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

Issue 42 - Evidence

HALIFAX, Tuesday, November 6, 2001

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

Senator Michael Kirby (Chairman) in the Chair.

[English]

The Chairman: Senators, we have with us two witnesses this morning, the first panel, Robert Cook, the President and CEO of the Nova Scotia Association of Health Organizations, and Cecil Snow, from the Canadian Auto Workers, who have a number of union members employed in the health care section of Nova Scotia. Heather Henderson, the President of the Nurses Union will join us, I presume, when she gets here.

Mr. Robert Cook, President and CEO, Nova Scotia Association of Health Organizations: Mr. Chairman, on behalf of our association, I want to thank the committee for making the trip to Nova Scotia and hearing from Nova Scotians. There is sometimes the perception that national organizations in Ottawa speak for the full country, but there is a great deal of diversity within the country. Today, we will be speaking to you about an issue that is uniquely Nova Scotian.

Our health care system is a part of the fabric of Canadian society. A strong federal presence is required so that all Canadians - regardless of which province or territory they reside in - can access comparable health services. Despite the increasing number of individuals who believe the system is in crisis, Canadians continue to be committed to a national, publicly funded health care system.

Canadians identify universality or equality of access as the most important principle in the health care system. This finding was reported by the Conference Board of Canada in February 2001. Clearly, it is relevant. It is current, and I think it has credibility.

Canadians also find quality, efficiency and effectiveness important factors and are willing to consider changes to the health care system to ensure its sustainability. These Canadian values must drive the national debate on the future of health care in this country. This debate must engage the public, with Canadian values providing the basis for tough decisions.

The federal government has a leadership role in defining and initiating this debate as well as resolving it. A sound understanding of public values and attitudes is vital for the development health care policy. Research has demonstrated that Canadians do not have strong opinions regarding which level of government delivers health services but they do believe that a national role is necessary to ensure equality of access. Federal leadership, with its financial incentives, is required to make the necessary reforms in the health care system.

The Nova Scotia Association of Health Organizations, NSAHO, wishes to focus on two issues in our presentation to you today: health as an economic investment, and the need for a needs-based, age-adjusted population funding model from the federal government. That is the core, Mr. Chairman, of the position we want to make to you.

Insofar as health is an economic investment, increasing federal funding for health care and providing tax relief have often been presented as conflicting priorities. Our health system, however, contributes not only to individual and collective well-being, but also to Canada's economic performance.

For example, companies that operate in Canada do not have to insure their workers' health, and this in turn is a major incentive for international corporations to locate in this country. If we are unable to sustain our current health system, the cost of insurance coverage will default to employers and employees. This would constitute an increase in taxation and diminish Canada's economic advantage internationally. This point was made by the President of the Toronto Dominion Bank. NSAHO encourages the federal government to view its commitment to health funding as an economic investment in addition to an investment in the health of Canadians.

Is more federal funding required? We say absolutely. This province is struggling to maintain health programs that are equitable with those offered in other provinces. We are failing in some areas.

The second point, Mr. Chair, is really the focus that we want to talk to the committee about today. It is the manner in which federal funding is apportioned out to the provinces. It is apportioned out through the Canadian Health and Social Transfer, CHST, on the basis of tax points and cash transfers. Clearly, tax points benefit those provinces with a strong economic base. Cash transfers are assigned on a per capita basis, and they are assigned without any adjustment for the need of the various provinces that are receiving this funding. We think that this mode of cash transfer is in fact a threat to equal access to Canada's health care system.

Our publicly funded health care system provides health care to Canadians on the basis of their need, not on their ability to pay. Under current federal policy, the CHST program transfers funding to the provinces on an equal per capita basis. The amount each province receives is determined only by the size of its population. This approach does not recognize the differences in the "need" for health services among populations.

In 1999, spending on health care amounted to 39.3 per cent of all provincial program spending in Nova Scotia. These data come from the Canadian Institute for Health Information, CIHI. The public accounts actually show a much higher figure, but I think CIHI adjusts its data for comparative purposes.

Nova Scotia showed the second highest commitment of any provincial government, with the exception of Ontario at 40.1 per cent. Yet, even with 39.3 per cent of all program spending going toward health care, per capita spending - that is, the amount for each Nova Scotian - was the second lowest in the country.

Hence we have a situation where the second highestcommitment of program spending serves to generate the second lowest per capita spending in terms of provincial government contributions. Mr. Chair and members of the committee, this is really a function of a low level of economic activity, which we find not only in Nova Scotia but in many parts of this country.

While the average per capita spending on health care in this country is $2,016, Nova Scotia only spends $1,835, according to CIHI. This is 1999 data. CIHI released up-to-date data just at the end of last week. It was very current, projected through to the end of this fiscal year. The relationships have not changed. Nova Scotia still is paying the second highest amount of program spending. It is still producing the second lowest amount in terms of per capita resources. This reflects a weak economy that is suffering declines in traditional industries such as fishing, mining, and steel, as well as the high debt burden this province must shoulder.

It is a well-accepted fact that older populations will place a heavier demand for services on the health system. According to Health Canada, seniors over the age of 65 consume 47.7 per cent of all health services. This is supported by the examination of provincial-territorial government hospital expenditures in 1998. After the age of 60, expenditures increase significantly, from approximately $1,000 to $2,000 per capita for those ages 60 to 64 to between $4,000 and $6,000 per capita by the ages of 80 to 84. The CIHI graph in figure 1 demonstrates this point. This graph shows use of hospital services per capita, by age and sex. You can see that as we start life we consume $4,000 in health care costs, which really reflect the costs of birth and immediate follow-up. There is an immediate drop in the first year, which remains reasonably stable until the age group 50 to 54, after which point it increases steadily with age. I think it is a very dramatic presentation of the point we are trying to make, and that is, health care costs increase with age.

Seniors' health care is very expensive. The chart on the next page shows that the share of health expenditures is at 47.7 per cent for 12.7 per cent of the population. Clearly, there is a great discrepancy between the use of health services and the various age demographics within the province.

You may well ask, "Well, so what? What is the difference?" In fact, if the age were spread equally across Canada, there would not be a lot of difference. Each province, of course, would try to provide for its population. The problem is that the age spread across the country is not evenly distributed through all provinces.

The next graph shows that point and shows the percentage of individuals over the age of 65. Now we have had a bit of a drop in some of the headings. At the top where you see "percentage," that is a percentage of the population over 65 years of age. You can see down in the shaded area that it varies from 9.8 per cent in Alberta to 14.5 per cent in Saskatchewan - a 50 per cent variation between the senior populations in the two respective provincial health care systems. That is the essence of the difficulty: The disproportionate distribution of seniors across the country gives rise to a real problem in relation to funding on a strictly per capita basis.

Moving on to the next overhead, we see that even when population figures appear static, it masks a tremendous migration throughout the country, which presents disadvantages in certain parts of the country. This chart shows that there was a huge out-migration from Nova Scotia between 1990 and 1998; almost 9,000 people in their twenties left the province. Therefore, we have a situation where young Nova Scotians leave to work in other provinces. They presumably contribute to the tax base and the economy of those provinces. They may be laid off. They may be retiring. They come back to Nova Scotia with a diminished economic capacity and at a time when their needs for health services are growing. So again it just illustrates what we believe is a serious problem that arises from relying on per capita funding from the federal government.

If we look down the road, this chart shows a projected population growth for Nova Scotia up until 2016. You can see that the big growth area is people over the age of 65, a 57 per cent increase compared with a total population growth of 13 per cent as projected by StatsCan. The situation is projected to get worse.

The last chart shows participation rates in the Nova Scotia economy. This is obviously the number of people who are working in Nova Scotia, and you can see that there are substantial declines projected through until the year 2025. Again, the reason we point this out is to say we have a problem now and it is going to get worse.

I would like to just summarize a few points. Transfers from the federal government did not take into account the age structure of the province and territory. For example, Saskatchewan has the highest percentage at 14.5 versus Alberta at 9.8.

So there are two arguments, Mr. Chair. One is that there is an inherent favouritism built in for those provinces with the strongest economic engines in this country. I expect some of you might be thinking, "Well, Bob, there is equalization to look after that." Equalization does not address the disparity of age distribution throughout the country. Equalization cannot address the fact we do not have the economic powerhouse in this province that is evident in, say, Alberta or Ontario. There is no adjustment for age. There is no adjustment for morbidity or mortality, which are also distributed unequally throughout the country.

I closing, I would like to remind members of the committee that when each province goes about distributing its resources to its service providers, none of them use a per capita means of distribution. All of them factor in - either formally or informally - the needs of the organizations, the regions within their provinces. We believe it is critically important that the federal government likewise factor in need based on age and morbidity.

The Chairman: Thank you for a thoughtful - if scary - presentation. I knew the data was bad but I had never seen anything in print. When you see it in graphic form, you realize that what looks like a problem is a huge problem. Thank you very much.

Mr. Cecil Snow, President, Nova Scotia Health Care Council, Canadian Auto Workers-Canada: I am the President of the Canadian Auto Workers' Nova Scotia Health Care Council. I would like to introduce my colleague and union brother, Jim Mott.

The Canadian Auto Workers Union is the largest union in the private sector in Canada. We also represent 22,500 health care workers in Nova Scotia and Ontario through mergers with our unions in the past decade. Our members and other Canadian workers have come to rely on the universally accessible, publicly funded and administered health care system to provide the majority of health care needs.

We offer the committee our views on the future of health care in Canada, particularly in regard to the key issue: ensuring the long-term sustainability of a high quality, universally accessible, publicly administrated health care system in Canada.

The CAW-Canada views our health care system as an icon cherished by Canadians. We see it as a model for other countries.

We acknowledge the considerable stress in the health care system in recent years as funding cuts and cost-containment efforts at both federal and provincial levels have affected funding and delivery of health services. They have allowed greater opportunity for overt and passive privatization; cost-shifting and downloading in financing; and rationing in delivery. There has been a broad erosion of the commitment by governments to the principles of universality and accessibility.

The union rejects any effort to resort to market mechanisms that would deny Canadians access to health. We resist efforts to privatize the existing funding of health care delivery systems - whether through user fees or co-payments, "two-tiered" access to service, medical savings accounts, "catastrophic care" insurance, privatization of agencies in service delivery or any other form of "commodification" of health services.

The Canadian Auto Workers-Canada recommends that the committee advocate the long-term sustainability of our high quality, universally accessible, and publicly administrated health care system in Canada. This system depends on health reforms that: expand the coverage under CHA medicare to include pharmacare, home care, and long-term care; develop national standards and programs supported by national funding;democratize health through popular participation, involvement, and control. Furthermore, the reforms should: invest in health promotion and develop health performance goals whilemaintaining accessibility and quality curative services; implement a national pharmacare program; implement primary health care reform; acknowledge the contribution of health workers and call for effective health human resources strategies; utilize these capabilities to renew medicare.

As trade unionists, universality is but an expression of our commitment to social solidarity and an awareness that "an injury to one is an injury to all."

Canadians have recently become even more concerned about the future of medicare. Governments at all levels have first cut funding and then reinvested as the system strained under emergency room overcrowding, ambulance re-directs, physician and nursing shortages, and other symptoms of crisis.

The past 15 years has been a period of public sector cost containment. Canada has capably demonstrated that in a publicly funded, single payer health system, cost containment can be achieved - although often at the cost of public confidence in the system.

Despite the current economic slowdown, Ottawa has ample fiscal room to provide additional spending. The surplus for fiscal year 2000 was $15 billion - well over the $11.3 billion forecast in the October mini-budget. For fiscal year 2001, the impact of tax cuts and slower economic growth will reduce projected revenues, but this loss will be particularly offset by the impact of lower debt charges as a result of falling interest rates. Ottawa has much more fiscal manoeuvring room than is commonly assumed. In fact, program spending could rise by an additional $5 billion in 2002 and 2003 while still leaving aside $5 billion for reserves.

Recently alarm has been raised of an impending "demographic apocalypse" associated with an aging population resulting from increasing life expectancy, declining birth rate and the sheer effect of the "baby boomers" cohort reaching age 65. The alarm focuses on fears that an aging population and its greater demand on health services will bust the health budget without drastic reform of either or both the financing and delivery of services.

We must preserve and strengthen the Canadian Health Act. The five principles of medicare must be maintained: universal coverage, accessibility, portability between provinces andterritories, comprehensive coverage, and public non-profit administration. The National Forum on Health Care in 1997 concluded that the basic principles of medicare accurately reflect Canadians' values of "equity, compassion, collective responsibility, individual responsibility, respect for others, efficiency and effectiveness." In fact, the forum concluded the public will not support the changes to the health care system unless the essence of medicare is preserved.

We call for a substantial federal presence in funding medicare through an increase in transfer payments to guarantee universality and equitable access to services across provinces as a right of all Canadians.

With respect to the pharmacare program, from 1990 to 1999, provincial-territorial health spending on drugs increased 87 per cent compared to hospitals at 16 per cent or physician services at 30 per cent. In 1997, expenditures on drugs overcame spending on physician services to rank second after hospitals in terms of relative share of total health expenditures.

At the World Economic Forum, Raymond Gilmartin, President and CEO of Merck and Company, USA, said, "Medicine is for people, not for profits and if we remember that, profits will follow."

The essence of health is in intimate human bonds that caring and compassion nurture and sustain. Social support in the form of friendship, positive social relations, and a strong support networks is known to improve the health status and outcomes. The frontlines of our health delivery system are daily the sites of genuine compassion, solidarity, respect and affirmation of personal identity in the personal contact - especially eye-to-eye - between health care service providers and patients.

Regrettably, our health workplaces have been increasingly transformed into a crude approximation of mass assembly. Health care workers have endured a decade of health restructuring through reduced funding, consolidation of facilities, closure of one in four hospital beds, and drastic reductions in average length of stay of patients. The remaining work force has been subjected to virtually every private sector managerial initiative of "speed up" from lean production methods, to just-in-time processes, benchmarking, re-engineering, "patient-focussed" care paradigms and Total Quality Management.

In closing, Mr. Chair, I would like to recall Tommy Douglas' exhortation in 1982 when he said that those who believe in medicare must not only raise our voices, we must also commit and develop our capabilities as communities and collectives to work and act democratically in both imagining and creating those forms and projects in local, provincial and federal domains, which allow us to move forward and ensure a healthy society constructed in a space that is free from the corrosion of the market and built upon the foundations first laid down by our parents.

Sister Cathy Brown, from the Izaak Walton Killam Hospital in Halifax said:

The cutbacks add to the stress, both physically and mentally. People are no longer at 100 per cent when they are on the job, as each day takes its toll on physical and mental strength. It becomes absolutely exhausting and impossible to balance your workplace duties with many other daily family responsibilities. It is a real shame that they let the people caring for those most in need suffer so much.

Senator LeBreton: Mr. Cook, interestingly enough, we had a witness in Alberta who advocated that funding levels be based on demographics and not on the equal per capita basis. If the government were to decide to follow that course, what do you think it would cost across the country? Would it equal out? How much more money would it bring into the health care system in Nova Scotia?

Mr. Cook: I am not sure that I can tell you how much more it would cost. The chief concern is that the means of distributing the pot - whatever size the pot may be - is inequitable and will get worse as the years go on. It is simple to distribute it on a per capita basis and it may have been the right thing to do 20 years ago when we did not have as much data and information about morbidity and mortality as we do now.

However, it works a hardship on those provinces that have high morbidity and high mortality rates and high average age. We have the data now. We have the capacity to be more sophisticated. I am suggesting that equity of access requires that the pot should take into account the needs of the various provinces.

Senator LeBreton: Because as you pointed out, you have an older population and a smaller tax base. I was just wondering if there has been data that CIHI or human resources have extrapolated out if they were to base it on the demographics of the population. Mr. Chair, perhaps somebody should look into that in terms of reconfiguring and seeing what it would actually cost and what difference would it make to the provinces that have the older populations.

The Chairman: We will in effect try to run those numbers.

Senator Callbeck: Following up on that, you would like to see seniors taken into account when figuring out the CHST payments and I can certainly see why. In Prince Edward Island, we have a very high senior population; we always have. It looks as though the trend will continue.

Is the Province of Nova Scotia pushing for this position in their talks with the federal government?

Mr. Cook: I do not know. Our association is non-governmental. We have not sought out the province to try and harmonize. Our board is made up of the governors of many of the district health authorities that have just been created in the province. They are concerned. The people who govern our health system are realizing that this province is in a very difficult situation. We continue to operate in a deficit. We have cut all our social programs to the bone. We realize, as a vested interest group, that sustainability for health care will never occur until we get out of deficit spending.

Our organization has asked, "What is causing us so much grief here?" One of the fundamental issues is that Nova Scotia cannot get out of the hole in terms of finding a level playing field. We have just come through one of the periods of greatest economic expansion in this province or in this country. Nova Scotia cut and reduced its services. Still we were unable to get out of a deficit situation. That issue is driving our board and our governors in this province. I do not think the province would argue with it.

This afternoon you will hear from Dr. George Kephart, Director of the Population Health Research Unit. He has done a lot of good work looking at the imbalance between morbidity and mortality across the country and funding. He will address this issue. I have heard on the radio that the Premier of the Province has endorsed that study and has embraced it.

Senator Callbeck: Are there any other changes that you would like to see in the CHST?

Mr. Cook: We are concerned that the committee is examining the notion of a move towards more tax points, less cash transfers. That is a concern for two reasons. First, such a move would favour those provinces with a strong economic base. The rich will get richer and the poor will get poorer under that scheme. The other big issue is that the federal government will lose clout in ensuring that the Canada Health Act is sustained and enforced.

Frankly, our board does not believe that the federal government should be renouncing any of its powers or its authority in this area. If you are going to have equal access across the country, that is a responsibility for the federal government, which has the muscle to make it effective. We are alarmed when we look at that.

Senator Callbeck: Mr. Snow, at the end of your brief, I noticed a number of reforms that you would like to see. One is to implement primary health care reform. Would you spell that out, please?

Mr. Snow: In Nova Scotia they have tried health care reform over the years. I am speaking for the hospital workers now. A number of years ago the was a lot of downsizing and the workers were offered packages. Many took them because the average hospital worker in the province is 46 years old. The idea was that by cutting staff and offering packages, they would save enough money to improve the health care system. The reform did not work. It backfired. A lot of the workers who took the package returned to work as casual workers.

Primary health care reform was tried back in the early nineties and failed miserably. Now there has to be reform in health care, but you cannot take the people off the shop floor. You have to have the workers in the system to work the system because it is an aging population. That is what we mean by primary health care reform.

Senator Robertson: My questions this morning to both of you relate to the funding for health car. You may answer each one of my questions or any one upon which you choose to focus. All provinces find themselves trying to meet the health demands required by the public with not sufficient monies to give the care that is required. Some people would say we are in crisis.

We started with medicare with a percentage of 50 per cent federal, 50 per cent provincial. We now average about 17 per cent across all provinces. Some are higher; some are lower. What do you think should be the level of the federal government's contribution to health care? How much federal funding do you think would be enough? Should it be an absolute percentage or a desirable percentage? What form should the federal contribution take? Should it grow over time or should it be a given amount so provinces can budget around it? If the federal role was to be broadened to include more services than the current hospital and doctor expenses, how should this additional expenditure be financed?

Mr. Snow: In my brief, I mentioned about $15 billion in surplus and revenue in the federal government. I think that the transfer payments have to increase by population and by need. I come from Cape Breton Island and we have the highest cancer rate anywhere in Canada. We have a disaster down there with the Tar Ponds. The hospital administrators there are strained under the budget. We have such a high rate of cancer in that province, there should be more increases coming from the federal revenues, in my opinion.

I cannot speak for the nurses, but I think they have to go back to the old system of a two-year program for nursing. As you know, we have a shortage of doctors in our province. They left back in the nineties. You know the problem we have with Bill C-68 with the nurses and other groups. The two-year nursing program was an excellent program. Now they have a four-year program, a Bachelor of Science in Nursing. A lot of people go into that and they are not going to stay in a province that does not pay fair wages. They want to move on.

The transfer payments have to be increased to the poorer provinces, especially in view of the sickness in our province, of the aging population, of the environment. That should be relayed to the federal government.

Mr. Cook: You have posed some interesting questions. I wish I could answer them all with assurance. I need to take a moment to explain the situation in which the Nova Scotia Association of Health Organizations finds itself.

As you may know, this province restructured and district health authorities took over in this province as of January. Our association had a wholesale change in our governance as a result of that. Our board has only started to try to deal with some of these issues. Unfortunately our timing and your timing did not work out very well because these are very complex issues. Our board has not had an opportunity to canvass them in depth. As I am here speaking on behalf of the association, I certainly have to reflect the board's views. I can only tell you that the board has not had an opportunity to evaluate, discuss and take a position on many of these issues.

I do have some personal comments that reflect the sentiments that generally exist within the province. The federal government needs to maintain a strong role in financing and it needs to use that role to show leadership. There is no question that health care needs strong leadership over the next 20 years. We will face huge challenges. It is the federal government's responsibility to lead that way. You need to up the ante, quite frankly.

The federal government certainly solved its deficit problem quite nicely in the mid-nineties, but it did so at the expense of provinces, because health spending did not go down. The fact that the federal government reduced its contribution simply meant that provinces had to shoulder more of the burden.

I think that the federal government has to step up to the plate, but it has to fund in a strategic way. I think it needs to use that money to demonstrate leadership and find innovative means of addressing many of the problems that the country faces in health care. I think it needs to demand accountability. The federal government needs to reinforce or create a culture that requires accountability from provinces, from individual health providers, for results. There is a strong sentiment in this province that the government endorse and follow that role and to do so with some hard cash. Frankly, in money will talk in federal-provincial discussions, is money.

Senator Robertson: If the hard cash does not come, then where do we get that? That is for another round of questioning. If you would like, the clerk could provide you with some of my questions. Perhaps your board might want to try to digest them. It might be helpful to this committee.

Mr. Cook: Absolutely.

Senator Robertson: I have one final question. This committee has heard across the country about other determinant factors such as poverty and lifestyle and the need for preventive programs, all of which affect the quality of health of the individual. Are Canadians are willing to let their government - I suppose I should say "governments" - spend less on health care and more on these other sectors that so largely impact the quality of the health status of the population?

Mr. Cook: There is growing recognition that the system has to move to a population health model. We have to get to root causes. We have to get to lifestyle issues. We have to invest more in education, in poverty, all of the determinants of health. I do not think there is any question about that.

The problem is that while we are doing that, we still have a lot of people who need hospital care. Cecil Snow has mentioned that the Province of Nova Scotia has the highest rates of certain cancers in the country. The rates in Cape Breton for cancers are very alarming. Heart disease is high. It is a nice notion to say, "Take money and put it over into promotion and prevention activities." We know that is what you have to do, but it is very hard to do that when you have wait lists of six and eight months, and you know that will result in further time delays and further curtailing access.

Any form of complex change requires resources. I agree that is where we have to go. What I am suggesting is that you cannot pull the money out of one sector before the other has had an opportunity to bear fruit. We need to run parallel systems for a while. We need to invest in a population health model for the province and that will take more money.

Senator Cordy: Being a Nova Scotia senator, it is wonderful to hear witnesses presenting the health system from a Nova Scotian perspective.

Mr. Snow, we had a witness in Ontario who said that in fact we do have enough health care workers but they are not being utilized properly. I wonder if you would comment on that.

Mr. Snow: Well, I cannot speak for the Province of Ontario, but I know in our union in Nova Scotia, we are getting into multiple tasking now. Sometimes unions do not agree with that, but in some of the smaller hospitals it is necessary. We have people who have to do three or four different tasks and maybe that is happening in the province of Ontario, I do not know. I do not agree with it, but I have no choice.

Senator Cordy: I was not sure that a lot of people did at the time, but nonetheless I thought you should comment on it.

My next question, Mr. Snow, is dealing with morale of the health care workers, and we have heard witness after witness talking about the low morale of health care workers in Canada. I know in Nova Scotia the nurses have gone through a particularly difficult time recently.

What would be the first step in starting to increase the morale of health care workers? I know that the feeling is that it is a very difficult job in this day and age - with all of the cutbacks and things that you have mentioned earlier. What would be the very first thing that we could start with to increase morale?

Mr. Snow: Scrap Bill C-68. We had a very strained summer with Bill C-68 and that is on the back burner right now.

Senator Cordy: I am not sure that everybody knows what that is.

Mr. Snow: Bill C-68 is a bill taking the rights away from unionized workers to negotiate collectively in the final offer selection. By the way, our union is the only union that is into bargaining that is not under that bill. We did not sign up for it yet. We might have to.

I think that has a lot to do with it because for forty odd years, my union formally CBRT and GW, now Canadian Auto Workers have negotiated with Bob Cook, AHO. Anyway, we negotiated over those years and we did get good collective agreements for our workers. The morale was good back in the 1970s and 1980s. In the 1990s we had to deal with cutbacks and restraints.

The only way to improve the morale is to have a happy workforce. The people who work in the force must be appreciated first. They were not appreciated this summer when they came out with Bill C-68. Traditionally, health care workers are not a radical bunch like coal miners and steel workers. They are not wielding baseball bats and stuff like that. They negotiated fairly over those 40 years, reached good collective agreements, and are caring and sharing people. People who work in the health care system work with patients and elderly people. They have to have compassion; they would not be there if they did not have compassion for those patients.

With the cutbacks and the bad morale and the amalgamation was the thing that affected a lot of our workers. When they amalgamated all the hospitals together, it was almost like taking a little family, say they were working in Sheet Harbour and amalgamating with the QE II and having workers changing jobs, going back and forth, and the bumping process and all that. That caused a lot of bad morale.

To answer your question, I really do not know. I think they have to get more people on the shop floor, more workers to ease the burden that the workers have there now. I think that is one resolve probably. They will probably have to give some kind of programs where the workers are appreciated. I think the thing is to let the workers bargain effectively.

I know in the Province of Ontario they have binding arbitration. As bad as that is, that is better than final offer selection. The administrators have collective bargaining the same as our workers do and when the government steps in and tries to tell us how to run our business, we do not like it. Thank you.

Senator Cordy: Mr. Cook, you talked about accountability. I attended a health forum sponsored by the Dalhousie Medical Foundation and they had representatives there from across the country. Accountability came up repeatedly over the three days that we were there.

How do you go about doing that because as it stands now, the federal government gives the provinces the funding, and the provinces say, "Hands off. Do not tell us how to spend the money." How would you go about ensuring that there would be accountability for the funds that are given to the provinces?

Mr. Cook: That is a good question. I know that the federal government tried very hard a year ago to get an accountability framework with the provinces. It is an appropriate start, I think, to require the provinces to show what is happening with those dollars.

I do not think that the federal government can do this alone, and I would not suggest that it is your responsibility alone. I go back to the issue of leadership. If the federal government provides the wherewithal to make this possible, then you lead by example, and you start to create a culture within an industry that says, "We are accountable. We have to demonstrate what good did we do for the funds we received."

Our association is partnering with the provincial health council, for example, to develop an accountability framework around the province's health goals. We have health goals, but we have never measured the degree to which we are achieving them. That is our contribution.

It is all part and parcel of demonstrating and setting an example - setting a culture of expectation that people be accountable for the vast sums of money that are going in.

Senator Cordy: I think too the Canadian public are ready for accountability because you keep hearing that, not only from the health forum but from other Canadians as well.

You talked about migration from the smaller provinces such as Nova Scotia to the bigger provinces, to Ontario or to Alberta. There is also migration within the province. While the population figures may look the same in terms of Nova Scotia, what seems to be happening is that people are leaving Cape Breton, for example, and going to centres such as Halifax. That creates problems within Cape Breton particularly because, in addition to health concerns, you tend to have an aging population that you may not have in other parts of the province.

What about something like a national pharmacare system? The statistics that we have show that within the smaller Atlantic Provinces, 25 per cent of the population do not have any pharmacare coverage whatsoever. So what would you feel about a national pharmacare program?

Mr. Cook: I think that conceptually it is great. Conceptually, insured long-term care coverage is great, but we do not have it in the province. I think all of these are wonderful, and would make a positive impact on the health of Canadians and would alleviate a huge cost burden to them. To be honest though, we do not know what that might cost, and what other kinds of programs would be foregone to provide that.

There is a host of competing issues, and again, I go back to the point that our board is cognizant that this is a very complex area. If you spend $250 million or $500 million on a pharmacare program, that is $500 million that you do not have for some other purpose.

There are many competing interests out there. We are focussing on things like investment. The investment in information systems is just that; it is an investment so that we know how we are spending our money, and what works and what does not.

We are suggesting that the first priority for the federal government needs to be on those kinds of things that create an investment. Information systems are critical. Anecdotally, we are aware that there are many medical interventions that do not benefit the patient. We have the capacity to measure this. We do not necessarily have the infrastructure and the systems in place to do so. A great role for the federal government is to invest in information systems that allow comparison from province to province. Again, this raises the notion of accountability and bench-marking, and also allows us to evaluate medical procedures and the benefit that flows from that. That has been the focus of our brief.

That is not to say that pharmacare is not an important social program. However, our thrust right now is what can we do to eliminate inefficiencies and to try and streamline the system.

The Chairman: May I thank the two of you very much for coming this morning. We appreciate your taking the time to be with us.

Senators, our next panel consists of representatives of the Insurance Bureau of Canada, the Canadian Coalition Against Insurance Fraud and the Atlantic Institute for Market Studies.

I will begin with George Anderson who is the President and CEO of the Insurance Bureau of Canada. I say this to my colleagues who were not on the banking committee. George has probably testified before me as much as any witness I have ever run into, so I am delighted to see him in a different format. I will also say that this may be the last time he appears before us since he has announced he is leaving his job and retiring next July. In case this is the last time, George, thank you, it has been fun over the years. I hope you have fun after you move on to other things.

Mr. George D. Anderson, President and CEO, Insurance Bureau of Canada: Thank you very much for those kind remarks, Mr. Chairman. I do hope perhaps in another life to actually have the opportunity to come and talk about some other matters at another time. However, you are quite right, I am leaving after 10 years in this job, which had to be one of the most interesting jobs in Canada for the range of things that we deal with.

Now we are asked to deal with health policy in Canada. The Insurance Bureau of Canada represents property and casualty insurers. Those are the people who do home, auto, and business insurance. I make the distinction between the life and disability insurers and us. We employ about 100,000 Canadians in all parts of Canada.

With me today is, who is the Senior Vice-President of Policy Development. He has done a lot of work on this file and is quickly becoming, I think, an expert in the field.

Mr. Chairman, last year property and casualty insurers spent more than $1 billion outside medicare on health care for injured individuals and by far the largest portion of these expenditures were for rehabilitation services for automobile crash victims, as you might logically expect.

During the 1990s, these costs underwent phenomenal escalation. I will give you some figures from Ontario where we have the most reliable database. In Ontario, the average insurance cost for medical claims and rehabilitation for crash victims rose from $5,200 per claim in 1990 to more than $16,000 per claim in the year 2000. That is an increase of 210 per cent in one decade.

Now insurers also fund the health system in other ways. For instance, automobile health levies made by the provincial governments provide those governments with direct funding on top of the rehabilitation costs that we incur. The value of these levies in 2001 is $174 million - a 300 per cent increase over what was paid five years ago.

In addition, the industry pays about $3.6 billion in corporate and payroll taxes. We calculate about $1.2 billion of that constitutes another major contribution for the medicare system from our industry. Therefore, the total commitment of our industry is about $2.5 billion. That is growing at what I would call breathtaking rates. It gives us a very large stake in Canada's health system.

A number of factors have been at work in the dramatic rise of these numbers in recent years. Not the least of these, of course, is the trend for provinces to shift growing portions of health care costs associated with injury crash victims directly onto the insurance industry. I believe we call this off-loading. That trend has come with fewer services being offered by hospitals and the failure of publicly supported rehabilitation services to keep pace with demand.

While the industry has accepted responsibility for these additional costs, there is little reason for insurers to have confidence that the parts of the system with which they work are adequately accountable or that insurers and their customers are getting value for money in terms of improved health outcomes. I think the committee has probably heard this before in its hearings.

Mr. Chairman, IBC tabled its submission with your committee in September and it included seven recommendations. I will not go over all seven today. My remarks this morning will focus on two aspects, injury prevention and rehabilitation. Naturally we are pleased to discuss any of the other matters in our submission.

I think there are two main messages that come out of the work we have done so far on health care. The first is the urgent need for political commitment to move from discussion to action. The brief submissions I heard this morning indicate to me that the issues at stake now are simply too important to allow us to indulge in what one commentator called "the Canadian tendency to talk about excellence in health care without looking at the implementation routes to achieve excellence." I think we are at the point now where we have to drill down on this file, well beyond where we have been in the public discourse in Canada for many, many years.

Our second message is that privately funded health services need to be considered in concert with the public component when it comes to issues like performance standards, accountability, and cost containment. I would like to explore these two messages just a little bit. In the property and casualty insurance injury, we do not subscribe at this time to the crisis language that some people have used in describing the health care system that most Canadians have become attached to. Rather, we believe - and I think we find support for this in the Fyke and Clair commissions, the National Forum on Health and other authorities - that a high quality patient-centred health system can survive and prosper in Canada. This will not happen automatically and without the commitment to leadership and action on the weaknesses of our system. Indeed, these weaknesses have been known for some time. Canadian health care - while perhaps not in crisis - is certainly facing significant problems and challenges.

One of the longstanding issues includes the need for a great deal more attention to prevention and population healthpromotion. In the mid-1970s, the Lalonde report indicated the need to reform the way primary care is delivered in the country, and the need for a modern information infrastructure and the ability of providers to share personal health information. I think one of the previous witnesses talked about this.

