Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 41 - Evidence
ST. JOHN'S, Monday, November 5, 2001
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 9:00 a.m. to examine the state of the health care system in Canada.
Senator Michael Kirby (Chairman) in the Chair.
[English]
The Chairman: Senators, our first witnesses this morning are Robert Thompson, Deputy Minister of the Department of Health and Community Services, and Beverley Clarke, the Assistant Deputy Minister of Policy in the department. Thank you both very much for coming. We appreciate you taking the time to come and chat with us. We will hear your opening comments, and then we will ask you some questions.
Mr. Robert C. Thompson, Deputy Minister, Department of Health and Community Services, Government of Newfound land and Labrador: We are delighted to have an opportunity to present our views on the health system in Newfoundland and Labrador, and the issues that your committee is addressing.
In particular, we will address the finance and population health dimensions of your Volume 4 report. I apologize that our presentation is not before you, but we will make sure that copies are deposited with the clerk later on today.
Accelerating costs in health care, high public expectations, inadequate federal revenue, waitlists, and the difficulty of transferring resources into population health programs are problems that Newfoundland and Labrador face along with many of the provinces across the country. While we are proud of our health professionals and services, and we observe high levels of patient satisfaction, we are concerned for the sustainability of the current system.
To address these issues, the Honourable Julie Bettney, Minister of Health and Community Services, has launched a consultation process called "Reaching Consensus and Planning Ahead." The purpose of this consultation is to reach a consensus on the key principles for decision-making for the future of health system in this province.
This process started with regional stakeholder forums, and will conclude with a provincial forum on November 27 and 28. It is a process similar to your own.
The timing of this consultation is critical. The government must make short-term decisions to deal with the pressures of public finance, but wishes to make these decisions within a long-term framework. In this sense, the outcome of these consultations will have a direct bearing on operational plans and budgets for next year.
In the area of health finance our provincial discussion paper highlighted some of the key dilemmas facing the system: a substantial reduction in federal transfers through CHST, depart mental expenditures which make up 44 per cent of the program budget of the whole government, and rapidly growing expenditure pressure in areas like pharmaceuticals and home support.
In response to these issues and others a discernable consensus is emerging in the consultations. So far, the preponderance of opinion rejects alternative approaches to financing the growth of health costs, whether those alternatives include user fees or other kinds of private payment for medical services. There is also a fairly broad consensus against tax increases, and the reallocation of funds from other parts of government to the health sector.
The most broadly accepted strategy is one which supports all the principles of the Canada Health Act, and commends the reallocation of funds within the health system away from areas of lowest need and into areas of highest need.
The standing committee observes in its report that the reallocation of efficiency savings is too narrow an approach to serve future health needs and that new sources of revenue must be found. While the provincial government has not yet adopted any position on the issues being discussed in the health forums, the financing strategy that will likely emerge, based solely on these discussions, will indeed be a reallocation strategy.That would require us to identify efficiencies, raise productivity, move funds from declining areas of need over to areas with increasing need, and most importantly, introduce innovations that contain cost- growth for the future. We concur with the standing committee's option of reforming primary health care.
A number of significant pilot projects, as well as legislation for nurse practitioners, have laid the base for further primary health care reform in this province. A ministerial advisory committee on primary care has also been struck and it will report on November 28.
We hope that the recommendations of this committee, plus other inputs, will help establish a system of primary health care where people can access the proper providers, in the right places as well as contain cost-growth.
We also support a single process for the evaluation and scientific approval of new drugs for inclusion within drug subsidy programs. A single and highly credible evaluation process will ensure that jurisdictions adopt drugs that are effective, both clinically and economically, and still reserve room for jurisdic tions which, for cost reasons, may not be able to afford the listing of certain new drugs.
In the area of increased revenue, improvements are needed to both the equalization program and the CHST. Premier Grimes recently presented to the Standing Senate Committee on National Finance our province's position on equalization. Equalization adjustments alone would improve the flexibility to provide reasonably comparable levels of public services to that of other provinces.
Your committee has drawn attention to the Atlantic Provinces inability to provide drug programs, even though these provinces have the highest proportions of their population without some form of private drug insurance. Equalization can play a role in correcting that problem.
The shortfall in CHST funding means that provinces must draw upon their own fiscal capacity to meet the expanding costs of health care. Increasing the level of CHST transfers to the level in 1994-95, along with an appropriate escalator, would correct this anomaly that bears so directly on our ability to provide accessible, high quality and sustainable health services.
Whether or not additional revenue is available from the federal government, it is necessary to control costs, introduce new flexibility into the health system, and expand the priority being placed on wellness.
Wellness was a key theme of the regional health care forums. This theme covered many of the same issues raised in the standing committee's report. Although residents of this province, on average, outperform the rest of the country on indicators of self-assessed health status, the sense of control over their lives, chronic stress, and death rates due to suicide are indicators of poor health status that are a cause of great concern. For example,28 per cent of adults smoke, as compared to a figure of25 per cent nationwide. This province has the highest rate of obesity in the country. Eighteen per cent of people over 12 years of age are physically active, as compared to the national figure of 21 per cent. Death rates due to coronary heart disease, cardiovascular disease and stroke are among the highest in the country.
The standing committee has also highlighted the determinants of health framework, which helps identify broader causes for health status. On many of the key determinants, Newfoundland and Labrador also faces challenges. The key indicators are unemployment and income and literacy levels. The need for a population health strategy focused on wellness is compelling. This case was broadly endorsed in the regional health forums. Minister Bettney is also firmly committed to a wellness strategy as a fundamental part of a long-term health strategy for the province.
The standing committee makes the point that a multidiscipli nary multi-departmental approach to population health may yield greater benefits than a purely health sector effort. This point of view was also endorsed in the discussions during the health forums. The standing committee raises the important question of how this type of coordination and integration among agencies can be mobilized.
In Newfoundland and Labrador, the institutional infrastructure to mount this type of approach already exists through the Strategic Social Plan, the SSP. The SSP was started in 1998. It involves economic and social departments and agencies in a comprehensive approach to promoting health, education, self-re liance, and prosperity for people in the context of vibrant communities and sustainable regions.
The SSP has resulted in multidisciplinary committees in seven regions, identifying social priorities that can be achieved through the complimentary activities of many departments and agencies. The SSP also promotes and provides institutional support for cross-departmental planning and policy development. So we will be relying on the SSP network, both within the government and throughout the province involving government and non-govern mental actors, to be a fundamental part of a wellness strategy for the province.
The financial challenges faced by the Government ofNewfoundland and Labrador is daunting. Making the system flexible so that new needs such as wellness and population health can be addressed is a strategic priority.
Hopefully, these comments are helpful to the committee. We will be delighted to discuss them further.
The Chairman: I want to be clear on the issue of financing. I understand why the consensus of a public dialogue would be that efficiency or productivity measures, combined with some element of what you called moving money from less important items to more important items is the way any changes in the system should be financed. I thought you also made some reference to a different suggestion coming from some committee, am I right?
Mr. Thompson: No.
The Chairman: Then let me ask you a question about the efficiency changes, one of which is obviously primary care reform. When you talk about moving money from less important things to more important things that really amounts to "delisting" certain services. Certain services that you are now providing, you would not provide in order to provide more important services, but the practical effect is that certain things get delisted. Is that right?
Mr. Thompson: That is not the only kind of reallocation that could occur. In an efficiency sense, it may be that we are delivering services in many more places than need be, or to a higher level of access. So that provides opportunities. Delisting is another strategy that could be taken as well.
The Chairman: In that sense, regionalization, for example, is an example of consolidating resources that would save you money. It is disturbing to hear that 25 per cent of the people of the Atlantic region have no drug plan at all. We are well aware of the increasing cost of drugs and the increasing importance of them. Have you looked at ways in which that problem could be dealt?
Mr. Thompson: We have not looked at the idea of a drug program that would cover more of the population. We have confined our analysis to how we can make sure that the drug programs that we have work most efficiently, and are contained within the level of costs that we assign to them now. There has not been any new initiative about expanding these drug programs to take in broader groups in the population.
The Chairman: What drug programs do you have now?
Mr. Thompson: They are aimed at low income, and aimed at seniors.
The Chairman: Low income means anybody on social assistance has a drug plan?
Mr. Thompson: That is correct.
Ms Beverley Clarke, Assistant Deputy Minister of Policy, Department of Health and Community Services, Government of Newfoundland and Labrador: One of the things that has happened over the last two years is through the Department of Human Resources and Employment, anybody who is on low income social assistance, and goes to work, they are able to access the drug program for at least another six months. So that has been one small expansion to see that makes a difference to people.
The Chairman: Are all seniors on a drug plan, or only certain seniors?
Ms Clarke: Low income seniors.
The Chairman: The gap that we see, not just in Newfound land, but in all the Atlantic Provinces is in contrast to the Western provinces there is some coverage. The gap that exists across the Atlantic region is quite different than anywhere else in the country. Clearly, it is the most inequitable part of the health care system at the present moment.
Mr. Thompson: I do not know how long this additional element has been in practise. I have been with the department now since February, and I have seen cases where low income people, not people on social assistance, that face situations where they have drug therapies of extraordinarily high cost. So certain of these cases can be assessed within the Department of Human Resources and Employment, and approvals will be issued to people who are not on social assistance but need assistance to obtain this very high-cost drug therapy.
There is also an expansion of support that has been underway in the provincial government for this as well, but there is not a broad policy approach to expanding drug coverage to a larger group of the uninsured population.
Senator Cochrane: How many people who are low income but not social assistance recipients apply for this help to pay for their medical costs, how many are approved, and who makes the decision as to whether or not they get help?
Mr. Thompson: The assessors in the staff of the Department of Human Resources and Employment who deal with social assistance programs make those decisions. I do not have the statistics on how many people apply, and how much assistance they ask for. We can certainly investigate that, and supply that information to the committee.
Senator Cochrane: We would like to know what number applied, the number that was turned down how many have received assistance. That information will be very helpful to us. In my view, it helps this low-income person to pursue the job market.
I know that you have had health forums on how to sustain this system, and the one that we have here in Newfoundland. Has there been a common theme or common suggestions on how we can sustain this system? Has there been something everybody has agreed with that we can do?
Mr. Thompson: I wish I could give a well-summarized answer to that. We just concluded our last forum last week. We are compiling all the summaries. We do not have them ready for presentation at this point. However, the support for the principles in the Canada Health Act is clear and compelling right across the province. If the health system requires more resources, those resources should not be acquired through additional taxes or through reallocation from other spending priorities of our society. Those are the key points. Of course that limits the range of options that government has to deal with. As yet, we have not staked out where the provincial government wants to be on this issue as a final outcome. Those are among the broadest parts of consensus.
Ms Clarke: Within the context of reallocation of resources the highest priority is wellness. People did not say take the money from the institutional system and put it into the community as clearly as that, but the premise seems to be that we need to shift actual dollars from institutional acute care system into the more community based system that focuses on wellness. Actual shifting of dollars is one of the things that we will spend some time looking at over the next little while, although no decisions have been made.
Senator Cochrane: Have there been any discussion on preventative measures?
Ms Clarke: Yes. Wellness has been discussed within the context of health promotion and health prevention. We have the highest obesity rate in the country, we have the highest rate of deaths through cardiovascular disease, and there is obviously some work that we can do in terms of prevention and early interventions within this province.
Senator Cochrane: It seems to me education would be a prime target here.
Ms Clarke: Yes.
Senator Cochrane: Educating the people on what to do for wellness. Has there been any discussion on user fees, or did you bring up the question on user fees?
Mr. Thompson: Yes.
Senator Cochrane: Were they for, or were they against user fees?
Mr. Thompson: Almost universally, user fees were seen as not the right way to go.
Senator Cochrane: Was there a specific group that was in favour of user fees?
Mr. Thompson: I cannot recall any group that was in support of user fees. The main reasons why they were not in support of user fees is the understanding that they prevent the working poor from using the health system in certain instances, and also that they do not prevent abuse of the health system to the extent that advocates of user fees may say. I have seen this kind of evidence presented in your reports as well. We hear that again and again.
The Chairman: We put in a comprehensive set of options in our report. When we put in the user fee option, we also point out the research evidence that shows that it does not work. It is strange to us that user fees are in place in every industrialized country, including many European countries that have universal health care systems. That strikes us as odd. Nevertheless, in the interest of comprehensiveness, we have to put user fees in as an option.
All the research evidence shows that user fees, in fact, clearly hurt people on low income. We put it in, as I say, in the interest of comprehensiveness. The thing that surprised us was that every European country, Australia and New Zealand, to take examples, which have universal systems, also have user fees. Nevertheless, we felt in the interest of comprehensiveness, we had to put all the options on the table. You put the options on the table even in your forums.
Senator Cochrane: Our doctors and our nurses are getting older and will soon leave the medical profession. They are going to retire. Do we have a strategy in place whereby we can get younger doctors, nurses and other medical staff to come into the system?
Mr. Thompson: We face interesting issues in the area of health human resources. This was another of the themes in our forums, and is an area of intensive planning, both within the province on an Atlantic basis and nationally. You have addressed physicians and nurses, in particular.
We are projecting that unless we do something about nurse graduates, we will face a shortage of nurses within the next five to ten years. We are looking at alternatives that will address that problem. We have introduced bursary programs to encourage our graduates to stay here rather than be recruited elsewhere. We have had some success with the bursary programs.
There is more difficulty in the recruiting and retaining physicians. We rely on international medical graduates to sustain our supply of physicians. The key strategy for us is to retain more of the graduates from Memorial University Medical School because they could make up entire demand that we have for physicians. There are multiple requirements of such a strategy, and it will be a costly one. It is always a difficult issue, and we apply as many resources to it as possible. We have not found the perfect solution, but if we can retain more of those graduates that will be the very best solution for Newfoundland and Labrador.
Senator Cochrane: That will help, especially for the rural areas.
Mr. Thompson: Indeed.
Senator Cochrane: We really have a problem there.
Senator Robertson: Are you having problems like the rest of Canada with long waiting lines, waiting lists for surgery, et cetera, or is that a problem for you?
Mr. Thompson: It is frequently a problem. We have some specialties in some areas where waitlists are probably better than the rest of the country, and some areas where they are worse. This is one of the most frequently cited complaints about the health system. However, we do not have comprehensive data on the subject. This is one area we need to work on to get a better understanding of precisely how long the lists are, but it is clear that for people who cannot wait, who require emergency treatment, there are no waitlists. For elective and other types of treatment, there are waitlists, and it is a source of some concern in some areas.
Senator Robertson: There are problems associated with the operation of expensive hospital equipment; finding sufficient dollars to do so is difficult and as a result the equipment is under utilized. To shift dollars from acute care into community care, prevention, or pharmaceutical programs, may be difficult. Have you considered this problem? You want the additional money that would be required to come from a reallocation strategy, and from increases in the general transfer payments. What happens if those increases from the federal government do not materialize? Where will you go for your dollars?
Mr. Thompson: I cannot tell you precisely where the reallocations will have to occur, only the alternative sources of funds. Clearly, we have to build a strategy around that because, in addition to waitlists, there are very expensive technologies, additional drug therapies, and demands that continue to multiply without ceasing. It is an important problem that we face, but I cannot give you a precise direction of the government today because that direction will result from further consideration of the forums. The broadest comment I can make is that we have not detailed our strategy yet.
Senator Robertson: You have determined through your studies that you want to retain the principles of the Canada Health Act. Is that correct?
Mr. Thompson: That is what we are hearing in the consultations, yes.
Senator Robertson: Have your people spoken to you about the inability of Canadian citizens to purchase insurance to cover the Canada Health Plan?
Mr. Thompson: No, we have not heard that in our forums.
Senator Robertson: I think a lot of the citizens are not aware of that, but just think of that sometime because it is quite interesting. Workman's Compensation, for instance, can pay fees if a worker is hurt or needs care. They seem to be able to access the system more quickly, whereas someone else working outside of the Workman's Compensation Board cannot. That person cannot purchase insurance to help in that instance, and they lose a lot of time in their employment. It is a worrisome thing. We are talking about equity here.
I will be interested in your final report. The CMA president, Dr. Peter Barrett, testified before the committee on May 16, in connection with health human resources. He dealt with five issues: the increasing workloads of physicians, physicians practising in rural and remote areas, the challenge of access to physicians, the quality of life concerns of physicians, and the issue of training and medical education of physicians. I understand that the medical school is directly under your jurisdiction. Is that correct?
Mr. Thompson: Yes.
Senator Robertson: Dr. Barrett said something must be done about medical education, and I quote:
Tuition deregulation has meant that tuition for our students is becoming prohibitive. If we do not do something soon, it will only be sons and daughters of wealthy Canadians who will be able to go to medical school and choose a career in medicine. That would not do good things for demographics in terms of distribution of physicians, as well as some of the cultural needs of some of our disadvantaged communities.I will add to his comment that it would also perhaps exclude some of the best brains that wants to go into medicine. Since your medical school reports directly to you, can you tell me if tuition deregulation has made it difficult for your medical students to train for the medical profession?
Mr. Thompson: I do not have the data on the particular socio-economic status of students entering the medical school here, and whether that has changed over time. What I can tell you is that the tuition fees for the medical school at Memorial are generally among the lowest in the country. While this year there was a controversy over whether tuition fees at Memorial University would rise, or be frozen, the government provided enough money for tuition rates to be frozen except for the School of Medicine. Their rates did rise slightly this year in comparison to the cost of other types of university education, but generally they do remain among the lowest in the country.
You are correct is saying that the Faculty of Medicine does report to our department, and that is probably unique in the country because generally the funding is provided through Ministries of Post-Secondary Education. We think that the relationship established here is a very beneficial one because we can collaborate much more closely, and access the resources of the Faculty of Medicine because we have this kind of day-to-day relationship with them. I hope maybe some of your other witnesses might reflect upon that as well. We think it is a very good model.
I would like to highlight the expertise that this faculty has developed in the areas of family medicine and primary care. The faculty reflects the needs of the residents of the province, and particularly the needs of our rural residents.
We find that students will come to Memorial because of the special nature of the program that enables them to get out into rural areas and experience what it is like to practice in that setting. The faculty has also been instrumental in some of the primary care enhancement pilot projects that are underway in this province and have been instrumental to their success. The projects have allowed student residents to experience the primary care setting. We believe this model works well. It is not just primary care reform but also brings the education element to it as well. It is a model that we hope to replicate in the future as we spread the reform model across the province.
Ms Clarke: We have hired a recruitment officer who is employed in the Faculty of Medicine who is working with both the department and our boards to see how we may better look at recruitment strategies for our young physicians.
Mr. Thompson: I would like to re-emphasize that very point. The close between the ministry and the university has enabled us to place our central recruiter inside the Faculty of Medicine. That is not something you will find in other provinces.
