perfectly welcome to do so.

However, we do not need those extras built into our health care system. What we need in our health care system is good care for everyone, not frills for those who can afford it.

Senator Keon: Let us take the example of endoscopy, which is another example of considerable numbers of patients, certainly from eastern Canada, going to the U.S. In the U.S., an individual can have an endoscopy under general anaesthesia, whereas in Canada endoscopy is done on an outpatient basis without general anaesthesia. That might be one reason.

However, I am bewildered trying to understand me why an eye clinic can survive charging twice as much as a publicly funded clinic.

Mr. Taft: Let me tell you why: In Calgary, there is no choice. In Calgary, 100 per cent of all eye surgery is done in one of five private clinics - and this raises the conflicts of interest issue, which is so important. The chief of ophthalmology in the Calgary Health Region owns a company along with two brothers that gets the largest one of those contracts.

An individual who lives in Calgary cannot have eye surgery in the public system. This is a serious problem.

The Chairman: Let me just clarify something. The eye surgery can be covered by the public system but not done in the public system; correct?

Mr. Taft: Yes. Under Bill 11, eye surgery can now be paid for by the public system. The public system pays a higher cost to the private clinics, however, than it does in Edmonton to the public clinics.

Senator Morin: Do you have any private eye clinics in Edmonton?

Mr. Taft: Yes, Edmonton has a small number of private eye clinics.

Ms Burdett: If I might go back to the endoscopy, if you are talking about best practices, best practices dictate the use of a local anaesthetic rather than a general anaesthetic. Far more complications can occur with a general anaesthetic than a local one. Hence, while it may be more comfortable, it is not necessarily the best choice.

Senator Roche: Mr. Taft, unlike my colleagues here who are real experts in this subject, I am not, and therefore I take a layman's approach to the issues here.

To date, we have found out that efficiencies will not do the job in meeting the increased demand for health care and that the system needs more money. That gets us into arguments of federal and provincial taxation bases, and so on. It then leads to the controversial subject of user fees as a way to get more money into the public system.

Would you take me through, as briefly as you can, the user fee question, so that I can straighten out my thinking on what is the best argument for user fees. What is the best argument against user fees, and where do you come down?

Mr. Taft: My experience with the user fees debate goes back about 20 years. At that time, I was hired by the provincial government to do a paper on user fees. My first reaction was that user fees look reasonable. Then I looked at the evidence - even 20 years ago the subject of user fees had been studied quite a lot. In any event, I had to reverse my position at the end of the project and acknowledge that user fees were not well supported by the evidence.

The appealing argument for user fees is the assumption that health care is a good marketplace commodity. Hence, if we increase the price of a health care service by adding a user fee, we will potentially reduce demand, and we will bring in extra money. Those would be, I think, probably the two biggest arguments in favour of user fees.

The evidence on that, certainly the Canadian experience, is that user fees are, more or less, as expensive to implement as they are valuable in bringing in revenue. Hence, there is no gain on the financial side as.

In terms of discouraging use, user fees do in fact discourage some use, but they discourage use merely from people who cannot afford to pay the fees. They do not have a fair filtering effect. The people who are discouraged from using the health care system tend to be those who need it more often, such as asthmatics and low-income people, for whom a $5 or $10 fee is, in fact, a barrier.

What is odd about this is that although those people are discouraged from using the system, the evidence I have seen suggests that the overall utilization does not decline, because physicians have this opportunity to simply increase their patient load through callbacks and things like that.

Hence, the overall impact of user fees is to discourage low-income people and people in poorer health from using the system without having any of the beneficial effects one might expect if health care were a good marketplace commodity. I missed the point, I think.

Senator Roche: How much weight do you ascribe to the negative side as compared to the positive side?

Mr. Taft: I would come down against user fees. At one time, as I say, when I first approached the issue, I thought they looked like a pretty good idea. However, the evidence suggests to me that they will not work in the intended way.

Senator Roche: What do you make of the Swedish example, where we are told that user fees did cut down on so-called abuse of the system?

Mr. Taft: I am reluctant to comment much on the Swedish example, just as I was reluctant to comment on the Mayo Clinic. My understanding is that comparing the Swedish safety net to Canada's situation is like comparing apples and oranges.

Nevertheless, I would want to look at the evidence. My opinion is that a simple importation of user fees into the Canadian system will not solve anything.

Senator Roche: I take it that the essence of your argument is that user fees are unfair to those people who are most economically vulnerable; correct?

Mr. Taft: That is a crucial part of it. However, beyond that, because of administrative implications, those who are economically vulnerable can actually end up costing the system more. Inefficiencies are increased. Clerks need to be hired; money has to be processed. It is a pain in the neck, frankly.

The Chairman: In Volume Four, we talk about patient pay, of which user fees is but one example. As we know, patient pay exists in Alberta. People pay health care premiums. Are there any studies on the impact of health care premiums?

Let me give some history here. Health care premiums have been in existence at roughly the same level that medicare began, or have they gone up over time? I presume they have gone up over time. Have there been any studies on the impact of health care premiums?

Ms Tammy Horne, Member, Friends of Medicare: It would be difficult to make that comparison, because they have been in place for so long. We do not know what would have happened had they not been in place.

Last year, the University of Toronto hosted a national round table on health reform; the round table included a number of health economists and policy people. Dr. Raisa Deber of the University of Toronto was part of that round table, and she has studied extensively user pay options, user fees being one of them. She and her group have made conclusions similar to what Mr. Taft spoke of, in terms of limiting access to poorer Canadians in particular.

In addition, the round table expressed a concern about those people who do not see a doctor early on and subsequently develop more serious symptoms and, thus, end up costing the health care system more down the road.

A Quebec study that looked at prescription drug fees for seniors and the introduction of the same fee for people on social assistance found that subsequent to the introduction of the fee hospital admissions and complications from untreated diseases actually increased, as did death rates. The adverse impact of the drug fees is a Canadian example of a study; as well, the University of Toronto group in their review found no positive benefits of user fees.

The Chairman: The reason I ask about premiums is that it is not a user fee; correct? A premium is not paid at the time of service; it is not related to a specific service.

Ms Horne: That is right. It is a different issue.

The Chairman: I know there is a lot of the academic literature on the subject of user fees. However, no one has pointed me to, and I have not heard of any, studies on premiums.

Ms Horne: Yes. It would be interesting to look at the percentage of people who have not paid their premiums. In Alberta, if an individual goes to the hospital but has not paid his or her health care premium, there is still a requirement for the hospital to treat the individual, and to try to collect the premium later.

The Chairman: I was about to ask you how that worked.

Ms Horne: People cannot be denied service for emergency-type things. I am not sure about all of the other issues.

The Chairman: It begs this question, I suppose: Why does anybody pay the premium?

Senator Morin: I thought this was part of your income tax. You actually pay the premium. It is a voluntary payment?

Ms Horne: Yes. Alberta and B.C. are the only two provinces that still have health care premiums.

Senator Morin: Is it a monthly payment?

Ms Horne: Four times a year.

Senator Morin: Do you actually receive a bill?

Ms Horne: If an individual does not pay his or her premium through the workplace, then a bill is sent. Those of us who are self-employed pay our own completely.

Senator Morin: What percentage of people do not pay?

Mr. Taft: There are many exemptions. For example, low-income people are exempt; some seniors. My bet is that the percentage of people who are expected to pay would be very high. Most people do not believe they could get away without paying.

The Chairman: That is the reason, I am sure, that there is no public information on the percentage of people who do not pay.

Senator Morin: Is it your impression that there would be a higher acceptance if it were a tax?

Mr. Taft: It is a tax. It is a regressive tax, in that everybody pays the same amount regardless of income. Nevertheless, it might be politically more palatable, yes, if it were a tax. One of questions that should be asked of the public is this: How much are you willing to pay for a good health care system?

The Chairman: By the way, that is exactly where I was headed.

Senator Morin: Its advantage is that it is stable. One of the problems with the health administrators is that government funding is not stable. Whether the funding is federal or provincial, it fluctuates from time to time. An insurance payment would be more stable, because it is dedicated; also, it is more palatable. That certainly would be an advantage.

Ms Burdett: I think having a portion of income tax dedicated to health care is more palatable than a health care premium.

There have, in fact, been many occasions when Albertans have attempted to abolish Alberta Health Care premiums. Therefore, I would not say that it was particularly palatable. It is just that most people pay it because they would pay their bills. If they get a bill, they pay it.

The Chairman: They are responsible.

Given that the health care premium is, in effect, an earmarked tax, does it go into a separate fund or does it go directly into the consolidated revenue fund?

Mr. Taft: Ultimately, it goes into the consolidated revenue fund, I believe; however, the premium is administered through its own system.

For your information, the annual rate for a family has risen from $474 in 1990 to $816 in 1995. I am not sure what the present rate is. Exemptions apply to very low-income families, basically.

The Chairman: My understanding is that with respect to low-income families, people who are receiving social assistance, for example, the government actually pays the premium on their behalf.

It is an internal transfer, but that is, in effect, what happens; correct?

Mr. Taft: It is obvious that for a family of four living on $15,000 annually an $800 premium is a tough thing to swallow.

Senator Roche: Mr. Taft, when Mr. Mazankowski was here this morning, he insisted that medicare is not dead; he went on to suggest, however, that it is time to find out what we really mean by medicare in the 21st century.

In your view, how should we define medicare in the 21st century?

Mr. Taft: I will not try to predict what Mr. Mazankowski's report will say, although his comments unnerved me somewhat.

We can talk about rebalancing medicare. An example of that is shifting the emphasis away from hospitals, which was the early push towards home care. I think we could actually reduce the total amount of money we spend on health care, public and private, and Christine's comment suggested this, by expanding the public role to include pharmaceuticals. In other words, it may make sense to expand the public sector role in order to reduce the larger system cost and to increase efficiencies in fairness.

If I look to defining medicare for the 21st century, my hope is that its scope will be expanded to include things like pharmaceuticals and home care. Oddly enough, that might actually save us money.

Senator Roche: Also, then, in more acceptance of private care, in the sense of not-for-profit care?

Mr. Taft: Yes. I am not always as careful as I should be. There is a huge difference between for-profit care and private care. I am far more comfortable with private care.

My experience with the Alberta health care system is that often the best care is provided through private, non-profit systems as opposed to either public or for-profit systems.

The Chairman: Dr. Taft, you asked us to imagine that each of the four major hospitals in Edmonton had its own specialty. In some European countries, some of the changes that are taking place - and I am not talking about the U.S. here, all of which, by the way, have universal medical care schemes - is that governments pay the entire bill for patient but no longer pay the hospitals in the sense of a global budget. What is happening is that the hospitals are being paid on a fee-for-service basis, similar to a doctor, so that there becomes - hospitals are still technically owned by the public sector.

There becomes, hence, an element of competition between public-sector hospitals, in an attempt to provide reduced waiting lines and better service. Patients feel as though they are more in control, because they have more flexibility and more choice. They do not lose any benefits, because the government is still going to pay the bill. The simplest way to explain it is the analogy of everybody being in one group plan.

Your comment, however, lead me to believe that you do not think that is a good idea.

I am asking, because our research indicates that a substantial number of countries with the same policy objectives are moving in that direction, and indeed Mr. Mazankowski, I guess, mentioned that issue this morning.

Mr. Taft: To my knowledge, only the British system, where they have brought in what they call internal markets, is similar to what you describe. In terms of the research I have seen on that, the most rapid increase in spending in the NHS in 20 years or so occurred when they brought in internal markets.

What I have to keep driving home is that these are all attempts to bring market forces into the health care system, and I will once again repeat that I am not convinced at all that those will work in health care. Market forces have become almost an idol that we worship. They are great. They are wonderful for some things, but not for health care. The evidence I have seen on the internal market reform in Britain reinforces that.

Perhaps you have other evidence, however, and I am open to that evidence.

The Chairman: I wish to thank you all for attending here.

Our next panel consists of Mr. John McGurran, the Project Director of the Alberta Waiting List Project, Dr. June Bergman, from the Primary Care Initiative, and Wendy Armstrong, from the Alberta Consumers Association.

I shall begin with you, Mr. McGurran.

We had a presentation several months back about the Western Canada Waiting List Project. Are you the Alberta portion of that? In the course of your opening comments, could you tell us how you fit with the WCWL Project, because we have heard about the other one.

Mr. John McGurran, Project Director, Western Canada Waiting List Project: There is only one project, and it is the Western Canada Waiting List Project, the WCWL Project.

Perhaps I can focus on some of the details of access that are included in chapter 7 of your report, and we can take it from there.

I think honourable senators have a copy of our short report; if not, they are all available on our Web site.

This is the in-depth documents, which describe some of the more fine details of the work.

This presentation is very much about the promising work of the Western Canada Waiting List partnership - a collaboration of medical associations, including the Canadian Medical Association, provincial ministers of health, regional health authorities and health research centres in the West - which addressed longstanding and well-documented problems with access to elective health care.