We have no doubt that had these issues been acted on earlier, Canada's health system today would be performing better and, I would submit, at lower costs. Unfortunately, as you all know, there is great resistance to change. That resistance has been strong.

In the face of resistance, political leaders have been unable or perhaps unwilling to act comprehensively on what is already known about how to improve and preserve the national health system. We call this the "log jam of self interest." This log-jam of self interest may prove to be the greatest threat to the future of Canada health care.

Second, the property and casualty insurance community views the presence of private sources of funding as a strength. Indeed, it is not now, in our view, as a practical matter to think of our system functioning in any other way. Based on our experience in funding medical and rehabilitation services for our customers, we believe that private sources of funding expand the capacity of the health system and contribute to higher levels of customer satisfaction.

At the same time we are very sensitive to, and aware of, the fact that private funding of some health services can be associated with unacceptable differences in accessibility to the system.

Yet, unequal care standards and health outcomes are not inevitable results of private funding. They happen because the authorities responsible for health policy treat privately funded services as though they were outside provincial health systems. For instance, privately funded streams of rehabilitation operate under separate legislative frameworks. They receive little or no attention from provincial ministries of health. There is no systematic data collection. There is inconsistent quality assurance. There is limited, if any, interest in cost containment, and there are few mechanisms to make privately paid providers accountable for health outcomes. Indeed, it often seems that government's concern for privately funded rehabilitation services ended once the costs started to be paid by the private sector.

For the entire history of health care in this country, private sources have played a significant part in the funding of our health system. This is not likely to change, in my view, nor, frankly, should it. However, the same performance expectations need to be applied equally throughout the system regardless of the source of funding.

We are asking for more leadership on the rehabilitation side. Bring rehabilitation and injury prevention into the mainstream of medical thinking of Canada and set up effectiveness councils of providers and research councils on rehabilitation that can get at some of the issues of the runaway costs in this sector, and what appears to be a serious lack of accountability for health outcomes. Those are our major recommendations.

Ms Mary Lou O'Reilly, Executive Director, Canadian Coalition Against Insurance Fraud: I am sure it is not news to those gathered here this morning that every Canadian pays in one way or another for insurance fraud, and so it is understandable that everyone must join together to stop those who seek to defraud not only the insurance community but the health care system.

An overwhelming number of Canadians have told us that they believe that consumers, lawmakers, bureaucrats, among others, must play a part in eradicating personal injury insurance fraud. Ninety per cent of Canadians also believe that the fraud coalition should be involved in the prevention of the abuses to the health care system, because the two frauds go hand-in-hand.

Our organization was founded in 1994, and our mandate then was to raise awareness of insurance fraud. Our member companies understandably include most of the private insurance companies in Canada who provide the majority of home, car, and business insurance sold in this country. We also count among our membership Manitoba Public Insurance, SaskatchewanGovernment Insurance and the Insurance Corporation of British Columbia. Other members included the Consumers' Association of Canadian, the Canadian Chiropractic Association, and the Canadian Association of Occupational Therapists. We even count the Canadian Cycling Association among our membership.

Armed with the experience and expertise of these groups, the fraud coalition attempts to raise both industry and public awareness about this costly crime, which is not only a serious drain on insurance policyholders but also the societal resources, including our health care resources.

Our submission today represents the view that all Canadians have the right to receive affordable, effective, and efficient health care. With hundreds and thousands of Canadians making insurance claims every year, it is not surprising that most of them receive some form of medical and rehabilitation service.

A portion of these claims is not legitimate. Those claims that are deemed to be illegitimate can become serious drains on the vital health care resources that could otherwise be going to individuals who are legally and legitimately in need of care.

As two leading participants in the delivery of medical and rehabilitation services, the federal government and the insurance industry must acknowledge that personal injury fraud is a crime. It costs honest policyholders, through increased premiums, and it costs all Canadians in terms of its serious drain on societal resources, specifically, valuable health care resources.

We have recently commissioned an independent study to uncover just how widespread the problem of this kind of fraud is in Canada and how much of a role it plays in personal injury claims to our industry. The results are astounding. More than one quarter of all personal injury claims that an insurance company receives has some element of insurance fraud. The industry, on an annual basis, is paying out more than $500 million annually for claims that contain an element of insurance fraud.

The insurers that we represent are vulnerable to unnecessary and inflated medical and rehabilitation claims because of a variety of different factors. First, while insurers expect to incur losses from accident-related injuries, the frequency at which such claims arise and the severity of these injuries cannot possibly be known in advance. So it is very difficult for insurers to simply interpret an increase in claims as a true indication of fraud.

Second, the fraud and abuse controls used by insurers to foil illicit claiming activities are not unerring. Most ambiguities in our current environment obviously are resolved in favour of the person submitting the claim. Consequently, this makes the detection of fraud difficult.

As a coalition, we are here before you today fundamentally encouraging that within the framework of any health care reform that is brought forward that the exchange of information continues to be aggressive between health care providers and insurers. I speak, as I had mentioned, for a coalition that represents not just insurance companies but health care providers who are committed to the detection and elimination of fraud in the system.

The one prevailing theme of every example - and there are hundreds that come before us on an annual basis - is that every claim that is denied is denied after valuable health care resources have been illegitimately delivered to a person who has committed fraud.

The Chairman: Thank you and the last member of the panel before we turn to questions is David Zitner, a Fellow on Health Policy at the Atlantic Institute for Market Studies. May I also just tell my colleagues, in addition to Dr. Zitner's brief today, he has also distributed with it a copy of a paper called "Operating in the Dark" which he co-authored with Dr. Brian Lee Crowley, who is also a member of Don Mazankowski's Task Force in Alberta. I would highly recommend that the members on the committee read it. Read the full paper, not just the executive summary. It is well worth it.

Dr. David Zitner, Fellow on Health Policy, Atlantic Institute for Market Studies: I am actually a family doctor and director of medical informatics at Dalhousie Medical School.

I think your committee will face the same problem as several other committees who have tried to study the Canadian health system - they are all staffed by dedicated people. You have all heard diverse views about what should be done, yet because of a serious lack of information on the impact of various manoeuvres on access to care and the results of care, you will be unable to choose among competing visions of health care delivery.

This lack of information occurs because no one has bothered to collect regular and reliable information on effects of various strategies on access to care and on the results of care or the direct and indirect costs of care, although we know those costs. It is interesting that every person knows whether they got better or worse.

We know that the purpose of health care is to improve comfort, function, and life expectancy. However, it is only in the health care system that we are unable to define and say what our product is. Hence, our first recommendation to the federal government and as well as to your committee, is that suggestions to reform health care or to change the way care is provided must always be accompanied by an estimate of how the proposed changes will influence access to care and the results of care. We have seen a lot of tinkering over the years with the health system, but no one has bothered to say what the effect has been.

You might be tempted to recommend a new organization to gather information about access and results of care. However, we have an organization in which we have invested heavily: the Canadian Institute for Health Information, CIHI, which has received $95 million of federal money. CIHI is responsible for health information in Canada. At the same time, provincial governments spend large amounts.

For example, at our hospital in Halifax, we spend about $1.5 million reviewing the charts of each patient who goes through and is discharged from the hospital. A detailed review is done. The chart review takes place by having a health record reviewer go through each page of the chart. They ask what the diagnoses were, what the procedures were, how long the person was in the hospital. They do not ask, "Did the person get better?" Or "How long did they wait for care?" This process costs, at our hospital, about $1.5 million. There are 22 people going through each page of each chart. The information that is collected is quite variable.

I see you have some astonishment. I think people do not realize that this happens.

The Chairman: Yes, I did look astonished only because you would think that anybody who has ever tried to run anything would first ask, "Does it work?"

Dr. Zitner: Exactly.

The Chairman: I am sorry, but that was why the look on my face was there.

Dr. Zitner: I actually find it strange as Director of Health Informatics that I get frequent flyer miles going around talking about this problem, saying, "We do not measure results." One of the things we heard about earlier was accountability and action. One of the issues that this committee will face is how to do you encourage federal and provincial governments to actually act on a recommendation?

In our paper, we included an outline of previousrecommendations, starting with the federal-provincial-territorial deputy ministers' working group, which was unanimously endorsed by all of the federal-provincial Deputy Ministers of Health, and they said at the time of health reform that they would provide the public with information about access and results, the two questions that people do not ask. Michael Decter, the Chair of the Canadian Institute for Health Information has said repeatedly that the two pieces of information that we need are information about access and results, but we do not get it.

So we are not suggesting a new system. We are saying that we should ask the system that is in place to work better. I believe the federal government can play a major role by simply asking the provinces "How long do people wait?" "Do you keep track of your waiting lists?"

Today in Halifax, Nova Scotia, the major hospitals have no idea who is waiting for care. No other industry can do that. When you consider that people waiting for hip surgery or other procedures essentially represent a future obligation of the hospital, it is sort of astounding that people can manage a business without having this information.

So why is the information not available? I guess one of the structural reasons is that we have a circumstance where there is a serious conflict of interest. Health care in Canada is essentially an unregulated monopoly.

Bill 34 in Nova Scotia, which established the health districts, said "These are the responsibilities of the health districts: To govern, plan, manage, monitor, evaluate, and deliver health services in a health district." Of course, the bill also says that the minister determines the services provided, so I am not sure how one reconciles that conflict. But there is a clear conflict between having the same people governing, planning, managing,monitoring, administering, delivering, and evaluating the services they provide.

Therefore, our third recommendation is that we do something to break up this conflict of interest in which governments do all of these functions. Since I am on a panel with a group from the insurance industry, if one thinks of government as a regulator, how would government behave as a regulator if an insurance company said that 10 per cent or 15 per cent of the policyholders did not have access to the services that they required? In Canada today, many people in many districts cannot get family doctors, which clearly is an insured service. If the insurance industry, fixing a car said, "Sorry, you paid your premium but we do not have any mechanics," the government would say, "You cannot do this. This is a problem."

The final comment that I would like to make is that apart from looking at errors, the health system produces miraculous results on a regular basis. My family has been beneficiaries. My daughter had a condition that was life threatening. She is fine now. Because we do not measure results, we do not get a chance to celebrate the miracles that occur on a daily basis. We begin to take them for granted and we focus our attention on errors.

I think we need to collect information both about errors and about excellent results. You probably will hear some discussion about error and error management. But errors are really a particular instance of a poor result. I think if we collect all of the circumstances where people receiving health care achieve poor results, we would be able to develop circumstances to remedy the causes - whatever they are, whether they are from error or from mistaken beliefs. The history of medicine is replete with instances where we believed that a particular treatment is valuable and we subsequently learn it is not.

Thank you for taking the time to listen to this, and I hope we have time for a discussion.

The Chairman: I have one question each for Dr. Zitner and Mr. Anderson. Mr. Anderson, when we were in western Canada, we heard, in Manitoba, Alberta, and BC from people who run private clinics who do not serve medicare patients. They either serve Americans or they serve Workers' Compensation Board claimants or people who have been sent by insurance companies, because the companies would prefer that the claimants get good service at the private clinic on the reasoning that the longer they are in the public line-up, the more the insurance company has to pay out.

As an aside, the operators of the private clinics tell us that, in fact, Bill 11 in Alberta has made it worse to operate a private clinic. They will not operate in Alberta, but they do operate elsewhere in the west, which is kind of funny given the press coverage of Bill 11.

Do you have any data on the frequency of use of private clinics that are outside the system that the insurance industry is using? I am trying to understand the frequency of use. We do that because we all know that there is no two-tiered system in Canada unless you happen to be a customer of a Worker's Compensation Board.

One of the things that has shocked this committee is the discovery that Workers' Compensation claimants have their own line-ups. They are completely outside the system. The doctors are paid separately from the regular system and so on. Then we discovered in the west - this is not a negative comment - that insurance companies, logically, in an attempt to reduce costs, were using the same set of clinics. I would love to have some data on that, if that is possible.

Mr. Anderson: We can try, senator. I have to say that the empirical base here is quite weak. We know this happens, of course, and the impetus for it is to get people better faster.

The Chairman: Of course.

Mr. Anderson: The longer they malinger in the system, the worse they get.

The Chairman: That is right. We were not being critical of it. I am just trying to understand how big it is. We know every Workers' Compensation Board patient gets treated that way. The question is: Who else?

Mr. Anderson: To some extent our customers get treated that way as well, although our ability in jurisdictions such as Ontario to direct patients to particular suppliers is very narrowly prescribed. In other words, we cannot just say, "You have to go here."

The Chairman: Right. What you are saying is if they do not want to get better quicker, you cannot force it.

Mr. Anderson: That is correct.

The Chairman: Anyway, any information like that would be valuable.

I have a question for Dr. Zitner. You talked about no information on the effectiveness of results and the length of waiting times. There was a third piece that I thought you would have added, and that is it is our understanding that hospitals across the country do not really know what it costs them to perform any given procedure.

Dr. Zitner: I think that is true as well. One of the interesting things, a lot of the arithmetic people do is by division. The Canadian Institute for Health Information essentially looks at the number of people with a particular diagnosis that are treated. They do that to develop what they call a "resource intensity weight." For example, delivering a baby requires fewer resources than brain surgery. Pneumonia, for example, might have a particular resource intensity weighting. They do not make any adjustments for severity. They do not distinguish between people with pneumonia who are very sick and people with pneumonia who are moderately ill. So there is a serious problem.

They take into account all of the diagnoses that someone has. So if somebody had pneumonia, plus diabetes, plus renal failure, there will be a higher resource intensity weighting. But if somebody just has acute pneumonia and is wheeled into the hospital, the system does not distinguish that pneumonia from a pneumonia that I would treat in my office with an oral antibiotic. They only look at hospital patients. It would take some time to discuss this, and I would be glad to discuss it with you at some future time.

The Chairman: We will do it off-line. What struck us was that, if you think of it, hospitals are major service-providing facilities and yet they do not know the individual costs. We have asked various hospital CEOs who have appeared before us what it would cost to do a hip replacement. So far nobody can even remotely begin to tell us. How you manage a business when you do not know your production costs?

Dr. Zitner: That is what distracted me from primary care into trying to deal with some of these issues. It is hard to see how people manage. By the way, since we are discussing private sector, the government-run organizations do not behave much differently. In fact, if you go into hospitals across Canada, including Nova Scotia, you find a huge effort in marketing foods - including high fat doughnuts - that may not be great for people. It is hard to get healthy food sometimes in a hospital.

That is done as a way of generating revenue, which is understandable because people need revenue, becausegovernments feel that they cannot totally support the system - but that certainly does not fit with the population health element.

The other anecdote that I will tell you is that accountability may be a cost of monopoly. In Nova Scotia we had a system similar to one used in Pennsylvania. We referred to it in our book. The Web site is www.phc4.org, where every hospital in Pennsylvania is mandated to provide information about severity-adjusted results. We were doing that in 1995, but when the Victoria General and the Halifax Infirmary merged, people said decided not to do that anymore.

The other issue is in terms of employees. I missedMs Henderson's talk earlier, but it is not clear whether monopoly circumstance actually benefits employees or harms them. If there is not a competition for employees, sometimes working conditions deteriorate. I suspect that you probably heard that working conditions for many health professionals are ones that probably government, as a regulator, might not accept.

Senator LeBreton: With regard to the Workers' Compensation Boards, we have come to the conclusion that there are not two tiers; there is an upper tier. In the upper tier, it appears that hospital beds are reserved. That is something we should really look into.

I have a short anecdote related to food. The Ottawa Heart Institute has a little restaurant called "Tickers," where healthy food such as low-fat muffins, is served. Perhaps that should be used as an example.

Mr. Anderson, my first question follows along with the Chair started. How does the Insurance Bureau of Canada deal with the discrepancies from jurisdiction to jurisdiction? On this whole issue of accountability and access, how does an organization like yours, which represents all across the country, get around the various jurisdictional issues that you must face?

Mr. Anderson: If I may, Senator, go on the record as saying that we do not cover doughnuts in our insurance policy.

That is a good question and it goes to the heart of the problem. We have 13 solitudes in Canada when it comes to the various governmental jurisdictions and who wants what from automobile insurers. The federal governments, the provinces, the territories, all have different rules. Those rules are not harmonized. They all have more or less lack of concern about regulating or in any way bringing rehabilitation and injury prevention into the mainstream of government medicare services. It is one of our fundamental problems.

We have started, in a very business-like manner, to challenge the bills we are getting from these outfits, which we think are outrageous. It has become simply the catchall to fund hospital services in Canada. We see levies paid to the provinces increasing by 300 per cent over a short period of time; we know medical costs are not. We are beginning to ask for empirical evidence of what the costs are in the system. We are doing that right across the country and we are not getting very much by way of tangible results.

In Ontario, finally, a month ago we got the government to agree to a standard invoice system where people billing our companies have to fill out standard claims so we know where the costs are; we know what the treatment issues are.

But this has only just begun. For years in this country, nobody collected these statistics and if they were there, nobody used them. CIHI, to which David Zitner has referred, for example, collects no statistics on automobile accident victims whatsoever. I do not know how strong its rehabilitation database is outside that.

There is fragmentation in Canada - a kind of "This is our territory; mind your own business" attitude that is one of the fundamental problems in this system. I know it is very difficult these days, but the federal government has to begin to show some leadership in these areas. I think every health provider across the country has been asking for this. We do not have the data to make the decisions we need to make, either in the private sector or, as Dr. Zitner said, in the public sector.

Senator LeBreton: Do the costs that are submitted to you vary greatly across the country? Is there any uniformity at all or is it equally the problem?

Mr. Anderson: In a word, no.

Senator LeBreton: Did you have a comment on that, Dr. Zitner?

Dr. Zitner: The incremental costs of collecting some of this would be very low, given that somebody already goes through every single page of every chart. The people who do this, by the way, are bright and talented people, and I do not know how they can spend all day trying to read some of our writing.

However, you would think that a person who goes through every page of every chart would bother to say, "Did this person get better? How long did they wait?" The additional cost is really quite marginal. People say it is difficult to do, but patients know if they can do more and if they feel better. There are systems, such as the one we had in operation at the infirmary, which give some estimate of whether you are likely to live longer.

Another issue that might interest you is population health. Addiction is one of the abnormal codes, so that includes nicotine substance addiction. In Nova Scotia people have stopped collecting that as a piece when they go through each page of each chart. So we cannot tell today how many people who are in the hospital were smokers and were not - despite the fact that smoking would have an impact on the length of a hospital stay.

Senator LeBreton: That is right.

Dr. Zitner: I confirmed with CIHI yesterday that hospitals have a choice as to what they collect and what they do not. This means that with each organization deciding on their own what elements they will collect and what they will not, they cannot claim to have a comparative database. This becomes a serious problem, especially when people try to use the data.

One hospital in Ontario reported that they received another $8 million because they went from retrospective coding, to concurrent coding. They had a coder on the floor. So without any changes in administrative or clinical performance or case mix, their resource intensity went from 2.5 per cent to 4 per cent. I think the people did not think they were being cynical. They did it because they thought it was a better way to code. I believe that indeed, it is a better way to code. However, if people are coding differently you cannot compare one system with another.

Senator LeBreton: I was reading a statistic the other day about the impact of smoking on heart disease and lung cancer. According to what you say you cannot even rely on that data.

Dr. Zitner: There is a set of Statistics Canada data population surveys that is quite reliable. With regard to the hospitals taking opportunity to code, whether it a is person who is in for pneumonia or congestive heart failure or heart disease, people have said: "We are not going to capture that."

Senator LeBreton: Dr. Zitner, you talked about the clear conflict of interest, and, of course, this has surfaced a lot across the country. You remarked that something has to be done to break this up. In a perfect world what is that "something"?

Dr. Zitner: Well, I think there are several ways to do it. It is clear that the group delivering care should not be the same group evaluating the performance. That is not a common case in any other industry. If government decides they want to administer government care then they have to get an independent body such as the Auditor General that has clear funding and is not dependent on what they report.

Our government seems to function very well as a regulator. Our highway system seems to work better than our health care system because we can go from place to place and the highways are repaired. However, governments have not developed organizations to actually build the highways; they put out requests for proposals. The government could be a standard-setting group and ask people to compete for the opportunity to provide health service. I think there are several ways to do that. Before anything can be done, people must agree with the principle that these functions must be separated.

Senator LeBreton: What is the ballpark figure on how much it costs Canadians in insurance fraud?

Ms O'Reilly: For all kinds of insurance fraud, our studies indicate the number hovers around $1.3 billion annually. You can add to that another $1 billion in societal costs - everything from crowded courtrooms to medical treatments that are unnecessary and fire fighters who lose their lives travelling to a fire or putting out a fire that was set by arson. It is a cost that touches almost every element of society and tallies over $2 billion.

Senator LeBreton: There is an urgent need for political commitment to move from discussion to action. I think that is what we are all about here.

Senator Robertson: Some days are more discouraging than others, and I think the testimony this morning reinforces despair. However, there is a better day ahead, I am sure.

Why is there such a lack of accountability in our health institutions, hospitals, et cetera? Administrators who are university-trained manage these institutions. Is it the type of training they get, the boards that they have to work under, or the fixed opinions of certain staff members like physicians that cause the systems to fall apart?

Dr. Zitner: As a physician I might say it is the fixed opinion of administrators, but that is another story. The answer to that question is very complex. People talk about participation, about groups getting together. To measure and monitor health system performance, you have to bring people together and have a dialogue. We have a system where the administrators are very busy micromanaging and dealing with problems as they arise. There are also clinicians who do not have a lot of discretionary time so collaboration seems to fall by the wayside.

Part of the problem lies with government structures because they have not asked the right questions. They have not asked the people who are administrating the organizations how many people are waiting and for how long.

Cardiology has done an exemplary job. They stratify people by risk. They have systems that measure and monitor the outcomes of people who are on the waiting list, so you know which waiting times are appropriate and which are not.

It is a governance issue. The governing boards should be in contact with the CEO and through him should know who is waiting, how long they have been waiting, and how many people got better. At QE II we spend $350 million and I believe it is reasonable for these questions to be asked and answered. We need to know how many people have gotten better. We expect some patients will get worse, but the good news is that most people do benefit from the service that we provide.

If we try to improve the care in the country and once we collect the results, I think we will have a lot of reason to celebrate. We will also be able to improve any of the inadequacies in the system.

Mr. Paul Kovacs, Senior Vice-President Policy and Chief Economist, Insurance Bureau of Canada: We are frustrated with the current approach where hospitals and the role of physicians are seen as quite independent than a broader view of the health care system. Doctors and hospitals play a role in rehabilitation, but a great deal does not happen in a doctor's office or in a hospital; there is another entire sector of people working on rehabilitation.

We have set up a system in each province where the Workers' Compensation Boards access the rehabilitation system independently from the way the auto insurers and public administrative system accesses that system.

When we are looking for accountability, let us take these three silos, have us work together, and have us define a single system. Let us do these things even if the payment might come in three different streams: through Worker's Compensation, through auto insurance, or through the public system.

The function being purchased - which is the rehabilitation - is singular. If you are hurt, it does not really matter whether the injury happened at work or in a car or in some other way. You need help, and there are professionals who want to provide that help.

We think the right resolution to the accountability starts by saying that we have one health care system. If we can start with that mindset where there is one system and it happens to include rehabilitation for a part of what we are talking about today, then it does not actually matter where the funding comes from. We have a patient in need of care. Let us have one system on accountability that holds it all together. That is where our optimism comes. We can have a system that uses existing resources much better to truly serve the needs of the injured public.

Senator Robertson: My last question is not specific to your presentations. We have heard a lot about the lack of finances from all segments of the health care system - the tightening of the belts, the long waiting lists, and so forth. Do you have any words of wisdom for us? For instance, how could the health care system that we have now contain financial incentives designed to encourage cost effectiveness both by the service providers and the consumers as well?

Dr. Zitner: We have been working closely with the computer science department at Dalhousie and we are developing a graduate program in health informatics that collaborates between medicine and computer science.

One of the papers that we wrote recently was entitled "Methods to Identify Pertinent and Superfluous Activity." There are ways to see which things contribute to a result and which do not. In the first instance, you have to measure a result. As long as we pay people for activities and not outcomes we will be in difficulty.

As an infrastructure piece, it will always be tempting to try to modify the way we deliver care to deal with the problems. Unless we deal with this information infrastructure problem first, we are going to be left in a circumstance where people have opinions, and if they are powerful speakers, they will be able to impose their view. But we will not know what works and what does not.

Mr. Anderson: We have essentially the same answer. It deals with focussing on outcomes rather than on processes, particularly on looking at more deliberately defined treatment protocols for the range of injuries that most commonly occur. When you look at the data, you have to ask why two people in roughly similar circumstances often get completely different levels of intensive treatment. There is no indication, at the end of the process, that the person that got the most attention had the better outcome.

The first part of the answer to this is a focus on outcomes. You begin to differentially reward successful outcomes.

Senator Callbeck: Mr. Anderson, you talked about the dollars that your industry contributes to health care and I believe you said it is now $2.5 billion. Then you mentioned that one of the reasons was government downloading. Would you explain that, please?

Mr. Anderson: Yes. Under provincial automobile legislation across the country, the governments in the last few years have off-loaded more and more of the rehabilitation expenses onto the automobile insurance policy. Today, if you are an injured accident victim, you are treated within the system, but many of your expenses are picked up by the private sector, whereas years ago they were picked up in the public system.

Senator Callbeck: You talked about the weaknesses in the system and pointed out that we have to pay more attention to prevention, population, health reform, primary care, and a health information system. All of these things, of course, take dollars.

Mr. Anderson: Yes.

Senator Callbeck: In your opinion, where should the finances come from?

Mr. Anderson: I am going to a little bold here, but I believe there is enough money in the system now to make these investments. They are not large investment. The payoff is to have better information to use on the delivery of health care is huge.

I am not convinced that the kind of explosion in health care financing we have seen in the country is a straight-line equation that has to continue to go that way. If we look at what we are doing within the system now, are we really convinced that we have the most efficient, effective, and accountable delivery of services? I think many of your witnesses would say that we are not. We have a good system, but it costs us a lot of money. Too often, the solution to our medical problems is for governments to make big dollar announcements, to say that they have put more money in the system. However, I have rarely heard a government describe what changes it expects to see in the system.

Senator Callbeck: So let us assume that we have not got enough money in the system, where would we get the extra dollars or where should we look?

Mr. Anderson: I do not know that I have a good answer to that, Senator. It is not something that we have thought about. Our proposition is we do have enough money in the system.

Dr. Zitner: We spend a lot of money on information systems. We spend $1.5 million doing manual coding. One of our graduate students is doing a project looking at machine coding of the charts. They may not be more accurate at the beginning, but at least they would be reliable and errors that occur can be corrected. We spend a lot of money on information right now; we just do not get the information we need.

We know that there are activities in health care that are superfluous; that do not lead to good results. If we reward activities that are valuable, and refuse to support activities that do not provide valuable in terms of improved health, we probably could look after the community with the dollars that we are spending.

Mr. Kovacs: The particular proposals that we are talking about: better information, investing, and prevention are not costly, and the outcomes are huge.

In the auto insurance industry, for example, there are twice as many people driving now as compared with 25 years ago. However, the number of fatalities in auto accidents was four times higher 25 years ago than it is today. We have invested money in reducing alcohol while driving; seatbelt use is much higher than it was 25 years ago. Today, young people have to earn the right to drive. We have huge increases with one-quarter of the people per driver dying compared with 25 years ago from fairly modest investment. We did not spend a lot of money to get people to think differently about how they drive.

If you take that concept and put it on the prevention side, the savings are huge with a relatively small amount of money. We are talking millions in a system that has many tens of billions of dollars in it.

Senator Callbeck: Initially it takes some extra dollars to put into the system. Dr. Zitner, you mentioned that hospitals can collect whatever information they want. We heard a witness the other day who said that if the public is going to have confidence in the system, they need more information. In Ontario they have put out a report card on all the hospitals. They compare one with the other, and I understood that they were getting the same information at each hospital.

Dr. Zitner: I have seen the report card and we have had some discussion with the people who prepared it. There are issues around the reliability of the data. It is not quite a free-for-all where each hospital can collect whatever they want. They collect information about diagnostic codes. They do not all collect information in the same way, so you get what appears to be comparable information but is not.

The last report that I saw from CIHI was that the agreement between coders for most responsible diagnoses for medicine patients is 80 per cent. When you include more than one diagnosis, there is only 40 per cent agreement. I am not sure what their most recent studies have shown.

They do not ask whether people got better or not. The concept of comparing hospitals and developing a report card looking at pneumonia by length of stay does not make sense. The recent report card suggested that for women who are having babies, that vaginal birth after a Caesarean section was a preferred alternative. In the New England Journal of Medicine recently there was an article that said that attempted virginal births after a Caesarean sections were associated with increased mortality. In the absence of information about the outcomes of the various manoeuvres, it is hard to know whether higher rates are better or worse.

The Ontario report card looks at resource allocation. It does not report how many people got better. It simply states the length of the hospital stays. There is no adjustment for the case mix.

Senator Cordy: My question is for Ms O'Reilly. I was struck by the fact that 25 per cent of claims have some element of fraud in them. That seems extremely high. I am wondering why this is so. Do people feel they can get away with it? How can we change this situation to reduce that percentage?

Ms O'Reilly: There are two different types of fraudsters. There are premeditated acts of fraud committed by sophisticated criminals who establish fraud rings that engage not only claimants, but health care professionals and legal professionals as well. They weave a sinister web designed to extract money from the system that obviously is not theirs. Those rings have sometimes cost us millions of dollars in losses.

The other type of fraud is committed by opportunistic individuals who are otherwise honest Canadians. They would never think of stealing from anyone. Those individuals have a legitimate accident or occurrence and they determine that this is an opportunity to extract funds to which they do not have a legal right. This occurs when these people make claims for income replacement dollars or auto accident benefit as a result of their legitimate accident. Essentially, they inflate their claim.

When these people are discovered and the remainder of the claim is denied it is usually after a good deal of health care has already been provided. They have already been to the chiropractor and the massage therapist and the physiotherapist. Canadians most frequently visit their general practitioner after an accident.

Mr. Anderson: The statistics show that people commit crimes when they think they will get away with it. In that respect I think our industry has some work to do. We have to alert claims processors to the common red flags that indicate that a claim is potentially fraudulent. We are doing that work now.

Senator Cordy: So this would be one way of stopping it?

Mr. Anderson: Yes.

Senator Cordy: We can certainly lower the percentage by better training our front-line workers.

Mr. Anderson: Somebody who comes to you with more medical knowledge than Dr. Zitner and knows more about underwriting insurance than any of us, is someone who is pretty familiar with how the system works.

Ms O'Reilly: Our study has shown us what the fraud indicators are. So that is one of the beneficial by-products that we will be introducing in the system.

Senator Cordy: Mr. Anderson, you talked about resistance to change. I am assuming you meant both on the part of the public and people within the health care system.

Mr. Anderson: Yes.

Senator Cordy: You used the term log-jam to self-interest. I guess I often refer to it as the "Not-in-my-back-yard syndrome." People say there has to be change until it effects them. How do we overcome that in making changes to the health care delivery system in Canada?

Mr. Anderson: I hope that my answer will not sound too simple, but Canadians have to know more about how this system functions. I do not know if this survey has been done, but I would be surprised if Canadians knew that 30 per cent of the system is privately funded. We have spent a decade saying there will be no second-tier health care in Canada, running campaigns on it, winning elections on it.

There is a second-tier of health care in Canada. It is significant and it is growing. Canadians do not know that. They do not know that there are benefits associated with that, because we made it evil to have the private sector involved in health care. We are coming to the point, I hope, where there is political courage across the country to begin to inform Canadians about how these things actually work.

Canadians love to complain about the system and how it does not work. It seems today you cannot go to a hospital without somebody having a horror story about his or her visit. It is a right of entry to social activity, and yet we seem willing to just continue to pour more money into that system. I think a better understanding of how the system operates; a more honest presentation of what the issues are; and treating Canadians as if they have the intelligence to cope with these issues and make the right choices, is a very good start.

Senator Cordy: Dr. Zitner, I know universities in the Atlantic region have difficulty when it comes to getting research dollars because it tends to be the 50/50 split. The universities in the Atlantic region do not have the funds that, for example, the University of Toronto would have. I wonder if hospitals in the Atlantic region are also at a disadvantage when it comes to receiving funding dollars?

Dr. Zitner: We are at a substantial disadvantage regarding health research and hospitals, because we depend on provincial coffers and this province is not wealthy.

We have been trying to develop collaborations between the academic sector and the health services administration provider communities to work together to make the best use of the dollars that we have. There is no doubt that people do feel constrained in their ability to make improvements in health care.

Nova Scotia is probably the ideal province in which to do health services research in because of our size. We are representative of the population. I think that the administrators, clinicians, medical societies, and academics all get along. It is a small enough community that we have the potential to do some things that are probably quite special.

Senator Cordy: I agree with you.

Senator Cook: You talk about accountability. How do you balance accountability against privacy, which seems to be a very big concern for Canadians today? Who should be responsible for gathering the evidence-based information in order to measure your income? What are the determinants by which you set your premiums?

Mr. Kovacs: These questions are at the core of our business. On the privacy side, we think that the insurance business in our part of the broader health care system is built on the important trust between customers and the industry. Customers have a lot of choices, and so a part of keeping a customer and dealing with that trust requires absolute privacy. We have a 200-year history of respecting that very well. We do not have any track record or problems and we have put a lot of processes in place in partnership with insurance regulators and others who are supervising us very closely. With the need for organization, there is a specific accountability - very well laid out - that if a customer has any questions or wants clarity about how these issues are dealt with, there are clear and crisp answers for all customers. We are quite proud of how we have taken privacy seriously and the systems are in place.