Senator Robertson: I just think that relationship is most interesting, and I believe it works well. Our province, as you know, uses a number of spaces in your medical school. We always have. Whenever I have had the opportunity of visiting your medical school, I have always been impressed with the quality of the teaching and the dedication that you have.
Could you provide us, please, with a socio-economic profile of your students of medicine? I think that would be helpful to us.
The Chairman: Senator Robertson was a long time Minister of Health in the Province of New Brunswick, which is why she understands the details so well. I was surprised at your comments on a number of the health status determinants being worse in Newfoundland than elsewhere in the country. Both my parents are Newfoundlanders, and my relatives are Newfoundlanders, so I have spent a lot of time in the province.
I would have thought that in the bigger cities you would find a much worse health status than you would find in Newfoundland. I am really quite stunned that that some of the key determinants, like obesity, and other things, are worse here. Do you have any understanding as to why that is the case?
Ms Clarke: Our surveys indicate that there are cultural issues that surround the health status of the people of this province. Also, we have gotten away from physical activities. We think of Newfoundland and Labradorians as people that are outdoors and enjoying the outdoors, and yet, when we look at our physical activity rates, we see that is no longer the case.
We are a culture in transition in many ways and we have to get back to some of those basics. We also have a portion of our population who are below the low- income line and providing nutritional food for their families is also an issue. As well as the many issues facing our young people these days, many of them are spending a great deal of their time on computers and in front of televisions and as a result they exercise less. Physical activity is no longer a requirement in the school system. That is an issue that we need to re-address. We are not sure that we have we done the right thing in that regard.
The Chairman: Physical education is no longer required, or no longer offered?
Ms Clarke: I think it is offered on sort of an ad hoc basis. It is no longer part of the core curriculum in the school system.
Senator Cook: Do you have a written policy? What do you mean by low income and the relationship to your drug program? Is it $18,000 a year? Is it $10,000? What is the threshold?
Mr. Thompson: We will certainly get you the specific documents, but the first definition relates to people who are on social assistance, or require social assistance. People who are low income can have access to assistance for the purposes of extraordinarily high cost drug therapies. I do not know if there is actually a clear and defined set of regulations but it has to do with the affordability of the drug therapy in the context of what their income is. We will get you any regulations that might surround that determination. It is in a different department. We administer the program once the different department says, yes, this person is eligible.
Senator Cook: Are you selective in the drugs that you provide to low income, and to seniors? Is it a blanket drug program, or are there just certain drugs available under this program?
Mr. Thompson: All of the drugs that are available on the provincial program administered by your department, yet most of those drugs are not extraordinarily high cost therapies. Those drugs would be a select few. What is defined as an extraordinarily high cost therapy, I cannot tell you today, but it is a matter of balance between the ability to pay, and the uninsured cost of the drugs to the individual.
Senator Cook: Mr. Chair, that information would be helpful for us, for the record. If I can share those numbers with you, and you have probably already seen it in our "Issues and Options" report: Newfoundland with 65 per cent, and PEI, 73, and Nova Scotia, 76, and New Brunswick, 67, we are back to the diversity that is Canada. When you look at Quebec, Ontario, Manitoba, Saskatchewan, and B.C., they are coming in at 100 per cent. Alberta is at 83 per cent. There is something radically wrong with a national system that allows this to happen. It would certainly be helpful for us if we had that information. At least we could look at a reasonable analysis of it.
Mr. Thompson: The structure of our drug programs are clearly tailored to the affordability of them to the provincial government in the context of all the other needs that we have to satisfy. Therefore, there is only a certain set that can be afforded within the revenue base that we have to operate within. If we cannot affect the revenue base, then at some point we will have to continue to tailor the size of that program to the amount of money available.
Senator Cook: We need to understand whether is it inclusive or exclusive. As a Newfoundlander I want to discuss equalization. The envelope called "equalization" comes to the province, and then the province determines what the priorities are with what is in that envelope. Am I correct? There must be other pressing issues other than health.
Mr. Thompson: Yes, correct.
Senator Cook: When we amalgamated the hospitals the feeling was that the government was going to save money. I do not think that the economic expectations of those changes were met. Do you want to comment on that?
Mr. Thompson: I don't have the data to comment on it. I can tell you that the cost of the health envelope in the provincial government has continued to rise. Of course, that may be more than likely the cost of direct services than administration, which is what you are referring to. Ms Clarke, do you know of any data that pertains to this question?
Ms Clarke: No. The only thing is I think we had is 50 CEOs for hospitals across the province.
Mr. Thompson: There used to be.
Ms Clarke: And we have gone down to 14 boards, which means we have 14 CEOs. I do not know if there has been any costing done concerning the period of time since the amalgama tion.
Senator Cook: Equalization reached a plateau in the mid 1990s during the time that we first started amalgamating hospitals. I want to know if there was an impact of cost expenditure. Never mind the human resources element that we moved all over: housekeeping, nursing, maintenance and so on. People were going all over the place. There were people being bought out. There were people taking early retirement. We did a massive job of restructuring. I wish someone could tell me what that cost the government.
Mr. Thompson: The theory, was that we would save funds that could be reallocated to frontline services, and contain cost over time. I do not have the data today to answer your question, but we will find whatever data is available to let you know. We still face the same questions. Where can we find consolidations or streamlining that can move cost from one area to another? It is the same question that never goes away in the health system.
Senator Cook: If you have any kind of an analysis or evaluations pertaining to that time they will not only help us, but they will help you.
I want to discuss the nursing profession. I think that our nurses are the best in the country. In the 1980s, we started a collaborative program with the nursing schools at Memorial and Corner Brook. We had a common curriculum. The goal was to have a B.N. program by the year 2000. That goal was achieved.
The Centre for Nursing Studies became an entity and the amalgamation went to Memorial. During that period of time, more nurses left Newfoundland because they could not find a job or a decent salary scale. Why? We turned out first-class nurses from an excellent program and yet they went left the province. Why?
Mr. Thompson: I cannot answer why they left, but I can tell you some of the things that we have been done since that time. Last year we did a reclassification of their salaries and as a result they enjoy a substantial increase in salary. This is keeping more of our nurses here in the province.
As I mentioned earlier, we offer bursaries to keep new graduates working in the province. We have added more full-time positions to many of the hospitals in order to convert casual nurses into permanent nurses.
As a result of all these measures, you will see in the national statistical data, that Newfoundland has the highest ratio of nurses per 100,000 population of any province in the country. It is clear from that ratio that we are not suffering from a shortage of nurses on a comparative basis across the country. There are certainly specific areas in the provinces, or specific areas of specialization where we suffer shortages, but overall, the ratio of nurses in this province is very healthy.
Senator Cook: The fact remains that at one time a well-trained nurse left this province to work elsewhere because she could not find work here. Yet now we are in the process of adding incentives. I hope that we learned a lesson from that. I have a lot of empathy for equalization and things do have to be done differently. One of the criteria for equalization is population based. Have you any data that shows how much we dropped due to the declining population. I think that information would be helpful as well. We were capped in 1994-95 and I think our declining populations and the movement of our people had a significant impact on that capping.
Mr. Thompson: You have hit on an excellent point. Both equalization, as well as CHST, are linked to population, and as a consequence of the declining population from maybe around 570,000, down to 530,000 we have suffered a substantial loss in the last ten or 15 years. The province has suffered a loss of transfer income. So that is an important loss, an important loss of fiscal flexibility.
In addition to that, we have a health care set of institutions, and a staffing level that cannot be reduced for every person that leaves. We just cannot reduce the system by an equal increment. There are some adjustments that can be made and there were some decrease in the number. If somebody is moved away, they are no longer coming into a hospital or doctor here, but there are elements of the system that cannot be reduced in the same proportion. So we have a revenue loss, as well as an inability to adjust our cost as fast as we would like to. We are caught in the double bind, and probably more so, in that regard, than any other province. We may be unique in the country.
In terms of the financial case that we try to make for federal transfers, this double bind needs to be recognized so that we can deal with our problems, not just by continuing the downward spiral of reductions, but by trying to provide cushions so that the impact is not as great as it might otherwise be.
Senator Cook: If that is not the option here is our government looking at other options and other programs to take care of the essential needs of Newfoundlanders and Labradorians? If you cannot get it out of that purse, are you developing anything else?
Mr. Thompson: That is exactly what the health forums are about is to identify through consultation what are perceived to be the best options. Then government will make decisions on the basis of that, and come out with a policy framework early next calendar year.
So far, the reaction has been that the reallocation strategy is the best one to use. If we have to live within our means, and we cannot take away more from other departments, then allocating from efficiencies, but also from areas of lowest need to areas of highest need is what we have left to do. That is what we are being told so far.
Senator Robertson: I think population based transfers is something we should look into. Population based transfers are very unfair. In the health system there is a certain amount of money that is required to put in very basic services. Whether you are dealing with $1 million, $1.5 million, or $500,000. The population based transfer programs simply do not work for the smaller provinces. They further jeopardize the health ability of those provinces.
The Chairman: There have been a lot of studies done on that subject over the years. You are correct.
Senator Robertson: Yes. I just wanted to make sure.
Ms Clarke: The region outside of St. John's has remained stable over the last five years. Labrador has had a small increase in population, but the population of Labrador is so small to begin with, that it does not really mean much. The rest of rural Newfoundland has lost between 10,000 to 15,000 people per region in the last five years. In those areas we are still delivering the same health services with the same numbers of staff even though we have had a significant drop in population. That presents a challenge to us in terms of the future if we are going to live within our means.
We have issues regarding the location of services. Can those services be everywhere that they are now? Those are some of the questions that we are going to have to deal with.
The Chairman: To put that in perspective, and do not hold me to the number, but Saskatchewan has closed 35 or 40 small community hospitals and converted them into clinics. The hospitals have been consolidated into larger centres. This has been done in the last two years.
Senator Léger: I want to ask about the user fees. When you discussed user fees in your forums did the people mention a figure of $1, or is it according to revenue, or is it simply zero?
Ms Clarke: People have brought up different amounts of money: $2 or $5 for instance, versus $15 or $20. The overall sense from people is caution because of our small population and the effect that user fees have on the working poor.
Senator Léger: I think they are afraid of the system.
Senator Cook: I would like to go back to your comment about desiring to live within one's means. I have never achieved that in my life, and neither have my children. I would like to leave with the Department of Health with the message that this is not about living within your means. This is about taking care of people, and this is the year 2001. If the environment is not happy, and up and running, then that impacts on that individual. That has to be part of the criteria. The workplace has to be up and running and first class.
The Chairman: Our next set of witnesses are Patricia Pilgrim, President of St. John's Branch of the VON, Sharon Smith, President of The Association of Registered Nurses of Newfound land and Labrador and Wayne Lucas, President of Newfoundland CUPE.
Ms Patricia Pilgrim, President, St. John's Branch, Victorian Order of Nurses (VON Canada): I am on the board of directors of the St. John's VON Branch. I also represent this province on the national VON board of directors. I certainly thank you for the opportunity to come and speak to you this morning, and I will be brief.
As you know, VON has a strong and well-established history in the provision of community based health care in this province and across Canada. This province supports the key messages that you heard from VON Canada earlier this year when they were presented to you.
Nothing that I say will be new to you, but we appreciate the opportunity to reiterate and reinforce the messages that you have already heard. I will make particular reference to two groups of people: home support workers, and informal caregivers.
The demand for home care workers continues to in relation to the changes in demographics, the aging population, chronic care, and changes in utilization practices within other sectors such as acute care. As the acute care sector continues to strive to reduce their length of stay to avoid admissions, we get greater and greater demand for home care services. We are seeing the public's growing desire to remain in the home. The demand that covers the whole spectrum of care from the need for the more acute care, convalescent, continuing and palliative care services. Home support workers provide a necessary service to the people of this province, but they are not adequately compensated. In many cases they are not appropriately trained or educated to meet the comprehensive health and social needs of the clients in the community. There is a shortage of home support workers. The workers that we do have are often buoyed by significant wage disparities, sometimes ambiguous and difficult working condi tions, and lack of support systems. There is a lack of national standards to ensure unity of service for clients. There are guidelines within this province for training or educational programs, but these do not apply to the areas of self-managed care situations, which are really growing in numbers in this province. Given the realities of the present situation, it is very difficult to recruit and to retain significant numbers and quality of home support workers.
VON recommends that the federal government take a leadership role in addressing the many issues related to home support services, to ensure adequate funding, and to ensure that standards of care are adopted and met.
The informal caregiver provides necessary care and support to families, neighbours, and friends in need. VON is pleased to see that the issues related to the informal caregiver network are being addressed or discussed at the national level.
Caregivers in this province are often located in small rural areas isolated from many sources of support. In many small communities all of the young people have left their homes to find work elsewhere. In those communities we have informal caregivers who can be 50 or 60 years of age looking after friends and family who are in their 80s and 90s.
Caregivers are often isolated and face obstacles and challenges without knowledge of where to turn for support and guidance. This takes its toll on their health, and often the financial security of the caregiver in the home, and threatens this necessary and vital component of community-based service.
VON fully supports and urges this Senate committee to include in their final report a federal commitment to lead the development of programs and policies that recognize and support the informal caregiver.
The Chairman: You used a term that I am not familiar with. You talked about "self-managed situations."
Ms Pilgrim: A self-managed situation is where the families actually employ the home support worker.
The Chairman: As opposed to the family hiring the VON worker.
Ms Pilgrim: The families actually hire them and manage them in their own home.
Ms Sharon Smith, President, Association of Registered Nurses of Newfoundland and Labrador: Senators, I represent the Association of Registered Nurses of Newfoundland and Labrador. We have 6,000 members in our organization, and we represent the professional needs of nurses within the province. That includes nurse managers, nurse educators, and frontline workers. We certainly appreciate the opportunity to address the Senate.
Our mission is to have healthy people in Newfoundland and Labrador. face. We will focus our response on selected issues and topics raised in relation to future health care policy, finance, and the nursing resource infrastructure. You have our brief, and I will attempt to be as brief as I can.
We concur with the committee's opinion that our health care system is not meeting the health needs of its citizens and the country needs a major overhaul in the delivery of health services. We believe the federal government needs to lead the development of a national strategy to shift the country to a primary health care and wellness model as the basis for the delivery of health services. We are not referring just to primary care reform, but a shift to a model of primary health care. Although both federal and provincial governments have funded primary health care demon stration projects throughout the country, the delivery of health care services has not changed. The system is still illness and provider focused, rather than wellness and client focused.
As the Senate committee has suggested primary health care reform will require the health professionals to buy-in on the value of a primary care approach. That is not going to be easy to sell. The public will need to be more active participants in their health and health care. We will have to see the reduction of "turf" protection among health professionals so that all team members can be utilized to their full scope of practice. Further, multidisci plinary teams of professionals who practice in a partnership of equals when responding to the health needs of various client groups will need to be created.
Although the committee's spectrum approach or the utilization of health providers needs to be refined, we believe the principle of better use of the full spectrum of health provider is essential for effective reform. This principle should be expanded to include the funding of insured professional services so the public can have direct access to the most appropriate health care provider.
In relation to the financial options, registered nurses are the largest group of health professionals, and the frontline providers of health services on a 24 hour, seven days a week, 365 days a year basis. We believe that there are inefficiencies in our current system, and are not prepared to entertain new models of financing the system until the inefficiencies can be addressed. We believe that reforming health care delivery, improving system effective ness and efficiency, and educating the public and other vested interests on the need for change has the potential to generate the money required to sustain the system. Governments must make tough decisions about what services our country can afford, and in consultation with the public, must decide what is to be covered by all medically necessary services. We believe that limiting financial coverage to medical and hospital care perpetuates costly illness focus care. Standards for the 21st century need to include health promotion and prevention, home care, and pharmacare. Standards should be benchmarked against available evidence and be consistent within the provinces and across the country.
Registered nurses do not support implementing user fees, as there is no evidence user fees improve inappropriate and inefficient services. There is no evidence that such fees will reduce costs. The profession is still concerned that implementa tion of user fees will result in a two-tiered system that will ultimately disadvantage the disadvantaged.
Similarly, nurses do not support moving to a two-tiered system where public and private systems coexist. The concern is that it would only be a matter of time before the private system would erode the public system. We support a publicly funded health system that provides essential health services that are determined by health need, and not the ability to pay.
In relation to the nursing resource infrastructure, our country and province is facing a crisis related to the supply of registered nurses. CIHI statistics indicate the number of nurses in Newfoundland rose by 2.5 per cent in the year 2000. However, despite this increase, our health boards still report difficulty in retaining nurses for both urban and rural settings. The shortage of nurses in our province is such that the number of graduates does not meet the current demand for nurses. In 2001, there will be a shortfall of 26 graduates, and a shortfall of 30 to 40 graduates in each of the next three years. Our workforce is slightly younger than the rest of Canada, as the average age is 40.6, but it is aging, and retirement of the baby boomers will begin in the year 2004. Our province needs to increase enrolments in our nursing schools now if we are to meet future demands. The current number of new graduates is 40 per cent less than in the early 1990s when the number of nursing education seats were higher. We had 273 seats at that time, as opposed to 180 now. It is also interesting to note that nursing is viewed as an attractive career choice in Newfoundland, as there is double the number of qualified applicants for each funded seat in our basic baccalaureate nursing programs. Many registered nurses, nurse practitioners, and advanced practice nurses, are under underutilized. There is well-established evidence to demonstrate the cost effectiveness of advanced practice nurses and nurse practitioners in the provision of nursing and primary care services in rural and urban settings. In addition, nurses with special expertise can play a bigger role in the care of high need populations, especially in community based populations. The evidence is available to demonstrate that when nursing services are optimized, they can improve the effectiveness and efficiency of health services.
The scope of practice for registered nurses and licensed practical nurses is evolving, and we support the implementation of practises that enables both registered nurses and licensed practical nurses to work to the full potential of their approved scope of practice and within their level of competency. Recently our association worked with the Counsel for Licensed Practical Nurses, and our health system, to develop a Learning Circles Project with nurses and LPNs. The goal of this project was to promote collaboration and teamwork by educating nurses on their respective roles and competencies, as well as to develop decision-making skills as a tool for issue resolution.
The issues surrounding the nursing shortage are complex and global in nature. Therefore, we support a federal role in leading the development of a national strategy to revitalize the nursing workforce. Furthermore, we believe the strategy should include concrete support for the education of registered nurses at entry and advanced levels, as well as basic and innovative strategies for the retention of nurses in the profession in the workplace.
Mr. Wayne Lucas, President, Canadian Union of PubicEmployees, Newfoundland: I would like to start by saying that our presentation is organized around three major themes: sustainability, funding options, and privatization.
