Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 33 - Evidence
VANCOUVER, Thursday, October 18, 2001
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 9:02 a.m. to examine the state of the health care system in Canada.
Senator Michael Kirby (Chairman) in the Chair.
[English]
The Chairman: Honourable senators, our first witness this morning is Mr. Ken Fyke, the former Chair of the Commission on Medicare in Saskatchewan. Mr. Fyke is well known to a lot of people who have been around the medical industry for a long time because of positions he has held as deputy minister in both Saskatchewan and British Columbia.
We are delighted to have you with us this morning, Mr. Fyke.
Mr. Ken Fyke, Former Chair, Commission on Medicare, Saskatchewan: Thank you, honourable senators. It is a pleasure to be here this morning. I would like to clarify that I will be speaking this morning as a private citizen. While I will be pleased to answer questions in regard to the commission report, I am not speaking on behalf of the government of Saskatchewan in any way, shape or form.
I appreciate this opportunity. I want to congratulate you for your extensive review and the important issues that you have identified in your report. I am sure your report will make a major contribution to the development of policies that will ensure that health services meet the emerging needs of Canadians.
The current problems are complex and they will not be solved with simplistic answers. Medicare is very important to Canadians. It has become the symbol of our country's sense of fairness and concern for others. Notwithstanding its popularity and support, Canadians feel it is not working as well as it should. I read your report with great interest and appreciation for the work that you have done. Today, I will limit my remarks to a general comment on the basic principals of publicly funded health services and to some selected issues in your report. I would be happy to answer any questions after that.
I agree that the health care sector must be prepared to transform itself into a 21st century service industry instead of remaining mired in a 19th century structure. To accomplish this transform ation, we need to redefine our vision, change the culture and realign the incentives. The current challenges in our publicly funded health care services - or medicare, as it has become known to all Canadians - are not the result of the principles of public health insurance. In an address to members of the Vancouver Board of Trade, Mr. Charles Bailey, Chairman and CEO of the Toronto-Dominion Bank said that it is high time that the private sector went on the record to make the case that Canada's health system is an economic asset, not a burden. He further stated that moving away from a single payer publicly funded system might cost government less but it would surely cost the country more.
Our challenges stem from our inability to focus on the real problems, act on the root causes and implement change. We need a fundamental rethinking of how we define, organize, and pay for success. Although the evidence demonstrates that a single payer public health insurance provides equity and cost control, the challenges must be met for it to remain sustainable and affordable. Medicare, as it is currently organized, is no longer equipped to deal with the present or emerging health needs of our society. Since the Lalonde report was released in 1974, we have known that health care is only one factor contributing to a healthy society and to have a healthy economy this country needs a healthy society.
Currently the provincial health care budgets are approaching 40 per cent of their total government expenditures and in some provinces exceeding 40 per cent. Health care is crowding out other programs, like education, that are also important to a healthy society. One finance minister told me his health colleague comes to the cabinet table and eats everyone else's lunch. This concern was addressed in July of 2001 by the Conference Board of Canada with the conclusion that governments must spend less on health care and more on education, research, innovation and job training.
A fundamental issue that has confronted us since the beginning is how to pay for what we want and not pay for what we do not want. This is not a question of private or public payment. It is a question about paying for appropriate services. It may not have been important at the beginning when medicare services were not as complex as they are today and society's main issues were infectious diseases and other acute illnesses. But today health services must address chronic and terminal conditions as well as acute services that involve complex technology along with a wide range of health professionals to provide appropriate prevention, treatment and maintenance.
The evidence is persuasive that today we focus too much on providing health care rather than achieving health. We focus too much on volumes rather than quality. I define quality as minimizing misuse, overuse, and under-use of services. In our quest for volume, work performed is work paid for, whether it results in improved health of the population or the client. We fail to measure, monitor or manage health. Rather, we focus on providing more and more health care.
While I was studying the health services in the province of Saskatchewan, I heard heartbreaking stories from physicians, nurses and the public about poor quality. I want to convey to you today the profound wisdom of one nurse from Prince Albert, Saskatchewan, who summarized her observations from many years of nursing. She said that today, "We do because we can, not because we should." Her plea, shared by many others, is to stop doing the unnecessary and frequently inhumane procedures and do only what is appropriate to improve the health of the client. We need to replace the culture of silence with a culture of safety and quality. We must stop fearing the truth and seek answers on how quality and safety can be improved. We need to move away from the culture of blaming. This is not a question of who is to blame, it is a question of what is to blame. As long as we regard quality problems as sources of embarrassment, we will continue to have accusers and defenders.
I wish to comment on the need to consider the issue of user fees with great care. Medicare is more than services rendered by physicians and hospitals. Pharmaceuticals and home care are two services that are critical today to the smooth functioning of an up-to-date health service. Today these services do not enjoy the privileged position of being included in the Canada Health Act, although they are not prohibited either. We currently have substantial user fees in both of these services for some citizens, and this has certainly not dampened the cost escalation of drugs. The user fees in home services, as we move patients from the hospital to acute care in the home are a major burden to many and are compromising the principle of comprehensiveness under the Canada Health Act. I have only seen two arguments advanced to defend the concept of user fees: to increase revenue, and to decrease the demand through more responsible choice. User fees do a very poor job of achieving either. Before we extend the application of user fees, let us ensure we are solving the root problems.
My final comments relate to the statements on page 50 in your report, where you refer to two schools of thought about whether new financing sources are needed to make the health care system sustainable. You characterize the first as one of operating in a system with a cultural efficiency and effectiveness, and you appear to minimize this approach because there is no evidence as to the amount of money that could be saved. This may be partially accurate. However, there is ample research evidence to demon strate practices in which drugs are over-prescribed, diagnostic tests are duplicated, surgical intervention rates vary enormously across this country, and providers, physicians and nurses and others, globally providers are not fully using their skills.
The second school of thought that the health system needs more money is, in my findings, much more questionable. If the system needs more money, it means one of two things: either the workers are not being paid enough, and if this is the case, increasing funding will not increase services, or, alternatively, under-funding means that there is not enough volume of the services to meet the required need. If this is the case, it means that all current services are useful and necessary, but there is clear evidence that many current services are neither useful nor necessary.
Also, consider that the problem has been defined as a revenue problem for many years in this country - since medicare's inception. The word "crisis" has fuelled the political rhetoric and has been prominent in the vocabulary of health care providers and in the media. The usual response of governments has been to add more money. Enormous amounts have been added in just the past few years, yet dissatisfaction with the system remains high, headlines are the same year after year.
I have concluded that doing the same thing repeatedly will not produce different results. Experience shows that adding money without changing the culture and improving what and how we do things provides only temporary relief. Why? The problem is not one of revenue. It is one of value for money and expenditures.
We need to address expenditures with a new strategy that focusses on achieving health and a culture preventing what is preventable, treating what is treatable, and abandoning the pursuit of the unachievable. While medicare is not sustainable - I repeat, in my opinion medicare is not sustainable as it is currently organized - I am not advocating that the current expenditures be frozen. I am advocating that all future increases go towards buying change and beginning the journey to measure, monitor and manage the service. Then and only then will we be able to determine whether the system is under funded. We will then make the decision based on evidence rather than anecdote, opinion, and self-interested rhetoric.
In summary, change is required as to how we organize pay and define success in Canada's health services. Money alone without a commitment to quality will not solve the current challenges. The real problems must be defined and solved with real solutions. With additional funds we need to buy change. The quality problems we are experiencing are not the fault of providers. Our providers are working in a system that is ill designed to provide quality service in a complex environment. Fixing these design flaws requires a concerted effort, very strong leadership, and investment.
For a social program such as medicare to succeed, all parties must honour the implicit terms and conditions of the contract that underlies it. Health workers must help to create incentives that reward good practice, abandon obsolete practices, pursue innova tion with tempered enthusiasm for unproven technologies, and realign the division of labour. Governments must report to the public the system's performance, ensure accountability for quality of service provided, and resist promising more than can be reasonably expected. The public must demand quality and insist on value for money so that other social needs are not crowded out.
To date, all parties to varying degrees have underestimated the fragility of medicare and have focussed on their own entitlements rather than their obligations. There are no villains in the piece. It has been a collective loosening of our grip on the terms and conditions of a sustainable system. Dr. Don Berwick from the Institute for Healthcare Improvement said that to improve quality you view every defect as a treasure, and "health care is loaded with treasures."
The Chairman: You talked about abandoning the pursuit of the unachievable. Can you give me some illustrative examples of what you meant by that?
Mr. Fyke: There are many examples, but one that comes to mind is how we treat people in the terminal stages of their lives. I believe that there is such a thing as a healthy death, but I believe that we do not do a good job in the health system in giving everyone a healthy death. I think that we try to achieve the unachievable - we try to delay that ultimate day and, in doing so, we create a lot of discomfort for the individual and the family. As one physician said to me, "In the health system we seem to believe that death is optional." There are certainly many other areas in which we pursue the unachievable, but how we treat people in the last six months of their lives is what immediately comes to my mind. I could report on other examples if I had a moment to think about it.
The Chairman: I wonder if you would share with my colleagues part of the discussion you and I had when we had a very lengthy and useful meeting - just the two of us - a couple of months ago. I am referring to cost of drugs and the drug care costs. You pointed out that Saskatchewan has a universal drug plan that is premium paid - about $800 every six months or so.
Mr. Fyke: Every six months.
The Chairman: You had said, as I recall, that when you were doing your study, you found that even though those people would appear in any statistic as people who had drug coverage, nevertheless for many of the seniors the $1,600 a year, was a substantial problem?
Mr. Fyke: Yes. There are two aspects. First, I believe that the whole issue of pharmaceuticals need to be addressed. While it might vary according to province, many Canadians have drug coverage - anyone who works in large companies or govern ment have coverage and it is not a big problem. But small businesses, some of the elderly and the poor do not have drug coverage.
Two problems arose when I was reviewing this in Saskatche wan. The elderly said, "I am doing without my drugs because I cannot afford to put out the first $800 - that is a lot of money." I met with a Métis lady in northern Saskatchewan and she was on 12 medications. I did not ask her why she was on 12 medications - that is another story. She said, "I do without my food the last week of every month in order to pay for my drugs."
Our Canadian health care system needs to deal with those kinds of situations. I recognize that moving into a drug program is going to cost money. I struggled with that issue in Saskatchewan. I concluded that it would be better dealt with federally than provincially for a couple of reasons. First, the purchasing power of a federal program would be greater than that of a provincial program. Second, we need to establish and reach changes in the health delivery system where the utilization of drugs is handled a lot more than it is today. Drugs are over-prescribed.
The Chairman: Does your second comment imply that you favour the options we have in there about a national formula, for example, increasing the buying power of the government?
Mr. Fyke: Yes, I absolutely support those.
The Chairman: I guess it also follows that when we look at data that say - if it applies in British Columbia or Saskatchewan - 100 per cent of the population have drug coverage. That does not mean that 100 per cent of the population can afford to pay for drug coverage, it just means that in some sense they are included. However, it does not mean that the problem has gone away.
Mr. Fyke: Absolutely. It does not mean that individuals are not falling through the cracks. The problems I identified relate to the poor, the small businessperson who may not be able to afford a drug plan.
The Chairman: Right.
Mr. Fyke: It does not relate to people who work for large organizations or government or anyone that can afford a drug plan.
Senator Keon: Mr. Fyke, I fundamentally agree witheverything you have said had to say, which would make debate on the surface seem a little difficult. However, the problem is, like most of us, you are laying out the problems, and I guess nobody has the answer or we would not be where we are. I am going to take you through a few of the things and see if we can grope for some solutions to them.
You made the interesting statement, "Pay for what we want and do not pay for what we do not want." I have frequently made the statement, "Pay for what works and do not pay for what does not work." Many years ago, Mark Lalonde told us that we had to base our decisions on population health, to look at the health problems in an objective way and to solve them and stop spending money in areas that are not solving anything. So let us deal with that one first.
How do you think we could implement a system that would monitor population health on an ongoing basis and would have a feedback loop to deal with the problems that are solvable and stop wasting money on the problems that are not? Some people have suggested that we separate payer, provider and the monitoring system, whatever we want to call it, and we might be able to do that. Have you any thoughts on how we could design our Canadian monitoring system that would work for the whole country and the provinces and so forth?
Mr. Fyke: I could spend all day answering that question because it is very complex. But let us look at one issue and take the population of a province or let us start with a million population and then we will see how we can do that across Canada. But in that million population, there is certainly the ability to develop health indices and monitor such things as diabetes.
Diabetes is probably one of the greatest problems in this country; it leads to so many other difficulties, and yet my observation would be that we are not doing a good job managing it. I think that that is one of the quality issues where there is under-use of monitoring and dealing with diabetics. There is certainly, with a population of a million people, whether it would be in a health region around Calgary or whether it would be the province of Saskatchewan, where you could start monitoring your patients at risk for diabetes and measuring their health. I know that there are certain programs in the United States within the HMOs that monitor diabetes very carefully.
We need our providers to work as a system because it is not a system now. I am not criticizing the providers. I am just saying that we have created a system in which all the little pieces work individually but not collectively. We need to organize it and we need to give them information technology so that they can monitor, for example, diabetics. There may be other disease entities. Some would say you should not go by disease entity. That is fine, perhaps there are other ways of doing it. I prefer the disease approach because I think it is easier to monitor 100,000 diabetics or whatever in Saskatchewan and make sure that their follow-up care is required.
We have to start small. We cannot start making all these changes all at once. However, we have to start moving towards a system, developing information technology and monitoring those patients at risk. In Saskatchewan, I believe there is an amputation every other day as a result of complications from diabetes. I suspect that the statistics would be the same in Ontario.
You may ask how I know diabetes is the greatest issue? Well, I am using diabetes as an example. If there is another issue, fine, we can deal with that, but there are certainly ways that could be done. The difficulty that I dealt with in my commission, the difficulty that you are dealing with and the difficulty that the Romanow Commission will deal with is that we have had upwards of 20 commissions in the last 20 years in this country. Why have we not implemented change? Why can we not make primary health a system? Why can we not do that? I have wrestled with that question and I do not have the answer for you today. That is a question with which you will have to wrestle.
Senator Keon: An extension of what you have just said is getting at quality. For example, in diabetes, we must strive for quality service, quality control, quality health, overall health and so forth.
You also mentioned information technology. I too have spent a tremendous amount of time working with others with information technology. My own feeling today - and it may change - is that we have failed because we have started at the wrong end. We have fallen into the trap of designing the big system - either nationally or provincially - of information technology, and on every occasion this has died of inanition.
I believe it would be quite simple to start at the other end, which is with the individual patient, and design an information technology card. In other words, a health record that the patient would own and carry. This card would release the various firewalls in that pool of information related to their psychiatric health or anything else that might be used against them somewhere along the way and the repositories would not be difficult to link. The repositories would be in the community clinics, in the community hospitals, in the tertiary hospitals, the provincial repositories and ultimately the federal repositories in places like CIHI. It is quite possible to link all this stuff technologically, yet we are not doing it. How do you see the universe unfolding in this area?
Mr. Fyke: I am not an expert on the technicalities of information systems. However, that information should be brought together at some point where people can make public policies. This way when we know that for a population at risk that X, Y and Z are not being met, that information can be brought together in a way that the performance can be measured and fed back to the person caring for that patient or the client. The performance can be measured, monitored and managed. There fore, that information has to come together collectively at some point and then fed back to the providers.
I think the United States' Veterans Administration has done an incredible job in the area of quality where that information is being fed back to the team that is looking after the diabetic patient. They can look at their stats and say, "We are going to have to change the follow-up on these three patients. They are having more difficulties than they should have." Instead of waiting until they end up in the hospital in the emergency department in a state of crises.
I am confident that we can design a sophisticated monitoring system for the health system. The problem is that we have not put at priority on it. The pressure is always - and I speak as an individual who served as a CEO of a very large region - on putting another nurse in the emergency department because of the waiting lists there. You can never defend publicly spending it on computers. I think that we have done it wrong.
We are very proud of the Canadian health care system for spending roughly 5 or 6 per cent on administrative overhead compared with the American system at 20 to 25 per cent. I know one health region in this country that is spending 3 per cent on administration. Maybe that is not something we should be proud of. I am not saying we should hire more people and increase the administrative overheads. However, perhaps we need to look at the information systems we need and acknowledge that we have to measure and monitor what is going on. Perhaps we need to ask why the emergency department is filled. It may be filled because we do not have an immunization program in the community.
Senator Keon: With regard to your statement that the system is not sustainable, I believe every objective individual who worked in the system for a reasonable period of time would agree with that. Yet we get bushed by it when we come out and say it.
Following the hearings in Edmonton yesterday, an individual stopped me because he had the impression that I was advocating private health care, which I do not advocate at all. Indeed although I have a background as a physician, I have spent my whole career working for a salary and not as a fee-for-service physician. I am currently a health administrator, but I am trying to deal with this conundrum that we are living with a system designed to pay doctors and hospitals, but it is not looking after anybody else. I see the enormous burden that we are placing on patients for intravenous drugs at home that are not covered or for home care where they fall through the cracks and there is no coverage. I have raised the question of if indeed we have a 70/30 system now, where about 70 per cent is government funding and 30 per cent is private funding. Should we spread this out? Should we increase the amount of funding and pay100 per cent? How should we deal with it?
Mr. Fyke: I want to just be clear on what your question is. Are you asking whether we should spread the 30 per cent share from private resources out into more than hospitals and doctors and cover everything with a 70/30 split?
Senator Keon: Yes. It is not quite that simple, but, yes, let us address that one.
Mr. Fyke: Well, let us try and keep it simple because I have difficulty with complexities.
Senator Keon: Okay.
Mr. Fyke: We pay 70/30 and we used to pay 80/20 and the OECD countries I think is about 75/25. As to the debate over whether it is public money or private money, I do not think that is the crux of the issue. Whether it comes out of my right pocket as taxes or my left pocket as fees, it is still coming out of my bank account.
We have to look at the GDP. Is 10 per cent of the GDP appropriate for a country like Canada to spend? I know some of your witnesses have argued that 10 per cent was the magic number. I do not think anybody knows. We can ask what is wrong with us going to 14 per cent? We could.
The difficulty that provincial governments are facing - you have heard this before - is the issue of crowding out other services that probably have a greater impact than health care. The research indicates that health care impacts 15 per cent of the health of the population. The remaining 85 per cent is impacted with jobs, education, and income. Look at the state of our universities; they are being crowded. Look at state of our highways or any number of other things. We could put so much money into health care that the health of the population actually starts deteriorating.
I think that we are pushing that border right now, given that some people argue that we should not be having tax cuts. Take Saskatchewan, for instance. Saskatchewan sits right next to Alberta. It is impossible for Saskatchewan to follow the pursuit of high taxation when Alberta is going the other way.
The reality is that there is tremendous political pressure on governments to lower taxes. Given that where are they going to get the 10 per cent increases for health care when revenue is going up at 1.5 per cent? They will have to take it from education. That would be a serious problem.
With regard to your question, I have wrestled with this as well. If we want to commit 10 per cent of the GDP into health and the split is 70/30, then some people are paying a tremendous amount of user fees on the drugs, home care, et cetera. We should even that out and have user fees for physicians and hospitals so that the use of user fees does not increase from what it is today. That is an option.
I have read a lot, looked at the RAND studies and the Saskatchewan studies, user fees do not raise revenues. If you set user fees high enough to raise the revenue, it is another tax and it really hits equity. I hear people in the media saying that user fees will prevent inappropriate patient abuse. I have not yet seen a patient yet who signs his or her own prescription. I have not yet seen a patient who can make a self-referral to a cardiac surgeon. Yes, I have met physicians who say that patients put tremendous pressures on them to prescribe antibiotics. One doctor said, "If I do not do it, they will go next door." I said, "Then what we need to do is change your payment mechanism so that you are not on fee-for-service, so that you can have the freedom to say, `Sir, you have a sore throat, you do not need an antibiotic because it is a viral infection.'" I struggle with user fees and I just do not see how they work.
Sweden has user fees, but their public side is at 84 or85 per cent, I believe. However, yes, one option would be to spread user fees across the piece and then everybody is paying a little bit and drugs and home care are included. That would be an option. In light of the political environment, that might be a way to go. It is not my preferred option.
Senator Keon: I must say it is not mine either. I will desist; I am being unfair here.
Senator Morin: Mr. Fyke, I read your report with great interest. I think it was an outstanding report. Two issues apply nationally. One deals with primary care reform and the other deals with quality care. I think you have been the first one to bring out the importance of quality care and monitoring it in our system. That is very important.
You may be familiar with the work of the National Institute of Medicine in the U.S. and their report, which followed yours shortly. I was wondering if you think that any of their recommendations are applicable to this country.
Also, would you expand on your primary care reform? I think that is a very important issue. I think there is unanimous support for this. The Claire Commission in Quebec, for example, supports it. However, there are various modalities, there were differences between the various recommendations. Can you could give us your own plan as to primary care reform?
Finally, I would like to make a comment concerning public money and private money. As you said very well - and I am a strong believer in a single payer - the problem with public money is that it competes with education and highways and things like that. Private money competes with a holiday in Florida or Victoria or the purchase of a new car. As you get older, you do not object if 20 or 25 per cent of your own money goes to health care. The cost of natural health products is increasing by 15 per cent a year in this country. Nobody gets excited about it because it is all private money. If that were part of our national health plan, we would find that many would be seeking ways to cut those costs.
Having said that - and I agree fully with you - the concern with regard to a single payer is that it competes with other social priorities that are certainly as important as health.
Mr. Fyke: I will answer the first two. I am not sure if I can answer the third question because I struggle as well.
It is a matter of perception of our approach to paying taxes. When we buy a new car, we do not worry that we are making a choice between improving the health care system taxes and buying a new car. We look at the new car purchase versus a trip to Victoria.
I look at health care from a public policy perspective. How much of the GCP are we going to spend and are we getting the value for our money? Whether it is private dollars or public dollars, we need to look at value for our money. In my 40 years in the public service, I have looked at a tax dollar as a dollar that needs to be cared for as much as my own dollar. I think that we have to take that approach to public dollars. I am not sure if I can help with the third question because it relates to the attitude that we Canadians have between the private and the public sector.
In regard to the National Institute of Medicine, yes, I have read the report. Some people say that that does not apply to Canadians. I say how do we know? I suspect that, given the litigious nature of U.S. citizens, it may even apply more here, I do not know. I know that the College of Physicians and Surgeons in the Province of Saskatchewan estimate that it probably does apply in Saskatchewan and that would mean one clinical death a day. In the United States, it is 100,000 - something like the equivalent of three airplanes crashing every day.
We have to look at those numbers as not something that we set out to criticize - they call them medical errors. I call them clinical errors because errors can be brought about many ways. It can be a physician error; it can be a misinterpretation at the nursing ward of a drug order; it can be the wrong dosage of a drug being given by a nurse; it can be a pharmacist in the preparation of medication. An error can be many things.
We need to address these issues and it is not a matter of blaming someone. We have to set blame aside and look at how we can improve the system. In the automobile industry and in other industries, they took a global approach to examining how they could improve quality. That is something we need to do in health in Canada and something that to date we have not been prepared to do.
With regard to primary health, there are many models. I recommended a model where the primary health networks would be organized within a regional structure in Saskatchewan. Primary health is important in many ways, but in rural areas where only one or two physicians in a community are on call 24/7, it is extremely important. Primary health allows them to be on call maybe once every fourth night or once every fourth weekend. It makes life in the small communities a lot more attractive for them and they are more likely to stay.
I have heard physicians say that 50 per cent of their practices could be done by someone else, but they have to put in the long hours because they are on fee-for-service. One physician told me that he had seen 54 patients in his office the day before and of those, he thought that of those, five really needed his services. The balance he said - and he broke it down - could have been handled with a telephone call. Now this was anecdotal evidence presented to me, and it is something that I criticize the health system for using, so we have to keep it in perspective.
One of the other issues around sustainability of the Canadian health care system that concerns me is not just the dollars, it is the intellectual capacity: the nurses and professionals. There are many other options today for young students to go into university rather than the health system. We have to start using people to 100 per cent of their skills - I say this not just from an economic perspective, but to ensure that we have the human resources available. I believe your report referred to research in OHIP where 33 per cent of specialists had billings that could have been carried out by family physicians, and 67 per cent of family physicians' billings could have been carried out by somebody else. We need to address these issues. They raise the question: Do we have a shortage of health professionals in this country? If you were to go by the nightly news, the answer would be, yes we do. However, I am not convinced that we do.
Senator Carney: As a British Columbian, I can assure you that we actually do in British Columbia have a shortage of specialist agencies like the BC Cancer Agency and other agencies, but they can discuss that.
I want to draw on your experience about the delivery of health services in rural areas because we have not touched on that here. Pragmatically, what are the expectations? What is the reality? For instance, I live in an area that has no health personnel. We have first aid workers, a 911 service and an excellent air ambulance service throughout British Columbia, but we have no health care personnel on the ground. The difference between Saskatchewan and us is we are very mountainous, travel is difficult, and weather inhibits airplane transportation and roads. In Nelson, if you have a prostate cancer problem, you have to go to Trail through mountainous country to see the only specialist in the region. You have the choice of going to either Kelowna, through another mountain range, for surgery or, in the other direction, Calgary - through another mountain range - for radiation treatments afterwards.
This is the reality. Is that the reality in Saskatchewan? Can British Columbians who live in a rural area expect the same level of services that are in the Lower Mainland or the Victoria region or are we going to have to continue the delivery of decentralized services through these other means?
Mr. Fyke: The way acute care is delivered today through technology, the reality is you cannot duplicate that in all rural areas. I am talking about acute care being where you need high technology. However, you can have primary health. Now, it may be at various levels; I will comment on that in a moment.
Second, you can have an excellent ambulance service. But when you live in a rural area, you will never have the same service, the same level as you will have two blocks from Vancouver General Hospital. In rural Saskatchewan, I found in looking at the ambulance services, and the standard I used was the average ambulance response should be - I chose 30 minutes. In talking to the experts in the ambulance business, they said it is not as important as to how far you are from the site, what is important is that the ambulance operator that arrives, that he knows what to do with you. In other words, he can stabilize you, get a line into your vein and an IV or whatever. I went with the 30-minute response time and then I went with an average 60-minute response time to an acute care facility.
In rural areas - whether it is Saskatchewan, British Columbia or Northern Ontario - we need to have a good every day service, primary health service. That can mean an advanced clinical nurse; it may be a physician that covers the area, a larger area; it may be a physician that is there three days a week, but we need advanced clinical nurses and a good every day service.
In the areas in Saskatchewan such as Beechy and maybe 10 or 11 others, where they could not keep physicians, they set up a primary health service. Now the physician there is on call every third week instead of 24/7 with advanced clinical nurses; the people around that community love it.
In summary, we need good primary health in those areas and we need a good ambulance service in those areas. But if you are asking the question will we always have an acute hospital in those areas, absolutely not. I think we have to recognize that today, little hospitals cannot provide safe, high quality acute care today because of technology and the infrastructure required to provide that service. Those are harsh words for people in a lot of our rural areas. I recognize that because the hospital bricks and mortar become the symbol of health, in reality they are not.
Senator Carney: I appreciate your candour on that because where I live there is a basic primary health service through volunteer first-aid workers and people like that and it is much appreciated. Can you give us a suggestion of how it could be improved? People must travel hundreds of miles for their radiation treatments, for example. Is there anything that you can see in the future that might assist people who have to go for treatment under difficult conditions?
Mr. Fyke: I do not have the answer to a snowstorm in Saskatchewan or even - and there is the odd snowstorm in British Columbia but not in Victoria. I guess the hope I am offering them is a good ambulance service. The other issue comes back to the question: What is an insured service? Is transportation and insured service? Right now, it is not and that presents a handicap to people coming from northern areas to, for example, Toronto. Transportation is a major problem. The question is whether there should be some assistance given to those people.
Another concern is that the patient should be admitted to the acute care service - whether it is open heart or hip replacement or cancer treatment - based on need and not location. I have heard rural people complain that the city folks always get the first chance on the acute care. I asked the nurse in the intensive care unit of a large major hospital in Saskatchewan if there was only one ICU bed and there were two accidents on Friday night, one just outside their door and the other one in Yorkton, Saskatchewan, which patient would get that one ICU bed? I wanted to know whether the decision was based on need or on access. I did not get a direct answer, but I assumed from the answer I got that probably the access had something to do with it. That should not be the case. The rural people should have access based on need within. I mean, it is a clinical decision. It is the physician in remote Canada talking to the specialist. We could certainly be a little more sensitive to that issue.
The Chairman: I would like to finish with one question that refers to your question regarding the need to change the culture. Goodness knows that changing corporate culture, industry culture is a very difficult thing. Most of the research we have seen has been based on changing the culture of physicians - almost as if the culture problem was purely a provider problem and the patients had nothing to do with it. That is one of the reasons we put in our report a section that asked how you instil behavioural change in patients as well as physicians. An example we have been bandying around in the committee is that of my own daughter, who takes our grandchildren to a pediatrician for those routine visits that could probably just as easily be done at a well baby clinic. I asked her why she did that. Her response was that there is no incentive not to do it.
It seems to me that there is an issue here. That is the responsibility of patients to use the system in a responsible manner. We have not seen any research in that area at all. Is it right that we should even be asking that question? In other words, how do you make patients more responsible for their own health and for the way they use the system?
Mr. Fyke: The only research that I have seen may account for 1 per cent and I think that came out of the Canadian Health Research Foundation's data there. But I think that the incentives do have something to do with it. I do not think every child needs to go to the pediatrician; that they could go to the well baby clinic. But I think also we are not organized in a manner in which the physician is tied into the well baby clinic.
I would just leave one comment with you before I conclude, that I would ask you to read a book by Clayton Christensen in the Harvard Business School. He talks about why good companies fail. On this note, he says that listening to the customer is a two-edged sword. Good companies listen to the customers, he says, but only to a certain point. He differentiates between sustaining and disruptive technology. He said that there is always tremendous pressure to make what you have got now better and he uses health as an example. We had the X-ray, then we had the CAT scan, then the MRI and now we have the PET scan. He says that it is time we looked at disruptive technology. The reason you do not implement disruptive technology is your main customer; customers do not like it, but there is a point a which you cannot listen to your customers. To survive you have to implement some disruptive technology. The laptop was a disruptive technology. Primary health reform is a disruptive technology. Christensen says it is time sometimes to save the company. The good companies who survive are the ones that know when not to listen to their customers and they move into disruptive technology for the good of the long term.
I think we are at that point in health, that maybe we need to look at some disruptive technology to save the health system. I refer you to Christensen's book from the Harvard Business School.
The Chairman: I infer from you, that you mean disruptive for patients as well as providers, not just for providers?
Mr. Fyke: Disruptive for the customers, all of them.
The Chairman: For all of them?
Mr. Fyke: All of them. These are tough decisions, but it a wonderful book to read. A very enlightening book I thought.
The Chairman: Do you know the name of the book?
Mr. Fyke: Clayton Christensen is the author. He has just written about it a couple years ago.