I say "promising" because, while the development work has been completed and well received, the implementation of the tools in the regional health authorities is the next logical step, and there is broad acceptance that these tools need to be tried and tested in the authorities. If implemented in an evaluative framework, we would then be able to say whether these tools that govern access to elective care actually are a value to the patient and the system.

Also noteworthy is the success of this partnership in itself. There has been consistent commitment to the high-level goals throughout, evidence of compromise as needed and leadership from the various sectors as the agenda moved forward. The partnership and the unanimous support given to its published conclusions and recommendations are unprecedented.

Further, I should say, in relation to your comments on the role of federal government with respect to research, that this project would likely not have taken place without the support of the health transition fund.

There are three brief messages I will leave with you today, and I am going to fit them into the time allowed, and then we can have questions at your convenience.

The first is that the Western Canada Waiting List Project has produced what we call beta wait list management tools. They have the potential to standardize and make access to elective planned care more fair for Canadians. The development of these tools represents an important first step towards system improvement.

The second message would be that the public's perspective, which is very important - and there were comments on that this morning - which came to light in a series of focus groups we ran, is that these prioritization tools and the process of wait list management that would utilize them are appropriate and acceptable.

The third message is that it is important to move forward with implementation and evaluation of these tools and to begin work on establishing benchmark waiting times for elective procedures.

With respect to the priority criteria, this project was conceived in the spring of 1998 at a meeting in Regina about finding solutions to chronic waiting list problems in the province of Saskatchewan. In November of that year, our 19 partner organizations met for the first time in Calgary, developed a project infrastructure and adopted an agenda to generate practical, valid, reliable and transparent tools to manage waiting lists in five elective areas.

We chose hip and knee replacement, cataract surgery, children's mental health, MRI scanning and general surgery. These encompass a range of diagnostic treatment procedures, single versus broad applications, and some for which the waiting has been problematic for some time.

I shall not deal with the methodology of how we got where we did; it is well documented in the reports available on the Web and will be shortly in published articles in the medical literature.

The Chairman: In the interest of time, I would ask you to jump down to the bottom of the page, and then go from there?

Mr. McGurran: Sure. The real issue is that if we have tools that have been developed and endorsed by stakeholders such as the provincial ministries of health, the medical associations, the research centres with respect to methodology and the regional health authorities, the location of where the service would be provided, and we have endorsement from the public that the approach and the tools themselves are appropriate, there should be support possibly from your committee as well in terms of moving ahead with implementing these and trying to show their value.

This is nothing new. Our work was based on the New Zealand experience, although we acknowledge that their culture is very different, both politically and with respect to the way they deliver health care.

The Ontario Cardiac Care Network uses the same kind of methodology in managing access to surgery in that province. The Ontario joint policy and planning committee is looking at some of these tools. What we are talking about here is using a point count urgency measure for ranking patients for elective surgery within the public system, and we think there is a lot of potential for that. There are some tools that we think have some currency, and a lot of others do as well.

With respect to public opinion, as we were completing our development work, we pulled together, using Ipsos-Reid, focus groups in the seven major centres in which this work had been done, the major cities from Winnipeg to Victoria. We began each of these focus group sessions by asking the participants about their views of the current state of the system. We also asked them for their views on how the system should run.

Not surprisingly, we found pretty consistent negative views about the current access to waiting for elective surgeries. You can read the verbatim some of the verbatim comments in a separate report. There was a diverse array of views among participants as to the workings of the system.

All seven groups said that the public had high, but realistic, standards with respect to the health care system. The focus group also concluded that the public's view was that if it is necessary to manage access to elective care - and it is necessary - then a system like based on urgency is probably worth looking at.

A critical piece of information that came forth from the focus group was that 60 per cent of the participants actually had had firsthand arm's length experience with the system. Hence, they were speaking as citizens, if you will, but also as either patients or close friends or relatives to patients.

The final message they left us with was that they felt strongly that the public should be involved in decisions of this magnitude with respect to influencing health policy. I mention this because we had distinctly excluded the public from the deliberations in developing the tools. We wanted tools that work clinically. We wanted to be able to predict or explain the measure of urgency.

The third point is with respect to benchmarking the waited times. Access to health care in Canada has not changed significantly in the last three years, over the time we were in the field with this project, and even new expectations were quite high with respect to where these tools might be now. Expectations are pretty unrealistic, if you have any sense of how the health care system actually works, and I think some of the comments from the two region CEOs this morning focussed on some of the challenges that await the implementation of this system.

The ability to fairly rank patients, if you will, according to the urgency of their need is one element. The next step - and we put this forward to the committee as something to consider - is to answer the following question: How long should one have to wait for care with the current system? In other words, when a patient visits an orthopaedic surgeon and is assessed for hip replacement surgery, there should be a fairly straightforward expectation as to what the waiting time would be. There are implications for resources and a lot of other issues that we are not touching on here with respect to waiting times, but the expectation regarding waiting time is really quite important and is something that we should be able to address within the public system.

Ms Wendy Armstrong, Alberta Consumers Association: Honourable senators, I shall leave with the committee a copy of a report entitled "Taking Stock." This report deals with the risk to consumers and their employers from the current health system in Alberta from 1996. With respect to the Canary report, there is an appendix that goes with it; the appendix provides the documentation to support some of the information in there.

Since 1986, the Alberta Consumers Association has worked to protect the interests of Alberta families in both medical and non-medical markets at both a provincial and national level. Over the past 10 years, I personally participated in numerous external committees and consultations dealing with all aspects of health care and medical markets as well as related areas such as biotechnology and integrated health information systems and insurance. The association has also been at the forefront of the debate on health reforms here in Alberta over the last decade because of our research.

The mandate of consumer groups is essentially to monitor the marketplace, to provide reliable information for consumers to enable them to make informed choices, to champion their rights and responsibilities and finally to develop advanced strategies to enhance fair and honest dealing in the marketplace - safe products and good value for money.

It is important to remember that these objectives are good not only for consumers but also for business, the community and the economy.

What does the work of the association I am going to present today bring to the health care discussion? The association brings a completely non-partisan view of the options and issues before policy-makers; years of experience with the regulation of medical markets, public and private; knowledge of other markets and how they work; an articulated international framework of where the consumer interest lies; timely research; regular and frequent contact with individuals purchasing goods and services in medical markets; and perhaps more important, as it appears day by day in our Canadian health care system, the ability to differentiate between competition and collusion.

Attached to my presentation are some overhead notes entitled "A Snapshot of the Impact to the Growth of Private Surgery Clinics in Alberta on Patients and Public Plan Members." I would ask you to take a look at them.

Words like "consumer choice" sounded pretty hopeful and promising to us here in Alberta in the early 1990s. It has a little bit less appeal these days. You see, for consumers of medical care and of health care plans, it appears that "consumer driven" has turned out to mean driving patients into high-priced retail markets for medical care and coverage and increasing numbers of families being forced to make a choice about whether to pay the mortgage this month or treatments for a child with cancer or a spouse with multiple sclerosis. It has also meant some pretty devastating consequences for those consumers who made a bad choice in the medical marketplace by choosing LASIK Vision, which recently went under.

I think, given your comments this morning, too, I would like to go into some of the evidence that we have accumulated here in Alberta over the impact of the introduction of user fees, income testing, co-payments and deductibles, which really happened big time here in Alberta in the early 1990s.

In the beginning, the Alberta Consumers Association reflected the views, I think, of most Albertans and most members of the Canadian public, that is, that they did want health care reforms. They were tired of big institutional care and the nasty side effects of some of the high-tech services. They were frustrated with rising public and private costs that many people faced when they needed care.

Consumers were certainly looking for some of those changes, as was the Alberta Consumers Association, which in the late 1980s was in the forefront in advocating many of these changes. However, when health reforms came to Alberta in 1993-1994 in a pretty drastic and significant way, we were anxious to see what would really happen. There was a tremendous debate in the airwaves about why there had been no significant change to quality, cost, waiting times and other horrors. It was very difficult to know from all the rhetoric what was really happening out there to real people in the community who were facing real decisions about where to go and where to get care.

In a study we conducted, we asked Albertans to call a 1-800 number and to let us know what was happening. What we found actually shocked and amazed us -that is, that while there were definitely some new highly desired opportunities for care in the community introduced through health restructuring, it came at a hefty price.

Changing the site of care, by moving it out of designated public hospitals, and changing the person who had been providing this care from a physician or hospital employee to someone else had resulted in the introduction of significant deductibles, co-payments, user fees, and income testing. In fact, in some cases, the province even abdicated its responsibility by becoming a payer of last resort only if there were no one else able and willing to foot the bill.

In this report, you will find documented real-life experiences in the follow-up investigation that the association did looking at areas of early discharge, care of the terminally ill, chronically ill children, intravenous therapy, the unbundling of goods and services in doctor's offices and hospitals, the delisting of medical services and some of the private insurance offerings that started to come on the market about this time.

A good example is intravenous therapy, which is a way of delivering very powerful fluid drugs directly into the blood system to deal with life-threatening infections, complications, multiple sclerosis symptoms, et cetera. For years, patients had been admitted to the hospital for a five- to 10-day course of this therapy at one time. With the changes that we saw in the Alberta health care system, patients who wished to have this therapy at home and were often forced to have this therapy at home found themselves paying 25 per cent of the cost of equipment and supplies as well as 100 per cent of the drug costs up to a deductible of $5,000, or they could try to find someone to drive them to the local emergency department two to four times per day. Incredibly, some Alberta hospitals even decided that, since patients had to pay for this at home, they should also have to pay for this at the outpatient department soon.

Really, it was a tremendous hit, and we heard many personal stories. One particular woman from Stony Plain, who even though she had an employer benefit plan to cover the cost of her services, talked about the many nights that she cried herself to sleep wondering where she was going to come up with the $700 to buy the feeding pump to bring her little girl home from the hospital. That was one piece.

I would like to move into what we called "Canada's Canary in the Mine Shaft." In the midst of this huge debate about increased reliance on private payment and private business is a way of reducing costs and improving quality and access within our health care system.

The Alberta Consumers Association had a lot of experience with eye surgery clinics here in Alberta. Hence, we decided to track people's experiences. We wanted to study the impact on patients and public plan members of the growth of private surgery clinics in Alberta. The issue was very complex. We found some interesting things.

Let me just refer you to our slides over here. Some of the unexpected results of our findings are as follows: higher prices, higher costs, less coverage, less choice, longer waits, loss of public scrutiny and loss of public confidence.

This slide shows the remarkable growth of private surgery clinics in Alberta from 1972 to 1999. If you look at the bottom of the slide, you will see here some of the landmark decisions that were made at this time. In 1975, then Alberta minister of health refused to fund private surgery clinics due to a lack of evidence of cost savings in a study that they did in comparison with public hospitals but allowed doctors to continue to bill surgical fees to the plan.

In 1986, when extra billing ended in Alberta at public hospitals, extra billing was allowed to continue at private clinics in the form of facility fees. Today, in 1999, as Mr. Taft has advised you, 100 per cent of all publicly insured eye surgery is contracted out to private surgery clinics in Alberta, from corneal transplants to tumour removals to cataract surgery to what have you.

The Chairman: Can I ask you to wind up quickly?

Ms Armstrong: Yes, Mr. Chairman.

What was remarkable is that we found that the longer waits for fully paid cataract surgery in public hospitals were only encountered by patients whose doctors also offered a private clinic option, for additional charges, with a shorter wait.

In summary, what our research to date has shown is that, remarkably, instead of being the solution to rising costs, longer waits and less than ideal care, increased reliance on new sources of private payment and private business interests over the past 20 years has been a major cause of these problems.

The second point that I think is critical to make is that the status quo is not what most people think it is. No one appears to be minding the store when it comes to either medicare or private medical markets in Canada. As a matter of fact, it looks like the referee skated off the ice a long time ago.

Few public policy-makers have any idea what is going on nor do the vast majority of health professionals. It is important to note - and this is a very important one from our perspective - that public safety is increasingly at risk from the overzealous application of poorly evaluated technologies by commercially oriented suppliers.

It is also important to note that many of the identified problems in health care, as you have already identified, Mr. Chairman, are not unique to Canada. This suggests that perhaps the problem is more modern medicine and medical markets than medicare.

Dr. June Bergman, Primary Care Initiative: Senators, I am here today because a friend of mine who was invited to the committee could not come. I am the second choice.

I only learned last night that I was required to have brief, so you have a bit of a conglomerate here.

I will give you a bit of my history, to help you understand where my comments are coming from. I am a family doctor. I have worked for 30 years within the Canadian system, in Saskatchewan, Ontario and Alberta. I am a mother of three sons; I am the wife of a man with a chronic illness; and I am the daughter of aging parents. Hence, I am a consumer on several fronts. I have also been a member of the health care accreditation team for the last three years; as such, I have travelled across the country looking at health care systems from a variety of perspectives.

Finally, I have a job, and that job is, at present, my family physician practice and, in part, driving a primary care initiative in the Calgary health region. It is under that hat that I am here for today.

