Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 43 - Evidence
CHARLOTTETOWN, Wednesday, November 7, 2001
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 9:10 a.m. to examine the state of the health care system in Canada.
Senator Marjory LeBreton (Deputy Chairman) in the Chair.
[English]
The Deputy Chairman: Each day, as we turn on our televisions and open the newspapers, we see many stories related to the delivery of the health care system. In the news today, there is a story about people using the MRIs on their own time at the Vancouver Hospital. They are paying $925 to have the complete body scan. User fees are also being considered in Ontario. In the National Post this morning, there is an article about Mr. Klein and the ramifications of Bill 11 in Alberta. It is a topical and crucial issue that we are facing and the Senate committee is making an effort to hear the views of all Canadians, so we can come forward with a comprehensive study and recommendations.
Ms Heather Henry-MacDonald, Chair, P.E.I, Seniors Advisory Council: The Prince Edward Island Seniors Advisory Council is a group of 12 people who represent the geographic and cultural population of Prince Edward Island. The Council was created in 1998 to advise government, through the Minister Responsible for Seniors, on issues that concern seniors of the province. I am highlighting the issues that most affect the older population.
The aging of Canada's population provides all levels of government with challenges and opportunities to plan for and respond to the diverse strengths and needs of current and future seniors. In Atlantic Canada where the population is aging faster than in other regions of the country, the challenge is greater. The percentage of seniors in the Prince Edward Island population has risen in the last several decades. In the year 2000, the population of Prince Edward Island was almost 140,000, of which an estimated 18,200 were 65 and over.
The impact of an aging population may not be the crisis some have predicted if we are prepared, if we anticipate the likely impact of an aging population, and if we are ready with policies and programs to meet Islanders' changing needs.
In recent years, governments, health care professionals, community groups and seniors have debated the issue of how social supports can best be used to enable seniors to remain living in the community. Seniors have indicated that they wish to remain at home for as long as possible. We agree that effective home care can lower long-term costs for the health care system. Furthermore, a national home care program will allow individuals to be cared for in comfortable surroundings rather than in an acute care setting, which should be only utilized as a last resource.
The September 1999 newsletter, Vol. 24, No. 3, of the Canadian Association on Gerontology reports as follows:
Home care is not currently available to all Canadians on a universal basis; it falls outside of the realm of Medicare. Provinces vary in the services they offer, eligibility criteria, and the extent and whether user fees are charged. Yet for many, home care is considered as necessary and appropriate in an integrated health care system. The National Forum on Health (1997), the National Advisory Council on Aging (1995), the Canadian Home Care Association (1996) and the Victoria Order of Nurses of Canada (1997) have all recommended comprehensive community based health and support services be recognized as essential services in the Canadian health care system. The Canadian Association on Gerontology recommends that the federal, provincial and territorial governments move without delay to ensure a universally accessible, comprehensive home care program for Canadians.
Prince Edward Island has established a home care support system, but it is not adequate to meet the needs of the elderly residents. Prince Edward Island ranks among the lowest of the provinces in expenditures on home care as a per cent of total health expenditures. The capacity of the P.E.I, Home Care Support Program to provide service is based on available resources. As a result, there is no emergency or on-call services provided on a twenty-four hour basis.
Prince Edward Island has no legislation or standard governing the public or private home care sector to address risk, liability and quality assurance issues, or to form a basis for relationships between public and private home care sectors. The issue of monitoring the care of vulnerable seniors has been raised by seniors' organizations as a major concern.
An example of a national program that assists Canadian citizens to remain healthy and independent in their own homes and communities is the Veterans Independence Program. I have described it in the brief. It has been successful in Prince Edward Island.
P.E.I, does not have an adequate provincial restorative care program. A pilot project has been established for one region and small acute care hospitals are being utilized for restorative care in other regions of the province.
In P.E.I,, individuals 65 years and over used 45 per cent of in-patient hospital days at the Queen Elizabeth Hospital, which is our largest hospital, and 54 per cent of the days at the Prince County Hospital, which is our second largest hospital. At the rural facilities, which consist of five smaller hospitals, 65 to 75 per cent of the days were used by individuals 65 years and older.
More in-home services are needed, so that individuals who have acute or chronic conditions can be as independent as possible. For example, now that hospital stays have been shortened due to new medical policies, specialized care in the home is required.
Caregivers must be specifically named in health care and home care policies, and they must be targeted as having specific needs to ensure their well-being. It is crucial that government allocate financial resources to support this group of potential clients, and to develop the services and resources which caregivers need in order to maintain their responsibilities without undue negative effects to themselves and their personal health.
According to an Atlantic report by Keefe and Fancey in 1998, informal caregivers provide 80 to 90 per cent of the assistance to older persons in their homes. The largest group of caregivers was comprised of women aged 45 to 64, while almost 14 per cent of the people aged 60 to 74 are also caregivers.
With an aging population, demands for care giving support will increase simply given the increasing number of seniors, which is not in proportion with the younger population. Trends impacting on the supply of informal caregivers include participation in the labour force by women, marriage and childbearing at later ages that may result in concurrent child and eldercare, the sandwich generation, smaller families, geographic distance between family members and higher divorce rates.
Although the older population is often seen as the main user of prescription drugs, addressing the issue of reducing the costs of prescription drugs needs initiatives to promote more appropriate prescription practices and more appropriate drug use. I have a quote in the report about advice on that.
Senior citizens, especially low-income elderly women, are in need of expanded coverage for publicly funded prescription drugs. A national pharmacare program would provide a safety net. In the event of illness, these individuals are not sheltered from drug costs or other high prescription drug costs.
Prince Edward Island has a Drug Cost Assistance Program for citizens 65 years of age and over. However, as not all medications are covered in the provincial formulary, some seniors experience catastrophic costs. In addition, when an elderly person is discharged from hospital, the necessary medications and supplies to restore function and health are not covered.
In the Atlantic provinces, there is no generally available public programs to limit the exposure of individuals and families to high prescription drug costs. A recent study funded by Health Canada's Health Transition Fund, found that over 25 per cent of the population of the Maritimes are without catastrophic coverage for prescription drugs, and that another 25 per cent might be considered under-insured.
We recommend that pharmacare be included in the Canada Health Act. The federal government needs to show leadership in developing a collaborative network of government, physicians, pharmacists and the public to create the environment for change. One of the strategies needed is to educate those who prescribe and those who use the medications on the use of alternatives to prescription drug use. Lifestyle changes such as active living, adequate nutrition, social interaction and intellectual stimulation, are examples of these alternatives.
Institutions for seniors who can no longer be cared for at home will always be necessary. Currently, only seven per cent of people aged 65 and older live in institutions and the average person entering Prince Edward Island nursing homes as of December 2000 is 83.1 years. During 1999 and 2000, the average length of the stay was 2.8 years.
People entering long-term nursing care in P.E.I, are responsible for the full cost of care. This similar to other Maritime provinces, but it is different from the rest of Canada as 90 per cent of Canadians pay only a portion of the cost of long-term care. If Prince Edward Island residents in long-term nursing care deplete their savings and require financial assistance from government, they will be subject to means testing, which includes a review of their income and assets.
When the hospital care and medical insurance plans began, one of the decisions made with respect to the method by which these programs would be funded, was that no means tests would be required of patients before they receive medical services. It was felt that a means test would discourage low-income patients from seeking medical assistance, because they would feel it was demeaning to have to say they were poor in order to receive full medical care. A similar policy should be extended to long-term care in the publicly funded system.
We agree with the idea of primary care reform and would like to see a health system where health care providers work in multi-disciplinary teams so that Canadians could access the most appropriate health care providers, which are not necessarily physicians. For example, health services by social workers, nutritionists and fitness and lifestyle consultants could be accessed and covered under medicare.
Unfortunately, the current medicare system contains few incentives for health care providers to reduce costs, to strive for better integration or for consumers to use the system in a responsible manner. We suggest that incentives be investigated to assist citizens in understanding that their perceived right to universal health care is accompanied by a responsibility to use health care in a reasonable manner and to maintain their own health.
Recent studies raise the question of why the elderly are getting much more health care. The prescribing practices of doctors with their older adult patients reveal some interesting information.
When we speak about ensuing fiscal sustainability, we have a suggestion there that possibly we could tie some of the costs of health care into income tax. An extra sheet describing that has been added to our brief. We propose bringing home care, long-term care and pharmacare within the purview of the Canada Health Act. This will ensure that every Canadian has timely access to all medically necessary services regardless of their ability to pay for these services, and that no Canadian suffers undue financial hardship as the result of having to pay health care bills. Comprehensive health care should fall under the Canada Health Act, and the four principles of universality, comprehensiveness, accessibility and portability in the Canada Health Act should be maintained.
The Deputy Chairman: Thank you very much for your excellent report.
Ms Mary Hughes-Power, Director of Acute and Continuing Care, Department of Health and Social Services, P.E.I,: In Prince Edward Island, funding for home care is provided to the Regional Health Authorities by the Department of Health and Social Services. The department is responsible for establishing core services, policy and standards. The Regional Health Authorities are responsible for program development, the service and service delivery.
The goal of our program in this province is the prevention of unnecessary, premature or prolonged institution. Home care services are provided to individuals based on assessed need, and are intended to help them maintain their personal health and independence and to supplement the care that is provided in the home by family members and informal supports.
In this province, we have a diverse group of people who are served by home care. Approximately 78 per cent of our home care clients are over the age of 65, and 45 per cent are over the age of 80. On a monthly basis, the number of seniors receiving public home care services represents about 6.7 per cent of the senior population.
We also have a large percentage of clients who have special needs, such as the physically or mentally challenged. We have clients who require long-term care services also and they represent about 75 per cent of our caseload. We have provisions in our home care program for coordination and integration, and we have one common assessment tool that we use in every region across the province. It manages the appropriate entry to the long-term care facilities.
The costs of providing health services are escalating. The future sustainability of this system as it currently exists is of increasing concern. Home care has received attention, both provincially and nationally, as an area which requires development in order to play a more significant role in meeting these changing needs, and to contribute to the sustainability of the system by enabling care to be provided in the most appropriate setting by the most appropriate care providers.
I will not go into the trends and issues, which are listed in our brief, but I am sure you will hear them repeatedly. They range from people living longer, to the baby boom generation and to the shift from chronic diseases. A trend that is particularly challenging for us is that many older persons in this province are care providers for their physically and/or mentally challenged family members.
Some of the challenges and opportunities for us in the future are around funding and resource allocation. The parameters of public funding for home care services vary widely across Canada. In the current system, private sector funding is essential to many of our home care programs. Further work is required to determine the appropriate balance of private and public expenditures, the appropriate allocation of resources within various sectors of the health system and consideration of what should fall under insured services. A comprehensive review of the Canada Health Act and its applicability to community-based services is recommended.
In January 2001, Pricewaterhouse Coopers was engaged by Health Canada to conduct a study of the private home care sector in Canada. This study was released in July and it provides valuable and current information about the involvement of informal caregivers in the provision of care in the home.
About 13 per cent of Canadians, ages 15 and over, are providing informal home care, either inside or outside the home. Caregivers provide an average of 22 hours of care per week in the home, and it is estimated that informal caregivers are providing approximately $4 billion in unpaid home care per year in Canada. Informal caregivers will continue to play a role in contributing to the sustainability of the health system. The federal government has an important role in exploring tax incentives and other measures such as options that support caregivers, in some cases, to leave the workforce temporarily to provide informal care.
The provinces and territories are responding to emerging issues and needs in the home care sector through increased activity in the areas of innovation and developmental initiatives. This is an area where the federal government should continue to play a significant role through funding for research, evaluation and innovation.
In the medium to long term, this will influence adjustment of the various programs to meet broader system challenges. Examples include the expansion of research activity, the establishment of programs targeting the needs of specific groups, support for development of information systems and the expansion of the technology that supports service delivery to clients in their homes.
Ms Deborah Bradley, Manager of Public Health Policy, Department of Health and Social Services, P.E.I,: Chronic disease is a serious public health issue. It is a major cause of death in Prince Edward Island, as well as a cause of years of life lost, hospitalization and reduction in quality of life. For our purpose, chronic diseases are defined as non-communicable and include conditions such as cardiovascular disease, diabetes, asthma, cancer and arthritis.
Islanders, like other Atlantic Canadians, are generally less healthy than the people in the rest of the country. We smoke more, drink more, exercise less and carry more body weight. Although the P.E.I, rate of smoking is declining, 26 per cent of Islanders are regular smokers compared to the national average of 24 per cent.
In 1999, we had the highest rate of physical inactivity in the country and our children are becoming less active. Research has shown that Canadian children aged 11 to 15 were 30 per cent less active than children were eight years ago. Thirty per cent of Islanders are overweight compared to the national average of 31 per cent, and in the 15-year period from 1981 to 1996, the number of obese children in Canada has more than doubled. In P.E.I,, we have one of the lowest rates of school completion and the second highest rate of unemployment in the country.
Not surprisingly, P.E.I, has some of the highest rates of chronic diseases such as cancer, heart disease and diabetes. P.E.I, has the highest rate of cardiovascular death among males in Canada, and we have one of the highest rates of death from lung cancer in males. In 1990, three per cent of Islanders over 25 years old had diabetes. In 1999, the number rose to five per cent, and for 2001, we are estimating that will rise to seven per cent of Islanders.
The direct cost of chronic disease to the provincial health budget of $278 million is high. In P.E.I,, approximately one in every 10 health care dollars, or $25 million, is spent on the treatment or management of diabetes and its related complications. Obesity costs the provincial health system from $9 to $15 million annually.
Chronic disease rates tend to increase with age. Over the next 30 years, the population aged 65 and over in P.E.I, will increase from 13 per cent to 28 per cent. We can expect to see the incidence of chronic diseases like cancer, heart disease and diabetes increase. Reducing the risk factors for chronic disease is our primary opportunity to improve the health of Islanders and Canadians, and to sustain our health care system.
To be effective, we must avoid becoming disease, risk factor or strategy focused. A population health approach must be taken. Population health refers to the health of the population. It recognizes that health is influenced by the determinants of health, including social, economic and physical environments, personal health practices, individuals' capacity and coping skills, human biology, early childhood development and health services.
Such an approach recognizes that many factors work together to influence the health of a population over the life span and contribute to the burden of chronic disease. Lifestyle factors that significantly contribute to chronic disease include smoking, physical inactivity, unhealthy eating patterns and immoderate use of alcohol. The societal factors include socio-economic inequality, deficient early childhood development, poor social connections and support, low levels of social-emotional competence and unhealthy environments. Several of these factors are outside the influence of the health system. Socio-economic status is a good example.
Health status increases as education and income levels increase. Therefore, Canadians with low levels of income and education tend to be less healthy. Of particular concern is that poverty in Canada falls disproportionately on children. We must work on increasing literacy skills and reducing social inequities to enable Canadians to achieve optimal health.
While much is being done, both in the province of P.E.I, and in Canada, there is more to do as the rates of chronic disease continue to be high. We must consider the comprehensiveness of current approaches and programs, and the setting in which they are delivered. To have a significant impact in preventing chronic disease, we must have a more formalized process to facilitate and ensure work is done in an integrated fashion. To do this, we need an integrated partnership with all levels of government, non-governmental organizations, the private sector and the medical community. Multiple strategies must be used and involve an array of organizations committed to reducing chronic disease. Supportive environments are key.
We must also use a population-based approach that considers the interaction of the determinants of health. The strategy needs to be comprehensive, integrated, and involve collaboration. It needs to be funded to make upstream investments and needs to consider settings. We know that integrated programs in settings such as schools, workplaces and neighbourhoods are more effective than isolated programs.
While using a population health approach, we should consider the role of health information and technology, as well as the supply of health professionals. Access to credible, timely and understandable health information is crucial for Canadians to make more informed decisions about their health and the health of their families.
The Internet is an important vehicle in delivering and facilitating access to consumer health information. While Canadians are high users of information technology, we must be cognizant that many Canadians do not have access to the Internet, and that many have low literacy skills. Therefore, it is crucial that the Internet does not fully replace other means to communicate health information and education such as print material, mass media and health intermediaries or health professionals.
The health system needs to be proactive in addressing the supply of professionals in our public health system. In particular, we will see a significant decrease in the current supply in many nursing professions over the next five years or so. This, coupled with an aging population, will only increase the demand for public health professionals.
There is a role for the federal government to play in identifying training, recruitment and retention problems and solutions. There is an increased need for ongoing training and skills development within the public health field to allow practitioners to adapt their skills and strategies to work within a population health approach. With research and careful planning, there is an opportunity to address many of the issues through the federal government's commitment to primary health reform or redesign.
There is great potential for a significant impact to be made in the area of chronic disease prevention in Canada. Our goal should be to make healthy living the norm. A shift, culturally and fiscally, must be made away from treating illness to preventing illness and encouraging individual responsibility for health. We can accomplish this with a comprehensive and integrated approach based on best practices, population health and the determinants of health. The development of such a strategy will enable Canadians to make an upstream investment in strategic areas, anticipate and keep pace with current and future pressures, and ensure continued effectiveness of interventions in protection, promotion and prevention and our return on investment.
The federal government can act as a leader and facilitator responsible for inter-sectoral action for health. In developing strategies to improve the health of Canadians, we must be cognizant of what the heath care system can influence or address.
The federal government can also take on a leadership role in initiatives related to health promotion and population health. They can facilitate partnerships and coordinate multi-sectoral initiatives with representatives of the sectors outside the health system. The federal government can also support such strategies by assisting in the dissemination of programs and materials and in the mobilization of resources and supports to ensure prevention initiatives are sustained.
They can also play a key role in facilitating and participating in research and demonstration projects, as well as through media campaigns, policy initiatives and surveillance and monitoring. With shared accountability for health outcomes, we can work together to meet common goals and objectives and ensure commitment to positive health outcomes.