We have had an open public dialogue with appropriate officials about how to properly manage a system with respect for the privacy of customer information. We are working with the federal Privacy Commissioner and the new legislation put in place by the federal government and the equivalents in provinces to deal with issues such as fraud.

If you have a group of criminals who are deliberately trying to take funds out of the system that are leading to higher costs for everyone, the only way to find those criminals is to look across information for a variety of different insurance customers and get at that. So the proper controls of that system are in place because the public want it, but they are managed well so that no private information gets out for any reasons other than what is in the public interest.

This has been put to very close scrutiny with appropriate regulatory officials and others so that we can be more effective and put more resources into pulling out criminal type behaviour.

We think we have found the commitment to the public where we have been able to deal with each customer and keep information private, yet also have complementary tools so that we can get at fraudulent practices and get more of that out of the system going forward.

Mr. Anderson: We were the first sector, the financial services industry, to have a privacy code approved and adopted under the Canadian Standards Association's standards of privacy. To my knowledge, in the years we have operated under that there has not been a single privacy breach or complaint.

Mr. Kovacs: With regard to evidence-based research, if I caught the essence of your question correctly here, we are insurance professionals. We are not medical professionals. We have tried to dialogue with the provincial governments who give us some of the authorities we need to manage these costs as well as we can. We have pointed out that we have a public responsibility for managing one part of health care. Rehabilitation is the biggest part we have. We would like the tools to properly administer and manage what we have been empowered to look after.

We compare ourselves with organizations like the Workers' Compensation Boards and others where someone is injured in the workplace. They go into the system needing treatment, and what are the ways to properly make sure that system is done effectively? We have been trying to access the same management tools that are available to the public health system and the Workers' Compensation Boards. Currently, however, they are not fully available to auto insurance companies, for reasons that are not clear to us. Perhaps we just did not ask before.

But in the course of that, our sense is the evidence-based work has to be done in the medical community. It has to come through a broad consensus of work. It often starts with academic research. It comes with engaging national communities. You have a broad agreement saying this is the injury that has taken place. This is the treatment that every professional would agree is the appropriate treatment, and any program that is following that process gets funded quickly. Anybody who has deviated from that should be questioned and there should be a discussion. That process comes out of the pure research and broad consultation process with the professionals delivering.

Finally, on the premium side, our premiums reflect our cost. To the extent that we have a way to make sure that our role of delivering health care is consistent with true costs and the best health and outcomes for the public, then the costs will be in our prices. Criminal fraud adds to the costs. Excessive treatment that is inappropriate because of mismanagement or absence of tools to get proper management adds to the costs.

The provincial insurance regulators will force our industry to say, "You must charge your costs. You cannot run an insurance company that does not cover its costs." So the public, all of us who drive, all of us who own homes, pay more for insurance than we would have to otherwise if we fail to get the right ways of managing these costs in place

We are looking for the management of privacy, the way to make sure we have the evidence-based research to get our costs in line, and the tools to manage those so that our costs reflect what is truly needed to get somebody well who has been hurt in an auto accident.

Senator Léger: We have heard a lot of talk about the insurance system frauds, the medical system frauds. We hear a lot about systems. I think we forget about why we exist. What about the honest people? How much money is being put in those who succeed? We have insurance because we need it. But then it becomes a system. It becomes greater. Why is there fraud? Where are the honest people? How come we do not talk about them? Mr. Anderson talked about putting monies into creating dialogues and changing a mentality.

I have seen in education, because I was a teacher, bit by bit with the years, yes, they have changed the mentality of students. You have a privilege; you have a responsibility of that privilege. Can we pass that on to our clients?

Mr. Anderson: I am mindful of what Senator Robertson said about if you sit here long enough, you are likely to be depressed. On behalf of our industry, I will say that we are not depressed, nor are we downcast. We think there are lots of good examples of how the health system in Canada works. We do not believe it is in crisis. We think the infant mortality rates are improving in the country. We think the longevity is improving in the country.

We are talking about is making that system better. It works pretty well now. I just would not want to be associated with coming forward and saying, "We have got a mess on our hands. It is out of control." That is not the situation that I see. My personal experience is that I get superb treatment every time I go. I do not believe that the system is sort of a welter of dismay, if you like. I am quite hopeful that we can, if we confront these issues now, get a very high quality health care system - the best in the world.

Ms O'Reilly: May I just add to that comment as well, just to give you some hope, Senator? When the fraud coalition began its work in 1994, we had exhaustive polling that told us 20 per cent of Canadians thought that it was acceptable to commit insurance fraud as it relates to health care. That number has now dropped to 4 per cent. So there is a pervasive public intolerance and acceptance for our work here today.

Dr. Zitner: We are very optimistic for two reasons: The first is that the results of health care are superb for many people right now. Second, we live in a country where people regard information as a communal good, so, for example, the tradition with the Canadian census is that we use private information for public good with respect for confidentiality. The CIHI process, where each chart is abstracted and the information is sent to Ottawa, occurs because people have a belief, I guess, that personal information can be used to produce good.

Our pessimism lies in the fact that there are groups of people who are disenfranchised; that within a public system - although everybody in this room is likely to get good care - there is a group of people who are less articulate, who may be poor. I believe that these people do not receive the same level of service as the rest of our communities. That is something that we need to be cognizant of.

The Chairman: Senators, our next three witnesses all come from Dalhousie University, although that is sort of the only thing they have in common. Their backgrounds are diverse and varied.

We will begin with Dr. Nuala Kenny. Anyway, for those of you who do not know Dr. Kenny, her very impressive CV is at the back of her attachment.

She is currently Chair of the Department of Bioethics at Dalhousie. In her past she has been Medical Chief of Staff at the IWK Children's Hospital here in Halifax. She has worked at the Children's Hospital, Sick Kids Hospital in Toronto. She has even for her sins suffered through 10 or 11 months as deputy minister of health in Nova Scotia, which was surely not an easy assignment. So we are delighted to have you here this morning in all of your hats.

Dr. Nuala Kenny, Professor of Pediatrics, and Chair, Department of Bioethics, Dalhousie University: Honourable senators, I just wanted to say that as you get older, I think actually you become more conscious of what you learn. I have always been passionately committed to the Canada Health Act, what it means and what it ought to be. As many of you know, I am an adopted Canadian, a passionately adopted Canadian, but I can tell you that my 10 months as deputy minister, trying to help our government here, helped me to understand in an absolutely new way how difficult it is to formulate public policy. I have done many things, and as a doctor I did residency. I ran a children's hospital. Nothing equals the pressures that people in public service, trying to respond to a huge range of demands, face. That was not what I was going to say, but you led into it.

I am also very conscious that when people work very hard to put together a report, having done that myself in a number of arenas, there is a tendency, when people comment, to only point out the negatives. I do not want to do that. Therefore, first of all, I want to really applaud and commend you for identifying the huge number of issues that you have put on the table as: "We have said this before. Now we really have to decide what we want to do about it." Particularly important are the clarification of the federal role itself, the question of population health, the determinants of health and how they always fall off the agenda, although we give rhetorical attention to them, the absolute centrality of good information, and the paradox that in reality, we have such poor information. My colleagues who appeared just before us emphasized that in spades.

I think you have done some very creative work on drug pricing, options and availability. You have made some very accurate comments about home care and the centrality of integration, so that for both acute care and palliative care, home care can become a launching pad for a number of other important things. You are correct that the reform of primary care is a must-do, overdue, and absolutely key. Think of it this way: We have a system that in fact protects that which is high power, high technology and complicated, and then whatever is left over goes to everything else, whether it is chronically ill mental patients or just primary preventive care.

We have to rethink the centrality and the importance, not only of the delivery, but also of who delivers it. I very much commend you for what you said about the question of hierarchy and conservative approaches.

Now having said that, I believe very strongly that you need to make sure, as you go forward - because you have the authority to do this - that you note the difficulties in effecting change. All those things that you listed as important in the first session - I have read Volume 1 to Volume 4 in detail - it is as if we hear them again and again and again. As the kids say, "Same old, same old." You ask, why is it that we know some things must be done to have a more efficient system, and we have not done them? I believe that you really have to pursue the question of whose interests and whose values are extant in the status quo. We have to be more transparent and honest about that. If you folks cannot help us do it, no one can. The question of who benefits from the status quo, I think, becomes a key question in unravelling why it is that when we know that there are things that we should do, with integration of information systems being an obvious one, it has not happened. Somebody has to benefit from the way things happen now, or it would be different. I want to suggest to the committee, through you, Mr. Chairman, that when you discuss the difficulties, the interests and the values, it is not good enough to say, "Look, we have tried to make these things happen. They have not happened, so now let's look for other options." We have to understand why we have not been able to effect change when we have good evidence of the need for it.

Third, I commend you on your commitment to a factual and non-ideological report. However, here the ethicist in me rises up and says, "I want you to be careful about definitions." I do not think you mean what you say, with respect. Ideology is defined as the body of ideas reflecting the social needs and aspirations of an individual group, class or culture; or a set of doctrines or beliefs that form the basis of a political, economic or other system; or an orientation that characterizes the thinking of a group or nation; or an imaginary or visionary theorization. I suggest, with great respect, that in fact you are centrally rooted in both factual information and in the clarification of and making transparent the values at stake. I think you do that in two areas that I want to comment on briefly in my short time. However, I want to say now that I think that what you mean in the introductory component of Volume 4 is that you do not want people coming with fixed understandings, unable to be open and transparent, and laying out not just the option, but what is the underlying conception of either justice or health care or community that is at stake in that choice. You do not want people to be biased, to come with fixed ideas and create a situation of confrontation. I would only say that if I am right, that that is not what you mean by a strict reading, then go for it. If there is one thing that we know has happened throughout the entire decade that we have just been through, it is that we have had meeting after meeting about health reform to which people have come with their vested interests. I do not mean that in a strictly pejorative sense. If I am here advocating for the Canadian Diabetes Association, the Canadian Nurses Association or for the families of those with Alzheimer's, I come trying to make the case that you need to give resources to my people. In ethical terms, you are trying to do good. The issue I see is that we have never had a forum that has really required that we examine these questions as citizens. I am therefore going to conclude with that challenge. That is the task. No matter what formula we find for today or for the next five years, the question is, how do we address, as citizens, these fundamental questions of meaning on what health care is all about? I think what you mean by "non-ideological" is an unbiased, open view. However, that then demands enormous courage in ensuring that you are making things transparent, taking the layers off the onion and articulating the value issue at stake.

I want to speak about two issues from your report that I think do become valuated and that are of concern to me, and then make a final comment.

You identify your analysis of health care within the context of a cottage industry. First of all, that is right, and especially if you look at the way physicians operate within this complex system. We are very key people, and yet we have never been fully accepting of the system and still able to function as individual entrepreneurs. You ask the question: "What is the good of health care?" Since I am just now trying desperately to write a book on this very topic, I will only say this to you: It seems to me that in laying out the transparent values underneath your specific objectives for the federal role, the first thing that needs to be made clear is exactly in what way health and health care are not amenable to the rules of the market.

In what way is health such a value-laden concept, replete with moral meaning, that if we open it up to things like competition and advertising, we actually wind up with people being sold more when more is not better? More is not, at times, even good.

I would suggest to you that fully fleshing out that section of your report is incredibly important to the way in which health care is or is not amenable to market rules, not at the level of dealing with laundry, but in dealing with individuals coming for care. Those are two different kinds of activities, one of which may be very open to market measures, market theory and market efficiencies, and another which is not because of the nature of illness and the dependency in the relationship.

In what way health care is a different good becomes extraordinarily important, and not only in terms of your options. More importantly, if we look at evidence, we have advertising here and we have evidence here. They are not the same thing. In fact, most times, advertising does not want to consider the evidence, because the object of advertising is to create a need and then sell some kind of good or product. That is health care as a commodity. The fundamental question of what kind of good is the health care system needs to be made transparent.

The second issue is equity. I understand equity as treating persons the same, taking into account substantive differences. "Quality" is treating them the same. I suggest to you that we need to reflect on in what way is illness, disability and dying a substantive difference, and how should Canadians take into account - that is exactly what you have on the table - this difference? It is in relationship to the differences that the options become real.

Finally, you suggest that we are not sure about how much efficiency is connected to the question of money, and you think it is prudent to pursue options just in case there is not enough. I think that is almost exactly the wording. I think you have given a very good outline of options, the best I have seen. However, when I read that you want things to be factual, and we need to be clear about the fundamental values, and then you want to lay out a number of practical options, I want to say to you that they all have to come together in some way.

As for financial options, what I know from international comparisons gives me real pause about some of them. I do not think they should be on the list because they do not achieve the objectives that you set for containing costs and preserving the public system.

Unless we change the objectives, the evidence, I think some of them should be deleted. Then there are some, as my colleagues before me said, where we have some information but not enough to be definitive. We really do need to pursue definitive information.

Finally, no matter how you cut this, it is a crucial question. It is a crucial question for me, because when we say the Canada Health Act has meaning for the country, it is a manifestation of public policy that has said something to Canadians about who we are and want to be. Therefore, whatever options we put on the table, we must think of the kind of people we will become when we choose. That, for me, is the fundamental question.

The Chairman: Thank you for an extraordinary series of comments.

Our next witness is Dr. Kusumakar.

I must say, doctor, you were very kind to begin your brief with a quote from our report that touched on mental health. You could have justifiably said that it is very unfortunate that that is our only discussion of mental health, because all of us around the table are woefully aware of that gap. We intend, as we move on past this phase of our work into further things next year, to do a very specific, separate report on mental health. Frankly, we were appalled at some of the things we heard about the state of the mental health system around the country. Please rest assured that we understand how inadequate we have been thus far on that issue.

Dr. Vivek Kusumakar, Head, Mood Disorders Research Group, Department of Psychiatry, Dalhousie University: Thank you, senator, for starting off with that and sparing me the job of pointing it out. I am, like Dr. Kenny, a very gladly adopted Canadian. I came here from Scotland. I also worked in Ireland, and I would like to start by saying that there is a lot that is right about the health system in Canada, a lot of which we can be proud. Most importantly, it is not, I think, purely an ideology to support the idea of equal access and free services at the point of contact, because medicine, for most of us who practice it, is about wanting to do the best for everybody, irrespective of their background, ethnicity, education or finances.

Having come from Britain, where a major, radical experiment took place in the 1980s, and which was flawed in many ways, I would like us to look at how to improve the system through some radical changes, but without necessarily throwing out the baby with the bathwater.

Dr. Kenny made a very important point, which is, how do we ensure that clients in our system who do not necessarily have a voice, or have illnesses that are not "sexy" or recognized as being that important in society, actually receive reasonable services. That is a very important and challenging issue, especially since the cake has, in some way, already been cut and people do not want to give up their share.

Earlier witnesses actually talked about there being enough resources in the health system. I would not pretend to know the details of that, but I do know, for example, that when it comes to mental illness, whichever way you cut it, depression will be the most prevalent, common illness in the western industrialized world by 2008.

Of the top 10 diseases that cause disability and put a burden on society, five of them are mental illnesses. There is a very intricate relationship between depression, other mood disorders and cardiovascular disease. That means that it is not simply a functional illness; it is a medical illness.

If we look at the cost to society of lost school days, lost work days, lost productivity, then we have to ask ourselves why, for example, in Nova Scotia, less than 5 per cent of the entire health budget is devoted to mental health. We know that over 60 per cent of mental illnesses start in childhood and adolescence, yet only 0.5 per cent or less of that money is devoted to child and adolescent mental health.

As people in a very privileged country that has very reasonable resources overall, we have to ask ourselves, what are the values and the facts on which we base our health service plan?

I am not going to go over the little handout that I have left with you. I am sure that it will make bedtime reading for some of you, but I would like to say that we really have to approach it from a few different angles. There are possible solutions. First of all, everybody has harped on the issue that we lack a strong informatics system. Informatics is not simply about utilization. We do not have adequate information about what works.

I think that when we health care professionals come before politicians and policymakers, our knowledge of what works is woefully inadequate. A top priority for informatics systems and research is to identify for you, the policy planners and the leaders, what works, because there is no point in putting money into things that do not.

For example, we know that the vast majority of children who have mental disorders also have disruptive behaviour disorders. The common treatment, even to this day, is to see the child individually in an office once a week. There are at least 21 different studies that show that that does not work. At 2:00 this morning, I was on an emergency call. It is, of course, very difficult to follow Dr. Kenny, but I can also plead the fact that I only had four hours of sleep.

This young person, who is suicidal, had to wait eight months before she came to the emergency room to get what would be inadequate treatment at 2:00 a.m. We have to ask ourselves how can we change this. I do not think that the answer is simply to have more specialists. We need a very different way of thinking about where we deliver our health care services. We have to have active screening programs in schools and the workplace to identify these problems. We have to have people who are trained to identify and then to refer.

Again, we need a very strong primary care arm that can identify problems and produce early interventions that are helpful. In mental health, we are guilty of waiting for people to come to us when they have been really ill for six years. We know the research. The offspring of the mentally ill are at very high risk. Those who have had perinatal trauma have high risks. Those who have been abused have high risks. Those who have urological conditions have high risk. However, we do not direct our health services on that basis, and we should.

Finally, I would like to thank you for the opportunity to share some of these thoughts. I would like to make a final plea for those who are mentally ill, many of whom are disenfranchised because of their education, their mental illness, their financial situation and their rejection by family and society. We should not give our sons and daughters a chance to say what fools our fathers and mothers were. Thank you.

Dr. Lawrence Nestman, Professor, School of Health Services Administration, Faculty of Health Professions, Dalhousie University: Senators, your committee is faced with some very difficult choices. In the last seven years, I have had the opportunity to work with WHO, both on assignments and as a full-time employee in the regional office in Copenhagen.

All of the 22 countries I worked with are faced with these difficult choices, because trying to make some radical or major changes to the health care system challenges the historical development, culture and values of that system. All the countries identify in some way with their health care system from a sociological point of view, and more importantly, a personal point of view.

Canadians are very proud of their health care system, but they are currently very concerned because they are hearing all sorts of news about the health care system being in difficulty. They have centred on one issue that I am trying to centre on, which is the federal-provincial relationship.

The public looks on it as if it were just a big squabble. Canadians are becoming very impatient, because there is strong support for the principles of the Canada Health Act, and I think Canadians largely agree on their value system in terms of health, in terms of showing compassion to their fellow Canadians.

It is very evident that federal-provincial relationships have to be more cooperative, coordinated and collaborative. I would like to give you three proposals that I hope could accomplish that.

One of our major problems is the turnover among deputy ministers and ministers of health. I was really struck by something I read just recently, that Allan Rock is the longest-serving Minister of Health. We have had something like 57 deputy ministers of health over the last 10 years, and some 40 ministers. How do you get stability in policy development with that kind of turnover? You could not do it in a private corporation, and I dare say that the Insurance Bureau of Canada, with whose last presentation I was very impressed, would have a difficult time being very focused.

Elections, re-organization of governments and turf protection have come to dominate the scene. This has created a sense of unpredictability in policy formulation. One government makes an announcement, which destabilizes other governments because they have to react.

I would like to propose that a Canadian health services council be established. The council would be the major forum for federal-provincial relations, including discussing, evaluating and recommending solutions, laws and regulations. The council should have a permanent secretariat with full-time staff to provide continuity, predictability and expertise. It should be funded by a partnership agreement between the federal and provincial governments.

I am not recommending a new agency be set up amongst all the others we have in Canada. We probably have enough of them. I am suggesting that the mandates of some existing agencies be turned over to the council. The example I have given is that the meetings of the ministers and deputy ministers of health could be folded into the council, as could other joint federal-provincial initiatives.

Consideration should also be given as to how this relates to the Social Union Framework Agreement, because that document says governments will make decisions in a collaborative way. I think this could be an important centrepiece of the council and would send a strong message about how we should collaborate in the future.

I propose some roles in my paper, which I will not go over for the sake of brevity, but I want to centre on three things. One problem, particularly in the 1990s and as we moved into the year 2000, is that it has become very evident that the policy apparatus in almost every country is having a very difficult time absorbing science-based evidence. The current foot-and-mouth disease problem in the United Kingdom is a good example, as are our current problems in dealing with the anthrax scare in the United States and Canada.

In your report, you indicated that a number of pan-Canadian agencies should be set up. This is very true. We have a number of agencies already with important mandates, but somebodysomewhere has got to coordinate these activities and reflect on them, so they can be absorbed into the policy apparatus.

One major piece of work on this, by Daniel Fox at The Commonwealth Fund, was published just last month. He looked at six countries to see how their health care systems absorb scientific information. He indicated a need for some kind of forum where public officials, policymakers and researchers can get together privately to reflect on what policy ought to be, so that it could be fleshed out and streamed into actual policy.

Finally, on this topic, I noticed that your Volume 4 indicated very nicely the roles of the federal government in a health service system. I think that was a real contribution. However, I feel that the roles of the provincial governments and the joint federal-provincial responsibility should also be spelled out. I think that would be a good first task for the council.

Secondly, we have had a problem in this country in balancing off accountability, redistribution and provincial politicalautonomy. This is a difficult juggling act, and I notice that comments about accountability are always coming up.

One of the major reforms in the 1990s in Canada has involved setting up regional systems for health care services. It is too early to assess the efficiency and effectiveness of these; however, regionalization does present some issues in accountability.

First, a local area government, a regional government, with quite independent authority in some cases, with executive authority, is allowed to make policy pronouncements. It begins to seek funding from municipalities as well as undertaking fundraising activities, which creates other funding issues, because we have a single-payer system. The regional systems have the potential to become a multi-payer system within the public system.

We know that single-payer systems have better cost-control methods, and I think a lot of provincial administrators to date are being confronted with pressure from these regional systems. It appears to me that that pressure is so strong, many provincial governments are now in the process of provincial standard setting and controlling, the same way the federal government has done with the provinces.

I am proposing that the principles of the Canada Health Act be legislated provincially as well as federally. This would provide for some coordination in policymaking between the federal and provincial governments and enforce and improve accountability. However, I would like to go a step further and ask the provincial governments to legislate portions of the Canada Health Act into the mandates of regional authorities to make them accountable for aspects of the act that are their responsibility.

I think this would also improve accountability within the system. More importantly, it would bring home to citizens of particular regions and provinces that they are part of a national health program in which some portions of the Canada Health Act are visible in their own region.

Lastly, I would like to make some recommendations for improving federal-provincial fiscal arrangements on equalization. Your report has lain out the options for cost sharing of resources between the federal and the provincial governments. It was clearly evident, however, before the 1970s, that the cost-sharing arrangements for the hospitals had one really visible component. It was that the poorer provinces received money from the richer provinces and equalization was built into the formula. It was very visible.

When we came to the 1970s, 1980s and 1990s, and started implementing other cost-sharing arrangements such as Established Programs Financing and the CHST, it became a block payment system. Some of the visibility of equalization was lost. If you talk to the general public about those two funding arrangements, about tax points and other things, people's eyes glaze over.

If the equalization and sharing in the funding mechanism is not visible, and experts such as accountants and economists get mixed up on it, you can imagine where the general public is on this issue.

Therefore, I have proposed that a visible equalization formula be built into future funding arrangements, and I am asking you to consider making that recommendation. I say that under four rationales. One is the economic rationale that if you have a built-in equalization formula, it will decrease regional disparities and also address the spill-over effects from health programs in one province into another.

Secondly, I think it has political connotations, in the sense that if the federal government can stimulate needed expenditures in the provinces, such as on home care and drugs, it will make a positive contribution to national unity. Over the years, our program has also made possible a somewhat uniform level of services across the country. As a result, people can see the unity of the country, as opposed to a series of fragmented parts.

Thirdly, the social rationale is that some Canadians want to feel that the health needs of all their fellow countrymen are being met equally.

Lastly, I think it is a prerequisite for successful federal-provincial negotiations. I cannot envisage a negotiation between the federal and provincial governments, now or in the future, that did not include an equalization formula, so that the rich provinces will help the poorer ones. In fact, I think it is likely to be the deal breaker or maker.

Senator Cordy: Thank you all very much for appearing this morning. It is nice to see two doctors who have chosen to come to Canada. By the way, Dr. Kenny, your enthusiasm in contagious. You talked about who benefits from the status quo, and I agree that that question is important.

I also think there is some fear of moving away from the status quo because health care is such an emotional issue. We all know that we will have to use the health care system at some point in our lives. How do we make Canadians and health care stakeholders or personnel more accepting of changes to the status quo? We will start with an easy question.

Dr. Kenny: I was going to say that if I knew the answer to that, I might be Prime Minister. That is so difficult. We are all contributing to this. I am trying to do research and reflection on what I call the "deeper" issues underlying the health care crisis. I am a doctor who has been trained as an educator and a speaker, so I speak better and far more easily than I write. However, I am trying to write something about these fundamental questions.

There is an article, and I cannot remember the author, but the title is - and I can get it for you if The Chair wishes - "Doing better and feeling worse: The political pathology of health policy." It captures what I want to say to you about this.

On the one hand, "Doing better and feeling worse: The political pathology of health policy," which is a wonderful title, really means that if we look at ourselves as Canadians in 2001, we are the healthiest we have ever been in human history. We live longer. We are healthier at every stage of life, from me the ones I take care as a baby doctor, right up to the elderly, who are living healthier and longer lives. By just about every standard, we are doing better.

The political pathology of health policy is that the healthier we are, the more we can do, the more we can intervene earlier, and the wider the scope of what I call "the medical."

New moms do not go to grandma for advice on feeding. They go to the pediatrician, who then sends them to a nutritionist. We have expanded the power of science and technology and widened the scope of the medical, but the political pathology is that we are constantly terrified that health care will not be available to us and our loved ones when we need it.

There is something about that fear, Senator; you are absolutely right. It has to do with the moral meaning of health, illness, dependency, all of those realities, and then the way in which what I call "the belief" in modern science and technology has played out.

I am amazed to find that some lines in my little written submission say exactly what both of these colleagues said, because we did not talk about this. I have not seen these two gentlemen in ages.

If we were to talk about evidence of benefit as contrasted with belief in benefit, the number of issues we could put on this table would mean that we would not get out of the room. It is not that we are not trying to do good, but because people hope for benefit, and there are so many potential interventions, we provide them, because we are a very consumerist, autonomous, self-determining society now. As we get more fearful about health, we turn to science and technology to answer our concerns.

Therefore, from the patient side, from the population side - all potential patients - you are right. We have to begin to develop what I think is the most difficult question: "How do we help ordinary folk understand the strengths and the limitations of empirical evidence?"

Then on the flip side, my colleagues and I do not respect science and empirical knowledge as much as we ought. There is a huge literature on practice variation, on the failure of evidence practice. It is supported by some legitimate claims. If a general information guideline says that a woman of 57 with this kind of blood pressure should be treated A, B, C, when my doctor talks to me about my blood pressure, she tries to make a judgement about whether or not that generalized information is applicable to me. However, that is then extended, at times, to clinicians who pay no attention to what the evidence says, and in the name of the specification and their judgement, do something different.

The evidence about our respect for science is reallyproblematic, and the education of the public is competing now with direct drug advertising that comes to us every day from the States. Finally, the biggest issue is what I call "perverse incentives."

Senator Cordy: You talked about new mothers not asking their grandmothers for advice and so on. Certainly, patients are far more knowledgeable than they were 30 years ago. You can find information on the Internet about drugs that you are using. I just read a report that discussed the fact that because doctors are paid on a per-visit basis, a patient will come to them saying, "I read about these tests and I want these tests," or, "I read about this medication and I want this medication."

The doctors' time is limited because they have 25 patients in the waiting room. It is more expensive, but easier, to agree to the tests or the medication, whereas if they were paid a salary, they would probably take more time to explain things to the patient. Is that a reality?

Dr. Kenny: I will answer very briefly and my colleagues can also reply. It is absolutely, positively true - incentives, incentives, and more incentives. Unfortunately, money does make things happen or not happen. You go to the heart of the issue in your own report when you talk about reimbursement, particularly for physicians, but I think it is a more general issue.

When Dr. Kusumakar talks about early identification of children at risk for mental illness, when you talk about reform of primary care and a different way of bringing in other colleagues, we are talking about that. Incentives matter profoundly.

Secondly, when I last checked on this three weeks ago, there were 15,000 easily accessible Web sites in English about health care, available to anyone who sat down in front of a computer.

There is no way we can make judgements about which is Nuala Kenny's home page on toenail fungus, and which are the most definitive, authoritative statements. That is part of the problem. The doctor, who is busy and paid on a piecemeal basis, as you identify, has a patient come in who wants to be informed, but who brings information that could, if not factual, be quite dangerous.

Thirdly, if the patient gets pushy and the doctor is frustrated, there may be some exertion of power, and then people become angry because they were not dealt with in a way that enhanced education. It is a complicated issue, and incentives to do it the right way are central.

Dr. Kusumakar: I would just like to add a couple of things. Firstly, overall, our health status is better. However, many of the illnesses we are faced with cause severe dysfunction - not necessarily death, but dysfunction and a very poor quality of life. Therefore, when ordinary citizens are clamouring for more health care, they are also clamouring for some solution to the dysfunction and the lack of quality of life that goes along with illnesses, because we have reached a stage in the practice of medicine where we have been able to eradicate many causes of infant mortality, or, for that matter, of deaths that are preventable.

However, we still deal very poorly with chronicity of illness, with the recurrences of illness, with quality-of-life issues. How we are going to deal with that is a major issue for health services. These are very expensive things for which to plan. Currently, our health services do not plan for it. They are geared for acute problems. If you have an acute problem, you get very good service, overall.

The second issue that you raised, Senator, was salary. I think it is quite clear that incentives are important in ensuring that quality work is done. However, it is also true that in countries that have had only a salaried system, and have not necessarily built in other incentives or ways of monitoring, there has been a lack of accountability. Having worked there, I can say that the United Kingdom is a very good example of that. The person who actually worked very diligently got the same reward as those who put their feet up. It needs to be a balanced system of salary and incentives.

Senator Cordy: You are saying that there is no easy answer.

Dr. Nestman: Just a very quick comment: Dr. Kenny was right that the incentives and money do make a major difference. When we started cost sharing on hospitals and medical care in the 1950s and 1960s, it was on a 50-50 basis. I think that was basically because of a perception amongst health-care policy people that there was a shortage of hospitals, a shortage of physicians, and they wanted a volume-driven kind of system.

The problem was, by the time we got to the late 1960s and early 1970s, the federal task force on health service costs was indicating that that kind of system did not work. However, we continued with it for quite some time until we hit a problem in the 1970s, because if you leave a payment system in too long, it starts to become dysfunctional. That is a notion that you may want to entertain, that when you recommend a new federal-provincial cost-sharing agreement, you only recommend it for a certain period of time.

The second point I want to make is that the way you set up a new funding arrangement has tremendous impact on the programs. In the beginning, we excluded mental health and public health from cost sharing. Then we moved to more global funding, where you could redistribute the money. The problem with that is, once the system is set up a certain way, it has so much momentum, that even after you change the funding arrangements, it is very difficult to change. That is why provincial governments had difficulty putting more money into prevention and mental health. The existing acute care system had so much momentum that when you put in more money, it gobbled it back up.

Those are the kinds of perverse incentives that have been set up over the years, and that is why it is strategically very important for you to sort out what is going to be included and what is not, because you are sending a major signal to the system.

Senator Cordy: Dr. Kusumakar, certainly the issue of mental illness requires a great deal of public attention, in my opinion, and I think Canadians, and especially employers, would be very surprised to learn the number of days missed because of depression or stress-related illnesses.

I know Michael Wilson is doing a tremendous job of educating the Canadian public, but how do people who are feeling depressed or stressed tell an employer that they want to take a month off, before things just get so out of hand, they may never re-enter the workforce?

Dr. Kusumakar: I think that when we wait for the employee to become ill, become dysfunctional, and then go to the employer, it is often too late. Employers are driven by other exigencies, such as wanting to have a very productive workforce. A novel idea - not necessarily novel in other parts of the world - is to set up early detection programs, occupational health programs within the workplace, which, using risk factors, can identify people before they develop the illness. Interventions at that stage, as part of a package of occupational health programs, can work.

Now this means that you are not expecting people to become depressed and remain depressed for many weeks before they go to the employer - in fact, a detection program has incentives for them.

It is a little like when you get your blood pressure checked. If you keep your blood pressure under control, would there be an incentive? Some companies do provide incentives. For example, employees who go for a medical every year get an extra couple of days of leave. You can do things like that.

If you bring mental health into the occupational health arena, you also de-stigmatize it in the workplace. In some situations, you may actually need laws to back that up.

Senator Robertson: The witnesses this morning have been just excellent, and we are learning so much from all of you. It is good to see you again, Dr. Nestman. I saw you sitting in the back there and was waiting for an opportunity to ask you to defend the institutional system, which was criticized by the last witness - I don't know if you were here all the time or not - for its inefficiencies. I thought it might be good to have both sides of the argument on the table.

I appreciate the positions that you have put before us regarding the role of the federal government. If you would care to defend, in your present capacity at the School of Health ServicesAdministration, what goes on in hospital administration, it might be interesting and helpful to us.

Dr. Nestman: I think the key questions raised this morning were, one, the interface between the private and public sector, and two, the future role of the acute care hospital. I will start with the second one.

We really do not know what the role of the acute care hospital will be in the future. We do know of some worldwide trends. We know that the acute care hospital sector is shrinking in every country. The number of beds is decreasing. People are now talking, in policy circles, of having 1.4 to 1.5 beds per thousand. Those statistics are quite remarkable.