The Chairman: Thank you very much for coming. As usual, a conversation with you is always fascinating.
Senators, our next witnesses are Dave Barrett and Marc Eliesen, the co-chairs of the Tommy Douglas Research Institute. You are among old friends, sir, as you know, and, in fact, Marc and I go back to his Manitoba days in the early 1970s, so that really dates us.
Mr. Barrett and Mr. Eliesen have circulated a brief. I wonder if you would hit the highlights of your brief because, as you know, we will want to ask you a lot of questions. Thank you very much for coming and it is nice to see you again since I first met you in the early 1970s just after you became premier.
Dave Barrett, Chair, Tommy Douglas Research Institute: I want to say at the outset how much value there is in this committee doing what you are doing. As a former politician, I think there has never been an understanding of a functioning senate. That does not mean every senator unfortunately. But you represent a functioning senate in a role that the shapers of this nation originally intended. Senator Lawson as well from British Columbia and Ms Carney and Mr. St. Germain, it is a pleasure to see you here and I look forward to the exchange and some useful results out of this experience.
As you said, Mr. Chairman, there is not much point in going through this in detail, but there are a couple of points that I want to make. One of these I struggled with at the end of the last presentation. This is the idea of well baby clinics.
When I was a young social worker in St. Louis, Missouri, and taking my masters in social work, my wife and I arrived in St. Louis with our first child and we went to a well baby clinic in an urban area, close to two university medical centres. It was one of the most shocking experiences I have ever had. If anybody thinks that the private sector is going to run a well baby clinic or the well baby clinics that are available for children in the United States are some kind of example of something different than what we have here, bluntly I say forget it. Go down there and spend a day in a well baby clinic. The smell, the filth, the lack of service is appalling. Young mothers, mostly black, wait for hours, if not a whole day, to have someone do a perfunctory examination of the child. Forty-five million children in the United States do not have primary health care coverage. That is the two-tier system. Anyone who thinks that it is cheaper to go the private route for well baby health care just does not understand or get it in terms of the primary example of the alternative that is available to anybody who wants to see what goes on in the United States.
We in this country went through a culture change, a 30-year political struggle that culminated in the province of Saskatchewan developing a universal payer system. This was not socialized medicine, not an order to attend any particular doctor. It was a universal single payer system that combined the best and the worst of both systems. It has functioned well. It is still provided at a lower GDP than in the United States. It embraces everyone in this country from coast to coast. I would say that if there is a single thing that keeps us together as a nation, it is the single payer system that we have. That is not to say we do not have problems with it; we always will. The problems seem to always focus on money, but there are other problems as well. Canadians cherish their health care system because it underscores our sense of being Canadian. I have made that point. There are serious challenges.
We started the Tommy Douglas Research Institute because our wives complained to us about our constant complaints about what was happening to public services and over a bottle of wine one night we decided we would start an institute. Fortunately, we were successful in getting the institute going and we hope to be an "unbiased" biased spokesperson on health care.
Our first publication was to reach out to experts in the field and in January of this year we presented in Toronto "Revitalizing Medicare: Common Problems Public Solutions" by four major health care experts: Dr. Morris Barer, Dr. Robert G. Evans, Dr. Michael Rachlis and Mr. Patrick Lewis, some of whom are very well known to you. The study suggests that the problems in our health care system are being influenced by those with an agenda for profit-based health care. That is an opinion we hold very strongly and - to be blunt about it - one of the spokespersons is the Fraser Institute. The study provides numerous examples where reforms and innovations can occur to make our system more efficient, less expensive and result in a higher quality of medical services.
The major finding is that Canada's public health care system provides the fairest and most efficient mechanism to meet the health challenges of Canadians in the future. It rejects alarmist calls for privatization, noting that many of the innovations already reforming the country's health care system are much easier to introduce in Canada's public system than at a fractured private for-profit system south of the border.
On that, I would just like to relate our own experience in the early 1970s with the unanimous approval of all members of the House. We initiated a province-wide ambulance system that is still functioning today and, along with Seattle's, rates as one of the best in North America.
As stated by Dr. Evans, one of the study's authors, a professor of economics and a member of the Prime Minister's National Forum on Health:
Over fifty years ago, Tommy Douglas launched our grand experiment with universal public health insurance. Back then, Canada and the United States spent about the same proportions of their national income on health care and had similar health status. Now the United States spends50 per cent more, has 42 million uninsured, and poorer health. Americans are deeply dissatisfied with their health care system, yet can see no way out. We have made a better choice.There is no question that although medicare still enjoys broad support, many Canadians have become increasingly concerned that care will not be available for them when they need it.
However, we would argue that these concerns reflect to a considerable degree the public opinion results of the alarming and catastrophic media headlines that Canadians have been bom barded with over the last few years. It is easy to kick the media and some of them are here, so do not take it personally. They represent largely both the nature of the journalistic business as well as the political bias of the owners of the large chunk of that business. They also represent those who historically have always seen health care as a business opportunity. Today, those same critics, with the same motivation, know there is a great deal of money to be made by wrecking our health care system. Let us be blunt about it, there are a lot of bucks to be made in the private health care system - big bucks, lots of money. Look at those survivors on the U.S. stock market.
While the mobility of the media to affect the perception of Canadians is real, there is an entirely different story from the data on those who use the health care system. A study undertaken in October 2000 by Price Waterhouse Coopers indicated that although nearly 60 per cent thought the system worked well, more than 40 per cent agreed that major structural changes were needed to the health care system. Price Waterhouse is not exactly a left-wing organization. Yet, 93 per cent of women, 83 per cent of men, who were patients in the past year of that same survey, describe themselves as very or somewhat satisfied with their care. Noting the differences, Price Waterhouse Coopers representatives suggested that people do not tend to go along with the media.
Seven out of eight patients in Ontario hospitals last year felt they received good to excellent health care, according to an exhaustive health care survey. Based on the responses of 30,000 overnight-stay patients in Ontario hospitals last year, 88 per cent rated their care as good or excellent. More than 90 per cent were happy with their physician care, 89 per cent expressed satisfaction with the services provided by nurses, and 93 per cent hailed the work of physiotherapists, X-ray technicians and other caregivers. According to Michael Dector, Chairman of the Canadian Institute for Health Information, which compiled a report for 95 hospitals for the Ontario government and the Ontario Hospital Association, "It may be that reading the headlines is scarier than actually being in the hospital." I have to give him credit for that line, although it's not a bad line.
The Manitoba Centre for Health Policy and Evaluation commented recently on research undertaken in both British Columbia and Manitoba on how hospital bed closures affected the health of the population, especially on people aged 65 or older. Media headlines in both provinces were full of doom and gloom, forecasting more deaths and more difficulty getting into hospitals. In both cases, the data did not bear out the predictions.
We believe, with some bias, that there is a well-orchestrated campaign to destroy Canada's public health care system. It is a campaign characterized by a language of crisis to describe the current state of the Canadian health care system, and in our view does not contribute to a thoughtful debate about the future of the country's national health care system.
The reform rhetoric on Canada's health care system over the last number of months has focussed on the exploding costs and our "inability to pay" for increasing public health expenditures.
The Tommy Douglas Research Institute maintains the cam paign on "sustainability" is profoundly misleading and bears no relationship with the numerous studies and reports undertaken for the past 30 years showing that our public system is more efficient and less costly than any for-profit alternative.
Publicly financed health care costs have never, ever over their entire history "exploded" out of control in Canada. In fact, the rate of health care expenditures decreased after the establishment of the completion of universal coverage for hospitals and medicare, thus containing costs rather than escalating them.
I would like to refer you to a Stanford University study on the comparison of costs between the Canadian single-payer system and the American system. One of the things that stood out in my memory of reading that particular Stanford study was the administrative costs. Twenty-three per cent of every dollar in private health care in the United States goes to administration; here in Canada it is 9 per cent. Think about it. Think of that tremendous difference in costs in administration.
Total health care expenditures in Canada over the last 25 years - 1975 to 2000 - adjusted for population and inflation, shows small, steady increases from 1975 to 1991, with annual decreases from 1992 to 1996, followed by a forecast average of 3.6 per cent increase in the last three years. Actual total health care expenditures are not yet available for 1999 and 2000.
Prior to the introduction of universal health care insurance, the private sector accounted for 57 per cent of the total health care expenditures. After full medicare implementation by 1975, the public sector share had increased to about 75 per cent, while the private share stayed at 25 per cent. These respective shares remained relatively constant until 1985. Then there was a levelling off of public expenditures with the public sector sharing amount reduced to 70 per cent and the private sector share30 per cent.
Again, when adjusted for inflation and population, public sector expenditures increased slowly with no out-of-control spiralling from 1975 to 1992 - "No out-of-control spiralling" will be the major headline in the newspapers tomorrow, but don't bet on it. It then decreased in real terms from 1992 to 1997. I emphasize "decreased" in real terms. During this time Canada was the only OECD country to experience a decrease in public sector health financing on a per capita basis. The forecast real increase of 3.6 per cent for the 1998-2000 period has been acknowledged as catch-up increases, which resulted from the federal government's allocating an additional $23 billion to the provinces in the year 2000.
In comparison with other OECD countries, Canada public sector health spending in 1998 accounted for 69.6 per cent of the total health care expenditures, compared with an average of 73.6 per cent for the OECD countries. Accordingly, Canada placed 21st amongst the lowest level of public health care costs for these countries.
The historical record provides no evidence, past or current, of "out-of-control" public health care expenditures. The advocates for profit health care introduced the notion that the aging baby boomers will bankrupt our universal health care system. Well, I want to tell you the baby boomers have got one on all of us: They are looking after themselves. They are reading books on their individual responsibility for their own health care maintenance. If Canadians would accept their individual responsibility for health care maintenance for their bodies as much as they do for their automobiles, we would all be one hell of a lot better off. Cars are taken in for oil and lube jobs. Cars are taken in to have the air pressure in their tires checked. Cars are taken in and shined up and polished. A little bit of cleanliness, check up on your blood pressure once in a while, drink a little less scotch for lubricant, and stop smoking and things can improve. The baby boomers are showing that. There is actually a decrease in the use of acute care beds for chronic illnesses in this country. Do not tell everybody about that, but hospital administrators know it.
We have to assume individual responsibility for our own primary health care, and that comes from education. While I lecture everybody in this room about that, that does not apply to me when I overeat. It is the restraint shown by the baby boomers that my generation has not. It is tough to look after ourselves when we are tempted with so many things. It really is. We are too well fit, frankly. Thus we see a repeat of the same tactics used against Canadians in the early 1990s - that Canada was hitting a debt wall given the extrapolation of then current public sector deficits. When the economy reversed itself and experienced substantial growth, government revenues increased, deficits disappeared, and all provinces were doing much better.
It is true, of course, that older people do, on average, need and use more health care. The rhetoric of crisis, however, which portrays the health system as facing imminent collapse, is at odds with all the available evidence in Canada and international empirical evidence as well.
For those wanting to introduce to Canada a two-tier health care system, a for-profit, private health care system, along side our current non-profit one - especially in hospitals - it is instructive to review the numerous studies and evaluations undertaken. The basic conclusion: For-profit health care delivery is significantly more expensive, with poorer quality health care, compared to public or not-for-profit health care.
I want to talk about something that is very serious, along with the serious things that we are all talking about related to health care. It is a bit of a diversion, but I would like you to listen to this because it is alarming and I was so alarmed with this I wrote a personal letter to Premier Mike Harris in Ontario about this issue because of a statement he made about bringing private health care to Ontario. The U.S. Department of Justice has estimated that of the US$1.5 billion recovered from fraud cases between 1997 and 2000, some $840 million was from the for-profit health care sector, with the remainder of that recovery coming from drug lords and organized crime. To respond to the rising private sector health care fraud, many states have had to create health care fraud units. The numbers of lawyers and investigators dedicated to health care fraud has risen 58 per cent since 1994 and the FBI have increased field agents in this area by 340 per cent. It is clear that health care services provided by the for-profit sector are more prone to fraudulent abuses than services offered by the public or not-for profit health care sector. This has led to a booming increase of litigation by people in the United States on the private sector health care givers simply as a matter of knee-jerk response.
On a personal note and I do not think it is totally inappropriate, Extendicare has pulled out of some of the American states, Senator Kirby, because of this reason. It is a fact that these things are happening.
In concluding this presentation, the institute would like to comment on your desire to seek a non-ideological debate on the question of health care. I do not think it is possible, but I will try to be non-ideological. We note, however, that some of your questions and possible recommendations by their nature and structure are ideological. You ask, "Whether it is fair to deny people who can afford to buy health services the right to buy those services." I have never refrained from saying "go south and buy your own health care if you want to." I never denied it to anybody. Anybody who wants to spend money in the American health care system; if they are not happy here, go right ahead. However, read the Harvard study that shows the comparison of satisfaction between Canadian health care providers and users and American providers and users and Canada comes out far ahead in satisfaction. I have never denied the right of a billionaire or a millionaire or anybody to head south and spend their money. No problem, you are free to do it, but that should not be an argument to deny increased access to better public health in this country.
Dr. Bob Evans at the University of British Columbia has properly classified health user fees as a "zombie" of health care policy - "a dumb idea that has been discredited again and again but just won't die." What Dr. Evans does not understand, those of us who were in politics often enunciated dumb ideas because we thought we could get votes with it. I did it myself. I had to pay the benefit or the penalty of it on occasion. User fees are a dumb idea; they do not work. Just as plain and simple, all the research shows that. Not that that stopped me from using dumb ideas again and again, and I was my own victim of my own policy on occasion.
Senators, Tommy Douglas, the father of hospitalization and medicare, saw well ahead the need for reshaping andstrengthening of our health care system. In 1961, he described his groundbreaking Saskatchewan legislation "to remove the financial barrier between those who need health care and those who provide it" as only the first step. The second step, he suggested, would be to establish a new type of delivery system in the health care field; a system that included community-based care, preventative medicine that focussed on maintaining health care and alternative mechanism for paying providers of care.
During the very brief period of time we were in office in the 1970s, we asked an eminent physician, Dr. Richard Foulks, who had had a tremendous career in the Royal Canadian Air Force and later as a hospital administrator in New Westminster, to do a study for us. That Foulks report was barely touched by us in government and that fact is one of my major, major regrets in the condensed time that we had when we were in power. It was a blueprint written in the 1970s that mirrored what Tommy Douglas dreamt and hoped about us reaching based on community care facilities. The position, with emphasis on the principles of universality and public administration, has been supported by numerous provincial reports and by the National Forum on Health which submitted its four-year report in 1998. It would be foolish, and indeed disastrous, to accept the diagnosis and "therapies" offered by medicare's enemies; enemies who know there is a great deal of money to be made by wrecking medicare.
I want to thank you, senators, for giving us the opportunity to present our biased point of view. We cherish our biased point of view. We back it up with the statistics and information that we can provide to our biased point of view and we are happy to debate this anywhere at any time with any other institute which is to present their biased point of view. Let us have a go publicly. All the evidence to us indicates that we are a very, very lucky people in this country. We are very lucky to have the kind of health care system that we have and we have an obligation to maintain it.
We would be happy to answer any questions.
The Chairman: Thank you for your usual, "unprovocative" statement and as usual, sir, extremely well expressed.
Senator LeBreton: Mr. Barrett, thank you very much for appearing today. It only makes me wish as a federal politician that we had had you in Ottawa a little longer. Unfortunately, Parliament is missing some of this right now.
I was there at the time with Diefenbaker when the Hall Royal Commission was struck, which was the forerunner to medicare in Canada and where the five principals of medicare were established: universality, accessibility, comprehensiveness, afford ability, and public administration. The system at the time, as we have heard many people say, was designed in the 1950s and 1960s for a doctor-hospital based system as you quite rightly point out. You talk about community-based care, preventative medicine and new ways to pay for care providers. If Tommy Douglas were here today, how would he have been portraying the system that was set up in Saskatchewan in light of modern day needs, the aging population, the home care requirement, now pharmaceuticals and the new technologies? What would you think he would be saying to us today if he were sitting in your spot?
Mr. Barrett: I think Mr. Eliesen worked with Tommy in the administrative realm far more than I did. My experience with Tommy was totally political. I can say from his own sense of who he was and why he came into public life and the deep religious conviction within him, his response would be fairly close, I hope, to what Mr. Eliesen and I are trying to do with the institute. I think he would want to talk about incorporating new ideas and approach innovative methods. Beyond that, I think one of the things he would single out is that "doctor-bashing" or "nurse- bashing" is a serious mistake in this country and it does take place. We have dedicated staff and they do not get enough public attention for their dedication and the service, as the statistics show. Mr. Douglas would encourage choices made by the professions in terms of delivery of service, which still seems to be a stumbling block.
There are 298 nurse practitioners now in Ontario who are not being fully utilized because of a barrier that is real or perceived between the medical profession and the nurses. He would be concerned about that, the need for the deeper dialogue and understanding of integrating services and roles professionally. He would never have lost his sense of humour.
He would say, in my opinion that this is a time for the pause to reflect perhaps later than sooner; this is the time to pick out the best from our experience. If somebody wants to use an industrial relations or business practices as an example, all businesses, public or private, have to re-evaluate what they are doing and how they do it. Excellence comes from making hard decisions.
One of the hard decisions on the cancer clinics was to go to Kelowna and Victoria. He would make those kind of decisions in terms of an urban centre being able to provide the services - but are we also assisting in the transportation? In some cases we are. This kind of constant thinking and revising and challenging would have been T.C. Douglas' approach. Even after that disastrous doctor strike in Saskatchewan, there was never any hostility held between the profession and Tommy Douglas and, of course, his successors.
One of your own colleagues, "Staff" Barootes, I believe - was an opponent of T.C. Douglas. I was on a parliamentary trip with Staff and he came up to me in his wonderfully colourful language and described to me his own reaction from the beginning of health care with Tommy and he ended up loving the guy. Tommy was able to sell, to move, to push. When I saw one of his most severe critics coming around to saying he was right, we were wrong and we all have to move forward together, it kind of bowled me over.
I do not think he would have said any simple solution. I think he would have said to do what you are doing here as a Senate committee is very important. The Romanow Health Care Commission is very important. Yes, I know that people are in a hurry, but hurry is when you make mistakes. Tommy Douglas would say take your time, think it through, this is a good time to pause, nobody's getting hurt by it and then go on from there. That is what I think his response would be.
Senator LeBreton: Mr. Eliesen, do you want to add to that?
Mr. Eliesen: The first job I had after graduate school in economics was with the Hall Commission. I was the research economist to the commission's director of research. The principal issue at that time for a group of small `c' conservative commissioners who had certain biases given their experience over the years, was that the evidence was to overwhelming in terms of a single payer public system that that is what they had to recommend. The evidence suggested it. Tommy Douglas always felt that way. However, his primary purpose - given his early personal experiences, problems with his own body, et cetera as a youth - was the question of accessibility and the inability to pay. I feel quite strongly today that he would want to ensure that the system maintained the accessibility, which is based on ability to pay to continue in the future.
Senator LeBreton: In the changing dynamics that we live with now, where there is less time spent in hospitals and more time spent recuperating at home, how would you restructure the system to make home care as part of the coverage under the health care system?
Mr. Eliesen: This is obviously is a difficult area. We do not live in a unitary state. We have a federal-provincial system and clearly, health services, although greatly influenced by the federal government through financing mechanisms over time, must remain a provincial responsibility. However, as I think your own paper points out, there are opportunities for the federal govern ment to provide certain kinds of financing, to change some of the methods for future benefit. I think that has been a problem with which a lot of people have struggled over the last number of years: The federal government - particularly during the 1990s - opted out of the health care sector and tossed the burden over to the provinces.
For the future, it is significantly important that the federal government to come to the table and provide that kind of leadership - not only in home care or primary care, but also in terms of overall drug policy.
Senator LeBreton: As well as preventive health care.
Mr. Eliesen: Yes, very much so.
Senator Carney: I have one practical problem with your report and that is that as far as I can see, the report that you have given us contains no bibliography. The quotes in it are not sourced so we do not know what the studies or the references are.
Mr. Eliesen: Senator Carney, we can easily make that available.
Senator Carney: Okay, because you draw conclusions based on material you present to us, but in the absence of source data it is hard to evaluate how you reach those conclusions.
Mr. Barrett: A valid criticism and we will provide that to the Senate.
Senator Carney: My second point is I think that you are in denial about some of the material that you have presented here. One topic is wait lists. You indicate in this report by saying that once people are in a hospital they are very satisfied with the experience. I think many Canadians would agree that once they get into hospital they are very satisfied with the experience.
The problem is that it is undeniable that we wait and increasingly wait for services. I have been associated with the Arthritis Society and I am currently associated with the Arthritis Research Centre of Canada and people wait months to get in to see a rheumatologist; they wait months to get into treatment. Then after they get diagnosed, they wait for months for surgery and that is a reality. You suggest that wait lists are overstated. You say that the publicity surrounding these dubious findings makes it clear that the Fraser institute's intentions are to affect a response, not to inform decision makers of a general debate.
I think that I would like to have you comment on my perception that you are in denial that there are wait lists and that access to medicare, access to medical services is a problem.
Second, you have made an interesting observation in your report in terms of cancer patients. You say that it is widely reported that a number of provinces currently consider their waiting times for cancer care to be unacceptable. You say that there is little information on how waiting periods affect survival rates. Nor has there been much evidence available to compare the effectiveness of longer duration therapy.
I would ask you to comment on that. Indeed, agencies with which I work have the perception that if you do not get quick access to, say, care for breast cancer - you cite the Ontario study - or care for prostate and other forms of cancer, it does affect your survival rate. I am interested in your assessment here that there is little evidence of that. Possibly it is an area that you might do some research. So these are my two issues, otherwise I agree with much of what you say in the report.
Clearly, I gather from your report, you do not do primary research - you do secondary research in the sense that you review other studies and present your interpretation of the studies.
Mr. Barrett: Yes, that is right. We do some, yes.
Senator Carney: That is why your sources are important. Are you denying that there are wait lists for those of us who are in the line up? Are you denying that access to treatment and times of treatment have nothing to do with survival rates? Those are two provocative questions.
Mr. Barrett: It would depend on the illness.
Mr. Eliesen: Senator Carney, let me deal directly first with your first question on wait lists. We can and will provide a whole list of federal and provincial studies that have evaluated this particular area in detail. They have been used and misused for public consumption as part of this "crisis" on our health care system.
The latest report, which was the western provinces' "Waiting List Project," which has just been completed, goes into quite detail on the whole measurement of waiting lists. The waiting lists that appear to get attention in Canada are things like the Fraser Institute's waiting list, which is based on a physician survey. I will provide sufficient, professional quantitative background.
Senator Carney: I understand that, but how do you deal with the fact that myself and other people in B.C. are on a waiting list? Technically you do not go into the waiting list until you reach a certain point. Are you denying this? Is it a myth that I will have to stand in line for two years?
Mr. Eliesen: No one is in denial. However, everyone has a different perspective in terms of how long they should wait, whether they are real or unreal in terms of their physician or specialist, and, furthermore, the kind of treatment that is required. I will provide to you all that detailed material which goes into that measurement problem.
The point is no one is denying that there are not wait lists. It is how those wait lists have been used and abused. In our system, anyone who needs emergency treatment gets it. No one is denying that. We are dealing with the judgment that is required, whether someone waits for two months or three months or two years.
We have to look at who is doing the measurement? What are the sources for the measurement? I will provide you with federal and provincial studies that go into the whole measurement problem which casts doubt on the scare tactics that have been used on those who come out with their waiting lists suggesting that the sky is falling and continues to fall every particular year.
Senator Carney: You do state the position that some studies of surgical wait lists in other jurisdictions have found that many people are not candidates for surgery; some may even have died. You might make the connection that they have died because they are still waiting for surgical procedures.
Mr. Eliesen: No, I think the U.K., which has had the most experience in terms of trying to measure wait lists, still has great difficulties, although they do have an independent auditor who tries to assess cases. I think what you are referring to, in the fact that people have passed away, is that in the latest audit that took place on the U.K. waiting list one-third of the people should not have been on that waiting list. Now, these are judgments that are being expressed from different points of view. But I can provide all that detailed information to you.
Senator Carney: Can you explain about your conclusion that there is little correlation between survival rates and access to treatment for cancer patients?
Mr. Eliesen: Well, you are referring specifically to the Rachlis-Barer report I think.
Senator Carney: How would I know? You do not source them.
Mr. Eliesen: Yes. I will give you the references with regard to that.
Mr. Barrett: I would just like to add something to that very valid question. No bureaucracy supersedes the medical practi tioner's decision. We have on this senate committee one of the North America's premiere cardiologists, Dr. Keon.
Senator St. Germain: The best in the world.
Mr. Barrett: Well, the best in the world, okay, but I do not evaluate beyond North America. Dr. Keon will tell you that if there is an emergency, the service will be provided. If there is a life and death situation, the service will be provided. There is no dispute about that.
Senator St. Germain: Thank you, Mr. Barrett, and both of you for coming this morning. Well, my questions, Dave, are going to be - I can remember 1972 when you were elected. You know what? You know what you did to me when you got elected? I drove my truck in the ditch and I started running and I have been running ever since. I have been running three and one-half miles ever since. I started an exercise program with ParticipAction in Port Coquitlam and so I thank you for that.
Mr. Barrett: You should have waited and you would have been covered by ICBC.
Senator St. Germain: But you know, there was a saying. Remember the saying, "Barrett cares, not the millionaires"?
Mr. Barrett: No, but that is a good slogan.
Senator St. Germain: That was one of your slogans at that time, I recall.
The Chairman: Listen, it is a lot better than "The land is strong."
Senator St. Germain: To give you a perspective on where I am, my mother is in hospital. She spent a number of days in the emergency room - her wait for a room seemed like seven days. She finally got a room and she is being well looked after. I am curious as to how anyone can say that there is no waiting lists or no problems in there.
Mr. Eliesen: I didn't say that.
Senator St. Germain: My daughter has just gone through surgery for cancer and another major surgery and just got out of the hospital in the last day or so. I am aware of what is going on in the hospital system from a personal point of view. However, I do not think we should really talk to a personal point of view as much as we should talk about just what is happening to everybody else out there.
Perhaps you can explain this to me: You say the millionaires and the billionaires can go south - you do not mind where the heck they go - and spend their money and get health care.
Mr. Barrett: Yes.
Senator St. Germain: Why then, would you not be prepared to have clinics so that a millionaire or a billionaire could not spend those dollars here in Canada and establish these places of excellence here. What is the danger? What danger do you see in establishing facilities of that nature here so that we can keep our money at home and utilize the services possibly of some of the best surgeons in the world? We have got one sitting right at this table.
Mr. Barrett: I know that.
Senator St. Germain: As far as I am concerned he is the best in the world in his field. Why would you want to deny those who have the ability to pay that possibility, sir?
Mr. Barrett: First of all, I would like to point out that people who have wealth are free to spend their money wherever they want.
Senator St. Germain: Yes.
Mr. Barrett: I would never take away that right.
Senator St. Germain: No, you said that.
Mr. Barrett: But the question I am raising here is adequate taxation. We have a mania across this country of tax cutting based on some kind of voodoo economics, as it was described under Ronald Reagan, that drives us into massive public debts and increased competition for tax dollars in public services. For example, Alberta cut massive amounts of taxes. British Columbia cut $2 billion in taxes six months ago and now is predicting huge deficits comparable to what they cut off the budget.
Now, what is going on here? We are reducing taxes at a time when Japan and other jurisdictions are using public funds and maintaining public standards and investments. Even President Bush next door is coughing up with extra money after the election. The whole idea of cutting out public funding as some kind of panacea to providing continuing service is mistaken.
We have short-changed the public sector and so I say charge taxes at an equitable rate for very healthy estates and, of course, very wealthy people. There is a price to pay for making money and that is a fair share in taxation.
Now, if you want to get into a whole taxation argument, I could give you an hour's rhetoric. However, I will come to the lists. I will come to the lists.
Senator St. Germain: I am not talking about lists. If I may, what I would like you to answer is why do you not want these private clinics here so that I can spend my money here if I have the ability to do so, as opposed to sending the money offshore? It is not a question of taxation. It is a question of having the money to be able to pay for the service and why not allow me to do it at home?
Mr. Eliesen: It is a very simple reason, which study after study after study has shown. That is, the private system - what you are describing - does not add additional supply. Nor does it add additional doctors or additional nurses. It will take away from those who are currently involved in the public sector. Thus, it is a basic economic question of allocation and accessibility and equity to the degree that you want to establish private for-profit clinics. They will take away from the public sector.
When you are dealt with the question in terms of fairness and equity and availability of the supply, to whom do you make the service available? What you are proposing, in effect, would be those who have money, who have the wealth. If it takes away from those who need it on a medical basis because they are working already in the public sector, so be it. Those are the vagaries of the so-called market system.
In Canada, so far we have said health care is different from other commodities. It is a different factor and that is why the arguments all along from all the royal commissions, whether it is the Hall Commission, or you name it, have rejected the establishment of a kind of two-tier for-profit health clinics because of the unfairness and the accessibility that is associated with it.
Senator St. Germain: There has never been a way to establish where one would not interfere with the other as far as you are concerned?
Mr. Eliesen: Well, from what we have learned either in other countries, no. You are dealing with a supply problem and you must make a choice. This is what Dave Barrett talked about earlier: the question of values. If you have a limitless supply and if you have come to a decision that you want to allocate that supply on a fairer basis, those who advocate for private clinics, because they have money, they would get that service first, to the detriment of those who have less money.
Senator St. Germain: Fortunately at 64 the only medical problem I have had is with my back - chiropractic care. I pay a user fee and that user fee has gone up and it went up during the time of the last government, you know, here in British Columbia. I pay that user fee and I get the service that I need. There is always the debate between doctors as to whether chiropractic care is this, that or the other thing. It keeps me going and it keeps a lot of people going and it keeps a lot of people productive. Inasmuch as there are those that will question the importance of it in the medical system, I think it is tremendously beneficial to all of us, and there is a user fee. I pay the user fee.
Why is it that it has not undermined the system totally if a one payer system, as you have advocated, Mr. Barrett, in your presentation is the only way to go?
Mr. Barrett: Well, first of all, there is the historical dispute between medical practitioners and chiropractors - the same problem we had with dentists and denturists. Frankly, the one between dentists and denturists we resolved by recognizing denturists. Dentists are not trained to be denturists, let us get real here. Now, there are alternative medicines practiced legally by a lot of people. But there is always a constant dispute over what the public purse will pay and there is a prolonged experience of education.
I give the denturist-dentists example, which proved eminently successful in incorporating the denturists under the public health system. The same thing is the difference of opinion between using medical skills. I gave the example of 298 nurse practitioners in Ontario, highly qualified, highly skilled, available to work. There is a grey veil between those nurse practitioners and the medical profession. I do not wish to exacerbate the difference of opinion, but it seems to me, especially in the public sector when our universities turn out these highly skilled nurse practitioners, that this grey veil should be lifted. One doctor can supervise four nurse practitioners and provide primary care in rural areas where they need the service, but these are internal disputes amongst the professions. Just like a dispute between a psychiatrist and a social worker. I do not want to get into that. I know the psychiatrists are wrong and we are right.