Mr. Bill A. McKinnon, National Representative, Canadian Union of Public Employees, P.E.I, Division: CUPE P.E.I, represents over 2,200 working Islanders in various public sector occupations throughout the province. For a proportional overview of what that means is that one in 59 Islanders is a CUPE member. These employees are employed in areas such as Neil's Ambulance Service, the Queens County Residential Services, Southern Kings Group Home, the Cities of Summerside and Charlottetown, East Prince Health Authority, Eastern School Board, French School Board, Prince Edward Island Atlantic Baptist Nursing Homes, P.E.I, Federation of Labour, P.E.I, Teachers' Federation, Queens Health Authority, Southern Kings Health Authority, University of Prince Edward Island, West Prince Health Authority, Western School Board and Eastern Kings Health Authority.
Many of our members work in the health sector, for example, hospitals, nursing homes and ambulances, and we are also citizens of this province, so we have an appreciation and a special understanding of the problems in the health care sector, both from the inside as workers and from the outside as citizens receiving an important service.
For workers, the situation has been difficult. In the hospital sector of Prince Edward Island, there have been many changes in the name of restructuring. People were moved from one bargaining unit to another, or to a different position within a particular health facility. Due to cuts to the provincial budgets and lack of spending on the part of government, health care workers have to do more with fewer resources.
This has led to a number of problems in the workplaces. The main one is workload. Health care workers are trying to provide the best services possible, but there are not enough hours in a workday, or enough staff to do the work. Working in health care is not like working on an assembly line in a factory. You cannot increase the speed and get more production in the end. When you are working in health care, you are dealing with human beings who are quite often at their most vulnerable. They are in need and health care workers must be there to care for and assist them.
The general problems that we are facing on Prince Edward Island are related to the amount of money our province spends on health care. In a report released on December 11, 2000, the Canadian Institute for Health Information reported that Prince Edward Island was the province that spends the least per capita in health expenditures. They said:
After adjusting for variations in the age and sex of provincial populations, estimated provincial government health care spending per capita in 1998 was highest in Newfoundland ($2,007) and British Columbia ($1,899), followed by Alberta ($1,825), Quebec ($1,764), Ontario ($1,762), Manitoba ($1,743), Nova Scotia ($1,965), Saskatchewan ($1,685), New Brunswick ($1,637) and Prince Edward Island ($1,602).
In a report release last week, the CIHI said:
Expenditures per capita in six of the provinces were within the range from $1,800 to $2,000 during 1999/2000. British Columbia, Manitoba and Newfoundland exceeded $2,000 while Prince Edward Island was the only province to spend less than $1,800 per capita.
This shows that there is an urgent need to spend more money on health care. We are facing a number of challenges because Prince Edward Island spends the least per capita in Canada. For example, we have a shortage of physicians, although recent reports tell us that we are going to have a few more, it will not be enough, and we have the lowest ratio of physicians, at 73 per 100,000 population in Canada.
The situation does not improve when you look at specialists. Again, Prince Edward Island is the lowest with a ratio of 55 per 100,000 population. There are tables with facts that substantiate those numbers that are in our brief.
With the reduced spending in health care, there are other problems that exist in the lives of people on Prince Edward Island. For example, there is a shortage of beds in nursing home or long-term care. The home care program is virtually non-existent. Although, Mary Hughes-Power did illustrate that they are doing the best they can with the resources they have. There are a great many people providing voluntary or non-professional care and that becomes the underpinning of home care on the Island. That is not good enough. It is much less than it could or should be.
There are a number of services not available on the Island. People have to drive to Nova Scotia and New Brunswick for specialized services in areas such as cardiology, neurology, oncology, burn unit services and specialized pediatric care.
One of the most important issues for Prince Edward Island is the level of funding from the federal government. The table in your presentation illustrates the equalization payments and the EPF plus the CAP - which changed in 1996 to the CHST - to the province from the federal government from 1980 to 2002.
Prince Edward Island lost money in equalization payments in 1991, 1992 and 1993. For that same period, the level of funding from the EPF and the CAP increased only marginally. In 1996-1997 and 1997-1998, the funding from the CHST decreased. It was difficult for Prince Edward Island to replace the money lost from the cuts in the funding from the EPF and CAP, and later CHST, because there was also less money coming in from other sources of revenue.
Health care for profit or privatization of health care is a very dangerous road to follow. The example of the United States, where health care is a private operation for the most part, should be enough proof that this system does not work. There are no savings and it is much more costly than our public health care system. Canada's private corporations are knocking on the door in the hopes that we will hand over control of our health care system.
In 1999, the Prince Edward Island government wanted to build a hospital using the public-private partnership, or PPP. This would have resulted in the loss of control of an important infrastructure to the private sector and the long-term costs for the province's taxpayers would have been higher. Citizens and workers on Prince Edward Island spoke out and opposed that formula. In the end, the government resumed its responsibility and now owns a new hospital being built in Summerside. Across the country, there are unfortunately many stories of privatization that did not end like the story in Summerside.
Governments and hospital corporations are opening their doors to privateers. They are doing it bit by bit. You see a laboratory, a kitchen, laundry services or cleaning services privatized but this slow movement takes them on a very dangerous course.
We recommend to the Senate committee that they demand that the Canadian government provide long-term and proper financing of the Canadian health care system. Cuts like the ones that we have seen in our health system in the last 10 to 15 years should never be permitted to occur again. This committee has a chance to influence the government in a way that would reinforce the fundamental principles of the Canada Health Act, and most importantly, leave a legacy for our children and grandchildren that we can all be proud of.
The Senate committee should oppose privatization. The only proper system of health care for Canadians is one that is affordable, accessible, publicly funded and publicly owned and operated. We have already mentioned the number of services that are not available to our population in this province. Privatization would only exasperate that problem. The experience of privatization elsewhere has demonstrated that it creates a two-tier health care and would be especially devastating for Prince Edward Island. We urge you to stand up for our precious health care system as a beacon for universal and accessible public health care.
Senator Callbeck: Ms Henry-MacDonald, you mention that there are few incentives in the health system, both for the providers of primary care and the people who are receiving the care. In your presentation, you say:
We suggest that incentives be investigated to assist citizens understand that the perceived right to universal health care is accompanied by a responsibility to use health care in a reasonable manner.
What are some of those incentives?
Ms Henry-MacDonald: The more education we can have about drugs and drug interaction and drug use and so on, the less people will be asking for prescriptions. An example is that some people expect to get a prescription every time they go to see a physician. We certainly should use the medicare responsibly and not everyone does, partly because they do not know. They do not have the education. That is just one example.
Senator Callbeck: Education is important in the whole health system. The other day in Toronto, we had a witness who said that in order for Canadians to have more confidence in the health system, they have to get more information and people have to become aware.
Ms Bradley, you provided statistics that do not show Islanders in a very good light. I remember that survey. You talk about the area of professionals, and that we are going to be lacking in so many categories. We are now, and the situation is going to get worse. Did you say that you thought that the federal government should take the major role here in coordinating all of this?
Ms Bradley: I think the federal government can take a role in assisting and working with the province in identifying some issues, trends, and training opportunities.
Senator Callbeck: Yesterday in Fredericton, we had a witness who felt that the role of coordinating all this, how we are going to deal with the situation and putting a plan in action, should be taken by an independent body outside of government. Do you have any thoughts on that?
Ms Bradley: It depends at what level. An independent body can evaluate the situation and make some recommendations, but the provinces and the federal government need to be involved in facilitating the training that is required. An independent body can look at what our needs are, but we need to be proactive to ensure that our health professionals have the skills required to do the job, and to address the needs that CUPE have certainly addressed. I do not see an independent body doing it alone. We need to be involved.
Senator Callbeck: No, I did not mean alone, but to take the initiatives and to get the federal government working with the provinces on this.
Ms Bradley: Regarding the question that you posed to Ms Henry-MacDonald. it is a large issue and education is extremely important, but another area that we need to look at is creating the supportive environments to make sure that it happens and that seniors can be educated and to take action. Not only by themselves, but also with physicians, home care workers and other professionals who may come in contact with them. Creating a supportive environment to make that happen is important.
Senator Callbeck: Mr. McKinnon, in your brief, the statistics illustrate the problem that a small province like Prince Edward Island has in providing these services and paying adequate wages to our people in the health field. You mentioned the funding from the federal government, CHST.
Yesterday in Fredericton, we had some witnesses talking about this formula and they felt there should be changes to this. Are you familiar enough with the formula to talk about that?
Mr. McKinnon: I will turn that over to Raymond who is our research person. He works in that area and would have the knowledge and expertise to answer that question.
Mr. Raymond Léger, Research Representative, Canadian Union of Public Employees, P.E.I. Division: The formula has been looked at and different groups have different options. If the federal government reduces the total amount of money spent on health care then whatever formula you pick will reduce the amount given to the provinces.
Each of the provinces reacted differently. Some continued to increase their provincial budgets and took money away from other services and put the funds into health. Other provinces did not do that, and as a result there were cutbacks and layoffs and less people working in the health sector.
We can discuss the formula, but the bottom line is that the overall funding that the federal government spends cannot go down. There may be a little adjustment, but the fundamental issue for us is still the total spending.
Senator Callbeck: The CHST is really based on per capita. Do you feel that is fair? Do you believe that we should get the same amount per capita as a province like Alberta? In Prince Edward Island, for example, our senior citizen population is large and increasing. When the federal government sets the amount of money that we should get per capita, should need come into it? If it does not, then how is a province like Prince Edward Island ever going to get their services up to the level of provinces like Alberta? The services will never be the same if each dollar per person is worth only 90 cents. There should there be a lot of other things that go into this formula.
Mr. McKinnon: You are talking about the CHST, but the other side of the equation is equalization. The balancing act that you are talking about is not just funding that comes from CHST. The bundle of money that used to be the EPF and the CAP is now the CHST. My understanding is that they took those two programs and melded them into one.
The balancing act that you are talking about between the "have" provinces versus the "have not" provinces becomes equalization. Our government has been screaming in the federal forum for months now, as have New Brunswick, Nova Scotia and Newfoundland. We have been saying that equalization has to increase to offset the imbalance that we have with provinces like Alberta.
I think the issue is not so much whether the CHST is fair on a per capita basis in Alberta versus P.E.I. The question is, on top of CHST, what about equalization which is intended to offset those imbalances?
Senator Callbeck: Yes, equalization is intended to bring it up to a certain level. I go back to the CHST when the two programs were combined. It has been suggested that the program should be looked at again and that other factors be considered such as the number of senior citizens or greater need in certain areas. We have very a very high incidence of certain diseases here that should be considered.
Mr. McKinnon: I think I agree with where you are going. I go back to when the CHST was established in 1986. CUPE was demonstrating at the legislature. We said, "Look, the EPF and the CAP are not perfect, but what they do is force government to focus money that is assigned to these programs, whether they like it or not." Because if they do not, they do not get it, or they have to cough it up.
The CHST created a formula where a province, as I said before, can pluck. What we end up with is per capita now instead of everyone spending $2,000 per capita on health care. The statistics range from $2,007 in Newfoundland and $1,602 in Prince Edward Island, and you are absolutely right. Instead of that extra $400 per capita being forced to targeted programs we have seen the chipping away of those monies into what are seen as other necessary programs. We cannot get the money any other way, and the programs that everyone here is talking about have suffered.
In 1996, we said, "The CHST is less preferable to what we already have. The EPF and the CAP may not be perfect, but why not try and fix those programs and prop them up?" That was not the direction taken by the government of the day. I agree with you that they should have, instead of going to the CHST and the "do with it as you please" process that resulted in these imbalances in per capita. Yes, they should have focused the money and said, "You cannot touch that health care money. It has to go into health care."
Let us talk about putting more money in so that everyone has a higher per capita in that area but no one can pick at it for schools, for roads, for that sort of thing.
The Deputy Chairman: We have had witnesses from all across the country talk about bringing in other demographic figures because of the aging population and the differences in the cost of living in the different regions of the country.
Senator Léger: I am very, very happy to hear about the seniors and home care. Is that an avenue that is being augmented as far as demands are concerned or is it just simply always the last one on the list?
Ms Henry-MacDonald: Do you mean studies about the use of home care? Up until now the concentration has been on acute care. When individuals are discharged from hospitals they need home care. As a result of the need for home care we are hearing more about it. We do not have enough, but it is being talked about.
I know our government is trying to switch from keeping seniors in hospitals to sending them home to be cared for. This has presented the need to supply a service at home. It is difficult to stop the use of the acute care and start up home care because in the interim we need dollars for both. However, I think that it is coming.
Senator Léger: How about that group of old people, with different illnesses that need help but not necessarily hospital care? Are you getting help for these people who are getting older and want to die at home?
Ms Henry-MacDonald: We are getting some help but we are not getting enough. We recognize that some people need to go to nursing homes, people that need 24-hour supervision. Our government cannot provide the type of care that they need in their home. Many aged seniors would stay at home if they had some help. We have the funds to help some of them but not enough money to provide adequate services for all of them.
Mr. Léger: The balance between long-term care, nursing homes and home care, is a difficult one. I know that you have a lot of specialized services in nursing homes and long-term care facilities, and yet when it comes to home care, there are a lot of people in need of those same specialized services who are not getting them.
You have to find a balance between services that are provided in nursing homes and long-term care facilities, and services that are provided to people that want to stay at home. They should have access to all of those so-called professional services. That is where the discrepancy occurs. Home care has not been developed in such a way as to provide all the necessary services to the people who need them.
If we want proper home care we must provide the patients with the same quality professional service that they would receive in nursing homes. In New Brunswick the government pays $10.50 an hour for home care and for the most part, none of those people are professionals. They are people who are either hired by agencies or by the government but they are not health care professionals.
In the nursing homes we had the same problem, but the government addressed it by asking that 40 per cent of the workers be RNA's, 20 per cent nurses, and the other 40 per cent "aides." They have increased the RNA's to 40 per cent in the nursing homes. We need to look at a balance similar to that for our home care system.
Ms Bradley: Moving from acute care to home care is a good example of our challenge. We have limited funding. You talk about balance, and that is a good word to use. We almost need two parallel systems while we make that shift. We are in a position where it is very difficult to do given the limited resources that we have.
The Deputy Chairman: There is a lot of support for home care provisions under the Canada Health Act, but there are great discrepancies between the provinces, and no uniform model to follow. There seems to be 13 different little islands.
It is my great pleasure to thank each and every one of our witnesses for appearing. Your testimony was very compelling and we will certainly take all of your representations into consideration when we prepare our report. We heard you loud and clear, Mr. McKinnon, about privatization. I would like to call the next set of witnesses to the table.
Dr. Peter MacKean, Chairman of the Board, College of Family Physicians of Canada: I am privileged to be able to meet with you today. I want to thank you for forming this committee. It is a very important time in our history. We are at a crossroads and I think your work is going to be critical in ensuring the future of medicare in Canada.
I have been requested to appear before this committee as an individual citizen. However, I do happen to be the Chairman of the Board of the College of Family Physicians of Canada.
I respectfully suggest that it would be very appropriate for you to invite the College of Family Physician to appear before your committee. We have many suggestions that may assist you in your deliberations. The principles of founding medicine mesh very closely with the principles of medicare. They are virtually indistinguishable.
I have read your document with great interest. I am especially interested in primary care reform. At the College of Family Physicians of Canada we have been looking at this and we have put forward a document that we feel offers a solution for health care in Canada. The document is called "Primary Care and Family Medicine in Canada: A Prescription for Renewal." It is based on a model of family practice network where networks of family doctors work in teams with nurses and other professionals. The hierarchical system would be eliminated and instead there would be two teams working together respecting each other's function.
We see the doctor as the primary coordinator of medical care but also see them working in teams with the other professionals. We see nursing having a major role in this proposed new system. We feel that public education and working within the communities is very important. We also feel that this network would support your goals of addressing population health.
We see multidisciplinary teams being part of the community. Situations like Davis Inlet would not have occur if there had been a family practice network with multidisciplinary teams working in the community. I believe that situation would not have occurred if the networks had been in place.
I wanted to comment on incentives and I want to comment on fee for service. You are suggesting an alternate fee for service for the Canadian medicare system. We have looked at this. Our organization has issued briefs on this since the early 90s. At that time we proposed changes to the payment system. We feel that the solo method does not meet the needs of Canadians or physicians very well and we have suggested changes. However, we do urge some caution when introducing alternate payment plans for physicians. Changes should not be brought in under the element of coercion but rather with the support of the physician.
I have highlighted some of those comprehensive cares in my brief. They concern items such as home care, hospital care, palliative care, and obstetrical care.
We have a crisis in obstetrical and maternity care. Within the next ten years, we are going to experience a shortage of midwives, family physicians and obstetricians. This issue is not being addressed and incentives are not in place to keep those professionals in Canada. I think incentives and alternate payment plans is the way to go. We can not force the physicians into this line of work but must encourage them by positive plans that will make them want to come into this particular type of practice.
Population health is a very complex area. It involves multi-centre work. The terms of one of our principles of family medicine is advocacy for the Canadian people. This principle is one of our cornerstones and we believe that we must address all these things but we cannot do it alone. It must involve other health professionals and other members of the public. We need to work together to meet these needs. Many of the issues in population health really lie outside of the health sector. The importance of education is paramount to the issue of population health.
We strongly support information technology. Many of these networks are virtual networks, especially in isolated areas of Canada. In order for teams to work together we need a solid information technology service. We strongly support all efforts that are being made in that area. Our College thought we had a solution to that problem and had a multi-national company working on it. However, due to the economy, they were unable to carry on their work in Canada. We understand that others are prepared to take that on.
Research is another cornerstone to making the proper decisions for the future. We support your idea of doubling the amount of research dollars. We support the Canadian Institute of Health Research structure. We are concerned how primary care research, structure research, basic clinical research and the health system are going to fit into the CIHR. We have had researchers trying to work in this area, but there is just not enough money for us to do that.
We strongly support phamacare, home care and all medically necessary home care services. We support essential prescribed medication and believe it should be included within the medicare program.
We feel there should be a single payer in Canada. Whether services are delivered by the public or private system we feel that both should meet the same standards. There needs to be further research in this area of private sector delivery of services.
We have two other briefs for your review. One of them is a report we submitted to Honourable Roy Romanow entitled, "Shaping the Future of Health Care in Canada." The summary is on the last few pages and presents a blueprint for the future of health care in Canada.