I have some thoughts about the whole issue of primary health care reform, how to do it and what to do. I suspect that you have had many presentations on primary health care reform and what that means and all of the jargon connected with it; therefore, I will not go into the basis of that but will, instead, just add a couple of things.

The situation in Alberta is unique, in a couple of ways: one is the strong linkage of primary care with secondary tertiary care; the second is that we believe very strongly in a respect for the parties involved and so are moving in an evolutionary manner through partnerships towards common goals. The situation is quite different from the way it is in many places.

For example, it is getting close to 20 years ago when the CLSCs were built in Quebec and subsequently developed a separate way of being; but the other system still continued.

Hence, we have decided that there is something good about that system that we should not lose and that we should work from where we are to a new direction but while maintaining what we have in the good one.

I read your report, which I found to be extremely good. It is time, I believe, for a very public debate on many of the issues that your report raises. I do not think I am the person to hold a discussion with about how to pay me. However, I think that public debate has to happen, and has to happen on a couple of fronts.

I will make a couple of comments with respect to your document that you might consider.

It is important that we have a clear direction. Primary care reform is mentioned in every health care document now as the answer. We do not have a clear direction at this point, and I think we need one. Perhaps that is one of the debates that must take place. By that, I do not mean finding the model. I mean finding the broad-based principles that you will paint primary care under. We are close. The College of Family Physicians has come out with some; the Canada Health Act has come out with some. It just needs a little bit of fleshing out, but I think that debate is essential.

We have put a lot of money into health care reform, health transition funds, health innovation funds, and they are all wonderful. They have kick-started us here in Alberta. Everyone you talk to talks about how that idea started with health transition funds.

All of those ideas are pilots, though. There are a lot of ideas out there, but there has been nothing to bring things together. We need to think about what it is from here on in that we are doing in terms of those things that are contributing to true integration and not just another good idea. As a matter of fact, the response to the last health innovation fund request was that no old ideas will be funded. We know that many of the ideas have been good, but they need to be brought along from the pilot stage through to the demonstration stage and into the way we do business.

Also, the idea of partnership or joint venture, I think, needs to be through the whole report.

The second comment that I picked up in your document is the reference to the cottage industry versus 21st century with respect to primary care. Primary care is a cottage industry, and we cannot lose it all. Health care is experienced, and illness care is experienced at a very personal level.

Sickness really detracts from one's ability to be a competent consumer; in other words, one's ability to ask the right questions at the right time is just not there. The World Health Organization put forward a recommendation that every person deserves a caregiver who knows his or her name. Family medicine, your primary care physician, tends to provide that.

How do we maintain that inside a system that needs to move into the 21st century and become more efficient? I believe there are ways, but I think it just needs to be put forward. We do not want to lose the humanity in our health care system in honour of efficiency. So, we need to achieve a balance.

The third is issues around teamwork. I noticed expressions - and some of these are just trigger words for me - like "The doctors have to give up the power." That makes me ask myself this question: What power? There is no power here at midnight when somebody is calling me for test results or whatever.

We have tried to construct some language around this, an interdisciplinary team versus a multidisciplinary team. The multidisciplinary team is like a downhill ski team - everybody is out there doing their best. An interdisciplinary team is like a soccer team. They all depend on one another to get the job done. We have found those to be useful constructs when thinking about these teams. We are using the construct to divide tasks on the basis of need rather than professional scope of practice. If tasks are divided along professional scope of practice lines, there are many tasks that everybody wants to do and some tasks that nobody wants to do. Unfortunately, the individual at the end of care needs all of those things done. Therefore, it is patient or client-centred - and I struggle every time I say the word "client," probably just like nurses do when they say "patient."

We need to look at how our education system is contributing to these team-based skills. When we start to put teams together, the first thing we recognize is that nobody knows how to work in a team. There are questions around how you do that.

With respect to your report, we need to go ahead with a unified message on primary care so that everything we do is fitting into that area. We need stable financial support for that direction.

Under research and evaluation, there are a couple of points. First, pilots need to be brought along to demonstration and the way we do business. Evaluation involves time and infrastructure, and the costs involved must be factored in when thinking about how much the health system costs. These things must be supported.

Under infrastructure, connectivity is the prime need. The prime need is not the electronic or medical health record; it is the ability for all people involved in the patient's care to be connected. More important perhaps than that - and we are running into this every day - is that we try to connect 80 per cent of our family physicians.

We need a national public debate about privacy versus freedom of information, about putting information onto electronic webs. We need to know the public stand on that and where physicians are on that. Let's get that debate going, get it over, make a decision, and get on with it. Britain has just done that, and their medical information system is currently on the Web, no particular protection on it. We need to get on with this.

Regulation might be another area where we can contribute to connectivity. The free market actually detracts from connectivity. You do better in business if you can get people to stay with you and buy your product that only fits with your product. And we need to recognize the costs of change management and new ways of doing business.

Population health fits well with primary care.

The last area is service-delivery models, and we need help with the things that will promote change management, integration, and evolutionary change. Thank you for the opportunity.

The Chairman: I had the pleasure of sitting next to a doctor from rural Nova Scotia who I believe runs a primary care study group - whatever the terminology is - for the Canadian Medical Association. Are you part of that project?

Dr. Bergman: No, but I am aware of it.

Senator LeBreton: Mr. McGurran, in terms of the focus group studies, did you find a variance in the perception of those who did not have to access the system and those who actually did access the system? There seem to be a lot of myths about the length of waiting lists. Often, with respect to access, we find that the people who have in fact accessed care do not have the same horrendous stories as those who have not had to access the health care system.

Mr. McGurran: There is no definitive answer to that question. We found a real diversity in the views of the focus groups, and those views were consistent with reported studies. Some studies say that, yes, there is a lot of turmoil respecting access, that is, waiting times and problems. However, many surveys of patients who are released from the hospital say that they received great quality of care. That kind of research can be looked at in a number of ways.

To summarize, however, although we found the public to have high standards we found an element of fairness. There was a very honest sentiment that, regardless of whatever else, the more urgent care patient should go first, and we incorporated that in a couple of places in our report.

Senator LeBreton: Did you find that the public opinion was driven by the media? For instance, two winters ago in Ontario there was a huge flu epidemic. All kinds of people crowded into emergency wards. The newspapers ran many stories about long waits, et cetera. Last year, most Ontarians got a flu shot and, as such, hardly anyone was abusing the system for that type of an illness. Consequently, stories about long waits in hospitals seem to have fallen off the front pages.

When you put your focus groups together, or when Ipsos-Reid do a survey, is what is on the front page of newspaper at the time factored in?

Mr. McGurran: In this case, no. To take that one step further, in fact, when there are epidemics of flu and high demand for services, elective surgeries, for example, are one of the things that drop off.

When the system is stressed and surgeons have to cancel their procedures within the last minute to the patients, surprisingly that did not get more press.

Senator LeBreton: Ms Armstrong, this morning we heard from witnesses who had very positive news about the health care system in the Alberta example. I realize you are dealing primarily with private surgery clinics, but you talked about unexpected results, higher prices, higher costs, less coverage. Did your association find any good results when they did this study?

Ms Armstrong: I have spoken to hundreds of cataract patients. Cataract surgery dramatically improves an individual's quality of life. Therefore, most people were pleased with the results of their surgery, whether it was done in a public hospital or a private clinic. Any complaints or accolades were related, generally, to things like the anaesthetist or the doctor or the staff.

The most frequently cited attraction we heard about private clinics - and this is something that might be instructive to the public health care system - was that patients did not have to wear those backless blue gowns seen in hospitals and that the parking was free. Anyone who has had to pay to park at an urban hospital will understand the attraction of free parking.

Senator LeBreton: You are not in danger, I presume, when doing a study like this of being accused of going in with a bias?

Ms Armstrong: I have been accused of a lot of things over the last 10 years; however, people cite my studies.

We have done these surveys. We have called the clinics and have asked the questions. We have played the role of a consumer, saying: "I would like to know how much the surgery costs and how long the wait is." We have invited anybody anywhere to duplicate our work and come up with a different answer. We are not tied to the results.

What also came through in our work is that people seem to like the rural or medium size hospitals, where there is any aspect of humanity, rather than the bigger institutions.

Dr. Bergman: I just wanted to add a couple of comments about waiting lists. A family physician prioritizes the referral process, the surgeon prioritizes the surgery process. That process is not always in agreement with the individual, but it may be the best solution.

When you are involved in a system where there are waiting lists, you are forever trying to make sure that the sickest person goes first or the one for whom there will be the biggest problem. Tools like that which Mr. McGurran has developed make a tremendous difference, because it gives us a rational background to be able to do that.

What also helps are the relationships that are built through shared care, the ability to call people and actually have them answer at the other end of the telephone. Within the last 20 years, probably more the last 10, regionalization has been a major disruption for old relationships. Our system worked on relationships. When the relationships are gone, our ability to manage or manipulate within the system to get to people to care is reduced.

Ms Armstrong: I should like to refer to another important factor that we discovered. Our study found that, in Calgary, where there were the longest average waits, the minimum reported wait for cataract surgery out of 23 surgeons was 1 week to 40 weeks. What is important for people to realize is that every waiting list depends not just on the availability of a facility but on the availability of a surgeon. What we have found is that, generally, surgeons who have the opportunity to earn more money by providing non-insured services such as laser eye surgery are simply less available for referrals from family physicians or for cataract surgery or for many of the publicly insured procedures.

Doctors tend to follow the money. For example, if you can earn $2,000 for 15 minutes work as opposed to, say, $400, where would you spend your time and resources?

Hence, it is important to recognize that waiting lists are very individual to the surgeon and where they choose to spend their time as well.

Senator LeBreton: I actually did see that number and wondered how it could be possibly that much of a variance.

Ms Armstrong: I can provide you with all the original data, if you wish, from the phone survey.

The Chairman: Mr. McGurran, you raised the issue of setting benchmark waiting times, which is really what it is all about. There are some European communities that are doing that. What we are talking about here is saying that for, say, procedure X the maximum waiting time ought to be X number of weeks. In fact, in a couple of European countries where such a standard exists, if an individual gets to the maximum waiting time the government will send the patient out of the country to have the procedure done, which has had a huge impetus, by the way, in the efficiency of hospitals that would like to get the revenue themselves.

Can you just tell us a little bit about what the time frame is for coming to some sense of benchmark data?

This goes back to Ms Armstrong, because it seems to me that the people who will, in the end, determine whether a waiting time is reasonable - or, if you want to put it in political terms, saleable - are the consumers, the voters. That, to me, is one of the key waiting line issues. I would love to know how you will come to grips with it.

Mr. McGurran: Let me first just comment on one other issue. I am not sure if you caught Ms Bergman's comment that from time to time we have invested in developing a solution that looks like it will work, something that has broad acceptance, but that, for some reason, its moment in time passes.

Ms Armstrong: Ten years later.

Mr. McGurran: Perhaps, but I think that is the premise to the answer. In other words, what we will do now is ask the provincial governments, the deputy ministers of health in the four Western provinces, to support the implementation of these tools to move that process forward.

To answer you question, however, Mr. Chairman, on the waiting times issue, we see that as a national agenda. We would argue that you should begin, not with an arbitrary time based on a political promise or fiscal forecasting, with an urgency score.

That is the principle behind the cardiac care system in Ontario. I am not suggesting that cataract surgery can be compared to cardiac surgery, but there are some similarities. For example, if you have a range of scores, you would guarantee a particular surgery for certain patients in a certain period of time.

The Chairman: Yes. Senator Keon, as you may know, is also the director general of the Ottawa Heart Institute and the creator of the Cardiac Care Network in Ontario. We can come back and talk about that later.

It seems to me that if we do this there has to be an obligation on the government, as the supplier, that the government has to suffer the penalty if the deadline is not met. There has to be a balance of forces here. One of the things that has intrigued me about some of the European models is that when a patient gets to the end of the maximum waiting period the government has an obligation to send that patient out of the country, from Sweden to Germany, say, to receive the medical service, and the government has to assume the costs of that.

What I am saying, I suppose, is that the there has got to be a cost to government of continuing to ration the service.

Mr. McGurran:We use the term "acceptable" in the report, and we use that pretty non-scientific term.

The Chairman: It is a term that Ms Armstrong's people would absolutely understand.

Mr. McGurran: Acceptable to the providers, to the government.

The Chairman: And acceptable to the consumers who actually are the reason we have the system.

Ms Armstrong: The plan members who pay for their plans - if I could just add something to that -

The Chairman: I am deliberately being provocative here.

Ms Armstrong: I understand. What is really important, and what we sometimes forget, is that, as patients, when we seek advice from health care professionals they have a fiduciary responsibility to us. We are very dependent on them. Essentially, the consumer element comes in in terms of us being consumers of health plans, whether they are public or private. I think what you are talking about is this: Where do we get value for money in terms of who is running our plan and ensuring an adequate supply of services?