We are opposed to a two-tier health care system, we are opposed to user fees and we are opposed to privatization. We cannot afford private health care. We are opposed to user fees and health care premiums. We are opposed to health as a taxable benefit. We are opposed to a medical savings account. We are opposed to private insurance coverage.
We believe the solution is a made in Canada solution. We believe that privatization is bad for health care. We have led major anti-privatization campaigns throughout the country over the last number of years to bring these issues to our members.
We believe that the committee's recommendations must follow the principle that good health is a fundamental right and that the way to preserve public health is through the active measures of promotion, prevention and protection.
We recognize that health care is for the public good and that the few must not profit at the expense of the many. We are strongly opposed to any commercialization or privatization of health care. We believe that the federal government must negotiate a general exclusion of health services and health insurance from all trade agreements.
The federal government must assume its responsibility with respect to health, particularly by restoring and increasing federal transfers to levels sufficient to secure the integrity and the enforcement of the Canada Health Act 1984.
The federal government must reaffirm the original version of a truly comprehensive public health care system for Canadians and provide a continuum of services.
We believe in the need to move away from a fee-for-service model and move towards community based multidisciplinary approach to the management organization and the delivery of services and care.We believe in a health care system that is accountable and works in democratic participation and govern ance at all levels. We recognize that health care workers are critical to the effective operation of health care system, and that decent wages, working conditions, and training opportunities are essential to high quality care and the retention of health care workers. Thank you very much.
The Chairman: I just have one question for each of you. Mr. Lucas, on page seven of your brief did you mean to infer that for the federal government to continue to transfer money without restriction or obligation on the part of the provinces would be a serious mistake.
Mr. Lucas: Yes.
The Chairman: So you and I come from the same camp that says that if the federal government gives money to the provinces, that money ought to be used for what it is given for. I will give you a classic example. In the agreement of September 2000, part of that federal provincial agreement included $1 billion dollars for MRI machines and other similar equipment. The billion dollars was given, but there was no accounting system that allowed the federal government to know whether the money was actually spent on the equipment or not.
I have opposed block funding since 1977. I thought we should have stayed with the 50/50 formula.
Mr. Lucas: I am a strong federalist, and I believe that if the federal government is going to be involved in the social programs throughout the country, they have a responsibility to make sure that the provinces are towing the line. If not, I believe the full effect of the Canada health system should focus on them. What I mean by that is that the federal government then should have the ability to withdraw funding or hold back funding from provinces that go astray.
The Chairman: And if the federal government wants to encourage a particular area of development like MRI machines, then they ought to be guaranteed if they are going to put money into it that it gets spent.
Mr. Lucas: I think that there should be close consultation with the provinces as to what the needs are. Once you have made that decision, I think the provinces should follow suit with what the federal government has to say and what they are paying for.
The Chairman: Ms Smith, you referred to a report I have never heard of. As part of our report we are concerned about the work environment of nurses. You say there is a report called Commitment and Care: The Benefits of a Healthy Workplace for Nurses, their Patients, and the System. Is that a book? Is it an article? Do you know what that is?
Ms Smith: It is a research study that was done by the authors that are listed. I am not sure of how available that report is, but we can look into finding it for you.
The Chairman: I will have our researchers look for the report. That issue troubles us. The statistic that we heard a while ago was that the occupation in Canada with the largest number of sick days due to stress is the nursing profession. Given the other stressful occupations that exist, particularly in heavy industry, it is an amazing comment. On the topic of primary care reform, you have said that getting a buy in from health professionals is going to be difficult and that buy in from the public, who will need to be more active participants in their health and health care, will also be difficult to obtain. Do you have any thoughts on how we can do that? We absolutely agree with you on the need and on the difficulty, but we are looking for some good advice on how to do it.
Ms Smith: It is a very complex issue. There have been some primary health care projects within our province. There was one funded on the Southern Shore of this province. It takes a long time.
Mr. Chairman: Where was it funded?
Ms Smith: In Ferryland, on the Southern Shore.
The Chairman: I was curious to know where it was because my relatives are from here and I know this province well.
Ms Smith: There is an actual report on that project that you can access.
The Chairman: Did it deal with the question of how to get public buy in?
Ms Smith: It is very difficult. It involves a total education of the public in terms of their responsibility for health. Until now, we have looked to the physician as the person who is going to make us better. We have to get people to realize that they have a responsibility. It this education that has given people access to the professionals, such as nutritionists, physiotherapists and occupa tional therapists, who will help them make lifestyle changes. Support is what people really need.
The Chairman: Men are probably worse than women in this regard. I think that if you get sick then the doctor will fix it. It is like going to the garage when your car is broken.
Ms Smith: That is the attitude that many people have. The attitude that you can stay in the hospital until you are completely better has to change as well. We have to change our focus completely. The team approach of having all the health care professionals in a primary health care setting will enhance the educational opportunities for individuals, help them identify their risky health patterns and then give them the support they need to change these patterns. If we do not give them the support, they will never change.
The Chairman: Did the Ferryland experiment work well?
Ms Smith: There were some changes made, but it takes time. It will not happen overnight.
The Chairman: That in a generation we changed our attitudes on drinking and driving is proof that change takes time.
Ms Smith: Yes.
The Chairman: It took a generation, but it certainly has changed. There is no question about that.
Ms Smith: That is correct.
The Chairman: Ms Pilgrim, I want to make sure that we are using the same language. An informal caregiver is someone who has no formal training and someone who is typically an older female, in their fifties, who is looking after an aged parent; is that correct? Have there been any studies done on the enormous level of stress placed on informal caregivers and the impact that being an informal caregiver has on income?In my parents' generation, when relatively few women were in the workforce, my father had my mother to look after him when he was sick because she was not working. Now, some people have to quit work in order to look after spouses or parents. There is not only the stress level, but also a huge economic impact. That is a significant element of the cost of home care, but I have not seen any data on it. Do you have any information on that?
Ms Pilgrim: I will defer to Ms Blake-Dibblee, who accompa nied me here. There is a study in the province. I believe I saw a draft of it.
Ms Bernice Blake-Dibblee, Executive Director, St. John's Branch, Victorian Order of Nurses: I am a part of a steering a project called "Caregivers, Out of Isolation." It is a three-year project funded by the J. W. McConnell Family Foundation. A preliminary report has been created based on a survey done with informal caregivers across the province. The purpose of the project is to identify the needs of informal caregivers, connect them to information and resources, stimulate support through community volunteers, and support the caregiver's system.
The Chairman: Could we read that preliminary report, even if it is unofficial?
Ms Blake-Dibblee: I am not sure. I am not the owner of this report.
The Chairman: Can you find out? It would be a useful piece of information.
Ms Blake-Dibblee: I will. There is excellent information in this preliminary report.
Senator Cook: We are talking about community care. I heard the phrase from Dr. Abby Hoffman when she talked about the elderly and the frail elderly. There are two types of caregivers. One is the family caregiver, for example if my mom comes home with a broken hip, suddenly I am not the daughter any more. I have to give care to a person and I do not know how to do that. This is complicated by the fact that I am her daughter. Then the professional caregiver, who has limited training, comes in to take care of the person. If she is coming into an environment called the family unit, I think it is difficult.
What national standards and training are in place to take care of the two trigger points that I talked about?
Ms Pilgrim: Within the province, there are standards for training of home support workers. These do not necessarily apply, for example if I, as a family member in my small community, bring my elderly mother home, and decide that I am going to go to my friends in the community and ask them to help me and I will pay them.
Senator Cook: Would it help if that were attached to the trades college, or somewhere that you could go and get three or six months of training?
Those caregivers are paid a minimum amount of money and often have to find their own transportation back and forth. Have you looked at the possibility of it being curriculum based, if only for the informal caregiver or family member?
I attended the National Caregivers Association meetings in Ottawa last week and I heard not only some wonderful stories, but also horrendous stories about the impact on the other family members. People said: "Mom has to stay home to look after whoever. There is one salary coming in the house. It impacts on the young people there because the money is not available to give them things. They also have to turn down the TV because Granny is sleeping." The whole dynamics of the home changes when care is needed, and often the person giving the care needs some kind of respite care as well. Do we have anything for that issue?
Ms Blake-Dibblee: There are training programs in the province through colleges for personal care attendants, and there is a provincial committee looking at standardizing training for home support workers and for personal care attendants in nursing homes and hospitals. That work is in progress. The home support workers that agencies employ must be trained. The issue is with people who are being hired through self-managed care. Many times those people are not adequately trained; therefore, they are not providing the kind of care that the client should be receiving.
Senator Cook: It is a savings for the system when people who need this care remain in their own setting; is that correct?
Ms Blake-Dibblee: Definitely.
Senator Cook: My neighbour has been in and out of the Miller Centre for six or seven months, and she is now home. She said that she loves pea soup, so we made the big pot, we packaged it all up and my daughter went off to visit. My daughter said that our neighbour has her walker and she has her lifeline. She has all the things around her, but she is still alone. Someone goes in in the morning, but she is still very self-sufficient. The program that you are offering is a laudable thing to have in place.
I am concerned about the salary scale of the caregivers, who are primarily women. Could you speak about that?
Ms Blake-Dibblee: The Department of Health recently developed a new standard for payment of home support workers, but it is a very low salary. The attrition rate for the recruitment and retention of these people is a major challenge for agencies across this province.
Senator Cook: If the same person were in a primary care situation, there would be help and support services. However, you are on your own in the home care setting. The work should be valued accordingly.
Ms Pilgrim: I think it really underscores the need for the research that we talked about. The document was an eye-opener to what informal caregivers go through, and the rifts in the family when you are isolated.
Senator Cook: Last night one of my friends came and said, "Put on the kettle." I said asked her what was wrong. She said, "I have got to go to mom's and dad's to sleep tonight, they are two elderly people in their 80s and they have tests done at two different hospitals." One has to go tomorrow morning, but she has to take both parents because she cannot leave one home alone.
The doorbell rang, and my other friend came for a cup of tea. She said, "Mom just called and said what are you doing Wednesday and Thursday because I have to go to the hospital both days for tests." We are into the frail elderly syndrome of society. While they could have their tea and have humour, the amount of money that the system is saving as a result of dedicated family members has to be documented or valued somewhere.
The first woman learned how to give insulin shots to her parents who are both diabetics. It is not without its humour. She would put her mother's clothes on the bed, and when she would turn around, her mother hung it up in the cupboard because she did not know where she was going.
There has to be a place for caregivers where someone says that you can go to a movie, or you can go to the mall. That is really lacking in the system. There is a potential for a myriad of delivery of services. What is your opinion about that? Is that a direction where we can go with options?
Ms Smith: I feel very strongly about nurse practitioner and advanced nursing practice roles. We have implemented them within the city of St. John's in some of the health care boards. We have implemented advanced practice roles that have improved the utilization of services. It is heart warming.
We have had buy in from physicians in relation to some of these positions, to the point that other services are looking at advanced practice roles. It works best when there is buy in from the group you are working with so that you are not saying, "You have to take this person and you have to incorporate them in your practice."
Within the associations, we have worked hard to ensure that there are standards of education for nurse practitioners and that people are able to meet them. We have helped put positions in place in the northern part of Newfoundland where they work very well. In areas where there is isolation, and the nurse practitioner is the only provider of health services for that area. It works very well.
In other areas where the nurse practitioner is an add-on to the physician practice, there have been some challenges. Some of it is turf protection in relation to who does what work. Some of it is people who see this as an add-on service, and are going in to see the nurse practitioner and the physician. If we educate people properly, and they go through a program of a nurse practitioner role and are able to go in the community, it will work very well. It is not only nurse practitioners in the primary care setting, but also nurse practitioners in the specialty areas, such as the cardiac program.
Senator Cook: In a holistic sense, including psychological. Is that correct?
Ms Smith: Yes.
Senator Cook: Could you see the nurse practitioner being part of a cluster group with the VON and the caregiver to build support groups, particularly in rural areas?
Ms Smith: It would work very well with the primary health care model. All services would be put together in one organizational group and would help provide the care.
Senator Cook: I envision a cluster as including a sociologist, maybe a psychologist, and a physical therapist. There are a number of people geared toward the elderly and the frail elderly. These people have to come together into a cluster. I believe that we are operating in isolation.
Ms Smith: We are.
Senator Cook: There is a need to come together for utilization of services.
Ms Smith: Very much so.
Senator Cook: Mr. Lucas, you have indicated in your brief what will not work. I would like to have your eight recommenda tions that may work.
Mr. Lucas: The eight recommendations are listed at the end of my brief.
Senator Cook: You are a strong federalist. We know that money comes from the federal government and is administered by the province. Do you see provinces and the federal entity coming to a consensus, province by province? Would you agree to a national standard to deliver whatever was necessary?
You mentioned health promotion. I want to be well and I want some strategy in place to take care of that. I am back to the cluster idea. I would like you to comment on one of the negatives regarding the taxable benefit. Would you be able to support a threshold for a taxable benefit?
Mr. Lucas: The problem with any type of tax system right now is that we are creating another bureaucracy. In that type of bureaucracy, it would cost us more money in the long run for administration and other costs.
If there was a threshold based on a salary of $25,000 a year, which is not a lot of money, then anybody with a salary over $25,000 would then have this bureaucracy to deal with. They would go to the doctor, get a form filled out by some sort of auditor and then file it with their income tax forms at the end of the year. That would prolong an already cumbersome system. There would be extra costs added in.
The simplest and the fairest approach is that all Canadians should have access to ready health care. You go your physician, you get service the way you are right now and the bill goes to the federal government.
Senator Cook: Would it be workable if we have a threshold that could be administered in a simplistic form? I am trying to explore options and not get my feet stuck in concrete.
Mr. Lucas: No, I am not convinced that it would be workable. Would you like me to comment on the other two issues and the national standards?
Senator Cook: No, you are clear about the user fees.
This report is for discussion, something to get a response. There are no conclusions here. This is the interesting one for me. I view this as thinking outside the box. The purse comes from the federal government and is administered by the provincial government. Would you advocate the federal government having total responsibility for funding? How would the administration of the funding for the application work?
Mr. Lucas: Yes, I believe that the federal government should fund it as they have in the past through transfers and through the Canada Health Act. They should have a greater say. The problems of Newfoundland and Labrador may have a priority in health care, and they may stray from the Canada Health Act, whereas the problems of Alberta may have a different completely point of view. The funding comes from the federal government. Therefore, the federal government should be able to say, when any province strays away, to get in line to what the federal government has paid for, or we will withhold funding from the Canada Health Act.
Senator Cook: The taxable benefit will be difficult to administer. To put those strategies and protocols in place for a nation such as Canada would challenge the best brains that we could find.
Mr. Lucas: I am not arguing your point. We do live in the greatest and the most wonderful country. I have travelled extensively across the country, from Vancouver to St. John's, some 60 flights this year alone. People that I have talked to cherish the Medicare system, and they want improvements in the Medicare system. It is Medicare that makes Canada great. There is a challenge ahead of us, but I think that we can overcome that challenge.
Senator Cook: Maybe we can look at the taxable benefit, and see how convoluted that might be before we are finished. Medicare is what makes us uniquely Canadian, and we all cherish what we have. We all realize we are going to have to look at things differently. I believe that if we can keep our options open, and work together, we will come out okay.
It is not going to work unless we have an adequately trained group of people, whether it is the LPN, or the RN or the caregiver, paid for the value of the work that they are doing. I have excluded the primary care because I think we have focused a lot on that, but we have not moved on to community care or beyond to the wellness piece. I would like to hear what your opinions are on that.
Mr. Lucas: We mention in our brief that we need to train all of our health care professionals, including the person that works in the hospital who cleans the floors, our doctors and our administrations, because all of those people are professionals.
All of us need to constantly be evaluated and trained. The workers within the health care profession also need to be adequately paid. Most health care professionals are underpaid, no matter what walk of life you look at. I advocated last week at a Senate committee hearing that we need more in federal transfer payments, and the reason is in Newfoundland and Labrador many people left this beautiful province to find work elsewhere. Transfer payments provide for health care, education and other social services.
Newfoundland and Labrador spend a tremendous amount of money on educating our youth, only to find out when these youth are 20 or 21 years old, most parents are encouraging their children to move to the mainland where they can find a decent job paying decent wages and benefits, where they can pay taxes.
That tax base then goes to Ontario, British Columbia or Alberta. Therefore, we do not benefit from that. Like all other Canadians, everybody wants to come home to roost. Everybody wants to come back to Newfoundland and Labrador to live out their retirement. We are then hit with a double whammy. We are hit with the extra cost of health care.
Therefore, my argument is that equalization is another one of those great measures that binds us as a country. Not only do we want equalization to be at the standard it once was, but also, now that we have a 10 billion dollar surplus prior to September 11, we want equalization payments to be greater because Newfoundland contributes, and the other poorer provinces contribute, greatly to the well-being of the whole of the country.
Senator Cook: The problem with the equalization formula is that it is population based. Once you move to bring a province such as Newfoundland up, Quebec scores up 60 odd per cent because of the current formula.
Mr. Lucas: More obstacles we have to come over.
Senator Cook: There have to be other options and other programs. We have a responsibility to determine what they should be with the best practice and evidence based information. Only saying this is not going to work. Equalization is not the answer. There has to be something more.
The Chairman: It is true that the population of Newfoundland has a disproportionate percentage of people under 18 or over 65, relative to other provinces. Therefore, the equalization formula ought to reflect the number of people who are most likely to be receiving the three social services you talked about, which are in the age groups under 18 and over 65.
If it were only done on the basis of population, then a province like Alberta, where the economy is going crazy, would have a much smaller percentage in those two groups because it has a large percent of the population on the working age group. We should rethink the formula on the basis of the number of dependents on social services. I have never heard that idea before, but it is interesting.
Senator Cochrane: Mr. Lucas, were you part of this health forum that has been travelling across the province? The government has just finished this forum now.
Ms Lucas: No, I was not. By trade, I am a carpenter and I work for a school board in St. John's. I am the President of CUPE, Newfoundland and Labrador. I have been kept informed by our Vice President of CUPE, Newfoundland and Labrador.
Senator Cochrane: Has he been travelling with the forum? Has there been representation from your union on this forum?
Mr. Lucas: The forum travelled throughout the province. In different areas of the province, we have CUPE representatives. Our CUPE people went in and made submissions.
Senator Cochrane: Have you received feedback?
Mr. Lucas: Yes.
Senator Cook: Has there been one common theme, or a few particular suggestions that they have offered that would sustain our health care?
Mr. Lucas: First of all, you have to realize the history behind Newfoundland and Labrador. We just had a major strike in the province where we just received a 15 per cent increase in wages. When the Premier called CUPE to the table, we said to the Premier that we would cooperate in whatever way possible, but there are two criteria. First, we will not agree to any layoffs of individuals, and second, we will not go into the collective agreements.