We have suggested a comprehensive solution to activate primary care renewal and suggest that by working collaboratively we can ensure a strong and sustainable medicare system that will promote the best health for Canadians now and for generations to come.
Mr. Iain Smith, Drug Utilization Coordinator, Queen Elizabeth Hospital: I am an employee of the Queen Elizabeth Hospital. However, the opinions expressed are mine, and not those of the hospital.
My remarks will be limited to pharmaceuticals and specifically to the concern about pharmaceutical costs. In general, the efforts that are collaborative or give some top-down direction from the federal agencies are to be welcomed within the provinces in terms of reducing the amount of time and energy spent on creating similar things and in terms of creating continuity.
In looking at the report and its objectives, it is clear to me that we are examining the federal role in the provision of health care to Canadians, and specifically the issue of reducing the cost of prescription drugs. This issue is discussed in section 8.8.
There is an area of discussion that is conspicuously absent. The cost of prescription drugs is increasing at an alarming rate, and according to the report prescription drugs take up 16 per cent of the total health care budget.
I believe that if the federal government is going to make a significant impact on reducing this rate, more effort should be devoted to the approval process for drugs in Canada.
As things stand, new drug products get approval based almost exclusively on clinical data generated by drug company sponsored trials. In many cases, the principal investigators have an inherent bias towards returning positive results because negative results will lessen the likelihood that the individuals will be invited to participate in future trials. It is a natural sort of bias that arises.
The federal government should take a more active role in assuring that new drug therapies are approved based on reasonable evidence and not solely on evidence from the pharmaceutical companies. Toward that end, clinical trials in Canada involving human subjects should be closely scrutinized by federal agencies. Pharmaceutical companies should not be able to claim trial results as intellectual property and do with them as they please because they are human trials. All clinical trials involving human subjects should be open to examination and criticism and an outside and impartial body should analyze the data from the trials. Such a body should have no vested interest in returning positive results.
Pharmaceutical companies should support such impartial bodies with mandatory contributions and presumably this would reduce their operational cost and their cost of bringing drugs to market.
All clinical trials should be registered, and whether or not they are published in scientific journals, they should be made available for public scrutiny. There are registries in place but they are mainly voluntary.
The pharmaceutical industry should be accountable for false claims made through extrapolation of possible benefits of new drugs, either in journal articles or through advertising. Society not only pays for the drug, but also to prove its worth.
The federal government should take a more active role in supporting the provision of education material promoting the concept of reasonable expectations for what the health care system can provide.
Consumers should be made aware that unless they are willing to support very significant tax increases, there are limits on how much society can afford to pay for any therapy, even those that may be clearly efficacious, if the cost is extreme. Consumers should be aware that the complaint that it takes too long to get drugs to market is diametrically opposed to the demand for safe and effective medications.
Consumers should be very clear that drug companies are big, big business and they are not part of the health care system in the same manner as health care professionals. While they do employ health care professionals, decisions made by drug companies are business decisions and they are guided by profit and not by society's needs.
Strategies discussed for reducing drug costs, expanding drug coverage, and distributing the load are all reactive to the high cost of new therapies whose price tag is largely dictated by the drug producer, often with minimal supportive evidence. It is left to the health care sector of individual countries to then validate the claims that are made.
Drug companies may be accountable for the consequences of the adverse effects of drugs only when it is shown that they had prior knowledge of the risk and had not clearly represented it. They are conspicuously unaccountable for initial claims for increased effectiveness, or improved tolerance that has been shown to be invalid, often years after they have entered the market. There are numerous examples of such drugs.
Recently, the British government entered into negotiations for a risk-sharing strategy for drugs, specifically the ones used to treat Multiple Sclerosis. Under this proposal, the government will provide the drug but will seek to recover the costs of therapy from patients who had not benefited. A similar strategy could be applied to many different categories of drugs in this country.
With respect to reducing the cost of prescription drugs the report does an admiral job of representing the strategies that are currently under consideration. Arguably, the best we can hope for is to use what we have in the most effective way possible.
The people that are doing drug use evaluation, be it at the hospital level, at CCHOTA or any of the bigger agencies that provide guidelines, are not going to have much of an effect on that rising 16 per cent of the health care budget. Each time an area of high cost is brought under control, something will take its place and this has happened over and over again.
The government needs to take the initiative to put some of these processes in place, make the initiatives happen, and step back, because too often individual politicians will overrule what hired independent agencies have found to be the most efficient way to proceed.
Ms Neila Auld, Executive Director, P.E.I. Pharmacy Board: The Pharmacy Board regulates the pharmacy profession in the province. We license pharmacists and pharmacies and we set the standards by which they must operate. Our primary mandate is public safety with regards to the services that the profession offers.
As noted in section 8 prescription drugs make up the largest expenditure with regards to all drugs. Third party payers, as well as the public, struggle with how to control these costs that ultimately determine what balance of dollars are left for other health care services. With all the options that are proposed, there are clearly positives and negatives to consider. Prior to initiating any particular one, a decision will have to be made as to whether prescription drug coverage will be universal or strictly for qualified Canadians, and if so, what those qualifications will be.
A national drug formulary would create a financial positive in establishing a venue for all provinces and territories to purchase drugs at the best possible price. Will these savings be made available to just federally funded programs, or will the private sector also have access? The answer to that question is important. If there are to be both private and public providers, the savings to the public providers may ultimately be a cost, or a negative, to those insured with private providers. The cost will manifest itself in increased premiums and will be passed on to cash paying patients.
A consistency in the drugs that are covered will provide the country with consistency in care. It will also provide consistency in pharmacy inventories. Having to supply two or more formularies would see community pharmacies having to carry additional inventories at a cost to supply the different providers.
The pharmaceutical industry will, most likely, attempt to recoup their losses by having two prices: one for government formularies and one for non-government formularies, or by increasing future drug prices for new drugs to markets. The question is: Would a national drug formulary serve its purpose without a national pharmacare program?
Using the lowest cost and most therapeutically effective drug is not a new policy to pharmacists, nor is it new to the public. As mentioned in the report, this has been a difficult "sell" to the medical profession, particularly outside the hospital setting. Even hospitals have had problems in convincing practitioners to abide by the decisions and policies of the Federal Pharmacy and Therapeutics Committee. It is usually the pharmacist that must bear the brunt of the negative acceptance, whether it is from the prescriber or the patient who perceives newer and more expensive drugs as better. How far is the government willing to go to enforce such a policy?
With pharmacy, particularly in the community setting, there is little objection. Rather, there are far too many advantages. The public benefit from access to lower health care costs, either through taxes to finance, user pay costs, or direct costs for cash paying customers. The public also benefits, particularly with regard to antibiotic use, in limiting or minimizing the risk of drug resistance development, saving the new, often more expensive drug therapies for cases of such resistance. Pharmacies, both in hospital and community settings, benefit from lower inventory and operational costs. Governments benefit from all three notations above.
However, there are always negatives to the positive. We must ask: What effect will such a policy have on the drug industry, particularly the research and development of these newer second and third generation drugs?
Does the consumer really need or benefit from direct-to consumer advertising? Why do they need to know what prescription drugs are available? It is the prescriber who decides, based on an educated, informed professional decision, what drugs should be or will be prescribed. Industry can and does communicate with consumers on the availability of non-prescription drugs.
Unfortunately, the consumer most often cannot make an educated, informed professional decision with regard to prescription drug use. A diagnosis must be made and knowledge of the options of treatment protocols explored. Even with non-prescription drugs drug scheduling processes are in place in the provinces to assure public access to the professional knowledge, training and expertise of the pharmacist where it is proven beneficial and important to health outcomes and public safety.
Canadian pharmacy regulators are working with pharmacy regulators in the United States to adopt or adapt their VIPPS program, the Verified Internet Pharmacy Practice Sites. While Internet activities are difficult to control, the public can be educated to be aware that should they wish to utilize an Internet pharmacy, they should see the VIPPS approval designation signifying that professional standards have been met.
Advertising restrictions should prevail in Canada and the government should take whatever measures they can to enforce those restrictions. Industry can and should be able to promote to professionals. This promotion includes vital information for the practitioner to assess, prescribe and monitor health outcomes for disease states and drug use.
Consideration must be given to the impact on industry. However, given that industry has not been able to advertise directly to the consumer in Canada, the impact should be minimal.
With regard to expanding prescription drug coverage, the report confirms there are groups of people who are under-insured or not insured at all. There are those without employer coverage or who do not qualify for government assistance, and there are those with catastrophic illnesses. How does government decide if and how to improve access?
A national pharmacare program would expand prescription drug coverage to those who are under-insured or uninsured, and bring consistency of drug benefits to all Canadians. Funding would vary, depending on the design. In addressing the design we have to ask the questions: Who, what and how? The answer may be clearer if the context is broadened to take into account a national formulary, a drug utilization policy or review, and positive financial effects to other government programs. Who should administer the programs? Whether provincial government, federal government or the private sector, they must be accountable to the public purse that ultimately pays the bills.
Certainly, a comprehensive public program is ideal but not without initial costs. The advantage would be that if properly administered and monitored the overall savings of improved health care outcomes could alleviate some of the costs.
Public-private initiative is another option but it is not without risks. Employers may discontinue the benefit should costs increase to a point that cannot be maintained, and it has occurred that third party payers, that employers and individuals subscribe to, will either increase premiums when usage increases or they will actually eliminate a person's eligibility for specific disease state coverage.
Until a long-term solution is found, an initial step may be to assist people, whether directly or indirectly, through their employers or other government programs, to obtain coverage that otherwise would not be available.
The options mentioned above would not suffice in addressing the catastrophic or high drug costs scenario. Private carriers would obviously end up needing to increase all premiums to assimilate the costs. We must consider and realize that it is this increased cost, the catastrophic drug cost, that Canadians fear most. Many maintain a prescription drug plan only to assure themselves that should they develop an acute or chronic disease with expensive drugs, they will be covered, as once they develop it, they are rendered uninsurable.
There is a need for a population health approach for all Canadians. Our health professionals need to be better utilized. We need to encourage our professionals in order to reach our goals of better health care outcomes. The synergism of these professions will improve health care at the least public expense.
This process could be a federal program, but would also operate in a provincial capacity to encompass the individuality that exists in the provinces. A health commissioner or a new department should be instated that can monitor these programs and study the impact of all affected government departments and not just health.
The Deputy Chairman: Dr. MacKean, I was very interested in your brief, and when we are doing a further study we will invite your association to appear before us again.
There is a myth about doctors that they are territorial and especially so in remote and rural areas and that it has caused a problem with physicians that are not in the primary care area. We had a doctor from Prince George tell us that doctors very much want the team approach. It would take the pressure off the smaller communities because they would not have to drive great distances into urban centres. How much effort has been put into this team approach proposal and are you trying to promote it? Are you trying to promote it with doctors, health care providers and with the general public? I think doctors have a bad reputation in this regard. Do you have any comments on that?
Dr. MacKean: We have been working on this area since the 1995 Green Paper. The paper you have in front of you was shared with the federal Minister of Health, and the provincial Ministers of Health. My brief indicates that most of the provinces are already moving in this direction. Ontario is taking the lead, and Quebec's Clair Commission, and our Health Minister is putting together alternate payment plans and opportunities for physicians to come together. I give credit to all the governments that are trying to put this together.
There is a document in front of you called "The JANUS Project." It was released last week. It indicates that there is a serious shortage of family physicians in Canada. We feel that is a serious omission in your document. You have mentioned the nursing shortage. To put together these teams we need nurses in reserve. There are not enough to support our model. There are not enough family physicians to bring this forward. In fact, they are going to increase, projected each year because of the decisions made in the early 1990s. We have suggested numbers that can bring that it back to where it needs to be so we can work together.
Most doctors want to work in teams. The models that have been forwarded to us have not allowed us to do that. For instance, the fee for service method is one that does not promote teamwork. You need alternate models to promote teamwork. There are many other things that are required in order to bring people together. Many doctors are already working in teams. There are many models already in Canada. This is not a totally new approach but we have embraced it.
In terms of working with other professionals we have invited a Canadian Nursing Association representative as an observer. Next week we are hosting a collaborative practice seminar to promote cooperation between the Association of Nurses of P.E.I. and the Medical Society of P.E.I. These types of workshops are going on all across Canada. Does the public know about that? It is difficult to get that message out to the public. We have had press releases. Each time we do a release, it hits for a day or so and then some other news stories take over. It is hard to get this message out to the public.
The Deputy Chairman: We can relate to trying to get messages out to the public. All the good work we do sometimes gets overshadowed by one bit of bad news.
I brought a report with me that was in The Globe and Mail. The report explains that family practitioners are overworked. We need to increase the public's confidence in the system. I really do believe most Canadians, especially in rural and remote areas, would want a doctor to build the team because of his or her medical expertise.
Dr. MacKean: Yes, we need to restore confidence. "The DECIMA Survey" shows that 94 per cent of Canadians believe that the family physician should be a coordinator of care. In Canada, up until the last few years, over 90 per cent of Canadians had a family physician.
Our survey shows that the major problem that Canadians have is finding a family doctor. It used to be that over 90 per cent could obtain a family physician. That percentage is down to 67 per cent and is causing overcrowded emergency rooms and inappropriate use of health care resources.
If you look at our model you will see that we can restore confidence in the health care system by providing solid primary care support. The World Health Organization has embraced this model as the model for the world. We have been doing it in Canada for a number of years but it has been breaking apart and we need to bring it back together and enhance it.
The Deputy Chairman: One of the terms we zeroed in on was what we call "orphan" patients. These are patients whose doctors have retired. They are at a loss to find another practitioner. People do not understand the psychological impact that this situation can have on seniors.
How do you deal with the advertising of pharmaceuticals? How do you deal with this age of satellites and communication and the advertising of drugs in the United States? People are being influenced by these advertisements and go to their family physicians demanding particular pharmaceuticals because they believe the advertising. How do you plan to deal with that?
You have pointed out that the pharmaceutical companies are big business. How do you deal with that and how do doctors deal with that fact? Dr. MacKean, you may want to respond to this as well.
Ms Auld: I realize that the consumers are getting some of the information and it does filter its way into the local pharmacies, whether it is a hospital or a community. Again, it is a matter of educating the public and reassuring them that we have a different system in Canada. Quite often drugs are advertised that we do not have access to. It is a difficult situation and I certainly would support the government trying to filter out those ads, but it is almost impossible to accomplish on the Internet. I think something could be done with the television and magazine ads.
Mr. Smith: Education is crucial because you are never going to be able to stop the flow of information from other countries. Obviously the United States has taken a completely different route on how to address drugs and the pharmaceutical industry than we have in Canada. They treat it as though it is just a sort of open market for pharmaceuticals just like any
You cannot stop the information from getting here. You can block it. We block cigarette advertisements even though they come through cable television but we do not block pharmaceutical ads. We have to alert the public that advertising is not evidence. They must go to a respected source to find out what the real story is.
Dr. MacKean: As physicians we are here as advocates for the best care of the patient. It is important to keep a barrier between the pharmaceutical industry and the physicians, and there are guidelines in place to insure that is done. One of the popular strategies that we teach the residents, and we teach residents all across Canada in our training programs is to give the prescription with advice: walk 30 minutes a day, do not smoke, have balanced family time and eat well. Having physicians separate from the pharmaceutical industry is very critical.
There is a perception that there is a magic pill for everything. Very often this is not the case and a change in a persons' lifestyle can often make the difference. We only prescribe drugs when they are needed.
Our association strives to ensure that physicians get unbiased evidence-based information on pharmaceuticals and their appropriate use. There has been a lot of very good work in collaboration with pharmacists and physicians and I think our relationship is becoming part of a family practice network.
Senator Callbeck: Dr. MacKean, I was reading an article about family physicians on P.E.I. that are working 96 hours a week.
Dr. MacKean: Seventy-three hours a week is the national average. We had the dubious distinction of 96 hours per week. That is correct. We are not proud of that and have issued solutions that include increasing the number of medical school enrolments and increasing the number of family medicine training programs. Both of those programs had been slashed in the 1990s. If this trend continues, we will not be able to keep the family practice base to sustain primary care in Canada or in P.E.I. in the future.
We have issued recommendations to reverse that trend. We want to promote balance to our patients and also promote balance in our own lives. "The JANUS Project" shows that we need to find ways to create balance in physicians' lives. Other health professionals are very overworked and are suffering from stress.
Senator Callbeck: The situation is going to get worse before it gets better. I know you have a lot of recommendations. You mentioned increasing the medical school positions. Whose job is it to spearhead that? We are not going to have an adequate heath system if we do not have the professionals to work in it. Whose job is it to ensure that we have these professionals for the future?
Dr. MacKean: We believe in a collaborative approach. I have indicated that Health Canada and HRDC are committing $4 million into a health human resource strategy for Canada. The Canadian Medical Forum Task Force II, which is looking at the long-term human health resource needs for Canadians will add funds to that joint venture. I am very encouraged by that and believe that it is the right approach to our problem. I think it will work. I feel optimistic and encourage your support of the initiative.
It takes six years to train a family physician and up to ten years to train a Royal College specialist. We have a crisis now and the next few years are going to be worse. We have looked at foreign medical graduates to see whether they can help us through this void. We are cautious and are talking with the licensing authorities actually are trained according to our standards to deliver appropriate health care in Canada.
Senator Callbeck: I will be interested to read about your family practice network. I think it is a very positive step from what I take from your comments, and I compliment you on that.
Mr. Smith, you talked about drug trials. Does the federal government not have any involvement in those drug trials? Does a pharmaceutical company develop a drug, do the trials themselves, and then take the information to the health officials? What is the federal government involvement?
Mr. Smith: The federal government has a small role in the process but it is not a significant role. The information that is submitted to the government agencies for approval is in large part information from studies that have been conducted by the pharmaceutical company itself. I cannot say categorically that there is no federal involvement but it is not to the extent that it really needs to be if we are going to address this rising cost of the health care budget that is being eaten up by high cost drugs.
Senator Callbeck: You said that if the pharmaceutical companies were not involved in the trials, that cost of the drugs would go down considerably.