I am trying to tell you that these kind of disputes go on and on and on, and the public sector has a difficult job making a judgment about professional lines of authority and responsibility. That is why I went into politics. As a social worker, I would say, "How do you feel?" In politics, I would say, "I know how you feel." There is a big difference, a big difference. Now, to ask politicians to make these distinctions, it is trouble.
We hope that more maturity, more awareness, moreunderstanding, more sharing between those in the professions and overlapping that takes place, some of it is valuable. A chiropractor indeed may be valuable to you, but we have got to make that point to the doctors to understand that these are auxiliary services. That is where the fights come. Perhaps they are valid fights, I do not know. But you have got an anecdotal experience, your back is better because of it.
The other thing I want to say about lists, my wife is here with me and she waited her turn on a list for an operation. The decision of making her wait on the list for operation is need versus gap for emergencies. My wife has been out of the hospital three weeks since that operation. I have been a nurse practitioner for those three weeks and I have enjoyed the experience.
The point I am trying to make is: We had a personal experience of waiting on a list. The wait was justified, the results have been spectacular. We accept that.
But let us look at the other alternative. Part of that waiting list also has a major social purpose. If you live in the United States and you think that you do not need to wait for that particular operation under your health care plan, you can jump the queue - even under your health care plan. The highest single reason for personal bankruptcies in the United States of America are those hospital bills and those doctor bills base, not on good medical opinion, but on patient panic, which is totally explainable. However, I can say that rationally if I went] to a doctor who said, "Well, you've got a problem but you can wait to deal with it." I would leave the office with, "I've got a problem; I can't wait to deal with it."
What we rely on here is professionals who are telling us that some people can wait. If you cannot wait, you are put on ahead of the queue. Nobody is going to allow somebody to die deliberately because of a wait. It is a call made by the experts - not the politicians - and I trust the experts. We have some of the best medical practitioners the world has ever seen. We have a large percentage of doctors who go to the United States and come back to Canada. They do come back to Canada after that experience.
Senator Morin: I agree, I think we have a problem with the waiting lists in this country.
Mr. Barrett: Sure we do.
The Chairman: I should say for your benefit that Senator Morin, in addition to being a senator, was Dean of Medicine at Laval.
Senator Morin: As an example - an undeniable example - I think that the fact that our provincial governments send Canadian patients to the U.S. for cancer treatment is a national disgrace.
I have read this report carefully. It is very good and I know these people very well and they are all excellent people. However, I think they are too much in denial of the problems that are facing our system right now. When we say that there is a waiting list, it does not mean we want the American system. But I think one problem we have in this country is that we should shorten the waiting lists. That would be an objective. I do not think we should deny that.
Mr. Eliesen: Senator Morin, no one is suggesting that this is a black-and-white kind of situation. All countries have problems with regards to waiting lists. We point out, for example, in the United States 45 million people do not even have an opportunity of being on a waiting list.
Senator Morin: Can I just interrupt? I think you are obsessed with the U.S.
Mr. Eliesen: Well, it is not a matter of being obsessed.
Senator Morin: You are. No one is talking about the U.S., you are.
Mr. Eliesen: Those who advocate a kind of two-tier health system with user charges are basically going after the American model. I find it interesting that in your options paper, of all the countries that you talk about you have not one reference to the United States.
Senator Morin: Because nobody wants the American system.
Mr. Eliesen: Okay. Then let me ask you, why do you toss out for consideration then a two-tier health care system, private clinics or user charges, which study after study after study conclusively have shown do not work, are not accessible, are inequitable, et cetera?
Senator Morin: These are options and the only reason we are raising them is that every country in the OECD, with the exception of Canada, has user fees, has proven insurance, and private clinics. This is occurring in Europe, in Sweden, throughout Scandinavia, Britain, New Zealand and so on.
Mr. Eliesen: Maybe we should consider that if we were at a higher level of publicly financed health care expenditures. However, right now or the last time we looked we are at the 21st level. So in those countries to which you refer - Sweden was mentioned earlier in the top 80 per cent - health care expenditures are publicly financed and there is an additional top-off.
If we get to an 80 per cent of our current 69 per cent, maybe then we should consider to the degree that there is demand or people think that there is something to the user charge principle, either in terms of additional revenues - although if it is additional revenues, then why should people not seek it through additional taxation.
When we have had major tax cuts in this country, no one questioned whether there was a sustainability to those tax cuts. We had $100 million dollars in Ottawa; every province had major, major tax cuts. No one at that time questioned whether or not those tax cuts were sustainable and the impact that would have on health care, on education or other areas which now people, those who are decrying the possibility of some fiscal crisis in health care, no one raises those kinds of questions.
What we have tried to do in our paper is point out that the whole question of non-sustainability of the public system does not wash. Your options paper does not have it. The first paper that you have released does not have any quantifiable information to suggest that the system is in a fiscal crisis, which is the premise of most of the options that you are tossing out for consideration.
Senator Morin: I would like to point out that last year, according to CIHI, the provinces' increase in health costs for the provinces was 9 per cent. That is way over the cost of everything.
Mr. Eliesen: If we do not have population increasing, if we do not make adjustments for inflation, in real terms that 9 per cent becomes something significantly lower - maybe 3 or 4 per cent. There are revenues. Revenues do not come in on a flat basis. I have been a deputy minister of finance. I am aware of the kinds of stresses that exist in all systems, but our simple point is no one has yet to provide any detailed, quantifiable evidence to suggest that our system is in crisis on a fiscal basis, but that is the premise of a lot of the discussion that we hear today.
Senator St. Germain: If chiropractic services are increasing in this province and yet the user fees are going up and the service is excellent, why does it not work? What you are saying does not make sense. These things are part of the medical system, whether you want to accept it or not, whether you want to argue about it.
Mr. Eliesen: No, sir, with respect, they are not part of our system. Most of the revenues for financing our health system come out of general taxation. That is the nature of our system. To the degree that anyone is advocating additional revenues and the revenues they are advocating should come from personal resources, such as user charges. That is a form of taxation. The individual is being asked to finance a particular form of health treatment and some things obviously are covered under our system and others are not. Dave Barrett referred to the ongoing debate regarding what services should and should not be covered.
However, all the studies have shown user charges on existing covered services - to which I believe you referred - will have an affect of decreasing accessibility to those who are unable to pay but who need the services and those who are wealthier and have the ability to pay. The latter will get more of the service.
Senator Lawson: The last time I was with Mr. Barrett was at a roast. Dave Barrett volunteered to be the roastee for the Big Brothers organization and this was after his term of government when he had been defeated. They were all picking on Dave Barrett and one of the roasters said, "Well, why are you picking on Dave Barrett? He took this loose collection of politicians, welded them into a tight, fighting force and took them from nowhere and led them to oblivion."
Mr. Barrett: I worked hard at it.
Senator Lawson: It is nice to see you.
Mr. Barrett: Yes, but there is a legacy.
Senator Lawson: I think we have a problem here because you keep saying that nobody wants the American system. Why do we have to have a total of the American system versus the Canadian system? If there are better parts of the American system, why can we not take the better parts and integrate them here? That is the first question.
Mr. Barrett: What are the better parts of the American system?
Senator Lawson: I am just coming to that.
You talked about wealthy millionaires and billionaires that are able to go down and have this expensive coverage. Well, I have U.S. coverage. Not as a result of being in the senate on a small, fixed government income, but as a result of earning it for many years as a union representative as a part of my fringe benefits.
Mr. Barrett: That is right, yes.
Senator Lawson: I have had U.S. coverage for 30 years in the U.S. Now, I had a recent experience a number of months ago where I had a problem and it appeared I needed an angiogram. We went through the nuclear tests and it appeared to be quite urgent; then they told me I could not have it for quite a number of weeks. My doctor said, "If you have got any way of doing it," he said, "Do you not have U.S. coverage?" "Yes." He says, "My advice to you is make a different arrangement." We had a relationship with the University of Washington Hospital. I contacted them and they said, "Why do you not come on down? Come right on down and we will check you out." They checked me out and then they said, "Now, here's the situation: You need multiple bypass surgery immediately." Now, you talk about being safely put on the list and they leave you there, it is a professional decision; nobody made that decision. It was only when I got there they said, "You need surgery immediately and we have scheduled you for surgery tomorrow." I had the surgery and it went very well and that is eight weeks ago and very successful.
Now, I did not take anybody's spot on the list. I got off the list. I went at my own expense as a result of paying premiums for 20 some years. No bills came back to British Columbia or to Canada. I am not just the only one who has that kind of coverage. There are literally thousands of people in Canada who have worked for international organizations, do work for international organizations and have that coverage. How does that affect what we are trying to do here?
Mr. Barrett: It does not.
Senator Lawson: Ideologically it might affect but not really. Now, on the other question about private clinics, the one thing I notice about U.S. coverage is the speed of delivery. Now, you cannot pick up a paper in California without reading CAT scans available on a daily basis, MRIs, ultrasound and every other new treatment you can find for preventive maintenance is available almost on a daily basis if you are prepared to pay for it. Now, many people are taking it because they need it. Many people are using it because they see it as preventive maintenance for their longevity and so on. I see nothing wrong with that.
I know ideologically the previous government was opposed to private clinics, while operating private clinics. It made good economic sense to operate a private clinic. You are talking about who is it used by: the Workmens' Compensation Board, ICBC. Now, you take a worker, Dave Barrett, he has a bad back, he needs surgery, he is going to wait eight or ten months. Compensation is going to pay him a couple of thousand dollars a month for eight or ten months and they say, "Wait a minute, this doesn't make economic sense. Why do we not put him into surgery right away at a private clinic and we'll pay $5,000 for it and he's back on the job in 60 days?" You are already doing it.
They had a situation over in North Vancouver with the other clinic, which they have to finesse - you cannot have a private clinic - it would have to be a subcontract from the hospital. Now, they tell me when they were doing their cataract surgeries in the hospital and cluttering up all those surgery centres, which could have been used for more important surgeries, in one shift they were doing nine operations. When they went to a private clinic, I guess because of the limitation of some of the union rules that apply, they were able to do 20 a shift. Now, what is wrong with those systems? Why can't we have a combination of private clinics that are effective?
I have a letter from a doctor friend of mine who wrote me a couple of months ago. He wrote a company in the U.S. that has 20 or 30 clinics. He says his company is prepared to invest either in the province or in Canada, to invest in partnership with the government private clinics on a for-profit basis sharing the profit with the government. Well, we've got a 12-storey building up here that is empty, why wouldn't the provincial government make a joint venture arrangement and make a floor available for a private clinic, bring the doctors and go to work, cut down the lists?
With regard to the lists, I read some of the studies that they had there, they are there for six or eight or ten months. In analyzing the list, they found that many people had strokes, heart attacks, and other complications. So now you have the double problem. But in addition to that from a cost point of view, your costs multiply two or three times by not getting them in, having the people taken care of and getting them back to health. Why can't we have a combination? Why does it have to be either this block or that block?
Mr. Barrett: First of all, we have to put it in context. The points you make are valid as isolated points, but let us put it in context. The public sector financing of health care in this country took a serious blow up until an election came. Every dollar that was taken out of the public sector puts strain on that sector. When you go to a private sector, you are using skills that are also a drain from the sector. Are we committed to universal prepaid health care or aren't we? Now, up to now we have not shown a philosophical commitment to keep the funds and the training going.
Let's understand a couple of other things. Why in the world are we charging nurses such an astronomical amount of money to go to nursing school? If we want to keep them here, let us start paying good scholarship funding for nurses. Let us make sure, like the Canadian Armed Forces does, that they pay back the doctors the cost for them to becoming doctors. Canadian Armed Forces are doing that now. If it is good enough for the army and our armed forces, it should be good enough for the rest of us. We see the necessity for the armed forces. We see the necessity for politicians. Those of us in the House of Commons and in the Senate can have access to military hospital facilities. Yes, we can. You didn't know it; I didn't know it either.
The Chairman: Anyway.
Mr. Barrett: Anyway, okay, you know, and besides they are going to write a story about it over there.
Senator St. Germain: We've got special treatment.
Mr. Barrett: Okay, special treatment. Well, psychiatrists for my need, but anyway. The point I am trying to make is every time you move into that area you are deleting from the public sector.
Senator Lawson: I do not understand. How are you deleting it?
Mr. Eliesen: The establishment of a private clinic does not give you additional doctors or additional specialists to deal with a particular treatment. It will take away from the public sector. What you are talking about is really a private clinic system. You have got a box in terms of supply and you want to establish a private system as part of that box. The eligibility for that private box is, quite frankly, your pocketbook. If you have the ability to pay for it privately, then you would have accessibility. Those who advocate that are prepared to say "if you have got money, then you are number one on the list." However, you are taking away from the resources that are currently working in the public sector. You are not adding additional new resources.
Senator Lawson: One response to that. First off, at no time while I was paying my own costs based on what I had in the U.S. did I ever ask to be relieved to pay my share of universal care. So I am taking nothing away there. You are wrong when you say that. I am taking nothing away.
Number two, if one of these private clinics came in and there is a thousand doctors in the Greater Vancouver area and he starts a clinic in a partnership with the B.C. government and hires 50 doctors, now we have 1,050. What do you mean we do not have any more doctors?
Mr. Barrett: Where did you get the 50 doctors? You took them out of the public sector.
Senator Lawson: Well, wherever we may have had them. We may have brought them from the U.S. we may have brought them back. You were talking about bringing them back from Canada. You may have hired what was available.
Mr. Barrett: You do not train doctors overnight.
The Chairman: We do have to wind up, but I want to leave you with three questions to which I do not want answers now, but I would like you to think about them and give us your views on.
One goes back to a comment that Mr. Barrett made in his opening statement when he talked about the responsibility that the baby boomer generation was taking for themselves. I happen to agree with that and I am also in his category. My father was an Anglican minister who always said, "The only sermon I could give is do not live bad, look what it did to me." So I am in your camp on these scores. But the policy question is what can government do to essentially encourage people or offer them incentives to behave responsibly? I mean I just give you a for instance, okay.
Currently, there is a uniform flat B.C. health care premium rate. Well, for example, if there was a national one, should smokers pay more? In other words, are there things you can do in that category? The second question has to do with the structure of the system. I mean I suspect if Tommy Douglas were designing the system today he would not design it to cover only two delivery systems, hospitals and doctors. What he would do is he would design it to cover all delivery systems for low-income people. As your income rose, the amount of services you received would be less. In other words, it is a very unusual system in which federally you pay a hundred per cent of two delivery systems for everybody and in theory zero per cent for the others.
Now, I know there are some transfers that cover part of that. However, look at all the European countries with universal health care systems; they are not designed by delivery system, they are designed largely by segment of the population. So the question is how do we move from what I would call a "vertically structured? system to a horizontal one?
Finally, there is a lot of experience now in Europe that shows that even maintaining a single payer - namely the government - but having the providers be different from the payers has huge economies in the sense of setting up an element both of consumer choice and competition among the hospitals themselves. So that in essence that while it does not affect the patient - the patient's bill is still paid by the public sector - it makes a difference to the hospitals in the sense that whether or not they attract patients to their hospital is a function of their performance. It also drives the creation of very efficient clinics because they can do it more economically. As I say, all the social democracies of Europe are moving in that direction with various kinds of experiments; have you guys any thoughts on that?
It would be most helpful if you could can give us some thoughts on these three questions in the next month or so because they are three very, very difficult policy issues on which we have not had much in the way of commentary. If either or both of you want to make a closing comment, please proceed.
Mr. Barrett: I just want to say that I appreciate the opportunity of being here and I want to reiterate what I said in the opening. This is the best demonstration of what the senate is about. In my own frame of reference, I have attacked the senate frequently, but this particular use of senate committees - this or on any other subject - is essential and I am glad to see you all there. Thanks very much.
The Chairman: Thank you very much. It has been nice to see both of you again.
Senators, we have one last witness before lunch, Joan Gadsby, President of Market-Media International.
Ms Joan Gadsby, President, Market-Media International Corporation: Good morning. Thank you very much for the opportunity to be here. I assume that the material I supplied in March has been circulated to all members of the committee.
The Chairman: We have circulated them.
Ms Gadsby: Today I have also supplied another document called "Appearance/Presentation to the Canada Standing."
The Chairman: We have that in front of us.
Ms Gadsby: By way of background, I grew up in Ontario, graduate of Western; MBA Studies in Marketing; at UBC worked with four of Canada's largest companies; former elected official at the local level in North Vancouver for 13 years. My background is large corporate marketing with four of Canada's largest com panies. I am a former elected official at the local level in North Vancouver as an alderman. I am also author of a book entitled Addiction by Prescription, which is here in front of me, which was published by Key Porter a year ago. It is about the over-prescribing of drugs and my own personal experience. I also brought with me a copy of a television documentary, which I co-executive produced with Jack McGaw of W5, which was aired across Canada on CTV.
In covering this issue, I would like to draw to your attention to the serious and continuing problem of mis-prescribing, overme dication and use of benzodiazepines, which are tranquillizers and sleeping pills and antidepressants in Canada.
I was prescribed these drugs for 20 years after my son died with a brain tumour. I almost lost my life February 2, 1990 from an unintentional overdose. I have been rebuilding ever since. I have been off of the pills for 11 years. I have gone through the death of my daughter with breast cancer May 1, 1999. The point here is simply that we have hundreds of thousands of Canadians who have become accidental addicts from the over-prescribing of these drugs. People have become accidental addicts because they trusted their doctor to do no harm and took the pills. I would like to draw your attention to the fact that this was known 20 years ago. I talked to Monique Bégin, who was the health minister at the time.
A book, The Effects of Tranquillization: Benzodiazepine Use in Canada, came out at that time. It was distributed to all doctors in Canada. Patients did not know anything about it. Essentially the material I am bringing to this Committee is covered in this book - all aspects of the over prescribing of drugs.
I would like to touch on the very serious socio-economic impacts of these drugs. In my case, I have gone through$2 million in lost income and assets in regaining my health. But the socio-economic implications are not only the effects on the health care system. Let us talk about quality of life - my quality of life today is 10 times what it was.
What are the costs of these drugs? Costs have included health and safety in the workplace; career devastation, family dysfunc tion; productivity losses; and insurance claims. These drugs have been known to cause car accidents - 40 per cent of the people who are prescribed these drugs and who have tested positive, have been involved in car accidents. Falls are another problem. On the North Shore, where I live, $2 million has been spent on people who have fallen from the affects of these drugs. People lose years of their lives - as happened in my case. People lose their lives to overdoses. There are also additional costs to the legal and justice system; WCB claims, insurance claims from suicidal ideation caused by these drugs.
In respect to the health care system, we have got doctors' fees, drug costs, emergency admissions, and pharmacists' fees. We also have detox facilities, which are lacking sadly in respect to these particular drugs. You cannot put people who are in withdrawal from prescription drugs in with cocaine and heroin addicts. They cannot identify. You cannot put them in with alcoholics; the AA philosophy does not apply here.
Here are some statistics. Between 10 and 20 per cent of the Canadian population are prescribed these drugs - over half of that number, repetitively. Up to 30 per cent of seniors over the age of 60 are prescribed these drugs. The problem continues.
The Pharmaceutical Manufacturers' Association essentially markets - pardon the expression - the hell out of these drugs. That is my background in marketing. I put multimillion-dollar marketing plans together. Doctors bought in and a lot of the doctors have refused to change. There is some ignorance, with due respect, denial and some apathy on behalf of the medical community in respect to these drugs.
What are the elements? The four elements of the problem are: Unnecessary prescribing beyond short-term use - seven to ten days. This 1982 publication shows two to four weeks. In my case, I was given Valium, Librium, Dominal, Restoril, Serax and Ativan and antidepressants. I had a chemical cocktail in my body and I did not even know it. There are serious and often dangerous side effects of the drugs. I would like to refer you to the publication which is on the Web site www.benzo.org.uk.
It is important to look at the side effects of these drugs. Number one - the one that hit me the most and affected my career - is brain damage or cognitive impairment, that affects 51 per cent of the people who use these drugs. I have gone through extensive cognitive re-training at my own expense to bring myself back.
When they are on these drugs, people have impaired judgement, slurred speech, impaired learning, decreased short- and long-term memory and in the case of seniors, dementia resulting from long-term use.
The second issue of adverse effects is behavioural problems; paradoxical reactions; increased behavioural disinhibition; in duced rage; release of hostility; and, anti-social behaviour. In my case - I only use mine to illustrate - I bit a policeman's finger, I bashed a suitcase through an airport door in Kelowna coming back from a conference. I stood on my deck railing of my home and was going to fly, thought I could fly. These are the effects of these drugs.
Psychomotor effects affect spatial ability, impaired driving, and blurred vision.
There are also serious psychiatric symptoms. What is key here is that these pills create depressive symptoms, which ultimately impact on the health care system because people are then given anti-depressants. We have suicidal ideation created by these drugs. The DSM-IV - with which I am sure you are all familiar - says that you cannot diagnose psychiatric problems when people are on these drugs.
These drugs create anxiety disorders. I see that Dr. Peter McLean is speaking to this group later on today; I have talked with Peter about this issue. When the people get off these drugs, the anxiety goes. The anxiety is caused by mini-withdrawal between pills.
Addiction, what is addiction in respect to these drugs? It is not pleasure seeking. The people using them are not going out and buying these drugs on the street - mind you, a minimal number of people who get hooked do buy them on the street. People who are prescribed these drugs go through mini-withdrawal between pills, depending upon the half-life of the drugs. For example, you can take a sleeping pill at night and the next day you can go into withdrawal, which is your body saying I need another pill. Your body builds up a tolerance.
Another issue is alcoholism. People who never drank alcohol before often will drink alcohol to counter-act the mini-withdrawals between pills. There is a cross-addiction here.
I bring to your attention emotional anesthesia. The prescription drugs following my son's death did not allow me to deal with it.
Another issue that is very important here is floppy baby syndrome. The House of Commons recently dealt with the issue of fetal alcohol syndrome and labelling for alcohol products. I contacted and I have been in touch with a lot of the politicians, I said, "What about benzodiazepines and floppy baby syndrome?" Floppy baby syndrome is very similar to fetal alcohol syndrome. Mothers who are prescribed these drugs can in fact have babies who are born going through withdrawal. There could be the long-term effects very similar to fetal alcohol syndrome that these people may not be productive members of society.
The Chairman: Can I ask you to start to wind up because you have been going for ten minutes.
Ms Gadsby: There is lot of ground to cover here.
The Chairman: Well, you have been going ten minutes.
Ms Gadsby: Well, this is most unfortunate.
In any event, withdrawal systems, they are highlighted there. You have a lot of material on the facts of benzodiazepines, you have material on the research in respect to cognitive impairment.
I would like to spend a few minutes on one of the key recommendations, which are in the document entitled "Call to Action" in the package I have given you today. This is what needs to be done. There are fourteen points here: lots of studies, little action; redirection of research funding; guidelines are not being followed; doctors' lack of ongoing education; lack of legal accountability; lack of objective information provided to the consumer; incentive for pharmacists; high demand for these drugs; and, lack of alternatives.
People do not need these drugs. What we need is a healthy lifestyle. I run two and a half miles every day. My diet is impeccable. I have a great support system around me. Lack of infrastructure. Key point. Doctors' knowledge in how to help people to go through the withdrawal is minimal and there are no facilities for people to go to. There is a lot of minimization and denial by the government.
With regard to the conflicting relationship between profit and motivated drug companies and research funding, we have seen a lot of this in the press lately. What is needed here too is the integrated effort.
When I met with Senator Lucie Pépin when I was in Ottawa, this young woman, 20 years of age, died. She did not survive; I did survive.
Senator Carney: Can I just point out a technical point. The stenographers cannot transcribe if you just wave something. You have to tell them what it is.
Ms Gadsby: I am referring to an article that appeared in The Vancouver Sun, May 8, 2001 entitled "Prescription drugs blamed for death of Abbotsford woman." This is illustrative. This young woman was prescribed in a two-month period, four different benzodiazepines, antidepressants and, finally, anti-psychotics. Those drugs killed this woman.
In respect to another key recommendation, to which I would like to refer - and I feel very, very strongly about this - is the recommendation that is in the package today which deals with a resolution to the Canadian government which has been passed by the B.C. Liberal Women's Commission here in Vancouver and I would like to refer to it. The bottom line in this resolution is that the Canadian government and the Minister of Health and through you, members of the Senate committee, must hold a national public inquiry and a series of nationwide hearings into the prescribing of these drugs to assess the amount of damage.
I happen to have had the assets to use to rebuild my life. A lot of people I know in this situation live on welfare or have disabilities. We need a series of nationwide hearings. We need a multi-stakeholder strategic action plan.
The health minister Allan Rock has read my book. I have spoken with him a number of times. No funding has been coming forth. We need an awareness program and to establish account ability when the drugs are prescribed beyond established guidelines. The next stage of the resolution is simply this, the provision of financial compensation for the extensive costs of personal injury to affected Canadians caused by benzo addiction. In the U.K., where I spoke at an international conference last November, there were 17,000 litigants from the effects of these drugs.
The second part of the resolution also refers to financial support for treatment programs and the development and dissemination of patient withdrawal protocols to deal with the issue. We have looked to programs in from the U.K., run by a Dr. Heather Ashton, who is an international expert. We have tried to get funding from the health minister Allan Rock. He wrote back to one of my colleagues basically saying, "Very important, keep up the good work, we have no money. We have no financial revenue streams."
The Chairman: One last comment.
Ms Gadsby: We need to investigate financial contributions from the medical community, its organizations/regulators, and from the research-based pharmaceutical companies. I have spoken to Marie Elston about this. I have got proposals out. A lot of the material that I have presented is on the Web site but I would also, before I conclude, talk about advertising by the pharmaceutical companies. This is my background.
I refer to an advertisement that appeared in full colour on the back page of the one of the Canadian Medical Association's journals - the CMA News - in October 1995. The ad, for Prozac, infers that "You too can be happy if you are on Prozac." Look in the small print: "Seldom has one drug helped to change so many lives." What are the side effects? Anxiety, depression, nervousness. So what happens? You have got people on benzos put on antidepressants, or conversely you have people on antidepressants who get put on benzos. This is not the kind of thing, this is not ethical.
In winding up, thank you for the opportunity. I have not had a chance to go into the material about antidepressants, but the concern about antidepressants is this: We have a lot of women who are hurting their children and these women, a lot of them have not been diagnosed. They have shot, they have killed their children. They have not been diagnosed as being homicidal prior to being put on the antidepressant or being suicidal. One of my colleagues in the U.S. is bringing this to attention.
Senator Carney: I would like to thank you for your presentation and I realize how deeply you are committed to this public awareness program. I have looked at the list of trouble-making drugs that you outline and thank goodness I am not taking any of them, so that is a relief. I would like to ask you two questions. One is what are your views on drug companies financing medical research?
Ms Gadsby: That is contained in my material that I gave to you today.
I have major problems with that from the standpoint, and it is in my "Call to Action" section. My recommendation on that is for a public body to establish criteria for research. I know firsthand that there is interference.
Senator Carney: Tell us so it is on the record. Do not read it; just tell us what are your views on that issue so it is a matter of record.
Ms Gadsby: Number one, they have a vested interest in the results. We have the Dr. Olivieri situation in Toronto; we have the situation in the University of Wales and the Centre for Addiction Medicine and Medicine Health. You need to have an ethics committee. I do know where results have been swayed as a result of a pharmaceutical company's involvement.
They are not going to do research on the side effects of the drugs because a lot of them now have gone from patented to generic labels. I recommend that control of clinical trials and research funding by pharmaceutical companies who have invested interest in results needs to be publicly regulated by an independent body, including the publishing of findings in medical journals. We have seen some progress on that, Senator Carney, recently where the medical journals have said, "We are not going to publish these results." There is inference and influence even with the New England Journal of Medicine.
Senator Carney: You say you have trouble with it. What do doctors tell you? I mean there are two eminent doctors on this committee at least. What is their response? Since this is a known and identified problem, how have doctors responded to you with regard to why it is continuing?
Ms Gadsby: I have worked with some excellent doctors on this issue. Dr. Jim Wright, Head of Therapeutics at UBC, is trying to get the message out; I have got Dr. Dennis Kendel, who is the Registrar of the College of Physicians and Surgeons in Saskatchewan who is trying to do something about the problem. The issue is that there is fear of litigation - and so there should be when people's lives are devastated. There is a lack of continuing medical education among the doctors. Some of the doctors will say, "Well, you know, so-and-so is on these pills. She cannot go through the withdrawal because it is horrendous."
I went through withdrawal for two years. I am a strong woman, but I was scared that I was going to die. You need to work with a group of committed doctors. Recently the Health Transition Fund, conducted studies on doctors' prescribing habits in the 15 continual medical education colleges across the country. Attempts to change prescribing habits were unsuccessful. The response from some of the doctors was, "Well, who are you to question my prescribing habits?" This is a problem - a problem of ego, arrogance, whatever.
In B.C., the College of Family Physicians conducted a similar kind of study, also without success. One of the major drawbacks is the lack of knowledge of how to help people get off prescription drugs. Doctors are into - and pardon the expression - "turnstile" type medicine. They do not have the time to help Joe Blow or Jane Smith go through it. They do not know how to do it.
When you are going through the withdrawal, you are so frightened. When I was going through the withdrawal, I phoned the one doctor at night, his colleague was in there, he said, "Take a pill," I said, "You go to hell." That is why people go back on the pills. They cannot handle it.
Senator Keon: Ms Gadsby, I just want to acknowledge the tremendous effort you have made also and commend you on it.
My own perception of this situation is it comes under the broad category of quality care, which can run amok in prescription of drugs and the use of a lot of therapies. For some time, my feeling has been that we will not overcome this until we have an appropriate information system that can monitor patients as individuals and so forth and we cannot impose this on patients from above. However, an information system would be very helpful. For example, if you had owned your own health card when this was happening and there was an appropriate monitoring system in place, this could not have happened to you. I think perhaps it would be worth your while, as you continue your advocacy role, to think about this.
Ms Gadsby: In British Columbia we have a Pharmanet program, which shows what the prescribing is. The Pharmanet program is very important, but that is not going to deal with the issue. We have stats, we have an information system out there and we have a lack of medical supervision to help people going through withdrawal, and a lack of knowledge amongst the general population. For your own information, sir, without funding my efforts will not continue. They will have more deaths.
I have put a lot of my own money into getting this message out, but without funding I cannot continue. There is a class action lawsuit being contemplated here in Canada to drive the system to change. Lillian Bain, who is now working with Roy Romanow and his commission said, "Joan, the only way you're going to affect change is through media and class action." We have a situation here that is very similar to the Red Cross blood scandal. The problems are known by government, by doctors and by the pharmaceutical companies.