The Chairman: What I really want to know - and I know you do not have it now - is whether you think it is indeed possible to get to the point where the government would say that for service X the maximum waiting time is X, that for service X, something less urgent, say, the waiting time X, and where consumers would agree, kind of grumblingly, I imagine, that it sounds pretty reasonable.

Ms Armstrong: I would encourage you to read my presentation, but one of the dilemmas is an aggressive commercial parallel private system, which we have in Canada.

The Chairman: I was not talking about a parallel private system.

Ms Armstrong: No, but we have one in Canada.

When I listen on my radio, I hear about bone density testing, about the importance of colorectal testing, that drug X will save my marriage, my pain, my nausea, my what have you. One of the realities of embracing commercial values and marketing in health care is that regardless of what you do in the public system you will drive demand. In fact, what have we seen here with the parallel private public system is a loss of confidence.

The private sector often sells experimental surgery as state of the art, essentially as part of a large clinical trial, but part of selling it is to create expectations. The expectations created by the commercial sector are what drive, essentially, the public's expectations of the public sector.

I highly suggest that you take a look at the evidence around things like direct consumer advertising, marketing of medical devices, all the information that the public is being bombarded with

People need to feel confident and to believe that they are not being cheated by the public system. For example, we need to find a way to stop doctors from saying to their patients that if they want to avoid complications, say a detached retina, or avoid pain, to end up with better eyesight, they have the option to purchase, in the retail marketplace, an upgraded lens implant for $750. These are the same doctors who advised the Regional Health Authorities that they did not think upgraded implants were of value. Until you find a way of controlling what the physician is saying to the patient, it will be very difficult for patients to have confidence in the system.

The Chairman: Dr. Bergman, I happen to agree very strongly with two of the bullet points you made on population health, which is not what you read out, but I will just read them to you.

The first is this: "We need to shift the focus from caring for who comes to caring for who needs the care." The second is this: "Services need to become more directed at needs rather than wants." We totally agree with those observations.

You may not be able to answer this right now, but any thoughts you might have in terms of what the federal government could do to implement these ideas would be really helpful to us.

Dr. Bergman: I do have some ideas, but perhaps I will put them in writing, where I can be more detailed and concrete.

The Chairman: That would be great.

Senator Keon: Mr. McGurran, one of the interesting things we experienced in the development of the Cardiac Care Network was that we overdid it a couple of time. For example, we ramped provincial services too high, and we then found we had created tremendous inefficiencies in the system because there was not enough flow through to utilize the resources that had been set in place to deal with the blip. Of course, these resources are unionised, and so forth, and so you we were stuck with a minimum of three months or so before we could ramp back.

In the development of efficient waiting times, there are two major concerns, and of course the first is the patient, the consumer. There also is the concern of the facilities involved in the overall system, the efficiency of the system, just how many people are needed in the pool for whatever to make the system work logically. Would you like to comment on that?

Mr. McGurran: You know, your observations are very valuable and will bring a lot to the debate. You are right, there is an implication for resources, and possibly as a result of your experience in Ontario they may be more conservative.

As I understand it, a certain number of joints is allocated to a region. Hence, supply is fixed, and then it becomes a case of which patient should have access to them. The situation would be far more complicated if both ends were unknown.

With respect to the needs of the patient, a lot of work needs to be done to determine the minimum criteria for that service. Other than the fact that once an individual has had a hip replacement or cataract surgery his or her quality of life is likely going to improve, it is very tough to know, and arguably it is unknown right now, at what point that intervention should take place. Nevertheless, you raise an issue that should remain on the table for thoughtful discussion.

Ms Armstrong: Another factor, although perhaps not as significant with cardiac surgery as some other surgeries, is that Dr. Raisa Deber has done some very insightful work on what patients wants and desires are. While it is clear that individuals expect somebody with expertise to be able to assess and diagnose them, they would like more say in terms of the kinds of treatments they may choose to follow, based on their personal experiences, current circumstances, and a variety of factors.

The Alberta Consumers Association worked with the Alberta Medical Association for a year on a project called "Partners in Care to Improve Patient/Physician Communication." The most common complaint you will hear in the whole health care system relates to communication. Patients and physicians need access to good quality information in order to evaluate the situation; decisions cannot be made without access to good information. They must communicate effectively with one another. I do not want you to lose that aspect either.

Senator Keon: You mentioned in passing the problems as a patient moves from full medicare coverage, so to speak, into the private system. In Ontario, for example, a patient with bacterial endocarditis needs intravenous drugs for six weeks. At $1,200 a day, we cannot keep this patient in the hospital. However, when we send them out, it is costing them $1,000 a day. This is an area that really concerns me, and one in which we seem to have blinders on. The health care system pays doctors and hospitals, among other things, but not a lot of other things.

Ms Armstrong: The list is shrinking.

Senator Keon: Yes. There is more and more delisting all the time. The government covers about 70 per cent of the services; about 30 per cent people are paying out of pocket. Often the things that are not covered are related to ambulatory care or custodian care, matters that are not even considered health care anymore but that are expensive.

I have asked many of the witnesses this question, and I am going to ask you also: How should we deal with this? Should we level the playing field? Should we fund 70 per cent of everything and let the public fund the other 30 per cent?

Yesterday, one of the witnesses said the public purse should pay for everything. I pointed out that that would mean about 14 per cent of GDP, fundamentally doubling the public expenditure on health right now. Hence, how are we going to solve this?

Ms Armstrong: I am pleased you raised that point. An incredible burden of these costs has shifted not only to individuals and patients but also to Canadian employers, particularly small and medium-sized businesses. There have been incredible hikes in premiums. If you go to www.benefitcanada.com, you will read there some remarkable evidence about crippling premium increases that many employers are facing.

With respect to home therapies - intravenous, et cetera - what most people do not realize is that bulk purchasing is very advantageous, both for the insurer and the institution. For example, the same lenses that were being sold retail in Calgary for $750 were purchased for less than $100 by the Lethbridge and Lamont hospitals.

Let's look at the issue of tube feeding. Patients on tube feeding who were released from the hospital were forced to spend $450 a month on tube feeding. That would be their only source of nutrition. Alberta now has a province-wide program, run out of the major care centres, that enables a hospital or a regional centre to purchase a month's tube feeding at $100 rather than $400 or $450. The program was almost lost, because of its impact on the retail pharmacies, which is a bit of a problem.

As a consumer group, we deal with private health benefit plans that cover an increasing number of the basket of services that are required by individuals. It may be not as much as 70 per cent of the cost, but if you look at the number of services, they are covering more and more. I think you need to go to them.

Medicare was created in the first place by transferring the funds people paid through their employer benefit plans, through private insurance, into the public purse to enable bulk purchasing, cost controls, price controls. We must sit down with business in this country and identify a way to fairly and equitably shift the significant dollars that workers and employers are currently spending on private health insurance products in the workplace back into the public system to enable some cost efficiencies.

The Chairman: May I thank all of you for attending here.

Senators, our next panel is made up of Ms Patricia Raymaker, Chair of the National Advisory Council on Aging. Ms Raymaker is joined by Neil Reimer, Secretary-Treasurer of the Alberta Council on Aging, and George Arès, the President of the Fédération des communautés francophones et acadiennes du Canada.

I shall ask Ms Raymaker to go first, because she has a plane to catch. We will follow with questions, Ms Raymaker.

Ms Pat Raymaker, Chairperson, National Advisory Council on Aging: Honourable senators, the National Advisory Council on Aging is pleased to have this opportunity to respond to Volume Four: Issues and Options. As you know, Dr. Michael Gordon responded to one of the other volumes in your report.

I shall begin by thanking you for your interest in our views on the issues and options discussed from the perspective of today's seniors and tomorrow's seniors. I would like to pat the committee on the back for a couple of things. NACA is very pleased to see that the committee has confirmed the legitimacy of the five distinct federal roles in health and health care.

The council also notes with agreement that the committee has included within the federal financing role the funding of innovative health research and evaluation of innovative pilot projects in support of the health care infrastructure. We have just heard the previous speakers talk about taking pilot projects into demonstration projects, and I see that the federal government sees that as one of its roles. Hence, we commend the committee.

I will talk about seven areas. You have my written presentation before you. I will address one or two points relates to each, and then we can move to questions.

The first area is health promotion and disease prevention. The National Advisory Council on Aging has recommended that increased priority be given to health promotion, disease prevention, and population health. We would like to see a priority given to that area.

The council is encouraged that the committee believes that the federal government has an important role to play in the fields of health protection, disease prevention and health wellness promotion. Furthermore, we feel that older adults need to be targeted as much as younger Canadians in federal health promotion efforts.

On the topic of primary care, a couple of issues. There has been a lot of talk about primary care, and I think the committee recognizes that certainly a geriatric practice, which is care of the elderly, requires time with the patient. Hence, our council recommends that the method of physician remuneration, which is a traditional fee for service, be critically examined and modified as necessary to be more compatible with the principles of good geriatric care.

NACA agrees strongly with the committee's views that the federal government should play whatever role it can to facilitate the restructuring of primary care, and the council endorses the committee's conclusion that primary care reform is one of the most critical aspects of modernizing the Canadian health care system. Hence, primary care restructuring can be a big area for reform.

Home care and home support services to help people stay independent in their homes is very important to seniors. Over the last decade, the resources given to home care, as a result of the restructuring of the hospital aspect of health care, although doubled, are insufficient. It is our recommendation that that area be looked at.

In our written brief, we discuss the various strengths and weaknesses of each of the four funding options you have given us. For the purpose of today's presentation, I would like to say that the council recommends the adoption of the first option as being the only option, a national home care program, a national home care program federally led through increased CHS transfers with established national standards and public accountability.

The council is very pleased that the committee has recognized the burden placed on informal caregivers as they attempt to meet the needs of aging relatives and friends. A national home care program would go a long way to relieve the stress and out-of-pocket expenses for informal caregivers. As noted in your report, further support could be provided through adjustments to the CPP and employment insurance to accommodate individuals who leave the workforce temporarily to provide informal care.

In the area of prescription drugs, the reality is that prescription drugs have become an essential element in health care, often replacing or delaying hospitalization or surgical intervention. Seniors, of course, are among those who make the most use of prescription medication.

The committee outlines four possible options for a national pharmacare initiative. NACA could accept either of the first two initiatives, but neither of the other two initiatives. If you want to ask questions about that, I will expand. We feel that a comprehensive public program or a comprehensive public-private plan would meet the dual NACA objectives of having universal, comprehensive prescription drug coverage for all Canadians, with medical necessity being the criterion for access to prescription drugs rather than one's ability to pay.

NACA recommends adopting the third option, and that is the public-private initiative to protect against high drug costs. There is a potential that drug costs could consistently fall just under the catastrophic threshold and therefore present a cost burden. We must recognize that seniors take a large proportion of prescription drugs and as such have high prescription drug costs. They could fall just below that threshold and it would still be causing a fair amount of hardship. The burden would be in the choices they would have to make, prescription or food.

With respect to the Canada Health Act, NACA is pleased to note that the committee is strongly supportive of the four patient-oriented conditions or principles of the Canada Health Act. While acknowledging the committee's observation that the fifth principle, public administration, has been rather narrowly interpreted in practice, NACA recommends against any interpretation of this principle that would lead to a two-tier health system.

In our brief, we have talked about deviations. However, because there are deviations does not mean that it detracts from the principle of public administration being a good principle to strive for.

With respect to issues and options for the financing role, the committee analyzes various financing options for the health care system. Whether it be efficiency gains to the current system or developing new sources of financing, I think we will say that NACA supports fully the goal of improving efficiencies. Concerning new sources of financing, the council recommends that this funding, if it is deemed necessary, should come from a general tax revenue.

In the view of NACA, relying on individual Canadians to improve financing of the current system through user charges and alike will lead to a two-tiered system. We do not feel that there is compelling evidence in the literature that a private tier accomplishes anything more than providing those with means preference to those without means. Private financing options suggested by the committee do not increase significantly funds for health care, yet they could create barriers to access. The committee has put forth three suggestions on page 68 of ways to avoid the negative aspects of a two-tier health care system while maintaining the quality of a publicly funded one. However, while in theory these suggestions may appear to be sound, experience from the United Kingdom and elsewhere strongly suggests that this is not the case. Evidence indicates that a parallel private system diminishes the quality of the public system. It is NACA's view that a private tier benefit some physicians and some patients at the expense of the rest, and it is the least ethical of health care system arrangements.

It is interesting that the Kirby committee was mentioned at the Canadian Bioethics Association in one of the keynote speaker's talks on exactly that. They had stated that some of the options were unethical, so just as you are also making the Canadian Bioethics seem -

Senator LeBreton: I do not know whether least ethical or unethical is a better term.

Ms Raymaker: Least ethical.

There are some concerns that NACA feels have not been addressed in the report, and I would like to just mention them very quickly.