We have been telling the committee that on a day-to-day basis in every community, there are certain things that the St. Pat's home here in St. John's may be able to do. For example, one of the recommendations of St. Pat's home is that you can save money, rather than doing outsourcing, by contracting work in. We believe there are considerable savings in that area.
In Western Memorial, for example, the use of overtime should be curtailed. Where it is possible, individuals can work and rather than use overtime hours, schedule people where they use straight time hours. In every community, we have said that we believe we should use the position we have in our collective bargaining of LPNs. We have licensed practical nurses, and where that is possible, we have asked government to implement that program. I believe, to a certain extent, they have already done that.
Senator Cochrane: Tell me about the licensed practical nurses.
Mr. Lucas: Licensed practical nurses have been trained to do a specific job. I do not want to go into the details of that because I may slip up in one of those areas.
Senator Cochrane: We have qualified people right here.
Mr. Lucas: Donna Ryan may be able to help with that one. LPNs have been trained to do certain jobs. In the past the government has not availed of those individuals. Last year in the House of Assembly, we had an all-members debate where they unanimously supported using LPNs in the health care system.
Senator Cochrane: Would the other members of the panel also like to respond?
Ms Smith: Do you mean in relation to the health care forums?
Senator Cochrane: Yes, that is correct.
Ms Smith: Our association has had representation at nearly every regional forum, and we have also been invited to participate in the provincial forum. Each of the forums is coming back with the same messages, because they have been asked to look at specific questions related to the service delivery within the province. They have been asked to look at whether the people participating in the forum believe, for example, that there are enough health care boards within our province.
The message has been to evaluate the changes that have been made before we look further to make other changes, and use evidence as a basis for decisions. Many of us within the province do not have the information systems we need to support the evidence-based decision making processes that everyone would like us to be using. We are stuck.
We need to define insurable services. We have to look at specifically what are we insuring and that we agree what is covered by the Canada Health Act. Those are some of the messages coming from the forums. They have been consistent across the province.
Ms Blake-Dibblee: We also had the opportunity to participate. There are about 12 questions that they are asking. They are very thought provoking questions that focus on the primary health care model, health promotion and wellness. There is a lot of thinking and dialogue going on within the province as a result of the forum.
Senator Cochrane: That is interesting. It is probably a good time for us to be here. Ms Smith, would you address the statement that you made that inefficiency must be addressed? Did you make that statement?
Ms Smith: I did. We believe that there are inefficiencies within our system. From a nursing perspective, we have become inefficient because we have not been able to fill nursing positions. You cannot run the service as you would like to because you do not have the staff positions filled. You have to use overtime costs to support basic service.
There are many inefficiencies, for example, lengths of stay, that we recognize and that many of the health boards are trying to address. We need to look at what community supports need to be in place, for example, to enable people to go home earlier. There are ways to do things better, and if we are able to find those ways, we would certainly have more funds to use in other areas.
Senator Cochrane: Do you think that will solve our problem?
Ms Smith: It may not solve it completely, but it will give us resources. We will know that we are running things as efficiently as we can. Within the province, we have been told that we are over 20 per cent inefficient within the management of our acute care beds. I do not think we are that bad. I am not convinced that we are comparing apples to apples when we compare our CIHI data within the province of Newfoundland to the province of Ontario. There are many complex issues that we are all addressing in terms of inefficiencies and ineffectiveness within the system. It is a challenge because sometimes it cost more initially to put the supports in place to become more efficient. Where do you start?
Senator Cochrane: Would the other panel members like to address that?
Ms Blake-Dibblee: In the community care sector, we see inefficiencies, for example, with delays in getting patients out of acute care institutions, because a huge gap exists in the community, and we do not have the home support services to support that. The inefficiencies are glaring in that regard.
Mr. Lucas: I have been involved with CUPE, health care and the school board for 24 years. I have been to numerous rounds of bargaining and debates about efficiencies in the system. I have heard health care professionals and health care administrators, when talking about efficiencies, say that if you are talking about the administration down then let us look at better ways to do things.
I want to caution people that when we talk about inefficiencies, we are not talking about more layoffs, or that we have got people who are not doing their jobs. We all know that health care is, as I heard it paraphrased one time, "beyond the bone right now; we are into the marrow." What we need is a new infusion of money, a new infusion of trained people, and a new pride within the health care system, because everybody takes pride in ownership, and then we go forward from that point.
Senator Cochrane: I would like to know about the compara tive pay that home support workers are getting. We are looking at Atlantic Canada. If you were a home support worker, you would be hired by an agency; is that correct?
Ms Blake-Dibblee: That is correct.
Senator Cochrane: How much are the agencies paid to hire a support worker, and how much is the support worker being paid? How is that comparable in Prince Edward Island, Nova Scotia and New Brunswick?
Ms Blake-Dibblee: In Newfoundland, the home support workers agencies are paid at a rate of $9.93 to hire a home support worker. That would include the cost that they have to bear for administration, workmen's compensation benefits and other costs. The home support worker gets paid $6.66. That will increase to $7.01 on December 1.
Senator Cochrane: Is that comparable to the other provinces in Atlantic Canada?
Ms Blake-Dibblee: In Nova Scotia, the pay is quite a bit higher, but I cannot tell you exactly what that is. In Atlantic Canada, I believe that Newfoundland has the lowest pay rate for home support workers.
Senator Cochrane: Do you have a problem recruiting home support workers?
Ms Dibblee: It is a major challenge to recruit them and to keep them. Oftentimes, these home support workers have to find their own transportation to get to homes. We cannot service the rural communities surrounding St. John's because of the transportation system, and the inability of home support workers to get from one place to another.
Senator Cochrane: Did you say that the rate of payis $6 an hour?
Ms Dibblee: That is right.
Senator Cochrane: Who can work for that?
Ms Smith, you have said that the public needs to become more involved. Can you elaborate on that?
Ms Smith: We can probably spend the whole day talking about primary health care. Making changes in people's health and practices within their lives takes time. We have been of the mentality that if we are ill, we go to a doctor and get a pill.
It is sometimes difficult to get people to understand that their dietary habits need to be changed and that they need to become more physically active. The primary health care projects have been done within the province, specifically at the Southern Shore. It is not enough for a physician to tell an individual that their blood pressure is up and they can no longer have salt meat and cabbage, someone has to tell them what else they can have to eat. Otherwise, they are going to go home and still have the salt meat and cabbage.
In order to effect change, we have to put the people in place, for example, in the cluster that you spoke about. If I am overweight and my blood pressure is high, and I have now become diabetic because of my poor health habits, I need the resources to help me become healthy. Resources are also needed in the community so that people can prevent children from becoming ill.
That is not going to happen overnight. We have to be patient. We have to put things in place so that the right people are there to give the right information and the right support. There are places that are doing it in Newfoundland to support dietary changes.
Senator Cochrane: It is hard to set-up this cluster of professionals in smaller communities.
Ms Smith: It is hard to get them to work together in large communities. There are many challenges, but we have to be courageous and patient to effect change. This is what will work.
Senator Cochrane: In 1986, I was on the Labrador coast and the nurses there were fantastic. Some of the nurses who had come over from England were still there. The nurses were doing the gamut of everything. They were wonderful, and they provided a great service.
Is this what you were talking about when you suggested that nurses could play a higher role and that they need to work to their full potential? Are you talking about nurses being able to prescribe drugs and services similar to that? If that is the case, we have to change the whole standards of nursing; is that correct?
Ms Smith: No, not necessarily.
Senator Cochrane: Maybe standard is the wrong word.
Ms Smith: The scope of practice is what you are referring to.
Senator Cochrane: Probably.
Ms Smith: We have certain people who provide care within our system. We have licensed practical nurses, we have registered nurses, we have some nurses in advanced practice roles, such as the first assist in the operating room, and we have nurse practitioners. We also have primary care nurse practitioners and specialists in some programs. Each of these professions has a defined scope of practice.
With the nurses, we have done this learning circles project and we have helped them understand the role of the licensed practical nurse, so it is not as threatening. They understand that if they work in conjunction and collaboration with the licensed practical nurse, they are able to provide the services that they are better educated to do, for example, conduct in-depth assessments.
The nursing role needs to be examined to ensure that they are spending time doing the things that will effect the most change. If I have a person in the hospital, for example, or if I am in the community care for someone who has got heart disease, I am able to focus on what they need to change in terms of their health patterns to become healthier. If my scope expands, then the scope expands for the LPNs, the nurse practitioners and physicians. Everyone would be happier. It would be more fulfilling.
Senator Cochrane: That is not happening now; is that correct?
Ms Smith: No, it is not.
Senator Cochrane: How do we change it so it works?
Ms Smith: We have had reports that it is working well in some areas. Your example illustrates that it works well on the coast of Labrador.
People are use to the licensed practical nurses' role, the nurses' role, the advanced practice nurses' role, and the physicians' role, and they work well as a team. Getting the allied health groups in some of those areas is a real challenge. With physiotherapy, occupational therapy and clinical nutrition, it is a recruitment issue. If we can make it work in some specialized areas, we can look to use that as a model and expand it.
The Chairman: Your experience in Labrador is consistent with the experience across the country. It is much easier to get people of different professions to work together in rural communities, than it is in urban communities.
Ms Smith: It is need also. When you put the need there, it is a community need.
The Chairman: It is also the nature of the community spirit in a small community, which is a different concept, where everybody feels that they are part of a common group.
Senator Robertson: Medicare has been in place for almost 40 years without too many changes. A business that has been in operation for 40 years without management changes, in particular, would not be in business. The whole system has to be challenged and looked at if we are going to do the job properly.
When Medicare began with the Canada Health Act, 50 per cent of the funding came from the federal government and 50 per cent came from the provinces. It was directed only, and still is directed only, at what goes on inside the hospital and the doctor's office. Those are the only two things that are covered.
Federal contribution is down to an average of 17 per cent across Canada. In some provinces it is as low as 11 per cent, and in some provinces a point or two higher. That seems to be the lack of change and the inconsistency over 40 years. The reduction in funding has caused a crisis in the health system. We do not have the resources.
Change costs money. Many of the provinces, particularly the Atlantic provinces, are asking where they will get the money to effect the change. For example, they would like to take advantage of the federal contribution to the MRI, but the attending dollars for operational does not come along with the equipment. It only adds more expenses when already they cannot do what they are supposed to be doing. It goes around like this. It is a very serious issue.
As you continue your study, which sounds excellent, I hope that you will consider all of those issues that, particularly in the Atlantic provinces, make delivering health care very difficult to meet the demands of the people. They are worrisome issues, and it is going to take the cooperation of all of us to make any progress.
In Atlantic Canada, we export a lot of people, so we have a higher proportion of youth and elderly in our population than in Alberta, Ontario or British Columbia. There is another group that have not been able to move to find jobs, which also adds to our population problem. Over the years, we have had a build up of physically and mentally challenged citizens who do not feel secure in going to another province to find an opportunity. This makes our problems in the Atlantic provinces more difficult.
You will find that where women are the chief participants in a labour force, it is more difficult to get wages. When men enter the labour force, the wages gradually increase. For example, years ago educators had very poor wages. Once the men got involved, the wages started climbing and they are now presentable.
This has not happened to the same extent in health care. There are a few male nurses, but we will not be adequately recognized until we encourage more diverse population to the services. There is no pay for the home caregiver who is a family member who stays at home and quits his or her job to look after mother or someone ill in the family. Has anyone applied to the federal government?
There was a housing program called granny apartment or something, where there was assistance to create an apartment within a home, so that the parents could live there rather than going to a public facility. Could that type of program be transferred in a different way, in cash perhaps? Have you tried anything to get money to these people? In your hearings, did you hear of anything that would help these people?
Ms Blake-Dibblee: We have not gone that route. However, we know that the need is there. One of the major findings in this preliminary study is that financial remuneration would help to provide the caregiver and the recipient with a much better quality of life.
We know that 91 per cent of caregivers are female. The average age of the caregiver in Newfoundland is 55. Their household income is around $20,000, and some of that is from the old age assistance program that the recipient gets, which helps to support the family.
Senator Robertson: It is sad that we have deteriorated to this state. You are short of nurses. The home support workers who are paid make $6 an hour; is that correct? If someone were to give an income to these people to stay at home to care, it would be much cheaper than institutional care.
You could get trade-offs there. Rather than the paid home support workers, the nurses, and the nursing assistants trying to do all the professional things that you want to do, these people could spend their time training family caregivers to do a more comfortable job at home. There would also have to be some adequate compensation for that caregiver at home.
You do not have the staff to do it all. These are some of the options that we have to look at. I hope in your study of Newfoundland that you look at all the options available to you.
Senator Cook talked about clusters. If you talk to any of the nurses in the Extra-Mural Hospital in New Brunswick, you will find happy nurses. They are independent. They report to the doctor once maybe every night, or maybe not even that, as long as the patients are doing well. They are in charge. Doctors should not admit to hospital. Nurses should do the screening. Why would a doctor have to admit to hospital?
I got caught in Kentucky, which is probably the poorest state in the United States, and I had to go to the emergency ward. The first person I met was a nurse. The nurse did the screening. The lab did all the tests that the nurse had decided should be done. The pharmacist then came in to review the medications I was taking. Eventually, I saw the doctor for five minutes, and then I went back to the hotel.
The Chairman: Any last comment from a member of the panel.
Senator Robertson: Keep doing a good job, but remember it costs money.
The Chairman: The example that Senator Robertson raises gets exactly at the issue that all of you have been talking about in terms of scope of practice, and getting people who are qualified to do things. The phrase we used in the book was that you would not hire an electrician to change your light bulb. Getting a doctor instead of a nurse to do some things is an equal sort of example.
Mr. Lucas: We talked about if someone is in hospital, and if we can put him or her back in the home. I believe the example you used earlier this morning was someone was in the Miller Centre. I had an experience with a family member, and not only did it cost less for the government to take care of this person by putting the person back in the home, but the quality of life to that member increased ten times fold. It works out all the way around.
The Chairman: Our next witness is Ms Maude Peach, who has had an extensive career in the health care voluntary sector in Newfoundland. Thank you, Ms Peach, for coming.
Ms Maude Peach: I was formerly the Director of Volunteer Resources with the Health Care Corporation of St. John's. In addition to this role, I was responsible for hospital and community education, which included conducting seminars in the area of child abuse prevention. I am presently the vice-chair of the Newfoundland and Labrador Lung Association.
I only received the interim report on Thursday, so it is difficult for me to comment on all the areas of concern. However, I have taken the area of volunteerism in order to demonstrate its importance in the field of health care and not-for-profit organizations in the 21st century. Thank you for allowing me to share with you some information about the contributions that a dynamic group of people have made to the quality of life to those who use our health care system, and in addition, have enhanced the life of our community.
This dynamic group of people are called volunteers. They work in our hospitals and nursing homes, supplementing the care provided by staff and families. They are your friendly visitors. They provide music and pet therapy programs. They supply transportation for hostels, make Christmas tray treats for Christmas and work with the various clergy providing spiritual care. They provide way-finding services to the patients and to the elderly. They give a more holistic approach to health care. They provide entertainment and work in our gift and coffee shops.
They provide many thousands of dollars a year to our hospitals, which enable them to buy much needed equipment. This year, the 1,200 Health Care Corporation volunteers at tertiary care donated 80,000 hours. They also donated $685,000 to the hospital foundation for equipment.
This is in addition to the monies raised by the foundations themselves, which is staff driven, but supported mainly by volunteers. One example is the Janeway Children's Hospital Foundation, which raised in excess of 17 million since 1985, and 1.4 million in this year. Newfoundlanders give more time and money per capita than any other province in Canada. In our province, volunteers contribute millions of hours a year helping people who are ill, elderly, disabled, disadvantaged, and illiterate. They provide first aid and counselling, meals on wheels, CanSurmount programs, and help to care for the environment. These are just a few examples.
There are more than 20 health related associations in the province, which offer education and support to patients and families with various diseases and disabilities. Examples of these associations are the Arthritis Association, Autism Society, Cerebral Palsy, Heart and Stroke Foundation, Kidney Foundation, Newfoundland and Labrador Lung Association, and MADD Association. Most of these do not receive any funding from the various levels of government, and they deliver their programs and education and support through volunteers. All revenue is volunteer driven.
The Newfoundland and Labrador Lung Association is a not-for-profit organization dedicated to achieving healthy breath ing for the people of Newfoundland and Labrador. They do this through programs in education, research, and advocacy. This association is sustained for formalized activities of fund raising, voluntarism, and organizational development.
With a staff of only five and with 500 volunteers, the Lung Association delivers 20 educational programs, which in many cases are the only sources of direction and information in Newfoundland. The association has an annual budget of approximately $380,000, all of which is raised by volunteers and supported by the general public. This association continues to strive to find new and innovative ways of fulfilling their mission.
The YMCA-YWCA, of which I am a member, has in addition to its volunteer board of directors, approximately 120 volunteers who are on the front lines delivering programs in exercise, sports, and recreation. They give 9,000 work hours per year, all of which support the objectives of the various governments that are promoting exercise in a healthier lifestyle, which correlates into better health. This organization's fund raising activities and operating budget is once again volunteer driven.
Volunteers are the defining characteristic of every charity and not-for-profit. They contribute to our ability to achieve our missions, to effect social change and to provide an important link with the community in communicating health policy information, which includes healthy lifestyles.
It has long been understood that there is a correlation between healthy lifestyle and prevention of disease, yet we see our fitness centres, such as the YMCA-YWCA, which are mainly operated by volunteers, having to collect 15 per cent HST. In some countries, this expense is tax deductible.
As an aging population, we need to look at innovative ways to make services that promote healthy lifestyles more affordable. Government needs to entertain the idea of removing such taxes from all centres and services promoting healthy lifestyles, thus helping to reduce costs to the health care system.
There is limited access to information on wellness and health promotion. When I was at the Janeway Child Health Centre, I was the only person responsible because I was willing to take on this additional task. I found that there was very little information for moms. After breastfeeding stopped, there was nothing. There might have been an item or two on potty training. There are many issues single parents face that they need assistance with. It is too late when you have to go to the physician to get advice. The problem has already occurred.
If we are to educate the public to take more responsibility for their own health and well-being, then this information should be readily available. When you go into a doctor's office, there is some kind of waiting room, and there are one or two pieces of information on health, promoting wellness and raising children, and it only gets filled up when somebody in the office has a little time. These should be readily available to families through family information centres and wellness centres, funded by government, which could easily be supported by volunteers.
I will forward a copy of this brief to the legislative clerk. If you would like copies, she will make them available to you.