Mr. Smith: A trial should be designed to show that the drug could be beneficial. The drug company should not be designing the trial and then producing the results. All this is done pretty much behind closed doors and even when the results are published we must pay attention to where the information was gathered. Many of the studies are not well done. They are not good science and there should be more of an onus on the companies to do good research. The only way that will happen is if there is an agency put in place to make sure that good studies are done.
Senator Callbeck: Are the pharmaceutical companies not really accountable for what they say about a drug?
Mr. Smith: A company may put a drug on the market and say: "This new painkiller is better than all of the other painkillers in its class and has less side effects." We pretty much have to take their word for it. They did the study, they churned out the data, they did the statistics on it and presented it, and we have to accept that until we can prove it otherwise.
Validation means the drug coming on the market, people taking it, looking at how many adverse effects or how effective it is in relation to other drugs that are there and then making a judgment. Often that takes years, and in the meantime, we are spending money hand over fist for this particular item.
Senator Callbeck: You mentioned England has risk sharing?
Mr. Smith: It is a very new idea. I am not sure if it was in The British Medical Journal or The Lancet and it struck me as having a lot of merit to it. They talked about some of the drugs for MS that have been contentious in that the evidence for the effectiveness of them is very difficult to show. Some people argue that they are not effective. The British agencies that look at the effectiveness of drugs have said that these drugs are not effective enough for the public to fund them. However, they are have reached a compromise with the pharmaceutical companies that allows them to recoup the money for treatment failures in return for funding the drug. It is an interesting concept.
Senator Callbeck: I have never been able to understand this. Sometimes there is a new drug that comes out that is in the States and it is not accepted yet in Canada, but it is possible for a doctor to prescribe that drug in Canada and get it for the patient.
Mr. Smith: It depends on the drug. Some drugs are made available if they are on the market in the States. If the drug has been tested and depending on the situation, it may be available through what is called the Special Access Programme.
It is actually not illegal for an individual to obtain a supply of pharmaceutical drugs from the United States for personal use, even though it is a prescription drug. That would not be true for a narcotic but for prescription drugs. For example, when Viagra came on the market in the States and was not available in Canada a Canadian resident could have had somebody send it to them. That would not be illegal. There are some wrinkles in the system.
Senator Callbeck: Ms Auld, so the people of P.E.I. have the history of their prescriptions online?
Ms Auld: If a patient receives a prescription through a provincial government program, then that information is put into the provincial database. If they have been to another pharmacy for a prescription there is a medical check. We would know that they received a prescription at another pharmacy however, we would not know where and when. At that point the pharmacist has to make a decision as to what to do.
The program intends that all pharmacies, physicians and hospitals be a part of the system so that they all could access a patient's information.
Senator Callbeck: Is it the intent to expand this program as funds become available?
Ms Auld: I am not sure. I think funding has been a problem but technology has also presented some difficulties. The pharmacies are ready to go but it is not fully operational.
Senator Callbeck: Why are we going to have a shortage of pharmacists in Canada?
Ms Auld: The supply of pharmacists is one reason. The demand has been increasing for pharmacists because of the expansion of pharmacies. Hopefully that problem will soon be alleviated. As with medicine, pharmacy schools are starting to increase their enrolments, but that solution will take four or five years.
We have lost a great many pharmacists to the States. Financial incentives, higher salaries plus the strong American dollar are taking our pharmacists out of Canada.
New pharmacists leave school with heavy debt-loads. Some students study for as many as eight years and have enormous debts. It is more lucrative for them to move to the U.S. in order to pay their debts.
Other pharmacists leave because of disincentives. They just are not able to practice pharmacy the way they want to. They are very technical and they want to be clinical. The system does not support them, they become frustrated and they move, or they leave the profession altogether.
Senator Cook: I would like to discuss the drug companies. Does the Patent Medicine Act impact on drug companies? Are you saying that this industry stands alone and that they can move drugs from production in a lab to a researcher? What is the process and how do the drugs get through the system?
Mr. Smith: We must remember that first and foremost the pharmaceutical companies are big business. The U.S., for the most part, controls the industry in Canada. The pharmaceutical industry is the single biggest lobby in the States. The have more pharmaceutical lobbyists than there are Congressmen. They are in the top 48 Fortune 500 industries. The pharmaceutical industry ranks first in return on investment and return on profit. In the year 2000, Merck, which was the biggest profit maker earned $9.8 billion in profit, or at least that is what they declared in the United States. So when you talk about power, the pharmaceutical industry has incredible power and that power is not something that we should take lightly. It is something that consumers should be aware of too. With the amount of power they can control legislation. It was the pharmaceutical industry that blocked the Clinton Universal Healthcare Initiative. It is mind-boggling how influential they can be.
Senator Cook: Under The Patent Medicine Act, you get a patent for a drug for so many years. There are some safe guards in Canada but the U.S. does not have a similar act.
Mr. Smith: They do have drug patents in the States and their patent protection is, in general, much longer than ours.
Senator Cook: How does the Patent Medicine Act, which takes care of the registry of the drug that comes on the market, impact on the drug industry itself? I am looking there to see if there is accountability there.
Ms Auld: I am not too familiar with the Patent Act but I am familiar with Health Canada's TPP, Therapeutic Products Program, where they do the drug evaluations and assessments when products are brought to the market. The industry does have to provide the information to TPP, and receive what they call a Notice of Compliance. They are requirements that must be met before the Notice of Compliance is given to them.
I do not know if industry can just put something right to market and have no accountability. There is a process and I believe the Canadian model to be more strict that the American. We often see U.S. drugs that cannot get their Notice of Compliance. However, there is a leak because see drug recalls from products that did receive a Notice of Compliance but have been nevertheless found to be harmful. In that situation there is an emergency recall and all the pharmacies are told to pull all the stuff off the shelves and send it back because of problems such as unforeseen drug interactions or side effects that are often detrimental to people's health. In some instances those reactions may be fatal.
Senator Cook: Would you advocate a risk sharing strategy with Health Canada to guard against that kind of thing?
Ms Auld: I do not think so, but they are still using studies that industry provides. There still has to be that $hands-off' group that are actually evaluating and deciding, doing the studies, and coming up with the decision whether it should pass.
Senator Cook: Do you think that they are bypassing the system?
Ms Auld: I do not think the system is there to bypass. They are using whatever system is there.
Senator Cook: Do you see a solution? I am concerned that I might get the wrong drug.
Ms Auld: There is a need for a stronger step before the drug gets to market. That step is missing.
Mr. Smith: I am not too concerned with the safety of the drugs because I think we do have pretty good safeguards in Canada. Once the drugs are on the market, we can get a look at them. There is a big push to report adverse drug reactions and collect those and see if they relate to a drug in a significant way.
My point is that there is no accountability for things that do not work or that do not work any better than the other ones that are on the market. I disagree with the big advertising campaigns that say, this product is better than the other one. That is where there is no accountability that I can see.
Senator Cook: There is no evidence-based information at the point of entry and it is too late after it is signed up.
Mr. Smith: Yes, and it depends on your definition of evidence. It is almost impossible to determine whether the evidence is scientific because the pharmaceutical company itself has provided the evidence.
Senator Cook: Do you have any solutions that you might offer?
Mr. Smith: When you get to the point of clinical trials in humans, to substantiate the approval for marketing in Canada, there should be some independent body that performs those functions or at least oversees them. We need an impartial body to ascertain whether the trial is appropriate or not. That body could also recommend that changes be made to the drug before it is marketed. The trial costs a lot of money and that cost is factored into the price of the drug. Once the drug is on the market we pay to do other studies to show that, what they say is true is true, and honestly, often it is not.
Senator Cook: Would a national drug formulary mitigate this and make it simpler?
Mr. Smith: I think a national drug formulary is a useful initiative, if only that it gives a top-down kind of continuity that at least provincial governments will be able to use as a basis for how they treat drugs in their own provinces. The drugs that are on the formulary will have undergone some measure of approval if things are done in a good way. Yes, I think it is a useful idea.
Senator Cook: Dr. MacKean, I would like to talk to you about the family practice network. I come from rural Newfoundland and our population is aging. We lost 30,000 people from rural Newfoundland in five years. I think the health concerns that most people have can be dealt with in a community or regional setting. I call it "one-stop shopping" and I think your family practice network would work well in our area. I wonder if we could have a blend of population health, community health, and patients where there could be a registry. This would be so much better than having people sitting for hours in a primary care hospital waiting for blood pressure pills, an insulin check etcetera. Do you see the elements that are outside the program now?
Dr. MacKean: I have outlined some of the things to show how we can do it. We think it is achievable. It is service oriented. It is comprehensive care for Canadians with on-call services. One-stop shopping is a good way to look at it. It makes it easier for the public to handle. We have visions of it becoming virtual-based. In other words, isolated communities could be in contact with other areas as well.
I think the model is achievable, and it does not have to be one method that fits all. Different communities have different needs and they could find a system that works best for their particular circumstances.
Senator Cook: I know it is not possible to achieve it for each community, but we could expect it to be available within a region. Do you see it in an urban setting as well?
Dr. MacKean: We imagine this will work in all areas of Canada. We believe it will work in the urban and inner city settings and in some cases work even better there. We talk about the crisis in rural Canada, but there is a crisis in urban and inner city Canada as well. We imagine all areas of Canada would fit into the model and that all Canadians would be included in it.
Senator Cook: Have you gotten to the point where you are ready to do a pilot project?
Dr. MacKean: We have discussed this with all the provincial ministries. Ontario is taking the biggest lead. They are trying to put this process together right now. There are pilot projects all over Canada. We need more research on the pilot projects. Health Canada has put together a fund to do this study. We need to look at the pilots and make sure that we choose a model that will work best for Canadians.
Senator Cook: Do you see this as a federal initiative?
Dr. MacKean: I think it will have to be a partnership. The delivery of health care rests with the province and they are taking the lead. However, the federal government could become involved and ensure the principles in medicare
Senator Cook: Medicare was designed for people in hospitals. The needs of the country have changed. We need continuing care and home care for the critically ill who are recuperating and need it four or five days or a week and so on.
We have to focus on the well-being of seniors and the frail elderly, and that concern me personally as I will be that age soon enough. I hope I live long enough to see some system in place that cares for those people. I would like to see public health for the population, educational programs for new moms, for breast feeding, for PAP smears and so on. If we could take those programs out of our hospitals, I think we would alleviate a lot of the stress and some of the costs.
Dr. MacKean: We have recommended more education, more work on childcare, early childhood development and parenting education. These networks can achieve these goals. It is unfortunate that they are nowhere near the volume that they should be. Those are the areas that we need to work on. That is where the biggest investment will be: population health, children, parents and families. This is a big area, yes.
Senator Cook: Where will problems such as contaminated drinking water, immunization against smallpox and anthrax be housed? Are they going to be housed in community population health? Will the emergency room in the hospital respond to these problems? There are a lot of concerns about the ongoing things that we need to be doing.
Dr. MacKean: I think immunization is one of the successes in Canada because we have virtually universal immunization as opposed to the United States where a third of the population have immunization. We are well ahead of the U.S. in that regard. These sorts of programs will ensure proper health promotion.
Hon. Archibald H. Johnstone, Former Senator: I have heard some statistics concerning the shortage of doctors and nurses, drug addiction, tobacco and alcohol use, cancer, the cost of prescriptions, inactivity in our population and the problems facing Canada's overweight population. Most of these are problems are found in Prince Edward Island. To what do you attribute these factors?
Dr. MacKean: We are living in a high technology world that is fast paced and people do not get back to the basics. How do you bring that back? How do you bring "the old way" back to Canada? It is very tough, especially when you have all the media promoting the latest pill for you. That is very tough to fight.
I can tell you that it is going to take approaches from all levels. In terms of our proposal for family practice networks, we think we can at least address the health issues in a better way because we will be there and we will be a resource for the population. We will try to include nurses, pharmacists, physiotherapists, dieticians, mental health workers and addiction workers in our networks.
We actually see this as a solution to all of our health problems if it done in a concerted way. We feel we can actually move to improve those health parameters that we heard earlier that seem pretty devastating.
The Deputy Chairman: Thank you very much for your testimony, Dr. MacKean. I can assure you that all of your views will certainly be taken into consideration when we deliberate on our hearings. Thank you again on behalf of the committee. We will invite our next group of presenters to the table.
Ms Sylvia Poirier, Chair, Queens Regional Health Authority: I am the volunteer Chair of the Queens Region Health Board. Health care reform and regionalization of health care services in the early 1990s necessitated changes in governance that saw our hospital boards become regional boards. There are five health regions in P.E.I. The Queens Region encompasses about one-half of the geographic area of P.E.I. and one-half of the population, about 70,000 people. We have some 25 facilities including the largest tertiary care facility, the Queen Elizabeth Hospital, with a 287-bed capacity. We have a staff of 2,500 and a budget of over $150 million that is a little less than one-half of the provincial health care budget.
The composition of the boards is defined in legislation. The legislation allows for a combination of elected and appointed members. The larger regions, such as Queens, have a board of nine, with five people elected and four appointed; whereas the smaller regions have a total of seven members, four elected and three appointed. The recent addition of elected members ensures accountability to the community.
Each board is responsible and accountable to the citizens of its region for the delivery of health care in that region.
Our board operates under a policy governance mandate. This means that we spend our time at the policy level and not at the operational level. We do not make decisions about particular programs, staffing or specific budget items.
This is a difficult concept for our board members to grasp. Many of our board members have been on other boards that operated in a more traditional manner with board members getting into the particulars of the everyday operations. It continues to be a challenge for some members to stay out of what is staff work and stick with board work.
Boards must deal with outcomes and they want to achieve for the organization as a whole. In the meantime the CEO and staff deal with the means of achieving those outcomes. It continues to be a challenge because the most interesting stuff, as we all know, is in the area of staff responsibilities. To quote John Carver in his textbook, Boards That Make a Difference:
The board is ultimately accountable for an organization it does not see, that carries out a multitude of tasks it does not understand.Along with the Minister, the board hires a CEO. It is the board's responsibility to define the role of the CEO. The CEO is the only board employee. The rest of the staff is accountable to the CEO, and the CEO is accountable to the board for his or her own actions, as well as the performance of the whole regional organization. The CEO is also accountable to the minister. We have seen that there are challenges involved in serving two masters.
In addition to setting goals and providing broad direction, monitoring the work of the CEO and the work of the region with respect to programs and services, the board's job also includes being accountable to the citizens and representing their needs. This is a big job and our boards take this very seriously. Boards do this in a variety of ways including conducting community needs assessments, holding community meetings around specific concerns, having board meetings which are open to the public, and linking with volunteer agencies who also have a significant role in the delivery of health care services.
In addition, our boards have played a role in educating the public, promoting health, and advocating when community needs require such action.
Katherine Kelly, Chair of the East Prince Health Board, conducted a survey of the members of the P.E.I. health boards as part of her Master's thesis. She was studying the experience of present board members with respect to their understanding of their roles and responsibilities. Her study reveals the following: Board members, elected and appointed, feel a strong commitment and accountability to their communities even though by legislation they are accountable to the minister. However, there is a high degree of frustration among board members with respect to role clarification, authority for decision-making and accountability.
Some of the specific challenges identified include: Board members feel too far removed from the organization, possibly a result of the Policy Governance Model; lack of clarity as to whether a board is governing or is acting in an advisory capacity, especially since boards do not hire their own CEOs independently; lack of clarity in distinguishing the roles and responsibilities among and between the Minister of Health, Deputy Minister, Boards and CEOs; a feeling of lack of power over how the resources are controlled and allocated; uncertainty as to the extent to which boards are responsible and liable for their decision making and a concern that the board really does little in the way of decision making; clarifying financial accountability, the tension between what is logical and what is politically palatable.
If the senior manager, CEO or board will not deliver what a particular individual or group wants, the accepted practice is to talk directly to the minister or to the premier; and this last issue probably explains why, even after almost eight years of having regional boards, it is debatable whether the community sees the board as a credible governing body with authority for the deliver of health care services.
There were also strengths identified by the study and some of those include: committed board members; a consultative minister and deputy minister; frequent and reasonably effective communications; CEOs who meet regularly with the deputy minister; twice yearly regional board working sessions with the minister and the deputy minister; and a provincial strategic health plan developed in consultation with regional boards and staff and the community at large.
Those of us in regional governance recognize that these issues arise in significant part from the changes that we have undergone, and we realize and we hope that they are a result of the transition force and eventually the issues will settle.
I do want to make clear, however, that the confusion around the role of the boards is an issue separate from the state of health care in this province. Regionalization has been a very positive undertaking with respect to the delivery of health services, and I would wholeheartedly agree with your conclusion on regionalization. You state in the brief that:
... regionalization and health care reform have been a key element in improving the integration of health services,I would add to that, "on P.E.I."
Mr. Ken Ezeard, Chief Executive Officer, West Prince Health Authority: I am the Chief Executive Officer of West Prince Heath Authority. I am also currently National Chairman of the Canadian Healthcare Association for 2001-02.
The Canadian Healthcare Association, as a federation of provincial and territorial associations, is very supportive of the voluntary governance role in administering health care organizations and services across the broad continuum of health and social services. CHA has prepared and submitted several briefs to emphasize the importance of voluntary governance and is currently preparing a comprehensive statement of its position on the roles and responsibilities within the Canadian health care system. However, my remarks are based on my role of Chief Executive Officer of one of the health regions on Prince Edward Island, and my comments are a short summary of some of the values and issues facing regional governments in P.E.I. and by implication across Canada.
Sylvia Poirier described the regional framework and the number and size of boards as defined by legislation. Queens Region is the largest and West Prince Health Region is the second smallest in terms of population served. Our population is 16,000 and we have an annual budget of $18 million. Our population is small but the region is the largest geographically, covering the entire western end of the Island.