The province has been limiting the growth of long-term facilities and NACA worries that this trend may result in an insufficient number of institutional beds. The council recognizes that this is a provincial jurisdiction, but we urge all levels of government to develop plans. We urge the federal government to take a leadership role in this, to ensure that there will be adequate numbers of long-term care beds to serve the needs of that population that will require this level of care, because they will be older, they will be frailer, and there will be more of us.

The other comment I would make is that the committee considers that institutional long-term care be financed by individuals first, using public funding only after an individual's resources are depleted. NACA sees several problems with this financing option. First, if seniors are required to spend their savings on long-term institutional care while being eligible to receive public money only after their savings are depleted, there will be no incentive for seniors to save for retirement. If they have private savings, they may have to spend it on long-term care; if they do not have private savings, public financing will fund their long-term care regardless. It is a fairness factor.

Second, the council believes that a person in a long-term care facility should be publicly covered for all their medical care, including palliative care, just as they would be if they were in a hospital or in home care. However, the individual's private cost for lodging and meals should be commiserate with local market value. Hence, we are not saying you pay the lodging and meals; we are saying you pay the health care. This is consistent with the national forum on health care.

So, in conclusion, I would like to say that all Canadians should have better and more equitable access to the growing range of health care services and sites. This is especially important for older Canadians, who are more likely to have both acute and chronic health care needs. However, improving access does not have to be accompanied by increasing the privatization of financing across the system.

NACA is not convinced that increasing upfront private costs would lead to more cost-effective use by users or improve efficiencies in the system or substantially increase total revenues available in health. I am talking about total revenues. The more promising solutions are to invest more in evidence-based upstream interventions and in system reforms.

Instead of considering more private sources of funding to address potentially rising costs, perhaps we should consider whether Canadians would be willing to pay more taxes for a stronger and more accessible health care system that truly does deliver what health care they need and when they need it.

Senator Marjory LeBreton (Deputy Chairman) in the Chair.

The Deputy Chairman: Thank you very much Ms Raymaker.

Mr. Neil Reimer, Secretary/Treasurer, Alberta Council on Aging: Senators, the Alberta Counsel on Aging comprises all the seniors' organizations in the province. Approximately 400 seniors organizations are members with maybe 5,000 individual members. We are represented in all the constituencies, so that I think we have a good feel as to the positions of these seniors.

Why am I here? I do not profess to be a doctor or anything like that; however, I have been involved in this arena for some time. As a high school student, I travelled with my father to establish one of the first municipal health schemes in Canada. At that time, the doctors were very happy to work for wages. The client relationship just did not work. There was not any money during the depression. We have followed this through all the way.

My job is in many respects international, and I have some feel as to what goes on in other countries.

I should say to you that I am also a patient. I have had my cataracts removed. I have had both knees and both hips replaced. I was very encouraged the other day; they said it is not impossible now to replace the head. I did not pay health care premiums during that period of time just to demonstrate that they were not premiums; they were taxes.

There number of seniors in Alberta has jumped from 200,000 to 300,000 over the last decade, but the percentage has only increased 1 per cent. Alberta seniors comprise about 10 per cent of our population, which perhaps other than the Northwest Territories is the lowest percentage in Canada. By 2016, it is estimated that 16.4 per cent of the population will be 65 years of age or older.

As seniors in Alberta, we have a sense of celebration. Not everything is wrong, you know. We are living longer; we are healthier. We are doing something right. When I was a kid, life expectancy was such that I should have been dead 10 years ago, but here I am, and the largest sector of our population grows faster than those 80 and over.

I want to say that many things have to be changed. Seniors generally feel good about what is happening, except they are very concerned about the future and where we are going. The profile of seniors that I am talking about, really, is contained in a report developed in Alberta that I have left with you. It is significant in the sense that the Alberta government has adopted it and so have the seniors. The situation must be monitored so that the report does not gather dust on the shelf, and that is what we are doing.

Health is clearly a priority of seniors, but we found that health cannot be dealt in isolation. There are so many other factors. For example, let's take the city of Edmonton at the present time, where we have a waiting list of 600 people who need long-term care. They have not got a place to go, so where do they stay? Many of them are in the hospitals, and that really increases the cost artificially. The other systems should be made to work, such as home care. Factors such as cost, income, affordable housing, home care, education, transportation and volunteers all have a direct impact.

We have always felt that health care in itself cannot be assessed in isolation. We must have a global view in order to make the system really work and have a municipal and local support system in place.

Education is a real factor. There are not enough health professionals trained in geriatrics. Many specialists departed for the U.S.A. at a time of severe budget cuts. A member of my family is a doctor and practices geriatrics, and it has become clear that many doctors do not have enough training in geriatrics. I will give you an illustration.

A fellow is walking in the streets in Edmonton today. He was in palliative care for two years and was misdiagnosed. He was sent to the Glenrose, where they found he was misdiagnosed. Again, he is now walking in the streets, but he was in palliative care for two years.

As we speak, my younger sister is in intensive care. She is only 77. Congestive heart disease was not diagnosed, and the doctor took her pills away. She was on a trip, got as far as B.C., and is in intensive care now. I can go on and on with these kinds of illustrations. It is not that we have not got good doctors, but I think there is a responsibility in the heart of the educational system to make certain that there are an adequate number of geriatrics specialists. I know that we cannot blame everything on the education system because the United States has come in and paid huge bucks to get the people who specialize in this discipline to move down there.

Privatization introduces a dimension into the Canada Health Act that we believe was not intended and is not in the best interests of Canadians; but the question of the shareholders in a corporation adds a new dimension. In other words, in the corporation, the responsibility of the CEO is to shareholders. I think that is foreign in spirit to the kind of operation that we are used to in Canada.

Seniors experience the high costs of cataract operations. Over and over again, I have had calls from all over the province saying, "Why do I have to spend $4,000 and get the cataract operation next month, whereas if I go with the public system, I have to wait 10 months? These kinds of things remind us of the olden days. Moving to private health care is turning back the clock, really, in many instances.

We think the federal government made a serious error in agreeing with the Alberta government in the manner they did. Bill 11 allowed private enterprise to come to the public. It opened up private hospitalization within the medicare system. I think the Alberta government should just admit that it made a mistake and that it should go back and pass legislation if it is necessary. I am certain that this Senate committee is aware of overwhelming evidence in support of the public system.

With respect to finances, we favour a progressive tax system to pay for medicare. If that system is not in place and Canada resorts to user fees, co-insurance, premiums, et cetera, doing so invites huge administrative costs.

Let's take a look at our health care premium. First, it is not a premium but a flat tax. A person who gets a million dollars a year pays the same rate as someone who gets maybe $30,000 a year.

Again, it is not a premium but flat tax. It is income tested. According to reports, $50 million was written off last year as uncollectible, and $10 million was spent on collection agencies. Now, you can access medicare without paying them, but one way or another, they will get the money because if you die, they will take it out of your estate.

Who will pay or not pay insurance, user fees and premiums with our medium income of a little more than $16,000 a year? The medium income for seniors in this province is $16,500. That means that 350,000 people get more than that and 150,000 get less.

Now this issue goes back a long way. The province is out of the "bricks and mortar" business. It will not build long-term care facilities, and private enterprise does not have an incentive to serve lower income people at all.

There is a big hole in the cost of medicare and a huge amount of money because people are not placed in the proper setting. Some say that to have a bed in a hospital - and I guess you know better than I do what the costs are - costs $1,000 a day. I think that should be corrected before we talk about charging people money.

A study on pension arrangements or other income sources is required. In Ontario, for example, steel workers, auto workers, petrochemical workers, public servants have good pension plans, and they are unionized. Newfoundland, at 50 per cent, has the highest percentage of unionized workers, but in Alberta the figure is reported to be 21 per cent. Part of that is because in a province like this, 70 per cent of our work force is employed with small employers of 25 employees or less.

We also have to look at trends. When it comes to patients in the next ten years, you will see people retiring with larger and larger incomes. After that, retirement incomes will drop because for contract employment there are no pension plans. There will be more income, which is enticing for people who want to have private health care, but later on that large retirement income will disappear.

Only 6 per cent of seniors get $50,000 dollars or more, so there is a myth that we are all rich. It is simply not true. You cannot take a 50 per cent cut in wages and be rich.

Prescription drugs are a huge concern. There is no question that the cost of prescription drugs is escalating, and seniors get angry when they see the extremely high salaries paid to drug company executives. In my brief is an example. The CEO of company number 1 has a salary of $27,847,378 a year plus $164,775,907 in unexercised stock options. At company number two, the chairman's salary is $21,604,408 plus $16,000,987 extra in unexercised stock options.

We would welcome a national drug formula as mentioned in your report and move on from there

In B.C., of course, they do have family care arrangements, and their health care premiums go toward paying that. It is not the same as Alberta.

You talked about incentives. In the report entitled "Alberta for all Ages," it is agreed that all individuals have a major responsibility in having a healthy lifestyle by using the health care system reasonably and judiciously. However, the ACA would argue that this can best be accomplished by providing information on education, ensuring safe, affordable and appropriate housing choices, support of communities, as well as recognizing and supporting informal caregivers and volunteers.

Let me say to you that we have such communities. I would invite you to visit Camrose or Edson where seniors are invited to come to live in those towns. Those towns have been made senior friendly, and seniors have been incorporated into the community. Once that is done, everything else seems to fall in place better. However, if you isolate seniors and make them feel lonely and unneeded, if they are blamed for the problems with health care, then what the heck? It has a tremendous effect on morale.

With respect to new health technology, many things have happened. The health care system is unlike an industry where old practices stay in place until they finally evaporate. I think there ought to be some sabbatical leave or something like that for people to update their skills. If they do not want to update their skills, get out of the business.

In conclusion, we think it is appropriate for the federal government to be involved in setting conditions and standards for provinces to qualify for financial assistance. This would help standardize the health care system in Canada and minimize ideologically based decisions.

[Translation]

Mr. George Arès, President, Fédération des communautés francophones et acadienne du Canada: Madam Vice-Chair, I would like to thank you, as President of the Fédération des communautés francophones et acadienne du Canada, for allowing us to make this presentation before you today.

The Fédération des communautés francophones et acadienne du Canada was founded in 1975 and has been working since then to represent the one million francophones and Acadians in Canada.

We have been working since that time to strengthen and develop our communities. The struggle is long, perhaps even endless. There are many challenges, but also many successes. In the areas of education and justice, to name just those two, the FCFA, working in co-operation with its member associations, has overcome challenges, resistance and many obstacles to ensure fairness and respect for francophones in Canada. We are now faced with another obstacle, another major challenge that we intend to overcome: the health issue, or more specifically, access to health care in French for francophones in Canada. We are not asking for the moon, as you can see, but as incredible and unfair as it may seem, we still have to convince our governments, in the year 2001, that it is vitally important for all francophones across the country to have access to health care services in French.

The Constitution and the Canadian Charter of Rights and Freedoms guarantee us the right to be educated in French. The Supreme Court guarantees us the right to legal proceedings in French. Is it not high time that we should also have the right to be born, to receive care and to die in French? Is it not a question of basic dignity? Moreover section 7 of the Canadian Charter of Rights and Freedoms defines this as a fundamental right in Canadian society. Everyone has the right to life, liberty and security of the person. This right cannot be violated except in keeping with the principles of fundamental justice.

The right to life necessarily implies the right to health and, consequently, the right to health care. I would add, in line with the Charter of Rights and Freedoms: "the right to health care [...] in one of the two official languages of our country."

We are fighting today, as we have unfortunately had to do so often, to regain rights that we once had. The first hospitals in Alberta were founded by French-speaking religious communities. Two of the biggest hospitals in Edmonton, the General Hospital and the Misericordia Hospital, were managed by French-speaking religious communities until quite recently. The Sacré-Coeur Health Centre in the Peace River region, a concrete example of how dynamic francophone culture is in Alberta, has its origins in the Sisters of Providence Hospital. That hospital was created in 1929 to provide services to the many francophone settlers who came to Alberta after the First World War. Franco-Albertans had health services in their own language for many decades.

However, as the years went by, these services disappeared. We all know what happened. It would be useless to point the finger at anyone or anything for the sad pass we have come to. But it is not too late to change the situation. Over 60,000 Franco-Albertans will tell you that. Nearly one million French Canadians will tell you.

We have gained the right to education in French and legal proceedings in French; we will also gain the right to health services in French. Your support, honourable senators, is vital in helping us successfully reach that goal.

As I mentioned already, access to health care in our own language is a question of dignity. It is also a question of basic fairness. As you know, the quality of health care depends necessarily on good communication between the patient and the doctor or other health professional. When our governments put their heads in the sand regarding the two official languages, the francophones across the country inevitably receive lower-quality health care.

Many studies have shown that language barriers reduce the probability that treatment will be followed properly, increase consultation time and raise the chance of extra diagnostic tests, diagnostic and treatment errors, influences the quality of service, particularly where good communication is essential - for example, in mental health services - and reduces the probability that health care services will be used preventively.

Simply put, a patient must understand clearly the doctor's instructions and advice. The patient's health and even his or her life is at stake. So there is no room for compromise.