Senator Robertson: You, like all volunteers, are doing a tremendous amount of work for your community. If you added up the dollars that we save with the army of volunteers across the country, we would be astounded. I do not know what we would do without volunteers.
In your work as a volunteer, what is the most difficult thing you have had to contend with where you have said that if things were different, it would be better? What aggravates you the most?
Ms Peach: When I was a volunteer director I coordinated many volunteers. One of my most frustrating or biggest challenges was when we changed the program management and I found that you were no longer part of a team. Often, you worked in isolation and it was very difficult to do needs assessments.
You were not part of the team that cared for the patient, even though you were very much part of the psychosocial care. It was up to you or the volunteer to find out what it is that the patient wanted, and that is fine for a person who can speak for themselves, but for seniors and children, it is difficult. They almost need an advocate.
Senator Robertson: I am not surprised about the requirement for a patient's advocate.
Ms Peach: Yes.
Senator Cochrane: I realize what volunteers do and the contribution that they are making, especially to seniors. The volunteers in rural Newfoundland are doing a fantastic job.
Are people using the public health system? I am talking about the public health nurses and people of that nature. Do they take advantage of that, or would they prefer to go to a hospital to get treated or for shots?
Ms Peach: I think if we had a wellness centre, or a location where families could go, they would go there. People do not want to wait two or three weeks to make an appointment to see the doctor. If you go into a doctor's clinic, you will wait for two or three hours, and when you get in there you have got five or ten minutes. There is nowhere to go for information on wellness. If I am taking seven or eight medications that I have been taking for the past 20 years, how do I know that I need to continue to take them? I would like to have a drop-in centre where I could go and say would you check this out, or could I get weighed, can I get my blood work done.
Senator Cochrane: Absolutely. We have some public health nurses within various areas. They are not doing that now; is that correct?
Ms Peach: In some cases they are, but our public health nurses are overworked. They have too many clients. I have a couple of elderly friends in their home, and they have home care come in, but there is quite a turn over. There is no continuity of care given by the person, and if I was not going in and filling out their papers, applying for their apartments or their old age pension and paying for their prescriptions, there was no one to do it. The public health nurse will come in to see how they are doing, and they are there for crisis intervention, but aside from that there is not much time given to each patient.
There is just not enough time in the day for the public health nurse. We need drop-in centres. Many people go to the emergency department that should not be going there. It is an abuse of our emergency department.
The Chairman:It is the only option they have in some cases; is that correct?
Ms Peach: Right now, yes.
The Chairman: It is not the only option that could be available. It is the only option that is available now.
Senator Cook: The frustration that Ms Peach referred to happened when the province went from a clinical care approach to a program based approach, and that was a change that really impacted on the system.
The elderly and the frail elderly need the proper application of medicines, insulin shots, and any number of things that could be taken care of in my cluster in that wellness clinic, possibly supervised by a nurse practitioner. Along with a caseworker, that would act as a drop-in centre, and it would take the pressure off our institutions and waiting rooms. Do you share that view? How do you see it working out?
Ms Peach: Definitely. Just recently, my mother-in-law had a bad foot, and this continued for a number of months. We returned to the hospital. We waited to see the specialist, only to be told her foot looks perfect now and to come back again in six months. If we had gone to some kind of clinic, the nurse could have easily told us this, and would have been qualified to do so. This would have freed up the specialist's time. Wellness clinics are the answer to many of our problems here in Newfoundland.
Senator Cook: How do you see this happening in rural Newfoundland? We cannot have one in every community. Do you see a radius or an area? Given our aging population in rural Newfoundland, do you see that as an option for our people?
Ms Peach: Some system has to be put in place, such as the nurse practitioner, if we empowered them more. The nurses that have worked in these areas and have come into St. John's have always said the work in the outlying areas was more challenging. It was not limited to changing bandages, bed making, and that kind of thing. Now that many nurses are getting their bachelors degree in nursing and taking special courses, I think it could work.
Senator Cook: Given the drop in our economy, especially since September 11, what do you see as the future with respect to revenue for the agencies you mentioned? I will single out the Lung Association, because you said that there was a budget of $400,000. Is it realistic to think that we are going to be able to support those agencies that are delivering such a wonderful service through volunteers and the public's ability to respond, or is that going to come back on the system? What kind of an impact is it going to have on the system?
Ms Peach: It is increasingly difficult each year. However, we manage. We are always trying to find new and innovate ways to raise money. We work very hard, yet the revenue does not increase every year.
Even with the anthrax scare, we do a mail out at the Lung Association called the Christmas Appeal. People are probably going to be afraid to open the envelope because it is bulk mail. Now we have to find a way to let the general public know that the volunteers at the Lung Association handled them envelopes themselves. It is a big challenge.
I mentioned 20 associations, but I am sure that there are more out there. At one time, the provincial government gave money to the Newfoundland and Labrador Lung Association, but I think it was discontinued in 1991. Since then, we do all of our own fund raising with our volunteers.
Senator Cook: Those volunteer agencies will have to be grouped somewhere to show where the saving is, and if the impact moves because of what is happening in the community.
The Chairman: As governments cut back, the role of the voluntary sector, which was always important, becomes crucial. Big institutions can no longer operate without them.
There are two members of the House of Assembly here who I would like to recognize. Ross Wiseman is the opposition health critic, and Sheila Osbourne is also a member of the legislature. Thank you very much for coming.
When my wife was in the hospital with cancer a year ago, there was a volunteer who met you when you were going in for chemotherapy and other similar procedures. I realize that does not require much training, but a number of the positions that volunteers take require some knowledge of the health care system. Do the volunteer organizations provide training programs before putting someone in place?
Ms Peach: Yes. All volunteers have an orientation, and they go through a very rigid process. It is similar to applying for a job. You fill out your application, supply letters of reference, and go through a police check.
The Chairman: It is a rigorous process. That is not unique to Newfoundland, it is nationwide; is that correct?
Ms Peach: Yes, as far as I know. I am a member of the Canadian Volunteer Bureau, and they all have extensive training programs.
The Chairman: How do you recruit people? Do you wait for them to come through the door? I do not see ads for volunteers.
Ms Peach: You advertise. Most of the time you use the media that do not charge anything. You go to the local newspaper, the church bulletins, radio and use word of mouth. We are very lucky that we have a university and medical school here, so we get many students interested in the health care field.
The Chairman: This is not just people in our age bracket. You are finding people at the age of students; is that correct?
Ms Peach: Yes. We had a very active volunteer program. Our Janeway youth in the 14 to 16 age range gave 7,000 to 8,000 hours per year. Newfoundlanders give more per capita, in terms of both money and time, than any other province in Canada.
The Chairman: You are even talking about high school students when you are talking about 14 to 16; is that correct?
Ms Peach: That is right.
The Chairman: I had not appreciated that. That is an enormous additional free support, in terms of dollars, to the health care sector. It would be very interesting to know what that is worth. If you ever had to ever replace it, it would be staggering.
Ms Peach: Most hospitals have volunteer programs, especially in paediatrics.
Senator Cook: They did away with the candystripers; is that correct?
The Chairman: No, they still do it. At least, when my wife was in, they did it.
Ms Peach: Especially where there are paediatric settings, we feel that youth relate to the children better. All of them have training programs. If you were to work with the VON, St. John Ambulance or in Palliative Care, additional training is required over and above what they would get during a normal orientation process.
The Chairman: I want to thank all of the witnesses who appeared before the committee this morning.
The committee suspended its proceedings.
Upon resuming.
The Chairman: Honourable senators, this afternoon we have with us Dr. Roy West, President, National Institute of Cancer, Dr. Catherine Donovan, Health and Community Services, Gov ernment of Newfoundland, and Marlene Bayers, Regional Manager, Weight Watchers. Welcome, and thank you all for attending here.
I notice that we have received written briefs from all of you. What I would like to do is ask each of you, beginning with Dr. West, to do a synopsis of your brief, and then we would be delighted to ask you questions.
Dr. Roy West, President (St. John's), National Cancer Institute of Canada: Although I am the President of the National Cancer Institute, which is, as you may know, the research arm of the Canadian Cancer Society, I am here today because of my public health experience in my career in Canada. I have gone back and forth between government life and university life, so it is in that context I am responding to your "Issues and Options" report.
The Chairman: Are you still associate dean at the medical school?
Dr. West: I stepped down on August 31, and I am fortunate enough to be on leave at the moment.
The Chairman: I have enormous sympathy for anyone who does academic administration, having done it myself many years ago. It is one tough job.
Please proceed with your presentation, Dr. West.
Dr. West: If you turn to the folder that I have just given you - ignore the first couple of pages, which just describes my background - you will find an executive summary there. I should like to take a few minutes to go over it with you.
Basically, I am in the same camp as people like Michael Rachlis and Ken Fyke. It is not surprising Ken Fyke employed me to Saskatchewan. I believe there is enough money in the system, but I do not believe there is enough money in the system if we keep going as we are going. It is totally unsustainable.
I believe that we have to make major changes, and I believe those major changes are possible. We have to think outside the box. We can maintain, with the proportion of the GDP that is going into it at the moment, a universal publicly funded health system in Canada, expand it so that it also includes wellness and health promotion, and do it on roughly the same amount of dollars we are spending at the moment.
What I have done is respond to the chapters of your report and make a few recommendations. In the executive summary, on page 5, you will see that I have indicated the cost effect of the recommendation.
Under the Canada Health Act, I strongly believe that the act has to become the Canada Health Act and not the Canada Illness Act and that it has to include public health and health promotion. I would urge that the Canada Health Act be expanded to include health services such as childhood immunization, health promotion programs, anti-smoking programs, and so on, services that will help keep people well. In expanding the act, we need to maintain the same principles of the act. Both of these together will increase costs.
From the point of view of the system, the major problem we have at the moment is that our treatment system - hospital services and doctor services - budgets are based on previous services; they are not based on priority and need. What we are doing is increasing the number of services to keep up with our aging population, and to me that is dealing with the margins. As I say, to get outside of the box, we need to priorize what services are required based on need.
You will gather that I am not a great fan of regionalization, in that we put it in place starting in Nova Scotia in the 1980s and it has never been evaluated. Different provinces are using different models.
All of these points are expanded on in my written presentation.
I mention in my brief that what literature I could find largely comes from Europe but that it pertains largely to dense populations in small geographic areas. In fact, in the literature, there is very little evidence that regionalization with less than 1 million population in the region is efficient. Compare this to Newfoundland with a population of 500,000 and six regions. Saskatchewan is the worst now, because they have 30 regions in a population of 1 million people.
I really question where we are going with regionalization and whether we need to pull back to the core and rethink where we are going.
From the point of view of primary care, we must reorganize primary care. The current model of physicians working in their own practices is not working. It is pushing up the costs. We must get to the point where we are working from comprehensive health centres, with various health professionals working within those centres. In fact, I would prefer a nurse practitioner to be the gatekeeper for those centres. He or she would triage people as they enter the centre. Some people would go on to the doctor, some may go to a social worker, or some may go to a mental health worker.
We must rebalance the continuum. We have been putting 95 per cent of our effort into treatment. We have been giving very little thought to prevention and wellness at one end of the system, and very little attention to supporting people with dignity and giving them good palliation at the other end. Those balances must be achieved.
I have mentioned the gatekeeper. I believe we can save considerable money by actively monitoring drug usage in this country. I was the person who instigated the use of the universal drug database in Saskatchewan for research in 1983, and I have quite a bit of familiarity with drug use studies. I am firmly of the belief that if we were to embrace technology and move forward in that area we would save considerable money.
In terms of research and evaluation, we should continue to increase funding for research. CIHR is a marvellous step forward, but it is still waiting for the allocation of further funds to move it towards $1 billion dollars a year. Needless to say, researchers are quite anxious in these times of talk of money having to go into a security budget, which I recognize is important for the country, but one of the last places that money should come from is the research budget.
From the point of view of using research to formulate policy and practice, we need to train managers and senior professionals in government, and in other services, and the professionals themselves who are in practice, to use the research data that is forthcoming. There is currently quite a bit of research data out there that has not been used, and we can go on adding to that. Obviously, both policies and practice should be based on evidence.
From the point of view of technology, we must continue to develop systems. If we are going to have the ability to manage based on outcomes, we must collect information on those outcomes. If we move in that direction, I believe we can reduce costs by eliminating services that do not have good outcomes.
Finally, on technology and information systems - and you are right on in your brief - health researchers and others are finding it difficult to get together to make suggestions for amendments to the Privacy Act. One of the problems researchers are having is that Health Canada and CIHR, the two organizations that help to lead research, are not willing to criticize legislation put forward by another department of government. In fact, the CIHR document on PIPEDA - the Personal Information Protection and Electronic Documents Act - does not tell researchers what to do from the point of view of lobbying for change. It tells researchers what to do from the point of view of working within the act.
I am reading into your comments that you also believe that there needs to be some modification to the act, and I personally believe we need that to take away the threat from research.
Of course, the other voice, which is opposite to that, is that of the physicians, who are saying, "We want it even stronger," which is their way of showing the public that they are looking after their patients and their patients' privacy.
I shall just make a quick point in terms of health and human resources. I believe we have to work towards not only salary scales for professionals, including physicians who are on fee for service, but interprovincial salary scales. Currently in Canada, as you must have heard many times, the smaller provinces - Newfoundland, for example - are losing out to the bigger provinces and salaries are being ramped upwards by the bigger provinces.
Finally, from the point of view of population health, I note that Dr. Donovan will be talking strongly from this point of view so I will not say much. However, there needs to be an investment in prevention. There must be a national strategic social plan - which we have; Newfoundland is the first province to develop a provincial strategic social plan. Newfoundland is having some difficulty implementing the plan, because of lack of resources, but it is heading in the right direction, in trying to empower communities to make them healthier and to make them economically more viable. From that point of view, we need to invest in our communities.
I just want to take 30 seconds to point out something in your folders. If you go past the first blue marker, you will see a graph, which is a graph for Newfoundland, but this is true for the whole country. I have plotted the increase per capita in health expenditures in constant 1992 dollars. That is the line with the squares. The decreasing percentage increase in life expectancy every five years - I apologize, I have cheated a little bit, the last point is only two years. What this tells me is that we continue to invest in treatment, but if we use the ultimate measure of outcome, that is, life expectancy, it is going down. In order to change life expectancy, we can prevent premature death, and to change premature death we must have disease prevention and health promotion.
Lastly, we have developed a way of putting data together by towns and communities in Newfoundland. The intent is to empower towns and communities to be able to see how they stand compared with the rest of the province. We have this simple bar chart - and I have given you two examples, but we can do this for many of the determinants of health. I have given you two examples, life expectancy and self-assessed health status in Clarenville, which happens to be in Dr. Donovan's health region. The second page of each one plots on the map of Newfoundland how the other communities are doing. This is our way of trying to get information out to communities, so that they can begin to take measures to improve their own health and see how they compare with the rest of the province.
Dr. Catherine Donovan, Medical Officer of Health, Health and Community Services, Eastern Newfoundland: Thank you for the opportunity to speak with you, and thank you, Dr. West, for setting up my presentation.
I will be speaking to you from the perspective of a public health practitioner, and in that role I am still acting as the principal investigator for the Newfoundland and Labrador Heart Health Program.
From that perspective, I will not address the treatment and care system - I think that has been done very well in the "Issues and Options" report - except to say that from a public health perspective, obviously, as a determinant of health, I am very supportive of a high-quality and accessible treatment and care system.
I will speak about population health and some of the issues in the report that have an impact on population health and the public health system that tries to address population health. I will also speak about the Canadian Heart Health Initiative, the CHHI, which is an extraordinary model of health promotion that has been funded by Health Canada and is a good example of how we should be proceeding.
For the purposes of the discussion, when I talk about public health and public health services, I am referring to those services that promote health in the population. They include health promotion, disease and injury prevention, and health protection.
In the "Issues and Options" paper, you discuss a 21st century context, and I think it is important in considering the health system to look at the public health system somewhat differently than you look at the treatment and care system. There are certainly some unique issues and different approaches to the administration of public health than to the treatment and care system. There are also some issues around measures of consumer-centred quality that are distinctly different for public health, in that some of the things we do may not be perceived by individuals as in their best interest when they may be in the interest of public health. So when you are looking at the public health system, it needs to be looked at somewhat differently than the institutional care sector.
In terms of the federal role, not surprisingly, my paper does support what Dr. West has already said in terms of expanding the definition of "medically necessary" to include health promotion and protection services. I refer in my paper to a Centre for Disease Control Report called "An Ounce of Prevention," which does a very nice job of concisely documenting some of the economic savings that can be achieved by an investment in public health. Even though those are U.S. dollars, we could expect proportionately equivalent savings in Canada.
Health Canada has played an important role in funding innovative research and pilot projects. The Canadian Heart Health Initiative is an example of that. Health Canada has often funded projects that would not fit the standard protocols for traditional research, especially from either a methodological or a subject perspective. Hence, it is important for Health Canada to continue to take that leadership role, because there are some concerns, particularly in those of us based in the community, that CIHR may not be quite as receptive to that kind of innovative research and programming.
One of the failings of that program, however, is that we seldom follow through in terms of funding implementation of successful projects or implementing knowledge that has been acquired through the research.
Another role I see again is something Dr. West has mentioned in terms of evaluating health system changes. There has been an incredible amount of restructuring and reorganization, with very little evaluation. Others are jumping on the bandwagon without paying due attention to recent history or the experiences of other jurisdictions. From my colleagues in the public health sector across the country, there are anecdotal reports that the public health system is not fairing well in the rush to regionalization and integration.
Facilitating the dissemination of knowledge between jurisdic tions is another important role for the federal government. Again, the Canadian Heart Health Initiative is an incredible example of how the federal government, Health Canada, has facilitated collaboration and cooperation between provinces.
The discussion of the health system infrastructure, in virtually any context, usually fails to discuss the public health infrastruc ture. We usually talk about clinical physicians, nurses in hospitals, treatment and care professionals, and the capital structures, but there is seldom talk about the public health infrastructure. There is definitely concern across the country about public health capacity. I would urge the committee, if at all possible, to get access to a report on the public health infrastructure that was prepared and delivered earlier this year to the Conference of Deputy Ministers of Health.
The public health system needs adequate resources to support the kind of innovative health promotion and protection program ming that is going to have a long-term impact on health in Canada. Canada has always been very good at developing theory and approaches to the promotion of population health, but we have done relatively little to follow the path that earns us international recognition. We really are seen internationally as leaders in population health and health promotion. The "Issues and Options" paper does a very good job of recognizing population health, and clearly demonstrates that the committee has a full understanding of what that means. The options that are proposed in terms of addressing population health fall prey to what is often a problem in discussions about dealing with the population health issue, that is, a kind of inertia that comes about that "This is too big an issue, one we cannot do anything about it, so let's deal with what is easier to deal with, and that is to fix things after the fact."