I have taken a very constructive approach to get all the stakeholders to work with me. I gave Jean Chrétien a copy of the book and I have told him of my frustrations in dealing with Allan Rock and the former minister of health David Dingwall. I presented to the standing committee on health in Ottawa in April of 1997 - more than four years ago. In the last few months, I have been personally aware of 17 deaths. The other night I had a call from a 50-year-old man going through withdrawal in tears. This is a tragedy.
That is why I felt very strongly about the opportunity to present to your committee and hope that there will be some sort of action.
Senator Carney: I do not know what the other provinces have, but I do know that in British Columbia we do have a system where if you go to order a drug or get your prescription refilled, the pharmacist has a list of all the medications you are on from all sources.
The Chairman: It exists in some other provinces, but not even in a majority of provinces.
Senator Carney: If we are talking about monitoring the health care system, I think that is a very useful contribution. It is a good start. If there is a databank that shows all of the things you are on, maybe that is a first step in making people more aware.
Ms Gadsby: Yes, but what does happen, Senator Carney, is that the provincial government, as a result of Pharmanet, has cut people off these drugs in 30 days. You cannot do that. The withdrawal process takes several months. People need to be tapered off these drugs.
The College of Physicians and Surgeons here in B.C. have been very slow at addressing this issue and they, like the Royal College of Physicians and Surgeons across the country, are responsible for the public health system.
I want to show you something else. You probably had presentation from Terry Young on his daughter's death in Ontario. Terry Young's daughter died from a different drug. In my material, I referred to your review of the coroner's inquest and the recommendations, which are similar to what you have heard me say today. This issue is not going away with just Pharmanet. It requires leadership.
I am working on a project on Responsible Prescribing and Informed Use with one of the regional health boards. One of the doctors sitting on the advisory committee is trying to scuttle because he is feeling threatened.
The Chairman: Thank you, Ms Gadsby.
The committee recessed.
Upon resuming.
The Chairman: Our first group of witnesses this afternoon are: Dr. Galt Wilson, the program director of the family practice residency program at UBC; Dr. John Cairns, Dean of Medicine, UBC; Dr. Joanna Bates, Associate Dean of Admissions; and Mr. Gerry Fahey, the executive director of the health professions council.
Mr. Gerry Fahey, Executive Director, Health Professions Council: I am accompanied by Ms Dianne Tingey who is a member of the Health Professions Council.
Dr. J. Galt Wilson, Program Director, Family Practice Residency Program, Prince George Site, University of British Columbia: Just to clarify, I am the director of the Northern B.C. site, the Prince George site, of the Family Practice Residency Program. I believe my invitation was prompted by an anxious essay I sent the committee predicting the extinction of family practice in this country.
Officially, I will be speaking on behalf of family practitioners in the field, and particularly those in the northern and rural communities. I have been sent to give you, what I would call, a "scouting" report. Over the years, in difficult to recruit areas, we have regarded ourselves as scouts for the health care system. Whenever a shortage of professionals or a collapse of the service is just over the horizon, our locations are the last places to fill up and first to lose staff. We tend to hear about these things first.
I want to thank and compliment you on behalf of general practitioners of Northern B.C. for the excellent work you have done. In fact, we are inclined to try to have you made honorary family physicians for the way in which you have used the available resources to get on with the job.
Senator Carney: We need your resources.
Dr. Wilson: In the medical field, we do the best job we can to address the problem at hand by using what is available. Without wanting to be too hysterical about this, our real anxiety is that we see primary medical care across the country melting down at a rapid rate. You refer in your reports to primary care reform as being, perhaps, the most important issue facing the system, although it is, admittedly a provincial responsibility.
On behalf of the practitioners in the field, I would predict a phase of primary care recovery rather than reform. I want, briefly, to share several quotes that have been distributed to you from the field, so you do not have to take my word for it. These quotes are a reflection of where we are with primary care at the moment.
The first is from a fellow who has worked in Northern B.C. for 25 years. Over coffee he remarked that Americans are reluctant to quit a job for fear of losing their health insurance. Some of you might have seen the movie, Jerry McGuire, where the question was put: "Do I still get my health insurance?" We have reached a point where a Canadian with a chronic illness moving to any community in this country may find that he or she cannot find a family doctor, period. In some communities there is no care at all.
We are moving from a discussion of reforming the system to one of trying to provide even basic service to people. The tragedy of all this is that never before has there been so much we could do to improve the quality and future lives of people with chronic illnesses, whether that is diabetes, ischemic heart disease, chronic lung disease, cancer, mental health disorders or substance use disorders. These people are finding themselves unable to access any care at all.
A surgical colleague from Southern B.C. told me that he now does all his cancer follow-ups because he no longer trusts GPs to do them. He thinks that the commitment is not there and that their practices are too unstable. I am a GP. Our specialist colleagues are finding that, at the foundation level, they cannot rely on the primary care sector to do the work. Another surgical colleague in my own town told me that increasingly patients referred by GPs have had no work-ups done at all and that sometimes not even a basic assessment has been done. The patients are sent with symptoms like abdominal pain and breast tenderness.
When people move south, as they could in considerable numbers, they ask me to help them find a family doctor in the city. In the past, I would give them the name of a physician that I knew, and acceptance was automatic. Recently that has not been the case. A fellow in a very nice Vancouver suburb told me that, in six months, they had lost 14 GPs to a variety of other jobs. GPs are taking jobs as locums in walk-in clinics; they are providing palliative care consultation; and so on. They are abandoning the field. When I last spoke to the founder of our UBC department of family medicine at the time of his retirement, he told me that, on the west side of Vancouver, arguably the nicest neighbourhood in the world, he was unable to find a younger doctor to take over his practice.
In a small town in Northern B.C. with 15 family physicians, all of them have converted their practice to a walk-in clinic. Nobody is delivering babies. Nobody is following patients up. One of my residents, who was working in that part of the country, told me that the five doctors in the small town down the road were delivering all the babies for the 15 doctors in the other community.
This was unheard of just two or three years ago. Even in the 1960s and 1970s, when the population of Prince George doubled and doubled again - it went from a population of 20,000 to 80,000 in a decade - we would always squeeze people in. If a doctor left or retired, you could always find somebody to take responsibility for those patients. The normal way of moving on from practice at the moment is to make an effort to find somebody, to fail, to give the patients notice, and at the end of three months, or whatever the licensing body requires, you close the doors and you turn those people loose. It is then up to them to find care.
Even at the most idealistic level in our discipline, the College of Family Physicians of Canada, an Atlantic Canadian member of the board told me that they meet, they make idealistic plans and talk about the values we hold and then, over coffee, they talk about how they are going to get out. It is very difficult.
Just to illustrate or drive the point home, we lost a colleague and we scoured all of Canada to try to replace him. We placed this ad: "The best GP job in Canada. Busy fully-equipped practice. Congenial group. Rent-free building. Established training program. Relocation expenses. Signing-on bonus. Generous northern fee premium and educational allowance." I monitored the various e-mail lists of family physicians, the Society of Rural Physicians of Canada, and almost every day I would see: "I am through with my town. They are treating me so shabbily." I would put forward our pitch. We had not one Canadian applicant in six months. We are recruiting a fellow from Aberdeen, Scotland.
Finally, our BCMA president was quoted as saying a week or two ago that there are an estimated 100,000 British Columbians who are "orphan patients." That is a new term with which I am sure you have become familiar. There are patients who have no access to family physician services. My experience indicates that the number is climbing exponentially as family physicians abandon the field.
The message I want to leave with you is that the problem here is more complex than simply a shortage of doctors. There has been a demographic change within the profession, just as there has been within the population. When I was a brand new doctor, the practitioners were fiercely independent men - it was a number of years before we had one female colleague in Northern B.C. - who were able to dedicate their entire lives to only doctoring. They worked 70 or 80 hours a week because they had a very competent life partner who did everything except the doctoring on their behalf. They were workaholics. Most of them were up to their eyeballs in debt from overspending and not paying their taxes on time. It was indentured servitude and it was very productive, though arguably not very healthy. Nowadays our group is comprised of older men and younger women. Many of the older males got their comeuppance in the 1981-1982 recession and decided to pay their bills and pay their taxes and not be in financial difficulty. In my early days, my colleagues wanted to do my on-call because they needed the money. They were going down with MURBs and things like that. We pay significant premiums for people to do extra work because the physicians are not prepared to do it. They already have a full-time job and there are enough financial and personal pressures. Workaholism has gone out of fashion.
Similarly, the men are in a pre-retirement mode and the women have young families. We hear reassuring comments from health economists and others who count heads and tell us that there are just as many people as there have always been. That may be true, but it is not a work force that has the same capacity.
Coinciding with that has been an explosion of options for family doctors to make a living. Some are working as hospitalists, doing locums, working at walk-in clinics, and some are performing all kinds of consultative roles. Some are collecting sessional payments for geriatric and palliative care. There is a whole bunch of ways to earn a living in family practice besides providing direct care to a list of patients. The doctors are streaming out to do those things.
In a number of places in your report you point out some commonly quoted shortcomings of pure fee-for-service for primary care such as: the quality of care may not be promoted; and there is not the opportunity to get other people involved in the provision of primary care. These things are true. Currently, the acute shortcoming, as I experience it, of pure fee-for-service, is that it covers only visits and not case management. There is little incentive in the current system to take on additional patients. That applies particularly to pre-retirement physicians or the physicians who must deal with the demands of young families. New patients are a challenge and a burden, and there is no incentive or even any need to take on new patients.
Practices have been closed, and practices are closing, and a growing number of Canadians cannot access even basic care.
The Chairman: Thank you.
Dr. John A. Cairns, Dean of Medicine, University of British Columbia: Mr. Chairman, I will be speaking from, primarily, the perspective of Canadian medical schools, and particularly the perspective of the Association of Colleges of Medicine of Canada of which I am president. Dr. Bates will focus on a particular area of concern in the health care system which you have identified, and that is Aboriginal health. We at the University of British Columbia, have been taking some progressive steps in the issues surrounding Aboriginal health. We will be making two quite different kinds of presentations to you.
Most of you will know that Canada's 16 medical schools are the centre of the education of physicians and numerous other health professionals for the Canadian health care system. They are also the centre in which a very large number of our medical scientists are educated and carry out their work. The major education establishments are the focus, the centre, of health research in the country. By far the greatest portion of health research in Canada is conducted under the auspices of Canada's 16 medical schools.
As well, they play a very important role in service, particularly in tertiary and quaternary settings. The Academic Health Sciences Centre, the backbone of our referral health care system in Canada, is integrally related to the medical schools. It is the place where the teaching specialists work, where the highest tech facilities are located and on which Canada's health care system is absolutely dependent. Those three areas: Education, research and service are vital as we think about Canada's medical school, and then as we look ahead to your issues of sustainability, potential federal roles in Canada's health care system, and the implied need for change and strengthening.
In your issues identification document you identify at least two of these issues as they relate to education. You have indicated an awareness of the concern about physician supply in Canada. I am not sure that the issue has been fleshed out as it needs to be. It is addressed in chapter 11.
The big problem in Canada is that we have never accepted the position of most other western nations in terms of physician self-sufficiency. We are quite distinct from Western European nations, from the United States, in terms of the fact that we have depended on other countries to educate the physicians that we need here in Canada. This was extreme in the 1960s when well over 50 per cent of the physicians needed by Canadians were found in other countries.
The situation ameliorated. Important federal roles were played in the creation of medical schools. There was the creation of the health resources fund. There were four new medical schools; enrolments increased at other schools across the country; and we had begun to move toward physician self-sufficiency. This was dramatically reversed in the 1990s with the provincial deficits, the federal deficit and debt.
The issue of physician education is one that Canada has stepped away from again. Of an annual need of 2,500 physicians, simply to sustain the current ratio of physicians to population in Canada, we are producing about 1,600 physicians. We must find the remainder in other countries. This is an inherently unstable situation and any self-respecting western nation would not tolerate this approach to its physician supply. I do not think that has been sufficiently addressed in your report to date.
The ratio of physicians to population in the country is actually falling. It reached a peak in about 1993, and it is now dropping. It is difficult to know what is the ideal ratio of physicians to population, but it cannot be right to have the lowest ratio of all western nations except the United Kingdom, and the United Kingdom is currently increasing its ratio of physicians to population. Canada is on a steep decline in this regard. I think that issue needs to be clearly before the committee as it deliberates.
The nature of the need for physicians in Canada involves some high profile concerns. The need for physicians in remote and rural areas applies to every province. Dr. Wilson has referred to that. However, it is critically important not to lose sight of what is happening in the cities, in the major referral centres, where we find extreme problems in a number of specialities in terms of meeting the needs of the population. The overall ratios of physicians to population is a major concern.
We also look to the federal government in this regard. Your issues of sustainability are key, and you have coupled those to the federal role. I would submit that the federal government showed enormous leadership in the 1960s. I would remind you of the Hall commission. There was the delineation of the problem of lack of physician self-sufficiency in the country, and they found ways to invest through capital infrastructure and through the encourage ment of the development of medical schools. That has not been seen since the 1960s and mid-1970s. I submit that the federal government needs to show leadership in this area. This is not something that can be left to the provinces. The provinces sustain the educational environments and fund them, but the federal government has to find ways to move into this field again, to show leadership, to coordinate, at the very least, and perhaps to find areas where there is a well-respected tradition of investment through capital infrastructure, through research, perhaps through areas of special interest to the federal government, including the problems of remote and rural Canada and Aboriginal health. I am advocating imagination, innovation and leadership, which must come from the federal government. This is a national problem.
You address the issue of research to some extent in chapter 9 of your report. There has been much discussion of Canada's unenviable state in comparison to other OECD countries. We have had significant federal movement in this regard. We are enormously grateful for the initiatives around CIHR, CFI, the Canada Research Chairs and other endeavours initiated by the federal government, but we are last on the list of western nations. We must remember that, although we have moved forward, we have a long way to go. I think this committee needs to have in front of it the target of an investment of roughly one per cent of health care expenditures, which would be about $1 billion a year in research. We are running at about $500 million now, but we are still last in comparison to major western nations.
I fear also as I read the report that the focus of this committee is primarily on Canada's health care system. When it deals with research, it deals primarily with health care research. As we think about our health care system, we must consider where the new knowledge will come from to provide the drugs, the devices, and the new approaches to therapy that we need to fuel this system of health care. There is a requirement for the federal government to support basic research, clinical research, and health services research. All of these are necessary in order to support the health care system, and they have major economic benefits to us as a nation.
A further component I will mention in regard to medical schools and the health care system is the Academic Health Science Centre. The major network of leading referral hospitals in this country are central to any medical school. They are the leading centres for the provision of high technology surgery, new innovations in care. As the backbone of our health care system, with their related education and research facilities, they are in serious difficulty. Again, I believe the federal government needs to take some leadership and initiatives in terms of preservation of this outstanding network of tertiary and quaternary referral centres, which is at the absolute centre of our medical schools and, in fact, of our entire health care system.
I have tried to give you a sense of what the medical schools do, the major issues that emerge, and to relate those to some of the excellent work I have already read in the reports you have put together. However, I would urge that you consider more data and the deal with certain issues in greater depth. I am particularly advocating federal leadership in this regard. We have seen that in the past, and it is timely that it emerge again. The mandate of this Senate committee and the existence of the Romanow Commission indicate an interest. This is a major step towards leadership, the delivery on the recommendations, and the sustained leadership as it becomes operational. That, I think, is absolutely critical.
Dr. Joanna Bates, Associate Dean, Admission, University of British Columbia: Mr. Chairman, I would thank you for the opportunity to address you.
My comments will focus primarily on chapter 13 of your report, Aboriginal health. I was pleased to see you identify that as a particular area of interest to this committee. If you read the papers and listen to CBC you will know that we attracted a bit of media attention at UBC for our developing policy around admissions for Aboriginal students to the Faculty of Medicine. Chapter 13 deals with, first of all, the need for access for culturally appropriate services to Aboriginal people and, secondly, the call for an increased number of health care providers from the Aboriginal population.
Over the last four years we have been attempting to address this issue within the Faculty of Medicine and in other faculties across Canada. We have been addressing the call, which was made by previous Royal Commissions, for increased numbers of Aboriginal health care providers. The work that we are doing is focused, to some extent, on the concept that, in order to be a just society in Canada, we must have Aboriginal people at all levels of society, including health care professionals. In order for Aborig inal people to receive appropriate health care service delivery, they must be part of the health care service delivery system themselves as health care providers.
Having said that, we have identified a number of significant barriers to the acceptance and the involvement of Aboriginal people and students entering into faculties, not just medicine but other health careers as well. Specifically, issues around early education are major issues in having Aboriginal people achieve the level of education required to enter professional faculties. The issue of dropout rates and lack of completion at the high school level prevents many Aboriginal students from even getting to the point where they could consider a health professional career.
The call for increased seats for Aboriginal people and their increased involvement came at a time, for the faculties of medicine and other health programs, when our overall funding and the number of seats were decreasing. It was a difficult time to put these kinds of opportunities into place. However we are now at a point where that is starting to reverse. I think there is a real opportunity for the federal government to make use of that opportunity by providing some initiatives and by providing some funding towards national programs to increase Aboriginal enrolment.
Finally, we see a need for real cultural accommodation within our organizations. Calls for increasing enrolment and involvement will not be effective unless there is cultural accommodation at the point of admission and within the educational processes as well. We are working extremely hard on this part. I will stop there.
The Chairman: What does "cultural accommodation" mean in ordinary parlance?
Dr. Bates: In working with our Aboriginal students who are interested in careers in medicine, our admission processes focus on the kinds of activities and structures that students coming from non-Aboriginal backgrounds would be involved in, and those do not accommodate the communication processes that occur with Aboriginal students who are raised on reserves. For example, we look for rapport development with eye contact, and that is not culturally appropriate.
The Chairman: It is not a code word for affirmative action.
Dr. Bates: No, no.
The Chairman: You are saying that you will use unique admission tests for certain people that are more reflective of their background.
Dr. Bates: Yes.
Senator Carney: Do you mean lower admission standards?
Dr. Bates: No, we do not mean lower admission standards at all. We are often asked that question. We have similar admission standards for all applicants, but we feel that we have not been identifying appropriately excellence and performance in certain groups, including Aboriginal students.
Ms Dianne M. Tingey, Member, Health Professions Coun cil: The Health Professions Council is a six-person advisory body appointed by the government of the province under the Health Professions Act to provide advice and recommendations to the Minister of Health Planning, regarding the regulation of health professions. When we speak about the regulation of health professions in the context of the Health Professions Act, we mean self-regulation of the health profession so that the practitioners form a college, or are already a college, and regulate the admission to practice and the issues of competency, discipline and so on of the practitioners.
The current mandate of the Health Professions Council is three tasks, two of which are essentially completed. The first, which is an ongoing task, is to consider and report to the minister on applications from professions which are not currently regulated within the province and who seek regulation under the act. I am involved in this area of the work of the Health Professions Council with two other members.
The other two tasks are the ones that I understand you want to hear more about today. One is the review of the scopes of practice of the 15 currently regulated health professions in the province. Those professions include physicians and surgeons, registered nurses, chiropractors and so on. The third of the three tasks is to review the legislation under which 10 of those 15 regulated health professions is governed. Each of those 10 professions has its own act, such as the Medical Practitioners' Act and so on.
Members of the Health Professions Council are appointed by Order in Council. None of the members of the council is a health professional. Our work is supported by three researchers. Our research director Gerry Fahey. He was very much involved in the scope-of-practice and legislative review, and he will now address you on those.
Mr. Fahey: This scope-of-practice and legislative review culminated in a 1,400-page report which was issued earlier this year. I know time is short, so I will try to summarize that lengthy report for the committee.
I should also say that, obviously, this is a provincial matter. Our project, which basically recommends the creation of a new model for regulating the scope of practices, follows on similar initiatives already in place in Ontario and in Alberta. The relevance today is that perhaps these types of new models for regulating scopes of practice, with their focus on preventing harm, will allow more flexibility in the use of health care professionals and in that sense may, perhaps, be part of the solutions that this committee is looking for.
I will touch very briefly on the history. Approximately 15 years ago, a commission was conducted in British Columbia in the area of health professions, regulation, and scope of practice. They noted that this was an area prone to jurisdictional disputes, for want of a better term, turf battles. Who can do what; who is qualified to do what; and who should not do something, is our bailiwick. The main reason identified by the commission was the system then in place for regulating scopes of practice. It was known as the "exclusive scopes-of-practice system." In that system, each profession is granted a descriptive statement of its practice, which is, generally, very broad, and within that statement they have the exclusive right to perform. For example, the practice of medicine is defined, as you can imagine, very broadly. Under that system, generally new professions coming along would, in effect, be granted exceptions or exemptions to the scope of practice of medicine. There would be a working out at a hospital level, at a college level, I should say regulatory body level, of how the tasks would break down. That is why, of course, disputes arose. That was the view of the commission. The recommendation was that we move to a new system. Ontario has got a good one, which is called the reserved-axe or controlled-axe model. The theme of this system is to increase choice amongst health care professionals within safe parameters. In more basic terms, if people are trained and educated to perform certain tasks, they should be allowed to perform them.
This meant that there was no longer exclusive scope for everything, but it did apply to certain dangerous tasks. Ontario and British Columbia developed a certain list of dangerous services.
Then we went through each profession, all 15, and determined what their scope of practice would be and what their reserved axe would be. The basic theme was to increase choice within safe parameters.
The focus was also on the fact that the old system had prevented substitution amongst professionals for tasks and services, and it impinged upon flexibility. Part of the reason for this new system was to promote interdisciplinary practice. I will not go through our process in detail, obviously, but I would refer you to our recommendations on nursing. From having reviewed some of your material, I know you will find this of interest. We believe the reserved-axe model will assist in promoting special ized practice for nursing and primary roles for nursing. Many experiments have been conducted across Canada, including several in B.C. with regard to primary care nursing. We felt that there had been enough experiments and that we should get moving on this. We recommended that the RNABC, which is the regulatory body for nursing in B.C., should get started on that. We believe our system, the system implemented by the government, will promote that. Details of this can be found in our report. You may want to contact our Web site which is www.hbc.bc.ca. I have provided some copies of our executive summaries.
At the same time we were doing the scope-of-practice review, we were asked to review the legislation. This involved reviewing eight to 10 different statues, all with different structures. One of our main themes was to review for barriers to entering a disciplinary practice. This initiative was very important because, buried amidst all this subordinate legislation, regulatory instru ments and bylaws, there are, even for one profession, many rules that create barriers for other professions. For example, there are provisions in several statutes that prevent a member of a profession from practicing with another. There are provisions preventing prescription release. There are provisions about who controls laboratory facilities. We identified these as not only barriers to access to the public, but also barriers to solutions coming from government in terms of how they want to use health care personnel. I am going to leave it at that because I know we are pressed for time.
Senator Morin: I would like to thank you very much for coming. My good friend John Cairns I have known both as a cardiologist and as a dean. We are in good company.
Dr. Wilson, you have given us a very good picture of the problem, its scope and the difficulty in finding a solution. As you know, primary care has been at the centre of all commissions that have studied health care. I am thinking of the Claire commission in Quebec and the Fyke commission. Everybody has a plan. Our report also mentions a reform of primary care. I will take the Claire model but I think the other models are quite similar. The Claire model for primary care is a primary care team with four basic elements. It is interdisciplinary. It proposes a move from fee-for-service to capitation for the MD. The team is responsible for the total health needs of a given population, a fixed population. The team has a gatekeeper. It is responsible for all referrals, and you cannot access health care outside without authorization and/or referral.
I recognize that this is not a solution to your problems related to increasing the number of seats to medical schools and so forth.
However, what is your reaction to that?
Dr. Wilson: The overarching theme is that some form of population-based compensation is essential. Collectively, as a group of family physicians, as long as we serve the whole population, we could make an argument that the machine is not broken at this point, even with 100,000 people in B.C. and others across the country. A year or so ago, in our town, we said that we would, all of us, declare publicly that we would take the next 10 families that present to us, and that we would sweep in a few thousand people on that basis. There was a crushing increase in the workload. My colleagues said that they would not do that again because there was no increased compensation and there was a lot more responsibility. All of us are as busy as we can be.
I think there has to be some reworking of the carrots and the sticks so that there is some incentive to take new patients. I think the multidisciplinary approach is key.
When I asked colleagues why they dropped out of family practice, they told me that it was wearing them out. They were doing all the sympathetic listening and all the follow-ups. They wanted to do the doctoring. In the teaching centre we have the privilege of having learners, nurse practitioners, from the local university. I have a bias, but and I think the simplest way to do this would be to allow physicians to employ other workers. Obviously I am not the benevolent dictator when it comes to that.
We hear reference to hierarchies and unwillingness. The implication is that we will not cede power and control as doctors. I think that is old news. We have trained 50 young people in our program, and there is a yearning to share the load. The rest of the team wants the doctors to provide leadership. It is not as though there are other professionals. I think doctors are sophisticated enough to see that. I think this notion is a red herring.
The one warning I have is that fragmentation is a huge risk. As we empower other professionals, my nightmare is that in my town there will be a nurse practitioner, a midwife, a nutritionist, a pharmacist and a counsellor, and we will all be wasting time by working at cross-purposes. Whatever the administrative regime may be, I believe that we should be under one roof working together.
Senator Morin: Would you be in favour of a somewhat similar model to the one I have described?
Dr. Wilson: I have one further comment about pure capitation. I would recommend that you read about managed care in the U.S. and under the NHS in Britain. Capitation will purchase the willingness to take new patients and to hire other professionals. That is important. There is a risk of underservicing if there is no visit fee. I speak on behalf of hundreds of my colleagues who favour a blended system.
Senator Morin: That is a very good point.
You have raised the issue of what we lack. You mention figures of 2,500 and 1,600, and you say that we are importing 900. These are very important numbers and I think we will include them in our report.
I have two questions for you. When you mentioned the federal role, that is, federal leadership with federal programs to help the medical schools in this very difficult time. As you know, we are faced with the problem that this is really a provincial jurisdiction. It was easier in the days when the lack involved bricks and mortar. It is not easy to find programs. As you know, there is strong federal support for research. Would supporting the indirect costs of research help in any way?
Dr. Cairns: Yes.
Senator Morin: Is that the way we should go, or should we think of another program and then interfere and have problems with the provinces?
Dr. Cairns: How the federal government can help directly is a complex issue. It is an issue for the federal government and the provincial governments to address. We are advocating that they find a way to do that and show national leadership. The federal government has always taken a time-honoured, active approach to research. The turnaround that is occurring in the Canadian research establishment came from federal leadership. It did not come from the provinces. Unlike most western nations, we do not have any indirects on research federally. Grants are given for operating costs, and universities and hospitals face enormous costs trying to deal with those grants when they come in. I think there might be innovative ways to redirect some of what they are facing in costs now if the federal government were to take on responsibility for indirect costs. It would have additional benefits but it might also indirectly lead to benefits on the education side. It might be a very wise way to address this issue.
Bricks and mortar are extremely expensive, and the federal government found a way, through the creation of a health resources fund, to do that. Why not do that again?
Senator Morin: Is there a requirement for more infrastructure, bricks and mortar, at the present time?
Dr. Cairns: Absolutely. Our medical education and research establishment is about two thirds the size of what it ought to be. We are unique amongst western nations in not taking up this responsibility. Our medical schools need to be larger, the research capacity needs to be increased, and the facilities in the major referral hospitals need to be refurbished and, to some extent, enlarged, so there would be significant capital costs involved. Were there to be federal leadership in this regard, and if the provinces were able to feel comfortable with that relationship, that would be an excellent way to put some of the much-needed resources into the system.
The Chairman: Are you saying that in the sense that it involves the federal government making capital contributions, but the ongoing education role remaining with the provinces?
Dr. Cairns: I am saying that there needs to be leadership; there needs to be coordination; and then there needs to be ways found to do that. Some of it may involve reallocations. If the federal government takes on some responsibilities that are managed by the provinces now, they could be reallocating to some of the operational costs involved in the education programs.
Senator Morin: Our views concerning research may not have been clear in our report, but I believe we support your points. The figure of $1 billion is actually written in the report. It is an objective. It is what we are aiming for. We also support basic research. Maybe the word "basic" research is not included in our report, but it should be. We strongly support those two points.
What is the actual situation for admissions in medical schools? I know that in Quebec, at Laval especially, the number of admissions for first year medical students is increasing. I hear it is increasing in UBC. What is the situation across the country?
Dr. Cairns: We are currently graduating about 1,580 students. We peaked in 1985 with 1,835. We have fallen about 18 per cent since then, and this at a time when our population has been growing. Currently it is at the lowest it has been since the early 1970s. Quebec has added over a hundred students a year to their intake, and the same applies to Ontario. The total picture across the country for enrolment is still under 1,900 per year. At UBC, the Government of British Columbia has a major platform plan to double the size of enrolment by 2010 and to get most of the way towards that goal by 2004. We will begin to move towards self-sufficiency but we should be having an entry class of 2,500 students a year. We are currently at under 1,800 and, until recently, we were under 1,600. There has been some movement in this regard, but it is just beginning.
Senator Morin: Mr. Fahey, we were talking about nursing practitioners playing a primary care role. You suggested that we should get started on that. As you know, the problem with that is that there are a large number of unemployed primary care workers, nursing care practitioners, in my own province, in Quebec and in Ontario. We have been training them but they have no place to go. Will we be faced with a similar situation in B.C.?
Mr. Fahey: The B.C. experience, perhaps, is slightly different. Obviously, I can only speak about the B.C. experience. For 10 or 15 years, we have had in place a program called First Call, so it has been tested. There are nurses working in this role as primary care practitioners. From our hearing process and from all the submissions we have received, we recognized that there was a great demand for this, particularly from rural communities. Indeed, some communities would have been in dire circumstances if they had not received this type of professional service.
Our role is not necessarily to come up with ideas, I think it is to point out that, to the extent that there are any legislative or policy barriers, we should move ahead. Generally speaking, government accepts our recommendations, and I understand that staff are working on implementing those as we speak. Certainly, we had no information or evidence of a lack of demand or of unemployed people in that area.
Senator Carney: There is so much to talk about that we need you here for the next three months, I suppose. I have three questions. The first one is for Ms Bates. Could you clarify this issue of admissions relative to Aboriginal admissions? Can you draw a parallel which would clarify the situation?
I have been serving as an adjunct professor of the UBC School of Planning for the last 10 years and when I have Aboriginal students in my class I am faced with the dilemma that they do not present information in a way that meets my highly structured model that reflects my culture. How do you accommodate that and still ensure that the reach a masters or a PhD level? Is that what you mean when you talk about admissions criteria being more flexible, but still maintaining that they are able to function in a peer group situation?
Dr. Bates: We are committed to ensuring that our evaluation processes are common. All students go through the same evaluations processes. What we have seen out of the last few years and what the experience has been elsewhere is that we are not good at anticipating which students will be effective, given the kind of indicators that we use when we look at admission. That is primarily because of the complexity of backgrounds that these students come from at the present time, and also because of the cultural differences in communication that we do not adjust to. I think it is true that we see our students operate differently. As you may know, medical education is shifting. It has shifted much more to learning in small groups and to small group communica tion. The emphasis is on communication skills, the ability to communicate, and to communicate in different ways. Our Aboriginal students are very effective once they get into medical school. However, there seem to be entry barriers across Canada.