The Region includes two hospitals, one with 27 acute care beds and the second with 13 acute care and 15 long-term care beds. We also have a separate long-term care facility of 49 beds and a full range of regional community health and social services. Services are based out of the towns of Alberton, O'Leary and Tignish. The board members represent each of these towns and surrounding areas as well as the rural area of Cascumpec. Based on our experience with a board that has been in place since 1996, the following are some of the benefits that the region has realized along with some of the issues that we are facing. The benefits include: the mandate and scope of the regions cover all of the major health service delivery disciplines as well as addictions and social services, including welfare assistance, allowing more direct referrals and interaction among services; it is much easier to get all of the professional staff involved in the patient, resident or client care at the same meeting or case conference, as they belong to the same organization. There are more right decisions being made at the right time with the most effective and efficient use of resources; governance linkages with the community now cover the entire continuum of care under a single governance organization, and regional boards can undertake an information needs assessment on all services; clearer separation of service delivery from the policy setting or direction of government and more decisions are made at the point of service contact; use of a modified policy governance model for the boards of the Regional Health Authority differentiates more easily between policy direction and strategic planning of the board and the day to day operations of management, including the accomplishment of the organization's goals and objectives; after a five-year period of uncertainty and instability as the organizations learned their new role, there is now a three-year period of growth and development as organizations have stabilized, planned strategically, and are now achieving objectives in all sectors of the health and social services system; the economies of scale of operation are occurring including administration efficiencies, effective group purchasing, consolidated service contracts and interaction among different sectors of the organization; there is greater accountability from the health regions to the policy setting and funding allocation of the provincial government in terms of measuring health outcomes and living within the budget allocation on an annual basis; there are more opportunities for inter-regional cooperation on sharing specialized services along the continuum of care.
At the same time, there are remaining issues: the orientation and education of board members is more complex and demanding, and new board members require a longer period on the board to be comfortable with the total and individual service scope of the organization; as the boards are now elected by the community, or appointed by government, direct physician participation of the board does not exist, except by appointment in one Region. Therefore, creative ways to ensure the necessary input is essential, through regular meetings and discussions with the Regional physicians.
Other issues include: the need for boards to honour and respect this past in order to create the necessary transition and buy into the emphasis on service delivery and not the bricks and mortar; considerable effort and attention is required to ensure that the board's legitimate role of representing the community and planning regional service delivery is not superseded; the modified policy governance model used by P.E.I. regional governance reduces direct board involvement in financial decision making except for setting key parameters of policy and monitoring results. To maintain board involvement and credibility, the system of budget preparation and forecast reporting must be developed in such a way that the boards are an integral part of the process. Otherwise, P.E.I. Regional Health Boards may be reduced to an advisory role which experience has shown leads to a loss of interest and the reduction in community involvement and support.
In P.E.I., we have strong, committed board members who have played a vital role in the evolution of the health and community services system and it is extremely important that their voluntary governance role be continued as an essential component in the future direction of the Canadian health care and in our case, the social services system. Thank you.
Dr. Don Ling, Director of Medical Services, Department of Health and Social Services, P.E.I.: I apologize for not having any sort of a brief available for you. I have been a family physician for about 23 years in that work. I have been the Chair of the Board of the Health and Community Services Agency in P.E.I.
I think that is how I got invited to this session on governance and I am quite happy to participate. I have been Director of Medical Services for the last five years or so.
It has been a wonderful experience to observe the changes in the health care system. One of the difficulties in our health care system is that it has been hard to attract providers, especially from the physicians' group, to be involved in administration and I think it is a pretty important role and it is not well understood.
I was fortunate to hear some of the last session that included the family physician and it was nice to hear the comments from some others. Their presentations were beneficial.
The issue of governance is extremely challenging. Provinces across the country struggle to find the most efficient system and I suppose that is why the systems keep changing.
We need clarity in the design of our acute care system in this country. Expectations are huge, yet capacity to provide is limited. We appear to be at our financial capacity right now. There appears to be very little added resource available in provincial budgets. There is a discussion going on between federal and provincial counterparts as to who is going to be able to support what. I liked your comment that perhaps everything is not possible within this system. I think that is a real question that has to be answered by our political leaders and hopefully will be found in the short-term.
In your document, you made reference to the reference-base pricing approach to drug programming in B.C. I think that is the kind of set-up that we need in this country. I think that we can only provide a limited level of service, shall we say, that I think should be available. I think if you are going to go up from there, whether it is in drugs or something else, maybe you better be prepared to pull your own weight at that stage so we can at least have some expectation of expenditure.
Technology, the pharmaceuticals companies and the American influence are tremendous cost drivers in the system right now. People want access to new and expensive technologies and the pharmaceutical companies are very powerful and unrestrained. Add to this the huge cultural influence that comes to us from south of the border and we have a society that is very demanding of the health care system. I am pleased to hear you have given some time to these issues.
The human resource issue is the third issue I would like to discuss. I have been involved in FPT committees, especially in HR, and I have been chair of a working group on physician resources in the country. I am quite informed and have been working hard to try and identify pathways for the future. What I have found is that the major barrier to efficiency is dollars.
We can train more providers but it takes more money, and provincial systems are stretched out. They own that system. The federal government could work in partnership with the provinces. This has been mentioned and I believe it is worth looking into.
Health care is the responsibility of the provinces, however, the federal government may have the funds that in partnership with the provinces might make the system work.
The Deputy Chairman: Mr. Ezeard and Ms Poirier did a very good job of the whole regional governance and laying out the benefits and also some of the remaining issues.
Mr. Ezeard, in your remaining issues section, you talk about the boards being elected by the community and the direct physician participation of the board does not exist except in one region. Does this cause huge problems? Is there conflicting interest in the whole area of governance? If there were not a connection between the physicians and the people actually delivering the service, and the board, would it not be better if there were some specifications of the types of people that make up the board?
Mr. Ezeard: Under the old institutional system, physicians played a major role. Usually, the Chair of MAC was a full standing member of the board. When we regionalized, that particular aspect was dropped.
Originally, the government appointed the board members and there was a strong emphasis to move any group that may have a vested interest in the operation back to an advisory role as opposed to direct participation in the board decision making. This procedure moved the governance out into the community and the legislation currently has some restrictions, vis-à-vis conflict of interest.
To try and replace that, the various regions have made a strong effort to try and make sure that prospective board members seeking election know exactly what is involved in their liaison with stakeholders, such as physicians or other major groups in the health care and social services system.
The intent of the appointment process of government is to try and balance the elected representatives to ensure that there is proper geographical sharing, gender split and cultural representation. It has forced us to be much more creative, particularly at the management level, in providing information to the board to make sure there are mechanisms for input.
In our region, we have two yearly meetings with the physicians and at that time they have the opportunity to present to the board, either in writing or in person, issues that they find relevant. I think there are opportunities for communication, but they are less than in the previous system.
The Deputy Chairman: Do you have any comment on that, Ms Poirier?
Ms Poirier: It certainly has been an issue. One of the arguments against it has been, why physicians? If you want to have physician representation, then you should perhaps also have representation from the other health professionals. The physicians are a very powerful force in the health care system. In the Queens Region there was opposition to the fact that there was not a physician represented on the board, and to the fact that we now have the Chief of the Medical Advisory Committee on the board. That has turned out to be more positive than we would have anticipated because with regional governance, the board has to speak with one voice and individual board members' perspectives are not supported. It has worked well and it is perhaps due to the individuals themselves, but certainly, it has been a good liaison and there has been much more harmony than we would have expected.
The Deputy Chairman: Has there been more pressure on the elected members of the board? Do they speak as a whole? I imagine that someone who has been elected to the board would have pressure on them whereas someone who has been appointed would not.
Ms Poirier: That is an excellent question and one would expect that would be the case. However, I was appointed and served a three-year term. Now I am elected and I see no difference at all. It may be due in part to the fact that the boards are not seen as very powerful organizations and not really in charge of health care. In our case, of the nine people on the board for the Queens Region, there is probably no difference between those who are elected and those who are appointed. The community has no idea who is appointed and who is elected.
Senator Callbeck: You think the public is not aware of who is elected and who is appointed on those boards?
Ms Poirier: I do not believe so. With few exceptions, the community may not be aware of who is on the board, let alone who is appointed and who is elected. We do not get large turnouts even though we do a huge amount of advertising. November is our annual meeting month and we encourage, plead, cajole, send out individual invitations, et cetera, but we do not get a big response. Our experience is that when there are big issues, people will attend. We had a very large turn out when we were about to close the acute addiction services in the East Prince Region. Otherwise, they do not attend and it is difficult to know why. Perhaps they are content with the system. We must also remember that this is a small province with a small population. If a citizen has an issue he or she can see the minister; and if he or she is not satisfied then the option is to go next door and talk to the premier. In P.E.I., that actually happens and I am sure the minister will elaborate on that point.
Senator Callbeck: You mentioned whether the community sees the board as a credible governing body or not.
Mr. Ezeard you talked about the last three years and remarked that the boards are doing more and reaching their objectives in health and social services. Ms Poirier do you think that in the last three years your board has become more credible in the eyes of the public?
Ms Poirier: I do not know if I can answer that. The only way to find the answer to that question is by conducting a public survey. I think they would pay lip service to us, but I think they think the power to make significant health care decisions rests with the minister and the premier.
Mr. Ezeard: There appears to be some difference in credibility and recognition of the boards between the rural and urban areas. In the rural area of West Prince there is a greater knowledge of who the board members are. In this small community people tend to run into each other in the grocery or drugstore and in this environment issues are discussed. It is a good way of determining what the concerns of the members of the community are.
West Prince went through a major upheaval and had a wholesale change of its board as a result of actions concerning the number of acute care beds, but I think that we certainly got over that and the regionalization of the whole system within West Prince has moved along quite satisfactorily. There are still a number of issues that have to be dealt with. However, we have had some success concerning long-term care, good publicity because of that success, and have become more confident as a result of being recognized as a region. Patients that would have had to become residents of an institution are now handled in home care. The community is aware of those changes and they are seen as being positive. Regionalization and involvement of the board in those kinds of actions has not gone unnoticed in our small rural area.
Dr. Ling: I spent a year on the provincial board. It is a tremendous challenge to be a board member. The profile is low especially in the urban areas. It is true that the power rests with the elected officials and as a result boards get bypassed. I agree that a public survey should be taken.
Ms Poirier: It is a complex system and people who work in it full-time are still challenged to truly understand all of its mechanisms. To give those similar responsibilities to people who do this work in a part-time capacity is unfair to both the system and the people. The responsibility of running Queens Region alone would be no small responsibility and it is a responsibility I would not want to undertake. Even with the help of well-trained, well-meaning staff, there is no one answer to a problem. It is not as though there is a pattern and then there is the answer. There are hard, tough choices to be made and I think in many ways the system is making those choices in the best way that it can.
We need more clarity. Very often the board members set out to do great things only to be frustrated in their efforts. There have very few discretionary resources for spending, etc. I do not want you to consider that our board wants to take over every aspect of what happens in the Queens Region. What we need, I think, is better clarification of exactly what the complementing roles are.
Senator Callbeck: As volunteer chair, approximately how many hours per week do work?
Ms Poirier: It depends on the work that needs to be done. During the spring months I worked between 30 and 40 hours a month. However, that is not enough time to do the job well.
Senator Callbeck: It is a lot of time, though.
Mr. Ezeard, in the benefits that you were listing here, one was greater accountability in terms of measuring health outcomes. We have been criticized for not doing enough of this. What health outcomes are we measuring that we were not measuring ten years ago, or before we did this?
Mr. Ezeard: In our region we are looking at about 30-40 performance indicators, to see how well we are performing. We are measuring patient and client satisfaction and also, staff satisfaction. We are addressing patient satisfaction through exit surveys or follow-up surveys conducted after discharge from hospital. We are looking at all of the services that we provide and dealing with any issues that are identified as problems.
There is a particular area that we have taken more interest in and that is staff wellness. We have conducted staff satisfaction surveys and are interested in outcomes. Therefore, we are looking at the outcomes of not only the clients but also our own stakeholders. Staff wellness has an immediate by-product on the productivity and the treatment of our patients and clients.
We have been measuring the regulars, the morbidity and mortality and that process has become more refined. Ms Poirier mentioned the accreditation process. All five regions are accredited at the same time. That has created consistency and measurement of outcomes in terms of results from activities. As a result, we get together and talk about areas where we fail to meet the standards that we have set.
Senator Callbeck: Do all the regions measure the same health outcomes?
Mr. Ezeard: Yes. We developed a pilot project in cooperation with the department and five key areas and a set of five developments were chosen. Staff wellness, cardiac outcomes and so on are now consistent across the province and that will be expanding to other services as this system gets rolling.
Senator Callbeck: Dr. Ling, you talked about the cost drivers, the drugs and the technology. Then spoke about the human resource sector in health which you say requires a partnership between the federal government and the provinces and that more money is needed. Is there anything else that we should be doing?
Dr. Ling: That is a complex question and we are having trouble finding the answer. Right now we are wrestling with the shape of the system, and if you are going to determine the human resource requirements, you have to know which way you are headed and how you are going to deliver services. If physicians are to continue in the role they now play and enjoy, and have for the last number of years, there are basically stand alone units that define their own business borders and have, like franchisees out there, and they do their work, and if that is the system that we are going to maintain, we will need more of them than we will in a different system. We have to know which way we are headed concerning primary care reform.
Senator Callbeck: You said that was coming on strong in Prince Edward Island. Can you elaborate on that?
Dr. Ling: We have been in medicare for a little over 30 years and for the first number of years, it worked very well and it worked well for everyone. It worked well for physicians because all of a sudden every account was good and they did better from a business point of view. That went on for 10 or 15 years and from a patient point of view, they had access to services when they needed them and there seemed to be sufficient providers to take up the work and so everyone was really content and the country rolled along.
To keep delivering these services, our scale of physicians per hundred thousand people began to rise and continued to do so for 20 years. Governments, of course, were paying for all the work that was being done and budgets became difficult to handle.
In the 1980s, interest rates were very high and there was a lot of difficulty in financing government programs. Naturally, something needed to be done. In the early years of medicare we opened up new medical schools, enlarged the ones that were there and produced more physicians. Our international borders were more open than they are now and international medical graduates were welcomed with open arms to come and be part of our workforce; they did so and our numbers rose.
Today we have a gap. We have tremendous pressure for service and we do not have as generous a workforce as we once had. How do we respond to that? I speak to this physician side because I am most familiar with it and I do not mean to be one-sided but I am sharing probably what I know best. Task Force II was referenced. The Canadian Medical Forum, which is organized medicine put out a report three years ago and said we need more doctors in this country. Our government was not sure about that but tried to change things. They decided that there was a need for 2,000 doctors to be produced every year. At the time there were 1,550 doctors graduating each year. In this current year we have between 350 and 450 of those spots filled or 80 per cent of the demand.
However, Atlantic Canada has been unable to do that. We are hamstrung. Dalhousie University is the only academic centre in the country that did not enlarge their medical school. Memorial University did it in a cheaper way. New Brunswick and P.E.I. purchased 12 of the 15 seats they usually sold to Americans. They did not increase any of their expenditures but instead closed off 12 of those seats to American candidates and increased their Canadian class by 12 students. Dalhousie still sits at the same number and that is unfortunate. The other 15 schools all had increases. That is where we are in the physician HR side and I just painted the picture a little bit. We have to enlarge our classes once again.
Senator Callbeck: Ms Poirier is the community clinic in Sherwood primary care or is it set up with a doctor and a nurse?
Ms Poirier: The Four Neighbourhoods is a Sherwood clinic and its concept is primary care. Originally, we wanted to do this a long time ago but we could not find a physician in our community who would work for salary. That, I think, has changed significantly over the last year or two, so we are ready to go.
Senator Callbeck: We have a clinic in Sherwood and one in Wellington. Are those the only two on the Island?
Mr. Ezeard: They are a bit different as well. Both were set up on a community service model, basically with no medical component, although Wellington for a time did enjoy a visiting physician. Six or seven years ago physicians were not receptive to the invitation to join the operation. We are moving toward alternate pay and as a result the doctors are more agreeable to the idea. Five years ago we had approximately 15 physicians out of a workforce of 150 that were salaried physicians. We now have doubled that number and will likely double that number again over the next number of years. I believe that to be a healthy trend for the system.
The Four Neighbourhoods wanted desperately to get into primary care and the medical aspect of it, and we were able to accommodate them with a new position. We hope to move up to two FTE physicians in the next year at that site.
I think they are very pleased with the outcome and I think their clientele enjoy a broader service delivery. The physicians have a role to play in the primary work that is being done and will do so if adequately compensated for their time. This new design with its incentives is bringing the physicians into the system more efficiently than was done before.
Senator Callbeck: Is it open in the evenings, too?
Ms Poirier: It is open but I am not sure if all professionals are there in the evenings, but it certainly is open for a lot of community events and it is a real community centre as well as a place to get health care.
Senator Cook: In my other life I was a board member. Have you looked at other models of governance, particularly in Atlantic Canada? I would like to offer you one from the Health Care Corporation of St. John's. It is a broader model than the one that you are working with. For instance, we had the department heads from finance, nursing, ethics, human resources, and two or three board members assigned to those subcommittees and we did detailed work and brought it back to the board. In addition to that, we had a medical advisory representative, a representative from the provincial Executive Council, and someone from the medical school so that our communication flowed fairly easy. In all of the structures, we had our mission statements and our policies. I do not know if we were doing a good job or not, but by and large the government listened.
I know that your 25-30 hours a month is not accurate. Again, on the issue of appointments and election, I think for a health board to achieve their mandate you have to be eligible. If you are going to have an election, there has to be an application in order to get the criteria of the people around the table that is necessary to do the job. There is a lot of expertise that comes from the volunteer community that sits at that table and something that the community can be critical of because all of you are all appointed. Those who go there with a particular expertise are strong people and believe in that commitment and go forward with it. I would like to offer you ours and I could send it to you and you may just pick up something from it, and good luck.
The Deputy Chairman: I would like to thank each of your for appearing before the committee. I really think it was important that we get some input on the regional governance and the regional boards. It is an area that is certainly getting a lot of attention across the country, some good and some bad. On behalf of my fellow committee members, I would like to thank you.
The committee suspended.
The committee resumed.