I will give you an example from my personal experience. My father was hospitalized in Stony Plain, near Edmonton, in January; he was quite elderly, 88 years of age. He understands English, because he has been living in Edmonton for a long time, but when he was ill, he spoke in French. Often the nurses did not understand him. He needed someone with him to interpret nearly all the time.

Do you not agree that it is totally unacceptable to require francophones in Canada, when they are at their most vulnerable, to receive health care in another language?

The bilingual institutions that we have at present have shown that they are unable to guarantee services in French at all levels and at all times. Services in French are generally the poor cousin, and francophones often find themselves in unacceptable and difficult situations. Too often, francophones find that they cannot make themselves understood as soon as they come in off the street, despite the nice bilingual signs. Too often, young parents who have received prenatal training in French find themselves surrounded by a medical team that does not speak their language when it comes time for the baby to be born.

Francophone institutions would guarantee service in French at all times. Experience shows that the institutions, whether we are talking about the Montfort Hospital in Ottawa, the Centre de santé Évangile in Prince Edward Island or Dr. Denis Vincent's clinic in Edmonton, are also capable of providing services to the anglophone community. Bilingual hospitals promote assimilation. That idea comes not from me, but from your colleague and my good friend, Senator Jean-Robert Gauthier. He was hospitalized for a long time, a few years ago, at the General Hospital in Ottawa, which is officially bilingual. But when the Montfort Hospital crisis erupted in February 1997, Senator Gauthier did not hesitate to publicly criticize the lack of French services at the Ottawa General Hospital which, because of its location, can potentially serve up to 300,000 Franco-Ontarians, out of a total of 500,000 in that province.

If health services in French are inadequate in a hospital that is officials bilingual, in a province that had a French Services Act, Bill 8, imagine the situation here for the 60,000 Franco-Albertans or for our neighbours, the 21,000 Fransaskois, or for the 51,000 Franco-Manitobans, for example.

Just a few weeks ago, this situation was hard to imagine. Hard to imagine, because there were no statistics on French-language health services in minority francophone communities. When the quality of health care was analyzed, the needs of francophones were simply not on the radar screen.

Thanks to a study that was submitted last June and co-ordinated by the FCFA for the Advisory Committee created by the federal Minister of Health, the Honourable Allan Rock, to advise him on the situation in minority francophone communities, we know that over half of francophones outside Quebec have little or no access to services in their language in hospitals, medical clinics, community health centres and for home care.

There is a table in the brief that I have given you that shows the extent to which francophones have access to health services in French, according to where these service are offered. I will summarize the information presented there. Only 25.9 per cent of medical clinics provide services in French, 37.1 per cent of community health centres, 30.5 per cent of home care services and 28.5 per cent of hospitals.

So over half of francophones outside Quebec are forced to receive care in English. Today, in regions where they are in a minority situation, French-speaking Canadians are between three and seven times less likely than anglophones to be able to receive health services in their own language. That is unjust, unfair and unacceptable, and as you can understand, it is even dangerous. This situation is serious, but certainly not hopeless. The federal government, however, must lend its support to this cause quickly.

The Canada Health Act is based on five principles. The provinces and territories must comply with five conditions in order to receive all the cash funding under the Canada Health and Social Transfer.

The FCFA is today proposing a sixth principle, a sixth condition: the Official Languages Act should apply to the Canadian health care system. Under this sixth principle, the provinces and territories would have to commit to providing health care services in French. This is not a pipe dream and we are not reinventing the wheel, since a similar principle already applies in the education field. In fact, that principle is entrenched in our Constitution. That is why francophone children across the country now have access to education in French in French-language schools run by francophones.

It is clear, as the honourable Marcel Massé said when he appeared before the Joint Committee on Official Languages as President of Treasury Board, that the times when you really need to be able to communicate in your own language are no doubt when you are ill, in the hospital and at school.

However, we are certainly aware that access to adequate health services in French will require a different approach. Moreover, we know that the situations in the various francophone communities in Canada are very different from one to another. So we will need to take flexible approaches that take into account the needs and resources in each region. It goes without saying that each community will need to be involved.

The communities are ready, but the direct participation of the federal government is needed. The federal government must act, co-operate, support us, contribute and intervene in the situation.

We are fully aware that legislative and constitutional changes cannot be made overnight. So we are asking the federal government to begin immediately by supporting those provinces and territories that are prepared to move ahead on this. We are asking for a special fund or a support program for the development and maintenance of health services in French for minority francophone communities.

Again, this approach could be based on what has already been done in education, where the national government, without interfering in provincial jurisdiction, contributed to the establishment of French schools and administration systems and offers stable, long-term financial support to cover those costs that are directly related to the language aspects of the services provided.

It is important that the federal contribution recognize that there is an element of restorative justice involved at the outset. That element has been recognized by the Supreme Court in Mahée with respect to education. I believe that that is why the federal government moved on this and provided the necessary funding to set up a school system across the country. The federal government needs to start with a desire to help these communities bridge the gap that currently exists as regards access to health services in French. This may appear to be an enormous and unrealistic undertaking. But we managed it in the education field.

The plan for this undertaking already exists. The Advisory Committee set up by the federal Minister of Health to advise him on minority francophone communities has just submitted a series of concrete recommendations to the minister to improve access to front-line services in French. The committee's report was also presented a few weeks ago to the provincial and territorial ministers of health as well as to the provincial and territorial ministers responsible for francophone affairs. Three provinces, Alberta, Manitoba and New Brunswick, are on this committee and contributed to writing the report. The report deals with, among other things, the major recommendations and networking. Networking, in this case, means that health professionals, governments, communities, institutions providing training and administrators from the institutions are creating a network to identify needs in their communities and provinces and to find solutions together.

The committee's plan will also be the subject of a national forum to be held in Moncton, on November 3rd and 4th. I would invite you to attend that. I would also invite you to invite the two co-chairs of the Advisory Committee to the Minister of Health, Mr. Rock, to present their report to you. It lays out a concrete plan for involving minority francophone and Acadian communities in health care reform.

In closing, I would also like to invite you, as you go around the country, to meet with people managing health services in French, people working on the front lines, who can explain to you the role of the services in our communities. I know that Mr. Romanow met with the administrators of the Centre communautaire Évangéline in Prince Edward Island. I believe that he was very impressed by the health services offered there.

Two years ago, the FCFA published a study on four pilot projects that provided community health services in French. The study shows that it is possible to provide high-quality health services in French. It also shows that, where the services are available, they are used by the francophone population and are appreciated.

[English]

The Deputy Chairman: Senators, we will now turn to questions.

Senator Morin: Ms Raymaker, you are proposing that government funding is for the full spectrum of health care, pharmacare. What is your position on dental care? In Britain, as you know, there is full government funding for dental care. As well, what is your position on eye care?

Many Canadians now are using natural products. Actually, the cost for natural products is increasing by 15 per cent a year. The only reason that we are not upset about that is because the government is paying, but Canadians are using more and more natural products.

What is your position on these various expenses in relation to government funding?

Ms Raymaker: We recommend that the health care pieces that are being funded federally or nationally should include home care and pharmacare - additions as far as services for the elderly - as soon as possible. We are talking about people reaching a certain age, not the full population. Dental care and eye care could possibly be added as well.

These are very important issues with the elderly. They may not be as important when you are younger because they do not really cut into your independence. However, as you age, the ability to hear and the ability to see become not just health issues but independence issues. I think there is nothing wrong with expanding health care into that area when and if we can. We have a position on recommending such extensions into that area for those reasons - health and independence. We want to keep people out of institutions.

With respect to alternative medications and natural products, I do not think we could do anything as far as the pharmacare program goes because do not have any standards. The important issue is that we know what is in alternative medicines so that we have a good idea of how they react with the drugs seniors are taking.

In the last 20 years, drug costs have gone up 170 per cent. We have heard evidence around this table today that if home care and pharmacare are put into a national medicare scheme, we could very well see the total cost of health care go down.

Senator Keon: I thought in passing you mentioned that this system could be financed with a public-private insurance arrangement. Did I misunderstand you?

Ms Raymaker: As far as the pharmacare program is concerned?

Senator Keon: Yes.

Ms Raymaker: There were four options set out for home care, and the only one acceptable to us was a publicly funded home care program.

With respect to pharmacare, you mentioned public-private. There are many good pharmacare programs out there administered by the private sector, which are not for profit. They are part of the employer schemes. It does not matter to us as long as they meet the criteria for medication, such as medical necessity.

[Translation]

Senator Morin: Mr. Arès, I would first like to congratulate you and thank you for the excellent work done by you and your federation. This work is often difficult and thankless, and you are working in conditions that are far from being recognized in the struggle to defend the rights of francophones outside Quebec and those of the Acadian community.

I read the report of the Advisory Committee to the Minister of Health, Mr. Rock, which was distributed to committee members. It is an excellent report. I am pleased to see that it has received initial approval, if I am correct, and that it will be discussed in a few weeks in Moncton.

I have two questions to ask you. Hospital health services in French depend to a certain extent on having health professionals in those hospitals that can speak French. As you said, there have to be more than signs that say that French is spoken, but also people who actually speak the language.

If I understand correctly, a second bilingual faculty of medicine will be established in northern Ontario, and there will be a substantial proportion of francophones - I am talking about Laurentian University in Sudbury - do you have any additional information on that? There is also some talk of creating a bilingual faculty of medicine in Moncton. Do you think that we should support this important initiative?

My last question deals with your proposed sixth condition for the Canada Health Act, which would be that the Official Languages Act would apply to the health system. I suppose that one would have to add: "where numbers warrant or where the necessary conditions exist". You would certainly have the support of Quebec anglophones for that kind of recommendation. You no doubt know that anglophones in Quebec have problems in this area as well. There would be an alliance among francophones, Acadians, francophones outside Quebec and anglophones.

Mr. Arès: The University of Ottawa's Centre national de formation en santé, which was created a few years ago and where I am a member of the board of directors, really wants to become a national centre by including other francophone institutions in Canada offering training for health professionals. This would include not only institutions in Ontario and New Brunswick, but also the Collège universitaire de Saint-Boniface and the Faculté Saint-Jean, here in Edmonton. It is recognized, I believe, that there is a need for more health professionals, but we really want the Centre national de formation to be recognized as a national centre. That is one of the recommendations that was made, and we hope that it will be implemented soon.

It is true that anglophones in Quebec would probably agree with us. You mentioned the idea of "where numbers warrant", and we should perhaps say that all francophones should have access to these services. We need to find ways of delivering health services, as we did in education. In Alberta, there is one school administration for the whole province, and the francophone boards decide how they can and will deliver services to all their francophone residents throughout the province. I think that we could do the same thing in the health sector. That is why I mentioned in my presentation that the networking we are looking to initiate would include representatives from the communities, governments, health professionals, administrators of training institutions and administrators of health institutions. All these networks could find a way of delivering health services in Alberta. These solutions may well be different in Alberta, in New Brunswick, or for anglophones in Quebec. Each situation is different, and we cannot say that we are going to have francophone hospitals everywhere, because that would not be reasonable. The important thing is to take a reasonable approach. Let us look at means and find reasonable solutions together. I believe that that is why the networking proposed in the report to Minister Rock is so important.

[English]

The Deputy Chairman: I have a question for Mr. Reimer and the Alberta Council on Aging. You said that 600 people in Edmonton are awaiting long-term care. What is your organization doing about this? Is there a solution? Are you lobbying the government extensively? Obviously this number will grow.

Mr. Reimer: There has been a positive development in Alberta. We now have a minister whose only jurisdiction is seniors, Alberta seniors. The government can no longer say, "Well, we have a big department that has to do all of these things." Now we have a minister devoted to seniors' issues.

We are having a good dialogue with the government in terms of getting non-profit organizations involved, such as Lions Clubs. They are proposing new facilities in Alberta, but they are not there yet. The foundations have not been poured. As the senior population increases, this problem will increase for a period of time until it is resolved.

Much of this problem has been the direct result of major cuts in this province, and now we are trying to catch up. The population of Alberta is increasing very rapidly, but it takes a long time to catch up.

Senator LeBreton: Where are these people living; with their families?

Mr. Reimer: Some of them are with their families; a lot of them are in hospitals.

The Deputy Chairman: Taking up extensive beds.

Mr. Reimer: Ever since the cuts to medicare, it seems that everyone is sick at every level. The system is backed up. I am not complaining about the care, but it has been very hard on a lot of the professionals and people who work in the institutions. We are optimistic that we can resolve the situation, but it will not happen tomorrow morning.

The Deputy Chairman: The other comment I wanted to make concerned your comment about the professionals in geriatrics. As our population grows and ages, this is an area in which we will fall very short. This is something we have heard from witnesses across the country.

Mr. Reimer: The senior population will swell fairly soon, and it is important we get on top of it.

The Deputy Chairman: The only comment I had about that is whether organizations such as yours will encourage educational institutions to train more people coming into the medical profession and streamline them into that area.