While there are two proposals in there that I think are credible and should be followed through in terms of the federal government's own services around Aboriginal health, as well as trying to encourage intergovernmental collaboration and coordina tion, one option that is not there is building up the public health infrastructure through national standards, ensuring there is allocation of funding, enhancing health promotion programs, and ensuring that public health workers have the capacity to support the community action that is possible out there and is happening. In medicine, if a physician failed to prescribe an adequate dose of medication, he or she would be liable for the adverse effects on the patient; yet our health system invariably fails to provide the preventive dose that we know can save lives and improve health.
The Canadian Heart Health Initiative is a good example of a program that has all of the features that are key to successful health promotion interventions. It has a multi-factorial focus, includes multiple approaches and involves intersectorial collabor ation and community action. It started with a sound evidence base. Surveys were done across the country on heart health and risk behaviours. It has created the largest database in the world around risk behaviours. Building upon the knowledge that was acquired through the surveys, demonstration research projects were developed, and now the Canadian Heart Health Initiative is into dissemination project phase. Though each province was distinct and developed its own programming, there has always been significant collaboration and sharing of knowledge and information between all of the provinces.
In terms of its success, it is relatively early to look at outcomes in terms of changing the mortality from cardiovascular disease. However, for an investment of less than $10 million in the demonstration phase, there were over 700 events across this country that reached almost 2 million participants. There were 1,400 contributors, in addition to Health Canada; these included provincial governments, universities, NGOs and volunteer organ izations. The initial investment of $10 million resulted in a total investment at the end of the demonstration phase of $33 million.
The Newfoundland and Labrador Heart Health Program is one of the most successful heart health projects of the initiative. We have reached into every area of the province, with community participation and heart infrastructure involvement and sustainabil ity. The demonstration phase of this project, which ended in 1996, showed a substantially increased and sustained heart health activity and increased capacity for health promotion throughout the province. A 1996 survey showed that 175,000 people in the province knew of the project and that 60,000 had actually participated in community-based heart health activities. In the dissemination phase, which began in 1998 and is still in process, there have been over 300 heart health activities, with1,600 participants and involving 500 volunteers. Most recently, the Newfoundland and Labrador Heart Health Program has taken the lead role in developing provincial health promotion and disease prevention strategy for type-2 diabetes, another critical national issue.
The story of the Newfoundland and Labrador Heart Health Program is a phenomenal one because of the enthusiasm and the sustained heart health promoting activity with very little investment. At the end of 2003, however, the federal funding comes to an end. Although I do not have any doubt that we will sustain some activity, it is becoming increasingly difficult to get the commitment of public health workers because of the growing demand for treatment and care in the community. Hence, the shift to community has not really meant a shift to health promotion in the community. What is has meant is a shift to treatment and care in the community.
The model of the Canadian Heart Health Initiative can be applied to most chronic disease prevention activities and to other population health initiatives. We do not have the resources in this country to ignore our successes. The federal government should be encouraged to use the knowledge and capacity it has developed through this initiative to develop resources and facilitate the implementation of a national health promotion strategy.
My recommendations are included in my paper. As you can see, they focus on evaluation, building on the knowledge and successes that we have and supporting the public health infrastructure, to develop the capacity and a national strategy to promote health of Canadians.
Ms Marlene Bayers, Regional Manager (Newfoundland and Labrador), Weight Watchers: Thank you for the opportunity to be here today.
Our company is an international privately owned company founded in 1963. We have been operating Weight Watchers in Newfoundland for 29 years now. Presently, we have 2,000 members attending 40 meetings weekly. Where we see an effect is in the prevention of so many illnesses and diseases associated with being obese and overweight.
We operate throughout many rural and urban areas in Newfoundland, conducting private meetings with our members. We use a nationally certified weigh scale that weighs up to 440 pounds, and we are seeing more and more members who need the use of those scales.
With obesity and weight-related illnesses reaching an all time high in this province, we find our services even more in demand. We are seeing good success in our members. Weight Watchers members lose weight by learning how to eat sensibly. We focus on the serving size as well as the nutritional makeup of the food. Our eating plan is practically applied to meet anyone's needs. We also provide the learning for living in the real world. People can still eat out, and they are educated about the benefits of adding physical activity as well as making choices that will support the long-term effectiveness of doing this.
We offer group support in our meetings. Group support has been the real cornerstone of this program. Hence, it is not just a matter of losing weight, gaining weight, coming back, that old cycle that has been around for a long time. Our members are encouraged to participate in the learning of changing those habits long term. We offer Weight Watchers tools for living, which are based on neurolinguistic programming and are very effective in dealing with weight loss obstacles.
We make Weight Watchers as accessible to as many people as possible. We are located in the workplace as well as many of the rural communities and cities throughout Newfoundland and Labrador.
In targeting obesity in Newfoundland, we have established a relationship with many of our doctors. We send out regular mailings to our doctors. When a doctor refers his or her patient to Weight Watchers, we waive the registration fee for that person.
We use the body mass index goals as a recommended weight target. Obesity experts now recommend that those who need to lose weight begin with an initial goal of losing 10 per cent of their present weight. This weight loss is achievable and can yield significant health benefits. Weight Watchers has adopted the 10 per cent difference as an enhancement to our program. Research has shown that simply losing 10 per cent of one's body weight will result in immediate improvements in areas such as regulating blood pressure, lowering blood cholesterol and lowering the risk for diseases such as diabetes and some forms of cancer.
Members no longer come to Weight Watchers exclusively for cosmetic reasons. The many health benefits to losing weight are varied and tangible. We have many members who have shown health improvement. One of our members has reduced the daily amount of insulin she uses by half; another is no longer required to take blood pressure medication at all, Many of our members have found relief from backaches, fatigue, sleeplessness, indiges tion, and leg pains.
I have a couple of specific examples a little bit closer to home. One young man who lives in Clarenville has just lost 90 pounds with the help of Weight Watchers. Before joining, this young man experienced sleep apnoea. He slept sitting up. He snored heavily, and suffered from elevated blood pressure and chronic back pain. He is now free from all these ailments. He still has over 100 pounds to lose, but he feels wonderful.
Another member, who lives near the St. John's area, has been hospitalized because of very high cholesterol and a heart problem. She has a family history of heart disease and her doctor was concerned about her health. This woman had tried numerous medications and diets without success. In a meeting with the hospital dietician, who had run out of suggestions for her, the dietician whispered to the woman confidentially that what she needed was to join Weight Watchers. They did not know what else to do for her. She came to us with a blood cholesterol count of 9.7, which was high for her age. After 10 weeks, her blood cholesterol dropped by 2.9, and she is entirely free of medication at this time.
All of these accomplishments are enhanced for our members because of the learning that led to them. It is through informing and educating that we are going to make a real difference in improving the health of Newfoundlanders - and we see our role as one of educating.
I have a number of references here that outline the benefits of losing just 10 per cent body weight. The Journal of the American Medical Association points out that, after smoking, obesity is the second-leading cause of preventable death. The NIH report on obesity clinical guidelines says this about obesity: "Obesity substantially increases one's risk of developing many chronic conditions, such as high blood pressure, type-2 diabetes, heart disease, stroke, gall bladder disease, cancer of the breast, prostate and colon, liver disease, lower back pain, sleep apnoea, stroke, and urinary incontinence."
There are a couple of other references to obesity in my written presentation.
We are seeing a number of younger people who are not necessarily obese join Weight Watchers to learn the principles of good eating, to stop the problem before it gets out of hand.
Weight Watchers has been proactive in getting nutritional information out to our members. Until nutritional labelling becomes mandatory in Canada, this does remain difficult. We want to know what we are putting in our bodies, and this is a challenge without having the details on labels. I have been told by one food manufacturer here in the area that he will not reveal to us what goes in the packaging in terms of fat-calorie content because he is afraid that our members, in particular, will not purchase it. It causes me great concern not to know what we are eating.
In the U.S., a recent change in the IRS guidelines for 2001 allows taxpayers to deduct the cost of a weight-loss program such as Weight Watchers when it is prescribed by a doctor to treat an existing disease. Taxpayers can also subtract the cost of participating in a weight-loss program to maintain healthy weight to treat a medical condition after weight loss. Further, the expense can be deducted even if the treatment proves unsuccessful.
The IRS has issued a publication on medical and dental expenses for use in preparing tax returns. In that publication, it states as follows: "You can include in medical expenses the cost of a weight loss program undertaken at a physician's direction to treat an existing disease (such as heart disease). But you cannot include the cost of a weight-loss program if the purpose of weight control is to maintain your general good health." I would like to see that used in the direction of maintaining good health.
According to the American Obesity Association, annual health care costs for treating diseases caused by obesity is estimated at approximately $100 billion, as about 60 per cent of U.S. youth and adults are overweight or obese, a figure that has nearly doubled in the past two decades.
Weight Watchers does represent one of the most cost-effective and widely available weight-loss programs. Research shows that people who go to Weight Watchers meetings are more likely to lose weight than people who try to lose weight on their own.
Weight Watchers will continue to offer the most up-to-date information in an affordable and accessible manner to as many people as possible.
In summary, some of the things that we would like to see would be more information on labelling, tax and health insurance benefits for our members to gain health improvements, as well as maintain their good health, and accountability of so-called weight-loss organizations and products.
The Chairman: Ms Bayers, I am surprised. I thought mandatory labelling existed in this country. Goodness knows, when we go to the grocery store, we are always looking to see how much fat is in a product.
Is there no such thing as mandatory labelling in Canada?
Ms Bayers: It is coming. I believe all manufactures will be doing it by next year.
The Chairman: And it is a national rule, not a provincial rule?
Ms Bayers: That is correct. It is not there yet.
The Chairman: That surprises me.
Dr. Donovan, I have a couple of questions. The report on the public health infrastructure was done for the Conference of Deputy Ministers of Health; correct?
Dr. Donovan: Yes, that is my understanding.
The Chairman: You have seen it?
Dr. Donovan: I have not seen it. No one has seen it.
The Chairman: I see. It is a secret document. Usually, secret documents are the easiest to get hold of.
I was intrigued by your first recommendation, where you say we have to use caution in making recommendations that may affect the public health system, on the one hand, and the treatment system on the other, and might affect them, as you put it, indiscriminately. I am trying to think of an instance that meets that test. Can you give me an example?
Dr. Donovan: One of the things is the rush to integration in terms of the structures, the integration of the acute care-chronic care institutional sector with the public health system. Let me give you an example from my own province. In the community health system, when this was developed as a regional structure, it was identified as a way to ensure that there would be more community services.
The Chairman: When you talk about the public health system, what services are you talking about? When you talk about community services, what services are you talking about? Just give me some examples of what is in and what is out.
Dr. Donovan: The public health system includes things like health promotion, health education, advocacy, all of those kinds of things.
The Chairman: What we have referred to as population health; correct?
Dr. Donovan: Yes. It also includes health protection services, environmental health, communicable disease control, those kinds of things.
The community health sector is much broader. It includes home care, continuing care services, all of those kinds of services.
The Chairman: But not acute care services?
Dr. Donovan: Not acute care services - excuse me, acute care possibly in the context of home care. Home care may be subsequent to acute care.
In this province, we have a health and community services structure. We have three types of boards. We have health and community services boards, which include community health services and what would be traditionally known as social services, child welfare, those kinds of things. We have institutional boards, which look after acute care and chronic care facilities.
We also two integrated boards - they include public and community health services and institutional services - and those two boards are in the north and in Labrador. They were created by virtue of their size.
In the province, the care services - home care, continuing care, the home support services - have expanded exponentially. In many respects, public health nursing services are often in conflict with health promotion programming, particularly when you have the same service provider. It is difficult for an individual service provider, such as a public health nurse, who also has to do health promotion programming, to say no to a patient who needs acute care services. That is my concern.
The Chairman: Dr. West, with respect to your comment on the Privacy Act, as you know, we are in the same court that you are. For your information, I am modestly optimistic that a resolution is going to be found, short of having to amend the act. It appears, so I was told last week, that the various and sundry parties, including CIHR, are close to reaching an agreement, including the CMA, on guideline interpretations of some parts of the act. We are not there yet, but we are close.
Dr. West: Thank you for that reassurance. I will feel more comfortable, as I say in my report, when we have had a couple of cases go before the Privacy Commissioner.
The Chairman: On that score, I should tell you that he is part of the group that is attempting to resolve the problem.
I now want to get to the issue that you raise in your opening paragraph. Essentially, here is why our report and some of the things you said differ. As you point out, in order to make the system sustainable, it will require a significant shift in what you call a paradigm - which in turns really means that there will need to be a significant change, as one of the earlier witnesses put it, both in terms of how providers behave and how patients behave.
I think we would agree, by the way, that if those things were possible there might not be a need for new sources of funds. Where we part company is our relative degrees of optimism, I think.
Those of us on the committee are inclined to say that it would be absolutely wonderful if your future came true, but we need to do some planning in case your future does not come true. As you point out, if your future does not come true, then we really need to do something. While that may seem like a very minor point of difference, it is a significant point of difference in terms of the issues that get debated, because to the extent that we do not need to make any fundamental change a lot of the things that are in the report are off the table.
I think our view is that if you are planning for the future you ought to plan not for the most optimistic scenario but for one that is, at least, semi-pessimistic, so that you are prepared to handle it if it works out. It is purely a judgment call.
My question to you is this: How can we be as confident as you are about this? We would love to be, but are not.
Dr. West: I completely agree with you. What I have put in my submission could be termed as a vision for the future. As you know, a vision is something that is almost out of reach, but not quite. It is unrealistic if it is totally out of reach.
I do agree with you that to bring it about we will need a 1962-type change. I believe that the major issue is the power in the system of the physician. I personally do not believe that that will change unless we legislate change, as Tommy Douglas had to legislate change in 1962.
That is partly why I suggest that we may want to pull back from regionalization, which, as you have heard from Dr. Donovan, is different in different provinces, and we are not sure what it is doing. Let me put it this way: In tough times, businesses pull back to the core and cut off things at the periphery.
We are going to run the system based on priority and need rather than on numbers of services, we may need to pull back to the core, that is, pull back the management of the system to Departments of Health so that policies can be set based on priority and need. If necessary, legislation can be used to legislate such things as comprehensive health centres.
The Chairman: Which is what we have called primary care reform.
Dr. West: Yes. What I would do is make the regional boards - in Newfoundland, we have two, an institutional board and a community board, except for in the two northern regions, as Dr. Donovan mentioned - advisory. We need an interface between the politicians and the community and the senior civil service and the community. If we are going to move upstream and empower the community, we need to have a means of identifying the needs of the community. I believe those regional boards, if they were advisory rather than managerial, could serve that role. Then we could start again from the centre, from the point of view of restructuring the system.
The Chairman: You are a doctor?
Dr. West: No, I am a Ph.D.
The Chairman: You have certainly been involved with doctors, in the sense that you are at the medical school. We have two doctors on this committee; however, unfortunately, one is in Japan at the moment and the other is at an OEDC conference. They have made comments similar to yours about the difficulty of changing the providers' attitudes. Why is that?
Essentially, you are saying that the only way of doing this might be to do it with brute force, as Tommy Douglas did it. I find that puzzling.
Can you give me some insight as to why you think that is the case?
Dr. West: To be fair to doctors, attitudes amongst physicians, particularly younger physicians, is changing. I think older physicians, to put it more crassly, were more motivated by money to become a physician. Almost all of them run their office like a business.
I think things are different with younger physicians, partly because there is more of a focus in medical schools today to train physicians about their responsibilities in the community and the greater community health role.
That other thing that has changed, quite frankly, is that today over 50 per cent of entrants into medical school are women, and I think women are much more likely to take a community outlook on the problem than men. If we were to look back 10 years, or so, men were entering medical school because they thought it was a financially rewarding career and looked upon it as business.
Hence, two things are changing, but changing slowly: the character of new physicians and, second, having more than 50 per cent women in our medical schools.
Senator Cochrane: As well, Dr. West, in regards to change you are saying that it is the doctors who have to change and that it will be difficult.
Dr. West: I think so. The provincial medical associations are probably amongst the strongest unions in the country. For instance, as you are probably aware, there is currently tension between the Department of Health and physicians in Newfound land from the point of view of salary.
Three years ago, the doctors were awarded an extra$30 million. There are 970 doctors in Newfoundland, so the increase amounts to approximately $30,000 per doctor. Before the three-year contract was up, they were demanding another $15 million, another $15,000 per doctor, on average, representing a $45,000 increase over the last three years. The average annual family income in Newfoundland is $38,000. I think their demands are unconscionable, given the local perspective.
In the national perspective, when they see what their colleagues are getting in Ontario, Alberta, and B.C., you cannot blame them. That is something else that we have to solve. That is why I was recommending that we go to interprovincial salaries or fees.
Senator Cochrane: Do you also not think that to bring about this change there will have to be a different way of thinking on the part of politicians?
Dr. West: Yes. I have never been a politician, so I have not put my job on the line every four or five years, or whatever the average politician does.
Nevertheless, there is no doubt in my mind that regionalization was attractive to politicians because it pushed the decision-mak ing process down one level, and gave politicians some breathing space.
Politicians are going to have to make hard choices. It is good politics for a politician to say that he or she has put a new MRI into a hospital. It is not such good politics for a politician to talk about putting a prevention program in the community.
Senator Robertson: Dr. West, I enjoyed your presentation immensely. Given that you were a colleague of Ken Fyke, your recommendation on financing does not surprise me.
I have one comment with respect to trying to get uniform delivery processes in each province, and other matters of uniformity, shall we say. There is always the constitutionality of the issues that impact on the provinces that make provinces draw back from that a bit. As you say, in a perfect world, your model might be there. I do not know what we do in the meantime, while we do not have a perfect world, to get the services to the people, services that the people are demanding and rightfully should have.
I want to ask you a few questions about regional delivery. This committee has heard a lot about the regional delivery of health services as we have travelled across the country, and there are pros and cons, of course.
Let me just state a couple of things that we have heard, or some of us believe in, and then I would like you to respond to those to see if we can get around them in another way.
One of the problems that some governments face in the delivery of care now without the regional concept is what some of us would call a vertical funding process, where the hospital receives its money from the Department of Health, public health receives its money from the Department of Health, mental health, nursing homes, et cetera. All the lines go up to the Department of Health. Each service has built firm silos around itself, making it very difficult to get cooperation.
One of the positive things that we have heard, and I have heard this in other forums as well, is that a regional delivery process would provide the opportunity for what we call horizontal movement of money. The region would get a block of money, and then the board members could make a determination as to the most required service, shall we say. If we do not go to a regional service, which breaks down silos, this business of everyone clutching what they are doing and not sharing funds or ideas, how would you get them to coordinate, cooperate, and priorize?