The Deputy Chairman: Welcome to our afternoon session. Please proceed, Mr. Ballem.
The Honourable Jamie Ballem, Minister of Health and Social Services, Prince Edward Island: What we are proposing to do today is that I will make some opening remarks, my deputy minister will make some comments and then I will deal with a couple of issues before finishing off.
To begin, I would like to thank you for affording us the opportunity to join you today and take part in these discussions. The fact that we are here this afternoon is just part of it. When I look at the list of presenters or panels that have appeared before you, it includes many of our staff, and our partners have also participated, and that is important for us in giving you the message about health care and our system in this province. Like you, we are very concerned about where health care is going and the direction it is taking. We are concerned about the issues that we are trying to deal with as a system, not just in this province but across the country.
One of our first priorities, as a department and as a health system, is sustainability, and we do not mean just dollars and cents. We mean our ability to continue with the success and access to quality services by Islanders, not only now but in the future, using the financial and human resources that we have available to us, as well as our capital equipment and the facilities that we have available and that will be available in the future. To put it into a little bit of perspective, with respect to the challenges that we face in this jurisdiction in regard to our Health and Social Services Department right now, we take 42 cents of every dollar that is spent in the province. Based on very conservative projections in a very few years, that could be 50 per cent if we do not do something about it. That poses a lot of challenges for us as a government as to where we have our spending priorities, how much we are able to do and what we are capable of putting in place.
We have a couple of strategies that we feel could be useful in improving the sustainability, and at the end of our session we will close our presentation by talking about stable funding, improved efficiency and innovation.
My deputy will be talking about our integrated system here in the province. We will talk about the health of Islanders, to highlight it and put it into perspective in relation to the challenges that we face. I will turn the session over now to Mr. Francis.
Mr. Rory Francis, Deputy Minister, Department of Health and Social Services, Prince Edward Island: I know the focus of your work is on the health system, and we are aware of that. I guess we just want to acknowledge the difference between health and health care, and the fact that, in our view, certainly the system needs to be designed around the citizens of the province and their health status. What our issues are in terms of the current health status, and how we ensure that we have a healthy population is obviously a very important part of determining what we actually must do, as a system, to respond to the needs of our citizens.
In P.E.I., we have very good results in terms of the health status of citizens in some areas, and not so good results in others. We have high rates of positive mental health - in fact, one of the best results in the country - very low rates of sexually transmitted diseases, the highest level of social support and strong social networks in the country. Our children have excellent birth weights, the lowest rate of child poverty in the country here in Prince Edward Island, and one of the lowest rates of infant mortality in the country.
At the same time, on the negative sides, we have some of the lowest rates of physical activity, the highest rates of children exposed to second-hand smoke, one of the highest rates of cardiovascular death among males, unemployment rates that we would certainly rather have lower, and literacy and education levels - which are also another important determinant of health - should be higher.
Like other Atlantic Canadians, Islanders are generally less healthy because we smoke too much, we drink more, we exercise less and, in general, carry too much body weight. As a result, we have some higher chronic disease issues, particularly cancer, heart disease and diabetes which are certainly a challenge and a burden on individuals and families and on the health system. Chronic disease is the major cause of death, as well as potential years of life lost, hospitalization, and reduction in quality of life. Cancer is the leading cause of potential years of life lost, and diabetes and depression are certainly increasing at alarming rates, a particular problem across Canada but also here in Prince Edward Island.
Our primary opportunities to improve health status within the system, we believe, and as you may have noted, lie within the strategy that we have been working through with citizens within our health system, putting a lot of emphasis on healthy child development. We believe that is an area where we really need to pay more attention and invest more resources, as difficult as that may be given the demands on the acute side of the system. We need to invest for the long term in healthy child development for many reasons that we could probably spend a whole hour talking about, in and of itself.
Reducing risk factors for chronic disease is another such strategy. Again, there are many lifestyle issues involved, such as smoking, lack of exercise, people being overweight and so on. This is another very important area that we must pay attention to if we are to have a sustainable system in relation to the prevention and chronic disease management side of things.
We probably have one of the most integrated of services in Canada in relation to health, social services and housing, in that it is different than what currently exists in most parts of Canada. We have a publicly-funded and administered system with universal access to medically necessary hospital and physician services. That, and many other health and social services, are funded in whole or in part by the provincial government. I do not think I need to talk about the governance system that we have. I believe in an earlier session you had representatives talk about our regionalized system, and some of the strengths and weaknesses of that. Certainly, we are making great gains in using effectively a model which involves regions and the department in a way that provides for better outcomes for our citizens.
The high degree of integration includes a wide range of services, health and social services, acute care, addictions, mental health and housing, all very broad and integrated on a regional level, which really provides opportunity for more client-focused, patient-focused care than would be the case if the system were modelled around programs as opposed to regions and citizens. Some specialty services are accessed within the Atlantic health care system so we do not try to do everything ourselves here in the province. We have strong partnerships with New Brunswick and Nova Scotia, in particular on some of the secondary and tertiary acute care services. That is what makes sense from a population-based standpoint, and if we were not already doing that, we would certainly be thinking hard about it these days because of the challenge of attracting to the region appropriately trained and qualified health professionals. These days, you need to have more than a sustainable system; in some of these service areas, you need to have the backup of human resources. One-off services are very fragile, and by working regionally around those services, we have a much better opportunity to maintain a sustainable, high quality service. Those relationships are very important to us in the Atlantic provinces.
Combined public and private spending per capita in the province is about $2,500 - slightly less than the national average. On the other hand, spending as a percentage of our GDP is 11.7 per cent, which is the second highest in the country. Therefore on one hand, while we are spending a large proportion, relatively speaking, of what the province earns in terms of GDP and what we can afford, on the other hand, the cost per citizen, if you will, is lower than the average in Canada.
I will turn the floor back over to the minister to talk about some of the critical issues in our system.
Mr. Ballem: The way we see it, there are a couple of critical issues that need to be addressed if we are to improve sustainability - or in fact have sustainability - and one of the biggest challenges we have is public expectation and demand. Without doing some advertising for a multinational, our public health system has become "Macdonald-ized." "Let me drive up to the window," or "I will give you something I got from the Internet," or "I have done some research, here is what is wrong with me, give me a pill and let me keep going because I really do not have time to be sick or stay home." With the expectation that I need to do it quicker, there is a feeling that we can have immortality if we could just afford it. We know science is doing it. It is just a question of when we can get there.
What is another challenge for our province, and again it is something that Senator Callbeck can relate to, is that we want to have that service next door. Mr. Francis entioned our relationship with Nova Scotia and New Brunswick whereby we have a number of services that are provided in Moncton or Halifax. The drive from Charlottetown to Moncton is not that long. If the service were in Ontario or in Saskatchewan or Nunavut, you would not think twice about it, but the expectation is that we should have that service here in P.E.I. For the most part, we try to do what we can. Where we run into difficulties is the ability to have any kind of a critical mass for professionals. We will not be doing heart surgery because we would not have enough for a heart surgeon to do, if we could get one. Thus when we see that the system is being demand-driven, how do we control that? That is what we are looking at: whether we should try to address the demographic changes, and try to quantify and qualify what public expectations are. I feel that one of the things we should try to do - and it is very difficult - is to tell people what things actually cost, but how do you measure that? That is another challenge for which we do not yet have the answer.
Another critical issue for us is the supply of health professionals, and here we are no different in this province than in any other jurisdiction in the country. It is becoming increasingly difficult to maintain the traditional supply and mix of health professionals. We have a situation where the perception is that health care is measured by how much money you spend, how many doctors you have, how many nurses you have, because everybody is in their box, and thinking "This is what I have traditionally done as a health professional." However, when you try getting more doctors, they are just not available. Money is not the issue. More nurses are needed; we have 40-plus vacancies in our nursing structure right now. I budget for more than that every year, for all those vacancies, and we will pay more than that in overtime. It is not a question of creating more positions. We just cannot get the bodies.
Thus we are looking at how to utilize the health professionals that we have: what the mix will look like, and who does what. We are trying to have attractive recruitment and retention packages. We are trying to make the workplace something that is attractive to keep people here. We cannot compete in dollars. If it was just a case of dollars and cents, everybody would be in Alberta. We are trying to create a situation in this province whereby it is an attractive opportunity for someone to come and practise their profession. As part of that, it makes sense to do some planning. However, when you are very limited in your resources, and the demand is in the acute care hospital or long-term care, it is difficult to take those resources and put them into future, down the road planning.
Demand is increasing for specialty services in our province. There is a big increase in the demand for cancer treatment. We are trying to address that. We are putting in more equipment to allow more of our residents to stay home and have their treatments, but right now our radiation oncology unit, for example, is shut down because we do not have a radiation oncologist. We are trying very hard to get one. It is difficult for a small jurisdiction to compete against larger urban areas for specialists. Having said that, we think we are making some progress and are hopeful that we will get there.
With respect to diagnostic services, we would like to have more of that done at home. We are putting out an RFP, or request for proposal, in the next few days for an MRI unit to be installed in the Queen Elizabeth Hospital here. Our target date is to have that unit up and running by next September, but that means taking resources away from other areas. We can access facilities in Moncton, but again, it goes back to the question of demand, and where we should have our service.
We are trying to improve our primary care services, and who delivers primary care. Instead of just treating people in the hospital, let us do a little prevention. Let us do some wellness. I go back to our resource issue and ask: who is prepared to give up some of their budget, or where do I get the money to put into prevention? As politicians, we do not have that long an attention span. If we do not see a payback in three or four years, it is very difficult to make that tough choice. Those are some of the challenges that we face and they are not unique to this province.
When it comes to speciality services and primary care, what we are looking at is using our existing health providers to the maximum of their education, their ability, and their training. I am not as concerned about what the title of the health professional providing the service is, as I am about their ability to do it. When we try to achieve more integration - and we do have that going on in the province - you meet a certain amount of resistance from all sides. Even though a doctor has always done such and such, a doctor does not always have to do it. Maybe we can have a nurse do it. By the same token, a nurse does not have to do all that they have been doing. Perhaps an LNA or an LPN can do more.
Another one of our critical issues is the lack of stable funding. When we examine our budget and determine where the money has gone in this province and in other jurisdictions, vis-à-vis the rest of the provincial budget, it is extremely difficult to garner a lot of sympathy at the cabinet table, or when you approach the budget cabinet, telling them you need some more money. To put that into perspective, last year the Department of Health and Social Services had a $23 million increase in its budget. Five government departments in this province have budgets of less than $23 million. With respect to research, one of the top issues has been the environment in the last number of years. It is second or third behind health care on a regular basis. However, the entire budget for the Department of Fisheries, Aquaculture and the Environment is less than $8 million. Therefore when I go into budget cabinet and say to my colleague in that department, "Can I have your whole budget, because that will do me about nine days," I do not get a lot of sympathy because we need to look to other components in the province.
We have identified the determinants of health, and it is not just health, per se - and this is not unique to P.E.I. We have all kinds of statistics on education and socio-economic standing. We have discovered, for example, that because most of our people are working in a seasonal economy, when we look at the demands on our health care system in the summertime, the demand is not as heavy as in other seasons of the year. Thus, as a province, we will be trying put more resources into that sort of statistic-gathering, long term. Let us get it into early childhood development and healthy child strategy, which we have done. We need to have more economic improvements so that we have our people working. We are moving towards more retraining so that we will have higher education levels. Again, though, we are in a constant year-to-year situation since we do not know for sure what our budget will be.
An example of that is CHST. The indication from the first ministers' meeting is that there is a stabilized CHST, and that no one will lose with CHST because it is on a per capita basis; the funding is fixed and it will be increasing. Let me tell you that our province is projected to lose almost $3 million this year in CHST simply because our population did not increase as fast as the Canadian average. On a per capita basis, our share has gone down. Ontario's population last year increased at the expense of P.E.I. I think the figure I heard was 135,000 or 136,000 people, just immigrants, went to Ontario. I heard a statistic the other day that 80 per cent of all immigrants go to three cities in Canada within the first year of arrival. We in P.E.I. will never have a large immigration influx. We have lost physicians in the last two years who were international medical graduates; they went to Toronto or they went to other places because of "community." They had nothing against P.E.I. or the people here, or the facilities that we have. It was: "I am of an ethnic origin and there is no community, and I cannot practise my religion here with anyone else." That challenge will always be there, and as long as CHST is administered on a strictly per capita basis, we will lose.
I want to say a word or two now about the cap on equalization. This is not directly related to health care, but equalization is an important part of funding for smaller jurisdictions. It has to be part of the funding. When our equalization is capped at a certain level, that limits our growth. When the money comes in, there is no separate cheque that comes from the federal government saying, "Here is CHST" that goes directly into the health budget. It all comes into general revenue. As I said earlier, we look at all of the things that we have to do to provide services to our residents, such as economic development, education, transportation, et cetera, and equalization is one of our major sources of revenue. If equalization is capped, then we are in real trouble. Part of the $50 million deficit that we are projecting this year is because of a decline in revenue. We know that it is no-one's fault. If the economies in Ontario, B.C. and Alberta are dropping, then equalization drops. All I am saying is that it is a challenge for us when the cap is there in equalization.
In summary - and I do want to get to some questions - there are three areas that we think are recommended, and in which we would like to see some improvements, including stable funding, and I will not say anything more about that issue. One is the effectiveness and the efficiency of the system. When we look at what we are doing to reduce costs, whether it is through automation, improved utilization of our health professionals, or whatever, we must get away from the attitude that "This is the way we are doing it because that is the way we have always done it." When we meet with resistance, it is a real challenge for us with some of the various groups. It sometimes needs working out very carefully.
I had an opportunity to speak to one of our health professions in the last couple of weeks and they were telling me how they, as a profession, could do more on the higher end, and I said, "How much are you prepared to give up on the other end?" The response seemed to be "Well, no, we can do more on the top end." to which my reply was "Sorry, but we cannot get more of you."
Strictly in terms of time on training, the hardest health professional to get is a specialist, and then a family physician. Family physicians are saying, "We could be doing more of what the specialist is doing." The RN's are saying, "We could be doing more of what the family practitioners are doing." We need to take a hard look at our health professionals, how efficiently we are using them, and make sure we are using them to the maximum.
In terms of automation and technology, we had a pilot project going in one of our health regions on telehospice. I am not sure if you are familiar with that program, but basically it involves putting a computer monitor in people's homes. It was operated by a nurse at the Western Hospital in Alberton, and on a daily basis she could call up. They had the little camera there and she could look at the patient, take blood pressure, the pulse, and a couple of other tests in monitoring that patient's health. That worked very successfully. We are looking at trying to put that in across the province.
At the same time, though, we have asked our people to tell us how much more we could do in respect of home care by putting in this technology, and the number is 15 to 20 per cent without adding more people. If we can increase our capacity with that technology, then we are still providing health care to our residents without getting more bodies. That is one of the innovations that we are looking at, and an area that we really would like to focus on.
We had a discussion before we came in: If there was one message that we wanted to give to you as a committee, what would it be? That would be with respect to the innovation opportunities that we have taken as a province, and you will be hearing more about this a little bit later from other people who are presenting to you.
We can do things province-wide that no one else can. For example, we can do things - and I will not use the word "pilot"; instead, I will use the word "model" - that no one else is able to do simply because of our geography and all of the issues entailed in trying to get to the population. Our doctors are all on electronic billing now. We all have health numbers, which I thought was not such a big deal until I found out some other jurisdictions do not have that yet. We can link all of our facilities with video conferencing very easily, which will allow us an opportunity to have access to specialists in other provinces. Under CHIPP, the Canadian Health Infostructure Partnership Program, the Atlantic provinces joined together and put in one proposal, creating an $80 million fund, of which we were asking for $25 million. I think it must have scared a great many people in Ottawa. If you think that Atlantic Canada is getting 30 per cent of this pot, you are wrong. In any event, we got $12.5 million, and I know that we had the best proposal in the country because we cooperated as four Atlantic provinces. We are putting in a PAC system right now, which is a picture archiving communications system. Thus when someone takes an x-ray in O'Leary, we will not need to get the film, find a courier, ship it off to some place where there is a radiologist and wait for the results to come back. We will be able to do it digitally, send it off to Halifax, Moncton, Charlottetown, wherever, which will allow us to have better, faster access to care without actually having people on-site.
We have a number of primary care models that we are working on. A number of physicians have come to us and said, "We think we can do things a little bit different. Are you interested?" The answer is that we sure are, and there is a fund available. Currently, Prince Edward Island's share of the primary health care fund is $700,000, which does not sound like a whole lot.
To put that into perspective, in early September we opened a Pap-screening clinic in this province. A doctor came to us and said, "You know, I do not need to be doing this procedure. I have a nurse who is trained and can do it but, under fee for service, the only way that I can get paid is if I physically see the patient." That fit in nicely with our prevention and wellness strategy because 40 per cent of Island women have a regular Pap screen, and it is the one preventable cancer. We agreed to see what we could do.
Our target in the first year was to have 1,000 patients go through that clinic. In the first three weeks, we had 182. At that rate, we will have about 3,000 go through in the first year. We had carloads coming from West Prince; we had three generations coming from eastern P.E.I. to this clinic. That will take about 10 per cent of our primary care fund for this one little project, and we have made representations to Minister Rock and his deputy, and officials at Health Canada, along with our counterparts and the three territories, to look at a minimum threshold for funding for provinces and territories on federal programs.
What we have asked for under the federal program, the primary health care redesign fund, is that everyone be given $2 million as a base, and of the primary health care fund I think 70 per cent of that goes to each province on a per capita basis. I am not asking to take away some of Ontario's per capita, but of the 30 per cent that is left, can we be topped up out of that? It does not give us a whole lot of flexibility and we are working on that one. If you have an opportunity to speak to anyone at Health Canada, we will take any plugs we can get.
Just to finish off on the innovation issue, we did an assessment of our acute care beds a couple of years ago and found that 73 per cent of the people in those beds should not have been there. They needed to be someplace else. They needed an intervention, long-term care, palliative care, or home care. For us, we need transition money. We need to set up the parallel system so that with home care, for example, we can have the capacity in place to deliver more home care before we take it away from the hospital. You just cannot turn the switch and say, "Okay, today we will put those resources there."