There is no question that the nature of the acute care hospital is changing quite rapidly. We now know that hospitals are shrinking for a lot of good reasons, clinical, financial, social and operational. We know we can do more things outside the hospital in outpatient clinics and in communities. There is certainly a perception that how much you put into the acute care system does not necessarily correlate with good health care outcomes.

The great health equation of the 1970s, 1980s and 1990s has been broken. We now know that more money does not necessarily lead to an increase in health status. Therefore, the role of the acute care hospital is really important because it begs the question, in regions and districts, of what the priorities ought to be.

As to the interface between the private and public sectors, the comment was made that the private sector can provide additional funds for the acute care system or for the primary care system because it expands budgets. I think there is a fallacy in that, because a country is always faced with setting priorities. Our health care budget is both private and public.

If you look at what President Clinton tried to do in the 1990s, he was not concerned with public health budgets running out of control, but the private budgets. He was getting complaints from companies such as General Motors, IBM and Apple, saying, "It is costing us so much to make computers, so much to make cars. Private health care services are getting out of control." A country has to control not only the public side, but also the private side.

I look on this idea of increasing money from the private sector as a bit of cost shifting and a bit of a fallacy, because the larger the total amount of health care dollars, the less money you have for other priorities in your economy, such as education, welfare and social services. These are currently being crowded dramatically.

Senator Robertson: Thank you very much for that. That is very helpful. You mentioned something about the regional centres or regional concept, I think, in Nova Scotia. I did not quite figure out, Dr. Nestman, whether you approved of the regional concept or not. Would you clarify that for me?

Dr. Nestman: Clearly, I do approve of the regional concept.

Senator Robertson: Good.

Dr. Nestman: I have some questions about why, in our province, we moved from four to nine regions. It does not make sense to me. One thing I learned in Europe, each region has to have a certain catchment area in order to hire appropriate staff, have good clinical programs, and sufficient volume to enhance quality.

I question whether some of our regions in Canada are large enough to do that, but I certainly approve of regionalization. I think it is bringing forth more-encompassing policy at the regional level. However, it has some pitfalls and one is the accountability issue with the ministries of health.

Senator Robertson: Have you written anything on that that might be helpful to the committee?

Dr. Nestman: Yes, I have. A couple of articles are mentioned in my bibliography of references.

Senator Robertson: Good. We will get to those.

Dr. Nestman: I can make copies of those available if you would like.

Senator Robertson: That would be very helpful.

Dr. Kenny, I see that you are in the Department of Bioethics. When you ask people who are involved in bioethics what it is, you sometimes get different answers. How do you define "bioethics"?

Dr. Kenny: Bioethics is a particular understanding of ethics that brings the discipline of philosophy to assist in making value-laden decisions. It is about the right and the good. It is a practical discipline. Bioethics is ethics in the realm of the biosphere, human biology. It is actually broader than human health, but most people use it in that context.

It asks how, in a pluralistic society, do you lay out the values, the issues and the interests at stake when making a decision about the right and the good, generally about an individual patient situation. Then, how do you assist the relevant parties in establishing some kind of priority, so that if there are competing goods or competing harms, you make your choices in a responsible way.

Senator Robertson: Who determines what is right and good and what is not? Do we have a national code, or something similar in Canada that gives guidance on bioethics?

Dr. Kenny: The nature of modern bioethics is that we can no longer, in pluralistic societies, use assumptions about formal, religious-based ethics. It is a discipline of philosophy precisely because it is attempting to discuss the issue from the perspective of rational principles, called "prima facie" principles byphilosophers. On the face of it, everybody can agree, for example, that respect for the person of the patient is a primary consideration. The Hippocratic tradition directs us to always employ science and technology to the benefit of the patient, using justice and fairness. There are some prima facie principles.

Many of my colleagues do ethical problem solving, in which they attempt to lay out, when there is a lack of agreement on what is the right thing to do for a patient, the issues or values at stake and get them on the table, so that through the discussion, they can get some sense of what they believe should be done.

Clearly, the reflection might, in fact, show that the values at stake are in competition. They are in conflict. That is an ethical conflict. If that occurs, then we would move to the lowest level of ethics, which is the law - the law as it is formally understood. I am not making a derogatory or pejorative comment. This is properly so. The law is the lowest level at which society will agree on understandings of the good if we cannot agree among ourselves.

When I chaired the values committee of the Prime Minister's National Forum on Health, we actually looked at whether we should recommend for Canada something like the American National Bioethics Advisory Committee. We actually contracted that work out and received a nice analysis. That work was done five years ago.

The Chairman: Yes. 1996.

Dr. Kenny: At that time, we were unsure whether, at that level of general oversight of health policy, we had either the capacity or the knowledge to deal with bioethics policy writ large.

However, there are specific issues, like reproductive issues, where recommendations for national oversight are absolutely correct. I did not get to say a lot about your report. As to what you say about research oversight, I have just come off a new council of the Canadian Institutes of Health Research, and the federal initiatives to ensure national oversight for the protection of human subjects in research are absolutely needed.

There is much lack of clarity about interpreting guidelines in very problematic areas. Canada must establish that and I just wanted to commend you for that recommendation.

More generally, senator, lots of people call themselves "ethicists." I am a physician interested in ethics. To do it right requires a large number of people who are careful, analytic and respectful of different points of view. They are hard to come by.

Senator Robertson: We will get there eventually, though?

Dr. Kenny: Yes, absolutely.

Senator LeBreton: Professor Nestman, when I was listening to you speak about federal and provincial responsibilities, it reminded me - I may be dating myself - of an old Abbott and Costello movie, Who's on First, because it kind of illustrates the problem.

You talked about the numbers of ministers and deputy ministers of health. Certainly we have heard about that all over the country. I have asked people on all sides of the debate about Canada having someone like the Surgeon General in the United States to provide some continuity in public policy. What do you have to say about that? The question is addressed to all the witnesses.

Dr. Nestman: I think that is another model that could be entertained, because it does provide for, in the American system, very strong symbolic discussion and interaction with the public. It is perceived as having high integrity and providing factual information to the public. Also, health professionals in the United States have to reflect on what the Surgeon General says, because it comes from a very central source.

However, there are some other models that you could consider. The Germans use what they call "the wise councils." They appoint a council of wise people to look at health policy and come up with a consensus. The German health system is very consensus oriented.

In Finland, participation in community events related to health is very high. When I lived in Denmark, I was just astounded to see the kind of people who would go to community health meetings to discuss health policy. There are other models.

I chose this one here because I think we institutionalize a lot of federal and provincial meetings, and to me, that is where the meeting of the minds seems to be in our culture. However, the Surgeon General model is another that could be used, maybe even in conjunction.

Senator LeBreton: It seems to speak of a higher authority and to take the politics out of it.

Dr. Kenny: I would say that my understanding of the operation of the Surgeon General is that he or she functions generally as a definitive authority when there is a clinical policy issue.

I would love to think more about what Mr. Nestman was proposing, because it was more at the level of policy coherence between federal and provincial governments writ large, not specifically what do we do in the face of anthrax for particular patients or smallpox or whatever.

If you look at page 2 of my submission, I say almost exactly what Mr. Nestman said. At the top of the page, I talk about federal-provincial bickering, and on the bottom I say, and with great respect, "An important comment you make in Chapter 6 is that political considerations have interfered with or overturned evidence-based policy decisions in other countries." Your report suggests that because all major parties in Canada support the fundamental principles of the Canada Health Act, that kind of direction is unlikely.

In fact, a major issue that needs to be addressed is the way in which political processes have interfered with long-term,evidence-based policy. Please understand that this is a non-partisan comment.

We have in fact seen politics interfere with policy. It is one of the reasons we are inefficient. Policy requires a long vision. We have parties - party "A" coming in, overturning what party "B" spent three years developing; party "B" coming in, overturning what party "D" put in place. That is the frustration across the country.

Then there is turnover of the senior officials in the ministry because they are thought to be the other party's stooges. In my experience as a doctor, it drove me crazy to be inside, not quite as a civil servant - it was an order in council appointment - because I had to decide what was right. I consulted. I was willing to bear the responsibility if I made a mistake, but I had the authority to go ahead.

You stand there saying, "Well, all the evidence says do this. What do you think should be done?" The pressure on ministers and deputies in portfolios like health is phenomenal. Think of the paradox. At the clinical practice level, we talk about evidence. Show the evidence. What is the evidence? At policy level, we have made changes just like that. Every party in this country is guilty of that.

If there are fundamental value differences among political parties, then put them on the table and make us choose. I assure you, that is generally not what is at stake. It is more a case of, "I have to show you that I am in power now." Therefore, I throw out your policy, it takes three more years to get a new one started, and a year later, it is off the rails. That is the reality of public policy.

Senator LeBreton: I have a question on the issue of mental health. You talked about primary care and early interventions. I think the one area where we are sadly lacking is in early intervention in the education system.

I do not know how this would impact on the health care system, but guidance counsellors, teachers in our schools, and particularly in the primary schools, could probably channel some potentially very serious cases into proper care. Have you any thoughts on recommendations or suggestions that we might include in our final report?

Dr. Kusumakar: When I first came to Nova Scotia nine years ago, one of my passions was to begin a school-based intervention program. Using research funds, we "adopted" four schools, a senior high school and three junior high schools, where every year, we conducted mental health surveys, education in early identification for educators, and actually put in nurses to triage young people and give them the opportunity to discuss a variety of topics, from health in a formal way to living and learning experiences.

We have clearly demonstrated the need in terms of the numbers of young people with mental illnesses. We have demonstrated the need in terms of the number of young people in distress. We have demonstrated the productivity of this kind of venture by showing how we actually reduced visits to the emergency room in that particular area.

However, we have not been able to convince either the institutional program or the province to make this a sustainable project and to extrapolate it to elsewhere. The real question is, where does the money come from? Here is a good example of what I would call "early intervention."

I think we really have to turn the paradigm on its head to be able to do that. We have to look at some long-term outcomes. For example, are the kids in these schools better off after five years of these interventions than kids who come to us six or seven years after they fall ill? I think the answer is yes. We have the evidence, but are we going to make policy on the basis of evidence?

Senator Callbeck: Mr. Nestman, you talk here about the per-capita basis of the CHST, and about how other things should be factored in, such as the status of health in each province, the number of seniors and so on. Further down the page, you recommend a clearly visible equalization component. I cannot see how all those factors add up to a clearly visible component.

Dr. Nestman: I feel that equalization pertinent to health care is very important socially, economically and politically across the country, and should be built into whatever new federal-provincial arrangement for transferring funds is arrived at.

I am not a fan of the per-capita method. How can we distribute health, social services and education dollars based on that, when we know that the demographics are so different? Health status is so different. I am trying to get away from that and at least recognize that fiscal capacity issues should be considered in any new cost-sharing arrangement and should be visible, so Canadians can understand that poorer provinces are being helped by richer ones, thus contributing to a sense of solidarity in the country.

What should the other components be? Fiscal capacity is one, but I think population health and demographics are also important. I know that developing a cost-sharing agreement on that basis will be complex. However, I think it will be very difficult for us to continue with the per-capita method, treating all provinces the same. The provinces are just too different in many ways.

I am well aware of the discussion in your report, including Tom Kent's views, Monique Bégin's views, and those of the Canadian council. My own sense is that the drivers of education, health, social services and welfare, and the outcomes that you would want to measure and put into a cost-sharing agreement, are quite different. I am leaning more to the kind of arrangement that the Canadian council brought up.

I also feel the same way about pharmacare and home care. Where should they fit in? I have some difficulties with including them all. I know Tom Kent's views, that in the long run, they would not be efficient if you separated them out. However, home care, primary care and pharmacare are not really mature programs and do not have the momentum of the acute care hospital system. If you include them, is the money just going to be dragged back into the existing system?

I look at what the Germans have done. They have isolated their home care and nursing home programs from the main system, using separate funds. The Australians have gone with a separate program for pharmacare. That may be a good idea for a period of time. Maybe after 5 or 10 years, you would want to then pull them together.

Until those areas mature, particularly community services such as home care, they will not be able to complete. When decisions are made in the ministries of health, I am afraid that things like public health and mental health are going to lose out. That is why I want to see them separated out for a time.

Senator Callbeck: That explains that. You said that Nova Scotia spends 5 per cent of its budget on health care. Is that high or low compared to other provinces?

Dr. Kusumakar: It is much lower than most other provinces. In fact, even among the Atlantic Provinces, P.E.I. does better than Nova Scotia.

Senator Callbeck: Yes, I thought so. Thank you.

The Chairman: Thank you all for coming. I just have two comments, one that I would like you to think about, Dr. Nestman, and let us know your conclusions. This probably reflects some 30-odd years of my own efforts in representing either Nova Scotia or the federal government in federal-provincial relations.

My concern with allowing only public servants to decide a lot of major health policy issues is that it lacks a certain element of "street smarts"; namely, there is a huge gap between public policymaking and knowing what goes on when you institute the policy. I would like you to reflect on whether it is possible to design a forum in which not only the policymakers participate, but also the people who have to implement the policy, because many times, we as policymakers think of smart things to do that do not in fact work out there on main street.

Finally, I have a comment for Dr. Kenny in relation to the article about political pathology in health care. Just to show you how little things change, 25 years ago, when I was teaching masters students in public administration, my opening lecture on the design of social policy was based on an article entitled "The Counterintuitive Effects of Most Social Policies," beginning with rent controls and going downhill from there. Political pathology in social policy has been with us for a long time, however frustrating that may be.

Thank you all for coming. It was extremely interesting.

The committee suspended its proceedings.

Upon resuming.

Senator Michael Kirby (Chairman) in the Chair.

The Chairman: Honourable senators, this afternoon we have with us as our first group of witnesses Georgia MacNeil, the Chairperson of Feminists for Just and Equitable Public Policy, Sharon Batt, the Chair of Women's Health and the Environment at Dalhousie and Maxine Barrett from the Nova Scotia Valley Caregivers Support Group. I know that Georgia MacNeil has to leave early, or at least by 2:30 p.m., I am told, so I will begin there.

I also should say on behalf of our colleague, Senator Pépin, she, unfortunately, cannot be with us today because she is having a minor medical problem. She treated herself, but she feels so strongly on a number of the issues related to women's health that she and I have talked about the fact that we will do something more on that issue come the beginning of the year. Anyway, I do extend her apologies to you.

Ms Georgia MacNeil, Chairperson, Feminists for Just and Equitable Public Policy: Thank you very much. I am very happy to be here.

Feminists for Just and Equitable Public Policy, FEMJEPP, is a coalition of 29 community-based equality seeking women's groups. Many of these groups are service-providing agencies and others are membership organizations. Most of the service agencies deal with women in poverty. That is really our focus and that is the lens through which we look at your discussion paper.

I want to touch on two of the roles outlined in the "Issues and Options" paper. The first is the finance role. We certainly agree that adequate and stable funding for the health care system is essential. We do not, however, support a user fee in any form. We feel that there are savings that can be made in other areas of the health care system that will allow for reallocation of health dollars.

For example, the primary care system uses very expensive personnel to provide basic services. We feel that nurse practitioner programs should be expanded and nurse practitioners should be considered as key members of a multi-disciplinary primary health care team.

The other measure we consider to be an effective health care strategy and a big money saver would be to extend public health care coverage to include the services of homeopaths, naturopaths, and acupuncturists. The services these practitioners provide are cost effective and they are effective in terms of treating ailments. We believe that savings can be made by making them an integral part of a health care team so that the more expensive physicians and tertiary care organizations are available because the pressure would be relieved by these other caregivers.

We also agree that timely access to all medical services is a very important objective. Services should also, though, be culturally appropriate and available with translation, or in the language of a person's choice. There are many people in larger cities, many immigrants and refugees and many francophones in non-francophone areas who have trouble receiving services in their language of preference.

The other point I want to make on this is that geographical accessibility is extremely important. Rationalization andregionalization may seem to be cost effective from a larger perspective. However, many people have great difficulty accessing services where they have to travel. Something must be done to ensure that there is transportation support or that services are available in smaller areas so that people do not have to travel.

Concerning financial hardship, certainly, the health care system should be there for people who need it. We find, with the women with whom we work and to whom we provide service whether they are single mothers, welfare recipients, seniors, disabled, or people who simply do not have access to extended health care insurance, that many are made poor by the cost of special health care needs and drugs.

There must be a pharmacare system to address these problems and there must be access to special health care services such as physiotherapy. As an example, one of our clients was told that she needed to see a physiotherapist. She had quite a debilitating problem. She was told that she could be put on a waiting list and wait a year to see a publicly-funded physiotherapist at a hospital or she could pay for that herself. She was not able to pay for it herself, so she spent a year on a waiting list and the condition got worse and worse. I do not think that is acceptable in the third millennium in Canada.

The other role we want to talk about, and where our work lies primarily, is the population health role. Because our work deals primarily with poverty, we were very glad to see the analysis presented in the "Issues and Options" section. You certainly have recognized that population health and poverty as a determinant of health is a very complex issue.

Certainly, the policy areas that impact on poverty and subsequently on health are not necessarily within the health care system. We, therefore, feel that the only effective way to develop population health strategies that work is to take an integrated approach. By an integrated approach I mean that the federal government should work across its departments to ensure that policies are consistent with promoting the health of individuals. Health Canada may have policies that promote health, but other departments may have conflicting policies or impede access to health. As well, integration has to happen between the federal and the provincial levels. People continually fall within the gaps of jurisdictions.

Finally, a point of integration that we see as being extremely important addresses a question that Mr. Kirby raised in the final presentation this morning. We feel that those who are affected most by a policy absolutely have to be part of identifying the problems and developing effective and workable solutions. That is what FEMJEPP works for.

I would like to leave you with two examples of projects that are attempting to bring first-voice participation to policydevelopment. The first one is called The PATH Project, which stands for People Assessing Their Health Project. This is a health promotion project that is based on the idea that people know a lot about what makes them healthy and that people at the community level should be involved in planning and decision making about policies and programs that affect them.

This project is co-sponsored by the Antigonish Women's Resource Centre, the Extension Department of St. Francis Xavier University, Public Health Services, Eastern Region, and the Antigonish Town and County Community Health Board. You will notice that there is already a lot of integration and collaboration going on at different levels within this project. The project is funded by Health Canada's Remote and Rural Health Services fund.

The main activity of this project is the development of a community health impact assessment tool that will become a resource to assess the effect of various policies and programs on the health of a particular community. It examines the broad spectrum of factors that determine health, which includes things like income, education and physical environment in addition to health services.

The project will also research health indicators that will be valuable down the line for measuring changes in health status in the community. The project, like many others, aims to provide opportunities for the public and policy makers to come together to bring healthy communities.

As Senator Kirby stated in his earlier comment this morning, it is very difficult to make effective and workable policies from "up there" because each community is unique. Each community has its own mix of resources. People know what they need and they can probably give you a more cost effective solution than you can come up with in Ottawa.

An example I will discuss is one that FEMJEPP itself has been working on for the last year or so. We have been working with our constituents - and that means the clients of the service agencies and the wider women's community across Nova Scotia - to develop a critical analysis of women's poverty. It is obviously true that current policies do not facilitate women's economic independence. They keep women in poverty and that has long-term consequences for the health of women, their children, and the communities. It is important to try to break out of this narrow mindset that perhaps is making this happen.

Currently we are developing an integrated policy framework that will provide a perspective on the linkages between the different policy areas and sectors that impact on women's economic independence. As part of that tool, we are also developing a participatory impact assessment process that will involve first-voice participation in the analysis and the identification of policy options that work. We would be very happy to share our findings with the committee when we get through that project.

Ms Maxine Barrett, Nova Scotia Valley Caregivers Support Group: I represent the Valley Caregivers Support Group in rural Nova Scotia. I would like to start by telling you a little bit about a caregiver. How does one become a caregiver? If a family member becomes ill, you become a caregiver. You take on the job without pay, without training, and often without support. The job can last weeks, months, or years. For me, it was 15 years. You live in isolation, lose friends, have little or no social live and ongoing stress becomes an intricate part of your life. If you permit caregiving to become all-consuming, you can lose your identity.

Thousands of Nova Scotians selflessly provide care for family or friends who are mentally or physically challenged, chronically ill, frail, or elderly. By providing care at home, these caregivers collectively provide an urgently needed service, which saves taxpayers millions of dollars. Many caregivers experience serious health problems due to caregiving. I know of two caregivers in Nova Scotia who died leaving behind a family member who still needed care.

With the increased number of seniors requiring assistance at home, primary caregivers are a valuable link in the health care chain and they need support. If you neglect the caregiver, you will end up with two people who are ill and who will become a strain on the health care system. The long hours of emotionally demanding work seem to be poorly understood and grossly undervalued.

Concerning admission to nursing homes in Nova Scotia and beyond, the Valley Caregivers Support Group has been in existence for seven years, in part, to help members cope with the sometimes unbearable stress of caregiving. A major source of this stress for a number of caregivers arises with the decision to place a family member in a nursing home. This decision is usually deferred until well beyond the limit of endurance, when the caregiver and the family member are in a highly vulnerable position. That is the moment when the family must face the cold, hard facts about admission to a nursing home facility.The impact of this decision can be overwhelming.

The group, therefore, decided to inquire into the admission policies of other provinces and territories as well as Nova Scotia. We approached Dalhousie University and Assistant Professor Robin Stadnyk, of the School of Occupational Therapy, undertook to do the research. The project has been expanded to study the impact of different funding models on families and members being placed.

Concerning Nova Scotia policies and practices, effective April 1, 2001, all applicants for admission to any licensed nursing home in this province must go through a Single Entry Access procedure, whether or not they can pay the full cost of care. It involves complete disclosure of all income and assets of the applicant as well as of the spouse. Any transfer of property or money to a third party, even a child, within three years preceding the application must be disclosed.

Income includes private pensions, Canada Pension, Old Age Security, guaranteed supplements, income arising from annuities and any other regularly recurring income. Assets include the contents of all bank accounts, any property excluding the designated residence, RRSPs, GICs, shares, life insurance, boats and any other fixed or liquid assets.

The government wants total disclosure of your financial affairs with no guarantee of confidentiality. This is to ensure that citizens will fully fund the cost of care in any nursing home to the utmost extent of their ability. For the private payer, this does not include medicines, wheelchairs, ambulance fees and numerous other items. Before any government support is extended, all eligible income and assets, with the exception of the designated residence, must be applied to the cost of care.

For a married couple the combined income and assets, excluding the home, are eligible and half of their value must be applied to the cost of care. The impact of such costs on the spouse remaining at home, whose income is drastically reduced but whose expenses remain relatively unchanged, is devastating.

This procedure entails the most drastic means testing any citizen will encounter, and throughout the process there is no one to advise and direct the caregiver who finds herself or himself intimidated, humiliated, exhausted, guilt-ridden, emotionally drained, and in failing health. Often the caregiver is demoralized by the outcome.You can rent or sell your designated home but all net proceeds must be applied to your care if the title of your home is still in your name.

Spouses can rent or sell the designated home, but half of the income must be applied to the cost of care. They can transfer the home to another person as long as they do not receive value for it. If the title is put into another person's name, that person can sell the house and the money belongs to him or her.

We work hard to acquire our designated homes, but if we sell it for any reason, the government can lay claim to the proceeds with the stroke of a pen. What happened to our dream of leaving a little inheritance to our children? Rates are steadily increasing in nursing homes and some residents have been warned that all nursing homes will be directly impacted by the labour negotiations with nurses in Nova Scotia.

Evidence that nursing homes may have a different rate for residents who are fully funding their care is indicated in the Department of Health information document, "Nursing Homes, Homes for the Aged, General Information, Department of Health," March 2001, page five.

Are private, paying patients subsidizing government-funded care? For years, caregivers have been trying to shed the name "informal caregiver," but it is still being used by the Department of Health in its Single Entry Access. There is nothing informal about the 80 per cent care we give day in and day out. If the department really wants to label us, it can call us the "unpaid caregiver."

If we compare policies of other Canadian provinces and territories, families in the Maritime provinces are expected to contribute to the full cost of care and will be means tested for both income and assets, as described above for Nova Scotia. In Newfoundland the same policy direction exists as in the Maritimes up to a maximum that is currently set at $2,900 per month. In Nova Scotia the cost can exceed $4,500 per month. That brings the yearly cost for nursing home care to over $50,000. In Alberta residents are not means tested. All persons pay an affordable price.

In contrast to the Atlantic provinces, other jurisdictions focus on recovering only the room and board portion and means testing is only done on income. The nursing care component is paid by the province, which is in keeping with the principles of universality in the health care system about which Canadians boast. Why are senior citizens in the Atlantic provinces being discriminated against?

Federal equalization grants are intended to ensure equal health and social services among all provinces. As citizens, we are entitled to the same treatment that exists in many other provinces: paying for room and board and being means tested on just our income. What a statement these policy directions make on the value that Maritime provinces place on the caregiver's contribution.

The federal-provincial-territorial Advisory Committee onContinuing Care, year 2000, conducted an extensive review on the continuing care system in Canada in order to bring a more coordinated policy focus on continuing care. It recommended action to reduce the inequity in personal contributions to the cost of nursing home care.

The focus on room and board cost is more in keeping with the spirit of the principle of universal health care. The Department of Health of the Province of Nova Scotia must address this issue. Our campaign for fairness will not be silenced.

References: Nova Scotia Department of Health, "Nursing Home, Home for the Aged," March 2001; "Nova Scotia Designation of Residence," question and answers, May 2000; "Preliminary Research Report on Nursing Homes AcrossCanada," February 2001, Robin Stadnyk, Assistant Professor of The School of Occupation Therapy, Dalhousie University.

Ms Sharon Batt, Chair, Dalhousie University: Senators, the Elizabeth May Chair was set up several years ago to promote debate and ensure that research results become integrated into public policy and in areas of women's health and the environment. I am here today because environmental degradation threatens the country's health in ways that our health policies must urgently address.

I will comment, particularly, on the issues of disease prevention and population health strategies. Another key area in the committee's interim report that I will address is the need to shift resources from treatment to prevention.

Hardly a day goes by without a new story about health and the environment. I have pulled together a few examples from newspaper and radio reports in the past few months. On September 5th, the Director General of Health Canada's Product Safety Program warned that pharmaceutical drugs areaccumulating in Canada's water system in concentrations that could affect human health.

I will point out that there are a number of aspects of health and the environment that are gender related. When we cut budgets to the public health, a disproportionate number of those jobs are women's jobs, including public health nurses and general practitioners.Women are poorer than men, and unhealthyenvironments favour the disadvantaged.

Research shows that environmental pollution impairs women's health in particular ways. These include the contamination of breast milk with fat-soluble chemicals, chemicals in theenvironment that mimic the female hormone estrogen, hormone-disrupting chemicals for which there is no safe dose.

If the fetus is exposed at critical points in its development to even minuscule amounts of these chemicals, they can cause reproductive cancers, sterility, and genital abnormalities. It has also been found that girls in Canada, as in other countries, are entering puberty several years sooner than they used to and plasticizer chemicals in the environment are suspect.

These health threats are an urgent call for preventive health with the focus on environmental contaminants and their effects on health. The committee has noted with justifiable pride that Canada was a world leader in the 1970s and 1980s in developing disease prevention strategies. I believe environmental health is an area where Canada could once again take the lead, but the government would have to show courage in confronting industry interests. The federal vision in the past decade has been one of partnership with industry and industry is generally not receptive to regulatory controls.

One central policy for disease prevention that has emerged in the last decade is a precautionary principle that can be stated: When there is a reasonable suspicion of harm to health and the environment, lack of scientific certainty or consensus must not be used to postpone preventive action.

Canadian policies have shown ambivalence to the precautionary principle. This was seen in the revised Canadian Environmental Protection Act in 1999. The federal government diluted an initially strong statement of the precautionary principle after industry interventions led to last minute amendments. Also in the federal government's 1998 discussion paper on health protection, the paper embraced a different approach from the precautionary principle, which was the risk management approach.

The Americans introduced risk management as a policy tool for health and environmental decision making in 1983. Many observers, including the American science historian, Robert Proctor, have pointed out that the net effect has almost invariably been to stymie health and environmental regulations. In contrast to Canada and the United States, which have embraced this risk management approach, European regulatory decision makers have taken a different approach to health safety regulations. They show a lower tolerance for risk and they take into account the broad social impacts of technology. I believe that Canadians value social justice in our health strategies and that the European approach to risk assessment is more consistent with the way Canadians think about health than is the competitive American approach.

In the short term, reducing and eliminating the causes of disease might cost industry by requiring cleanup of toxic substances, changes to polluting technologies, and workplace measures to prevent accidents or exposure to agents that cause disease. In the long term, such steps promote sustainable development and may save industry money. They have finite costs, provide long-term health benefits to the entire population, and usually prevent a range of diseases, not just one.

The committee has suggested that public health must be given more resources if diseases are to be prevented. I agree. Much of the committee's enthusiasm, however, is directed to lifestyle changes and to genomics. I have some reservations about that.

One way for governments to avoid confronting industry and still seem to be promoting public health is to focus on lifestyles. We have seen this in Sydney, for example, which is the most contaminated toxic area in Canada, where the residents were told that their problem is that they smoke too much.

It is easier to get individuals to change their behaviours than to get corporations to do so. Women, who are strongly socialized to please others, are especially susceptible to messages exhorting them to work harder at being healthy. Corporations seem to have a curious immunity to messages exhorting them to clean up the company's polluting lifestyles.

Only government regulation and enforcement can address environmental problems that threaten our health. Research into cause and effect mechanisms certainly must continue but, in the meantime, we have to act on the weight of the evidence from multiple sources that show that our health is at risk.

As far as genomics go, the committee does express enthusiasm for advances in genetics and genomics. This is certainly a burgeoning area of research. The rhetoric about genomics is one part hope, one part hype, and one part science. I would suggest that a careful examination of the literature on genetic testing for breast cancer - and as I am, myself, someone who has been treated for breast cancer, I follow this literature very closely - would ground the genetic hyperbole in sobering reality.

Why do we imagine it will be so simple to alter our molecular machinery? Molecular genetics is very exciting but it does not have a very good track record in terms of disease prevention. We are putting so much faith in high tech science and this is not the way to get out of the messes we have created. Preventing disease before it starts, using the precautionary principle, is an old-fashioned and low-tech idea with very little sex appeal, but it works. Life on earth is killing us. We must change our ways, not our genes.

I have four modest proposals. The first echoes Georgia MacNeil's sentiment that the committee must find ways to break down the silos between health and the environment.

Second, Canada should invest in policy research on health and the environment, which would have as its goal finding ways to successfully apply the precautionary principle and track the results. Such research would have a strong gender component and a focus on other environmentally disadvantaged communities, including Aboriginal communities.

Third, the regulation of drugs, food, radiation equipment, and the Canadian environment should be revamped to occur through a system that is independent of industry.

Fourth, for every lifestyle and genomics initiative, I would propose that the government mandate a parallel environmental initiative based on the precautionary principle.

The Chairman: Ms Barrett, when did the law change in Nova Scotia, with respect to payment for nursing homes? Is that a new law? Has that system been in existence for a while? Do you know?

Ms Barrett: To be honest with you, I cannot find out how long this has been in place, but, if you mean the policy directive that is being used, it has been in place for at least a year.

The Chairman: Right.

Ms Barrett: Some of the caregivers I work with have been dealing with this for over a year.

The Chairman: Okay, but it is not 10 years old.

Ms Barrett: To be honest, I have no idea how long it has been in effect.

The Chairman: Ms Batt, this is a part of the health department we have never examined. There is a branch of Health Canada called the Health Protection Branch.

Ms Batt: Actually, it has changed its name.

The Chairman: Oh, has it? It has probably re-organized because they do that. What is it called now?

Ms Batt: It has been changed into different components.

The Chairman: The Health Protection Branch, as I understand it, examines the impact of various drugs on health. It does not link the environment and health. That is because the environment is not a drug. It is not considered. Is there a part of the Department of the Environment that examines what I would call the health effects of various environmental issues?

Ms Batt: That is certainly acknowledged in the 1998 discussion paper that was issued. The importance of environment was discussed.

The Chairman: I know that is talked about it, but - I hate to say this - was anything done about it? In other words, if you asked me where, in the federal government, to get information on the health impacts of a particular environmental problem, I would not know where that would be.

Ms Batt: Chemical contaminants and radiation are considered to be impacts on health.

The Chairman: Is there a separate part of the department that does that?

Ms Batt: Yes, there is a specific section for radiation and chemical contaminants.

The Chairman: Your Chair sort of bridges the health and the environment, which is where I am headed. Do you focus more on what I would call the health impact issues of the environment, or other way around? Is your driving variable our health issues? Is that right?

Ms Batt: Yes. One frustration is that these two areas have been politically and academically quite separate.

The Chairman: Right.

Ms Batt: One of the purposes of the Chair is to try to bring them together.

The Chairman: They are also, as you say, politically, in government organizational circles, quite different as well.

Ms Batt: Exactly.

Senator Cook: I saw a hand go up in the back of the room that might give you your answer.

Ms Anne-Marie Léger, Policy Analyst, Health Canada: I just want to clarify. I work with Health Canada. The Health Protection Branch was re-organized. It has two components: Health Protection and Food Branch as well as HealthyEnvironment and Consumer Safety Branch. Under Healthy Environment and Consumer Safety Branch, it does, in fact, address those very issues of the connection between healthy environment or non-healthy environment and health outcome.

The Chairman: That is very helpful. Did this just happen in the last few months?

Ms Leger: Actually, I am fairly new to the department, but I know that it has been in place for some time.

The Chairman: How long has it been in place?

Ms Leger: It has been about a year-and-a-half.