Senator Carney: That is very helpful because I did not want to leave the impression we were looking at "standards."
Dr. Cairns, I have a question for you, and I am switching hats here because I sat on the advisory council to your school of rehab. Medicine, and Dr. Carswell told me something at one of our last meetings and that is that physiotherapists are facing a situation where they will not be certified unless they have six years of education. This is coming from the States, not from us. Currently, the school cannot graduate enough physiotherapists to meet the needs in British Columbia. There is a shortage. I do not think Clyde Smith will be a better physiotherapist if he or his students have six years behind them. Does this push for the increase in time to six years limit the accessibility of some students to physiotherapy? It will certainly reduce the number of physiothera pists and increases their wage expectations. Is this a valid concern? If so, what can we do about it in terms of sustainability? If you are going to sustain the system, can you keep pushing people from a two-year certification to a four- or a six-year certification?
The Chairman: Perhaps I can piggyback my question. For years, the nursing profession did not require their nurses to hold a degree. For generations nurses did not need a degree. The degree was optional. Now it is mandatory in most cases. So my piggyback question is: Is there an effort on the part of the professions to drive up the entrance requirements? I am thinking of the graduation requirements. Is this truly beneficial or is it an attempt to improve the stature of the profession, improve their income or whatever?
Senator Morin: That also applies to psychologists. It seems to apply to most professions.
The Chairman: You understand the drift of that issue?
Dr. Cairns: I understand it very well. It is a difficult area to step into. We call it the "credential creep." This is, as Senator Morin suggests, prevalent in many areas. There is no doubt that being at the masters or the Ph.D. level as a physiotherapist or as an occupational therapist is desirable if you are teaching, doing research, or taking on a major leadership role.
Senator Carney: If you are president of UBC you may need a Ph.D. in occupational therapy.
Dr. Cairns: Yes, but that career is quite different from what may be necessary to practice those professions. I think we need to look at differentiation. The same phenomenon is occurring in nursing. We need to look at medicine and decide where people begin to differentiate, and how much is required to do various tasks. There is not much question it takes many, many years to be a cardiac surgeon, but perhaps not all of them need to have all of the skills that would be necessary to deliver a baby. I think it behooves all of the professions to be examining just what they are doing with this credential creep.
Senator Carney: Dr. Wilson I have a last question for you, and it has to do with perception. In the last little while there was a strike or a withdrawal of services by northern doctors, and the perception that came through the media was that the emergency rooms were not jammed, nobody seemed to be having any crises, actually there was not a problem, and maybe we do not need these northern doctors. Was that perception accurate? How would you react to that perception?
Dr. Wilson: There must be a dozen crucial issues wrapped up in that statement. For example, there is some reference in your report to the national problem of people coming to emergency departments seeking primary care. I, like a lot of small town doctors, do my share of emergency shifts. Two weeks ago I saw four patients in an eight-hour shift, who required ongoing family practice care. One had ischemic heart disease, one had MS and she had just moved to town, one had symptoms suggestive of an interabdominal cancer, and the final one was a new diabetic. I feel I may have to withdraw from that service because, ethically, once I touch that person, he or she is my responsibility, they really are. The patient will thank me for the prescription and the advice, and then ask: "What am I supposed to do? I have been told I will have this condition for the rest of my life."
It is very important to get pressure off the emergency. Many people who go in there on any given day do it electively. If you encouraged the BCTV news team to go into the emergency and pan a camera around to show how awful it is, for a day or two nobody will come down. They will find other places to go. In fact, the number is growing.
However, I think the urban professionals who are attempting to provide full service, comprehensive care longitudinally are in an even more difficult position because, in a pure fee-for-service environment, the easy stuff is scooped by walk-in clinics. It costs $26.50 a visit and a dollar a minute for overhead, so they are becoming insolvent. We are lucky, we have low rents, people have to come and see us.
In answer to your question: Do we need more doctors in the North -
Senator Carney: I know we do, I am just saying that there was a perception that we did not because no patients showed up in the emergency rooms.
Dr. Wilson: We favour redeployment of the resource. We do not think that the primary care physicians are being well utilized at the moment. They are dealing with only a slice of the need. There is a great need out here. For a while we could ignore it because it was fairly invisible. People still had somewhere to go. With 100,000 in B.C. and soon to be millions in Canada, who cannot access any primary care at all, it is out of the bag now.
Senator Carney: You remind me of a lawyer who once told me that he could not afford me, that my problems are so complex he could not bill enough to cover the time he was going to spend to sort me out.
Dr. Wilson: That is exactly right.
The Chairman: That was a good analogy.
Dr. Wilson: It used to be the only way to feed your family in primary care medicine was to acquire a list of patients and look after everything about their needs, and that included referrals and so on. Now there are so many other options and the patients take the easy stuff elsewhere and then come back to their own doctor for what takes 40 minutes for a $26.50 bill. It is not sustainable. It is just tumbling down.
The Chairman: I love your phrase "credential creep." That will find a way into the report. Who decides on the credentials? I tell you why I ask.
I started out life as an academic and obviously it would be in my interest as an academic to have credential creep, because it would keep the demand up. There is no doubt that more knowledge is a useful thing, but we are trying to train people here with a pragmatic and practical orientation. Therefore, it seems to me that, if the academic community establishes the credential criteria, you will get a much broader academic base, and you will get some credentials are desirable but not necessary for people to have. The control of that process, it seems to me, has a huge impact on its outcome. Who controls it?
Dr. Cairns: The professions, for what are ostensibly the best reasons, control it. Very high standards should mean that we have the best possible practitioners in whatever field we are talking about. The universities provide the educational experience that suits students to meet the credentials of these professional bodies, but it is quite different from a Ph.D. or any degree in a non-professional faculty.
The Chairman: I am familiar with that stream. Essentially, you are saying it is the colleges themselves that determine the, say, 250 things you have to know to get through school.
Dr. Cairns: Yes, as well as the length of training and its quality. Often, those individuals are academics situated at universities but, technically, the setting of standards is done by the external professional community.
Senator Carney: It is important for me to note, in that context, that the pressure on physiotherapists was coming from the States. That is an added pressure that should be identified along with the academic pressure.
Dr. Cairns: Yes, and that is not all bad. Canadian and American medical schools are certified by a conjoined body. The Licensing Council for Medical Education in the States and a similar Canadian body work together. The 130 U.S. schools and the 16 Canadian schools are essentially all accredited against the same standard. That is desirable, but we are influenced by these sorts of credentialing issues, which generally tend to emerge in the United States.
Senator Keon: I have a question for the entire panel. I will start with you, John, and go to Dr. Wilson. The question concerns the empowerment for change. We sit and listen to people talking about the problems in the system. Everybody wants to preserve the system. We want to avoid radical change, but we want significant change so that the system itself does not dive into inanition.
John, you remember as well as I do that tremendously successful experiment back in the 1960s when the federal government threw out the huge amount of money called the Health Resources Fund. It built McMaster University, where you built your reputation, along with McGill, and it brought me back from Boston, maybe to the great chagrin of everybody around me I do not know. It resulted in all kinds of interesting things, and that was because the money was the empowerment for change. It did not upset the provinces. Arrangements were made at the federal-provincial level to disseminate the money, and the money was set aside for McMaster University to be built. That is one of the most successful endeavours we have ever known in the country. As far as academia was concerned, the money had to be spent to build McMaster University. Many tremendous people were recruited, and the rest is history. To a lesser degree the Ottawa Art Institute was built with the same money.
Why can we not collectively find a way to turn the levers of power to do this again? The need is just as great right now as it was in 1965 or 1964. We are all guilty, whether we are health professionals, patients, politicians, whatever, because we are not urging government to do this.
Let me start with you, John. If it could be done, how would you use it to get the things you want?
Dr. Cairns: That is a tough question, but it is obviously the kind of question that needs to be asked. I think it takes money; and there was a substantial amount of money in the 1960s. It takes a seeking for innovation and building a sense of excitement. The problems we are facing in the provision of health care in Canada should be seen as exciting. They are amongst the most difficult problems. Molecular biology is tough, but you can see a route through that. The problems of how to deal with the complex social and non-medical determinants of health are enormously interesting and exciting, but we have not seen them in that way. I think we have to get the money out of the federal pocket to the people who can do this. Ongoing federal programs, done through federal activities, are not exciting. They have all sorts of political elements to them and so on. There needs to be a federal allocation based on excellence. It probably cannot be an even allocation to every medical school or every health sciences faculty across the country. The tried and true route of research excellence has been based on excellence and peer review. Some elements of that sort should be brought into this.
A huge number of programmatic costs also have to be faced. The innovation aspect needs to be thought about quite carefully.
I think you are asking the right questions, but I would not presume to have the answers. Those are the sorts of questions that need to be asked and pursued. How can we bring some innovation excitement back into it? We are spending an enormous amount of money, and we all sense that we may not be getting the most efficient value for it. What can we do that is new; and how do we find the right people to try those ideas out and be accountable for the outcome so that we actually learn something?
Senator Keon: You will recall that was a one-shot deal. The critics of that one-shot deal said that it was going to be a disaster, that it would be like all of the little programs that were funded for a couple of years before the funding went down. In fact, the reverse happened. The programs that deserved to survive, survived; and those that did not deserve to survive, dried up. I wonder if another one-shot deal is not the answer.
Dr. Wilson, I commend you for resisting the use of the old, trite saying, "The solo practicing physician is an endangered species," but you said everything else apart from that.
Dr. Wilson: I have said that too.
Senator Keon: I knew you had. I was waiting for you to come out with it, but you did not. If you were given a mandate for change, with empowerment, the money to back it up, knowing that there would not be any follow-up, and that after the change you would have to live with the best parts and that you would let the worst parts go, how would you design your system to make it work?
Dr. Wilson: I would introduce a blended system of administer ing and funding primary care. Perhaps I am naïve. I would start with a pitch to the profession about a rebalancing along these lines. I believe in B.C. we are spending something like$600 million a year on direct payments to general practitioners. I would divide that into two funds: one, a visit fee, as is currently the case; and the other a case management fee. If you only provide visits, that is all you get; and if you put the patient on your list, you get the other fee. The case management fee has capitation. It carries with it some obligations like providing extended clinic hours, 24-hour telephone service, maintaining hospital privileges, participating on committees and all of the other things we thought we were required to do by right of entry into the profession. I would throw in some bonuses for employing others. The case management fee allows only care by a physician. However, I could have many more patients on my list if I were allowed to employ other professionals to help look after them. Right now it is: "No see; no fee." The only way I have of attracting financial resources to my practice is for me to see another patient. If I had access to some resources to expand the base, I would take more patients, as would my colleagues.
The average family physician in this country is about 48 years of age. The specialist group is in even more peril age-wise. The final part of my answer relates to the capital investment. One of the problems in the country is that never before have so many of us been 50-ish. We have all become our fathers and mothers overnight, and we are getting tired. In some cases, we are counting the days. We get tired. I do not view the world as I did in the 1970s, when we all dipped into our pockets to pay the leasehold improvements on our own offices and created the physical plant, and thought that over 30 years we would amortize our debts. I think there would need to be some capital money as well. From where I sit, the biggest problem in primary care is that we need an inducement for providers to take on more subscribers. Until we build it in, it will not happen.
Senator Keon: Dr. Bates, if somebody gave you authority and the money to make the changes that are necessary to improve your system, what would you do?
Dr. Bates: Are you asking about Aboriginal health in particular?
Senator Keon: Yes.
Dr. Bates: I should just clarify for the committee, I am a family physician and I have been a physician for 25 years. I just wanted to make sure you understood my background. Having worked with people and patients for change over 25 years, I think that the role for that kind of initiative is to look for long-term solutions. Rather than to look for the immediate solutions, we must move towards long-term solutions. That would mean dealing with the complexity of the issues up front, rather than putting simple solutions in place and creating incentives for moving forward at all stages. I think we must create incentives, remove barriers and actually put the action within a framework, a value system, that we hold as a nation. We must tie this into our values in some way.
Different universities and different people have different experiences. The experience in the States, where they have done this extremely effectively, and the experience in New Zealand, where they have also been very effective in addressing these issues, are very different. We need to look at what they have done that has been effective and start moving to those systems, which include preadmission processes and support for Aboriginal people into our system; rather than just focus on having someone in training as a physician. That is the immediate solution, but you have to deal with the long-term issues.
Mr. Fahey: I feel like my area of expertise is not on this point, so I have to defer to my 50-ish colleagues on that issue.
Senator Keon: You raised an extremely important topic. It is one of the areas that holds a solution to our woes. That is, we are not delegating down authority and ability to perform tasks that could be done for a much lesser cost than we are doing them. It is the reverse of what John was talking about. Everybody wants to be president of the university.
Mr. Fahey: Our sense was that some delegation was occurring. However, at least from our perspective, there are some rigidities which are preventing it from happening more often. It certainly can happen more frequently.
The Chairman: The point that Dr. Wilson was making is that you would be glad to do it if there were the incentives and an appropriate compensation arrangement for a group practice, not just physicians, but a group of professionals.
Dr. Wilson: Those arrangements are funded in very rare circumstances in this province. We have had the privilege of having UNBC nursing professors who have to maintain their skills come and do the work for nothing. It is a wonderful foretaste of how it could be.
The Chairman: What is the stumbling block? Is the stumbling block the funding?
Dr. Wilson: When I first entered practice I went to the BCMA's half-day seminar for new physicians where I was told that there are three Ps: the patient, the provider and the payer. As long as the triad is satisfied, the system chugs along. There is little impetus for change. The providers have been the proverbial amphibian on the hot plate. The temperature goes up gradually and they do not notice. They are being pushed into insolvency, but they will defend to the death the system that is killing them.
If you look at the variance within the GP profession, that is, how many subscribers are being served and how much income is being generated, you will see that it is very wide. Some individuals are generating a doctor's income with 1,400 people, and others are seeing 3,000. It is the devil we know. As an international example, a colleague from Norway told me that their capitation was unilaterally mandated. As I say, I think pure capitation has problems. They had similar problems to us. The doctors were disappearing into the woodwork, doing a little of this and a little of that and still paying the bills, but the population was not being served. He told me that they set 1,500 citizens as a full time equivalent.
The Chairman: "They" being the government?
Dr. Wilson: "They" are the government or the medical association. I do not know how much brute force was involved or whether the people affected were willing. He said that, in serving a population similar to B.C., 4 million, 600 FTE family physicians appeared out of the woodwork. I know for a fact that if you count the numbers and divide them, because we do not train as many, we do not have anything like that kind of slack in our system. We do have a lot of providers. For example, 77 people in my community could be described as general practitioners. My familiarity with how medicine is practiced tells me that we are about 44 FTEs out of 70-odd individuals. While we wait for the new people to become qualified and for new systems to delegate the work to others, I think we could be getting more productivity out of our workforce.
The Chairman: Do you mean by changing the system?
Dr. Wilson: Yes. It is not the answer to saving all the cash, I hasten to add, because I do not think there is that much slack. The other jobs people are doing are important jobs. We do need a palliative care consultant, we do need a geriatric leader, and we do need WCB physicians. We need to "rejig" things. What we have now is not working.
Senator Roche: Dr. Cairns, there are 1,580 medical graduates per year. The entry class has 1,900 students. I assume that all the places in entry classes are filled. That is the capacity, right?
Dr. Cairns: Yes.
Senator Roche: How many applications are there for the 1,900 spots?
Dr. Cairns: The 1,900 versus 1,580 is an unstable state and reflects the fact that it is very new for there to be any increase. In about four years the number of graduates will again equal the number of entrants. There is virtually no loss during medical school. Whatever number you bring in is almost the number you graduate. On average, the loss is about one per cent, and it is usually the result of problems other than academic inability.
Senator Roche: What is the number of applications for the 1,900 spots?
Dr. Cairns: It is about six to one across the country. It is very high. Ours are particularly high in British Columbia where we have half as many first-year positions per capita as any other province in the country.
Senator Roche: Are you taking the top academic achievers?
Dr. Cairns: We take who we think are the very best qualified students who have already met high academic standards in terms of their marks and their performance on the medical college admission test. Beyond that hurdle, we then put about half our emphasis on the marks and the other half on a number of features that we think are other key ingredients of successful practitioners.
Senator Roche: The problem, clearly, is not that not enough young people want to be doctors.
Dr. Cairns: You are right.
Senator Roche: Let us leave aside for the moment the problems they face once they become doctors.
The Chairman: Like politicians, they do not know what they are getting into.
Senator Roche: We are graduating 1,580 doctors. Six times as many young people want to be doctors and they cannot get into medical schools. We need 2,500 doctors per year to meet the growing demands. Clearly we have a problem. Mr. Chairman, we should get those figures across to the public and to the government.
Why are there insufficient entry-level places in the schools? Is it the fault the major-domos of the medical schools? I am in great company here with former deans of medical schools. Are they making the decision? Is it the fault of the provincial governments that are running it? Are they not providing sufficient funding? Is it because the federal government is not putting enough core money into the development of the profession?
Dr. Cairns: It certainly is not the medical schools.
Senator Roche: Do the medical deans or the presidents want more?
Dr. Cairns: Yes. They feel they have a national mission. I am not sure we need more in order for our own interests in any sense, but there is a social obligation to produce sufficient positions for Canada's needs.
Senator Roche: The problem does not lie with the schools.
Dr. Cairns: No. Occasionally, the problem has been at a professional level. These things swing back and forth. In the past there has been the perception that there are too many doctors. We have not been anywhere near that for a good many years. Almost nobody practicing in the country these days would say that, although that has not always been the case.
Senator Roche: Does the fault lie with government?
Dr. Cairns: The fault is that of the people of the country.
Senator Roche: That is pretty amorphous. I am people and I do not really get it.
Dr. Cairns: Whose fault is it? Perhaps the case has not been made adequately, but to me the case is very evident. We think of ourselves as a leading western nation. We think that other nations should educate close to half the doctors we need in this country. It is an untenable stance.
Senator Roche: I will touch on the 900 figure in a minute. Whose fault is it? Is it the fault of the provincial governments or the federal government? Is that the core problem that this committee has to address?
Dr. Cairns: In the first analysis you could say it is provincial in that they fund the universities that produce these students. This is a national problem. We are looking at a problem of providing health professionals, in this case physicians, across the country, to operate our health care systems. We need mobility, and we have that in terms of training people across the country. They get the best experiences, and then they go on to the best circumstances in terms of practice and choose where they want to live. We are facing a problem across the entire country. We need federal leadership in addressing this. This is a problem of government. "Government" is the people. It is a shared responsibility between federal and provincial governments. Some of the complexities, such as who funds what, the constitutional issues, and issues of habit, need to be looked into.
Senator Roche: Thank you for saying that.
Mr. Chairman, I do not want to get into a constitutional discussion here. It will exhaust us for the rest of the day. However, I think the committee should make a note of this.
Turning to the figure of 900 that makes up the deficit. Where do most of those 900 come from?
Dr. Cairns: The deficit is 900. We do not find 900 any longer. We are dropping the ratio of physicians to the population in Canada. Ours is the only western nation where that ratio is falling. In every other nation it is either stable or, as in the case of the U.K., it is rising. We would need to find 900 to keep the ratio constant. We find somewhere around 400 or 500, so we have a shortfall of about 500 a year.
Senator Roche: Where are they mainly coming from?
Dr. Cairns: They used to come from the U.K., but comparative practice opportunities between the U.K. and Canada are not in favour of Canada any longer. We have people going back to the U.K. We have great difficulty recruiting people from the U.K. at the present time. We look to South Africa. The morality of that is highly questionable: A relatively poor nation, putting tremendous resources into medical education. We are a rich nation and we are expecting South Africa to educate our physicians. We also find them in some parts of Europe.
Senator Roche: Is it right for us, as Canadians, to be depending on developing countries to be training our future doctors when they so desperately need their own?
Dr. Cairns: It is an absolutely immoral stance. It is not only immoral, it has created enormous vulnerability for Canada. Even if we did not consider the morality of it, we have to consider the vulnerable situation in which that places our country. We are completely at the mercy of funding circumstances and medical education initiatives in other countries to supply our needs, and that is an irresponsible national stance.
Senator Roche: I would turn now to the situation respecting our current doctors. Dr. Wilson, would you elaborate on your paper as it relates to the 14 family doctors? You talk about the 14 family doctors in your town who closed their doors, cutting thousands of patients adrift. You used the term, "orphan patients," which is also a phrase we ought to include in our report. You described the pressure of the work, but we all have pressure in our work. Did any or many go to the United States?
Dr. Wilson: Just to clarify, a number left our town. This was an example of a Vancouver suburb, a place where, when I graduated, I could not have gotten into even if I wanted to. Even in the most desirable parts of the country there is a fleeing. It has to do with personal issues. There is a pre-retirement group, who have the 24/7 concern. The most onerous part of my job is the way we carry problems on and on and on. When I see one of my patients I am thinking of the last 20 years, and the next three, and all the crises that may come up. It is my job to carry that ball and resolve the problems. I agree with you, we are well paid, I think it is good job, I am not complaining. If you feel that the burden is unbearable someone will always offer you a job. Fraser Valley Health Region is constantly in touch with us.
Senator Roche: Were these 14 offered jobs elsewhere?
Dr. Wilson: They took jobs in other places in the system, that is, doing informal work, locums, covering for other doctors. That is another story because there is no coverage if you want to take a break. They work in walk-in clinics, hospitals, with increasing numbers of people for whom they cannot do discharge planning because there is nobody in the community to do general medicine. They are having to hire family doctors to work as hospitalists. What happens to those patients of those doctors? They get orphaned.
Senator Roche: In your reply you have not yet mentioned the United States as a drain.
Dr. Wilson: There is some of that, but most of us like our community and we do not go to other jurisdictions. What I am saying is that there are lots of other options. For example, for my first 12 years my partner was an excellent guy who taught me to be a doctor. He went to work for the WCB full time. He is now the vice-president of medicine for the WCB in B.C. He is poaching our best doctors. He pays them a premium of about 30 per cent over what I get. They have no after-hours responsibility, and no need to tussle with the demands put on us.
Senator Roche: I do not see this as a problem for us to worry about. I consider this the internal dynamics of medicine. You people should sort that out yourselves.
My question is: Is it true or is it not true that Canada is losing doctors to the United States?
Dr. Wilson: It is true. Let me just tell you why it is a problem for us. Every country looking at this is having to sit down and decide what medical services they want to purchase on behalf of their population. The message I am trying to leave with the committee is that, I think, as a core, front line primary care is crucial, particularly in light of our ageing population and the growth of and our ability to mitigate chronic disease. Primary care for people with diabetes, cancer, ischemic heart disease and arthritis is crucial, and in our current laissez faire approach to it, those people are not being served.
Senator Roche: Dr. Cairns does the profession keep any sort of statistics which quantify whether Canadian doctors are, in fact, being siphoned off to the United States?
Dr. Cairns: Yes.
Senator Roche: I wanted to couple that with a second question. Like many other members of our committee, I bring a certain amount of personal experience to the question I ask. I lost my doctor to the United States. I live in Alberta. I asked him why he was going to the United States. He is an experienced doctor. He told me that he was fed up with government regulations and that he could not practice medicine the way he wanted to practice medicine. Is that a common theme across Canada or is it particular to Alberta? Are doctors going to the United States for economic reasons such as lower taxation? Is there a common denominator?
Dr. Cairns: The number is around 400 a year, which is equivalent to 25 per cent of our graduating class. It is substantial. It varies slightly from one year to the next. There are multiple reasons for this. Some of what you mention applies. They all go for a reason, but I do not think it is any single reason. This is an issue in every province.
Senator LeBreton: I have a quick supplementary question on the subject of orphan patients. I would specifically refer to the healthy elderly who need a family doctor but who are not necessarily chronically ill. What kind of a strain - and there are many of them - does that put on the health care system; and where do those people go?
Dr. Wilson: We are working through several phases of this. In the early days, people get episodic care at emergency departments and walk-in clinics. As their chronic conditions, which have the potential to be incapacitating down the road, are neglected because there is no ongoing care, it will cost us. It is inhumane to neglect those people.
Senator LeBreton: To say nothing of the psychological effect on them.
Dr. Wilson: That is right. Canadians are reluctant to move within the country because if they lose their doctor they will not find another one.
Senator Lawson: I am concerned about the extension of family doctors. I might just tell you a short story. A friend of mine who is a little overweight went to his family doctor. He said to the doctor, "I have an earache. Will you check me please?" The doctor said, "Yes, of course. Just take off all your clothes and stand in front of the window." My friend responded to that by saying, "You don't understand, doctor, I just have an earache." The doctor then adamantly said, "No, you don't understand. I hate my neighbours." Is the change in dynamics in the medical profession to do with the loss of patient loyalty as opposed to price cutting and so on? Is that part of it?
I have another reason for asking about this. Just a few weeks ago I talked to a friend of mine, who will be nameless, who was involved in trying to find a solution to the dispute that the doctors had with the government or the government had with the doctors. I asked him if he thought he could reach a settlement. In responding, he reminded me of the old blackball ferry strike in British Columbia when they did not have bargaining rights. He asked me, "Do you remember Premier Bennett asking for your advice?" I said, "Yes, but you started to talk about a strike." He said, "There is no strike. There cannot be a strike." I said, "All right. Let me rephrase that. What about this "mutiny" you have on your hands?" He said, "I accept that. We are in the midst of a medical mutiny here in British Columbia." I responded that I thought those were pretty serious words.
I get a feeling there is a breakdown in communication between the doctors and the government, that there is a feeling amongst the doctors that, if they are being listened to, they are not being heard; and that the government does not think that they have any role to play in any redesign of primary care. I am referring to the suggestions you have made here to make it more efficient, to generate more revenue or so on. In some cases there is a feeling that they just do not care and that is why we have what seem to be outbreaks of hostility all across the province from time to time. Is that something you can comment on?
Dr. Wilson: There is blame enough to go all around. As to some of the concerns about hierarchy and being hardnosed and so on, the B.C. Medical Association, in the document released just this past summer, came up with 48 recommendations regarding redesigning primary care along the lines we have suggested. Collaborative practice amongst doctors and with other providers and rejigging the payment scheme is the official policy of the medical association now, so I think that is enormous progress. I think we are on the cusp. There is a tension in all three Ps, the payer, the provider and the patient. Everybody is in a panic. We see the whole system disintegrating. If we can seize that moment and do something that integrates and gives us something we can afford, that would be great.
The other risk is that the providers and the patients will go off by themselves, and a $90 billion system will become a $130,000 or a $140,000 system because we will be trying desperately to buy the services we need in whatever way we can cobble together. That is the real risk.
The Chairman: I would thank you all for being here today.
Senators, our next witness is Dr. Brian Day, founder of the Cambie Surgery Centre, which is a private surgery clinic in Vancouver.
Dr. Day, thank you for coming. What we need to hear from you is not so much the argument of why private clinics are good, from your point of view, but how you fit into the system, what kind of patients you have, and what the overall reaction to your clinic is. Four days ago, when we were in Manitoba, we found out that there were a number of private clinics there which we did not know existed. We want to know how your clinic works in relation to the overall system, and we would like to get into a discussion with you about the evolution in this area.
Dr. Brian Day, Founder, Cambie Surgery Centre: I have prepared something for you which is taken from a talk that I give every now and then on private health care to people who want to listen. I will not read that, but I hope you take the time to go through it. You will need glasses to read it.
I will briefly tell you how we got into this. I am an orthopaedic surgeon. I have one of the biggest practices in British Columbia and I am a clinician. I am also what one would call an academic orthopaedic surgeon. I give lots of lectures and I teach. I am out of the country about three months a year lecturing and teaching. I am not just a private, for-profit entrepreneur.
About six or seven years ago we decided to build a private facility. It is actually a hospital. We call it a private clinic for political reasons. It is a hospital. It provides overnight stays; it is licensed by the City of Vancouver as a hospital, and it is a post-disaster facility for the province. We built it in the middle of the tenure of perhaps the most left-wing government that Canada ever saw. We have had 10 years of an NDP government. We did that for one reason and one reason alone. That is we, as physicians, were being deprived access to the public system. There was a choice: either we left the country to do our work; or we stayed and did something about it.
I will give you my own personal statistics. Ten years ago I had 17 hours of operating room time a week at the University Hospital. Six or seven years ago that was down to five and a half hours a week, and yet my practice, by volume of patients, stayed the same. I had, at one time, 360 patients waiting for surgery at that hospital, which was not accessible. This led to many problems. It led to a lot of doctors leaving. I had previously been the chairman of the Royal College of Surgeons of Canada's test committee in orthopaedics in charge of setting exams and graduating residents in orthopaedics. Of the last 16 residents that we trained in British Columbia, five are still in Canada. This is a real problem for specialists. We built this clinic because we had a choice of having nowhere to work or build a private facility. A poll of the 100 specialists who work at our facility indicates that between 35 and 40 would not be in British Columbia if it were not for our facility. I will explain why.
We have been able to go out and develop contracts with secondary paying agencies like the Workers Compensation Board, the RCMP and many other secondary insurers. In B.C. tourism is a very big industry. We treat a lot of Germans, American and Japanese tourists who ski here. We treat a lot of people off the cruise ships in the summer. We have a ludicrous situation here and it is that, if you are a Canadian skiing at Whistler and you hurt yourself and need a knee operation, you will wait between six and 18 months to see one of the doctors who specialize in that area. Then you will wait another six to 12 months to be admitted to hospital for treatment. If you are from Japan or Germany or the States, you can see a doctor and be treated within a few days. This, to me, is the legacy of the Canada Health Act.
If you look through what I have given you to read, you will realize that I am no great fan of the Canada Health Act.
The Chairman: I gathered that from flipping through your overview.
Dr. Day: I am sorry I missed Mr. Dave Barrett's presentation but I know exactly what he said. The Canada Health Act achieves the reverse of what it was set out to do. In fact, the people from lower social economic groups, people who do not have the ability to pick up the telephone and make a phone call, people who do not know how to wheel their way around the system are the ones who suffer in a system like this. I have read your recent report, so I know you are aware of this. It is the kind of system that existed in the former Soviet Union where, if you were on the Central Party Commission, you were treated and, if you were a peasant, you did not. I hate to put it in those terms, but it is almost that bad now. The people who are suffering the most are those who have the least ability to work their way around the system that we have as a legacy of the Canada Health Act.
I think that many of the people who make presentations to this group will also appear before the Romanow commission. Some of them are trying to influence public policy for their own end. For instance, I know that that CUPE spent many millions of dollars on a propaganda campaign with respect to Bill 11 in Alberta, and it succeeded. Bill 11, contrary to what many people think, has essentially stopped the development of any private facilities in Alberta. It has done the opposite of what it was originally set out to achieve. We, for instance, would consider expansion into any province in this country except Alberta because of Bill 11. That is because Klein gave into a propaganda campaign that was heavily financed.