Dr. West: Two things. If I may say, you may be putting me in a position where I am talking about the lesser of two evils. Quite frankly, in the regional system, as Dr. Donovan said, the treatment and home care services are encroaching on the public health and prevention services, what little there are. That is the downside of the regional system.
I agree with you entirely. When I worked in Saskatchewan as associate deputy minister for community health, we worked in silos. I was responsible for the 10 public health units in the province; they reported to me. I left Saskatchewan in 1991, and Saskatchewan regionalized in 1992.
I believe we have to change the culture in the departments of health and that deputy ministers and ministers can change that culture. There are ways of integrating at the department of health level, when you are setting priorities. In fact, I would argue that there may even be some merit, that you can protect money better at the department of health level when you can than you can in the regions.
For instance, as ADM in Saskatchewan, when I took over community health and recognized this problem, I split community health into two pieces: community health prevention services and community health treatment services. I created two budgetary lines with treasury board for myself, so that one could not encroach on the other.
I agree with you entirely. The old department of health model was very much in silos. My equivalent for hospital services and the equivalent ADM for insured services - the three of us never got together and integrated services.
If you set the right culture in the department of health, you can break those silos down.
Senator Robertson: I think the problem comes at budget time, because everyone is trying to get as much as possible into his or her silo, and that sometimes is where it breaks down.
Dr. West: That is where I come to my lesser of two evils. Even if you hand the money to the region in a global budget, there will be terrific pressure in the region to spend it on treatment services rather than on prevention services.
Senator Robertson: I will not pursue that any further right now, but I think we have a difference of opinion there, from listening to other witnesses and reading a lot about this.
Dr. West: I am really enjoying this conversation, by the way.
Senator Robertson: So am I.
Two of the areas that this committee has heard about from our witnesses - you will notice from our "Issues and Options" report - is that people are demanding good pharmacare for everyone. Many people are unable to fill their prescriptions because they simply do not have the money. These people are not necessarily on social assistance, either, or seniors collecting OAS and the GIS. Drugs are very expensive, and I am not knocking that. I believe it is cheaper to take $100 worth of pills than to stay in a hospital bed. There is a lot of replacement going on with new medications.
The other area this committee has heard is the issue of community and home care not being well organized anywhere in the country. Let us go back to the Canada Health Act, what we call medicare. Medicare covers you if you are in the hospital or at the doctor's office, but those two components only represent about 40 per cent of health care today.
What about community and home care, and drug costs? Most members of this committee believe that we need good recommen dations on how to serve the public with these two important pieces of health care. I do not know where the money will come from, but I do not think we can wait for the perfect system to evolve.
How are we going to pay for these things if we cannot wait for the perfect system to evolve?
Dr. West: Let me deal with the pieces in turn. I would add a third piece, the public health piece - the immunization and health promotion piece.
Let me deal with the drug piece first. When I worked in Saskatchewan, I was on the drug formulary committee. We had the most restricted formulary of any province in the country. The number of drug entities in that drug formulary was considerably less than most other provinces. This was in the days when the drug plan was still universal - except for the prescription fee, the plan paid for by the Saskatchewan government.
If we had a national formulary committee, and if the provinces were willing to work with a reduced formulary, we could afford that formulary. For instance, in the last two years Quebec has added 119 new drugs to its formulary. Ontario has added 10 in that period of time. Quebec wants to attract the drug industry to the province.
We continue to add drugs to our formularies but we do not take old ones out. For instance, in most provincial formularies, there are now something like 18 non-steroidal anti-inflammatory drugs.
If we had a good system of evaluating drugs and were more restrictive - the idea of a formulary is not to give all drugs to all people. The idea is to get the biggest bang for your buck, to get 98 per cent of the people the drugs they need.
In addition, there is a lot of wastage, which, if there were a decent information system, we could cut out. For instance, when I appeared before the Krever commission I was criticized for not introducing HIV testing in Saskatchewan fast enough. I am sure Krever would also criticize us for not having decent information systems in place. If we did, we could prevent a lot of the drug interaction and drug adverse reaction problems in the elderly.
On the topic of community health and public health, we are already paying a large part of those costs. It is just a question of reorganization. All our public health costs are paid. Sure, the proposal may be to try to get the federal government to pay its share, which would help the system no end, but if we were to take the money that is currently being spent on all of those services we would not need too much more money.
Senator Robertson: I appreciate your interpretation, and your belief there. It will be interesting to see where we go from here.
I should like to ask you a question about cancer research, if I may.
Can you tell us how cancer research funds are divvied up, how it is decided to spend X number of dollars on breast cancer and X number on prostate cancer, say? A number of people will say that more money is being spent on breast cancer, say, than prostate, or this or that. Is there a formula?
Dr. West: No, we do not have a formula. You have to remember that some of the special interest groups, like breast cancer and prostate cancer, match funds from the National Cancer Institute and Health Canada. Hence, although it appears that more money is being spent in those areas, in fact, those special interest groups have raised research funds. The National Cancer Institute, which gets approximately $50 million a year from the Canadian Cancer Society and the Terry Fox Foundation, puts only a small amount of money into those types of cancer; we are spending the biggest proportion of our money on general cancer research.
Senator Robertson: Dr. Donovan, of course we all agree with the importance of public health; public health has always been the cornerstone of good health in any country. Most of your comments, as I understood them, related to health lifestyles, education, valuations of research, and that sort of thing.
Where do the issues of water and sewage, the environmental impact of those, fit in? Do you work with those departments that are more specifically attuned to that, or do you share a common goal and a common process?
Dr. Donovan: They fit very clearly into the mandate of public health and would come under the health protection acronym - environmental health, water services, communicable diseases. They certainly would benefit from the enhancement and support of the public health infrastructure that I have talked about there. I have given more attention to the health promotion side because, even in the public health structure, health promotion will often lose out to things such as communicable disease control.
A perfect example is that last week I did nothing but bioterrorism, when I really would have liked to focus on this. Even in our own structures, health promotion often loses out. Certainly the intent is that the support for the public health infrastructure would include all of those things.
Senator Cook: Dr. West, you mentioned a strategic social plan. Exactly what is that? You indicated that the implementation piece of it was not in place yet. Why?
Dr. West: The provincial strategic social plan was put together. Cabinet decided that we needed a plan to empower the communities, particularly the rural communities in Newfound land.
What the strategic social plan involves is looking at each of the determinants of health, from the point of view of the commu nities, and deciding what strategies and programs need to take place to improve the communities. For example, the economy is obviously one determinant of health. The plan is aimed not only at improving the health and well-being of Newfoundlanders, but also at improving the economy in the small communities. It is an interdepartmental initiative. It is not just a health initiative, or a social services initiative, or a justice initiative, or an educational initiative; rather, the strategic social plan is an interdepartmental initiative.
The implementation has been slow. Each community has an implementation committee, which is consulting with the com munity. All of this takes time. It is also my observation that the government needs to put more dollars forward to make the system go. Communities can do so much on their own, but they need resources in order to do more.
Senator Cook: Hence, while you are up and running on the Web site, you are not accessible to communities; correct?
Dr. West: There is still password protection on the Web site at the moment. In speaking to the Minister of Health last Thursday, I urged her to take the password protection off.
Certain health professionals, Dr. Donovan, for instance - except that she is having technical difficulties with the Web Site - and the regional implementation committees, et cetera, can access the Web site with a password. However, the intent is to empower the people, to make it totally available to everybody in the community through the Internet. The sooner that happens, as far as I am concerned, the better.
As you can see from examples in your binder, it has been set up in a relatively user friendly way. People can look up all the determinants of health, the risk factors and the morbidity and mortality of a particular disease, and see how their community compares with any other community.
Senator Cook: Ms Bayers, how does your program teach continuing health lifestyle, and not regression? I had three pieces of dessert for lunch.
Ms Bayers: Buffets can be interesting.
Part of the long-term lifestyle change that we encourage is looking at the bigger picture. We need to make changes for our health for the long term. We must avoid the dieting pit, where we diet for a while to lose some weight. We need to concern ourselves with the broader scope, about what is in our best interests over the long haul. There is nothing wrong with the occasional piece of dessert.
Senator Cook: Is there a mechanism in your program for holding me, a once-a-month lifeline, say, or once a quarter?
Ms Bayers: We encourage our members to attend weekly and for a lifetime of, at least, once a month. Members are still encouraged to come every week. Once a member has lost his or her desired weight, we implement a six-week maintenance program to teach and help members to keep the weight off. It involves a learning process. Members are then invited to stay with us forever at no fee.
Senator Cook: So once I am in, I am hooked.
Ms Bayers: You are hooked.
Senator Cook: Dr. Donovan, on page 2 of you brief you talk about one of the failings of the Health Canada system, that is, capacity building. Do you have any ideas about how that issue can be addressed? It saddens me to know that so many worthwhile pilots and research sit and collect dust, never get to where they are needed, to the people.
Dr. Donovan: Absolutely. Health Canada has funded some real innovation, but just never takes it to the next step. The Canadian Heart Health Initiative is finished in many provinces now - Newfoundland is just a little later than other provinces - and they are struggling to find the dollars necessary to sustain that initiative. From a health promotion perspective, it is important to look at the knowledge and capacity that initiative has developed and use it for other approaches.
For example, there was no suggestion by the federal, given that we have created an infrastructure and a capacity, to see if that infrastructure could be applied to diabetes. It is up to the heart health programs themselves to build on what they have and to buy into the diabetes strategy.
The federal government must work harder to ensure that knowledge is disseminated beyond researchers and a few bureaucrats at Health Canada. Health Canada does fund a lot of innovative work, and this work needs to be shared. If it works, it works.
It is also important for funding to continue. Certainly from a health promotion perspective, the investment is relatively small, compared to the treatment and care sector. The payoffs are great; research rewards us in the end. We just need a long-term vision and some courage. Prevention is not a four-year health promotion; there is no four-year mandate with prevention.
Senator Cook: The government put a lot of money into the CHHI. It is a wonderful program. The CHHI has much evidence-based information, with measurable outcomes. It does not make sense for us to have put a lot of money into it and then to terminate it.
Dr. Donovan: Absolutely. As I said, in Newfoundland, there is no community capacity to start another health promotion initiative around diabetes. The risk factors are the same.
We need a national health promotion agenda, to build on the knowledge that was acquired though the CHHI.
Senator Cochrane: Dr. Donovan, would you just give me a rundown as to your organization.
Dr. Donovan: I am the medical officer of health in the eastern region. It is just a side job that I am the principal investigator for the Newfoundland and Labrador Heart Health Program. That is part of the Canadian Heart Health Initiative, which is funded projects in all 10 provinces, community-based projects.
The delightful thing about this project is that all 10 provinces received equal funding, as opposed to population-based funding. It allowed those of us who are poor in terms of infrastructure to have the same investment. The principal investigators meet regularly. The Conference of Principal Investigators of Heart Health, COPI, shares resources. We communicate regularly on successes and failures. Some of our biggest successes involve knowledge about the things that are not working, and we have built on that. We have learned from each other. Internationally, we are learning from each other. We are a leader in heart health internationally.
Senator Cochrane: Can you tell me more about the CHHI funding coming to an end.
Dr. Donovan: The Canadian Heart Health Initiative funding ends at the end of the dissemination phase. For some provinces, that has already ended. For us, that will end in 2003. Right now, aside from a provincial coordinator, which is a position funded by the provincial government, there is no other funding.
I will say, however, that we have done an incredible job of sustaining program activity at the regional level, with very little investment of resources. Because this is a research project, much of the money has gone into researching what is working as opposed to programming. We have done an incredible job. We can still do an incredible job, but the public health system is reacting to the demands of treatment and care and thus I have concerns about our ability to sustain the public health activity to support this programming. I certainly know that other provinces are already feeling that.
Senator Cochrane: When will this funding come to an end in Newfoundland?
Dr. Donovan: In 2003.
Senator Cochrane: Are you saying that some of the measures that your research has developed will not be implemented?
Dr. Donovan: It will depend on the goodwill of the people who are implementing the programs out in the communities.
During the demonstration phase, recognizing that the money would come to an end, we developed regional coalitions. These coalitions are made up of professionals in the community health sector and in the recreation sector, volunteers and municipalities working together to do heart health activity. It is not funded in any way. It is based on their goodwill.
Under the guise of research and information collection, we occasionally provide regional coalitions with resources to bring people together to do some training. We provide them with ongoing support and a communication mechanism.
My concern is that we are losing their goodwill, that they will say that although they are committed to the program they are preoccupied with budget demands for home supports, home care, those kinds of things, that they cannot devote time to the health promotion agenda.
Senator Cochrane: So you are going to offer them support through what program, through what group, through what organization, or through what department?
Dr. Donovan: Much of the support for the regional coalitions now rests in the regional health and community services structures, the public health workers and educators, the public health nurses, the people who are out in the regions right now. It is our hope that they will sustain their commitment to heart health.
To this point, there has been someone at the provincial level who maintains communication with them. We have been able to organize provincial workshops, where they share information with each other. We have regular teleconferences, where the regions can exchange information and feed off each other in terms of programming.
However, all of this is based on goodwill. By 2003, we will probably lose our provincial person. Accordingly, we will lose the provincial workshops and we will lose the teleconference meetings.
It is our hope that we have built enough into the system, but it may not be so.
Senator Cochrane: And there is no one there to follow up on that.
Dr. Donovan: We are trying to encourage our regional structures under the diabetes strategy that we have been developing to seek funding through that strategy, but, again, that will depend on the regional structures. They have already indicated they are struggling to do the work we have asked of them under the diabetes strategy.
Senator Cochrane: Ms Bayers, I am impressed with what you have said about Weight Watchers. Do you have any statistics related to the number of heart patients or diabetes patients your program has helped?
Ms Bayers: I do not have that information. However, I can certainly see what is available to me and follow up with you on that.
Senator Cochrane: Have you used any of these people, the successful ones, as role models?
Ms Bayers: We do, but not the specific people I have talked about. However, we often invite individuals to come in as guest speakers. We use them in our advertising, magazine articles, that sort of thing. It is very inspiring.
Senator Cochrane: Dr. West, let me quote a statistic I have here and get your reaction.
By 2027, 25 years from now, health care spending by provincial and territorial governments is expected to be 247 per cent higher than in 1999-2000.
Dr. West: My reaction is that that is probably correct, should we continue with the current model. That is why I believe something has to be done to change the model. Although it is a bit drastic to suggest we need another 1962, even if we bring in things like user fees and so on, we are not going to be able to cope with a 247 per cent increase.
We have to stop dealing with the margins. We have to make that change, and the sooner the better.
The Chairman: I wish to thank all of you for your attendance here. This has been a very interesting hour and a half.
Our last panel this afternoon consists of Bertha Paulse, CEO of the Newfoundland Cancer Treatment and Research Foundation, and Karen McGrath, Executive Director, Health and Community Services for the St. John's region.
Ms Bertha H. Paulse, Chief Executive Officer, Newfound land Cancer Treatment and Research Foundation: Honourable senators, the Newfoundland Cancer Treatment and Research Foundation is very pleased to make this presentation to your public hearings on the state of Canadian health care system.
When the publicly funded health care system was introduced in 1967, our population was relatively young and the acute care delivery model was appropriate for managing episodic periods of illness. Today, our demographics are different. The aging population and chronic health issues are presenting major challenges for the health care system. Consequently, we must consider other health care delivery models so that we manage chronic diseases more effectively and efficiently.
Cancer, a chronic disease, commonly occurs among the elderly population. Cancer incidents will double, mortality rates will outpace cardiovascular diseases, and survival rates will not improve during the next 15 years. This combined with new developments in treatment will lead to a very significant financial impact on Canadian society and will threaten the sustainability of the health care delivery system as we know it today. In spite of the advances in cancer knowledge and technology over the past 10 years, many shortfalls exist for a comprehensive cancer control program, both in Newfoundland and Labrador and throughout Canada.
This presentation will focus on the importance of an organized system of cancer control, highlight shortfalls for a cancer control program for the province of Newfoundland and identify four critical elements that need to be addressed for improving cancer services and rebalancing our focus in this province for consistency with the national cancer control strategy.
I have not given you any information on the national cancer control strategy, but I would refer you to their Web site at www.cancercontrol.org.
Let me highlight the four critical elements as we see it. The first is preventative oncology programs.
Cancer prevention and screening have the most potential for saving thousands of lives among Newfoundlanders and Labrado rians and for reducing future health care costs. The risk factors for cancer are similar to those of other chronic diseases. Therefore, an investment in cancer prevention will also reduce death and disability for other chronic diseases as well. A screening program that uses existing evidence-based strategies for breast, cervical and colorectal cancers will result in a 5 per cent reduction, approximately, in overall cancer mortality. An early diagnosis as a result of screening interventions will reduce the cost impact on individuals, the health delivery system, and society.
The second critical element is diagnosis and treatment. An excessive delay from the time a patient experiences symptoms to the time of definitive diagnosis of cancer can affect clinical and psychological outcomes. A delay in diagnosis will result in progression of the disease and the unlikelihood of a successful treatment outcome; as well, the patient will experience extreme anxiety and frustration.
Over the past five years in this province, the number of referrals for newly diagnosed cancer patients to the formal cancer system has increased by 20 per cent. The incidents of cancer increase annually. The lack of resources committed to cancer services in this province has a significant impact on access to care, fairness and equity. The system does not have the capacity for assessing and caring for patients in a timely manner for optimal treatment outcomes. Patients are either required to wait for lengthy periods or receive care that may be inappropriate and not based on best practices.
Professionals in this province are expected to carry patient caseloads in excess of national standards and recommendations by professional associations. Consequently, professionals become extremely dissatisfied because of the lack of opportunities to engage in research, academia, clinical trials, and evaluation of best practice. These professionals become extremely disenchanted and seek better opportunities in other parts of Canada.
The third critical element is supportive and palliative care. We see these as core components of a cancer program. Such services should be integrated throughout the cancer journey, regardless of whether care is delivered in cancer centres as part of the community care or within hospitals.
The fourth critical element is information management and evaluation. The role of information management is to enable and facilitate cancer control interventions through the use of informa tion and communications technologies. A key step in capitalizing on opportunities to evaluate the effectiveness and efficiency of a cancer program depends on the collection of and access to high-quality data on a wide range of dimensions related to cancer. Standardized and linked datasets are needed for identifying risk behaviours, health services utilization and measuring treatment outcomes such as survival and quality of life.
The immediate future for cancer services in this province is daunting, given the growth and aging of the population, the out-migration of young people, the incidents of cancer and the lack of resources available and committed to cancer services.