Senator LeBreton: My sister is in Treasury Board now, but she was in Health Canada and was working in the specific area when they made these changes. It has been about two-and-a-half years.

I have a question for Sharon Batt. I think it is rather appropriate because I know Elizabeth May, and she is certainly a pioneer in moving environmental issues where they belong. Years ago when we thought of the environment, we thought of trees. Issues like Walkerton absolutely underline that environment is a health issue. We cannot separate health and the environment.

You gave examples of news stories. There was another one in the news over the last few days about all of the antibiotics that are given to chickens, pigs, and cattle to prevent illness. Those antibiotics are coming into our systems too, which probably is one of the reasons that I am not eating much meat lately.

In any event, I have a question specifically for you, Sharon. I do not know whether you are able to do it from your position at Dalhousie, but are you connected to other like organizations across the country so that there is uniformity in raising the level of the environmental health issues across the country? How do you see that happening and being properly funded or properly administered through Canada's health care system?

Ms Batt: I actually work with a group called The Working Group on Women and Health Protection, which does get funding from the Women's Health Bureau in Health Canada. That is a national organization of activists, academics in policy, people who are concerned about health protection, which certainly includes the environment. I do not know if that answers part of your question. It is a very small organization with not a lot of funding.

Funding is very difficult when you are examining environmental issues if you do not want to take money from industry, and all the organizations that work with the Working Group on Women and Health Protection do not want to take funding from industry. This is the dilemma if you want to do research, which is very costly.

Senator LeBreton: Is the focus of your research more on the preventive side and educating the public, thereby impacting the system at the early stages rather than preventing the illnesses as much as possible and rather than trying to deal with people who are already ill?

Ms Batt: Exactly. The focus is on trying to eradicate the causes of environmental degradation. I should say the Elizabeth May Chair has been set up to work very much in an interdisciplinary way with other researchers and policy people and community groups in the community.

Senator LeBreton: Ms Barrett, you gave some very compelling testimony about unpaid labour, mostly women -

Ms Barrett: Mostly women.

Senator LeBreton: - caregivers. You talked about long hours, emotional challenges, vastly undervalued service and loss of identity. I know this happens a lot.

Ms Barrett: This can happen.

Senator LeBreton: As the Chair mentioned, you were specifically dealing with Nova Scotia. Have you worked with other groups? We find in our studies, not only on this particular homecare issue, that there seems to be a complete lack of uniformity or even co-operation from one jurisdiction to another. Are you connected, or do you have any support from other jurisdictions or any knowledge of other jurisdictions?

Ms Barrett: No. We are a little group of caregivers that has been meeting for seven years. Membership fluctuates around 12 but people change over the years. Half of those caregivers found themselves dealing with a nursing home. We examined the situation and we considered how we could approach our government. We thought the situation was unfair. We decided that the only way to do that was to get a research project.

We have no funding and this work is being done by a group of tired, worn-out caregivers. We were instrumental in getting Robin Stadnyk of Dalhousie to do this research. We have not been working with anyone else.

I read "Admission to Nursing Homes: Nova Scotia and Beyond." After we saw that research project four or five caregivers came to my house and we put a little article together, which we sent to 35 organizations across this province, including the Department of Health and the health critics. We heard nothing back from the Department of Health. We turned to our MLA in the area and he, in turn, got a little bit of exposure for us.

We have not been networking with other groups. We are just a small group of concerned citizens in rural Nova Scotia who feel it is unfair that the rest of Canada pays room and board and we are asked to pay for everything.

Just let me tell you of a situation. One of my caregivers has a 97-year old mother in a nursing home at $55,000 a year. Her father is 94 living at home and he is not at all well. If he enters the nursing home, the cost would be $110,000 for her mother and father. There is something wrong with this picture.

Senator LeBreton: Yes. The picture you paint would totally discourage anyone from saving any money at all. People would say, "Why bother?"

Ms Barrett: People with no money get good care in nursing homes. I have no problem with that. The group of caregivers I work with are more than willing to pay their share, which they consider to be room and board. The health care component falls under provincial jurisdiction and that is why it varies across the country. I do not know how we can stir for change in Nova Scotia and the Atlantic Provinces.

As I pointed out in this article, Newfoundland was able to cap costs at $2,900 a month. This year Newfoundland was able to put three-quarters of a million dollars into a fund for the sole purpose of assisting caregivers so that they would not have to drop their standard of living drastically when their spouses entered nursing homes. This seems fair and just.

Senator LeBreton: That is one thing. When we consider the whole homecare issue there is a lack of uniformity from one province to the other.

I have one last question for Georgia MacNeil. I was particularly interested in your comments about health care services being culturally appropriate, geographically accessible and in the language of preference. One cannot argue with that. Of course, we get into these issues in the province that I am from, Ontario. When you state that some people have difficulty, I am thinking that is culturally. Is this always feasible, though? We are a multi-cultural, multilingual country so that would be ideal, but what would be realistic? Where would you start in terms of dealing with people at the low end of the economic scale and how do you get a system to respond to their cultural needs, given this diverse country that we live in?

Ms MacNeil: I can give you an example from the Sandy Hill Community Health Centre in Ottawa. I worked there on a project in 1992. As you know, there are a lot of immigrants and refugees in the Ottawa-Carlton region.

Senator LeBreton: Yes.

Ms MacNeil: The Sandy Hill area had quite a number of Somali refugees in its community health catchment area and, in fact, they changed the signage at the centre to be English, French, and Somali because there were so many Somali clients that it was considered a necessity.

The community came together and worked with health promoters at the centre. It developed a health resource for practitioners that was quite widely disseminated. It developed a pool of cultural interpreters who could be called upon to attend medical appointments with people needing cultural interpretation. The cultural interpreters were paid a fee for service for the time they were used. It was not an expensive service because they were not kept on salary all the time. They were called upon when needed and given an honorarium and travel expenses to assist the client. That worked quite well. I have not been in Ottawa since 1993, so I do not know how this has progressed, but that seemed to be a very cost effective and appropriate way to meet the need of that community.

Senator LeBreton: Could you envision a resources problem in trying to find translators for people who have to be rushed to emergency? It becomes cumbersome. I am trying to figure out a way that could work, which would be feasible.

Ms MacNeil: At the same time this was going on at the health centre, the major hospitals in Ottawa also had listings of staff who could speak different languages and they were often called upon, as part of their jobs, to stop serving at the cafeteria and attend Mrs. Smith or whoever to provide assistance. That helps to address the problem in a cost effective way. The quality of the cultural interpretation might be questioned, but I think there are low cost ways to do that. That is very complex when you get into multiple language groups and multiple cultural groups. The larger cities, where the bulk of these people are likely to be, have more resources. I hate to say the "volunteer" word, and I think even if people are called upon as volunteers, they should be given honoraria to support travel and childcare and things like that. That would be one option to address language issues.

Senator Callbeck: Ms Barrett, I have a couple of questions on the nursing home program in Nova Scotia. You say there are different rates of pay for people. Do the people who pay100 per cent pay more than if the government -

Ms Barrett: No, I said for people who pay the full cost privately, above and beyond the $55,000 a year, there are other costs. That includes medication, wheelchairs and ambulance service to a hospital. You, as the spouse, have to pay for those costs. That is what I meant when I said costs above and beyond.

Senator Callbeck: Okay. When you say all applicants go to one place, is that within the region? Is that anyone who is applying for a nursing home?

Ms Barrett: Is that under Single Entry Access?

Senator Callbeck: Yes.

Ms Barrett: That just came into play in May of this year. My understanding of the purpose behind the Single Entry Access is that normally you might have half a dozen phone calls trying to get assistance, whether for home care or a nursing home. Now with the Single Entry Access, you would make one call and all your concerns are to be dealt with, whether that involves respite or nursing homes.

Senator Callbeck: That is not for the province, though. That is just for the region.

Ms Barrett: No, that is the province.

Senator Callbeck: It is.

Ms Barrett: That is in the province of Nova Scotia. It is called Single Entry Access. Actually, in May or June there were presentations around the province. I heard the presentation both in Digby and in Yarmouth.

The questions that came from the audience were disconcerting: "What happens to me financially when someone enters a nursing home?" That seemed to be the biggest question. This was put in place in April of this year and it is called Single Entry Access.

Senator Callbeck: That was put in place, but the rest of the system that you explained has been in place for a while.

Ms Barrett: The rest of the information I gave you came from the Nova Scotia Department of Health: "Nursing Homes and Homes for the Aged." There was a document put out for designating your residence. The purpose for doing that is to prove that you have lived in your home for two years. You sign that and have it witnessed. People are told that protects them from having their homes taken for cost of care. The moment you sell or rent that house, the money goes toward your care.

In my case, as a widow, if I enter the nursing home, and I have designated my home, it is protected. I would be told, "We are not going to take your home." But I am in nursing home and I cannot look after the house, so I sell it. The money goes toward my care.

If I am the spouse staying at home and I sell it because I am living on half of my husband's pension, which might be $10,000 or $12,000 a year, and I cannot maintain that home, half of the money goes toward his care. What I find unjust is that you can transfer this designated home to anyone, a family member or anyone. The person who then has the title in his or her name can sell the house and keep the money. You say, "I worked long and hard to obtain that designated home and now I have to part with it." I consider this a real concern.

Senator Callbeck: Yes. That certainly is very inconsistent across Canada.

Ms Barrett: It is certainly not consistent. It is only in the Maritime provinces that income and assets are considered, as I said in the article. In most other provinces, it is just your income that is considered and you only pay for room and board. The provincial government picks up the health care component.

The Chairman: Quebec considers both assets and income.

Ms Barrett:I am not sure about that, to be honest.

The Chairman: My mother is in a nursing home in Quebec, so I know that.

Ms Barrett: Are both considered?

Senator Callbeck: Ms MacNeil, you gave an example of people who were waiting one year for physiotherapy. That seems like an awfully long time.

Ms MacNeil: It certainly does.

Senator Callbeck: Would that be in a city?

Ms MacNeil: That was in the Halifax Regional Municipality. I know of people who have gotten access in some of the smaller municipalities to physiotherapy care at the hospital which was covered by Medical Services Insurance plan, MSI. That was a shorter waiting list. In Halifax you can forget it. The doctor just said, "You are going to pay for it or you are going to have to wait an awful long time." The woman waited a year. That is outrageous.

The Chairman: I thank all of you for coming. We appreciate your taking the time to be with us.

Senators, our next panel consists of John Malcom, CEO of the Cape Breton Regional Health Care Complex, and Dr. Mahmood Naqvi, Medical Director; Dr. John Ruedy who is Vice-President, Academic Affairs, for the Capital District Health Authority, which is the Halifax Regional Health Authority; and Thomas Rathwell, Director of the School of Public Services Administration of Dalhousie University.

May I thank all of you for coming. I will begin with Dr. John Ruedy, Vice-President, Academic Affairs, for the Capital District Health Authority.

You have all circulated briefs and I want to make sure we stay on time. The Canadian Medical Association, CMA, will follow you and those people have a plane to catch, so I want to make sure we have time for lots of questions. Can I ask you to briefly summarize your main points? We have read some briefs and can read the others. Then we will turn to questions.

Dr. John Ruedy, Vice-President, Academic Affairs, Capital District Health Authority: Honourable senators, it is an honour to be asked to address you. I am sorry Maura Davies could not be here.

The brief that I have submitted was developed by a number of senior executives of the Capital District Health Authority. I will speak to it briefly, but you will recognize that I will speak from my bias, which is 50 years of learning and working in Canada's health care system.

The Chairman: I should tell my colleagues, by the way, that Dr. Ruedy is the former Dean of Medicine at Dalhousie.

Dr. Ruedy: I was going to take credit for having worked as a practitioner of medicine before medicare was introduced and I remain an extraordinarily strong supporter of Canada's medicare system.

Let me just briefly tell you that Capital District Health Authority is the District of Halifax and a surrounding region of about 400,000 people. We provide primary and secondary care services for that district. We also provide tertiary care services to the rest of Nova Scotia, not exclusively but predominantly, as well as some to New Brunswick, Prince Edward Island, and Newfoundland. We are also an academic health district. We are the major clinical resource for university-based programs in medicine, health professions, and allied health sciences.

I would like to quickly highlight four items that are addressed in the report, which I think are very critical issues. The first is health human resources. There is no question that this is the largest issue that we face in the Capital District Health Authority. We are severely short of almost every kind of health professional.

We have 175 vacancies in nursing that we cannot fill at the present time. Those are in areas of heavy nursing responsibilities - critical care, in particular. We have been unable to retain and recruit transplant surgeons in the last year, so we have lost a very successful liver transplantation program. I could go on.

It is interesting, this week we had an accreditation survey and there were two Irish observers of this process. They reported exactly the same thing in Ireland. In one of the hospitals, they were dependent upon 200 Indonesian nurses to provide adequate nursing services. The entire cleaning staff was Latvian and could not speak English. This is a universal, worldwide problem and it will get worse, so we are strongly in support of developing a national strategy in health human resources.

This is more than numbers. You must address functions of health care providers or you will come to the wrong conclusions. You may want to address who should take on this responsibility. In the past, the self-interests of the institutions represented around the table influenced health human resource planning. I would suggest the universities and faculties of health professions and medicine may be the resource to which we should turn to provide us a not self-interested national strategy in health human resources.

We must learn how to optimize what we have. We greatly support Duncan Sinclair's statement, which is quoted in your report, that we are misusing highly-skilled health professional personnel. Physicians are doing things that physicians need not do. Nurses are doing things nurses need not do, et cetera.

A related issue is a healthy workplace. We have the second highest absenteeism in a health institution in Canada in the Capital District Health Authority of almost 7 per cent absenteeism. That is unacceptable. We know that stress is a major contributor to this. Twenty-eight per cent of absenteeism is related to stress. I could go on. We need a healthy workplace strategy. We need research into understanding the causes and cures for a healthy workplace because that contributes to our shortage of health human resource personnel.

The third issue is primary care reform. No matter where you go in the world and no matter what they ask you to address in their recognized needs, it comes down to a need for efficient primary care. I am talking about more than physician primary care. I am talking about primary care generically, and the infrastructure for primary care.

Unfortunately, the physician primary care system in this country has developed, based on a fee-for-service remuneration, with no recognition of the need for infrastructure to devolve functions of the physician that could be just as well if not better carried on by other personnel. The focus on primary care reform should not be focused on the physician. It should not be focused on remuneration. It should be focused on the infrastructure and the functions that should be fulfilled by a primary care system.

My fourth and last point is accountability. There is no doubt that much of what we have changed, what we have introduced, has been done without evidence that has benefited or risked the health outcomes of our patients. We need an accountable system. To have an accountable system, we need a useable health information system, which we do not have. We need a patient-set standard health information system of electronic record, if you like.

Let me give you an example of how archaic our system is. When you go to a physician and he or she decides you need a prescription, the physician takes a pad of paper, writes your name, address, the date, the name of the drug, the amount of drug and the directions manually and gives that to you. You may or may not take that piece of paper to a pharmacy. It may or may not be the same pharmacy you visited previously.

The pharmacy then puts the information into the computer, prints out a label, counts out pills, puts them in a bottle, puts the label on and gives you the bottle. There is no report back to the physician letting the physician know that the prescription has or has not been filled.

When you come back to the office, the physician will ask you what medicines you are on. If you are smart, you will bring a list and hand it to him. That is a completely archaic "non-system" and it is representative of the lack of a patient-centred health care worker information system that we need to deliver good care, to have an accountable system work and address issues as to whether we are benefiting our patients or not.

Those are the four issues that I call to your attention in the brief that I have presented: health human resource needs, healthy workplace needs for our health professionals, primary care reform, and an accountability in our system which is dependent upon a patient-centred health information record.

Mr. John Malcom, Chief Executive Officer, Cape Breton Regional Health Care Complex: Senators, I would also like to commend you on your report. In 20 years of working in health care, it is probably the best and most rational discussion that I have seen of the challenges we face.

I also have four points. The first point I will make follows up on a comment that was made by one of the former speakers. You must stick with your existing funding system, but correct it. A system that provides a straight per capita base funding on a cash allowance across Canada is not just. Whenever I speak to public groups in Cape Breton, I ask, "How many of you know someone who has moved to Alberta?" Virtually every hand goes up. When I ask them how many know grandparents or seniors who have moved to Alberta, every hand goes down. Yet, the straight per capita funding pays Alberta, through the federal treasury, the same amount of money to deliver care to people who do not use the health system as it pays to us in Nova Scotia.

In fact, there is evidence to suggest that Nova Scotia is the province of most rapidly aging. If the funding formula is not changed, we will be the first province to have our health system fail if there is not consideration of age and burden of illness in the allocation of resources. The present funding system is unjust. It is unfair. It is inequitable. It rewards the young and the healthy at the expense of the old and the infirm. If nothing else, if you could make that recommendation, you have a chance of sustaining our system.

The second concern I will discuss is the issue of best practice. In Canada we can do more in the way of learning how to do things better. I support the comments that Dr. Ruedy made earlier. We actually lead a national benchmarking best practicearrangement in Cape Breton that involves facilities from Vancouver to Newfoundland.

In one particular area, by giving up the right to purchase, we now belong to a national group purchasing initiative, and, learning from people across the country, we were able to add a second CT scanner in Cape Breton without asking the province for one cent of operations to run that unit. We found the full cost savings through group purchasing and improved performance possible by knowing what others are doing. That was a good deal for the province, but it was a better deal for the people we serve because we went from having the worst waiting lists in the province to the best.

The third thing that I would like to talk about is determinants of health. I have always practised in urban centres until I went to Cape Breton. I used to know, in a theoretical sense, what the determinants of health were. Now I know it from a real sense because I live it every day, as Dr. Naqvi does. The challenges of working in the area with the highest overall premature mortality rate is evident to us every day as we work and do what we have to do.

You must consider the needs of rural Canada. When Dr. Ruedy was dean, his department approached us about the idea of establishing a rural family medicine program. We jumped at that - to the point that we found all of the costs to operate the program locally. The university found the cost for the residents. We do a rural practice program where people go to rural communities. If you have been around the Cabot Trail, you have been into the hospitals where doctors practice as part of their rural family residency program.

We have no vacancies in any of the communities around the Cabot Trail and, in fact, we have one community where we appear to have one physician who wants to come more than what we need next year. If you expose people to the opportunity of rural practice, they will choose rural practice just as I choose to live in rural Canada and not return to urban Canada.

The other thing that we must consider is what the impact might be if the proponents for a private health care system are successful in that approach. That will most negatively impact areas of the country that have less resources, like Cape Breton or areas that are rural, because you will give added opportunity for people to follow the money - and the money is located in the major urban centres - thereby further disadvantaging rural Canada or the parts of Canada that have less income.

The final thing I want to mention very briefly is that we have to examine what it costs to run the system. Canadians do take their system for granted, without any consideration of the cost. Some time ago, I flew back from Halifax on a plane with an American who was travelling to Newfoundland. He was 40 years old. He told me very frankly that he paid $250 a month for health insurance. He was single. He would not use the system significantly based on what I know about the average 40-year old with a $5000-a-year deductible.

Canadians have no idea of the value they get in the health system. If you are going to examine how to raise additional money to support a system that is under great stress, I ask that you consider things like targeting health sciences technology, HST, revenue so that people know what their tax dollar is going for and understand that there is a cost to the system, or possibly examining the taxable benefit of our system.

Concerning Single Entry Access, we are the pilot area for the province. That is a best practice. We have reduced our waiting list for nursing homes from 300 to 50. The financial assessment piece has not changed. That has been around for 20 years. It has become much more evident.

Is it at all surprising that the provinces that have the lowest proportion of people covered by a pharmacare program and also the provinces that require the greatest contribution to long-term care are the provinces with the most elderly part of the population, the poorest economic situations and the biggest burden of illness? These provinces receive, I would remind you, the same amount of money that their grandchildren get when they move to Alberta not to use the system.

Dr. Mahmood Naqvi, Medical Director, Cape Breton Regional Facility, Cape Breton Regional Health CareComplex: Mr. Chairman, I would like to congratulate you and your committee for the excellent work that has been done so far.

Before I arrived, I did not know that Dr. Ruedy was going to make a presentation and, also, Mr. Malcom did not share his presentation with me. Because Dr. Ruedy and Mr. Malcom have already outlined most of the issues, I will just read the summary of my presentation. The opinions I express do not reflect my organization.

The most important issues facing health care today are human resources, aging technology, health care reform, and escalating drug costs. Our senior population is increasing rapidly and within the next ten years it will double. Our health care needs will be more taxed by the increased demand on health care resources by senior Canadians. We must consider the future and seriously address the issue of future health care funding.

In order to sustain the present level of health care with improved infrastructure and technology and bring health care reform for the 21st century, additional financing will be required. This should be addressed by the federal government by increasing the federal share in health care funding and other various approaches have been addressed to supplement the funding.

Options have weaknesses and strengths, but the simplest option would be a user pay service or co-payment, which will at least address overutilization and reduce the funding gap. Other issues require further exploration by appropriate professionals to determine how best additional funds could be obtained to maintain the services.

In order to reduce the long wait time in the emergency room and for diagnostic services and surgical procedures, there is an urgent need to upgrade the infrastructure, replace the old technology and develop newer technology and address the human resource issue of physician and nurses and other allied personnel such as nurse practitioners, midwifes, et cetera.

Primary health care reform is the top priority for providing an alternate means of health care delivery including health promotion, disease prevention, disease maintenance and, also, to involve non-physician personnel in the delivery of health care. The primary health care centres also should be able to staff psychologists, social workers and laboratory services to avoid unnecessary long lines in the hospital setting.

Primary health care centres must be provided with the tools of technology such as computerization of practice, electronic records, computer linkage, Internet linkage, and the telehealth consultation facilities. A system of accountability for primary health care centres should be developed and there should be a mechanism for rewarding physicians who provide the best and most appropriate evidence-based medicine.A system of alternative payment for these primary health centres should be mandatory and a fee-for-service system should be eliminated in these centres.

As Canada continues to have a shortage of physicians and nurses, it will be extremely difficult to have these centres operational unless efforts are made to increase the involvement of students in medical schools and nursing schools.

The national pharmacare program and the homecare program should remain under the jurisdiction of the provincial government; however, additional drug formularies should be collaborative with the provinces.

The health of Aboriginal Canadians should be integrated between federal, provincial, territorial and municipal levels of government. A comprehensive plan should be developed to include training of Aboriginal people in the provision of the health care. Services should be culturally appropriate to the population.

Finally, federal and provincial levels of government must stop blaming each other for the ills of the health care service delivery. They should make a co-operative, rational effort to address serious problems such as human resources, long waiting lists and lineups at the emergency room. This will only come about when the funding of health care is equally shared at the federal and provincial levels on a 50:50 basis. Additional funds may have to be secured through co-payment.

Finally, I would like to thank the committee for sharing this document with us. I hope some of suggestions that I have outlined will be of value in developing your final draft.

Dr. Thomas Rathwell, Professor and Director, Faculty of Health Professions, School of Health Services Administration, Dalhousie University: I would like to thank the committee for the opportunity to address you this afternoon.

Like my colleague, I found the fourth report, "Issues and Options," an extremely thoughtful document that covered the main issues. I have a slightly different interpretation of the relevance of some issues, but maybe that is a discussion we can get into.

I will confine my remarks to four points relating to the report.

Concerning the comment in the report about efficiency and effectiveness, you argue that there two schools, one of which argued that we have enough funding within this system and that it is just a matter of how we use it and that, if we were a bit more imaginative in the way we delivered care, we could have savings and use those savings to fund other aspects of health care.

The other side was that with better management we could do more with what we have. In essence, it is not really one school or the other, it is, in fact, both. Both schools are tenable, as outlined in your report. What really is lacking, both at the federal and the provincial level, is a coherent strategy for the health care system.

The system seems to be driven primarily by political considerations. That is not to say that political considerations are not important. However, that seems to be the sole strategy in making decisions about regionalization within this province and elsewhere. Decisions were made primarily on political grounds, not with any coherent and thoughtful consideration of the evidence about the effects of regionalization.

Your report comments about value of co-payments or user fees, in the jargon. You rightly point out that where these apply in most jurisdictions, particularly within Europe, that the funds raised through co-payments just about cover the cost of administering the system with all the various exemptions and everything that are built into it.

You comment about how important these seem to have been in Sweden in deterring inappropriate use of the system. The evidence that I have seen suggests that, in a sense, user fees deter but they do not deter effectively. In other words, you really would like to affect behaviour of certain people, but their behaviour is not necessarily affected by user fees.

User fees disproportionately affect those at the lower end of the economic spectrum regardless of whether or not there are exemptions built into the system. I am just adding a caution about the value of user fees. If they are to be introduced as a result of public discussion, then, in my view, it is a political decision to do that. It is not an economic decision and should not be considered as such.

The other major point in your report concerns the value of private medical insurance. You, quite rightly, point out that there are two perspectives of the value. One says it is valuable and will bring certain benefits. The other side of the argument is that it will not and that it has some negative effects.

From my experience with the public-private links in health care and a number of European citizens, there are clear issues that arise. There is an inconsistency in your report. There are some very interesting aspects of the private medical component of European health care systems that are well worth considering.

In the Netherlands, the structure of the system is that if your income exceeds a certain threshold, you are compulsorily opted out. In other words, you are no longer part of the social insurance system. You then have to take out private medical insurance. The interesting aspect of that, in the Netherlands, is whether you are part of the social insurance system or whether you have private medical insurance, there is no distinction in the level and type of treatment you receive. That underlines an important component within many European health care systems: concern about core principles of equity and solidarity - or, as we would call it here, universality - and that anything that is done does not undermine those core principles.

Interestingly, in Germany there is also a threshold at which you have the choice to voluntarily opt out of the public social insurance system. Only 10 per cent of the people in Germany have private health insurance, so, of about the 30 per cent or so who might be eligible in the total population, a relatively small proportion choose to pursue that option.

In Germany, if you choose to opt out, in other words if you choose not to participate in the public system, then you stay out. You cannot decide a year later or two years later that maybe you made a mistake when, all of a sudden, your private premiums have gone up because you have a chronic illness or whatever. You have to stay out. That is a legal requirement.

That brings me then to my final comment, which I will make briefly, and that is on the central role for regulation in any mixed health care system. In most European systems, there are very detailed regulations in place that govern both the public and private components of the system. If the policy decision is that there should be an increased role for private medical insurance within the Canadian health care system, then it is important to do a number of things.

It is important to regulate strategically, to think through what are the regulations we must have in place and when we must have them in place. The consensus from many European systems is that the regulation should precede change, not follow it. It is also important to be very clear that the regulations are tailored to policy and system objectives.

Last, it is not just a matter of having regulations. Once they are in place, it is important to follow the axiom of "trust but verify." In other words, once the regulations are placed, you trust the organizations involved to actually adhere to those regulations but not to the extent that you do not verify that they do.

The Chairman: Dr. Ruedy, is your health links project unique? You talk about it as a consumer-based information program, and it is a pilot project funded in part by the federal government. Is that a set of software and programs unique to your health region or is this sort of a roll-out of a national program?

Dr. Ruedy: It is a roll-out of a national program.

The Chairman: The health links program is national. Is this being pilot tested in several places?

Dr. Ruedy: Yes.

The Chairman: Do you know if it is being tested anywhere else in the region besides here?

Dr. Ruedy: I am unsure of that. John, do you know? I do not think so.

The Chairman: Mr. Malcom, can I ask you a question that came up in an earlier set of hearings? The issue was put to us in the following way: A lot of the federal government pilot projects require matching funding from the province and it was suggested to us that automatically meant that most pilot projects would only take place in richer provinces because the smaller provinces were having enough trouble finding money for the health care system and they could not afford extra money for pilot projects in, for example, Cape Breton. Does that coincide with your own experience? Do you think that is true, or is that not quite accurate?

Mr. Malcom: It is partially true. If you are committed, you will find the resources.

The Chairman: Yes.

Mr. Malcom: We were the first district in the province to commit to population health. We have a Director of Population Health and Research. That is it. We do not have the resources. We have "one offs." There is no question that, in an economically depressed area, we cannot raise the same amount of money through fundraising for equipment. We do not have the ability to match moneys that might come along or necessarily even the money to prepare the proposals in the first instance.

The Chairman: Right.

Mr. Malcom: We are too busy delivering care.

The Chairman: Yet, in some respects, it is the least advantaged regions that most need help.

Mr. Malcom: Yes, and, as I believe I have made the point, the system has to recognize that the problems are not shared equally across the country and, hopefully, the federal government will help to level that a bit.

The Chairman: Can I ask all of you one question? You may not have any information, but the committee has been seeking this information. One of the tragic things about the Atlantic provinces is the fact that, on average, there is 25 per cent of the population without any kind of a drug plan. That is a statistical fact. I guess I am trying to translate that statistical fact into real human consequences.

Have you, in the course of your own dealings with patients, run into cases, for example, where someone is given a prescription by a doctor but cannot afford to fill it or they are seniors at very low incomes with the problem of whether to pay the rent, buy the drugs, or pay for food and so on? I would like to try to put a human face on that problem and get some sense of its magnitude. That is open to the panel if anybody has any comment.

Dr. Naqvi: This is a good issue for your committee to study. As far as we are concerned, we do not have that situation. We are providing drugs to long-term mental health patients through the hospitals because these people do not have insurance otherwise. This is something for your committee to examine to determine if this is true. We do not have any situation where people cannot afford to buy drugs. If there were such a situation, somehow drugs would be provided through the hospitals.

The Chairman: Dr. Ruedy, is that your experience in Halifax, as well?

Dr. Ruedy: I am too far away from that to be able to answer the question.

The Chairman: It is not your area.

Mr. Malcom: Maybe if I could answer that from practical experience. We charge $1 a day to park at our regional hospital.

The Chairman: Sorry, was that $1 a day to park?

Mr. Malcom: Yes, we charge $1 a day to park.

The Chairman: Okay.

Mr. Malcom: In Cape Breton there is still a fight over $1 a day in to park.

The Chairman: Do you realize that gets you roughly 30 seconds in downtown Toronto?

Mr. Malcom: Right, I know. I have lived in urban Ontario, but I am giving you a perspective. I was standing in line at the cafeteria and the lady in front of me bought a bagel and she was scraping her last pennies to pay for that bagel. There are poor people in our area. I could not help wonder how she paid to get out of the parking lot if she had parked her car there.

Do we have the numbers of people who cut their prescriptions, or do not take the full prescriptions, or extend the prescriptions, or have prescriptions lapse because they run out of drugs before the next cheque comes? No, we do not, but I can say that there is a difference, having worked in Ottawa, Saskatoon, Montreal, and Cape Breton, and that has to do with the level of income.

This province has the lowest disability-free life expectancy of any province or area in the country. That was reported in Maclean's last week. I was talking to the Assistant Deputy Minister of Finance this past week and asked him a question on tax revenue. He told me that we have the highest proportion of people in any province in the lowest tax bracket. Those two statistics go together.

The Chairman: That is scary stuff.

Senator Robertson: Dr. Ruedy, I understand that you have or have had an association with the medical school here.

Dr. Ruedy: Yes, I was Dean of the medical school.

Senator Robertson: As a former Dean of the medical school, you probably have kept up with its activities, if you do not have an official capacity there now. I want to read a statement that Dr. Haddad, President of the Canadian Medical Association, made to us on May the 16th in connection with Health Human Resources.

I shall just extract one section here. He said that something must be done about medical education, that tuition deregulation has meant that tuition for students is becoming prohibitive and 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 in Canada.

I would add my own comment to that. We probably would not be getting the best brains. Can you comment on Dr. Haddad's concern?

Dr. Ruedy: I entirely agree with Dr. Haddad. In fact, there was a published study from the University of Western Ontario that followed the significant increase in tuition in the medical school, in which it was demonstrated that application and acceptance to the University of Western Ontario Medical School were more skewed to the well-to-do than they had been previously.

We have had an unbelievably difficult problem in this province in attracting our Aboriginal, Mi'kmaq and Black sons and daughters into medical school. Part of that has been that high school, home and peer environments make it appear beyond expectation that these individuals could ever afford to go to medical school. It is not that they do not have the brains, it is just economically beyond them. This has been seriously augmented by the very large increases in tuition that have occurred over the last five years.

Senator Robertson: That is very unfortunate. That might be a role where the federal government could be directly involved in the provinces through the medical schools.

Perhaps it was Dr. Ruedy who spoke about the need for our professionals in the health system to better utilize their time, and that there are things that doctors are doing that nurses could do and things nurses do that could be done by nursing assistants, et cetera.

We have heard, right across the country, that people are almost clutching to their traditional roles, at great expense and waste of the taxpayers' dollar. Can you give us advice as to how we could perhaps help the government to break down those barriers between the professions and have better sharing? It is a worry. Would anyone care to answer?

Dr. Ruedy: I disagree that the only factor is professions hanging onto their turfs. In fact, I do not think that is a major issue. I think the issue is that because of unionization of our workers, it is difficult to transfer tasks.

In primary care, there is nobody to transfer those tasks to because the primary care physician is working alone in the office, or perhaps with a secretary who may have had some professional training. There is not the infrastructure in human resources so that the primary care physician can delegate tasks.

What must be addressed is the human infrastructure resources rather than breaking down of professional turf. Physicians have enough physician things to do to keep them fully occupied.

Dr. Naqvi: The situation of integration, as I said in my brief, is that we do require people like nurse practitioners and midwifes. There is no problem for midwives to be part of the obstetrical program in the hospital. The issues remain the same: You cannot get these people into the workforce until you have infrastructure for them.

I do not know if there is a school of nursing or a school of nurse practitioners in Nova Scotia at the present time. They will have to go to Ontario for training unless something is started here. It is not available.