Our budget for advertising and promotion last year in our facility was $500. We are not out there lobbying and trying to persuade people that private health care is the best. I think that, like most doctors in Canada, if the public system could provide patient care in the way that it should, or promises to do so, then there would be no need for a private system.
This is now an economic reality. We used to debate the politics of health care, the legal aspects of the Canada Health Act. Incidentally, we have had three legal opinions, including one from a lawyer I regard as Canada's top constitutional lawyer, that the Canada Health Act, in the circumstances of today, is unconstitu tional. It is very important that people accept that this is now an act that is based on principles that were formulated in 1964, a time when there were no MRIs, no CT scans, no transplants and so on and so on. It is just not realistic for today.
We are the only country in the world that has no other system. A place like our centre cannot cure the ills of even the British Columbia health system. A place like ours, though, will show accountability, and I think that is where the public system can learn from us, that is, by applying some of those principles that we have applied in the way we run our centre in an efficient, fiscally responsible way without the massive, overbloated bureaucracy that exists in the public system.
I do not want to give a speech, so I will be happy to answer specific questions. I think most of them are answered in this document that you can take away with you.
The Chairman: They are.
When you were talking about your clinic you kept saying "we." Does "we" mean a group of doctors?
Dr. Day: Yes. About 14 doctors invested in this clinic, as well as some businessmen. Of those 14 doctors, 12 have still not paid back any of the loan that they took out six or seven years ago to buy their share in the clinic. It is largely physician-owned.
The Chairman: I know about the Workmens Compensation Board contracts. However, I was surprised to hear you say that you had a contract with the RCMP.
Dr. Day: We do not have a contract with the RCMP.
Various groups are exempt in the Canada Health Act. Those include federal employees such as the RCMP, the Canadian Armed Forces, and people in the federal penal institutions, criminals. We have been approached by the prisons to ask if we can take prisoners because they are on wait lists for surgery.
The Chairman: We are well aware of the exemption for WCB, but I must check and see who the others are. I am not disagreeing with you; I am just saying that I did not know that.
In your remarks regarding Bill 11, you blew me away when you said that you would go to any province in the country other than Alberta. What is it about Bill 11 that would make you say that?
Dr. Day: The evidence is there. When the time came and the offering went out from the various regions in Alberta - I am talking about a year after Bill 11 - there were no applications by any organization or facility to undertake any private health care in Alberta. Largely as a result of lobbying by CUPE, the restrictions and the penalties in the regulations were so severe that nobody bothered to apply.
Contrary to what you may have heard from other people, this is not a big money-making business. I am the largest single shareholder in our centre, and I still drive my 1994 jeep. I am not wealthy. I still have a big mortgage on my house. The facilities that were built, at least in this province, were built because the doctors had a choice. They have skills, they have talent, they have international reputations, but they have nowhere to do their work. That is the simple explanation. The choice was to go south, as many of our young people are doing, or do something about it. The government had been not able to fix it, so we fixed it. We are now operating and making a profit. I know that is considered a nasty word, but I think that people who criticize that forget that there are 25,000 private, for-profit clinics in this country. Those are your doctors' offices that you go to. The private office where you visit your family doctor is run as a business in a private, for-profit system, exactly the same as we run our facility. We already have, as I know you will know, a private system. Our family practitioners are mostly private; our specialists are mostly private. A surgeon with nowhere to operate is not a viable entity.
Senator St. Germain: Former Premier Dave Barrett and another gentleman appeared before our committee to speak on behalf of the Tommy Douglas Foundation. I asked them why they are so opposed to these particular facilities and yet they are of the opinion that it is all right to take your money and go to the U.S. and spend it on a clinic there. Their response I believe, if I am correct - and if any of the senators find that I am wrong in my statement I am sure they will correct me - was that a private clinic siphons the doctors off from the public system. Do you agree with that?
Dr. Day: It is exactly the opposite. If it were not for our facility, 35 doctors would have left this province. I am referring to top specialists. Imagine a mechanic with thousands of cars to fix and the staff to do it, but the government owns the garage and it will not allow the mechanics and the cars to go into that garage. The mechanic goes out and builds his own garage. That is essentially what we did.
Canada is the only OECD country in the world that does not allow private delivery of surgical services and hospital services as an alternative. We are the only system in the world that believes in a government monopoly.
I would like to ask each of you this question because no one has ever answered it to my satisfaction: If it is okay to spend money on alcohol, on gambling, on tobacco, what is wrong with Canadian citizens being allowed to spend their own after-tax dollars on their own health care? Does anyone have a moral problem with that? If they do, I would like to hear the explanation for that, because I have never heard it.
Whenever I have asked that of a politician, whenever I have asked that in a debate with a Dave Barrett or with somebody else, they have generally said, "Well, that is a good question," and then they have gone on and answered another question I did not ask them. That has been the strategy. There is nothing immoral about spending money on your own health. We do it all the time. It is just that we have kind of selected arbitrarily what is medically necessary and what is not medically necessary.
We have the ludicrous situation, for example, where a lens that is slightly crooked is considered refraction and it is not covered by medicare. You have to buy your own glasses. If it is slightly opaque, that is medically necessary to alleviate the problem. "Medically necessary," a phrase in the Canada Health Act, has never been defined. It certainly has not been defined by any doctor. Each provincial government can interpret it as it likes.
There is no question that we have reached the level where people want everything in unlimited amounts for free; that the system has run out of money: and that we have to start making choices.
In Alberta, in 1999, they tried to have a citizens' forum, a summit on defining core services and what was medically necessary so that the government could consider pouring the assets of health care into the most medically important areas. At the conclusion of the summit, the delegates who represented both public and private and health care, were unanimous in saying that everything was equally important and that they did not want to cut anything out of the health care system. This is something that has to be imposed by government because people will not voluntarily give up something.
In the press yesterday, Colin Hanson announced that routine eye examinations were not going to be covered. There was an uproar on the TV. People were complaining. Essentially what he was saying is that we are going to stop paying for new sets of glasses so that we can pay for your cancer treatment. Somehow that message has to be gotten across, and it has not been gotten across.
Senator St. Germain: It seems that every government tries to out-socialize the next. They look at this as the sacred cow that cannot be touched but now the cow is really in trouble and is at risk of dying.
I have one quick question on user fees. We currently pay user fees for chiropractors and physiotherapists. I believe, in British Columbia, the cost is $20 for each visit. Do you see anything wrong with that, sir?
Dr. Day: No, I think we must have user fees. You can exempt people on lower incomes. No country in the world - and I have worked in Switzerland, Britain, the United States and Canada, and I have studied this now for 12 or 13 years - does not have user fees. Not one. Of course, there is the possible exemption of Afghanistan or somewhere like that but, of the civilized countries, none is exempt from user fees.
It is like the deductible on your car. If everyone had comprehensive car coverage, every time you scratched your bumper you would take it into the dealer and get a respray and a polish because it would be covered completely. It is human nature that we will take everything for free, if it is offered, in unlimited amounts.
You will be faced with lots of quotations from studies. I used to be editor of a medical journal and one of the jobs of a medical editor, as opposed to an editor of a newspaper or a magazine, is that you have to check every reference that is given to you when someone submits an article to publish. Once you publish in a peer review journal, some people interpret it as fact. You will find quotes from "studies" done in Alberta on cataracts, "studies" published in the New England Journal of Medicine, and "studies" published by eminent Harvard professors. I have looked at all of these "studies." I have gone back to the original source and not one have I found where the reference that is now entrenched in the literature is supported. I have heard Allan Rock quote these studies. They are entrenched in the literature because they have been printed in so many newspaper articles, but if you go back to the original quote, look up the reference, in fact they say nothing of the kind. I will just give you one example.
The Canadian Health Coalition, for instance, will quote you the study on cataracts that was done in Alberta when Calgary contracted out cataracts to the private clinics. Lo and behold, the waiting lists are now longer in the private clinics than they were in the public system. However, you must qualify that information. Wendy Armstrong who is head of the Consumers Association of Alberta and, by the way, is a paid consultant for CUPE, did an audit on private clinics a day or two after the region handed all the cataracts to the private clinics, that is, before they had had a chance to treat any patients. The government has also issued quotas. They tell the private clinic that they will pay for five a week. Clearly it is not the private clinic's fault that there are waiting lists, it is because the government is not allowing patients to pay. They are saying we are going to pay for you, but we are only going to pay for five a week, so the waiting list is longer.
Those kinds of editorialized factoids will be given to you, and have been given to you. They are printed and on Web sites, and there are many of them. The same applies to the New England Journal of Medicine article that is quoted all the time that talks about studies which indicate that private hospitals in the States cost more than public hospitals. In that study, what they did, effectively, was compare the cost of a hernia repair at the L.A. County Hospital to the same operation done at a Beverly Hills private clinic where patients were provided with limousine service, caviar and wine. You will find a lot of that.
There is one quote in here from the Canadian Health Coalition that I hope you will read with magnifying glasses. They boast about how they bombarded the National Forum on Health Care. It is on the first page of the handout I gave you. They state that they were successful in the National Forum on Health Care in removing any talk of privatization off the table and that they are going to try to do the same with the Romanow commission and with the Senate committee.
Senator St. Germain: My doctor happens to be South African as is every doctor I seem to see. Do you have a view of the morality aspect of siphoning off doctors from countries such as South Africa?
Dr. Day: No, because I was born in Liverpool and I came here from Britain in the early 1970s. I think you cannot limit the free movement of doctors any more than you can journalists or any other group. We must make the system attractive enough that doctors will stay here and stay in the workforce. I listened to the dean talking about increasing the size of the medical school.If 25 to 30 per cent of the doctors graduating from medical school or, in the case of our specialists, if 11 out of 16 leave the country, it is not a solution to train 32 so that we will be left with 10. We have to "fix" why they are leaving. They are leaving because we are not offering them access to patient care. We are not offering them access to what is needed for them to perform their profession at the highest levels.
One of the big problems with the public system, as compared to a private facility, is that a patient in the public system, under the funding system in Canada now, uses up the resources of the hospital. Say the Vancouver Hospital is given $600 million a year. If you go there as a patient or a doctor brings a patient to that hospital, that patient is consuming that hospital's money.
Although a hospital vice-president or president will not admit this, that is not how it used to be. It used to be that a hospital was funded partly based on its performance. There is no reward for productivity in the way we fund our public hospitals. If they are in a crunch for money, they close down. We have a thing in British Columbia called "reduced activity days" when, even though we have one-year or two-year wait lists for surgery, 12 times a year we close the hospitals for what we call "rad" days.
Senator Morin: Your reputation as an orthopaedic surgeon is well known. In fact, Senator Carney just whispered to me that you are one of the leading orthopaedic surgeons in the province.
Senator Carney: Which means in Canada.
Senator Morin: In Canada, of course. I know you are very busy and we certainly appreciate the time you are taking to come here to discuss these aspects of health care.
I would like to talk to you first of all about your clinic. If I understand, you practice both in hospital and in your clinic; am I right?
Dr. Day: That is right, yes.
Senator Morin: We are trying to get a feel of what a private clinic is. It is, in fact, a private hospital, and there are not many in the country. Is there a difference in your practice between the hospital and the clinic? Do you treat the same types of patients?
Dr. Day: Yes. Actually, I am often asked why our facility is not targeted by the unions. Let me say right off that I am not an anti-union. I was brought up in a labour party family in Liverpool, a working-class family in Liverpool. My father's best friend was Bessie Braddick who was the MP that Winston Churchill did the "I am drunk but you are ugly" joke about." At least 60 per cent of the patients in our facility are working-class patients.
Senator Morin: What is the situation with respect to your hospital patients?
Dr. Day: They are a cross-section of the population. In our private facility our biggest client is the Workers Compensation Board and we deal with those patients who are injured at work.
Senator Morin: For those who are not part of that group, are your more difficult cases, your sicker patients?
Dr. Day: I see what you mean. No, no. That is another thing that is bandied around: that we skim off the easy stuff.
Senator Morin: So you have the same clinical mix.
Dr. Day: A couple of weeks ago I was asked by a reporter, "Where are you?" I said that I was at UBC doing surgery. He then asked me, "How many operations are being done there today?" There were five operating rooms, with an average of seven in each, so that 35 operations were being gone at UBC. All but one of them we could have done at our facility.
Senator Morin: So it is the same clinical mix.
Dr. Day: Yes.
Senator Morin: What is the quality control in your private hospital?
Dr. Day: There are several levels of quality control. One is the physical plant, which is under the City of Vancouver. The second is the College of Physicians and Surgeons of British Columbia. They do an extremely detailed audit of everything that goes on in our facility. They do the random taking out of patient files, they do audits of any patient that has any complication. That has to be reported to the college. If any patient has to be admitted to hospital subsequently, that has to be reported to the college with the file and an explanation, and the records have to be audited by the college. The audit mechanism for patients treated in our facility is far more rigorous than at UBC Hospital; far more.
Senator Morin: You are saying that the quality control is more in-depth than it is in the hospital.
Dr. Day: Yes. Every patient treated at our facility is sent a stamped, addressed envelope with a lottery ticket to win tickets to a hockey game and they are asked to fill in a patient-satisfaction or dissatisfaction questionnaire. We collect those and audit them.
Senator Morin: You say your hospital is more efficient than the publicly owned hospital. Can you give me some more details on that?
Dr. Day: When I came to the Vancouver Hospital in 1973, the hospital was run by one medical director, Dr. Lawrence Renton. Back then, the Vancouver Hospital had children's and obstetrics as well. It was the biggest hospital in the British Commonwealth. He was in charge of the laundry, the ICU and so on. By 1996 we had a president of Vancouver General Hospital, and we had seven vice-presidents, and each one had associates and so on under them. In 2001 we now have a CEO, two presidents,11 vice-presidents, an endless number of associate vice-presi dents and so on and so on.
The problem is decision making. Decision making is not happening in the hospital structure as it is now. It is a bureaucratic nightmare. Everyone is afraid to make a decision because everyone is under the political gun. It is unbelievably inefficient. I think it is the one area where we and the public sector unions would agree: It is very inefficient.
Senator Morin: Putting aside for the moment your patients from the Workmen's Compensation Board, are all your current patients, with the exception of tourists and so forth, medicare patients?
Dr. Day: No. We have patients whose treatment is paid for by insurance companies. I will give give you a statistic on the private facilities in B.C. Last year, in wage loss benefits, we saved the Workers Compensation Board $95 million. The disabilityinsurance companies are in a similar position, and they will pay for workers who were not injured on the job.
Senator Morin: I am trying to deal with the group of patients who are covered by medicare.
Dr. Day: Medicare does not pay for patients in our facility.
Senator Morin: You have no medicare patients at your facility?
Dr. Day: That is correct.
Senator Morin: Is it 100 per cent private, either insurance or WCB?
Dr. Day: Insurance companies such as Canada Life insure you in case you become disabled, and they will pay for you to go to a private facility.
Senator Morin: If you were in Alberta, under Bill 11 - and I understand you have objections to it - you would treat medicare patients.
Dr. Day: Only if the government contracted to send them.
Senator Morin: I realize that.
Dr. Day: There is nothing to stop the government from contracting with private facilities, and they have indicated their intention to do so.
Senator Morin: Would you think that is the way to go, to have patients with medicare that could go to your clinic.
Dr. Day: I do not think our clinic can solve the problems of this system. I feel sorry for anyone who is in administrative health right now because I think I know a lot about this subject and I don't think I could solve it. It has been battered so badly. I think that we can help. We can show the way to better administration. We do not have 11 vice-presidents. Perhaps I do not understand
Senator Morin: My question is, what would prevent you from receiving patients that are from medicare?
Dr. Day: Nothing, except we would have to charge the patients a facility fee.
Senator Morin: Why?
Dr. Day: Our operating rooms and our nurses are paid for by the corporation, the private corporation.
Senator Morin: Let us say you had a contract with the government. Would you have any objection to that?
Dr. Day: No, we would like that.
Senator Morin: You have nothing against the government being the payer?
Dr. Day: No.
Senator Morin: It is the provider part of it that you are interested in.
Dr. Day: That is right. We made an offer to the last government in British Columbia to take patients, for example, for cataract operations. Let us assume that Vancouver Hospital does 1,000 cataract operation a year at a cost of $1,000 each. That is $1 million. I am just making up these figures.
Senator Morin: Certainly.
Dr. Day: We offered to do them for, say, $600,000. We told them to figure out their costs and we said that we would do it for 60 per cent of the cost. I know we can do it for 60 per cent of the cost using the same doctors. We just were contacted by a hospital here this week to consider contracting our services. They ask us how much it is going to cost. I tell them that we will do it for 60 per cent of what it costs them. We do not know what it will cost us. However, that is the problem with the public system.
Senator Morin: Thank you very much.
Senator St. Germain: I have a short supplementary question. Is the government now sending people to private clinics in the States and not sending them to you?
Dr. Day: About four years ago, there was a patient who needed to have a hip arthroscopy. It is an unusual operation. I believe I am the only person in Canada who does that operation. There are five centres in the states. We did not have the equipment at the UBC Hospital. Our private facility said that we would treat this patient for Can. $3,500. The provincial government sent that patient, who happened to be the next door neighbour of one of the MLAs, to San Francisco to have the operation done at a cost of U.S. $14,500.
Senator Keon: Dr. Day, your infrastructure staff, are they unionized or non-unionized?
Dr. Day: Many of our nurses also work at hospitals. They may be mothers with young children, two or three-year-old kids, and they do not want to work nights. They find that they cannot work nights and weekends at the hospital. They elect to work at our place, and they do some shifts at the hospital. They have to belong to the union.
We are not a unionized facility because if we were, we would have the same trouble getting nurses as the hospitals have. We pay our nurses 15 per cent higher than the highest level they can achieve after 12 years in the public system, because we need these nurses. In many cases, we are taking nurses who are otherwise out of the workforce.
Senator Keon: What about your technical and support personnel; secretaries?
Dr. Day: Secretaries are not unionized. Similarly, the technical group would, in the hospitals, belong to the hospital employees union. The central sterile technicians who sterilize all the equipment, clean the equipment, are not unionized. Again, to attract those people, we have to pay higher than union wages. If we were unionised, the workers would have to take a cut in pay. We will never be unionized until public sector catches up with our wages.
Senator Keon: That is an interesting paradox, because the argument for contracting out services from the institutions, from the hospitals, whether they be financials services, cleaning services, food services or whatever, is that you can contract them out cheaper because you do not have to deal with CUPE; and the private sector can hire people cheaper than the hospital sector. Paradoxically, you are paying your people more than unionized people.
Dr. Day: Yes, we are. However, if we need to have the grass cut or tulips planted, we do not pay a gardener at health worker rates. That is one of the problems with the public system. If you plant rhododendrons at UBC Hospital, you get paid $10 an hour more than the same unionized job in the private sector union because you are a health care worker. We do save money there. We are not big enough to have a full-time gardener, but hospital employees, union workers at the hospital, if they are not in the technical area, then they still get paid higher wages than they would in the private sector.
The Chairman: Surely the real reason you are able to do it and I am referring to chapter 5 of our report - has to do with the fact that you are operating a very specialized clinic. This is not a criticism. It is always true that, if you have a very specialized facility, focused on a limited number of things, you ought to be able to operate more efficiently. One of the points we made in the report is that the move toward specialized facilities clearly has economies of scale, in terms of specialization and focus.
Dr. Day: You are correct. That is a Harvard Business School philosophy.
The Chairman: Right. I am not disagreeing with you, by the way, that you do it cheaper than the public sector. All I am saying is that, in a sense, when we look at the cost data we are comparing apples and oranges because we are comparing the cost data of a large general hospital with that of a specialized facility. One would have to compare a public specialized facility, which does not exist in the public sector, with a private facility in order to truly know the costs. Any specialized facility, regardless of who owns it, if it is as focused as your organization is, ought to be able to operate at a cheaper price and more efficiently.
Dr. Day: We have a situation here where we have limited nurses, doctors and facilities in the public system. People are waiting nine months for heart surgery and cancer surgery while, this week at UBC, in the hospital operating rooms dermabrasions are going on, face lifts are going on, cosmetic surgery and dental surgery is being done. These are the same nurses, and the same operating rooms.
The Chairman: People are paying for that.
Dr. Day: No. They are paying the surgeon; they are paying the anaesthesiologist; and the patient is paying the hospital. For a 10-hour operation the patient will pay the hospital, if they are a B.C. resident, $290. In other words, the taxpayer is subsidizing to the tune of $10,000.
The Chairman: Even for non-medicare expenses?
Dr. Day: Yes. It is even worse than that. If an American comes to UBC Hospital, and he has $10 million worth of Blue Cross insurance from the States, and I have to operate on him, I might do an operation on him that costs $6,000. I know these costs because of working in the private system. The hospital will bill that patient $560 Canadian. I phoned the director of finance and told him that that was crazy. The answer I got was, "We do not have the policies in place for that kind of auditing." It all comes back to the same thing: What is lacking in the public system is accountability. If you eliminated the global system of funding a hospital and made a hospital get its revenue based onperformance, you would make a major change.
The Chairman: That is essentially separating the payer and the provider.
Dr. Day: Yes.
Senator Carney: I should explain for the record, as Dr. Morin has pointed out, that Dr. Day has been my orthopaedic surgeon.
The Chairman: Dr. Day, you are here because Senator Carney recommended that you come.
Senator Carney: He asked for this opportunity. I want to make it clear that I was on his waiting list for eight months.
Dr. Day: She refused to make the phone call.
Senator Carney: In view of his comments about people phoning their neighbours and politicians pushing the system around, I wanted to make it clear that I was very pure in this matter.
Senator Morin: Was that a three-year waiting list and you waited eight months?
Senator Carney: No, it was one year - until an older lady fell and broke her hip, making a $3,000 surgery a $25,000 surgery. She was on the waiting list and I took her place.
I have one point on the structure. I am surprised that Senator Morin did not raise this. It says here that you are the first private company to develop the first private health care facility of its type in Canada.
Dr. Day: Of its type, yes. There are other private facilities, but nothing that is licensed by a city as a hospital that has five inpatient beds and has unlimited access and unlimited capability to keep patients overnight.
Senator Carney: You talked about the fact that you pay above scale and your expenditures are below norm. Are your fee structures the same as in the public system?
Dr. Day: That is the problem. The public system cannot tell us what their costs are. All I know is that I am confident enough to tell the vice-presidents of the hospitals that, if they figure out their costs, we will underprice it by 40 per cent and treat public patients.
Senator Carney: If I have a procedure done in the Cambie clinic, obviously I will pay more than the Government is going to pay you to do it if you did it in a public facility.
Dr. Day: It comes out of a different fund. That comes from more or less general revenue.
Senator Carney: You are not getting $500, or whatever.
Senator Morin: What you are referring to is operating room fee.
Dr. Day: Surgeon fees and anaesthetist fees are the same, whether it is in the public hospital or private hospital.
Senator Carney: I did not know that. Is your clinic the optimum model for you? Why have they not shut you down? Why has Victoria not come out and said, "You are running a private facility. We will shut you down"?
Dr. Day: We made sure they would not do that before we built it.
Senator Carney: Is this because of this specialized service?
Dr. Day: We talked to them. The fact is that the most common single patient group using our facility is an HEU worker, Hospital Employees' Union worker.
Senator Carney: Is that through the Workmens Compensation Board?
Dr. Day: Yes. We are treating public sector workers, union members, at our facility.
The Chairman: That is amazing.
Senator Carney: I am trying to establish whether senators can go to this facility.
Dr. Day: You might be able to. I can tell you that bureaucrats - and one of my friends is an orthopaedic surgeon in Ottawa - and civil servants in Ottawa go to Buffalo for their MRIs, and that is a public expense.
The Chairman: We can go across the river to Hull also.
Dr. Day: That has changed then.
Senator Carney: There is something I would like your views on too. You have included in your brief the "Hypocritical Oath for Ministers of Health."
Dr. Day: That was actually published in the Vancouver Sun about two years ago.
Senator Carney: Mr. Chair, this "hypocritical oath" is a play on the Hippocratic oath. I will read it. We are talking sardonically here. It states:
No private health care will be allowed in Canada, except for private, extended "two-tier" insurance such as we, the privileged, enjoy courtesy of the taxpayer.
That does include senators.
The 30% or more of Canadians that do not have such benefits will pay for treatment of their abscessed teeth, artificial limbs, arthritic braces, private rooms and nurses in public hospitals, and expensive, safer drugs. Queue jumping will depend on who you are or who you know. This works well for us.We have had discussions about this, and I think you have suggested to me that one of the reasons for the inertia in changing this system is that those of us who are at the decision-making levels already have a two-tier system. All public service employees, all MPs and all senators have the government plan which pays for all sorts of services that my twin brother, who is not a member of any of these groups, has to pay for himself. You say that this is a very large group in Canada.
Dr. Day: Seventy per cent of the population has what I call "two-tier" insurance.
Senator Carney: Could you address this issue? Is one of the reasons for the inertia in changing it that all of us benefit from a two-tier system, even glasses?
The Chairman: Can I just, for the record, just make sure our definitions are consistent? We have used the term, "two-tier" in the general way it is used, which is to mean a parallel hospital system. Senator Carney is using two-tier as meaning that we have insurance that covers not just hospitals and doctors but all of the other ancillary services such as physiotherapy, drugs, home care and so on. I am clarifying that for the purposes of our record. Senator Carney is raising an issue that bothers us, that is, the huge gap in the safety net for people who do not have "two-tier" insurance.
Dr. Day: That is right. The 30 per cent who do not have it are often the working poor. If you are really poor you have it. Everything is paid for you. If you are a unionized worker you have it, and if you are a non-unionized worker working for a big corporation, you have it. It is the small, lower middle-income group that does not.
The Chairman: In some provinces it applies to seniors, although not in British Columbia.
Dr. Day: I think it is important to point out that in this secondary insurance it is a completely grey area as to what is considered medically necessary. For example, a child might have a hindquarter amputation as a result of cancer. The artificial limb in British Columbia is not covered. It is not considered medically necessary to have an artificial limb. A patient brought me a letter, which I have on file, from the Ministry of Health in British Columbia from an assistant deputy minister saying, "Dear Mr... we have reviewed your file and have determined that a voice is not medically necessary." This patient had his larynx removed as a result of cancer. These would be covered if you have extended health insurance. We are not talking about a plastic cast for cosmetic purpose, these are important items.
Senator Carney: You have created your clinic to meet a need that is allowed under legislation. Is your clinic the optimum model for you? Piggybacking on that is the issue of how many orthopaedic surgeons do we have in Canada and how many do we need?
Dr. Day: We need a great deal more. There is an extreme shortage of orthopaedic surgeons. The new generation of orthopaedic surgeons is not like ours. New graduates do not want to work 80 or 90 hours a week. They will take call for no pay. Part of it is economic. This whole thing is about economics now. Part of it is remuneration. I will just give you an example in my own specialty.
Fifteen years ago we were the third-highest paid group of specialists in British Columbia. Orthopaedic surgeons of British Columbia are now seventeenth out of eighteen in annual income. Much of that is as a result of orthopaedic surgeons being cut off from access to hospitals to treat their patients. However, they are also diverting themselves away from clinical work. We are now in a situation, and this is an accurate statement, where orthopaedic surgeons are giving up clinical practice, and often at the peak of their skill level in their early 50s, to go into consulting, to do evaluations for insurance companies, and so on. An orthopaedic surgeon gets paid four or five times the hourly rate for describing an operation to a lawyer or an insurance company than he gets paid for doing the operation. That is an economic reality.
Senator Carney: I just want to establish on the record an analogy that you have made with me and that is that a hockey player who was given only five hours a week of access to ice time would lose his professional NHL skills, but this society deems that an orthopaedic surgeon is only allowed five hours a week to practice his skills.
Dr. Day: The Canadian Orthopaedic Association recommended a minimum number of hours a week for operating to maintain skill level, as pilots do in planes, and that was 15 hours. At St. Paul's Hospital the surgeons are given about four and a half or five hours. At UBC it is five and a half to six hours. That is why they need a facility like ours, and that is why 40 per cent of them would not be here if it were not for that.
Senator Roche: Doctor, I think you said earlier in your presentation that a significant percentage of patients who come to you are working-class people. In such cases do you deem it necessary that they be treated but they have not got the money to pay you? Does that occur?
Dr. Day: Yes, it does. They are not allowed under the Canada Health Act to pay for the service. When I said the working class, those patients are usually Workers Compensation Board patients who are going to our private facility and their fee is being picked up.
Senator Roche: Are these only Workers Compensation cases?
Dr. Day: Yes.
The Chairman: When the Canada Health Act was passed it explicitly excluded Workers Compensation Board patients. From the get go in 1984, Workers Compensation Boards were allowed to work in a two-tiered system in the sense that they could hire and pay their own doctors, and they would pay the hospital a fee and so on. As Dr. Day pointed out, certain other groups, were also entitled to this. However, by far the biggest group - and that is why we mentioned it in the last report - who clearly operated a two-tiered system was Workers Compensation Boards. If you are going to get injured, please get injured on the job because then you will automatically go to the top of the waiting list to be taken care of.
Dr. Day: It should also be pointed out that in our facility last year we treated 3,000 patients. If we did not exist, those 3,000 patients would be on some waiting list somewhere. They are extra to what would have been done. That is just one facility. They would have been on the public wait list. In British Columbia right now we probably have 100,000 people on surgical wait lists. We probably treated 15,000 we treated in private facilities last year. The waiting lists would be 115,000, if it were not for the private facilities.
Senator Roche: Mr. Chairman, I do not quite understand the differentiation between patients who come to your clinic who come via the route of the Workmens Compensation Board and other patients who come from other routes.
Dr. Day: Supposing a carpenter is on disability insurance because he was injured playing hockey. However, he is a carpenter who is unable to work. A disability insurance company, like London Life or Great West Life, would pay that person's wages while he waits a year or two to be admitted to a hospital for treatment. He was not injured on the job. The insurance company is in the same position as the Workers Compensation Board. It is paying out, say, $5,000 a month while the carpenter is waiting a year for an operation that could be done for $1,000. The insurer would pay the $1,000 and save $55,000 in wage-loss benefits.
Senator Roche: Are billing the Workers' Compensation Board for the WCB cases?
Dr. Day: I was talking about disability insurance. Suppose you have two carpenters, one is a homeowner and the other, he is hired to do a job, and they both fall off the deck and they both incur the same injury. One will be covered by Workers Compensation because he is an employee. The homeowner, who is also a carpenter, has to take time off work, but his only way to get into our facility under the Canada Health Act is - and even this is a grey area and could be challenged - if his insurance company will pay for his facility fee the way the Workers Compensation does.
Senator Roche: It is the insurance company that you bill in that case.
Dr. Day: Yes, in that case an insurance company will be billed. I would absolutely support that man's right to spend his own money on his own health care if he so wished. We did not elect our government to dictate to us that we cannot spend money on our own health care, and that is the practical effect of the Canada Health Act.
The Chairman: Dr. Day, thank you for coming.
Senator Carney: I just want to say that it will take me six months to see him, after waiting four months for my rheumato logist so I am walking him out to the hall for a consultation.