Mr. Reimer: We can do that. We can do what we did in this province on the occupational health and safety issue. We went to industry and got enough money to establish a Chair. There are other shortages as well, not just in geriatrics, so we will be doing that.

The Deputy Chairman: Excellent.

Senator Michael Kirby (Chairman) in the Chair.

The Chairman: Our next witnesses are representatives of the Nechi Institute and the Health Advisory Committee of the Executive of the Alberta and Northwest Conference of the United Church of Canada.

Please proceed.

Mr. Richard Jenkins, Director of Marketing and Health Promotion, Nechi Institute: Good afternoon, senators. Ruth Morin and I pleased to have been invited and thank you for the opportunity to be here with you today.

The Nechi Institute does addictions training and research in a health promotions kind of way. Our biggest health promotions initiative at this point is National Addictions Awareness Week, which is next month, the third week in every November.

One of our concerns is that there is no evidence in Volume 4 of your report, "Issues and Options," that new financing options will not limit individual payments toward health care at one level or another - taxes or user fees - which is a key component of a preferred public health care system.

We were able to give a cursory review of the summary document, but I did not even see the whole document. The only one available today is a French version. I struggled through it, with my bad understanding of French.

We like the idea of a national drug formulary. The options related to that discussion are appreciated and intriguing, as a larger economy of scale argument is presented, but there is a downside, and that is bottlenecking. We did not talk about that in our paper.

We are also applauding the fact that the committee recognizes that a national, rather than a federal, strategy involving all governments, including the federal government, is needed for health care.

We appreciate that the report recognizes the struggles of practitioners of various other kinds of alternative medicines, as Aboriginal traditional medical practitioners usually fall into this category and are often not afforded the respect that is due to them in Aboriginal communities and mainstream institutions.

Chapters 12 and 13 provide recognition of the deplorable, in the words of the committee's report, health conditions and status of Aboriginal peoples of Canada, and it is appreciated that the report provides a focal point for discussions regarding these distinct populations. It is regrettable, though, that the Constitution Act of 1982 is not referenced in chapter 13 - at least in the document that I read - in that all Aboriginal peoples are defined and noted in the act. The only fiduciary responsibility noted in chapter 13 is the Indian Act, which only addresses fiduciary responsibility as it relates to only two other noted population groups - that is, the Indians and Inuit. It leaves the Métis outside in the cold in terms of health care at the federal level, as well as non-status Indians, who are even more out in the cold and are harder to identify.

Suggestions for consideration: The development and maintenance of a national drug formulary must be implemented in such a way to ensure timely and effective drug interventions to those individuals with variant reactions to cheaper drugs. This must be done in a timely fashion. I will give you a quick example of someone with HIV whose viral load is high and T-cell count is low. In waiting for the approval of a national drug formulary, someone might be impacted by the onset of an infection the longer they have to wait. When your T-cell count gets down to a certain level, it leaves you open to all kinds of infections. Although a nice formulary is appreciated, there is some caution there.

In terms of evaluation of research, it is suggested that Health Canada facilitate - and this is very specific - the opportunity for the Canadian Institutes of Health Research, the CIHR, to be trained by community health groups in definitions and the implementation of community-based research methodologies, as the academic medical model of community research still seems to be the only approach known and accepted by CIHR academics currently controlling that regime. Recent meetings between them and some of my colleagues in one field of health research indicate that they do not get it yet. There are still ways for them to get out of the medical-model-only approach to health research in that there are different ways of looking at how to get good health outcomes.

We would like to see increased targets for research allocations in health promotion and prevention approaches across the public and private sectors, with some being directed and some being proposal driven. We get calls for proposals from different parts of the Government of Canada. They are all proposal driven. Sometimes it requires a more strategic, coordinated effort as opposed to waiting for communities to come up with the best ideas.

There needs to be an increase will by Health Canada to implement a targeted national addictions strategy that addresses the relationship between addictions, health determinants, and health status, as their currently does not exist such a strategy or even the focus on addictions outside of the First Nations and Inuit health branch and outside of the consumer safety branch, where they talk about regulations on alcohol and the sale of drugs that in product development.

In terms of surveillance, Aboriginal groups representing the health interests of Indian, Inuit and Métis peoples need to be directly engaged in an accountable but yet confidential manner with respect to the health records of populations they serve in order to better equip them with timely information regarding disease outbreaks within those populations. I cite the Manitoba Métis diabetes surveillance project. There was the political will by the Manitoba Métis, the province and Health Canada around diabetes to do a blind sharing of records so that the Métis Federation of Manitoba could actually identify who within that population group had diabetes and then do some interventions targeted work. Without the political will of the various provinces and territories, it is difficult to do directed work.

An increased number of Aboriginal training and post-secondary education initiatives in all aspects of health care provision must be developed to address the need to build capacity within Aboriginal communities using Aboriginal approaches to address our health issues in addition to the maintenance of mainstream medical model used by Canadian health practitioners today.

There must be an increased awareness of, recognition of and resources for First Nations, Inuit and Métis governance roles and responsibilities to ensure they are acknowledged and supported in the development of a national health human resources strategy.

My next point relates to the lack of adequate reference to HIV/AIDS, suicide and hepatitis C. Those terms actually do show up in the full document, so I was at a disadvantage not having the whole document in front of me. That is a moot point.

In terms of preferred options, all options in chapter 12 are preferred, as all are necessary to ensure that all Canadians are addressed in the development and implementation of simultaneous population health strategies among various population groups in Canada, because there is some crossover between groups.

I was born Métis and am now a status Indian, so I introduce myself as a Cree Métis with Indian status. Sometimes I get a chuckle out of that because people in Aboriginal communities want me to pick a side, which is unfortunate. There is the perception that there are sides to pick.

In terms of chapter 13, the option noted in section 13.2.1 is supported with the proviso that urban Aboriginal populations and the existing urban service delivery networks created by those populations be recognized and supported in the development and implementation of a national action plan on Aboriginal health. With many of the initiatives involving urban service delivery that I have been a part of at the national level, folks often get left out in the cold.

There is a propensity to think of Aboriginals as First Nations, Inuit, Métis and that is it because that is what the Constitution says the federal government has a role in. However, Aboriginals live everywhere. They do not just live in First Nations communities or North of 60.

The cross-discipline Aboriginal training option in section 13.3 is duly noted and supported. However, Aboriginal approaches to health training and services must be recognized and supported through the existing Aboriginal learning institutes throughout Canada - of which there are over 50 - where the capacity exists to address the health training and post-secondary education needs of Aboriginal peoples and communities. For example, efforts should be made to engage the National Association of Indigenous Institutes for Higher Learning, the NAIIHL, in coordinating the design, development and implementation of such a cross-disciplinary training strategy in Aboriginal health disciplines in cooperation with supportive mainstream education institutes

I could cite many examples of mainstream education institutes that are not particularly supportive. One of the comments I would make is that they are academically elite.

The development of an Aboriginal health policy is supported with the recognition of the work already done in this field in Ontario by the Ontario government and the Aboriginal communities in that province be used as a model for discussion. That work was collective, collaborative and multidisciplinary. That model works and is implemented now. Ontario is into their second phase.

The Chairman: Explain to me how you move from being a Métis to being status Indian? I understand how you can go the other way around. How do you do it?

Mr. Jenkins: In 1985, the Indian Act was changed, and Bill C-31 changed that act. It allowed eligible people to register as treaty Indians. One of my grandmothers had her status, but she married an Englishman and it.

The Chairman: But they had not registered, so you were allowed to essentially make up for it. I heard a number of cases that had gone the other way.

Ms Rogers, please proceed.

Ms Louise Rogers, Executive of the Alberta and Northwest Conference of the United Church of Canada - Health Advisory Committee: The United Church of Canada, as you probably are aware, has had a long history in the delivery of health care. In Alberta, what is today the Lamont Health Care Centre originated as a hospital in a remote community in 1912. Over 10 years ago, the board and staff of this centre redefined their mission to consider as part of their mandate the health of the whole community. In 1993, in an accountability report to the United Church Division of Mission in Canada, we said:

Perhaps more than ever before, the church's prophetic voice is needed in health care both within the health care system and without. There is increased pressure toward private administration, user fees and "Americanization" of the health care system. While their needs to be fiscal responsibility, finances need to be managed with minimum social dislocation.

The centre has been able to launch new initiatives and still continue to operate the facility well within the budget. A lens implant program is one of those initiatives. It was referred to earlier today by Kevin Taft and Wendy Armstrong. It is truly an example of a community in touch with the people it serves.

The United Church has made a conscious decision to remain involved in the delivery of health care. We do not see it as a business but as an opportunity to make a Christian witness. It is against this backdrop that we offer our comments.

Our overall position can be most clearly stated by saying that we agree with the observations and recommendations set out in the final report of the National Forum on Health. We agree that predictable, stable federal transfer payments are important. Increasing the scope of public expenditure may be the key to reducing total costs.

The following are fundamental to preserving and protecting medicare: ensure full public funding for medically necessary services; maintaining a "single payer" model at the provincial and territorial levels; and supporting the five principles of the Canada Health Act.

We must move to a more integrated system that funds care, not the provider or the site, and we must build a more integrated system. This requires action in the areas of home care, pharmacare and primary care reform.

If the principle of "public administration" means "maintaining a single payer model at the provincial-territorial level within a system that ensures full public funding for medically required services," then we agree. We would want to see the principle of public administration retained in the Canada Health Act so that it is a condition for federal funding.

We must emphasize that we are strong advocates of a system that employs public or not-for-profit entities to deliver health care services.

We reject any suggestion that the Canada Health Act places unreasonable limits on the rights of Canadians who have the means to purchase health care privately. We believe they can purchase it in the U.S. or from "opted out" providers in Canada. Availability of health care services is determined as much by the shortages of personnel as by budgetary allocations. To permit a parallel private system for medically necessary services, whether publicly funded or funded from private insurance, will go to serve those with money regardless of need.

The committee's report focused exclusively on patient charges as a means to make patients more responsible in the use of health services. Evidence suggests that cost sharing reduces utilization but does not contain costs. There is no mention in the report of approaches that emphasize informed patient choice, shared decision making and access to information and advice by telephone.

We are very concerned when we read news reports - this one in The Edmonton Journal of September 7, 2001 - quoting one of your fellow senators as saying "I don't see why we can't have a combination of private and public." We share the view of the endless commentary on the European experience: "In the opinion of several well-respected analysts, market mechanisms necessarily create conditions in which vulnerable populations - particularly the less well off - will not receive equal access to quality services.

We think that the approaches suggested by the World Health Organization need to be tested when we are looking at items around timely access and waiting times before jumping in to care guarantees or a patient bill of rights.

There is no doubt that regionalization has improved the integration of health services. The definition that we used for regionalization is the judicious allocation of resources. However, a very important element in the provision of health services - the payment of physicians - has remained centralized. We think that this exclusion has limited the potential for improving efficiency and effectiveness in the health care system.

As pointed out in the committee's report, regionalization has involved decentralizing services from the province to the regional level and centralization from the local to the regional level. In our view, the latter centralization has, particularly in rural areas, removed an important element of local community involvement. When you concentrate specialized services, you begin to withdraw services in rural, aboriginal and remote communities. This not only intensifies the denial of services; it increases the lack of physicians in these communities and transfers costs from the health care system to individuals who have to travel for care. As well, it has placed the regional authorities in the position of being planners, funders and operators. This will eventually lead to a tendency to drive out non-regional operators.

In contracting out to the private for-profit health care facilities, we believe that any savings will predominantly come from reduced wages. This sector of the health care work force is already low paid.

We are not in favour of the concept of medical savings accounts. We do not accept the arguments supporting their introduction. We believe that rather than stimulating "price competition," they will lead to an emphasis on risk avoidance to the detriment of those most in need of coverage and services.

Finally, we do not support the conversion of all CHST cash transfers into tax points. We think it would only serve to create greater inequities for persons living in the poorer provinces. As well, we believe that the monitoring and enforcement mechanisms under the Canada Health Act are an important role of the federal government and should be retained.

The Chairman: Ms Rogers, under your point on timely access, you say that the approaches suggested by the World Health Organization need to be tested. Since I am not sure what you mean by that, could you please explain that comment?

Ms Rogers: We have included the reference.

The Chairman: Those quotes are from the WHO?

Ms Rogers: Yes. The second quote is from the WHO report, and the third one is from a different report.

The Chairman: Mr. Jenkins, could you tell me a bit about the National Association of Indigenous Institutes for Higher Learning? I have never heard of it.

By the way, I think the program you gave the name of in Fort McMurray is obviously part of it.

Mr. Jenkins: Actually, no. The Keyano College is not part of NAIIHL, which includes institutes such as the Nechi Institute, Blue Quills First Nations College, Olds Community College, and Yellow Quill in Manitoba.

The Chairman: Do they focus primarily on indigenous students and on programs for training people to work in indigenous communities?

Mr. Jenkins: Both.