Dr. Rathwell: You do not have to go to Ontario to become a nurse practitioner in this province. The Faculty of Health Professions and the School of Nursing have a program for nurse practitioners and just graduated their first two recipients of that degree this year, one of which was an Aboriginal student who will work as the sole medical provider in her community in Newfoundland. We are progressing in making important professional changes within the province and within the region.

Mr. Malcom: I would support the comment. There is willingness within the health professionals to examine the issue. I will mention a very practical thing. I am not sure that everybody wants to always assume the higher task and the more demanding task. Right now in our system, as has been referenced, there are a lot of vacancies. The system is under a great deal of stress. It does not matter if you are a physician or a nurse.

Some of the tasks that you might be able to transfer to the nurse or the Licensed Practical Nurse, LPN, are very rewarding and not that taxing. The idea of giving up simple stuff that is rewarding in order to take on more complex stuff that is harder to do is a hard sell in some instances, but there is a willingness to examine these options.

Senator Robertson: That is encouraging and that perhaps is different testimony from what we have received. I found it very interesting. I guess what you are telling us, gentlemen, is that we should examine methodologies that would encourageinfrastructure changes in delivery rather than examiningprofessions.

Senator LeBreton: Dr. Ruedy, you spoke about your pilot project and you used the example of filling out a prescription. This is something that we have run into all across the country.

We talk about, for the lack of a better term, "health smart cards." When we were in Ontario, we heard a physician who advocated that if these medical smart cards were prepared on individuals, they should be held by physicians. Other people argued that smart cards should be held by the patient. Do you think the time for this has come? My colleague, Dr. Keon, described it almost like a dog tag in the U.S. Army. You control the information that is on your card. You control it, so you control the privacy access to it. However, if there is information that you want shared, you have control over that, as well.

It impacts on accountability because many people do not realize what is expended on their behalf in the health care system. Do you think that we will ever get to a health smart card or something along that line that would also address the issue ofoverprescription of medications?

Dr. Ruedy: I do not have a dog, but I understand from my secretary who does have a dog, that her dog has a health smart card. Everything is on that card. The technology is there and there are ways of controlling access. I personally think the patient should be the owner of all the information.

Senator LeBreton: So do I.

Dr. Ruedy: Access to parts of that information can be controlled so that the patient's physician can have access to some or all of the information. The pharmacist can have access to the relevant information. The technology is there. We must get to that level of information if we are going to make any move forward in being able to assess the health outcomes of what we do.

Senator LeBreton: Personally, I would not object, if I were to collapse in the street, to someone feeding my card into a computer to figure out what kind of a medical condition I had. I do not understand why people are concerned about it.

On issue of misusing resources, of doctors and nurses doing things they need not do, Mr. Malcom, you talked about nice tasks that you might be reluctant to give up.

We had primary care doctors in British Columbia who spoke about rural and remote areas. There seems to be some politics on this in the medical profession. I would like you to address the notion of having a primary care physician responsible for developing levels of services in the community in order to have some assistance. They were talking about burnout and a gap between doctors in their 50s and 60s and new doctors coming in. Many coming in are young women, who have different quality of life issues.

How would you feel about the primary care system, especially in rural and remote communities, being managed by a primary care physician who is plugged in to nurse practitioners?

Dr. Naqvi: In my brief I suggested that the time has come where this family physician model should be considered, in light of what is happening. If husband and wife are doctors working in the same community and want to be off at 5 p.m. and not to work every night, the emergency rooms may be loaded with patients because doctors record telephone messages directing patients to the emergency room. The concept of the walk-in clinic is one that has come up.

We established a couple of walk-in clinics on Cape Breton Island. We had some flak from the doctors, but we had a lot of public presence. That is one way to access care. In rural communities there are fewer doctors. They work 24 hours a day, so they do not want to stay.

One concept that the government should consider, incollaboration with those communities, is setting up walk-in clinics where there is a doctor present during the day, who could perhaps provide rotate on a weekly basis, or have a pool of physicians to provide that kind of a service. This is only one way.

The second way is the rural area should be netted with telehealth and telemedicine because that is a part of it. A problem with telemedicine is it is underutilized. A lot of studies have been done and every time there is a study we hear that only 50 consultations have been undertaken for a cost of $2 million. It is pretty expensive. Telehealth should be easily available in rural areas as well as to the physicians who are providing the service. That is the other area to view this.

We are doing a lot of telemedicine from the IWK health centre to the Regional Hospital, from the Regional Hospital to the community hospitals and rural hospitals in the Cape Breton area. We heard nothing but praise for these services. We are moving, but it is a slow move. A pilot project was done in 1993-94 and telemedicine has been here for the past ten years in this province. Although the net is all over the province, it is still underutilized.

Mr. Malcom: You talked about the idea of shared care models, which is using alternative providers where appropriate. As an administrator, I support the idea of shared management. That means giving people information, asking for their opinion, listening to what they have to say and determining if you can find the right answer.

Staff, physicians and the community have a better sense, when they are involved in shared management, that this is a public trust. We do operate a public trust. As long as we respect that public trust and involve people in decision making, we can find solutions that make sense.

Getting back to the need for good information, for best practice, I am lazy and if somebody else has a better way of doing something, I will steal it because it is a lot quicker.

Dr. Rathwell: I would just like to make a comment with regard to the smart card. My understanding is that there is an experiment currently in progress in the European Union using smart cards where individuals or patients have the details of their medical records on cards and they can use these cards in selected places in various countries. This has tried to facilitate a group of individuals within the European Union and to facilitate the transfer of important medical information from one country to another. The program is being evaluated but I do not know whether the evaluation has been published. That might give us a clear guide as to the effectiveness of the new technology of smart cards and where it will be advantageous and perhaps where not.

Mr. Malcom: Can I make one comment on that? All of the health districts outside Halifax were at the same age and the same level of information technology. It would have been very easy to replace, on an individual basis, but the eight of us got together and selected the single system.

So by the end of the implementation period of three years, if you are from North Sydney and you get sick in Yarmouth, your health information will be accessible. Likewise, if you are from Yarmouth and get sick in North Sydney waiting for the ferry to Newfoundland, you will be able to access the information.

We will have an electronic record between hospitals throughout the province in three years. It was not rocket science. All it took was a commitment of eight organizations to decide to choose one vendor to link us all together.

Senator LeBreton: Yes. It takes integration and coordination.

The Chairman: You emphasized eight organizations. Does that mean if you go from Yarmouth to Halifax, you are in deep trouble?

Mr. Malcom: The commitment we have is that Halifax will let us link into its already existing systems, so we will actually cover the entire province.

The Chairman: They are compatible. Okay.

Mr. Malcom: Part of the contract is to find a way to make them compatible.

The Chairman: Somehow Halifax always has to do some things.

Senator Callbeck, last question.

Senator Callbeck: Mr. Malcom, in your presentation you mentioned group purchasing and you referred to a certain machine and big savings. Is that group purchasing done among the Atlantic provinces or all the provinces? Who participates in that?

Mr. Malcom: The IWK and our organization joined a national group purchasing initiative. What members gave up was their right to choose a product. We have one vote. It is a co-operative of 13 members. If something is good enough for the Children's Hospital of Eastern Ontario, the IWK figured it was probably okay for them. The Hamilton Health Sciences centre buys more than the entire Province of Nova Scotia in a single year, and if it was good enough for them it was good enough for us.

The co-operative is run out of Ontario and we get the best price nationally for products. The savings in film, as well as our benchmarking on best practice, allowed us to have a second CT and fully pay for the operation of that CT without asking the province for one cent to run it. That is the magnitude of saving in one area. We gave up the independence of negotiating with vendors.

We get our paper products in Sydney from Halifax. Paper products are shipped into Halifax for Sydney. That is not a popular thing in our local business community, but we are continuing to employ health care people and we are getting fast access. I will take my paper from Halifax because the business I am in is the health care business. I am not in the paper business.

Senator Callbeck: How many Maritime hospitals are involved in that buying group?

Mr. Malcom: At the present time, there are five different groups; ourselves and the IWK in Nova Scotia as well as three regions in New Brunswick. Five of the 13 members in this national group purchasing arrangement are in Atlantic Canada.

Senator Callbeck: Are your savings in the range of10 per cent, 20 per cent, 30 per cent?

Mr. Malcom: Quantitatively, we estimate we saved in excess of $1 million dollars, which would be in the vicinity of about 7 per cent. In addition, we convinced the province, which had a single drug purchasing plan, to join a national plan and we experienced a further savings of 5 per cent. We thought we had the best price in Nova Scotia because our drugs were already bought collectively. When we joined the national group, we saved a further 5 per cent, or another $1 million savings to the province.

Senator Callbeck: That is a lot of money.

I have one other question for Dr. Ruedy. In your opening comments, you talked about the shortage of health human resources and the need to set up a strategy. Did I misunderstand that? Did you say that you felt the university should take the lead?

Dr. Ruedy: We have to be careful about who we give responsibility for developing a health human resource strategy. My experience over the last decade is that self-interests of professional groups and self-interest of government can greatly influence the planning process. An independent group that is without self-interest best does this. My experience is more from the medical side than the health professional side in a small province. The academic staffs at the medical school have as profound an understanding of medical practitioner needs in the province and health human resources as anyone else, and they have no self-interest. I have just identified the faculties as having resources that could be brought to bear to more independently develop strategies.

The Chairman: Senators, our next group is from the Canadian Medical Association. We have heard from them in the past. We have Dr. Henry Haddad, President, Bill Tholl, Secretary General; and Dr. Bruce Wright, President of the Medical Society of Nova Scotia.

We see you at one end of the country and the other, however we did not see Henry and Bill at the other end. We saw your predecessor, I guess. Thank you for coming, Dr. Haddad. You have circulated your brief. Can I suggest you go through your brief, but preferably not in detail so we have lots of time to ask you questions? Hit the highlights, and then we will proceed from there.

Dr. Henry Haddad, President, Canadian MedicalAssociation: Mr. Chair, honourable senators, I am accompanied by Bill Tholl, who is the CEO of the Canadian Medical Association, Dr. Wright, who is the President of the Medical Society of Nova Scotia; and Dr. Hanson from Fredericton, New Brunswick, who will be my successor in about nine months. He is President-Elect of the Canadian Medical Association. I am very happy that they are all here and we will all be available to answer questions.

I will take five to seven minutes, if you do not mind. As you well know, Mr. Chair, this is our fourth appearance before the committee and our second appearance in regard to your "Issues and Options" report. In Vancouver, the immediate past president, Peter Barrett, focused on principles and parameters for change.

Our principles for change include patient-centred focus, universality, choice, physicians as agents of the patient and quality. We also propose a number of parameters for change and I will outline them briefly: inclusivity, accountability, evidence-based decision making, evolution not revolution and health care as an investment good.

This presentation will focus on issues highlighted by the committee in terms of managing the health care system and accountability in the health care system. We had wanted to address many more issues but, as you know, you are a man of consensus and CMA is an agency of consensus. We want to have consensus with our partners before addressing the other issues, so we will be limiting ourselves.

The Chairman: Once you get consensus, if that is possible, we genuinely would be delighted to receive a brief from you.

Dr. Haddad: That is understood, sir.

When we consider managing the health care system, over the past few decades there have been shifts in the practice of medicine and basic cost drivers. These two have combined to significantly challenge the sustainability of our health care system.

There is good news. Patients are no longer hospitalized for conditions they once were. I have been practising for 32 years and I remember very well when we used to hospitalise people with gastric ulcers for two weeks, put them to bed, sedate them and give them milk and cream. We do not do that anymore. Of course, minimally invasive surgery has brought about enormous progress. All of this has resulted in a decrease in hospital stay.

The bad news, and again as a physician I observe this, is that patients are being discharged before time and they are off-loaded on the community. This has reflected by increasing the cost of drugs and by community-based services, which taxes community-based services.

In my hospital patients are much sicker. They are acutely ill and large numbers of patients are older patients with very complex problems. We agree that working harder and smarter is necessary. We agree with the committee in that regard.

The committee is suggesting a range of options to address financial sustainability such as increasing CHST transfers, which is most unlikely in today's climate, and examining user fees, which has been very controversial at best. CMA believes there are other innovative options, such as, for example, use of Canada's taxation system. The last thorough review of tax policy was more than 30 years ago and the last review of tax policy in relation to social policy was by Benson, I think, in 1971, which was 40 years ago.

Last week we recommended to the Standing Committee on Finance that the federal government establish a blue ribbon national task force to study development of innovative tax-based mechanisms to better synchronize tax policy and health policy. For example, increase the reach of the medical expense deductions' current 3 per cent of taxable expenditures, extend the medical expense deduction from a non-refundable tax credit to a refundable tax credit because there is a group of Canadians who do not pay taxes but who do have to pay out-of-pocket money, and also, examine inequalities arising from GST. We have been raising this issue for a number of years.

Primary care reform has been identified as another area. There are many good things that are happening in primary care reform across Canada and we could probably consider this in the question period. Much has been said concerning the need to change remuneration of physicians with suggestions ranging from fee-for-service to alternate payment plans. We believe that the form of payment should fit the function. Physicians are very open to alternate payment models.

The prevailing myth is that physicians are a barrier to change. Many progressive changes in medicine have been led by physicians. Physicians are willing to work in teams and CMA has developed a scope of practice policy that clearly supports a collaborative and co-operative approach.There is lack of evidence to indicate that fee-for-service is the root of all evils.

Surveys conducted by the CMA clearly indicate a willingness by physicians to consider different payment options. The key is to provide choice, flexibility and payment models. Now 58 per cent of Canadian physicians are paid mainly by fee-for-service. The rest, 42 per cent, are paid by all kinds of models: capitation, salary, sessional. There is not one way of remunerating physicians. We insist that the form must follow function.

In 1966, CMA with its major partners developed policy principles in response to alternative payment proposals called RAPP. We do not question the need for more integrated primary care models. We are concerned with the little attention paid to speciality care. Our 2001 National Report Card on Health Care and our physician resource questionnaire have highlighted the dismal state of access to specialized care across Canada.

Our discussion paper, "Specialty Care in Canada," which was released a few months ago, further details the deteriorating state of specialty care in Canada. Some of the issues we raise in our paper are health human resources, the workforce issues in specialty care, the poor state of our technology in Canada, the infrastructure, physical infrastructure, our hospitals, operating rooms, emergency rooms and academic medical centres, which have undergone a 22 per cent cut in hospital beds. At a time when we are increasing the number of admissions to medical school, we must consider whether medical schools have the goods to deliver the education our medical students are used to.

We believe there is a crisis of accountability, which is due in large measure to a profound problem in the governance of Canada's health care system. Those who have the most expertise in health matters have the least input to important decisions for tightening our future system. On many occasions, we have asked ourselves why this is so.

The tension between federal and provincial and territorial governments in relation to health care has been very pronounced and unproductive. For example, at the National Forum on Health, there was very little buy-in from provinces - and absolutely absent the non-governmental organizations.

The provincial and territorial health ministers' 1997 report, "A Renewed Vision for Canada's Health System," received very little play at the federal level. The non-government organizations have been absent.

Another example of executive federalism was a decision taken in 1992 by governments to decrease by 10 per cent the number of admissions to medical schools, and we had already a 6 per cent decrease. It is not a 10 per cent decrease, it is really a 16 per cent decrease our medical schools have undergone.

The Social Union Framework Agreement has been a barrier to strengthening accountability because it only binds one party. It binds the federal government to the agreement. Physicians have been targeted as part of the problem, not as part of the solution, unfortunately. Physicians feel disenfranchised. They are frustrated and angry.

There is no longer a sense of ownership of the Canadian health care system. Let us be clear, Canadians who have access to the system are satisfied. This was clearly shown in our National Report Card on Health Care. They are still receiving high quality care from all health care providers in the system.

What do we need? We need a new attitude. We need renewed partnerships. We need early, ongoing, and meaningful involvement of those who are on the front line seven days a week, 24 hours a day.

Another issues I will very rapidly touch on is health human resources. What we have been advocating is self-sufficiency in the workforce supply to meet the medical needs of Canada. The message we are getting from our partners all around the world is, "Stay away from our doctors. Fix your own problems but stay away from our doctors."

The other issue we would like to deal with very briefly is Aboriginal issues. Disparities in health status are very clear. What we have is a cultural access problem. At the last count, and I have tried to get the latest information, there are only 50 Aboriginal physicians in this country.

The CMA has been trying to do its part and has been offering bursaries to Aboriginal students. We have been offering a rate of $42,000 a year for a number of years to help Aboriginal students get through medical school.

In conclusion, we applaud the committee and its members for innovative long-term thinking. We also want to thank you for giving us the chance to be here.

The Chairman: Before turning to Senator LeBreton and Senator Cook, I wonder if I could just deal with a couple of points you make in your brief. One is in relation to the $1 billion that was announced in September of 2000 for technology, but with a big focus on MRI machines and so on.

Your brief says that you are concerned that little is getting through to the front line. The committee has expressed the view that the federal government clearly gave away the $1 billion with no way of knowing where the money is spent. We kind of have the same concern you do, but you see more of the front line than we do. Can you help us a little bit as to what gives you that concern?

Dr. Haddad: I will just start off. You are absolutely right that there was $1 billion. We had asked for $1.74 billion when we presented to the minister. The $1 billion was for the technology and the $.74 was for infrastructure. The equipment has to be housed somewhere.

At that time, just to come back a bit, the CMA had shown that amongst the 30 OECD countries, if we considered technology for diagnosis like CT Scans, MRIs, and technology for treatment like lithotripsies and radiation equipment, we were really at the bottom third of OECD countries that had a similar level of development as we did.

Now we have been trying to track what happened to that billion dollars and I did mention in my presentation that the Social Union Framework Agreement binds only one level of government.

The Chairman: Right.

Dr. Haddad: It binds the federal government, but we do not know what has happened to that $1 billion. I know Bill has been in contact with the Canadian Association of Radiologists.

The Chairman: I would like to hear from Mr. Tholl, but your gut feel is that all of it is not trickling through.

Mr. Bill Tholl, Secretary General, Canadian Medical Association: I have a two-part addition to what Dr. Haddad has said. Number one is that the OECD picture has recently been reinforced back in Ottawa; there is an OECD measuring-up conference; there is some very up-to-date data that have just been released as of yesterday that show that Canada is not just in the middle but near the bottom end of OECD G-8 comparators. The big debate is: is that a good thing or bad thing, the fact that we do half as many cathetorizations in Canada as do the United States without any noticeable difference in outcomes? It was the issue that was being raised yesterday by Dr. David Naylor, Dean of Medicine at U. of T. In any event, in terms of availability, technology, number of scans - all of those kind of indicators, Canada is near the bottom end compared with the other OECD countries.

With respect to the study that we are doing with the Canadian Association of Radiologists, we are very close to actually bringing it to closure.It takes a very innovative approach to looking at that billion dollar expenditure. There are two approaches you can take, and one is to go out and ask physicians and hospital purchasing agents whether, in fact, they have been buying more technology. Looking to assistance in that respect from Statistics Canada and other sort of reliable sources would take three years.

What we have done is actually approached the sales and service industry, which is kind of an interesting twist. If you are installing an MRI scanner in your facility,you need to have someone actually build it: in other words, put concrete underneath it and build a structure around it. Thus we have actually approached the top five or six medical device manufacturing and installation companies in this regard, and that covers about 99 per cent of all technology installers in the country.What I can tell you now is we do not believe that most of the money has been spent for the intended purposes. That is to say, not even 50 per cent of the billion dollars has been spent in that fashion.

Basically, the question was this: Did we see a marked increase in sales and service either before or after September 2000? We wanted to wait until the money actually started to flow. Half the money became available before April 1st, 2001 and half became available after April 21st, 2001. The second hypothesis is that they wanted to wait until the deal was signed in September and the money began to flow, so that the hiccup or the blip would occur in that period from September to April 1; or, on the other hand, they wanted to make sure that they had all the money, so they waited until the blip should start to occur post-April 1. Guess what? There is not much of a blip.

We are hopeful that we will soon be able to release that study. The problem we are having at this point is guaranteeing the confidentiality of these competitive folks who are in the installation business.

The Chairman: The study, though, in the way you are doing it, will clearly overestimate the amount of federal money that got through because you are making the assumption that, in that same period of time, the provinces would have spent zero, and presumably the federal billion dollars was meant to be incremental to whatever the provinces intended to spend.

Since what you are looking at is the total amount of money that was spent, you are clearly overestimating the amount of the billion dollars that actually got through because it assumes the provinces spent zero. If that figure is actually at 50 per cent, or whatever the number is, that is a problem, although it is not your problem.

Mr. Tholl: Mr. Chair, if I may, from a technical point of view what you are assuming is that there was an upward track and there was some real growth to begin with, and I do not think that is true.

The Chairman: Very well.

Mr. Tholl: The question is then whether there was a blip in terms of real spending.

The Chairman: So it might have been zero, anyway?

Mr. Tholl: That is right.

The Chairman: On your blue ribbon task force, the two examples you use, one was the Benson study of the early 1970s and the other was the Carter commission, although you did not use the name "Carter."

My question to you is, given what you want to do, and knowing the almost impossibility of undertaking massive tax overhauls in this country, whether it would not be better to perhaps focus your sights a little more on something that is doable, since the purpose of the study would be: How can tax policy be changed so that on the catastrophic end, people would be better protected if their medical costs became prohibitively high?

Second, you might even have built in there some incentives for putting money aside for long term care or whatever, as for instance the Clair commission suggested in Quebec. If that is the purpose of your study, why would you look at overall tax reform, which is a bit like constitutional reform: an interesting idea that has gone somewhere approximately once in 140 years? Why not narrow it down in a more focused way and just get it done?

Dr. Haddad: Mr. Chairman, I think I will pass that question to my economist friend here on the right.

Mr. Tholl: I have a two-part answer: First, we think we are already narrowing it down in terms of looking explicitly at how health policy can be reinforced by tax policy. We think that, in the first instance, it is incumbent on governments and others to look at what the benefit incidence is of the current odds-and-sods approach to providing relief; thus $400 for people taking care of people in homes, or the wheelchair allowances, or the disability tax credit. We think that, at a minimum, it is incumbent to look at what is currently there, and who is benefiting and who is paying. In fact, I can tell you that we are contracting out to some experts to do that tax benefit incidence analysis as we speak.

Thus, after having documented where we are and where in broad strokes we might go, you then raise a good question: What is, by the instalment plan, our pathway to the future? What we are basically saying is this: If you take pharmacare and home care as the two principle examples, there was overwhelming support for that coming out of the Prime Minister's National Health Forum three years ago. Why is it that we have not progressed those two files substantively? We think that, in large part, it is a lack of accountability and affordability. Such a big whack of money would be involved, and we have some estimates that we could share with you that are hot off the presses this afternoon. Nevertheless, it is such a whacking amount of money that it is likely to choke the system in terms of federal-provincial transfers or any other method.

We believe that it is worthwhile to look at buying that kind of pathway to the future by the instalment plan, using 10 and15-cent dollars applied where they might make the most impact, and that is on those folks who are currently not eligible for either pharmacare benefits or dental care benefits, or other kind of benefits. Supplementary benefits or other benefits that are available are rather disparate. If you look at the existing supplementary benefit plans that one would have at government versus CMA versus Heart/Stroke, or any of the otherorganizations I have happened to work for, you can see that there is quite a difference in supplementary health benefits. Thus we think that going by a sort of instalment plan, looking at targeted changes to the tax system might be the most doable pathway forward.

The Chairman: Very well, then, you would agree with me that we are better off to take it down to a bite-sized chunk with which something can be done and then go from there?

Mr. Tholl: But with a plan, Mr. Chair. If I can use an analogy, when we bought our new house 11 years ago, we could not afford to pay -

The Chairman: Oh, I agree, you want an input.

Mr. Tholl: Yes, and so can we have a plan?

The Chairman: Right.

Mr. Tholl: For example, get the interior decorator in to kind of figure out what room should be painted what colour, and then, yes, over 11 years - I just painted the last room.

The Chairman: I was not suggesting that we start off and then, after each step, decide what the next direction is. However, we must do it in bite-sized chunks or it will not happen.

Senator LeBreton: Dr. Haddad, you made a most revealing statements in your brief, and I think when you listen to the testimony before this committee, we have all fallen into this problem or this mess. You talked about remuneration and the fee-for-service issue, and there has been a preoccupation among policy makers for at least the past decade that fee-for-service is the root of all our problems, despite a lack of any vigorous evidence. If you follow the testimony, the whole primary care issue comes up again and again.

You then said that 50 per cent of physicians are on a fee-for-service basis and 42 per cent are paid by other means. I want you to expand a bit on what the other 42 per cent are.

You then say that, contrary to popular belief, physicians are very open to alternate payment methods. In a perfect world - not that we live in a perfect world - what is the best solution to this? Also, before you answer regarding just the 42 per cent, is that group composed mostly of salary workers, by and large, or salaried positions?

Dr. Haddad:The most recent figures I have is that 58 per cent of physicians are paid on a fee-for-service basis. That means that 90 per cent or more of the revenue comes from fee-for-service. Eight per cent are on salary; 24 per cent are remunerated by a variety of modes, but none of them more than 90 per cent; and5.4 per cent are sessional or on a capitation basis. What we are saying is that you should be paid according to what you are doing.

I use myself as an example: I am an academic. I am paid partly by way of fee-for-service and partly for being a teacher. I am not expected to see as many patients, for example, as a gastroenterologist in private practice. In fact, I see 50 per cent as many. Thus more remuneration suits what I am doing as a physician but, interestingly enough, it also has some consequences on the workforce because I am one head. I am onegastroenterologist in someone's file. Perhaps I should be half of one. Maybe we can get to that issue later on.

Senator LeBreton: Following up on that, that again goes back to this primary care versus specialty care issue. Are we going down the wrong road here in focusing too much on primary care and not enough on the specialty care physicians? What comments do you have to make on that?

Dr. Haddad: What we are saying, in fact, is that there are many good things that arise out of having primary care. We probably could do things better, and I think physicians are open to that. What we have been told by our members, and what we have been told by the Canadian public, when we questioned the Canadian public, for example, in that national report card, is that the problem is one of access. The result was the same when the Canadian Medical Association questioned Canadian physicians via the PRQ, or physician resource questionnaire, and also by the Janus project, a questionnaire undertaken by the College of Family Physicians of Canada.

What are they having major problems accessing? Specialists? Technology? It is funny. We have been talking about things such as the emergency room, and the fact that access to specialists is a major problem. What has happened now is that, the last time I looked at the figures, we have closed 36 per cent of our acute beds in this hospital. I am an academic. We have closed 22 per cent of our teaching beds in this country.

Very little money has been spent on the infrastructure: bricks and mortar. We have seen in Montreal major problems in emergency rooms, major problems in the operating rooms. They have had to close operating theatres for weeks and months. I was also about to mention technology, but perhaps Dr. Wright could bring us a local flavour on this.

Dr. Bruce Wright, President, Medical Society of Nova Scotia:I think part of what we are dealing with here is the schizophrenia that exists with respect to our medical care system at the moment. I use that term very advisedly, but we have an issue from the recent College of Family Physician's survey that 30 per cent of Canadians are having trouble getting a family doctor, and thus accessing primary care. Yet, we have more and more increasing ability to do things if we had the technology, if we had the infrastructure, if we had the specialist.

We have things going down in two different directions. Trying to bring those two together is an extremely difficult and complex task. As I say, we have people who cannot gain access to primary care and then we have people who need certain sub-specialty procedures or diagnoses and we do not have the technology or the support for those things. Trying to marry those two almost conflicting views is what the challenge for a committee like yours is all about, and that is one of the difficulties.

Locally, we have the same problem in Nova Scotia: people getting access to family physicians and people accessing to specialty care. I had a letter from a specialist in Halifax just about a week ago on that same issue of having to cancel necessary surgeries because there were not enough resources to go around; people left suffering with whatever it was because they were not able to access those things.

Senator LeBreton: You have a double problem, then. If you have people in primary care and you have them going down that track, and then they need speciality care or technology. You have access problems at both levels is what you are saying?

Dr. Wright: Yes.

Senator LeBreton: I have one last question. I know this is true, and we have heard it many times. This whole effort to get people out of the teaching system, and all of us, I guess, were guilty. No one thought down the road ten years as to what would happen when people came out the other end of it. Is this situation improving? Are we starting to ramp up now in the teaching hospitals, at universities and within the whole medical profession, not only for doctors but also on the technician side, as far as you know?

Dr. Haddad: You mean as far as numbers go?

Senator LeBreton: Yes.

Dr. Haddad: In 1998, if I can go back, we had about 1,550 undergraduate students in our 16 Canadian medical schools. Following a report that was presented at General Council in 1998, the recommendation was to rapidly increase that number to 2,000. We have now gone up to 1,000 so although we have not yet reached 2,000 we have gone a good part of the way.

With respect to the other recommendations, the feeling of our organization and that of the Canadian Medical Forum is that very rapidly we will need to increase to 2,500 our enrolment at medical schools. The problem I am having as an academic is that Canadian medical schools, our 16 medical schools, are accredited with the same accreditation standards as their American schools. In fact, often people who are accredited in Canadian medical schools, and I have been an accreditor, are a combination of Canadian and Americans. The standards are the same, so it is not an Ontario criteria or a Quebec criteria. These are North American accreditation standards.

We should be very proud of our Canadian medical schools. I have not looked at the situation for a while, although I used to follow it very closely when I was a vice-dean. Canadian medical schools consistently were amongst the top third in North America, and I think that is something of which we can be very proud.

The concern I have is that, suddenly having downsized medical schools and downsized the number of teaching hospitals, now we are asking for a sudden influx. We are having medical school rapidly increase the number of students, and I am not sure that the schools have the physical and human infrastructure to do so. As an academic, I am very concerned that the quality of our medical education may suffer.

Mr. Tholl: In response to the same question, just to add to what Dr. Haddad has said, again, in addition to the number of enrolment slots increasing, there was the recent announcement by HRDC of $5.5 million in a two-and-a-half-year study to look at some of the adjustment problems that Dr. Haddad has referred to.

Also in the works is a cross-cutting, multi-disciplinary study that will look at how we plan for future human health resource needs based, on a disease-based or a patient perspective, on what the needs will be, irrespective of how those needs are initially met. Thus the Canadian Nursing Association, Canadian Medical Association, and the Home Care Association are looking at one really good Canadian health needs assessment that will help inform these decisions taken prospectively.

I guess the other bit of good news, apart from the fact that we are working together, is that governments are starting to get it, in my opinion. There is a process in place that involves government this time in what is called Task Force Two. Task Force One is what Dr. Haddad referred to as kind of the initiative that got the initial enrolment going. Task Force Two is a multi-disciplinary initiative that involves and engages. Actually, the liaison deputy minister is a physician from Nova Scotia, the deputy minister here in Nova Scotia. That, I suppose,would be the third cause for optimism.

Senator LeBreton: You have got this study going on, but is it on a very short time frame? Because while the study is ongoing, meanwhile the problem is continuing. Then you report on your study: All of the horses are out of the barn by the time the study is in. How do you deal with something like that? To have a study is one thing; to deal with the problem is quite another.

Dr. Haddad: Senator, you are right. Family doctors take six to eight years to produce; specialists take ten years or more. We do have an access problem there. Dr. Wright is absolutely correct when he says there is an access problem. After all, 30 per cent of Canadians do not have a family doctor.

In fact, I had an interview yesterday on CPAC, and I was mentioning to the interviewer that my daughter moved across the river from Ottawa two years ago. Now I am President of CMA. I do not interfere, and she does not want me to interfere, but she cannot find a family doctor. She has tried on a number of occasions to find a family doctor. She cannot. When she is ill, what I do is I call one of my friends on the Ottawa side and he does me a favour and sees her. Thus, there are problems with access. Seventy per cent of Canadian family doctors just do not take new patients.

Senator LeBreton: No. I know that.

Dr. Haddad: They just do not take new patients, and that is very worrisome. What we have been trying to work at is a kind of global view. For example, let us increase the number of undergraduate students, increase the number of residents. We are going beyond counting heads, which is what we used to do, because all the heads are not doing the same thing. I am a perfect example of someone who is not doing the same thing as someone who is in private practice.

We will be leaders in the world, in my opinion, if this Task Force Two delivers what we think it will deliver, because the rest of the world is still counting heads.

Senator LeBreton: Yes.

Dr. Haddad: They are making mistakes. We made a major blunder in 1992 when we said we were overstocked with doctors, and that opinion was arrived at by counting heads. What can we do for tomorrow? Working harder will not do it; working smarter will not do it. We must increase our numbers. In other words, decrease demand, and increase our numbers.

One idea that we had, which we talked about to the Standing Senate Committee on Finance, is that we know there are 10,500 doctors south of the border. One thousand of them sit on the border and they practice north and south of the border. We also know that there is a health care work force, nurses and technologists, down south of the border, too, but I do not have their numbers. I asked but I could not get their numbers. What we are saying is if what the Canadian public is telling us is correct, then what government has to recognize and what we must recognize is that we are in a short term crises, and since what we are looking at, really, are long term solutions, how about trying to repatriate some of those physicians back to Canada?

Senator LeBreton: Yes.

Dr. Haddad: We then said to ourselves, "Let us consider giving them a tax break; say, 50 per cent for three years, a one-shot deal, not just for the doctors but for the health care workforce." That might help things. We are looking at many facets to our work force crises.

Dr. Wright: May I just add to that? With one of the issues locally here we have switched the words around. We used to talk about recruitment and retention of physicians. We are now saying retention and recruitment because it is our contention that it is a lot cheaper to keep me in the province than it is if I leave the province and you must then recruit someone else to replace me.The difficulty is that you need to balance out the incentives that Dr. Haddad is talking about with the people who are left. What do you do about the person who has made the decision to stay, while at the same time you are paying someone a large amount of money to come back on to come to the province? That is one thing.