The Chairman: I must say, we got to see you a lot faster than Senator Carney did. We only contacted you about a month ago. Thanks for coming.
Our next witness is Ms Lorraine Grant, Chair of the Board of Directors of the Health Association of British Columbia, followed by Ms Cynthia Ramsay, a well-known health economist who wrote a paper, which I have read, called "Beyond the private- public debate."
As you can tell, when we have the quality of people we have had today, it is difficult to stay entirely on schedule. May I say we had the same day yesterday when we started off withMr. Mazankowski as our first witness, who was followed by the CEOs of both the Calgary and Edmonton health authorities. That was a fascinating start.
Ms Grant, thank you for coming.
Ms Lorraine Grant, Chair of the Board of Directors, Health Association of British Columbia: I would like to introduce Ms Lisa Kallstrom, Director of Policy and Advocacy for the Health Association of British Columbia. We are both pleased to be here. We would like to commend the committee for its work in providing a comprehensive analysis of issues facing the health system today.
I will comment on some of the issues and options that have been put forth by the Senate Committee, and focus on recommendations that we believe will improve the health system significantly.
With regard to the general role of the federal government, the Health Association basically concurs with the five distinct federal roles in health and health care posted by the options paper and their related objectives. We agree that a major organizational overhaul in the delivery of health services is required, particularly in primary care. While we are sympathetic to many of the arguments raised regarding the constraints of the Canada Health Act, particularly with respect to reasonable and timely access, we reject the notion that the public should be able to pay for the cost of a procedure in order to ensure that they receive it in a more timely fashion. Private payment for insured services will eventually lead to a two-tier health system. Our Association feels strongly that the proportion of private financing should not be increased beyond the current 30 per cent, and we make a distinction between private financing and private delivery.
I should like to now address the financing role of the federal government. The Health Association disagrees with the commit tee's conclusion that we must now begin to develop plans and policies to identify additional private revenue sources. Proponents of the idea believe savings arising from changes to the way we currently deliver health services will be insufficient. We firmly believe the health system should implement the main recommen dations of the many reviews that have been conducted both provincially and nationally. These recommendations should be implemented and evaluated first, and only if they fail should we consider additional revenue sources.
The health association believes that efficiencies and improved effectiveness measures will be sufficient to ensure the long-term sustainability of our health care system. In fact, they are necessary ingredients. A stable funding contribution from the federal government is absolutely essential for undertaking fundamental changes in implementing required innovations. We suggest that your committee recommend that the federal government maintain the current CHST funding contribution to provinces, butincorporate an escalator.
With regard to evidence-based practice, the Health Association suggests that the federal government take a lead in supporting the development of clinical practice atlases for British Columbia and other provinces. The development of a base-line knowledge of the use of clinical services and their variations could be modelled on the work conducted by the Institute for Clinical Evaluative Sciences at Sunnybrook, Ontario. The federal government needs to play the same leadership role for the development of national clinical practice guidelines.
I will now move to the regionalization of services. British Columbia has regionalized many health services, but we believe regionalization needs to be extended to the full continuum of health services. The Health Association of B.C. agrees with the committee that primary health care reform is key to achieving modernization of our current medicare system. Again, the federal government will need to continue to play a leadership role, particularly in providing sustained funding for reform initiatives.
With regard to the federal government's research and evalu ation role, we think it should continue its current activities. However, we would also recommend that the federal government not limit its participation merely to pilot projects, but that it take a more fundamental leadership role in longer-term system changes.
Next, I will deal with the infrastructure role. The federal government should commit to a longer-term program of financing of technology so that the health care sector can take advantage of information and communication technologies. Without enhancing our ability to manage health information, we cannot begin to shift towards a culture of evidence-based practice and decision making. The federal government can provide intellectual leadership and use its funding power to develop new information systems that talk to each other and have standardized data sets.
As to the role of the national health care quality council, the Health Association strongly agrees with the recommendation to establish such a council which would undertake analyses of the performance of various aspects of health care at different levels, the system level, the organization level and individual levels, and develop performance standards and benchmarks. It could also be formed through a consortium of existing national bodies such as the Canadian Institute for Health Information, the Canadian Council on Health Services Accreditation and the Canadian Health Care Association.
We further agree with the recommendation to publish reports on the importance of all determinants of health in creating healthy populations. The federal government could show leadership in that area by drawing attention to the responsibility of individuals for their health choices.
With regard to the health human resources role, the Health Association of B.C. concurs with the committee's recommenda tion that primary care reform is essential to rationalize the use of our health human resources. Under a coordinated primary care model, the full spectrum of the variety of health care professionals can be utilized at their full capacity. At the same time, the unit cost of the service produced could be reduced. This will likely also have a profound impact on our health human resource complement.
We also recommend that the federal government fund an analysis of the potential savings in health care utilization through more extensive use of, for example, nurse practitioners.
Next, I will deal with the role of the federal government in population health. The document, "Health Goals for British Columbians", is framework for society to develop strategies that affect the entire province's health and well-being. This framework has helped regional health authorities structure their own health service plans.
Finally, I will deal with the role of the federal government in Aboriginal health. The consequences of having two jurisdictions involved in delivering health services are program fragmentation and difficulty coordinating programs. The Health Association itself has established a First People's Health Council. This is a committee consisting of Aboriginal governors from health authorities and representatives of Aboriginal organizations. Among many other initiatives, our First People's Health Council has collaborated with the provincial health officer to produce a special feature report on Aboriginal health. This report will include examples of innovative practices that may ultimately result in improvement in health status.
In conclusion, we should like to stress that there are opportunities for the federal government to leave an important legacy in health care by showing intellectual leadership in developing information systems, quality improvement and out comes evaluation.
We are also now developing a submission to the Romanow Commission that we will be pleased to share with the committee in November.
Ms Cynthia Ramsay, Health Economist, Elm Consulting: I would also thank the committee for inviting me to be here today. It came as a bit of a surprise because, given my history working with the Fraser Institute and other institutions, I have often not been asked my opinion on health care from the powers that be. It is quite an honour to be here today.
I do not have any written notes. I have gone through the executive summary of your report thus far, and some of the detail in the document itself. Many things I would like to say are already there, and I do not want to be repetitive, so I will talk about my latest report, which Senator Kirby did mention, called, "Beyond the public-private debate." The committee has done a great job in getting a variety of views on the public-private split. I have copies of the report with me.
With this report, I was trying to broaden the debate. As a proponent of more private-sector involvement in health care, I was often faced with one or two counter arguments. One argument is the private health care in the U.S. has been bad for Americans. The other argument I always encountered relates to the whole issue of who really is paying. No matter what the discussion, the topic of the payer would get in the way. The argument would be that you could not provide a particular service because it is not publicly provided. It would be said that you could not have private-sector involvement because only the rich patients would get treatment first, or they would get better quality treatment. As soon as mention was made of the private sector it was connected with a set of assumptions about the private-sector outcomes.
I set off to study various countries. I picked eight countries that differed from each other a lot as far as their mix of public-private sector involvement was concerned. Singapore's is probably is the most private but, ironically, at the same time it is the most government mandated and directed. Then we have the United States. It is about half and half, I guess. Canada, as we all know, is about 30 per cent private, and yet there are some areas that the private sector cannot touch. I looked at that. I also chose certain countries because of their somewhat similar history: South Africa and Australia. South Africa, Australia and Canada are all former United Kingdom Commonwealth countries, and each has a very different system, in spite of the fact that they were all born of the same system.
I used the United Nations' human development index as a ranking tool because my experience has shown that it is a relative measure. I considered doing an absolute measure, for example, following along the lines of assessing water quality. In that instance you have certain targets concerning what you do not want in your water, and if you pass or fail, it gives you a water quality rating. It is absolute. You know if you failed; you know if you passed. In health care it is not so simple. For example, you may say that you want the average length of stay in a hospital to be four days, but that may or may not be appropriate for everybody. It depends on who you are, what you are in for, and what hospital you are in. Therefore, I went with a relative rather than an absolute measure. I had the opportunity to broaden my own spectrum in that I started with every single variable that had ever been used in a comparison of countries. I had to narrow that down eventually because one of the conclusions of my study is that there is not a lot of data that is comparable.
Even this study has many caveats and, therefore, it should be taken with a grain of salt given that the data are incomplete in many areas. I ended up with about 100 variables at the end, which I then broke down into 17 larger categories. I will not mention all of them, but I looked at health status; socio-economic status; availability of services, which would include doctors, hospital beds and thing like that; and appropriateness of services, which would look at Caesarean sections and how many are done. I considered all 17 categories and ranked them. I then came up with an overall score for all of the countries. When I did that Singapore, out of a possible 100 being the best, came out about 62. I was disappointed that my country of choice only gota 62 out of 100.
Another conclusion of my study is that you cannot take everything from one country and impose it on Canada. I am not referring only to adaptations that take into account cultural differences; I am referring to the fact that, as I see it, no one country has necessarily gotten it right.
Despite a very different way of doing it, my rankings came out in the same order as the World Health Organization study 2000, apart from the fact that, in that study, Canada did better than Australia. The second country in that study was the United Kingdom which has a completely different system. We have heard lots of anecdotal evidence about the waiting lists there and other problems. You can have two incredibly different systems, one very private and one very public, and both seem to be faring relatively well, and definitely better than Canada.
Another conclusion is that we should not, in Canada, restrict our discussions to who is paying. If you structure it well enough, that should not matter in the end. There is no solely private, there is no solely public system out there.
The other part of the study has to do with population health. There are federal government departments devoted to looking at population health statistics. I wanted to assess whether the information they were putting out was kosher, so to speak.
There was also the assumption that health care comes within the medical system. I wanted to know how much the medical system has to do with population health status. The World Health Organization and other organizations and departments have said that the medical system does not have much to do with overall population health status. I am sure that is open for debate. My thought was: If that is the case, why are we so worried about ensuring that the least important part of health care is publicly funded and available to everybody equally? I am thinking of high tech surgeries and diagnostic testing. If literacy rates, income levels and immunization, which is a function of public health, are the more important correlations to life expectancy and lower mortality rates, perhaps government funding, if there is a restricted amount, should be more focused on those types of activities and public education, and allow for at least experimenta tion.
I am not suggesting that you go full swing into a private sector system because, if you do it wrong, you run the risk of leaving lower-income people behind. If you do it ad hoc like we are doing it now, randomly delisting things, you will leave lower-income people behind.
My recommendation is that we implement pilot projects that involve the private sector in a more innovative way.
The Chairman: Under your Aboriginal section you talk about a special report that your First People's Health Council developed.
Ms Lisa Kallstrom, Director of Policy and Advocacy, Health Association of British Columbia: Our council partici pated with the provincial health officer on this.
The Chairman: My only question is: How do we get a copy, or is it not available?
Ms Kallstrom: It is not quite ready yet. We hope it will be released before the end of the year.
The Chairman: Would you make sure that someone sends us a copy?
Ms Kallstrom: Yes.
The Chairman: My second question relates to the sentence at the end of your section on financing. You state:
The Health Association believes that efficiencies and improved effectiveness measures will be sufficient to ensure the sustainability of our health care system, rather than looking for additional revenue sources to expand health care expenditures even further.
As you can tell from our report, we have wrestled with that question in the context of the beauty of believing what that sentence says. Doing that, you manage to avoid many very difficult issues. Our view was that, since we did not know how much money was going to be saved, it was important that a discussion on other alternatives be started. I would like to know what your reaction is to our taking that point of view, and what it is that leads you to believe that there is sufficient money in the system.
Ms Kallstrom: We have literature evidence of services having no effect or a questionable effect. We should consider implement ing service-delivery processes within the health care system to ensure that our services are indeed appropriate. We might consider investing more federal funds into researching the effectiveness of procedures.
As well we might want to replicate some of the work done by ICES, the institute in Ontario so that we have a base-line knowledge across every province of the variation rates among all major procedures that are performed. That will start the clinical debate on what rates ought to be. Some rates vary phenomenally between local communities.
The Chairman: When you talk about initiating actions that trigger a debate and so on, it makes me even more convinced that our assumption is the right assumption. It seems to me very unclear - knowing how slowly this system changes, knowing that it deals with a major cultural shift - how much of an impact a debate will have, and when it will have an impact. Our view is that, however much wishful thinking goes on, we would like to not have to deal with the problem. We have an obligation, if you believe in any amount of system planning, or strategic planning, to be ready to deal with the problem when it arises. I am not arguing that there is anything wrong with wishful thinking. It is a good thing, as a matter of fact. I do see no evidence that makes the belief you express believable, I guess, is the best way to put it.
Ms Kallstrom: The Province of British Columbia may, in fact, be a real life experiment. We are facing the situation at the moment where we will have basically a zero, zero, zero increase in the health budget.
The Chairman: What does "zero, zero, zero" mean?
Ms Kallstrom: Zero per cent increase to the health expendi ture, to the budget for health care services in this province.
The Chairman: For one year?
Ms Kallstrom: For three years. That is a brutal situation for health care to face. It may actually force the speeding up the hard look at what services are appropriate and beneficial for what patients under what conditions. Alternatively, this province will face other approaches such as random cuts or across-the-board cuts. There may be significant reductions in overall services. It may be the catalyst that will force those mechanisms to be put in place very quickly.
Senator Morin: Ms Ramsay, what is the Marigold Founda tion?
Ms Ramsay: It is a charitable foundation group in Calgary. This is the biggest study they have conducted. They do not delve into policy. They have been a bit taken aback by the response to the study. What they generally tend to do is give college bursaries to mature students to go back to school, or they fund a park in a lower income area within the City of Calgary. That is where they tend to focus their attention.
Senator Morin: Who supports this foundation?
Ms Ramsay: It is a private organization that receives many donations. They have not shared all of that information with me.
Senator Morin: Would the donors be mainly corporations?
Ms Ramsay: I would assume so, yes. It would be the private sector, not government.
Senator Morin: I should like to quote from your report, specifically table 1 as it refers to "Technology" and "6.2." This demonstrates how well-founded your various figures are, because we found that, in other ways, we are well below the OECD countries on the list in the technology category. Over the years we have not spent enough on technology.
Waiting lists are a major problem, in spite of the fact that we are not doing things too badly.
I would also refer you to patient satisfaction. What is so clear is how dissatisfied patients are in Canada compared to those in other countries. They are even more dissatisfied than patients in South Africa. Their level of satisfaction, in fact, is close to that of the United States. It is as good as in the U.K., which has the second highest rating. The U.S. is not far behind Singapore. However, it surprises me that Canada is way below everybody. Why? Can we blame the press? I think the press reflects what the Canadian public is telling us.
Where I take issue with your score, and this also applies to the World Health Organization study, is that what we are really studying is the health care delivery system. Health status is another thing. To study health status then we go to health indicators such as the infant mortality rate, birth weight, the number of people who smoke and so forth. I read a good article on the plane last night, which indicated that the health care delivery system accounts for less than 25 per cent of the health figures. For example, what health indicator should palliative care come under? We have to spend on it. Large portions of our health care costs are expended during the last year of life, and that is how it should be. That does not show up on any health indicator.
I was hoping to remove a number of items that have nothing to do with the health care delivery system. For example, demo graphics, socio-economic status, have nothing to do with it. I would also remove spending. There is nothing wrong with spending a lot. You said yourself that the public-private mix is not important, so why bring it into the equation?
Ms Ramsay: In the overall score, demographics and socio- economic status are not included because it would be unfair to penalize South Africa for its turbulent history.
Senator Morin: You include total spending, that is, public sector spending and private spending.
Ms Ramsay: Yes. I was able to footnote myself as a dissenting opinion. I do not think increasing health care costs is a problem.
Senator Morin: So why did you put that in?
Ms Ramsay: The sentiment of the day of most health care experts and the government is that we should try to contain cost every which way with health care. I took the popular opinion of the day and assumed that higher health care costs were the worst option, but then I found that Singapore, which does not spend that much, performed better than Germany.
Senator Morin: I think you should look at it the other way. Singapore has a good health care system, but it does not cost very much. I think we should take it out.
Ms Ramsay: In one of the rankings in the more in-depth report, the fourth one, I took out spending entirely. That changed the picture somewhat for the other countries. Canada still stays sixth at table 2 in the executive summary. Germany, if you take spending out of it and do not distinguish between the private or the public sector, Germany comes out number one, followed by Switzerland, the United Kingdom, Singapore, the United States and then Canada.
Senator Morin: Are waiting lists dealt with under "Availabil ity of services"?
Ms Ramsay: Yes.
Senator Morin: The waiting lists in the U.K. are just terrible at 35. Britons will wait five years for a hip replacement. I cannot understand that number when compared to the 48 for Canada. That surprised me. I apologize, Mr. Chairman for dwelling on all these details.
Ms Ramsay: It is good to do that.
Senator Morin: I studied this list carefully and I thought it was excellent.
Ms Ramsay: As I say, if you want to look at the ones where spending is not included at all, then I would refer you to the fourth ranking on table 2.
Senator Morin: Even those who believe there is no problem with the Canadian system must admit that we are way below the other countries, and I think the two reasons we are way below is the fact that we are so poor in technology and that we are so poor in patient satisfaction. Those two elements drag us down.
Senator St. Germain: I would ask both doctors: Has the technology factor impacted your ability to carry on your profession in this country?
Senator Morin: Absolutely.
Senator Keon: I happen to practice in an institute that has state-of-the-art technology.
Senator Morin: You have a certain conflict of interest.
The Chairman: Is the patient satisfaction data obtained by surveys of patients, or is it a general population survey of attitudes?
Ms Ramsay: I don't know. It is from Commonwealth Fund surveys that have been done a couple of times in five countries, one of which I have not included here, New Zealand.
The Chairman: Their latest one was completed just last week. I happened to be at the conference where it was done. We should talk about that.
Ms Ramsay: Definitely.
The Chairman: It is, essentially, a general population reaction. I was in the market research business for a long time, so I know that, if you survey Canadians about the health care system and then break the answers of the general population who have had no contact with the system versus people who have actually had contact with the system in the last six months, the people who have had contact with the system have a substantially more positive view of the system than the general public. To that extent, in other words, the perception obtained through the media and elsewhere has changed people's opinion a lot more than actual patients, which is not, by the way, to say that patients are terribly satisfied.
Senator Morin: You should question patients on the waiting list.
The Chairman: Then you find, of course, they are very unhappy.
Senator Roche: I want to come back to Ms Ramsay on this point. I do not understand why it is so important to talk about patient satisfaction in any event when health status, which is the more important element, it is the substantive issue. We are the highest. Perhaps, as the Chairman has said, it is people who have not touched the system who are expressing dissatisfaction based on what they have heard. Is it not much more important to concentrate on what is positive in the system and that has produced the highest figure, that is, health status?
Ms Ramsay: Patient satisfaction is important because the whole system is there to serve patients. What they feel of it is important. That is why I included it. As far as the system's effect on health status is concerned, I would argue that the system - medical doctors, nurses, hospitals, technologies, surgeries - does not have much to do with the health status figure. We happen to be a richer country, a more literate country, more educated, and we do not have wars or famines.
The Chairman: The health status data in any country is not driven by the quality of the health care system, it is driven by all of the determinants of health other than the health care system.
Senator LeBreton: Ms Ramsay, I have seen this report myself so you must have had somebody promoting you.
Ms Ramsay: I did all myself, so I must have sent it. I do not remember.
Senator LeBreton: Our last series of witnesses were heard by means of teleconferencing with people in the United States, Germany, the U.K., Australia, and Sweden. Everybody assumes that Sweden is a socialist country, and yet they have a private sector built into their system all the way through and including hospitals. As a matter of fact, St. George's Hospital in Stockholm is a tremendous success story. I do not know whether you have looked at Sweden. You do suggest that we try some pilot, experimental projects. Where would you start with those pilot, experimental projects? What areas would you suggest we look at?
Ms Ramsay: I will preface my remarks by saying I am a bit of a dreamer in a way, I guess, and I do not work in the system. I do know, however, that a lot of practicalities would get in the way. In an ideal world, I would try some sort of a medical savings account system. In Singapore a certain percentage of your income is taken off your wages and put towards a medical savings account that has your name on it. It is for you and your immediate family to use for health care. That turned out to be inadequate and six years later they ended up having to introduce another insurance scheme for catastrophic insurance because people who had, say, a heart attack or were hit by a car had not saved enough to pay for their treatment. They then found that even that was not enough. Later they introduced an endowment fund. If you do not work or if you, for some reason, lose your job, or you spend all the money in your medical savings account and you have no family, there is a committee that will, if you prove need, subsidize your care.
Given Singapore's experience over 10 years or more, Canada could start from that point. Instead of starting with the medical savings account, Canada could try to implement something along the lines of a medical savings account-catastrophic insurance. There are many ways of organizing it. For example, it could be a government account. You could still have a completely public system. If the government spends $2,500 on average - and I am picking a number out of the air, I do not know what the latest per capita figures are on health care spending per capita - for everybody, then everybody has a $2,500 deductible before their catastrophic insurance kicks in and the government gives everybody their $2,000. There would be somewhat of a gap. You could use the tax system. There are many ways of doing it, but the general idea would be that there would be a gap so that, if you spend all the government money up to $2,000, there is $500, maximum, that you are responsible for every year. If you go over that, then the catastrophic insurance kicks in. Then you will not need to declare bankruptcy. If you only spend $1,000, then you have the $1,000 that the government gave you that you can now save for the next year. You are already $1,000 ahead of the game. Then you start saving your money. You get interest and you start capitalizing funds for the necessary care, as Dr. Morin pointed out, that you are going to need in the last years of your life.
That would be my ideal pilot project, but it would have to be large enough so that it could act like a true insurance scheme because you need a large risk pool.
Senator Carney: I was having my consultation with my orthopaedic surgeon in the hall when you slipped in. Could you give me an example of who some of your members are? When you say "health authorities" and "health organizations such as non-amalgamated health service providers," I do not know what you mean. Who are the non-amalgamated health serviceproviders?
Ms Grant: The members of the Health Association of B.C. are all of the health authorities in Prince George involved in the regionalization process.
Senator Carney: In Prince George?
Ms Grant: I am sorry, I meant to say "British Columbia." I come from Prince George. I am referring to those authorities in British Columbia, and the members that have not amalgamated with health authorities.
Senator Carney: Like the B.C. Cancer and G.F. Strong and some of the others?
Ms Grant: That is right.
Senator Carney: You mentioned regionalization, and you suggest that it should be increased to the point of covering physicians' service and things like that. There is some criticism that regionalization has led to a very bloated bureaucracy here, particularly in the Lower Mainland. I know that you probably cannot afford to point fingers, but a lot of money has gone into the bureaucracy of the regionalization process, vis-à-vis health care, patient care. What is your view of that? Is it still the case that no medical personnel can sit on a regional council?
Ms Grant: No, one member on every health authority is a physician and is obviously representing the point of view of physicians.
Senator Carney: In the beginning I believe that there were no medical personnel.
How do you react to the charge that regionalization has led to a bloated bureaucracy at the expense of patient services in terms of sustainability of the health care service?
Ms Grant: There have been a number of cases where efficiencies have been realized through regionalization. Therefore, the bureaucracy has not been expanded in every case.
Senator Carney: Have there been such instances in the billion-dollar Lower Mainland area? Do you think there is less bureaucracy now?
Ms Grant: I cannot specifically speak for the Lower Mainland but, in some areas, yes, there is; in other areas, possibly there is not.
Senator LeBreton: Ms Ramsay, one of the experimental projects you suggest is a medical savings account. Do you have any other suggestions?
Ms Ramsay: I think anything may be appropriate. I am not necessarily against regionalization as long as the regions are ultimately responsible for their decisions and cannot pass the buck to another region or to the provincial government, so that, then, the provincial government passes it to the federal government. I believe that anything that gets the financial decision-making process closer to the patient is a step in the right direction.
Senator Keon: We have one of the healthiest populations in the world and one of the unhappiest populations with our health care system. It highlights something that I think is of enormous importance to the health authorities in Canada if they are going to move forward with improvement. That is, when we look at population health, the health care delivery system is, in fact, not a very big contributor to the determinants of health. Consequently, the recommendations that come out of studies on population health deal with public health, disease prevention, and health related social conditions such as housing and wealth. We have never ferreted down to the detail that is necessary to look at our health care delivery systems. Consequently, this tremendous tool is not being used to monitor our health care delivery system.
That brings me back to Ms Grant's presentation where she made a very good recommendation, and that is that each province have a health atlas similar to the one in Ontario that comes out of ICES. The founder of that institute is a very good friend of mine. I have known him for years. He is now a dean rather than heading up ICES. That institution provides tremendously useful data. However, the problem with the ISIS reports and the atlases is that they are performance atlases. They are not looking at the problem that existed the year you went into it and the problem that existed the year you came out of it. They simply look at the performance of the health professionals and the health institutions in that year.
I would like to hear the views of both of you on how we could narrow the gap, because we are coming very close to a tremendously useful instrument, but we are not there.
Ms Kallstrom: In British Columbia, our health authorities do develop three-year rolling health services plans that are based on demographic characteristics, such as mobility characteristics, and socio-economic characteristics. They look at the services that are available within a health authority and consider, for the next year or three years, what the health services plan should look at in order to marry the two to address gaps, duplications, or unnecessary services. This is fairly new. It has not been in operation for more than two years. It needs to evolve.
The recommendation was that we need provincial and federal support to increase that information. We need evidence of what the population in each community looks at; what kinds of services do they have; who are they provided by; what are the outcomes of those services. The atlas, of course, provides how much service, per population, was provided.
However, an even more important indicator would be the actual outcomes. What were the results in those communities? Cana dians are healthy. Within Canada, British Columbians are the healthiest, with the exception, of course, of our Aboriginal population. We have a particular challenge from a population health perspective and from a health services perspective. How can we design our services and deliver them so that they will be maximally effective? However, we are missing the first base-line information.
Ms Ramsay: There is the difference between the general population and the First Nations population. In doing this study, I travelled up to Prince George and Vanderhoof. In many areas of British Columbia the health status figures are not as optimistic as those for the rest of the province. Certain areas are not doing as well. Ideally, you want the needs of your population needs so you can provide for them. We will always be guessing, to a large extent, if we do not ask the patients what they need or give them more control over where they can go or where they can direct their funds.
Someone asked Dr. Day if there were enough orthopaedic surgeons. The most we can say right now is that there are not enough; but how many is enough? It is very difficult to say when you are assessing it from the top down.
While I do laud these efforts - and obviously I like data, and the more I can have the better it is to look at the system and how it is performing - I do not know if we will come at it from the right direction.
Senator Keon: I think you will. Your problem is you are not drilling deep enough. You have a tremendous handicap in that you do not have a health care information system that is adequate. Again, I believe that will come.
If you do this on a yearly basis, a three year basis or whatever, one of the most important components you can look at is the change that is occurring and assess where you have come from. The next time you do the exercise, you must drill deep into the health care delivery system and into disease entities. Gather information on diabetes, for example, and assess how that impacts on the system. Do the same thing for cardiovascular services. I think you will find that information if you drill deep enough.
Ms Ramsay: Part of the problem is that we are strapped for resources. Where do you find the financial resources and the human resources to drill down that deep?
Senator Keon: You are absolutely right. We were discussing with the group who appeared before you how we can collectively get ourselves, our governments, our citizens, into the operational frame of mind to make the kind of quantum change that was made in the 1960s. Of course, if we could do that we could solve our problem.
The Chairman: Thank you for taking the time to assist our committee today.
Senators, we have one last panel today. We have Professor John Gilbert, who is the coordinator of health sciences for UBC, Dr. Charles Wright, Professor and Director of the Centre for Clinical Epidemiology and Evaluation, Barbara Mintzes from the Centre for Health Services and Policy Research and Dr. Kristina Sharma from the Professional Association of Residents of British Columbia.
Dr. John H.V. Gilbert, Coordinator of Health Sciences, University of British Columbia: Mr. Chair, senators, I am going to talk specifically about chapter 11.
The Chairman: That is the human resources.
Dr. Gilbert: That is correct. There are some interesting questions about health and resource planning in this chapter, but they give almost no attention to the way in which the education of health professionals should be changed to address changes in the health human resource. On page 100, paragraph 2, the report reads:
We need therefore to ask explicitly whether it is time to move away from the hierarchical way of thinking and attempt to adopt a `spectrum' approach to health human resources.This is a useful starting point for my comments. Since the Royal Commission chaired by Chief Justice Emmett Hall, every report on the health of Canadians, begins with the health care system after professional education has ended. If we are serious about changing the extant "hierarchical way of thinking," then I contend we should pay serious attention to the manner in which health care professionals are educated from the moment they begin their first day of instruction. If we do not begin with that first day of inculcation - some might say indoctrination - then it is difficult to imagine what real chance we have of changing the practice of health care and thus its delivery in this country.
To begin this inter-professional education process on the first day of classes is in no way meant to detract from the fact that each profession has a particular set of skills, that need to be developed, valued and deployed.
My sense is that one of the reasons we are not using our health professional, again, to quote, "to anything like the full extent of their capabilities," is because their educational programs are structured in such a fashion that they do not foster an understanding of the particular strengths and scopes of each other's practice.
Given the proliferation of health professions and the contribu tion of such proliferation to health cares costs - what Dr. Bob Evans termed the "upstream costs" - it is clear then that concerted attempts must be made to develop inter-professional education at a very early stage in the education process. Such an attempt would advance clearly the notion of a spectrum approach that is set out on page 109 in the report. Clearly the health education programs in this country attract outstanding students. Any dean will tell you that in spades. Realizing their full potential for the workplace, must occur during the time they receive their education.
There is no doubt that redundancy exists in the education of health professionals, beginning with that of physicians. Parallel courses are taught in programs under the guise of needing perhaps such a course for the "special" group being educated. I would challenge you to look at the multiple variance of statistics that are taught in our health care programs to see what I mean. The University of British Columbia used to have 353 statistics courses. We decided that was too many so we opened a department of statistics. We now have 353 plus the department of statistics.
This is true, of course, for many other areas. Currently, most students in health programs never meet students from other professional programs throughout their course of education. Ask one of the physicians-in-training about this. How can we promote the spectrum approach when this is the case?
Many professional programs still teach courses about subjects when they should be teaching courses about problems. Even when problem-based programs are put into place - as at UBC's Faculty of Medicine - the only professional who looks at the problem is the one in the specific program in which it is being taught. Problem-based courses offered to a variety of professional students would allow for all manner of professional interactions in the learning process. Such courses should be at the heart of the education of health professionals, rather than on the fringes. They should be offered to students from three or more professional programs taking them together.
The scopes of practice of professions, and competencies expected before graduation to practice - both developed by the health professions - need very careful examination. I know you have done some of this. Major efforts should be made to eliminate duplication of scopes and competencies across professions. They are expensive and they are protectionist.