Ms Karen McGrath, Chief Executive Officer, Health and Community Services, St. John's Region, Newfoundland: Senators, before I begin, I would like to make a clarification. While I am the CEO of the Health and Community Services Organization that Roy West would like to eliminate, I am not speaking in that regard this afternoon. I am the National President of the Canadian Mental Health Association as well as the division president here in St. John's. However, more particularly, I have been working in mental health for 20-plus years and it is from that perspective that I will speak.
I have identified in my written presentation some important issues. The first one relates to reform of the mental health system. I would like to postulate that while that reform can be contemplated in line or parallel to reform of the health system reform, I also think it is separate from the larger health system reform.
I would like to discuss with you the move to something we have espoused in mental health for many, many years, that is, a move to a community-based system. May I say that we have espoused it rather than actioned it. In that context, I would like to have some discussion on the notion of home support for mental health consumers, people who use the mental health system, and also creative use of one of our scarce resources, psychiatrists.
I would like to have some discussion on the issue of family burden. Unlike many other illnesses, mental illness puts a significant burden on the family. I would also like to talk about the fact that we are the only illness where in times of crisis the police respond instead of an ambulance.
The notion of mental health promotion, it being a different kind of promotion than Cathy Donovan and Roy West talked about, needs to be understood in the context of health system reform and the whole notion of early intervention. There has been a lot of talk about early intervention in the health system.
We have not been able to action that either, is my impression. I think if we are talking truly about mental health reform in this country, we have to talk about early intervention.
The above are themes that are explored in my written presentation. I would now be happy to explore them with you in the question and answer period.
The Chairman: Ms Paulse, what is the waiting time for cancer treatment here? In some parts of the country, one hears that it takes ages to get treatment. What is the situation here?
Ms Paulse: The wait time is sometimes varied by disease site, but the average wait time is eight to ten weeks for radiation therapy.
The Chairman: That is after diagnosis?
Ms Paulse: After diagnosis has been confirmed and the patient has had surgery, the wait time can vary anywhere from six to eight to ten weeks.
The Chairman: If the situation were different, if resources were not a problem, what would a reasonable wait time be?
Ms Paulse: Three to six would be the optimum time.
The Chairman: So there is a wait involved.
Ms Paulse: Yes. There is the waiting period following surgery also.
The Chairman: That has to be subtracted from the eight to ten weeks; correct?
Ms Paulse: Absolutely. The area where we have a major challenge is the wait time consultation for medical oncologists.
Newfoundland is the last province to have a medical oncology program; we have only had this program since 1995. Since then, over the last six years, we have experienced difficulty even attracting medical oncologists to the province. Once we get them here, we have problems retaining them. Over the last two years, we have had a turnover of somewhere in the vicinity of 10 medical oncologists.
They leave for the reasons I talked about earlier: Their caseloads are so demanding that there is no opportunity for them to be involved in research or academic work; neither is there any time for evaluation of the work they are doing. Consequently, they become totally disillusioned.
Of course, the other challenge we face involves the salary scales in this province.
The Chairman: Ms McGrath, two quick questions. You talked about a community-based mental health program. By the way, we are delighted that you made a presentation on mental health. There have only been two other occasions where we have had comments on mental health. It is really the forgotten part of the health care system.
What do you mean by a community-based system? Can you describe that in more detail.
Ms McGrath: For about 25 years now, the mental health literature has said that hospitalization for mental health consumers should be the exception.
The Chairman: Or institutionalized.
Ms McGrath: Absolutely. All services, including active treatment and ongoing support, treatment for those who are acutely ill, and mental health promotion, should be located in the community. If these services are targeted at the most significant user, the person with the mental illness, then de facto they should target everybody else with a mental health problem.
The Chairman: You made a reference to the scarce use of psychiatrists, or a scarce resource. Where do you place other counsellors? I am thinking of social workers and clinical psychologists, for example. Do you regard them as an integral part of your mental health program?
The reason I ask the question is that the medical profession does not always have a positive view of people who do counselling.
Ms McGrath: I am a social worker. I am president of the Newfoundland and Labrador association of social workers.
In mental health, I would argue that the role of other professionals is well acknowledged, particularly in this province. I do not think that is an issue in this province. In other provinces, however, I agree with you that there have been problems with full integration.
What I am referring to is the necessity of a psychiatric diagnosis, from which other interventions can flow. Hence, I would argue - and the psychiatrists would be absolutely floored if they heard me say this - that each person who has a mental illness needs at least once in his or her lifetime to have a definitive diagnosis, so they need to see a psychiatrist for that. The ongoing support can come from others.
The Chairman: I was worried from your comment that you meant to the exclusion of other mental health professionals.
Ms McGrath: No, no, absolutely not.
The Chairman: On page 5 of your written presentation, you say:
A broad brush promotion/education campaign about coping strategies and or ideas for stress reduction. Promotion of mental health has to be risen to the same level of consciousness in the general population that we have accomplished with respect to smoking and/or fat intake.I could not agree more.
How would one even begin to go about that? There is a stigma attached to mental health illness. I am of the generation that grew up talking about the insane asylum. That was not meant to be pejorative - that is what the building was called. It seems to me we have got a huge public education process in front of us. Mind you, we are seeing this now with various ads on television for diseases that were never talked about a long time ago. Any thoughts?
Ms McGrath: I think you are absolutely right. I do not think we have as big a journey as we thought we had four or five years ago, quite frankly. If you survey some of the national news media, you will find many U.S. citizens saying that they are stressed as a result of what happened on September 11, and that is how they actually describe it. They are talking about having long-term effects.
I come from the school of thought that says: "Call it what it is. Let's not call it something else." If it is mental illness, let's call it mental illness. Let's normalize it by saying that we all have mental health and we all have to look after it. Then we can talk about ways to manage mental health, a campaign something like ParticipACTION put in place, about the benefits of running, walking and bicycling. We can talk about the benefits of taking a hot bath, drinking a cup of tea, lighting a candle, exploring spirituality. I think what sells in terms of the media is tips, fast one-liners that identify for people what they can do to take control of their own mental health.
The Chairman: Has your organization, or anybody that you know of, developed the outline of such a program?
Ms McGrath: Actually, our organization, the one that we are going to eliminate, has done what we call cashless coping strategies - ten things you can do that will not cost anything but are guaranteed to improve your mental health - and we have used them now on three or four occasions. In fact, they are a huge hit, an absolute hit. We have an outline of those kinds of things that certainly could be used.
The Chairman: When this meeting concludes, I would love to see those. The committee would love to see those, so we will talk to you about how you do that.
Senator Cook: Ms McGrath, I want to talk about the coping skills and the lifestyles of this client population that we are discussing. I am aware of places like the Pottle Centre and Emmanuel House, places that try to put people back together again, give them coping skills to be healthy and happy.
For people with mental health problems, there are not a lot of support systems to help them live in the community. There are supports here and there, but there is no strong strategy, no lifeline for them. I would like your comments on that.
Ms McGrath: Absolutely. That is why I divided my discussion between mental illness and mental health concerns generally in the population.
Currently, most people with a major mental illness in Canada do not live a very dignified life. They generally live isolated. They generally live disconnected. They generally live from hospital admission to hospital admission. The reason for that is a lack of interconnected coordinated services to support them once they are discharged from hospital. When they are discharged from the hospital, they return to that isolated non-dignified way of living. They may have short spurts in which they get a really good program, but generally most of the programs are time limited. Mental illness is not time limited.
An individual who has had a major mental illness diagnosis will die with that diagnosis. The individual can learn to live with the illness, can learn to live a dignified life, but he or she will die with the diagnosis. That is why the mental health system has to think in long term rather than in short term.
The other thing that is important is early intervention. While we can talk about coping skills for today and about remedial work with mental health consumers, the real work, Senator Cook, has to begin at birth. We must intervene there; we must teach coping skills at that juncture. We have to be able to better target children who are at risk for developing a mental illness. We do know some of the indicators, and if we target them from birth, almost immunize them in terms of coping skills, then as their mental illness unfolds, and unfold it will, they will have those coping skills to draw on.
Senator Cook: Is my dream of a cluster approach, where all the health care providers act in a multifaceted way, something you would support?
Ms McGrath: The person with the mental illness must be at the centre of that approach. The rest of us have to provide a service to that individual. There must be a range of services available, because the needs of those individuals are so varied.
Senator Cook: Is it achievable?
Ms McGrath: It is achievable. Not only is it achievable, but also we know we can do it. We just have to do it.
Senator Cook: Ms Paulse, we heard earlier today that the treatment of illness is squeezing out health and promotion, particularly in the area of public health. My question for you is this: While cancer treatment is an active part of the illness piece of cancer, do you have an opportunity to do data collection and run it back through the system, or do you suffer from the pressures the public health system suffers from, that by the time they get through the community care and the nursing piece there is not a lot of time left for education and promotion?
Ms Paulse: Actually, we track cancer incidents and mortality rates for the population. Of course, we are part of a national database. Basically, we can do some excellent projections about cancer incidents over the next five, ten, fifteen, twenty years. We have historical data going back to 1969.
That being said, our information systems are still underdevel oped. For example, we are not tracking risk factors related to cancer. There are risk factors related to cancer that are not dissimilar to risk factors for other chronic diseases, as I have previously said. What we have to do, if we want to make a difference to cancer incident rates and mortality rates, is work collectively with other groups, such as community health, and other volunteer organizations that are promoting and fostering that whole health promotion and prevention piece. We have to work together. If we can make a difference for cardiovascular disease, we can also make a difference for cancer. I am talking about cessation of smoking, dietary interventions, and some of those other strategies. We know that those work as well for cancer in lowering the incident rate as what they do for cardiovascular respiratory diseases.
Senator Cook: The data that you accumulate, as well as other data that is available, runs back in through the system; correct?
Ms Paulse: Yes, it is available through the system.
Senator Robertson: Both presentations were delightful and thoughtful. Newfoundland is lucky to have both of you.
Ms McGrath, you talked about starting to work with mental patients at birth or very early. What percentage of mental health problems at birth is related to a disability and what percentage is related to genetics?
Ms McGrath: Actually, there is not a definitive answer to that, Senator Robertson. There are still two schools of thought on mental illness. One is genetics, that if your mother experienced depression you are more likely to experience it also. The other is the environment argument, that early life environment is a factor in developing or not development a major mental illness. Most people who work in the field believe it is a combination of both.
I talked about some indicators. An example of that is that an individual is twice as likely to have a major mental illness if someone in that individual's immediate family has a major mental illness. We know that a child who grows up in systemic poverty is more likely to have a major mental illness. What we are talking about is targeting vulnerable populations.
We can target certain groups who we know are more likely to develop a mental illness. Will we get everybody? No, we will not, but we will, at least, focus our attention on the most vulnerable.
Senator Robertson: At one time, it was the fashion to throw all the mentally ill patients out of the psychiatric hospitals. It was the fashion right across the country. We were assured that the appropriate systems and services would be set up in home communities for these patients. What happened? We had all those assurances, but nothing ever happened.
As you say, if there is a crisis, they can only go to two places really, and in most communities in Canada that is either the police station or the hospital. We see these people on the streets. They are not functioning right. We have talked about the street people. Large numbers of these people who were tossed out of the psychiatric hospitals are on the street. What happened? Why were those promises not fulfilled, even partially?
Ms McGrath: I do not believe it was malicious. I have to say that.
It involves another bugaboo I have about planning, that is, that you cannot downsize one system while you upsize another. There is no literature in the world that will tell you that that is possible. If changes are planned to one system, the other system has to be built at the same time.
In the situation to which you refer, we were going to build the community system from the dollars saved in the psychiatric hospitals. It never happened because no dollars were saved. The doors in the psychiatric hospitals closed, but there was very little growth in the community.
Some jurisdictions have done a very good job. Senator Cook referred to clusters. There are clusters. The Greater Vancouver Mental Health Centre does a superb job of supporting people with mental illness. There are other best practices around the country that did a good job.
Did we do a good job as a system? We did a dismal job as a system, quite frankly, because we did not build up the other system when we were closing down the beds in the psychiatric hospitals.
Senator Robertson: That is very helpful, the building up as you size down, and not only in mental health.
The Chairman: We have seen the same thing in the provinces, where acute hospital beds were closed with the intention of replacing them with better home care and other things. What they did, of course, was close the beds and never create the replacement.
Senator Robertson: My last question is for Ms Paulse. On page 4 of your written presentation, you say:
Patients are either required to wait for lengthy periods or receive care that may be inappropriate and not based on best practices.We have heard that right across the country with respect to cancer care. There are very few centres that have the type of care that is required.
Do you know of Dr. Thomas McGowan, his after-hours radiation treatment clinic located at Sunnybrook in Toronto?
Ms Paulse: Yes, I have.
Senator Robertson: We have heard a lot about private funding. I just want to put this out, to see what you think of it now. The waiting lists at Sunnybrook were such that the patients were unhappy and the doctors were unhappy. Dr. McGowan convinced the Sunnybrook board that he would bring in a private oncology unit that would treat patients either in radiology or chemotherapy.
Ms Paulse: Radiation oncology only.
Senator Robertson: Radiation only?
Ms Paulse: Yes.
Senator Robertson: Radiation oncology; okay.
Dr. McGowan's clinic was set up to operate when regular oncologists were not working at the hospital. Most of the staff in the clinic are people who want to work part-time. His clinic uses the equipment at Sunnybrook. The clinic bills the government the exact charge it would be billed had the radiation treatment been done by regular hospital staff.
Do you see anything wrong with that?
Ms Paulse: Providing there is no cost to the patient.
In fact, I was at the Sunnybrook Regional Cancer Centre just two weeks ago, and I met with Dr. McGowan. We do - and it is well recognized - have overcapacity in the system.
Yes, we have treatment machines that shut down at five o'clock at night. We could do something similar, but we are limited by staff availability. In a province such as Ontario, there are probably far more casual radiation therapists to call upon, and maybe even some additional radiation oncologists.
I have no problem with the concept - it is a far better deal than having to go to Cleveland or Buffalo, or wherever, for treatment. We had that experience last year. We worked with Cancer Care Ontario. We had to send 52 patients outside of our province for treatment.
The Chairman: Out of Canada?
Ms Paulse: Outside of Canada for treatment.
The Chairman: So they did not go to Nova Scotia or elsewhere in the country?
Ms Paulse: No. They went to Cleveland, Ohio. We worked with Cancer Care Ontario for that. It cost us $1.5 million for 52 patients. Had the resources been available to us, we would not have had any difficulty putting on an extra shift to have those patients cared for within our province. One of the reasons Ontario went in that direction is that they had some barriers to deal with, such as unions, and the availability of people to do that.
Senator Robertson: It cost you $1.5 million?
Ms Paulse: Yes, that is right.
Senator Robertson: What would it have cost you had you been able to treat them here?
Ms Paulse: As it is, each patient cost us somewhere in the vicinity of $30,000. To treat a patient in the province would have cost somewhere between $5,000 and $7,000.
Senator Robertson: You have no problem with the concept; correct?
Ms Paulse: No, not with the concept.
Senator Cochrane: Ms McGrath, with respect to early intervention, is there a pamphlet available - or do you have anything to distribute - within the various clinics advising parents about early intervention? You said that mental illness starts right at birth. How does a parent know what to look for?
Ms McGrath: I should be clear. You normally do not see a major mental illness until the teenage years. What I am saying is the vulnerability is there from birth.
The issue with early intervention is that there are things that need to be done in a preventative mode. I would argue that this applies to all children, but for children who are more susceptible, there needs to be an overdose in the growing years in terms of coping skills, self-esteem, self-reliance, and those types of things.
We know, emphatically, that children are wired before they are five years of age. We know that it is from birth to five that we have to do that.
If you are asking whether my organization does that, no, we do not. We do not have a children's mental health program. Our mental health program focuses on adults. There are very few children's mental health programs, if any, in this jurisdiction of a health promotion nature at all. Newfoundland and Labrador has very few initiatives that focus on mental health of children.
Senator Cochrane: We have had problems here. I know of problems that we have had with teenagers.
Ms McGrath: Absolutely. What we do, as I am sure other jurisdictions do, is treat the symptoms, rather than giving people abilities, and I use the word "immunization" for what they need when they are very young.
In terms of an early intervention, anything that has a good parenting component to it de facto immunizes the child for good mental health. Do we have a targeted program? The answer to that is, no, we do not have a targeted program.
Senator Cochrane: What percentage of the mental health budget in Newfoundland do you get? Do you get a percentage?
Ms McGrath: I cannot answer that for you. I worked at the psychiatric hospital at one time, and I know the hospital got the greatest percentage of that budget. When I worked there, which was in 1990, the hospital got about $3 million. That represented about 90 per cent of the mental health budget.
I can identify for you on one hand the people who are employed in my organization to do mental health, literally one hand. We have four mental health counsellors for a population of about 175,000 people, and we have a mental health crisis centre that operates 24 hours a day, seven days a week.
I have a staff of 600 and a budget of $64 million. The amount of focus on mental health, particularly on community mental health, in this province is extremely small.
The Chairman: I wish to ask Ms McGrath a question of clarification.
In response to Senator Cochrane, you said, in terms of early intervention, that young people need an "overdose."
Can I assume that you were not referring to drugs.
Ms McGrath: No, no, no.
The Chairman: It is just that we typically hear the word in the other context.
You also referred a lot to a "major mental illness." How do you define that? A lot of people seek counselling for major events that have caused trauma, for example, the events of September 11.
By the way, in that sense, I should like to make the observation that employers are obviously becoming more progressive. I was talking to the CEO of a company that has offices in a building somewhere around the World Trade Center. No one in this office was hurt, but the very first thing the CEO did was call in a team of crisis counsellors. This team actually came from Canada, because the local counsellors were so swamped. I am not sure whether 10 years ago a CEO would have even thought of doing that. Hence, progress.
Is that the sort of thing you would call "major mental illness"?
Ms McGrath: No, no.
The Chairman: Okay. By major mental illness, then, you mean something that is very serious.
Ms McGrath: It is also referred to as long-term persistent mental illness. Heading the group, in my mind, would be schizophrenia, and then would come some of the affective disorders and some of the depressions, depending on the length and the magnitude of the depression.
At one end of the continuum, we are talking about individuals who have major mental illness; at the other end is the rest of the world and the mental health issues therein.
The Chairman: People who get sick from time to time.
Ms McGrath: Absolutely. I think the current figures is that 98 per cent of us at some time in our lives will have to seek support for a mental health problem, for something that is going on in our lives.
We should check the pulses of the other 2 per cent, because virtually everybody I know has had to seek support at some time for a mental health issue, whether that support be from a friend or the formal system.
The Chairman: Thank you. That is a wonderful note on which to close.
The committee adjourned.