Also in Dr. Haddad's presentation, he talked about evolution, not revolution. We need to deal with these things sequentially. You cannot redesign the hull of a ship in the middle of the ocean, and we do not have the chance to go into dry dock here. Thus we must evolve this whole process. We cannot do a sudden left shift or right shift on this whole process.

Senator LeBreton: When you were talking about the increase in medical skills, you talked about the North American schools and the fact that there are U.S. medical students in Canada. When we look at those numbers coming out of medical school, we know we are going to lose a significant portion of them back to the United States. Is that right? We are training doctors here and -

Dr. Haddad: No. My understanding is that Canadian medical schools usually have a quota of Canadian medical students. Take, for example, my faculty of medicine. We have, let us say, 120 slots for Canadian students.

Senator LeBreton: But if only 100 fill -

Dr. Haddad: No. Oh, no. We fill 120 slots very easily.

Senator LeBreton: Oh, you do?

Dr. Haddad: One thing we still have in this country, compared to other countries such as England and the United States, is that we are still attracting amongst the highest quality of students. That is not the case now in the United States, or even in England. We are very fortunate. We have la crème de la crème, as they say en francais, still wanting to become doctors.

The other issue which I would like to deal with, seeing that we are on resources, is the Aboriginal issue. As I mentioned, we do have a tremendous amount of disparity in the health status of the our Aboriginal citizens compared to the rest of the population. We are dealing with, two, three, and four times the incidence of common diseases, such as diabetes, heart disease, stroke, hypertension, and social illnesses.

With respect to Aboriginals, there is an eight-year decrease in longevity at birth. It has been shown that Aboriginal children involved in accidents have eight times the morbidity of non-Aboriginal children who are involved in accidents. Thus we do have tremendous health disparities and we also do have a cultural access problem.

As I mentioned before, we have only 50 Aboriginal physicians in this country. Maybe I am mistaken with respect to the number; we may have a few more, or a few less. What the CMA has been looking at is to find a way to increase the number of Aboriginal medical students in Canada, and do it rapidly? We do have bursaries, but that is not enough.

Aboriginal health is a federal jurisdiction. I have mentioned the fact that medical schools have a reserved number of slots. University of Toronto, let us say, has 200 as an example. What we are recommending to the federal government is that they finance the number of slots above the 200 for Aboriginal medical students. Thus, for example, in Toronto there would be the 200 slots as usual but then they would buy from the University of Toronto an additional five slots. The number can be determined. We can determine which medical school they can go to. We feel that this could be a very eloquent way to encourage Aboriginal students to go to medical school and increase in the medium term the number of Aboriginal physicians.

The Chairman: You know how governments love precedents, so if you are looking for a precedent for your tax proposal, go back and look at the precedent that was used in the late 1960s and early 1970s to attract academics to Canada from the United States. The deal was - and you had better get the exact numbers - I think, in fact, that they came tax free, certainly for a period of two years. In any event, the Finance Department absolutely loves to have a precedent, and one does exist.

Dr. Haddad: Can I just give you a further, current precedent? The Quebec Government is -

The Chairman: You would be far better off to have a federal precedent, and I am talking about a federal precedent.

Dr. Haddad: But there is a precedent now, in Quebec where they are attracting -

The Chairman: Right. That, I understand, but I am talking about the way people think, the way the feds think.

Senator Cook: My questions are general in nature. I want to talk a bit about the need to develop core professional education programs. A previous witness this afternoon alluded to that. As a bit of background, I come from Newfoundland. In the mid-1980s, the nursing profession in that province looked at those whom they were educating, and I chaired that study. We found that the licensed practical nurse was being educated in a community college, that the registered nurse was being educated in a school of nursing, of which there were three in the city, and Memorial University was delivering a Baccalaureate of Nursing at two sites. We did not think that was a very effective use of resources or money, so we set about looking at a core curriculum.

This was the mid-1980s. It took us until the year 2000, which was our goal, and we called it BN 2000. Along the way, there were appropriate incentives, exits and entries even at the LPN level that a nurse could take a credit or two or three if she wanted to make choices to move on in the profession. I am just wondering how practical it is, or necessary, to move that kind of an educational program completely through the discipline of education?

Dr. Haddad: I do not know if one of my partners here can help me out, but I really do not have an opinion.

Senator Cook: We hear a lot, especially now, about nurse practitioners. They are coming close to the discipline of the medical profession and working in designated areas. I think we turn out a better worker for the health care system.

Dr. Wright: In the province of Nova Scotia, currently there are four demonstration projects where there is a collaborative practice between nurse practitioners and physicians. The final report card is not in, and it was done with federal money. The problems with that were that it was vastly more expensive than I think anybody had anticipated. It did not save money. It may have redirected the type of care that people are getting and the person providing the care, but I do not think it was a savings in terms of providing more care for the same dollars, or the same care for fewer dollars. At least, that was one of the issues in that area.

Dr. Haddad: I think the experiences of certain rural and remote communities are the same wherever nurse practitioners are working, and what has been noticed is that it has been cost effective as far as decreasing the access time to physicians. However, it has not decreased the overall costs. I do not know if that answers your question.

Senator Cook: From an educational point of view, building extra, appropriate courses into the system was not cost effective. Is that what you are saying?

Mr. Tholl: I just have two points, and I would want to go back and check my facts on the first point, which is that that was part of the vision at McMaster University. McMaster was another one of those four new medical schools that opened up in 1971, along with Memorial University, and that vision was that they exposed folks from different disciplines to at least a coordinated, if not core, curricula. I think the experience of McMaster would be worth looking at in terms of its efforts.

Second, the nurse practitioner program in Ontario: They trained the nurse practitioners and then did not get the change in the law, change in their ability to practice, so you had almost a lost generation of nurse practitioners. The evidence, I think, is very supportive of what Dr. Haddad has just said in terms of nurse practitioners in that they are not cost-producing but, in certain circumstances, they are very cost-effective ways of meeting unmet needs.

Last but not least, I guess, picking up on the witnesses just before us in terms of scope of practice, I think we are at a very interesting time in Canada where there is such a chronic shortage of health care workers across the board that the traditional impediments to a proper allocation of tasks are perhaps less than otherwise.

We would be happy to share with the committee what we think is a fairly instructive approach to defining scope of practice, which we have sent out to other disciplines. There has been very strong support for that scope of practice document that basically says it ought to be skills based; it ought to be education based rather than turf based. We would be happy to share that with the committee. We think that is an important next step.

Dr. Wright: Just to clarify, we have been involved with the Registered Nurses Association in legislation for nurse practitioners. There are two basic groups of people that I think we are looking at: One is the specialty nurse in a tertiary care centre who is performing a number of functions. The example I would use here is the dialysis unit, perhaps doing a number of functions previously done by a physician. Then there is more in relation to the primary care demonstration projects. The term "collaborative practice" is now in that legislation. Thus, it is coming in Nova Scotia. However, there has been no discussion yet as to how we fund it.

Senator Cook: One interesting thing that we saw in that process was that the student at university was in the second year of a program before he or she saw a patient, and when they did, a fair number of them said, "This is not for me." That was one of the benefits that we saw, even from an educator's point of view. I think we need to think outside the box when we are considering how to deliver the best care for Canadians in this health system, and look at all the options.

Dr. Haddad: What I can add here is that in Canadian medical schools, students are in contact with patients during the first year. I know in my medical school, what is very interesting is that they do not send the students to university hospitals.They send them out into the communities, some very isolated communities, to work with doctors doing house calls, and so on. Thus they are really at the front line. They get a taste of what medicine is like, not at the university centre but out in the communities, and they love it. They come back enchanted. I have not seen too many change their minds and want to do something else, so I think the admission criteria works.

Senator Robertson: I want to congratulate my New Brunswick friend on his future task. I have just a couple of reasonably quick questions, Mr. Chair.

I am not sure where - I think it might have been on your web site, or it might have been in Vancouver, but the CMA advised us that they would respond to each of our issues and options. Some of us have been waiting for that document with great anticipation.

The Chairman: I think, so are the witnesses.

Senator Robertson: Can you advise us, perhaps, when we might expect to receive this document? I understand you are all very busy, but we are very anxious to get it.

Dr. Haddad: We did mention at the start that we are still working on it. The CMA has to reach consensus with its partners. It is not always an easy task to do, but we are working on it, and as soon as possible.You will be the first to know.

Senator Robertson: We might have it as a Christmas gift perhaps.

The Chairman: As you know, Senator Robertson was a provincial health minister, and those of us who have been involved in federal-provincial relations for the decadesrepresented around this table think that any time you can attain a consensus is an achievement, even if it takes time. We do understand the problem.

Mr. Tholl: We are trying to do it differently this time.

Senator Robertson: Yes.

Mr. Tholl: That is a very bottoms-up process, building in the CMA divisions and, as both of you will know, building consensus is valued but it takes time. We are very pleased that we did get that consensus on our framework document which we have submitted to the other place, to Mr. Romanow, and I trust that the committee has received a copy of that. That is the framework that we are trying to apply. I can tell you that in areas except those relating to financing, we already have a very large consensus.

It would not surprise you to learn that on issues of user fees, people have different conceptions of what the term "user fees" means or does not mean, or medical savings accounts and other recommendations or issues that you put in your report. Thus it is that area, the area of finance, that we are struggling to gain that consensus. Perhaps that helps a little bit more to pin it down. We are still, obviously, committed to doing our best to reach that consensus, and we hope that it happens sometime between now and Christmas.

Senator Robertson: Thank you very much for that. You are hung up with finances.

The next question I have relates somewhat to the financial circumstance in which the provinces find themselves, the delivery of services. I can only speak for some of the witnesses, or reiterate what they said. I am sure Dr. Haddad would know where I am coming from on this one. What do the provinces do when they have equipment but they do not have the money to hire the staff for sufficient periods of time to get good use out of that equipment?

For instance, in a hospital near where I live there are eight operating rooms, and perhaps only half of them are in use because the support staff, the nurses, the anaesthetists and the doctors just cannot work all the time, and they do not have enough staff to keep them open. The line-up backs up. Before you start to answer that, I will tack on something else that is of concern to me, if I may.

People wonder what we can do about this. I do not know what they do about it because whether they can find the money, if the system were differently managed, I am not close enough to it now to make any determination like that.

I am sure you are all familiar with Dr. McGowan's project at Sunnybrook where he has a private clinic. It is called the Canadian Radiation Oncology Services. He uses the equipment in Sunnybrook for oncology and it is a private operation. When their system closes down because they do not have the staff and the waiting list for radiation keeps growing, then they have allowed him, as a private operator, to use the facilities and shorten the waiting list. It seems to be working out very well.

I do not know if there is an opportunity here for us to do that in some other circumstance, but I would like to know what your opinion is on this process or this application of private health care filling in where the public health care in those instances where there is a shortfall. Just like my operating rooms that I referred to earlier that cannot function because they do not have staff or money. The money comes first to hire the staff. Would you give your approval to something like that, a private service?

Dr. Haddad:Can I ask if this facility has a public contract? It is contracted out by the public - ?

The Chairman: Yes. Let me explain quickly how it works. They simply rent the facilities from Sunnybrook. All of their patients are medicare patients, so although it is a privately owned clinic, they treat nobody but medicare patients and they are paid on a per-patient basis by OHIP. They work from 6:30 to 10:30 at night.

Senator Robertson: They receive the same amount of money as if it had been done in the regular hours on the oncology unit.

Dr. Haddad: No. I really do not have any problem with that because here we are having private delivery but with a public contract, and accountable to the public health care system.

Senator Robertson: Yes.

Dr. Haddad: Let us look at doctors. Doctors are funded from the public purse, but most doctors are private workers.

Senator Robertson: That is right.

Dr. Haddad: They were working as private entrepreneurs, actually, if I might use the term.

Senator Robertson: Yes, indeed.

Dr. Haddad: The problem we are having is with the words "private practice." That, we are not in favour of.

The Chairman: This is really, I guess, a combination question/comment: In your accountability section in your paper, you talk about the desirability for a renewed partnership - that is your word - among the payers, which is the governments, the providers - yourselves - and the patients. We would strongly agree with that. The question is what does that mechanism look like?

We had a presentation this morning from Dr. Nestman of the School of Health Servoces Administration at Dalhousie, where he was really looking only at the federal-provincial issues. At the end of his presentation, just as we were adjourning for lunch, we asked him to please think about the question of how we might bring providers and patients into the system. This is simply because one of the dangers with government policymakers designing the system off by themselves is that one does not know how it will actually work, in practice.

Therefore I think we need much creative thinking on the part of many of us as to what that kind of mechanism would look like, recognizing, for example, that ultimate decision-making authority has to rest, in this case, with the people who pay the bills, which is government.

Dr. Nestman and I had a discussion on that particular subject over lunch, which was very helpful. The more the witnesses can be thinking on that subject and have even informal conversations with us, the better, because I think at some point we must move away from saying, "Gee, this is a nice idea," to saying, "Here is a very specific, concrete proposal that has every "i" dotted and "t" crossed so that people can either buy it or not buy it."

You may want to make a general comment, but the more thinking along that line, the better. It will take some quite creative thinking to pull it off. If you, or any of you, can do that, that will be helpful.

Dr. Wright: I agree with you in that concept, but something you said earlier was about taking it off in bite-sized pieces. This was my ship analogy. I think what you need to do is to have a larger project that demonstrates this kind of thinking will work, so that people will buy into it. If you have it on a piece of paper and then announce that we are suddenly going to make all the doctors in Nova Scotia or all the nurse practitioners do this, that, and the other, then that might not work so well. One of the concepts that we are floating from the Medical Society of Nova Scotia is a larger project for primary care. We do not have it all fleshed out yet, but we have suggested to one particular community that they should think about this as a buy-in, with 15 or 20 doctors or more, and look at that from the perspective of a much larger model rather than one physician and one nurse practitioner.

That sort of example would give you access and opportunity to look at the teething problems of the system and refine it before you tried to sell it to everybody else.

The Chairman: Right.

Dr. Wright: That is the kind of thing that we just floated at our board meeting.

The Chairman: Right. The only point I was making, though, was with respect to the policy level, because the policy level, by its very nature, is not done incrementally, at least at the federal level, in the sense that it covers everybody. Thus while I am all in favour of doing incremental things on the tax changes because I think it allows you to progress slowly, from the way in which I interpreted your accountability question, it seems to me that we probably need a bigger pilot project. I understand what you are doing, the one you are talking about.

Mr. Tholl: If I may, I have two comments: One, many things are going right at the moment in terms of the Canadian Institute for Health Information, the Canadian Institutes for Health Research. I am thinking here of the new institutes on health services, health policy with Morris Barer and the Population Health Research Unit. These are important elementa of future accountability.

The trouble is that there is nobody who can actually look with any detachment at policy effectiveness and evaluating policy change. There are the information folks who can put out information, and descriptive analysis. There is, as I say, the CIHR Institutes that can maybe add to the mix in terms of doing research.

I might say, as well, that some of the federal-provincial advisory committee structures are starting to open up a little bit; just a little crack. I think that is good news. My first point would be that we need to look at some of the progress and how to knit those kinds of things together in a useful sort of way, in a non-threatening way, to those whom you have pointed out. At the end of the day, you need to be able to look the taxpayers and the electors in the eye.

Perhaps the one idea that has received considerable attention from time to time over the years is the idea of a Canadian Health Council, Brookings North. It has been variously described: Surgeon General North, as an Officer of Parliament, maybe not unlike the Privacy Commissioner or the InformationCommissioner. By the way, the idea did not come from the CMA; it actually came from the old Canadian Hospital Association, so it has been around for some time.

Certainly, there are some documents that have been prepared over the years that we could certainly undertake to get to the committee, and we would love to talk to you more about that.

The Chairman: Yes. The more details we have, the sooner we can begin to flesh out our report, and that would be helpful. Thank you all for coming. We appreciate your coming down to our neck of the woods. Looking around the table, all but one of us are from the Atlantic region. That is great.

May I ask the next panel to come forward, please?

Senator Marjory LeBreton (Deputy Chairman) in the Chair.

The Deputy Chairman: Senators, our last witnesses for today are Dr. Desmond Leddin, Head, Division of Gastroenterology at Dalhousie University; Dr. George Kephart, Director, Population Health Research Unit, Department of Community and Epidemiology, Dr. Kenneth Rockwood, Faculty of Medicine, Division of Geriatric Medicine, and Ryan Sommers from the Cobequid Community Health Board.

Please proceed.

Dr. George Kephart, Director, Population Health Research Unit, Department of Community and Epidemiology, Dalhousie University: The Canadian Health Act implies that Canadians should receive the services that they require. Implicit in this act is the notion that services ought to be allocated on the basis of need.

The purpose of my presentation is threefold: first of all, to document differences in age structure and health status between provincial populations; second of all, to document that the current allocation of federal health care transfers is strictly on a per capita basis and does not take into account differences in age structure and health status between populations. I strongly urge the committee to explicitly recognize this fact in their report and in their recommendations, and urge that the federal government look at ways to more equitably allocate federal health care transfers.

What ought to be some of the guiding principles, in terms of how federal health care transfers are allocated - and that is a different issue than how much do you allocate. However, given what you do allocate, how do you decide how to divvy it up? Two principles ought to be equity and efficiency. On the equity side is the notion of unequal allocation for unequal need. That would be, equity is not necessarily the strictly equal per capita allocation.

Also efficiency, which is closely related. Efficient allocation of resources requires the allocation of resources according to need and potential benefit; in other words, effectiveness. Resources need to be invested where they are most needed. Resources need to be invested in activities that provide the greatest benefits per dollar spent. Resources also need to be invested with some longer term goals: obviously, to efficiently and effectively manage and treat current health problems in the population; improve the health status of the population and improve efficiency and effectiveness of the health care system.

Currently, in Canada, of the two major federal transfers that are directly for health care, or at least are closely related, are obviously, first, the CHST, or the Canadian Health and Social Transfer program. The CHST is now being allocated on a strict per capita basis, as determined only by the size of the population. Interestingly, at the time that the CHST was implemented, historical caps that were in the previous programs were carried forward, so that some provinces did not receive equal per capita money. Ontario, for example, received less money per capita initially with the CHST. In recent budgets, the federal government has moved to make that allocation strictly per capita. There has been quite a big deal about it in federal budget documents.

Equalization payments are allocated to poorer provinces, but it is important to keep in mind that equalization payments are designed to overcome the difference in the revenue-generating capacity of provinces. In other words, poorer provinces have lower average incomes and generate lower per capita revenues through the tax system. Equalization is designed to offset that.

However, with the current equalization formulas, even after equalization the wealthiest provinces still generate more money per capita at the same effective tax rate. In other words, even after equalization there are still differences in the revenue-generating capacity of provinces. The program does not generate higher revenue-generating capacity for the poorer provinces.

How do the provinces compare in their need for health care services? We released a report last September entitled "Federal Funding for Health Care: Are Provinces Getting Their Fair Share?" A copy of this report has been distributed to the committee. Not surprisingly, it is consistent with many previous studies and documents. This report shows that there are quite substantial differences in health status between the provinces. Some provinces, such as Nova Scotia, demonstrated across a whole range of indicators lower health status. In fact, Nova Scotia was in the top three. Other high need provinces, for example, are Saskatchewan and Manitoba, also show up as being very high, primarily because they have old age distributions. Otherprovinces, such as Alberta, show up as consistently high, for example, on a variety of different indicators in need.

How much difference in need does this translate into? We developed a series of models, some from the National Population Health Survey. We also took models that are currently used for resource allocation in the United Kingdom and adapted those for Canada. Thus we came up with a variety of comparative models. What these models clearly show is that high need provinces can have a ten to fifteen per cent higher per capita need for health care services, such as GP physician services and hospital services, as the Canadian average, while the lowest need provinces have five to ten per cent lower per capita need for health care services. This is really quite a dramatic difference in per capita need. Although we do not recommend any specific model, what this report does clearly show is that a variety of models yield fairly similar conclusions: that there are quite substantial differences in per capita need between provinces.

What, then, are the implications of the current system? If higher levels of need are met in a consistent pattern across the country, then high need provinces would need to be spending more per capita in their own provinces on health care, and that is not the case. We do not see that need as being correlated with per capita expenditures, even if you consider adjustments for things like wage levels. Moreover, high need provinces are multiply disadvantaged.

The CHST also transfers money for education and community services. When you think about it, the higher need provinces also tend to be poor. They end up with lower revenue-generating capacity, even after equalization. Migration also disadvantages them. For example, in the Atlantic provinces, a common migration pattern is out-migration of young adults at the prime of their working age that then really enhances the revenue-generating capacity of the wealthier provinces. There is then return migration in the older ages. Thus a lot of our older age distribution in a province such as Nova Scotia is generated by the out-migration of our young working population to provinces such as Ontario and Alberta, who then return in migration in their retirement years.

In addition, poor provinces also have higher per capita need for social services. Again, the CHST still transfers equal per capita money for social services through the CHST.

Obviously, ultimately, the solution here is bigger than how much money you allocate. The issue is addressing the inequities and health status in the first place. Ultimately, the key need is to improve the health status of populations of the less healthy provinces.

Just to give you some illustration of the quandary, both Nova Scotia and Alberta spend about the same amount of money per capita on health care. However, because of differences in the relative size of the provincial gross domestic product, Nova Scotia has to devote 11.5 per cent of its GDP to health care in order to maintain the same level of spending per capita. Mind you, Nova Scotia has a substantially higher need. Yet Alberta only needs to devote about 6.9 per cent of its provincial GDP to health care. Nova Scotia is continuing to run deficits and has a very high per capita debt, so that is layered on top of it.

The current system is one that may be a bit of a slippery slope, where provinces such as Nova Scotia are increasingly challenged to maintain a level of health care spending. If you look at Nova Scotia's provincial budget, what you see is that health care spending is eating up a larger and larger piece of the pie, so the percentage of total provincial expenditures that are going to health is getting larger and larger; in fact, much faster than is true for Canada as a whole, and detracting expenditures on things such as education, highways, roads, and things that we know may be important in terms of affecting the determinants of health. It is also limiting the ability of poorer provinces to invest in the future to improve efficiency, things such as information systems, for example. That, then, is difficult as well.

We are concerned from this report that this is an issue that needs to be really addressed. Interestingly, it has not received much attention in Canada. In fact, as far as I know, our report is the first report to really raise this issue around federal health care transfers. That is somewhat surprising because many countries are using needs-based resource allocation formulas to determine how they allocate money to regions.

For instance, the United Kingdom has long developed resource allocation models. A number of the Scandinavian countries use resource allocation models. Australia and New Zealand use resource allocation models. Interestingly, most Canadianprovinces now use resource allocation models internally. Alberta, for example, has a very sophisticated needs-based resource allocation model that they use to allocate money between regions. Ontario is using models for some types of services. Saskatchewan has models in place to allocate resources on the basis of need. Yet, this is something that has received remarkably little attention within Canada. I would really like to urge the committee to take a serious look at this issue and consider recognizing it in the section that deals with federal health care transfers.

The Deputy Chairman: This morning, Mr. Robert Cook from the Nova Scotia Association of Health Organizations had some very interesting graphs that showed young people leaving and then, between the ages of fifty-five and sixty, coming back. That supported what you have just reported.

Dr. Kenneth Rockwood, Faculty of Medicine, Division of Geriatric Medicine, Dalhousie University: Senators, I want to make two points: One is about the aging of the population and its need for health care; the second is about our need to better understand this and to not have that happen in a haphazard way.

The first point is this: you have probably heard conflicting views about what the impact of the aging of the population will be. There is a group people which takes as an article of faith that the more old people you have, the higher the health care expenditures will be. There are others who come along and say, "No, no, no." If we take into account other things such as drug costs and the way in which new technology is employed, then this seems to account for all of the growth in the expenditure within the population, and aging contributes a small proportion of that.

Both points of view often have an ideology behind them. Each of them ignores a central fact, which is evident to anyone who walks into a hospital, and it is this: There are two types of people from a health care standpoint. There are old people who have one thing wrong and there are old people who have many things wrong. Old people who have one thing wrong, if they have one thing wrong at once, are very well served by the current system of health care, and we can be extremely proud of what goes on with them in their doctor's offices and in the acute care hospitals. However, old people who have more than one thing wrong, particularly if they have more than one thing wrong at once, they do very badly. Our current system has no way to accommodate those folks. We do not think about them in the right way. We have not organized a system of caring in the right way. A lot of the low morale and dysphoria and poor mood that people feel comes not from caring for people with one thing wrong, for whom we are prepared to go to the ends of the earth. Organ transplantation is known to be the treatment of choice for certain problems. People do that even though the effectiveness is certainly not guaranteed, and they take pride in it. But there is often a sense of complete frustration when they are dealing with people who have many things wrong at once.

It turns out that there are systematic and effective ways to care for people who have many things wrong at once. They are the people whom we can conceive of as the frail elderly. If we think for a moment about what makes a person frail, we can get some insight into the sorts of systems that we need to care for them.People are frail when they have a complex interaction of multiple medical and social problems. People are well when they do not have that. Frail old people have certain characteristics. When they become acutely ill, they never have just one thing wrong. When you attempt to intervene with their acute illness, you cannot just do one thing at once.

One of the ways in which their condition of having more than one thing wrong at once manifests itself is that their function becomes impaired. Occasionally, we come across people who cannot walk very fast because of a single problem - a hip joint, or perhaps a stroke, or a bad foot. Most old people who cannot walk very well have many things wrong at once. When we apply the one-thing-wrong-at-once approach to them, we do them very badly. We give rise to all sorts of horror stories, like people going in to have a knee replaced and never walking again, not because the knee surgery did not work - it worked perfectly well, but because things happened when they were in there to their brain, or their hip, or to the other knee, which were never taken into account.

When, in the medical profession, we deal with patients who do not do well, our tendency sometimes is to think carefully and shamefully about ways in which we have failed them. But very often we do not. We think of ways to blame them. That is what you will hear in the hospitals these days, a number of denigrating terms that are used. That is probably the most systematic, reproducible response that we will find.

I am a geriatrician and my colleagues and I across Canada have devoted ourselves to thinking about, and effectively caring for, frail old people who are well. I always say, I do not care about well elderly people, even when they are sick, except in some non-specific way. It is when people have multiple interacting problems, that is the important thing. To do that, though, requires that we practice in a particular way in which we have to take into account that there are people with more than one type of expertise. We have to have them in a team, and we have to make the team work towards an effective series of goals. All of these things are against the traditional disease model approach, even though our view would be that anyone can look after a patient that has only one thing wrong at once. It is when they have five things wrong at once that it becomes interesting, and fun.

Our profession is not viewed as a high status sub-specialty. Even though we see the tremendous challenge that goes with that, there is a constant need for advocacy just to maintain our place within our peer group. The way in which our sub-specialty is viewed, for example, as you will hear from the brief from the Canadian Geriatric Society, is that across Canada right now there are only two trainees in the sub-specialty training programs in geriatric medicine. We feel that we need about forty in order to meet a now obsolete goal of 1.25 geriatricians per 100,000 population, which would be about one fourth of what many of the OECD countries have.

We have seen that that particular way of viewing things is not working. It is giving rise to dysphoria. We are getting incomplete analyses of what the problem is. People are not addressing what is, from our standpoint, the elephant in the room. Therefore when it comes time for you to report, I hope that you will take into account the dramatic needs of people who are frail, and old, and ill, and the ways in which they are underserved presently. That is my first point.

My second point is that it is a tremendous intellectual challenge to think about how to do this properly. The work that is done in this area is multi-disciplinary and needs many points of view. Historically, we have not funded medical research to take that stance into account. We are thrilled that the new CIHR has, as one of its central foci, multi-disciplinary work. However, we think that a lot of work needs to be done before that can be understood in a routine way and funded well. We need to know more and we need to fund the research by which we can know more and better. That is my second point.

Dr. Desmond Leddin, Head, Division of Gastroenterology, Dalhousie University: Senators, I would like to congratulate you on the report as it is so far. It is, from my perspective, a very accurate representation of what is going on. Secondly, I would like to congratulate you on your stamina in listening to what you have gone through today and many other days. It must be quite gruesome.

The filters that I bring to this, if I might, are perhaps a little bit odd. I grew up in a two-tier health care system in the west of Ireland. I worked in primary care in a rural part of Ireland before training in Canada and becoming a specialist in gastroenterology. I now have a responsibility for the largest techno-group, I would think, in the Atlantic provinces and will also be representing the Canadian Association of Gastroenterology in a couple of years, which association represents about 500 gastroenterologists from coast to coast, and they are notoriously a technically-oriented group.

I am a salaried physician. The areas of expertise that I am interested in are the relationship between family doctors and specialists. Particularly, I am developing different models of how we can do business with extended role nurses, technology, and other things. If I might, very briefly, just give you an overview of what I think is going on, and then perhaps very quickly I will make a few comments on each section of the report under "Issues and Options."

For me, this is, and continues to be, the best health care system in the world. It is certainly by far the most ethical, and it is a remarkable experience to work in it. There are many strengths, including the quality of the students who go into medical schools, and there continues to be a uniformly high standard and an absolutely superb post-graduate training structure that has been put in place by the Royal College of Physicians in Ottawa, which really is, I think, a world leader in the area. It is all very impressive.

The weaknesses you have outlined in your report - I think you got them all, including the lack of patient responsibility, the fact that physicians work in silos with as little communication between specialists and special care groups as we can possibly arrange, a very narrow perspective on what is going on and an extraordinary data lack. In other words, we have absolutely no idea what the effect of this ninety billion-plus a year system is in terms of real outcomes. Lots of opportunities and my bias from the interactions which I have had with the primary care group is that a fee-for-service system for primary care, as we go into what we are facing, will just not work. We need something quite different. I would certainly be open to consideration of a variety of different models, but processing patients on a number per hour for fiscal reasons will not be the way that we can do business.

If we go to some form of capitation system, it is very important to define work volumes. We were able to do that. Strangely enough, even though we were on this side of the Atlantic, we came up with precisely the same work volume with regard to gastroenterologists as the Royal College in London published a year ago.

I like incentives, as opposed to disincentives. If we want primary care physicians to vaccinate everyone, for example, I think we should pay them an incentive at the end of the year for reaching targets. In alternative models, there are tremendous opportunities. We have two extended role nurses, very highly trained individuals, working with us: one in hepatitis and the other in inflammatory bowel disease, and our experience has been very good. We look forward to extending that.

With regard to the specifics of "Issues and Options" - coming as I do from the very town about which Angela's Ashes was written, my bias is that that book should be mandatory reading for all medical students. I strongly believe in this health care system, but I recognize the realities, and certainly I recognize what our patients say to us. As one of them said, if you cannot provide it, let me buy it. I do not want that to happen, but I think it is unethical to be a monopoly and not provide timely access to services.

My comments on taxation, I suspect, are similar to many. With regard to "Issues and Options" for research, Dr. Rockwood is the expert in the area. One of the questions that you asked in the report is where the money should be spent. I would reply: What is the core business of the Canadian health care system? If someone can tell me that, I would be happy to make suggestions about where the money should go. My bias would be measuring outcomes.

With regard to infrastructure, your report is right on target. One word of caution: We piloted a project with respect to primary care in which we gave the family doctors access over the net to the consultants at the QE II Hospital in GI, and it was a spectacular failure. Even though our waiting lists are hitting twelve months, they do not want information from us. They want to send the patient into the system to be treated elsewhere. We have had almost no business. As result of that, we have gone back one step, before the family doctor, and set it up for the patients. Once we have worked it out, it looks as though that might be very successful and highly used.

With regard to the infrastructure role, I agree that a national human resources strategy is urgently needed. Training programs, as I said earlier, are very good but we receive almost no training in management. Many of us never become managers, and I might include myself in that. Although the Royal College has moved away from its traditional stance that emphasized the role of management and health advocacy, there are still some ways to go with that, in my opinion.

On the Aboriginal health issue, again, my experience is very small. I did hear what Dr. Haddad had to say about places in medical schools for Aboriginal people. The only thing I would say about that is that we need to go further back. The place to get people involved and excited about a career in medicine is in high school, if not junior high school. I would certainly be very interested in seeing programs where kids in junior high or high school have access, and work in internships in the summer with university or other physicians, as indeed we do for the children of many of our colleagues. We intend to pilot one of those programs next summer for a school in Halifax that does not have a lot of money, and I think I would do that. However, it is asking a lot of someone who comes from a background where, perhaps, the high school is not that great to really make it into medical school without significant trauma.

Again, I thank the committee very much for hearing me. Those are the filters that I bring to this subject matter, and I look forward to discussing them with you.

Mr. Ryan Sommers, Cobequid Community Health Board: I would first like to thank the committee for this opportunity to talk to you today. It is a unique opportunity for a young person, a rookie researcher and a volunteer, to have a chance to talk about some of the issues you are trying to challenge.

As my card says, my name is Ryan Sommers and I am co-chair of the Cobequid Community Health Board, which is a volunteer community health board that represents a number of communities outside the Halifax area. In my other life, I am a second year graduate student in the Department of Community Health and Epidemiology at Dalhousie University, and Dr. Kephart is my supervisor, but I am here in a non-academic role.

I was not able to get my submission to you in advance, so I brought copies with me today and I hope that you have them before you right now. It is a pretty short brief. There is a nice little story in there from one of our community health board volunteers and her experiences down in the Clare Region, working on community-based health initiatives. There is a short copy of my presentation there with some pictures, to try and put a human side to my presentation.