By developing inter-professional education possibilities, educa tional programs should be encouraged to pare down their course offerings, rather than bulk them up to add yet another layer of material to already crowded curricula. Educational programs should be encouraged to look for synergies with each other, and concentrate their curricula on the small core of knowledge particular to their profession. To achieve these ends we need a national funding agency whose mission would be to carry forward the incredibly important process of critically examining health education. At the moment, this kind of educational research is conducted piecemeal, and exceedingly poorly funded. We need a national health education program with resources to underwrite program development and evaluation at least on a par with some of the social science institutes in the CIHR. If we can afford four hundred million dollars for basic research - or whatever research is being conducted across CIHR - we can surely afford some money to look at the evaluation of the educational programs we have.
We need to come to grips with the notion that we cannot go on adding more and more health professions. I received today - from an unnamed Canadian university - yet another proposal for yet another program for yet another set of health professionals, and I have no idea what they will do. Not every technological group should aspire to a degree-granting status. The push from the bottom - from certificate programs wishing to become degree- granting programs then results in the "bread-rising phenomenon" - those with bachelor degrees now want masters degrees as entrance to practice.
We need to take prompt action to begin funding this process. Adding more and more resources to the training of more and more professionals - which is what I have read in some of your submitted data - can only be part of the answer to our health human resource problem. If we conducted a serious examination of the way in which our educational programs are organized; if we asked how we might introduce a strong and permanent element of inter-professional education into those programs; and, if we sought funding sources that would allow us to better understand the relationships between professional education groups, then we might have an outside chance of changing the practice of health care.
The Chairman: Thank you.
Now speaking on behalf of those who are being indoctrinated, Dr. Kristina Sharma on behalf of the Professional Association of Residents of B.C.
Dr. Kristina Sharma, Director, Professional Association of Residents of B.C.: Thank you for the opportunity to appear before the committee. I am a radiology resident at University of British Columbia and I am also a member of the Professional Agency of Residents of B.C., PAR-B.C.
I would like to briefly describe what PAR-B.C. is, so that you will understand why I am here. We are a trade union representing approximately 564 medical residents throughout the province, 20 per cent of whom are in family practice programs, and80 per cent are in specialties such as surgery, cardiology, medicine, et cetera.
Residents are MDs in the final stages of education for their career paths, whatever specialties these may be. They can either be a recent graduate from a medical university or a practicing physician who has returned to change their career paths or a practicing physician who has come to develop more skills, such as a rural physician who might return to develop skills in anaesthesia to take back to their home communities.
Residents are not students in the traditional sense. We train within the hospital in an apprenticeship format. We learn primarily by practicing medicine under clinical supervision. In doing this we provide the bulk of primary care for most physicians. We carry the responsibility for in-hospital care on nights and weekends. Depending on the training program, a resident is tied to the hospitals from approximately two to eight years.
Recently, we conducted a focus group looking at issues that the Kirby commission brought forth and two pertinent areas that came into focus for us. One was education or the barrier to education, and the second was a lack of input that is afforded to residents.
With respect to the barriers to education, the first one identified was increasing debt load. Medical students now have tuition to deal with as well as increased costs of university education. Most medical students will have at least one degree prior to entering medical school. By the time they finish medical school, they can have debt loads up towards $120,000. Unfortunately that can result in a student choosing a career path based on fiscal remuneration rather than what is a more appropriate choice for that person. They are basing it on how they may financially be able to pay off their loans.
The second barrier is a lack of flexibility. Medical students are being asked to make choices early in their training as to which path they will follow. That is most unfortunate because people are pressured to choose professions before having had any experience in those particular fields. Hence, when they are applying for a job they have no idea what it will mean.
Such inflexibility makes for very dissatisfied people later in life. People who find themselves in that situation are dealing with inflexibility in switching residency programs, and that is secondary to lack of positions and lack of funding for those positions. I am one of those individuals who found myself in a position where I was unhappy with my choice and was unable to get out of it, so I came as a re-entry position.
The second point that I made was the lack of input. With 564 residents in B.C. and approximately 8,500 residents across Canada, we are proportionately about 10 per cent of physicians. With the average age of physicians roughly early 50s now, in the next 10 to 20 years we are going to be having a larger proportion of younger physicians. The point I am trying to make is that now we have got a large segment of young, enthusiastic doctors who do not get to voice their opinion. Residents are largely unacknowledged when it comes to making any type of decisions with respect to health care and education.
PAR-B.C. and residents are prepared to accept responsibility for getting its voice out, however it is difficult to do when its opinions are not sought or assumptions are made that others can speak for residents.
Residents and established physicians are different. We have different perspectives. The BCMA cannot and does not represent residents, nor can medical students and medical student associ ations. I am hoping that my presentation today and PAR's written submission will, at the very minimum, serve to increase the visibility of residents and educate decision-makers as to need to seek involvement from us from the very beginning. Thank you for your time.
Ms Barbara Mintzes, Professor, Centre for Health Services and Policy Research, University of British Columbia: I am going to move to a different area to talk about two issues that are dealt with in section 8, which is on pharmaceutical issues. The first issue is advertising of prescription drugs to the public and the second is the recommendations in the report on how a national formulary might be constructed in terms of decision-making for including drugs in the formulary.
I wanted to bring up both issues because I work with the Centre for Health Services and Policy Research on a project, funded by Health Canada, assessing the impact of direct-to-consumer advertising on the Canadian health system. I am also working with the therapeutics initiative which is also situated at UBC and which evaluates the safety and efficacy of new drugs for the provincial Ministry of Health. Both issues are related to my work.
Prescription drug advertising has been rapidly increasing in volume in the United States in the last decade - from less than U.S. $100 million spent at the beginning of the decade to more than U.S. $2.5 billion. The only other country that allows prescription drug advertising is New Zealand. So Canadian law is very close to the international norm on this.
We prohibit prescription drug advertising on two health protection grounds. One of them is related to prescription-only status, which is awarded to drugs where there is greater risk of toxicity and where there is need for greater care with use. The other is related to the list of serious diseases in the act for which treatments or preventatives may not be advertised to the public. There the rationale is very closely related to the greater vulnerability of people when they are ill. Recognition that in seeking a medical treatment, being in pain or caring for an ill child is not the same thing as going out to choose a new pair of jeans or a new perfume.
Why would we change our law? From a public health perspective there would be two reasons. One would be that if our fears of risks were unfounded, if we found that actually there was conclusive evidence to exclude the possibility of harm, and the other one would be if there was very solid evidence of a health benefit in allowing prescription drug advertising.
I have carried out an extensive literature review of health economic business and marketing databases as well asunpublished literature to look at what kinds of empirical studies had been done. There is a huge body of literature, very little of it actually consisting of empirical studies. It is easy to answer the question about whether there is any evidence of health benefit because there is none. In terms of either decreased rates of serious diseases, decreased rates to rates of hospitalizations, improve ments in the use of pharmaceuticals or improved use of health services. These are all related to claims that have been made for prescription drug advertising. It is also in spite of nearly 20 years of this type of advertising in the United States.
There certainly is evidence that a substantial minority of the public in the United States does respond to prescription drug advertising by going in to their doctor and by requesting a prescription drug. If you believe the pharmaceutical marketing surveys, they are highly likely to receive the drug that they request.
There also is a very strong association with increased costs. In 1999, the top 25 drugs by advertising budget accounting for 41 per cent of a U.S. $17.7 billion dollar increase in retail drug costs over one year alone.
The commission's recommendations on direct-to-consumer advertising focussed on three arguments for introducing this kind of advertising. One was the consumer's right to know what prescription drugs are available. Second, companies' right to communicate to consumers directly. The third is our widespread exposure in Canada to advertising that is streaming across the U.S. border.
In terms of consumers' right to know what drugs are available, advertising provides a poor mechanism to let the public know what products are approved for marketing. A very, very small portion of the drugs available on the U.S. market or the New Zealand market are actually advertised to the public. Consistently in the U.S. about 40 per cent of spending is on just 10 products. These tend to be very new, expensive products for long-term use for a broad audience. In other words, the decisions are marketing decisions made on the basis of returns on investment.
Additionally there is no legal restriction in Canada on the public receiving information about what drugs are available and what drugs have been approved. Health Canada posts this information on its Web site.
In terms of the type of information contained in advertising, I think it is worth looking at the regulatory experience because regulatory violations are very common in the United States. The major reason is inadequate risk information or exaggerated claims of benefits.
New Zealand is a model much closer to what advertising would look like in Canada in that they rely primarily on industry self-regulation. The government did a spot check inFebruary 2000 and asked companies to voluntarily submit their ads and they found that over 80 per cent of the television ads violated the Medicines Act and about a quarter of the print ads.
In terms of the actual type of information reaching the public, there is a problem. It is also very rare that misleading information is corrected. Systematic reviews in the U.S. have also found that the educational value is quite low. A review of 10 years worth of print advertising in 18 major consumer magazines, looking at every prescription drug ad, found that 91 per cent of the ads did not mention the likelihood of treatment success with a specific medicine that was advertised.
The second issue that is addressed is the constitutionality of the current prohibition against prescription drug advertising. That is based on a 1995 tobacco advertising case that went to the Supreme Court, which had a very divided decision. The decision was five to four in favour of the tobacco industry. This decision found that Health Canada had not adequately shown evidence that a full ban on tobacco advertising met public health goals to a greater extent than a partial ban. As the commission mentions, there are certainly divided opinions about applicability to pharmaceuticals. With pharmaceuticals we already have a partial ban on advertising because the sale of prescription drugs is controlled and the advertising controls are actually in keeping with the controls on sales.
The report recommended that if we had a national formulary we could have prescription drug advertising and it would not be a problem in terms of effects on costs in the public sector because we could include a clause within formulary, saying that drugs on the formulary could not be advertised to the public.
PHARMAC, New Zealand's pharmaceutical management benefit scheme, tried to introduce a similar clause in 1999. They were prevented, they were told it was illegal to introduce such a clause because of the Commerce Act, because it was a restriction on competition within an environment where such advertising is legal. I wanted to raise a note of caution about that, and I have included in my written submission the correspondence with the Ministry of Health in New Zealand.
The other issue is that if there are concerns about risks from a public health perspective from advertising prescription drugs, then asking people to pay out of pocket for advertised drugs does not actually deal with that concern about risks. So that is another related issue.
The third raised by the commission was the increasing volume of advertising coming to the Canadian public through cable television. I was pleased to see the recommendation that we require cable providers to replace advertising that is illegal in Canada. That recommendation is long overdue. We have seen a large increase in this advertising since the U.S. changed its regulations on broadcast advertising in late 1997.
Another related issue is the difficulties we have had in Canada with enforcement of our law and with advertising campaigns that are originating in Canada. We have seen a reinterpretation of the current law and we have seen the industry going continuously pushing the limits of the law and beyond.
As a drug reviewer, I would like to briefly touch on the recommendations for the national drug formulary. The commis sion's report recommends using consensus opinion among all key stakeholders - including private and public payers, health professionals, regulators, patient groups and the pharmaceutical industry - to decide what drugs to cover in the formulary. Such an approach would be best described as "influence-based medicine" as opposed to "evidence-based medicine." He or she who has the most influence behind the scenes is more likely to get their drug covered by the formulary.
The problem with this kind of a consensus-based process is that it is unlikely to create formulary decisions that would reflect the best scientific evidence in terms of whether a newly approved drug provides a treatment advantage in comparison to what already exists. It is also very unlikely to lead to effective cost containment. There are certainly a lot of examples already of evidence-based approaches to decisions about formularyinclusion.
Dr. Charles Wright, Professor and Director, Centre for Clinical Epidemiology and Evaluation, University of British Columbia: Mr. Chairman, in this huge spectrum of questions you are dealing with I, too, was going to focus on one particular issue, which you raised this afternoon and which has certainly been raised in your previous publications. That is the issue of accountability, performance indicators, evaluation of the system, and how to make it meaningful. I am a surgeon by background, but for the last 10 years I have been in administration and research and consulting in the health system.
The need for greater accountability seems to be recognized increasingly in the system, particularly accountability foroutcomes - we have always had the necessity of accountability for financial management and so on. What has been missing is any significant accountability for outcomes of the services we provide. In the brief I have quoted a lot of Canadian sources there pointing to the need for this to happen in the system - including both sides of the administrative fence, if you like, practicing physicians, physician organizations, governments and so on.
This has to be done through evaluation. There are techniques available that have simply not been used in the system up until now. The good news is that everyone seems to agree. I do not know if this would reflect your views after so much work on your committee, but it seems to me that everyone currently in the Canadian health care system agrees that the current system, unchanged, unreformed, as it exists, is not sustainable. That is the good news.
The bad news is, of course, the difficulty in knowing what to do about it. There is a piece of this, in terms of the evaluation of services, where I think there are significant gains to be made. The argument about whether new funding is required bears on this and on access as well. If there are any services that, on evaluation, should be either done less or in different circumstances or are inappropriate, then we have to start flagging them. We know they exist.
Three major observations led to the major study, which is described in the brief. I will summarize the details briefly.
The observations that led to this project were, first, the huge variations that occur in all services, whether you are talking about prescribing patterns, patterns of hospitalization, treatments, diagnostic services, surgical operations, there are enormous variations in the rates.
On page 2 of the brief, I have shown a couple of examples. You could take these from any jurisdiction in Canada; these happen to be from British Columbia. You can see quite a variation in the rates from local health authority to local health authority. In this case, the figures show a surgical rate variation of up to500 per cent for intervertebral discs and cataract surgery, even when the data is adjusted for sex, age and residence. It is very difficult to argue that these differences are based on medical necessity of the population. That is observation number one.
Secondly, a large proportion of the services that we are now providing in Canada are designed to relieve pain and disability with little, if any, effect on survival. This is particular of the high-volume, high-ticket items in surgery.
Thirdly, that there are only two outcomes that matter in a health care intervention. One is survival and the other is how the patient feels about it, ultimately. Now, quite a number of surrogate outcomes will bear on that: for example, the haemoglobin is up, the tumour is smaller, the X-ray looks better. These are all surrogate outcomes. All that matters is whether we have relieved the patient's pain and disability or helped with what is called health-related quality of life, HRQOL.
That is what led to this project, which was funded, by the way, by Health Canada through the Health Transitions Fund. We looked at more than 5,000 patients having over 6,000 consecutive operations in a variety of services. We obviously could not examine every procedure in the book, but we examined gallbladder surgery, prostatectomy, hysterectomy, spinal disc surgery, and cataracts. The indications for surgery were evaluated according to an independent criterion set and the patient's results were assessed by the patient's self-reported health-related quality of life, for which many good instruments are now available. Unfortunately, health-related quality of life as a measurement is not yet on the average physician's radar screen because it has been seen in the past as a somewhat soft science. It is now highly respectable and it is a serious discipline.
The health-related quality of life was assessed pre-operatively and sequentially after operation. You may have seen some of the enormous publicity when the results were first released to the public and the press in April. As an example for context, the front page headline of the Vancouver Sun said "Most patients having elective surgery benefit." The front page headline on the Globe and Mail the same day said "Unnecessary surgery is rife in Canada."
Both headlines are true. This is a huge study, an order of magnitude greater than anything previously been done in this arena. It is true that most patients - most equals anything over 50 per cent - did indeed benefit and the great majority benefited in these procedures.
However, a proportion of patients in everything we looked had very mild - almost insignificant - pain and/or disability before an operation. Most are at the other end of the spectrum and one would not want to wait for a patient to be totally crippled, for example, with arthritis before they have their total hip replaced. Nor would you want to operate on someone who has just woken up with the first twinge of pain in the hip.
What has been lacking here, I think, is a balance of judgment, and public expectations are a major problem in here. Patients have to be constantly reminded of the balance of risks and benefits from health care interventions. Thousands of people die from taking aspirin in North America every year. Every operation has major complications. The most significant one of the six procedures that we studied was cataract. Where a large proportion - 32 per cent - pre-operatively had a visual function that was 91 or greater on a scale of 100. Essentially that means that they have very, very minimal visual disability. What is even worse, 26 per cent of the patients reported worse visual function after surgery than before. I think what we are seeing is what we call the "ceiling effect." If you are already at a very high level of functioning, you do not have far to go in the way of improvement.
The individual results for all the procedures are interesting, but that is the summary. What this leads to is a recommendation that evaluation of appropriateness and outcomes using this kind of assessment should no longer be a matter that is left to researchers doing little studies here and there. The major reason that Health Canada funded this project was as a feasibility study. We have demonstrated that, yes, it is feasible, it is not particularly expensive to do, and it needs to be done. If one were to do this - and this is the tough part - if one were to take account of the results in terms of potential resource allocation within the system, then we could make some major progress.
Senator Roche: I would like to thank the panel for very diverse presentations. I would like to focus, if I may, Mr. Chairman, on Dr. Sharma. I would like to spend a couple of minutes talking about the life of young doctors, it has interested me quite a bit.
On page 11, you say "Medical students who emerge with debts in the order of $120,000 are seen as having little choice but to choose to practice where they can make the most amount of money." Is the $120,000 debt load coming out of the fullness of medical school common? Or is that exceptional?
Dr. Sharma: I don't have exact figures, but I can tell you certainly the range of $80,000 to $100,000 is the norm.
Senator Roche: Pretty high debt load.
Dr. Sharma: Yes.
Senator Roche: What is the impact of that? You say it forces them to choose areas where they can make money and get rid of the debt, but how does that play out into the system?
Dr. Sharma: You may have more physicians stemming away from family practice, which is not as lucrative as a specialty. Within the specialties something like pediatrics is less lucrative than cardiology or opthamology, for example. What we heard from our panel, from our focus group, and from residents, was that some people are making decisions based on financial reasons and not particularly what they might want to do. Maybe they were drawn into medicine to become a pediatrician, but they do not feel it is reality because they are starting life with a $120,000 debt load.
Senator Roche: The fact that they start their practice with a high debt load does not seem to be an impediment in the first place since there are six times as many applicants for entry as there are places.
Dr. Sharma: For medical school, you mean?
Senator Roche: They do not seem to be worried about this debt load.
Dr. Sharma: I think that you are quoting a number prior to medical school. Medical school itself is becoming very expensive, especially in Ontario where it has been deregulated and tuition can be as high as $14,000 per year now. We are following very much the U.S. pattern in that and you see that repeatedly as well where medical students are choosing professions based on money.
Senator Roche: Now, in seeking to discharge their debt load does the U.S. factor enter in here? For doctors in your age group is going to the United States an attractive option for them for economic reasons?
Dr. Sharma: I think it is for some people, for financial reasons. It is not just limited to the U.S. either. Many physicians in practice - not necessarily new physicians - look at other areas such Saudi Arabia, or the United Emirates. As far as residents go, I cannot say that I know of specific cases where they have been driven to the U.S.
Senator Roche: I missed that. You could not say -
Dr. Sharma: That I know of a specific resident or a new physician who has gone to the U.S. directly from their training.
Senator Roche: What do you want to do in your medical life?
Dr. Sharma: Well, I should give you a little background of my medical life. I ended up in family practice. I graduated and got my CFFP, which is a specialization in family practice. I practiced for one year in both urban and rural communities. It became apparent to me, during my final year of training, that it was not a career path that I wanted to follow. I tried very enthusiastically to switch career paths and I was unable. I could not find an opportunity to do that.
Once I finished I looked at re-entry, and in Canada it is extremely difficult. I was looking at going to the U.S. because it is easier to get a specialty there. I know of two physicians who have done that as well, who have gone for retraining in the U.S. because they could not get access here at home.
Senator Roche: So what kind of medicine are you going to practice? What do you really want to do?
Dr. Sharma: I am going to be a radiologist. I am in the midst of my training currently. I was only able to do that because I got external funding.
Senator Roche: What does that mean?
Dr. Sharma: That means I worked out a return-of-service contract with Prince George, a community where I had done my initial training and practiced.
Senator Roche: Is that bad?
Dr. Sharma: That is not necessarily bad, but I do not believe it is the best option either. I think more people would change career paths, if they could, at various times - whether it be in their residency or following their residency. I am lucky to have a return-of-service contract as I do because I have a spouse who would be able to work in Prince George. If my spouse was an MBA or worked for a big bank or something, he would not be able to survive in Prince George. He would not have a job. It would not be something that I could consider unless I was willing to leave him behind. I am lucky because I had that flexibility, but other people do not. I am saying it is not the best choice.
Senator Roche: Good luck in your career.
Dr. Sharma: Thank you.
The Chairman: Professor Gilbert, in your comment you said that the students in one profession do not learn anything about the other professions and therefore it is difficult to learn to work in teams. You also mentioned the need to change the scope of practice and competency rules. I understand the problem, I completely agree with you. We identified the problem as well in our report, but I am puzzled that someone in your position - maybe I am unclear on what the coordinator of health sciences does - but it seems to me that you are in a position to be able to work towards solving the problem.
Do you understand what I am saying? What I am saying is that here you are in the academic institution that is training these professions. Can you people not have influence?
Dr. Gilbert: Have you looked at all the health programs in Canada? This is an interesting question, but we need about three weeks to answer it.
The Chairman: You understand the point I am making. Let me put it this way: I asked the Dean of Medicine the question, he made it very clear it was not him. I understand politics is the art of shifting the blame. I was curious, I am trying to find out who is supposed to deal with this problem.
Dr. Gilbert: It is a good question. I can tell you that last night at the University of British Columbia Senate we approved the establishment of a college of health disciplines. You might say, oh, another faculty, but in fact it is not. It is an affiliation of seven faculties who have agreed to collaborate to do what I have spoken about this afternoon.
The Chairman: Including medicine?
Dr. Gilbert: Including medicine. It has taken two and one-half years of hearings just like this to get there. Roosevelt said changing the curriculum is like moving a graveyard. Getting people to move to this place is incredibly difficult, but we have done it. It is absolutely amazing. However, we still need the tools to do what Charles has referred to in a different context: evaluate. We need to know: Does this work? If it works, where does it work? Where it works, does it work successfully?
The Chairman: I agree.
Dr. Gilbert: Okay. It is an incredibly difficult thing to do and we have spent all that time and we have done it.
The Chairman: Are you the first place in Canada to do it?
Dr. Gilbert: We are the first place in the world to do it because it is such a difficult thing. Universities are bound by acts, university acts. If you read them very carefully they place responsibilities with faculties. It is the statute that governs universities is what makes this difficult to do.
The Chairman: As a former academic I can say I have always thought universities were the only institution designed to be unmanageable.
I have one question for Professor Mintzes. On page 5 of your brief you talk about a reinterpretation of a Health Canada regulation under the Food and Drug Act which is now leading to some forms of prescription drug advertising that used to be banned. Can you give us some more detail on that either now or later?
Ms Mintzes: It is very simple, I can give you detail now. In the Food and Drug Act, there is one exception to the broad prohibition against prescription drug advertising to the public and that is an exception that was brought in 1978 to allow pharmacists to post comparative prices in pharmacies. It is in keeping with the public health perspective in that it is useful for the public to have comparative price information. That exception states that an advertiser may not make any representation other than name, price and quantity in an advertisement of a prescription-only drug.
That amendment to the Food and Drug Act has now been in place for more than 20 years. However, it is only in about the last two years that we have seen billboards that say "Zyban, ask your doctor" or that say "Dyan 35, ask your doctor or your dermatologist," or we have had Guy Lafleur on television flogging Viagra. There has been a large change in terms of the type of advertisements we are seeing originating in Canada.
I have been involved in several complaints to Health Canada about illegal advertising campaigns. My information about the reinterpretation of the law comes out of a letter from Allan Rock to a coalition of women's health organizations with which I work that had complained about an advertising campaign targeting young women. The reinterpretation says that an advertiser may state the name of a prescription drug as long as they do not state the indication or they may state the indication as long as they do not state the name.
If I read the Food and Drug Act that is very different from what is in it and it is certainly very different from the spirit of the prohibition in the act. Also even the wording "may not make any representation other than," well, a sort of advertising image is a "representation other than," so is "ask your doctor."
The Chairman: This was a reinterpretation, I presume, you said done two years ago?
Ms Mintzes: We first saw it in writing in a letter from Allan Rock in September 2000.
The Chairman: Could you do us a favour and give us the letter? We can chase the letter down through our bureaucracy but it would be much faster because you know where the letter is.
Ms Mintzes: Yes. I will work out afterwards how to get you a copy of the letter.
The Chairman: I have seen those ads and I wondered myself how they were not clearly a violation of the law.
Ms Mintzes: My interpretation is, yes, they are clearly in violation of the law.
The Chairman: None of us around the table are lawyers, but I would agree it is in violation of the spirit of the act.
Senator Morin: I have a few short questions.
Dr. Wright, as you know, in the health system there is a payer, the provider and the evaluator. Everybody has been talking about the payer; everybody has been talking about providers. If we had, let us say, several providers in the region, how would you set up an evaluation system for these providers? How would you go around to do that?
Dr. Wright: The proposition is that if there were a variety of providers and payer mechanisms? You would do it by contract. The tools are available for evaluating health services. It would be naïve to suggest that we have good ways of evaluating everything. However, for much of what we do - prescribing, hospitaliz ations, surgical procedures, diagnostic tests - we have means of evaluating them. It is simply a question of operationalizing them.
Senator Morin: You would contract that out to whom?
Dr. Wright: There is a cadre of professionals in the health care system - most of whom work in the acute care system in hospitals now - that have various names like quality manage ment.
Senator Morin: Do you think it is bit odd to have the people actually within the system evaluating themselves? Would you not prefer to have an evaluator that would be outside the providers if you want to evaluate them?
Dr. Wright: This debate goes on in any evaluation program. You need people who understand the system thoroughly, yet there is a potential, of course, for a bias.
Senator Morin: You cannot very well evaluate yourself and compare yourself to others.
Dr. Wright: I think in this case it is not a problem because the cadre of people I am describing do not take all the major decisions. Physicians and nurses take the m major decisions. The evaluators are almost all middle-management people, administra tors in the health care system, or people who have taken clinical epidemiology evaluation courses, administrative health science courses.
Senator Morin: Do you not see a possibility of having an outside organization that would be different from the providers to carry out the evaluation?
Dr. Wright: I would love to see an outside organization set some national standards and say "here are the means of conducting your evaluation" and "here is how we would suggest going about it," because a lot of people are floundering.
Senator Morin: Would that be a quality council or would that be something different?
Dr. Wright: It would be absolutely within the quality framework, yes.
Senator Morin: Thank you very much. I think Dr. Wright is the first one that has talked about this and it is an essential element of any system to evaluate what you are doing. Are you saying that the standards should be national and the actual evaluation done more locally but you have no objection to it being done within a hospital?
Dr. Wright: Any evaluation program needs an assessment of how much can be done within and how much should be completely independent.
Senator Morin: Professor Mintzes, I have read that there is a European pilot project, which is quite extensive, covering several countries, that has a view towards extending drug advertising throughout Europe.
Ms Mintzes: There is a proposal made by the European commission that has not yet been voted on by the parliament so it is not clear what will happen with it. That is a proposal for allowing advertising for three disease states.
Senator Morin: As a pilot project?
Ms Mintzes: I have seen the proposed changes in the legislation and certainly some of the public proclamations about it do not really match the proposals in the legislation. It looks like a project - pilot or not - to allow limited advertising for three disease states. Previously, there had been statements from the U.K. saying that the results of the European union review did not show any appetite among member states to allow this advertising.
Senator Morin: From what I understood Europe is moving in that direction, but time will tell where they move.
Ms Mintzes: It is not clear yet, but within the year, I think, the parliament will probably vote on it.
Senator Morin: If Europe moves that way, with the U.S. and New Zealand, we will be in a bit of an isolated situation here.
Ms Mintzes: Australia has carried out a review of their legislation from a trade and competition point of view and, contrary to what was expected, they recommended very strongly against allowing advertising.
Senator Morin: Australia is a different situation concerning drugs. As you know, they are on the special list of the most unfriendly country towards the pharmaceutical industry.
Ms Mintzes: I would not say that. In fact, they have a national medicines policy that includes supporting the industry.
Senator Morin: Dr. Sharma, thank you very much for coming. I think it is important for the national organization to be present on this debate. You have a few recommendations dealing with our program. For example, everybody is grappling with the primary care reform right now. I think you family physician residents should be right into this and they should do it fairly quickly because they will live with this.
Dr. Sharma: Yes.
Senator Morin: There are all sorts of issues. For example, should we go to fee-for-service capitation, that is the way they will be paid. How do they feel about interdisciplinary teams, - nurse practitioners working next to them? These are the people who are going live with this throughout their career.
I strongly urge you to have your national organization look at this, look at our report, like other reports. The Fyke report and the Claire report are all dealing with primary care reform. I think the family physician residents should be very much involved in this.
Generally there are other issues dealing with those who are in specialties, but I think we need strong input, fairly soon, from the family physician residents on the primary care reform - which would be a major reform if that gets through. I think they should make their point known quickly.
Dr. Sharma: I agree.
Senator Keon: Dr. Gilbert, I want to congratulate you on what you have achieved. In the health professions there is no question we have been turning in bad fits for some time. People are coming out of the system with an education that does not equip them at all for what they are going into, and that is one step along the way in making progress. We have got a long way to go in the health professions and I will just leave it at that, the hour is late.
Dr. Sharma, I want to move from that point to you. I am concerned about the way the Royal College has become rather inflexible. I was on council of the Royal College for more years than I care to admit; I also served as a professor of surgery for 16 years where I had to deal with resident flips from programs and so forth.
I would strongly encourage you to get involved. You are young, you have lots of energy, get your friends involved. You have got to change the thinking at the Royal College. I can you tell you, some of the elders there are getting a bit long in the tooth, like myself, and a bit out of touch. They need some young people to shake them up a bit.
I do specifically though want to come to your predicament, which is disturbing. You have trained as a family physician, you have discovered you do not want to be a family physician. You are now training as a radiologist. You are tied to the barn, going back to a relatively small community. I get the distinct impression you want to be an academic probably. I could be wrong, but I get that impression from what you are saying. So you sold your soul and it is not going to take you down the career path you want to go. That truly is tragic. However, I am sure you will surface and eventually get to do what you want to do. The important thing is you get there, even if it takes you a few years longer.
I will not question you, Ms Mintzes. Your presentation was clear, I know what your points are, and they are well taken.
Dr. Wright, I want to make one important point with you. I commend you on the study, and I read the headlines. This indeed, is the only way to go if we are actually going to any health care planning, but I feel very strongly that this has to be linked to population health. The directives have to come from the top on a population health basis. There is nothing wrong with contracting out to groups of epidemiologists who will probably do it better than bureaucrats located either in Ottawa or provincially or whether it is ISIS or some other organization that does it. It does not matter who does the studies, but the studies have to be connected to population health with the appropriate feedback loops so that appropriate health care planning can be done.
I hope you will agree with that. I am really teasing that gospel out of every witness we get here and I do not know if I am going down the wrong path.
Dr. Wright: I have no argument with that. That would be the ideal situation to me.
The Chairman: I thank all of you for coming, it has been absolutely fascinating. I think, Dr. Gilbert, you have the toughest assignment because trying to corral all those horses and get them moving in the same direction is not going to be easy. I will tell you one of my early academic assignments was trying to create a faculty of science out of a school of library science, a business school, a school of public administration, a school of health administration. Anything I have done in government was easier, so good luck.
Dr. Gilbert: Thank you.
The committee adjourned.