You will hear later on about a pilot project that we did with two of our regions in relation to palliative care. Eighty-three per cent of the people on those programs wanted to die at home, and seven per cent were able to. We have a plan of how we let the money follow the patient, but again, it lies with the availability of thos transition dollars.
That is the one point: In terms of innovation, we can be the model across the country, but we cannot do it on a per capita basis. In other words, we cannot get the money as a share of CHST. We have to have transition dollars in block amounts. I do not care if someone says to me, "Here is the cheque and its use has to be very specific to this area." Fine, but it is very difficult to get that cheque.
The Deputy Chairman: Mr. Minister, you mentioned housing and the whole socio-economic condition which contributes to proper health care, and it is an issue that we have heard in various parts of the country. The federal government got out of the whole housing field a few years ago. When you talk about housing, do you figure that into the whole package when you are allocating funds for different areas? What do you do in Prince Edward Island?
Mr. Ballem: Housing is part of our department, and it has received the short end of the stick. We look at issues of where does the money go and where are our priorities, and we do not put as much money into housing as we would like to. With the federal program that has just been announced on homelessness, where there is an equal contribution of federal and provincial funds into the construction or renovation of new social housing programs, that initially was dollar for dollar. Prince Edward Island's share was $700,000. That seems to be our magic number. Now, they are looking at what else you are doing, and that is difficult. We have citizens - seniors especially - who want to stay in their own homes, but in a number of cases, it is an empty nest; it is bigger than they need, and it now needs some repairs. Should we be saying to these seniors, "Stay in that physical building," or should we be trying to provide them with an alternative home that makes more sense for them? I do not have an answer to that question yet. We are working on it. We do not have as many as we would like in either area. Under the CMHC RHAP program, there is a three-year waiting list in this province to have repairs.
The Deputy Chairman: We have had witnesses from around the country really urging the federal government to get back into a special envelope in the whole public housing and low rental housing areas.
You are the Minister of Health and I realize that you do attend these ministerial meetings across the country. There seems to be a lack of knowledge among the general Canadian public, even to the degree that some people think our health care system is "free." In this age of technology, I am curious as to why systems cannot be developed whereby we can get itemized statements on our health care costs. We get them from American Express and from our gas providers and whatever. In terms of accountability, it would be better if the public actually understood what it was costing when they access the health care system. If I were to go to the doctor in Ontario, where I am from, for an ingrown toenail, how do I know that it says on my records that they have not amputated my foot or something? I have often wondered why there is not some form of accountability. I just have a sense that if people understood what they, personally, are costing the system that somehow or other there would be a little more care in how they access the system. I wonder why we seem to have such difficulty, especially now when people assume that, with technology, so many things are able to be catalogued.
Mr. Ballem: To begin with, I cannot speak for sure on other areas, but if health is not at the bottom in terms of utilizing technology, then we are very close to it. Yes, we have all kinds of diagnostic equipment but in terms of case management or client registry types of information, we are away behind. When I said that P.E.I. has all of our physicians doing electronic billing, which is pretty simple you would think, other jurisdictions, very few if any, can say that they have that. Yes, they have a lot that have electronic billing but some are still manual. Go into your doctor's office and look at the files that are there. We have a couple of physicians who have come to us with proposals, that they want to have a paperless office, and it can be done but it goes back to the priorities of where we spend the dollars and cents. I saw some research not long ago that showed that, when asked if the P.E.I. government is spending enough money on health and social services, 66 per cent of the group questioned said no. When they were told that 42 cents of every dollar goes to health and social services, that number dropped to below 35 per cent when people knew. We do perform audits. We used to send out a questionnaire to people: Did you visit the doctor on this time and what was the visit for? We used to get calls back from people saying that it was none of our business what they saw their doctor about. You have the people thinking that you are invading their privacy. However, I agree, if people realized what everything cost, I think that it would have an impact.
Senator Callbeck: Mr. Minister, you certainly have laid out a lot of critical issues facing the province in the whole area of health, and I guess most provinces face those. I want to commend you for the new initiatives that you have talked about. I think they are great, and that clinic in Cornwall is certainly a benefit. I agree with what you said about Prince Edward Island being an excellent place to try out new methods or pilot projects, or whatever.
I want to get to the funding issue, but before I do I just have a few questions that I want to ask, and one is on prevention. Because of our limited resources in a province such as Prince Edward Island, have we been able to find more dollars in the last two years to go into prevention?
Mr. Ballem: The short answer is no. In one of our sessions that we had in consultation across the province, one comment was that it was very difficult to make an investment in your RRSP when you do not have enough money to buy groceries, and that is sort of where we are now. We know that that is the investment that is needed. We know that if people were more active, and did a little more work with healthy eating, that it would save us huge amounts of money down the road. In our province, and you may have heard this statistic already today, we are diagnosing two cases a day of Type 2 Diabetes, and that is directly related to activity levels and diet. We know our doctors would love to be able to spend more time with individual patients, so instead of just giving them a prescription, they should be telling them that they can do other things. However, our system does not really allow for that, and it is a challenge for us to try to implement programs that are preventive in nature because it will take some resources to do it. Go out on the street and ask people if they know they should eat healthy or be more active, and everybody does know, but the question is: how do we actually convince people to be part of that?
Senator Callbeck: That really amazes me, that we have the lowest rates of physical activity. We are right at the bottom for all of Canada, are we?
Mr. Ballem: I do not have any statistical information, but I would challenge that number, and I know from people who have been surveyed that farmers or fishermen, for example, have been asked, "Here is what we describe as physical activity. How many hours did you participate in physical activity last week?", and the answer was none, in their leisure time. In my opinion, it is the questions that are the problem. I know on one survey, because I had this one beaten on me by a person responsible for the provincial side of it, that it had a sample size of three. I question it, but I do not have any other data to back it up.
Senator Callbeck: No, I would question that, too. When you talk about the integration of the system here, my understanding is that we are the only province in Canada that has an integrated system like this.
Mr. Ballem: The territories do, though not completely, but the Northwest Territories and the Yukon do. When you take into account that we have health, social services, housing, seniors, the disabled and Social Union Framework Agreement - or SUFA - all under our jurisdiction, it is very seldom that I see the same ministers at national meetings.
Senator Callbeck: Turning now to the funding issue, and certainly, as you illustrate in your brief, it is much harder for a smaller province. We heard this in Nova Scotia yesterday, as well. When you think that, in five years' time, the health budget may be 50 per cent of the total provincial budget, you just wonder how we will be able to stay in the system. In Nova Scotia, they were also talking about their percentage of GDP as compared to how much they spent. We are the second highest in the country, and in terms of what we spend as a percentage of our GDP, in terms of actual dollars, we are second from the bottom.
Yesterday, we had witnesses that talked about the CHST funding formula and they feel it is very unfair, that it should not just be per capita; that there should be other things considered such as the percentage of senior citizens in the province, whether you have very high cancer rates, and so on. In other words, the need should be looked at. What are your thoughts on this formula?
Mr. Ballem: I guess my first reaction to that would be, how complicated do we make the system? Do we complicate it to the point that there is no understanding it, and every year, you are back fighting because you are tying to show that this statistic is higher or lower than something else. One of the things that we would like to see, I think, from my personal perspective, I would like to know what my budget is going to be in five years' time. I know that is next to impossible to do, but I would like to have some stabilized funding. Our percentage of seniors to the population at large is one of the highest in the country, and it will get higher as Islanders who have moved away are retiring home.
I am not sure that I would like to see a system that is based on getting a little bit more because of having a higher senior population. We are trying to decide the priorities within our province, and if we get down to those levels then the federal government could get into how we run our health system in this province: what the priority issues are for Prince Edward Island versus the population or the priorities for someone in Ontario or in Alberta, because they are different.
Since 1990-91, the federal contribution as a percent of health dollars that we get towards health care expenditures went from 22 to 23 per cent in 1991 down to less than 14 per cent right now. Our health expenditures at that same time just went in the exact opposite direction: It went up from $170 million to almost $290 million, a 130 per cent increase, I think. They are just not keeping pace, and it is frustrating.
Senator Callbeck: In other words, you are satisfied with the CHST, not in terms of the number of dollars you are alloted but with the fact that you do not want to see that formula get any more complicated?
Mr. Ballem: I think from our perspective with respect to the funding issue, in terms of long term, sustainable, stable funding, that cannot come from CHST. It has to come from equalization, and I am sure you have heard this before from representatives from our province. Because there are so many other factors in the determinants of health, with CHST, the implication is that that is all going to health. In fact, some of it goes to social services and some goes to education. It is easier for us in some ways because we are integrated. What do we do when we are trying to rearrange the shelves, where do we put our money? I think equalization allows us to operate as a province and provide health care. It is the number one priority in every jurisdiction in the country, and it will remain that way as long as the residents feel that is the case. We will be putting the money there anyway. CHST is too restrictive, and I think the cap on equalization really hurts us as a province in general.
Senator Callbeck: If, for an equalization formula, we used the ten provinces rather than the five, do you know how much, roughly, that would mean to us?
Mr. Bill Harper, Assistant Deputy Minister, Department of Health and Social Services, P.E.I.: I do not know how much those numbers would be. I do not do a lot of the work on equalization. I know it is fairly significant in that what happens now is that some provinces are excluded, such as Alberta, and so the whole tax base that is available in the jurisdiction of Alberta is excluded from the calculations.
The other item that impacts on us also is that there is a cap on how fast equalization can grow, and that also impacts on how much we are able to receive. About ten years ago, the amount of dollars that we received from the federal government, the amount of the revenue that we received, was about 46 per cent. Today, it is about 40 per cent, or just slightly under 40 per cent. At the same time, we have experienced about a 5 to 6 per cent annual growth in health care. Our economic base is that our GDP represents about 70 per cent of the national average, so what has happened essentially is, in order to be able to finance health care, that has really restricted the other areas.
In the long term, we are at 42 per cent now for the whole package, including social services, but how far can you go when you still have to support major issues such as education, which takes about one quarter of the expenditure. There is not much left for everything else, which really also has an impact on how healthy the population is.
Mr. Ballem: I was just given a number here. When we talk about stable funding, and again, realizing how economies play into it in different provinces, our equalization could go up or down by $20 million or $30 million in the middle of a fiscal year, just because of changing conditions. Right now, of our $50 million that we are projecting for a deficit in this province, in excess of $30 million of that is a change in revenue. Yes, we are overspending, and we are addressing that side of it, but when you talk about stable funding and you say, "Well, by October - oh, by the way, those projections you had, they are not valid any more," and now you are talking about having $25 million less in equalization. It happens the other way, too. In the last couple of years, equalization has been higher than we anticipated, and in some cases I think it may be easier to manage when there is less money. People do not expect quite as much.
Senator Callbeck: No, I know all about that, about finding out your income is going down by $25 million. That is a figure that I would be really interested in having. If the ten provinces were used in the standard rather than five, where would that put Prince Edward Island? I do not mean today, but I would appreciate receiving that information.
Mr. Harper: The people who handle equalization have that number, and I have discussed it with them, but I just cannot tell you the exact number today. It would be a significant increase for us if the average of all provinces was used.
Senator Callbeck: Of course, if the cap came off, it would be much better still.
Mr. Harper: It has another impact, too, yes.
The Deputy Chairman: It is hard to believe that when they are doing the calculations, Alberta does not factor into it, and that Alberta is not one of the provinces. I would be interested in seeing that as well, based on the ten provinces.
Mr. Ballem: We will get that information for you.
The Deputy Chairman: Mr. Minister, you were talking about minimum thresholds, primary health care, transition dollars, and I think you said you would accept targeted federal funds. Was that only in regard to transition funds or would you accept conditions on a wider range of federal funding?
Mr. Ballem: I would like to see it on specific programs. I am not a hundred per cent sure, and I will probably live to regret saying this, but I am not a hundred per cent sure that we need more money in our budget right now. If we were able to reallocate our resources better, our human resources, our financial resources, make maximum use of our facilities, then I think that we can provide a pretty good health and social services system in this province for $350 million. What we are struggling with is that it is cheaper to have someone receive home care than it is to have them in an acute care hospital only if that hospital bed is closed. You just cannot leave it empty, because if you leave it empty, all that we are saving is the meals and the laundry. Thus, if we are staffing that bed, we might as well have it utilized.
However, we cannot, as I said earlier, just turn the switch and announce that we are now going to do this. We need transition dollars. Let us set up a parallel system and build the capacity in home care that will allow people to be treated there instead of in the hospital, and as we move along that case, then we do not need the acute care beds. Palliative care is another area.
Right now, the majority of people in palliation will die in hospital because that is where their pain medication is paid for, that is where the doctor is, that is where the nurses are at, and that is where the bed is. When we have a proposal such as the one that we are looking at, of having the money follow the patient, that will take some dollars in transition to show that this works, so that we have less demand on this side of the system.
When I talk about transition dollars, innovation and targeted funding, and your question was if I thought that I would get it, and I have met with Senator Carstairs and I have met with Minister Rock, and we have talked about the national primary health care, the redesign fund, and we have been telling them what we can do. For example, palliative care probably needs $2 million to start it up because we would need some technology, and then start at $1.5 million a year and decline over four years until we think we would be in a position that it would be self-sustaining, based on reallocating resources within our system. In the scheme of things, all we are asking for the palliative care project over four years would be $8 million or $9 million. That is not a whole lot, but there is a tendency to equate what you get on any program on a per capita basis. There are only 139,000 people in P.E.I.; the feds are hardly going to give us $8 million. That, again, is a challenge that we have.
On the other hand, if we did the palliative program, and did it province-wide, which no one else can do as quickly, as effectively and as efficiently as we can, we might come up with a model that someone else could implement very easily. I would love somebody to say, "Here is your cheque and you must do specifically this." That would be great.
The Deputy Chair: You talk about your smaller population but, other than the large urban centres, there are many regions of Canada that are in the more rural and remote areas and could use a model to follow.
I was very interested in your comment, "Allow the money to follow the patient" because we have had a lot of testimony on the whole home care issue, and one of the problems of people not accessing home care, such as it is in varying degrees across the country, is the cost of pharmaceuticals. They do not factor in the cost of a hospital bed and all the services of the hospital, but the minute that patient leaves the hospital and goes to a home setting for recovery, the pharmaceuticals that were covered in the hospital are not covered at home. It does not seem to make any sense because it is sort of robbing Peter to pay Paul, because it is very costly to keep those patients in the hospital.
Mr. Ballem: With the cost of the hospital, if we have a 25-bed unit, we are staffing it for 25, regardless if there is a person in that bed or not.
The Deputy Chairman: There may be people on a waiting-list who could be using that bed.
Mr. Ballem: I want to put a little plug in now. Prince Edward Island has one of the lowest waiting-list times in the country. We may not have the highest per capita spending, but in terms of our waiting-lists for surgeries, we think we are the best. If not, we are second.
Senator Cook: My observation from listening to the witnesses is that we are looking at delivering a health service to primary care with dollar amounts that were set in some kind of a formula way back when, and I think it is time to step outside the loop and do something, as you say, innovative. It would be great if there was such an envelope available: If you could roll under one umbrella community and population health, and put in there your determinants of health such as poverty, obesity, literacy, even legal aid, smoking, home care, or what have you, or if you could develop a plan and house it in either home care or population health, and present it to the powers that be.
You have no funding in your present system for that. You are maintaining the status quo with your system, but you are being plagued with all those new innovative things that have happened since the 1960s when medicare and the Canada Health Act came into being. I sense special frustration here, so why not move outside the loop and develop something that will stand alone, and go look for it?
Mr. Ballem: I have made the comment many times in the last year that if I could just convince the boss to make me dictator for a year, life would be much easier. If you ask individuals, regardless of their health profession, if they are involved in the health sector what do they think we should do, it is always, we could do this and we could do that, but do not touch me; do not touch my profession; give us more in my profession.
When we see an opportunity to do something, by the time we get all the players on side, then the opportunity has passed. Where we run into the frustration and the challenge is that the first question, inevitably, that comes up is: "It is all well and good to say we are going to home care, but where do you think we will get the money?"
We made the proposal at one function to convert acute care beds from acute care to palliative care, to take the money from that group of beds and have that money follow the patient, and thus we will make a palliative care fund. The words "convert" and "close" are what rang in people's heads. Our expectation is, how do you measure health care? Is it how much money you are spending, how many doctors you have and how many nurses you have?
If I sat in my office for the last 18 months and never came out, and asked people what kind of a minister was he, they would say, "He is pretty good because we have a bigger budget than we had when he went in, and we have more doctors and we have more nurses. We are building a new hospital and we are getting an MRI$" Do we have better health care for our residents? I am not sure whether we do or not. If we put the package together and said, "Here is what we want to do. Here is what we think it will cost, and how long it will take." and if I thought that I could get a receptive audience from the people who determine where the money comes from, we would have a proposal and be sitting in front of Minister Rock's office every chance we got, and we would be beating on Minister MacAulay's door and the door of anybody else who would listen to us.
The money cannot come from our provincial budget. It has to come from a national fund, and I am not asking to take away from any other province. However, the response is always that we get back to the per capita, and we are just not big enough.
Senator Cook: Sooner or later, those of you who are leaders will have to move, because the determinants are there: the declining birth rate, the aging population, poverty. The economy will determine how healthy we are as Canadians, and you may as well be the first out of the pack, because you will have to move, and now is the time to do it.
Mr. Ballem: I agree one hundred per cent, and you have heard us talk about it a lot through our presenters here today, and you will hear it some more this afternoon. We are better positioned than anyone to do exactly that. I was talking to Dr. Ling and asked him, "How much do you need to do primary care?" and he said, "Give me the money and just watch what we can roll out." We have a better, closer relationship with our health care providers than any other province because we are so small. You can walk into the hospital and chances are that you know half the people or their families. We have an opportunity to do that if we had some resources.
Senator Cook: You have little pieces of different envelopes all over the place. I am sure that if you gathered all of those pieces in, rearranged them and did something innovative, you could show the powers that be that this is what is required and it is workable. Your province is small enough to be able to measure outcome.