The other thing I would like to note is that this is a consensus document. There is no body that governs all community health boards in this region. Mainly all of the ideas and experiences that are in detailed in that document are what we call "Experience that comes from the parking lot." We always talk about things in the parking lot, and so some of us decided to try and put together a formal document.

I know it has been a long day. I am sure you are pretty tired and you have probably heard a lot of statistics, so I promise that I will only cite one or two statistics. Most likely you have already heard this statitistic already today.

Basically, you probably want to know what a community health board is. Similar to health councils in Alberta and similar in concept to the community health centres in Ontario and Quebec, a community health board is a legislated, volunteer,community-based group, consisting of up to fifteen members from the local communities. Board members come from a variety of backgrounds and age groups. There are many students like myself; there are many retired persons, homemakers, engineers, business people, nurses, other health care workers such as nutritionists - even some physicians as well.

Currently there are thirty-seven health boards across the province, each varying in size, composition, and location. Yet we all share one common characteristic: we are dedicated citizens committed to enhancing the health of our communities. You have probably heard about the community health centre model in other parts of the country. We are not at a central location. We are not directly involved in health services. We are primarily involved with pharmacare activities. We are not directly involved in research and services. That is an important point to get across.

What we do is we go into the community and we talk to the people there, and do focus groups and surveys. We try to get a consensus of what are the health issues facing our region and what are the assets in the region to try and tackle these issues. What we do every year is produce a health plan which details the strategies we will choose to address the issues, and perhaps suggest to our larger district health authority - or DHA - structures, our larger regional health administrative structures, what are the problems and what actions should be taking place. They, in turn, take this information and include it in their business plans.

We are involved in a number of activities, anything from community development, health promotion and prevention, education, advocacy, and community capacity building. For example, some of us in my health board region have worked with the Sackville Seniors Club to help develop a fall preventions program. Other health boards have looked into developing a community garden and even to supporting a school breakfast program.

Similar gains have been accomplished throughout the province. In the Kingston-Greenwood area, their community health board has developed quite an innovative program known as Youth Boost, whereby they financially assist families with enrolling the children in community sports programs. Finally, newly established health boards in the Cape Breton region have already set to work and are partnering with the Meals on Wheels programs up there to help extend their days of service.

My main point that I want to get across to the committee is that the challenges facing many Canadians exist at the local level and cannot be tackled in isolation. By working together at the local level and helping to develop our communities, community health boards, volunteer agencies, senior clubs, local businesses and local health providers can adjust pertinent health care issues.

The new trend in health promotion-prevention is capacity-building and empowerment. By providing people with the right tools and resources, they can learn about health issues and take action. One mechanism to help build our communities is community development, and the federal government definitely has a strong and important role to play in this model.

Again, the five recommendations which I and other board members have come up with are only a consensus, and have not been voted on by all health boards in the region. These are just some ideas and things from our experience that we have encountered by working with the community.

Our first recommendation would be to improve and increase stable funding for community-based projects. Too often we hear of really successful volunteer initiatives that fail because their funding dries up. A common theme you will hear from the community health board people and people at the community level is that there is this lack of sustained funding. Most projects now in Nova Scotia, at least the ones working with community health boards, are either working through funding from the community health board or they are basically living day to day, or year to year, based on either sources of revenue.

The recent HRDC incident, with the billion-dollar blunder, will really affect the way that communities can address health issues. The funding system is a lot more strict now, and there are many more regulations and more paper to go through to help develop a community-based project. For a lay person seeking some resources and partnering with other groups, it is extremely difficult for them to move ahead.

Another recommendation from community health boards is to provide more opportunities for community-based research, as in more participatory types of research. Most national funding agencies are linking with decision makers now, and there are efforts to link the communities. We feel that this should be continued and perhaps strengthened even further.

A third recommendation is to develop mechanisms to share the experiences of other successful community-based projects. All the time I meet people and hear about projects that are going on in other parts of the country and they sound really great, but nobody knows who is doing what. This also extends to the health care community as well. There is a lot of important stuff going on. For example, in one community health board, they are working on developing a volunteer transportation system for seniors. It is a matter of trying to let people know what is going on out there: that there are these resources and tools out there that can help health care people and other, non-health care people.

That sort of leads into my fourth recommendation, which is to link community-based health projects with local, primary health care professionals. I am sure you have all heard of the recent survey conducted by the Canadian College of Family Physicians which indicates that family physicians are working an exhausting seventy-three hours a week. With all that work, and with a fee-for-service payment structure that encourages quantity care over quality care, few family physicians have the time to properly invest in their patients.

Finally, this last recommendation is a stretch, but it is an important one. I think many people within the health world would agree that it is perhaps time to start legislating population health, or determinants of health targets at all levels. From the community, region, province, to the national level, population health is a great approach. Directly, it is a great framework within which to challenge issues, but it often fails at the largest societal level because you need to work with other groups; you need to work with finance, and you need to work with education. There really is no model in place within government to accomplish this goal and to try to work together.

We thought that if perhaps the government could legislate initiatives, and sort of set targets in law that they need to address, this would be useful. Probably the best example of this is if we could just imagine, back in the late eighties or early nineties, if we had actually legislated the reduction of child poverty. We would be in a lot different situation today.

Those are just quick recommendations from people within the community, arising from what we experience every day.

The Deputy Chairman: Dr. Rockwood, you talked about conflicting views with respect to the aging population in our communities. As we go across the country, I find myself feeling rather badly for people who are getting older, because I think they are being blamed for much of the perceived increased costs in the health care system. When it really comes down to it, the most expensive year of your life is the last year of your life, whether you are older or younger. I just wanted to know if you had any views on that, or what we could put on the record statistically that would dispel this myth, because it was one of the myths listed in our first report under "Myths and Realities." I have spoken to older people, and I have actually heard from septuagenarians who were quite concerned that, somehow or other, the younger generation would blame them for the increasing costs of the health care system. If you have a comment on that, or if anyone else has a comment, I would appreciate having it.

Dr. Rockwood: I think there are three points to be made here: Number one is, of course, that the last year of life is the most expensive one. That is how it should be for most people, particularly the younger ones.The second point is that, contrary to the argument that the aging of the population is what fuels the costs of the pills that are used and the technologies that are employed, these are not employed in respect of age but, rather, employed in respect of particular diagnoses.

In addition, many of the things that are employed there are initiated without an adequate understanding of why they are being employed. I say that on two grounds: The first is that they are initiated without insight into how the use of the medicine or technology will change the overall health of that patient, and there are many examples. A controversial one would be to ask what is driving the widespread use of anti-hypertensive medications in elderly people in long term care with advanced Alzheimer's disease? What is the end of that? That is a controversial one. However, there are less controversial ones involved in which pills are being used and which technologies are being employed in the absence of understanding why it is all being done. The people who are most likely to have that happen to them are older people. It is not their age which is the determinant of that, but the idea that they have complex problems, and our failure in this respect is our failure to deal with complex problems.

If you wanted to argue the age case, you would say, "Who is having all of these things done?" It is the old people. If you wanted to argue the "not-age" case, you would say, "If we understand what the diagnosis is, it is the diagnosis that is driving the pills and the technology." My comment would be, in essence, who cares about that, if it is being done to a good end?What I object to are things that are employed where, standing back, it is very unclearas to me as to the end to which they are being employed.

Senator Robertson: Gentlemen, the wisdom that you bring to the table is greatly appreciated. In some ways it is almost a contradictory effort that we are conducting here - at least contradictory in regard to the types of testimonies we are receiving. If you are in one spot, you get this testimony, and if you are somewhere else, you get another type of testimony. It makes you think, what is the happy medium of all this?

I will be asking general questions and any one of you can perhaps respond to those questions.

Let us start with the Canada Health Act. Would the health system be more effectively delivered if we had a clearer interpretation of the Canada Health Act within the act itself? I sometimes worry about how the act is interpreted.For example, with respect the "accessibility." I suppose to you, Chair, accessibility would mean one thing. If you want to define it, it might mean something different to someone else. To Dr. Leddin, it might be totally different, and to Dr. Kephart, it might be something else again. How do you define these things and is there a misunderstanding in some of these issues?

Perhaps you might want me to pause after each of these questions? If not, I will just proceed with my questions.

The Canada Health Act, of course, is the foundation under our system. It has been in place for forty years, and it is a bit like an old house; every once in a while you need to check its foundations and perhaps rebuild it to make sure that you are in a secure position. Should I stop there until you think about that, or do you want me to go on?

Dr. Leddin: I think that should keep us occupied. That is, after all, an extremely difficult question. The principles of the Canada Health Act are what has defined this health care system as the most ethical one that I know of in the world. On the other hand, we are facing many challenges, and it is perceived now as being a box that restricts the options that we can use to deal with some of these challenges.

I am not so sure that there is anything wrong with the principles of the Canada Health Act or that they need to be changed. The starting point is that they are principles, and principles generally apply to a clear mission statement. I am not sure that I have heard clearly, either provincially or federally, just what business we are in. Those are great principles, but to which mission do they apply? I do not know.

Senator Robertson: Does anyone else have a comment on the Canada Health Act? That is what my question was aiming at, Dr. Leddin. We all seem to think we understand, but really, when it gets down to the fine tuning of it, you ask yourself, "What does that really mean?" It causes some confusion. I will leave that with you for the moment.

Of course, back when the Canada Health Act was first drafted, and medicare - for facility, I will just call the health system medicare - came into existence in Canada, as we know, back then it covered sort of a hundred per cent of health care. Today, as you probably know, it only relates to about forty per cent of the health care that is offered in the local doctors' offices or hospitals. The other sixty per cent is either in the home, in the school, or in the workplace.

The witnesses who have come before us, there has been absolutely no difference in their testimony when they list the things that are important. Sometimes their ideas may have been expressed differently, but the bottom line remains the same: The most important things left out of the system right now is home care, community care and pharmacare.

Let me just leave that there for a moment and move on to where we are today. The witnesses who have come before us have said, almost consistently, that the waiting lists are too long. In relation to some diseases, it seems almost criminal the way in which the waiting lists seem to have built up. Many of our citizens cannot get access to a family practitioner. I have a neighbour who drives about sixty miles to see the family practitioner. These people are saying that the system is not serving them well. If you have to wait ten, twelve, fourteen weeks for tests, or if you have been diagnosed with a very serious illness and you cannot get treatment for another ten or twelve weeks or longer than that, how is the system serving you?

What I am saying - perhaps poorly - is that once they get into the system, people are pleased with the services they get there. The frustration lies in trying to get there; trying to access the service. I do not know what we can do about that without two things occurring: more human resources, of course, which really means more money, I suppose. If we go into pharmacare and really strong home care, community care, that will require funds as well. We know especially in Atlantic Canada, but we hear it from all across the country. Alberta, for instance, is almost throwing up its hands, and it is the richest province we have. They are looking at implementing drastic methods. I know that we all love the system, and we are proud of it, but people are frustrated and angry that the system is, in some ways, failing them.

Thus, if we want to provide the proper care, and if we want to provide it where sixty per cent of the care is given, where do we find the money? Do you think we can actually find the money in doing what we are doing now, better? What else do we do? Tied to that, I suppose, if we need more money, should that money come from the taxpayer in the form of higher taxes, or should it come directly from the users of the system through some form of partial payment for services rendered?I will stop there.

Dr. Kephart: Yes, the money issue. I heard Nuala Kenny speaking to you earlier today, and a statement she often makes is that the biggest problem for us in the Canadian health care system is making choices. In fact, we have tons of health care. We have lots of things we can do, and the list of things we can do and the options for us are growing at a rapid rate. In fact, one of our key problems now is a rapidly growing set of choices. Mixed in with that are very difficult decisions being made every day on a patient-provider level around, "Is this the right thing to do? What should I do? What is the evidence?" In Canada, we have some three hundred new drug products per year coming out and being approved. This is an enormous intellectual challenge for providers. However, the issue is how are we to make choices? That is the big challenge. We can either make choices as a system, or we can move in ways that force choices on individuals. If we are to move in a way that will force choices on individuals, we must think about whether people will make rational decisions.Will we be achieving the goals that we are trying to achieve?

If our solution is to simply provide more money, and do it through user fees, for example, the question is: will people make appropriate choices? Will they make rational choices that will be efficient? What we have at this point is really overwhelming evidence from many studies that show that patients frequently do not make efficient and rational choices when presented with a cost. Why? Well, they are not the experts here. The studies, for example, on drug user fees are showing that user fees may not affect use/non-use very much, but they do affect the quantity of how much you will use. Thus, patients may reduce the amount of blood pressure medication they are taking, for example. That may be one way they adapt to the cost, but they are not the key decision maker, necessarily, on what drug is prescribed.

The evidence is fairly overwhelming at this point that, yes, you are creating an incentive. Does the incentive work? Yes, it does work. People change their behaviour in response to financial incentives. Does it raise revenue? Of course it does. When you put in user fees, you bring more revenue into the system. You are creating an incentive, and that incentive is being put on people who do not necessarily have the tools, in many cases, to make the right decisions, or make decisions that will best affect their health. The evidence is very clear: People do not make the decisions.

If you are interested in creating incentives in the system to change behaviour, then by all means put the incentives on the people who are best able to make good decisions. The evidence is that frequently it is not the patient who can always make those best decisions. Perhaps there are cases where they can, but in many of the contexts where we are talking about user fees in the system, we know that patients are not making those decisions professionally.

Senator Robertson: I was not thinking particularly about user fees, but that is fine. Anyone else?

Dr. Rockwood: I think, in both your questions and the answers that Dr. Kephart has given, it is evident that there are certain tensions. There is the tension between the vision that we hold and the things that turn out to be reasonably non-controversial, and the ways in which people achieve them, or the difference between whether the decision is made at the level of the system or whether it is made at the level of the individual. I have no scepticism whatsoever about user fees. I am sure that for the population they would serve, they would be a disaster.

I do have scepticism about the way in which our system makes decisions because we either seem to wind up doing more of the same or, as we have done in the last ten years, less of the same. While there have been exceptions, such as home care which have come about incrementally and proved to be a good thing, there is still too much the idea of continuing along the same lines of the way things have always been done.

I can remember twenty years ago, in medical school, being told about studies that looked at ways to get doctors to stop ordering unnecessary tests. Here we are, twenty years later and, apart from last year, I have never worked in a system in which, every year at the hospital in which I worked, we did not announce cuts. People say, "The system is growing. The money is growing." I have never worked in any environment other than an environment in which we have been announcing cuts. Even in that constrained environment, you can still walk up to any ward, right now, and pick up a chart and see tests there that do not need to be done. Thus, our ability to effect change at the system level by simply doing less of the same has not been very effective.

I think that the time is appropriate and there is a good philosophical argument to be made that while we would share certain principles such as accessibility, we would allow a very wide range of experiments in accessibility to be done. I think that it certainly would be of interest at the community level to see what people would opt for if they were given a range of choices about accessibility. In other words, if everyone can get to the same doctor or the same procedure, but the accessibility issue revolves around the amount of time that it takes to get there; or if one doctor can order any test, but the accessibility price is the amount of time that it takes to get that test, versus if only certain doctors can order particular tests, there is an accessibility issue then in how you get to such a doctor, and how it is done. These would be effective choices, but they are not the sorts of choices right now. Right now, we tend to tighten our belts and push ahead. I do not think that is wise.

Dr. Leddin: With regard to the accessibility issue, I think there are innovative ways in which we can do business. Our new extended-role nurse, for example, in inflammatory bowel disease will be seeing real patients in the physical plant five half mornings a week, but will be running a virtual clinic via e-mail for the other five, for patients from Cape Breton to Yarmouth. A lot of what we do is information transfer rather than actually needing to see people.

With regard to pharmacare, it is an interesting problem. People get caught without coverage for a variety of reasons. For example, in our business, Crohn's, a common condition, has an onset at age 16. If you are diagnosed with that disease, you will never get insurance for medication. It will just not happen under a private system.

On the other hand, for adults, there is a little bit of the ant and the grasshopper syndrome where the ant saves and pays insurance for medication and the grasshopper sings and does not, and then gets ill with an M.I. at fifty, and wants the public to pay for it. There are, indeed, some contradictions. Certainly, if we are to have a national pharmacare program, we should all pay into it.

Senator Robertson: We should all pay into it?

Dr. Leddin: We should all pay into it to avoid the issue of some people choosing to pay in when it suits them but not contributing at the early end.

Senator Robertson: How would you have them pay into it? Would you have a system run by the government or would you have it run by a private insurance company, or a combination of both?

Dr. Leddin: In running through your report, if I read the tenor of it correctly, it is that you would welcome increased patient responsibility for using the services, and so would I. I think people should have the equivalent of a Visa or Mastercard report every month for the services or drugs that they are accessing so that they know exactly what they are getting. I think it would be very interesting.

We have patients who come back from Florida and are very indignant in the clinic, saying, "Why could we not have a screening colonoscopy six months ago? This is disgraceful." My reply is, "Why did you not pay U.S. $1,500 in Florida to have it done there?" The public does have extraordinary expectations. On the one hand, nationally, we want universal coverage and high quality, but people compare us to a U.S. system that apparently has no problem with having 40 million people with no coverage. It is not a very fair comparison.

Senator Robertson: They want the American system with our costs.

Dr. Leddin: That is, without paying for it. I have, perhaps, just one other point: The national debate, which I think a number of you touched on in your questions. This is an extraordinarily difficult country in which to have a rational debate with respect to this issue of health care. There is something strange about that. I mean, many other countries seem to have a more tolerant attitude to disagreements. Perhaps it is the tradition of soapboxes at Hyde Park Corner, I do not know. However, in this country, this issue seems to be a hot button issue that is very difficult for people to debate without instant polarization. It is very odd.

Mr. Sommers: I can probably just comment on my experiences in working with communities. Home care is a huge issue right now, and I am not sure what it will look like in a decade from now. There will have to be some huge choices made there. Right now, at the community level, people are frustrated that they cannot get into a nursing home, or they cannot get their parents into a nursing home, but people are working at the problems; they are trying to make their own solutions, their own alternatives.

In our region, members of church groups are working together to initiate daycare programs for seniors and elderly. All of these support groups are popping up through seniors clubs or, as I said, the churches are working to address these issues. Right now, I do not see this issue being resolved in the future any time soon, because there are significant problems.

Again, my bias from the community is that there are solutions within our communities. People are working together to get around these systematic issues. It is another way of investing in our communities to have the community work together to address these issues. Throughout the entire province probably every health board with each of the nine regions are working with seniors groups around daycare programs or programs for seniors.

Right now, it is an extremely difficult trade-off and it is one that has to be debated at the national level. People talk about values all the time, but it is hard to really know what people's values are around this issue. Again, my bias from the community level is that there are solutions at that level. They are not a total fix, but there are some minor things that we can do at that level to address some of these problems.

Senator Callbeck: Mr. Sommers, I wanted to ask you about the community health boards. You said there were 37 in Nova Scotia. Your volunteers, are they elected? Are you appointed?

Mr. Sommers: They are not elected in the way they are out west. You enter a community health board mainly through an application process, where people submit a resume and then they go through a screening process. In our region at least there are standard questions to ask and a waiting system to ensure that we have people who are community-focussed, who can bring a different aspect, or who can bring certain aspects from the community to our board. But we are not elected. Through my studies I saw that, out in Saskatoon where they are elected, they get dismal turnouts. Only ten per cent of the people participate in these elections. It does not seem to be a very effective way to go, plus, I think that elections bring the political factor into play.

The great thing about working at the community level is that the whole political spectrum disappears. There are no "left" or "right" people on a board. We all know what the issues are and we all work together. Our board, at least, works very well together to address these issues. I think having people go through elections would be very difficult and would bring the political process back in.

Just on another note: In Nova Scotia we have these nine district health authorities.There have been recent changes to legislation, and also past legislation, that two-thirds of the membership on a regional or a district health authority must come from the community. Thus the community health board takes people to be on these boards who they feel represent their community and will advocate for the issues. There is some trade-off between the elected and non-elected system.

Senator Callbeck: Who makes the final decision, the regional boards or who?

Mr. Sommers: No, at the community level for the community health board, we set up an external group that is not directly involved in the health board. That external group is made up of former health board members from a different region. They go through the screening process and they are sort of disconnected, so they have an unbiased view in going through all of the applicants.

Senator Callbeck: You mentioned that you do surveys, you do focus groups and you come up with a community health plan, is that right?

Mr. Sommers: Yes.

Senator Callbeck: How do you implement that? Do you have any budget or do you have to go to the region for funding?

Mr. Sommers: One of the neat things that just happened on January 1 this year is that we were legislated, meaning that we no longer have an advisory role; that what we produce for the health plan has to be addressed by a regional structure, namely, the district health authority. The problem is that it is how they address that, and when they address it, that is an issue.

However, the health plan is basically our strategic document. We identify the issues through our consultations and then, based on what the community says and, again, based on the evidence, we try to develop ways to address the issues in our community. This could be by trying to identify both the issue and the solution, and bringing them closer together. This could entail just working with other groups or it could entail advocating for a community, going beyond health care structure and perhaps going to the Department of the Environment or the Department of Justice to take these issues forward.

The greatest thing about this recent change is that it gives us a lot more power. I think most health board people would say that since we are now legislated, we feel we have a greater say in the health of our communities. Most people do not necessarily feel that they are tied to the district health authority; that they feel tied closer to their community. They do not like the idea of being a mouthpiece for the district health authority.

I think it is really an empowering process, too. I think people are really willing to work hard and take issues forward. It is one part of the community health board model, a very new idea which has really not been adopted elsewhere. I know in Alberta they have community health councils, but they only have an advisory role. If the government has concerns or questions, they usually go to these councils but the councils do not usually have a decision making or a power role.

Senator Callbeck: You say that it has just been legislated this year. How long has it been in effect, though?

Mr. Sommers: The councils came in in 1995, so from 1995 until recently, they were primarily advisory. Then we went through what you will probably recall as the process of Bill 34, which is now Act 34. That sort of changed our structure and it gave us a lot more say in the health issues influencing our communities.

Senator Callbeck: I have one question for Dr. Kephart. You talked about transfer payments and you mentioned the CHST, that it should not be on this per capita basis; that there should be other factors involved there such as need, and so on. Then you mentioned equalization payments. I take it you agree with that program as it is, or do you think there should be ten provinces involved in the figure rather than five?

Dr. Kephart: Politically, what we have seen on the national level is that provinces have crunched the numbers, and have come to realize that pushing for changes in equalization may be more lucrative than pushing for changes in CHST. However, I would agree that equalization should probably be based on a 10-province formula. One of the interesting things in Canada is that, at the provincial level, the concepts are not big issues in many ways.

At the provincial level in Nova Scotia, for example, or in Prince Edward Island, we would see that the amount of revenue raised per capita in some parts of the province would be far less than the amount of revenue raised per capita in other parts of the province. Yet I do not think that, at a policy level, we would envision that the amount of resources that should be provided should be tied to the revenue-generating capacity of that part of the province. Nationally, however, we do that. Nationally, equalization is partially addressing this issue, but the amount of revenue available nationally to pay for social programs is tied to the revenue-generating capacity of provinces.

There is one other area where this is the case, and that is at the municipal level. Where municipal resources are raised through municipal tax systems, it is still the case that the amount of revenue available to municipalities to pay for certain services is linked to their revenue-generating capacity. I think there ought to be a principle here that, when it comes to social programs, the social programs you can afford ought not to be linked to your revenue-generating capacity, because once you go down that road, you are heading down a slippery slope.

One illustration of this occurred in a very widely-cited study, which you probably heard about in your deliberations, published in the British Medical Journal last year. That study showed that income inequality in the U.S. is highly associated with mortality; income inequality in Canada is not nearly as highly associated with mortality.

This finding has been widely talked about in Canada. One of the main hypotheses about why this is the case has to do with the provision of public goods; that the education system in the U.S. is linked to the municipal tax base. In Canada, our education system is largely paid for through our provincial tax base, so we have a more equitable distribution of our education funding. In fact, we have a more equitable distribution of the whole range of government services in Canada than we see in the U.S. In addition, new studies that these same people are doing show that the U.S. is the aberration; that in other countries which have a Canadian-style system of distribution of public goods, we do not see that strong relationship between income inequality and mortality.

I think it is important to look at what we do federally, in contrast to what we do provincially. We need to fall back on basic principles here, and yes, equalization should be based on the 10-province formula. The revenue-generating capacity of a province ought not to be linked to its ability to provide services, because otherwise you will be going down the slippery slope of growing inequality and ability to provide basic social services.

Senator Cook: I would like to focus for a moment or two on population health, and I notice, Dr. Leddin, that you advocate increased federal involvement to set national goals. Ryan, if I may call you that, you recommend that the federal government legislate population health. Given that the provinces implement the goals that are set out, or whatever, or they have some say in this process, how do you see the implementation?In other words, once you legislate or you set national goals or standards, how do you see the implementation of those in the provinces? How do you see that working itself out?

Dr. Leddin: I think, throughout your report, there are a number of areas where the tension between an increased federal role in health care and the provincial role comes out. It is not just in this one but in funding, and in a number of other areas as well.

However, the provinces, perhaps because of disparities in wealth or in current intent, do not necessarily seem to focus on a uniform set of goals for problems that are common to everyone. The manpower, for example, or human resources, is a perfect example of that. We have seen net migration of health care workers to richer provinces because salaries are higher. That comes as perhaps a loss to the poorer provinces. The constant poaching from Memorial would be an example of that, too. Those kind of issues transcend provincial boundaries and I think there is a strong role for a federal government in setting goals in both human resources and population outcomes.

In this country, there are always tensions between the two levels of government, and I would be astonished if those ever went away. But, clearly, in my opinion, the federal government, even though its percentage share of total spending is quite small now, still it has a very significant role in overall steering. Many of the main population health initiatives, particularly with regard to prevention, which has a long term focus as opposed to a shorter term focus, that you might argue should be provincial are probably best served by a federal approach.

Mr. Sommers: We are stepping on the grounds of federal and provincial relationships, which is a science in itself. The national government does have a strong say in the health of the population. Probably the best example right now is the healthy child development initiative that came into place a couple of years ago. It is really a perfect example of how the federal government is attacking the public health issue. The problem is that research on the issue of health keeps seeing that income and the importance of social status and of social support is important as well. Turning that around and applying that to practice, which is extremely difficult, as I mentioned in my brief, requires a new way of thinking. It requires a considerable political will and a way in which to work with others, too. We say that we should legislate it,because that is the most extreme way we could think of to move toward that type of model.

With regard to setting goals, we have all seen them fail before. I gave the example of child poverty. We said in the late eighties or early nineties that we intend to reduce child poverty by the year 2000, but over that time it has increased. It is a matter of achieving goals, which sometimes do not get addressed at all, and thus it becomes a subject for legislation.

There is probably something that exists there in between, and perhaps it really comes down to a question of leadership. Who will stand up and take this role? I think we all have a part to play in that. There is, of course, the federal and the provincial people as well, but as common, everyday citizens, we too must start to take a greater role in these issues.

These are extremely difficult issues. This is a whole science in itself, and it will probably take a couple of more years of research and work until something comes about, and then another couple of more years of actually moving towards a type of model. Thus we recommend the legislation route because it is the most extreme, and we thought, why not be extreme?

Senator Cook: Yesterday in Newfoundland I listened to a population health witness talk about the size of the envelope and having to set priorities, and some of them just have to be done first, like immunization, home care, and the other front line things that you need to take care of. However, there never seems to be anything left for wellness, for obesity classes, for well baby clinics, for neo-natal moms with breast feeding problems. The programs, the education, we never seem to be able to get there because the envelope is so small that the priorities are still in the illness corner, and we cannot seem to move out to wellness.

The other thing that concerns me now as I read the daily papers is the whole new issue of immunization, anthrax, smallpox, and the list goes on. We have not heard about the cost yet. We have heard about the need, and I read yesterday that there is talk of vaccination or immunization for smallpox. Who will deliver it? Who will manage the availability? Where willl it go? Possibly, because I see immunization in population health now, it may go there, but wherever it goes, it will impact on an already overburdened system.

I would like your comment on that, any comments from any one of you.

Mr. Sommers: September 11 has definitely changed everything in terms of public health. Switching from the acute model to a more preventive type of model is extremely difficult. People keep saying that we need more resources. Others say that we should take resources from elsewhere, or bring in some sort of resource sharing plan, which, again, is difficult to do. It is an extremely difficult question.

This will be a difficult shift. I do not know how we will do it. Again, I think it comes down to leadership within our communities, and that we will have to start pressuring our governments and other leaders to think of this other approach.

What we hear at the community level is that people want to move to this population health model. They know what is important to them. Again, the difficult part is that it is very tricky. I think we would probably do it on a regional-local level. I think at a regional level we can address issues, sub-priorities or goals to challenge these health issues.

However, there are still broader issues. For example, income inequality is a huge determinant of health. One of the things we could do is flatten out the income distribution system, which you could do, but politically I do not think that the people at the Fraser Institute would like that very much.

Dr. Rockwood: Yes, I think one of the subtleties in terms of knowing how to priorize within health care, which we are vulnerable to having go wrong right now, is that many of the things that are being promoted as being good, health-promoting factors and wellness-promoting factors do not have an evidence base that would support their being taken up in a broad way. There appear to be two ways in which people are approaching this issue: One is to say that certain of these factors should not be held to the same standard of science, which I think is the wrong approach. However, given the way that we have funded health research up until now, we cannot possibly hope for that view to compete with evidence of effectiveness which is funded by a multi-billion dollar multinational pharmaceutical industry. Thus, if we say that things must have an evidence base, we put them on an equal playing field.

At the same time, if we do not invest in the effectiveness assessment of these more low-tech things, then we will not really know how to advocate for particular wellness programs. I think that is an important point that needs to be made.

Dr. Kephart: I would like to applaud that comment. It is very interesting that when you look at, for example, even the current approval process around medications, the focus is on efficacy and safety. We have all of these trials, for example, comparing new medications with placebos when, in fact, from an efficiency point of view, one of the things we need to know more about is the effectiveness of the new medication relative to other types of medication that are currently being used, or the effectiveness of this medication relative to the herbal remedy that is being frequently used. In my mind, this is an absolutely critical issue that needs to be addressed in the way we approach research and in the way we approach research funding.

I am concerned that continued focus on matching funds for research from the private sector will continue to steer a large share of our federal health care funding going into efficacy research down the same track that we have been going in the past, which is not focussed on some of the key, most important policy questions that we need to be addressing around relative effectiveness of different treatments and interventions.

Senator Léger: First of all, I would like to thank you, Dr. Leddin, for the compliment that you gave us at the beginning, that we had gone through this all day, and that I am not a specialist. I am new here, but I would just like to say one thing: You mentioned how difficult it was, and wondered why it was so difficult to have a rational debates without polarization. Let me concede that we know that. You were also talking about an increase in patient responsibility.

Can you tell me, is the gap between non-professionals and professionals, and between highly professionals and specialists - and I am going more and more with that description - is the gap between those groups shrinking a little bit?

Dr. Leddin: The economic gap?

Senator Léger: The knowledge gap. I think the polarization is a kind of self defence.

Dr. Leddin: I think the difficulty with having the debate is linked to the patient responsibility element for sure, because people have no understanding of what the costs are, or what the choices are. I would imagine at the community-based level, it is very nice to make recommendations about long term programs, but I doubt that anyone would be willing to close a coronary care unit bed to achieve them. As you say, the choices are very difficult.

With regard to the gap in knowledge, I think it is actually blurring a bit. Certainly if you look at the nurse specialists whom we have working with us, after four years of nursing school they then do a masters degree for two years, and they have the equivalent training of a physician coming out.

Senator Léger: What about the ordinary people? Are they beginning to be more open to change, perhaps because of television programs such as we see on Discovery and the Learning Channel? Is it a bit better?

Dr. Leddin: That is a very interesting question. Some of them are certainly more open, and some of them are reverting to pre-Galileo science in that it is a belief system rather than a science-based system. It is quite an interesting situation. A great number of people are actually moving away completely from an evidence-based, scientific medicine to something that is more of an actual belief system. It is quite odd.

Dr. Rockwood: Let me just make one point about that. Sometimes when people come to us, the knowledge gap is partly a knowledge gap and sometimes it is an expectation gap. It is often salutary for us to understand what their expectation is, and then to understand that the evidence that we have will not help them reach a determination of whether their expectation will be met. For example, there is a huge debate right now about whether the new Alzheimer drugs work. When I am asked about that by a patient and I go to the scientific literature on this, none of the things that they are interested in knowing about are actually demonstrated within that body of work, which has been assembled there at the cost of tens of millions of dollars. None of my patients ask me, "At the end of this will I be able to spell `world' backwards better than I can do right now?" Yet that has a determining influence on whether or not we understand how the drugs work. I am not picking on the Alzheimer group, because in some ways they have done more about this than have other groups. However, very few of the ways that we have chosen to evaluate the effectiveness of what we do right now takes into account patient preferences. Part of the reason you have noticed that groups retreat into a defensive posture is that they cannot really answer the question in the way that the question is put to them. Once again, the instinct within medicine is sometimes to say, "Gee, I wish we could do it in that way," but very often it is to insist that knowing how to spell "world" backwards is actually the preferred thing to be able to do, and the question that you raised is not very important. I would hope that one of the changes that coping with the aging boomer population will bring about is that it will no longer be acceptable to evaluate drugs and technologies without taking patient preferences into account, because we sure get away with it now.

The Deputy Chairman: I wish to thank Mr. Sommers, Dr. Leddin, Dr. Rockwood, and Dr. Kephart for bearing with us here. It has been a very fascinating hour and a half.

The committee adjourned.