The Chairman: So they are not only indigenous to the First Nations or Aboriginal students, but they are also training people to work in aboriginal communities.

Mr. Jenkins: Yes.

Senator Morin: I going through your material, I was very impressed.I see that you have two Web sites. Your brief mentions a number of research projects on native suicide and family violence. I am wondering if this research been published.

I know yours is a charitable organization. Who supports it?

Ms Ruth Morin, Chief Executive Officer, Nechi Institute: We are less than half government supported by Health Canada and the Alberta Alcohol Drug Abuse Commission. Together, the combined sources form less than half.

Senator Morin: The other half is voluntary?

Ms Morin: We are self-sufficient.

Senator Morin: It is voluntary, or is it through the training program?

Ms Morin: We sell our training programs. We support ourselves because we do not get enough from both of those sources to completely support all of our endeavours.

Senator Morin: I was not aware of that.

I see that you offer several programs, mainly in the field of addiction but in other fields of health promotion as well.

Have you ever carried out an evaluation of what you are doing? I know it is not easy, but have you evaluated the number of people who are addicted or the number of patients presenting an emergency? Do you have a handle on whether you are actually effective in changing the situation?

Ms Morin: We are a training institute. We also do research and health promotions. The people we serve are national, so it is hard for us to keep track.

Senator Morin: I know that, but have you seen a change in the First Nations communities? I know it is all anecdotal evidence, but have you seen any evidence of change in the people you train in those communities?

Ms Morin: When we started 27 years ago, the situation with alcohol and drugs was much like the Davis Inlet situation is today. There has been improvement, but we are also the fastest growing population. In addition, in many of our communities about 65 per cent of our population is under age 25 years of age. Today's young people are a different sort, getting into cocaine and more of the hard drugs. Also, they are less and less able to take part in our cultural teachings and traditional methods of healing, so we are seeing an impact.

Because with the impact of the mainstream populations, it is harder for us to convince our kids that our traditional methods are just as good as and, in some cases, superior to mainstream ways of healing.

Senator Morin: Are you are saying that it is more difficult with the younger generation that it was in the past? Is it true to say that in the past the problems were related more to alcohol and that now they are related more to hard drugs?

Ms Morin: Today, there is still a big problem with alcohol, but it is added to by addictions to hard drugs and prescription drugs. That is different than when we started 27 years ago.

Senator Morin: There is still a big problem, then.

Ms Morin: The problem is more multifaceted than it used to be.

Senator Morin: Thank you very much and congratulations - you are doing an excellent job.

Senator LeBreton: My question is for the representatives of the United Church of Canada. One of the concerns that we have heard consistently is the impact on services in rural and remote communities. Witnesses this morning talked about the regionalization of health services. Though you talk about improving the integration of health services, has there been a further deterioration, in your view? Services can be integrated, but if they are not there, it is not going to do much good. What do you see as a solution for rural and remote communities?

Mr. Kent Harold, Executive of the Alberta and Northwest Conference of the United Church of Canada - Health Advisory Committee: Being involved with the region and having a non-voting seat on the regional board, I am able to observe a number of things. I think that to increase and enhance the health care to people in the more remote regions, we must address the problem of training people from those communities for health care work.

In our region at the present time, for example, there is a program for the training of registered nurses. The majority of the trainees are in their mid-30s, have families, are well established in the communities. Most will very likely stay in those communities.

A program is also being launched to train licensed practical nurses, which I think will be equally successful. There are no dropouts, and the program is in its second year. I see no reason why it would not work in First Nations communities, although I am not familiar with the situation there.

One of the problems with regionalization is that as there is a centralization of specialties, the resources of particular communities are diminished, which makes these communities much less attractive to medical practitioners. Try as we might to get doctors to serve in remote areas, we need an infrastructure and support systems for them to enhance the work that they do.

Young physicians coming out of medical school feel very exposed. Even long-term physicians feel exposed going into communities where they have no backup system, where there are no contemporaries, for example, to share the work. They quickly burn out. This problem must be addressed if we intend to address health care in rural and remote regions.

Senator LeBreton: Working conditions, then, can be become a major deterrent to physicians because they are out there on their own.

Mr. Harold: Yes, that is a big part of it. I think we need to look at things like more nurse practitioners. They do operate in the North, of course, but we need to investigate that at a closer level. That is my own opinion. That is not the opinion of the church, particularly, just my own observation.

Senator LeBreton: Would you say, then, that regionalization has exacerbated the problem? I guess I am saying that the problem has become worse since regionalization. Medical professionals have gravitated to larger centres, and rural and remote areas have suffered because of the regionalization of health services.

Mr. Harold: I would have difficulty linking the two without more objective evidence. Certainly, rural areas do have a great deal of difficulty attracting physicians, but I could not say that it is directly connected to regionalization. I think a more definitive study would have to be done to determine that, so I just do not know.

Senator Keon: Mr. Jenkins, with regard to the question of adequate health human resources to deal with your situation, do you, at this point in time, have a strategy for that? Have you thought about how you can educate health professionals, or would you draw from your own communities to educate people so they come back to your communities?

Mr. Jenkins: In terms of an Aboriginal health resource strategy, no. At the Nechi Institute, we try to develop different provincial health initiatives, such as the Alberta Mental Health Board. We are trying to have an impact on the creation of an Aboriginal human resource service and program base. That is a bit of a challenge because the cabinet submission was denied by Alberta Health and Wellness because it had other priorities. That project became less of a priority.

In terms of an overall cross-discipline strategy, there must be collaboration between traditional medicine and mainstream medical health services. I do not think that has been done in any province in Canada, because you have got a proliferation of AIDS service organizations that are becoming little silos.

You probably see something similar with hepatitis C. People who have that disease need specific lobbying efforts because there is a stigma attached to it. Hepatitis is much like the issue of alcoholism 25 or 30 years ago where there was a lot of stigma attached.

I just want to make a quick comment about the rural challenges. You might want to consider mobile treatment providers some 15, 20 years ago in Northern B.C., the Tache Indian reserve experience indicated that mobile treatment for addiction services was a growing concern at that time. I do not know where that service has gone. Maybe it is not supported anymore. I am referring to mobile treatment from a team of medical practitioners who would travel from community to community on a weekly basis as opposed to public health nurses that only do so much. I mean, they are kind of strapped in town, never mind going out to the rural communities.

Ms Morin: And they have to work with the community members in the different communities because they have the knowledge of the community and the people.

For instance, it became apparent to the Alberta Cancer Board that Aboriginal women had increased rates of breast cancer and were dying at a much higher rate than other Canadian women. It was discovered that Aboriginal women were not coming to get mammograms. Why? Part of the reason was due to travel, but there was also a high rate of sexual abuse associated with the whole residential school thing. Going through the whole process of getting a mammogram was seen as a huge mountain that a lot of people were not willing to climb. However, when a mobile mammogram was brought to the communities and they had lunch and they picked up the ladies and they had child care and things like that, Aboriginal women were more willing to be involved. They liked the safety of their own community, with their own people helping them. The women came, the mammograms were done, and everyone was happier.

Senator Keon: We keep getting the flip side of this idea of increasing the scope of public expenditures, that the panacea for health services should be an effective cost reduction. I think most provincial ministers and deputy ministers are really quite afraid of that. They think increasing the scope of public expenditures will put their costs out of sight. I can see that there might be some efficiencies by pulling private services out in the public that people are paying for now. Extending into that whole area, I think, has intimidated the provincial authorities. What is your comment on that?

Mr. Don Junk, Executive of the Alberta and Northwest Conference of the United Church of Canada - Health Advisory Committee: We think that the total amount being spent on health in Canada as a percentage of GNP is sufficient to accommodate it. However, there are possibilities for efficiencies from single payer models and from the larger ability to contract for pharmaceuticals. I think the National Forum on Health was the one to reach that conclusion, and we are persuaded by those arguments.

Looking at other countries - and we do not have the research that you have - research seems to indicate that within a lower GNP, they can adequately provide this range of coverage for their populations.

Senator Keon: Why do you think nothing has happened since the National Forum on Health reported?

Mr. Junk: I do not know why nothing has happened. For us, there is a certain frustration. Why are we still talking about this when we thought the forum made good recommendations?

The Chairman: Ms Rogers, in your document, you state:

There is no mention in the report of approaches that emphasize informed patient choice, shared decision making and access to information and advice by telephone.

I know why you missed that: It is not in chapter 8. It is, in fact, over in the infrastructure chapter, which is chapter 10. We did discuss the importance of rural and remote communities moving to "telehealth" and a much more system-oriented, rural-based information system. We strongly support that concept, though not quite in the terminology you have used in your brief. We simply did not put those ideas in the financing chapter.

Mr. Jenkins, we will have a report that will be out next week. It is a background document that focuses on the main cost drivers of the increased cost of the health care system. A substantial section of the report - I mean tens of pages - deals with a number of Aboriginal issues and specifically talks about the AIDS/HIV issue and the addiction issue.

When that report is issued, you may want to just give us a call. After you have read it, you may have some additional thoughts.

Mr. Jenkins, I believe it is true, but I was stunned by your comment that the federal government, as part of its population health strategy, does not have a strategy to deal with addictions other than the addictions program. I guess it is technically called the anti-addictions program of the First Nations and Inuit Health Branch.

I always make assumptions about governments, which turn out to be wrong. I just began with the assumption that given the growing importance of that issue, there would have been a national policy recognizing that service delivery would have to be done at the provincial level. I just thought that this was a national thing. Do you want to make any comment on that?

Mr. Jenkins: We went to the Professional Addictions Conference that the Alberta Alcohol and Drug Abuse Commission put on about a year ago now. One of the issues raised was the lack of a national addictions agenda. We are trying to manage the National Addictions Awareness Week campaign, and in looking for a public health branch responsible for addictions within Health Canada, there is no one.

The Chairman: I know they are national organizations. There are national anti-alcohol organizations. There are a number of national drug abuse organizations. I am right?

Mr. Jenkins: There is the CCSA, the Canadian Centre on Substance Abuse.

The Chairman: Is that a federal organization?

Mr. Jenkins: It is an arm's-length agency established through an act of Parliament.

The Chairman: So it is not part of the federal government. Thank you for that observation because the lack of a national additions strategy is a weakness.

Senators, we have one walk-on witness this afternoon. Mr. Noel Somerville is a retired teacher.

Mr. Noel Somerville: Senators, my interest in reading Volume 4 of your report was sparked by reading a quote from The Toronto Star in which your chairman was quoted as asking the following question: Is it just in a democratic society that government should ration the supply of health care services by constraining health care budgets and simultaneously denying Canadians the right to buy the services in Canada?

I was intrigued by that question and started to wonder: Where does the injustice lie? Does the injustice lie in preventing us from buying the services, or does the injustice lie in constraining budgets so that the services which were supposedly guaranteed in legislation are not available to people?

The Chairman: Exactly. That is why we asked the question that way.

Mr. Somerville: That is right. I appreciate your candour in stating it the way that it was stated.

As I thought about that, I was struck by a number of parallels between what has happened in health care and what has happened in the field of my expertise, which is education. There are a great number of parallels starting with the constraining of budgets, of course, the fallout from which has been the movement to alternative programs and the movement toward privatization.

In Alberta, while allocations for public education have been reduced, the allocations for private schools and independent schools have gone up by 50 per cent in that same period. As a result, there has been a huge movement toward private schools. Private schools talk about a tripling of their enrolments in the last few years because of the availability of larger amounts of public funding and the fact that parents no longer have to pay high additional fees to access those schools as they did before.

Even within the public system, we see the proliferation of all of these alternative programs of choice. We see charter schools coming into the public system. The thing I want to point out is that there is a cost for all of that. The basic premise of public education was equality of educational opportunity for all children. That concept goes back at least a century. The idea was that it was of benefit to society if we gave equal opportunity to all children.

I think a very symbolic principle was initially intended to be built into the Canada Health Act - that is, equality of opportunity. I also think that many of the options you are looking at today will do what they have done in education: They have made wealth and poverty self-perpetuating because those who can afford it get the better service. Their children get an advantage. I can understand that. Those who cannot afford it, or those who do not care, do not get that service and their children suffer. I care about that.

We must maintain some sort of equity in the system. I notice that you gave very strong support to what you call the four patient-oriented principles of the Canada Health Act. You were somewhat more equivocal about public administration. I think public administration is crucial to preserving the whole notion of equality in the system.

I will close with something that came to my mind quite recently. It was a line by Winston Churchill, who said, "I was not elected to preside over the dissolution of the British Empire." I hope, ladies and gentlemen, that you do not feel you are in a position where you will have to preside over the dissolution of Canada's health care system.

The Chairman: I will say that I had never thought about the analogy to education. I think that it is a profound insight. This is exactly why I like to hear from walk-on witnesses at the end of a day. It is amazing what one can learn from a very common sense point of view.

Senator Roche: It is a great pity, Mr. Chairman, that we have no time for questions.

The Chairman: We will read your brief, Mr. Somerville. Thank you very much.

The committee adjourned.