Mr. Ballem: That is for sure. I am normally an optimistic person but I am not quite as optimistic as you are, senator, that we could show the powers that be that we can do it, but I agree, and we have no better opportunity than right now. When it comes to measurables, we all want to know whether we are getting not only good value but good health care.
There is another thing on which we have an advantage: We are trying to increase our research capabilities, especially illness research, because we have extended families living closely together. If you are studying genetics, my parents still live here, my cousins or my brothers and sisters, so we do have so many advantages.
However, the problem is trying to get over that hump. We are constantly told "You cannot do it, Prince Edward Island, because you are too small. This is really something that Ontario should do, or perhaps Alberta." That is the reality that we are facing.
Senator Cook: I, on the other hand, am a born optimist. I am a Newfoundlander, born in rural Newfoundland, and I believe that anything is possible, but you have to work hard at it.
Mr. Ballem: I agree.
Senator Léger: You were talking of programs, and you talked about the questionnaire in which they asked the fishermen if he did exercises, and he said, no. I wonder if the questions in the questionnaires are the same in Ontario as in Prince Edward Island? It is not the same language; it cannot be. That is just one thing that I wanted to say.
The real question or comment is about programs. When I was teaching in high school, they developed entrepreneurship. Nowadays they teach young people how to open a business right away, very young, how to have your own business, your own sweaters, and what to do in all the steps. Is there a way of having a program where we could educate young people about the costs if they go to a doctor's office, if they go to the hospital? If we began it there, if the bill is $500, is that a learning process? Could there be a program in that line?
Mr. Ballem: That is a good idea. We are in the process now of instituting a waste watch program and the way in which we are having it sold is through the students. Ask kids about computers or the environment and they know so much more than our generation. If people only knew. Perhaps that is a way to do it: go to the kids and say, "Did you know?"
Senator Léger: I think they would want to know. There is curiosity there and then the adults would automatically start poking in and might be interested in their own bills.
The Deputy Chair: On behalf of my colleagues and myself, I would like to thank you, Minister, very much for appearing here today.
Mr. Ballem: Just for Senator Callbeck, we did some quick calculations. If all provinces were in the equalization formula, it would provide $41 million more on a base of $260 million.
Senator Callbeck: Thank you, Minister.
The Deputy Chairman: I would like to call the next witnesses to the table.
Ms Betty Fraser, Chief Executive Officer, Southern Kings Health Authority: I am the CEO of Southern Kings Health Authority, which is a small rural community east of Charlottetown, a regional health unit that serves a population of approximately 15,000 people and we do provide core health services to that population. It is primarily rural in nature and the largest centre has approximately 2,000 people. Our main referral centre is the Queen Elizabeth Hospital, which is about 30 miles away, and our main industries are fishing and farming. Seasonal employment is certainly a big factor in our community.
What I have chosen to do this afternoon is to address four of the areas that you have in your report around the issues and options, and relate those to some of the concerns that I have within our own regional health unit. I would also like to relate those to some of the concerns that I encounter as part of a national board that I sit on, the Canadian Association for Community Care, and some of the issues that are encountered from that component.
I will begin with the transfer of funds for the provision of health services administered by other jurisdictions. Medicare has become a very familiar term across the country. We grew up with this system. As Canadians, we take this "free" service for granted, and we expect it will be there to provide for our every medical need, and that it should be at no out-of-pocket expense to any of us.
The principles of the Canada Health Act were evoked as part of medicare. A comprehensive review of this act must be undertaken. Currently, insured services relate to the site of care, and that is primarily in hospitals. Given the recent move to more community-based services, we must give serious consideration to what is an insured service and where can this service be provided.
Currently, across the country, home care programs vary widely from jurisdiction to jurisdiction. Clearly defined standards have not been established. Pharmaceuticals and supplies are not covered in many jurisdictions.
The cost of providing health care services continues to escalate. The system as it currently exists cannot sustain the future. A recent report by the Conference Board of Canada estimates that medicare costs will grow by an average of 5.2 per cent between 2000 and 2020. This translates into approximately 42 per cent of budgets consumed by medicare. We heard earlier from the minister when he talked about the percentages of our budget now that have been consumed for health care in relation to some of the other budgets for the government departments on Prince Edward Island. These are very alarming statistics and should provoke discussion at both a federal and a provincial level.
This underscores the urgent need for federal/provincial/ territorial agreements on core services which are provided not only in the acute care sector but in the community as well, and to which the principles of the Canada Health Act would apply equally. I would recommend that the federal government take a leadership role in determining core services to be included and establishing national standards related to the provision of such services.
We will now move on to funding innovative health research. Health Canada needs to be commended for the role played in funding health research and innovative pilot projects. As a small rural community, we have benefited greatly from the funding available to participate in such projects, and the minister has already made reference to the rural palliative home care project, and a second one that we have been involved with called "Little Expressions Mean a Lot" which is a speech language project that is currently under way.
The federal government has a key role in the funding for ongoing research projects and the dissemination of these results to policy makers, which provide for credible information as a framework for decision making. Prince Edward Island as a province and smaller regional health units are well suited to develop and carry out innovative projects which demonstrate capacity to offer services more effectively in rural communities.
The time frames associated with project proposals and implementation is problematic. The minimal time required once a proposal is presented can be anywhere from 18 months to two years, and we talked earlier about putting projects together and looking for funding. Those are often the time frames that we are confronted with if we do have what we feel is a good idea. The hiring process is time-consuming. For example, a 6-month start up delay on an 18-month project places significant demands on an organization to complete the project within the proposed time frame. The inability to extend projects or to carry funding forward into the next fiscal year is problematic for a project to achieve its full potential. Often we find ourselves in a situation where we are spinning our wheels to spend money before the end of the fiscal year, and that is not good management.
The inability of health regions to act as a prime sponsor without ministerial approval is an unnecessary and unwarranted barrier to moving forward on proposal submissions. Small rural regions, such as Southern Kings with a population of 15,000, are limited in the range of appropriate sponsorship for project proposals. The guidelines or direction are often unclear and results in time-consuming duplication.
I recommend that the federal government remove the barriers in place which limit the capacity of a regional health authority to act as prime sponsors for federally funded pilot projects, and that greater flexibility be provided for project time lines.
My next heading is: Support for Health Canada infrastructure and the Health Infostructure: The issues related to the planning of human resources in health care is indeed a national concern. Support is recognized for a number of studies which are currently under way. However, the crisis is now and the demands far exceed the supply available in many areas of service provision.
There is a need for greater cooperation among the provinces relating to credentialing and licensing of professionals. The federal government can play a leadership or coordinating role in facilitating this process. When salary ranges and incentives drive the recruitment process, the smaller provinces cannot compete, and I think we are well aware of some of the salaries that are offered in places such as Alberta and British Columbia. Prince Edward Island cannot touch those, or ever hope to. We cannot create a bidding war as we strive to ensure an adequate supply of trained professionals.
The area of para-professionals is less clearly defined, and this is especially evident in the home and community care sector. The training for para-professionals is a provincial responsibility. This may be done by the province or through a private company, but it is often on an ad hoc basis. The funding to support this training is limited and is often inadequate. The federal government could work more closely with provinces to ensure that adequate funding is available for training and skill development, and that appropriate standards are in place.
One area which I feel should be given careful consideration is the provision of technology to support training programs. Funding is often not available for start-up costs. Federal support of the infrastructure for such initiatives could be beneficial in many of our rural communities.
When the federal government does provide funding to the provinces, whether that is through CHST transfer payments or, more recently, through funding of Health Canada technology, this funding is often directed to high-end technology required in the acute care sector. Targeted funding aimed at specific sector areas would greatly increase our capacity to provide alternatives to service delivery in rural areas.
I wish to use an example from our recent palliative care project in Southern Kings and the telehospice project in West Prince. An evaluation of these two programs clearly identifies the cost benefits and enhanced quality of service that can be provided through telehealth. However, the start-up costs are often prohibitive and cause delays in implementing such programs in rural areas. The federal government could play a greater role in the provision of start-up funding for specific projects aimed at enhanced service delivery in rural communities. The availability of appropriate technology can also lessen the demands on some of our scarce professional resources.
Finally, I want to to talk about health protection, health and wellness promotion and illness prevention. In the past, the primary focus in health care was to treat. Emphasis was placed on research related to the treatment and cure of disease. Health promotion, prevention and responsibility for one's own health received limited attention. As a system, we continue to increase our spending on health care with little evidence to demonstrate if Canadians are healthier.
Support of the federal government in a move towards a population health approach is crucial for the sustainability of the health system. The recent report on the health of Canadians highlights many areas and opportunities for policy makers and service providers. A population health approach must go beyond the traditional health providers. Federal, provincial and municipal governments must work collaboratively to develop effective policies and strategies which encompass the broad determinants of health.
"Toward a Healthy Future" recommends and encourages building alliances with other sectors as primary strategy for improving population health. Many of the determinants of health are outside the traditional health system. Further dialogue must occur that will enable the development of healthy public policies across many sectors. It is not solely the responsibility of government. There is a role for public, private and not-for-profit institutions in achieving positive health outcomes.
The federal government must be recognized for initiatives currently under way to assist key population groups: children, youth and Aboriginal peoples. However, this is just a beginning. The federal government must continue to fund programs and research in all of these areas and to monitor and report on the health impact of all government policy.
In conclusion, I do not believe the medicare system as it currently exists is sustainable into the future given the demographics, demands for new technology, and shrinking human resources. If there were to be no change in the per capita health expenditures and the population were to age as projected, total expenditures would be 30 per cent higher by 2030. Statistics such as this reinforce the necessity to improve population health to mitigate the financial effects of aging. We must strive to create a system for the next century which is based on solid research and evidence-based decisions. The current model focused on illness care is no longer sustainable. We must seek opportunities for health promotion activities and develop incentives which encourage individuals to become more accountable for their own health.
The federal government can play a lead role with the provinces by encouraging partnerships and developing frameworks which will embrace a national approach. Some initiatives currently under way that hold potential are the Social Union Framework Agreement, CHST, the Canada Health Act and the possibility of new legislation in support of health promotion and prevention.
The issue of a two-tiered system continues to be controversial. In essence, we have elements of such a system in various parts of our country. Individuals can purchase insurance which enables them to go to the United States to have tests or surgery, which will avoid the long waiting lines in Canada. There is increasing demand to have these same benefits available in Canada. Insured services under medicare must be identified and clearly defined. Ethical issues related to technology must also be addressed.
Many of the discussions related to how we pay for the system revolve around user fees, co-pays and increased taxes. We have given little attention to providing incentives for individuals to maintain a healthy lifestyle. There has been minimal emphasis on the role of informal caregivers and the contribution that they provide to a sustainable system. I believe that the federal government can provide leadership in exploring tax incentives or tax breaks which will support caregivers and, thus, lessen the demands on the system. A similar approach can be undertaken to encourage individuals in the areas of prevention and health promotion.
I thank you for the opportunity to present my views on some of the issues raised in this report, and I look forward to future discussion as we strive to create an equitable and sustainable health care system.
Ms Susan Maynard, Senior Health Planner, Department of Health and Social Services, P.E.I.: Honourable senators, I am pleased to join you today. The focus of my presentation will be on several of Prince Edward Island's successes in piloting regional and provincial innovations, some comments on the issues and options relative to palliative care, and to financing and evaluation of innovative pilot projects.
Because of its small size, integrated structure and strong community focus, P.E.I. has had success in piloting a number of national, regional and provincial projects, and I think you have heard a number of references to those here today already. Support of these initiatives at the federal level through health research funding has been instrumental in creating the opportunity for innovative demonstration projects that have implications for longer term sustainability of the health system.
The projects that I will briefly describe to you are both specific to the area of palliative care. As you know, the demand for palliative care is a challenge facing the Canadian health care system, in large part due to the growth of our aging population and the shift towards end-of-life care from hospital care to home care. These challenges are most notable in rural areas which tend to have few specialists and less access to health care resources.
I would like to tell you a bit about the Rural Palliative Home Care Project. You have heard some references to it earlier today. This project was an inter-provincial initiative funded through the Federal Health Transition Fund. The mandate of this 18 month project was to develop, implement and evaluate a model to improve the delivery of palliative care to persons living at home in rural areas. A unique aspects of this project, I think, is that it was a joint project between two provinces, and that was certainly of great benefit for us. The project had three demonstration sites: two in Prince Edward Island, in the East Prince and South Kings Health Regions, and one in northern Nova Scotia. The project was completed in January, 2001, and the results have been widely disseminated across the country through a number of national conferences.
The goals of the project were to increase accessibility to palliative care in rural communities; to increase support to health care providers; to develop, implement and evaluate an education curriculum, and to define the barriers to receiving palliative care in rural communities. Several initiatives helped to meet those goals. One was to develop and implement an integrated program model for palliative care; second, the development of an education curriculum which was delivered to front-line staff and to recently created palliative care resource/consult teams; and third, a comprehensive evaluation of the impact of the new program. An important part of the evaluation was the sample of clients and families who contributed confidential and detailed information about quality of life issues and client and care giver satisfaction and needs.
One of the key features of this project's success is that it was developed primarily by building upon and strengthening existing resources, a feature which enhances its sustainability beyond the pilot phase. An important component of the development process was the collaboration across a number of sectors including home care, acute care, long-term care, family physicians, pastoral care, pharmacy, other allied health professionals and the volunteer sector.
The second project that I would like to tell you about is the West Prince Telehospice Project which was initiated in 1999 in the West Prince Health Region with financial support from the Health Infostructure Support Program. This pilot project utilized telehealth technology to provide support to rural families caring for a dying loved one at home. The project enabled a dying person and their family to access live visual and audio contact with health professionals up to 24 hours per day. The initiative tested a number of key outcomes including the degree to which home-based technology can enhance and support palliative care for patients and families in rural communities, and the determination of specific needs which can be well served by the use of this technology.
An evaluation of the project demonstrated that the use of this technology has enabled an enhanced level of service to both patients and caregivers, and can be a cost-effective method of service delivery. The evaluation found that the number of physician office and outpatient department visits decreased for those involved in the project. It was also determined that a telehome care nurse can make approximately 20 visits per day, whereas a conventional home care nurse can make 8-10 visits per day.
The findings of this project highlight telehome care and telehealth technology as options which can contribute to the future sustainability of the health system. As one method of service delivery, this technology has potential for addressing issues faced by rural communities where distance and travel time can affect accessibility to service. It also has implications for more effective and efficient utilization of health human resources, which are in short supply both provincially and nationally.
The West Prince Telehospice Project has received visitors worldwide and has been the recipient of a gold medal for "Excellence in the Provinces" at the 2000 GTEC national conference.
One of the recommendations of the Rural Palliative Care Project advocates for income assistance and job security to be provided to family members choosing to care for a palliative patient at home. I believe this is an area where the federal government has an important leadership role, that is, to explore tax incentives and other options which support caregivers to leave the workforce temporarily to provide informal care. The project also recommended that provincial and federal governments move to collaboratively fund a strategy that will support end-of-life care for Canadians.
With respect to the federal role in funding innovative health research, I strongly support this as an important role which contributes to a sound knowledge base and enhances evidence-based decision making.
I also support the emphasis on financial support for evaluation of pilot projects as this contributes to the sustainability of the health system by encouraging and facilitating innovation, and by fostering reform and renewal. Dissemination of results is another key feature which is often enabled by involvement in federally funded projects.
Ms Fraser also referred to this in her paper: One of the deterrents to thorough evaluation of pilot projects has been the short time frames associated with a number of the federal research funds. Greater flexibility is recommended to ensure sufficient time for program development, implementation, evaluation and dissemination of results.
I am pleased to have had the opportunity to highlight several of our innovative projects that have been made possible through federal funding initiatives, and to present my views on some of the issues and options raised in your report.
Ms Kathleen Flanagan-Rochon, Community Services Coordinator, Department of Health and Social Services, P.E.I.: Honourable senators, I would like to focus my comments today on two particular aspects of the federal role in health, and those are the federal role in population health and also in funding innovative research. I will also frame my comments within the context of Prince Edward Island's Healthy Child Development Strategy. As Director of the Children's Secretariat, I am involved in that strategy, and the experiences we have had in being involved with both Health Canada and HRDC have given us some context to make some comments. I will just summarize that our Healthy Child Development Strategy is evidence-based. It was based on consultations across the province and we have integrated those consultations with the ones that we did for the National Children's Agenda, and so the vision values for our own provincial strategy build on those of the national agenda.
In carrying out our strategy, this is not solely a government strategy: It is a partnership between government and community. There are five provincial government departments involved, including Health and Social Services, Education, Office of Attorney General, Development and Technology, and Community and Cultural Affairs. We have a Premier's Council on Healthy Child Development that is comprised of individual Islanders. These are community people with a wide background and a variety of experiences that have to do with child development, and all of whom are parents and grandparents. There is also a Children's Working Group that includes the members of the Children's Secretariat, as well as community representatives who, in turn, represent various networks of people who are involved in the key areas of action defined by the strategy.
The components of our strategy are compatible with the four components of Canada's Early Childhood Development Initiative which was described in a first ministers communiqué of September, 2000. There is tremendous excitement and enthusiasm, both within government departments and in our communities, about the potential of the strategy. There is evidence to indicate that if we invest in the early years, we can make a real difference in how children perform in school, and in how many young people graduate from school and develop a life-long attitude towards learning. We understand the links between early childhood development and crime prevention. We know that the early years set the stage for health lifestyles and overall good health, and we know that early experiences have a life-long impact on how we form future relationships and how individuals become contributing members of society.
The federal government has actually played a key role in informing provinces such as P.E.I. about the importance of the early years. The National Longitudinal Survey of Children and Youth has given Canadians comprehensive and reliable information about how Canadian children are developing.
The challenge that we face in implementing this strategy in Prince Edward Island is in moving resources from remedial and acute care services to investments in young children and their families. We describe it as moving from a propeller plane to a jet, in the middle of the flight. Your report addresses some of these issues and recognizes the role that the federal government plays in supporting this kind of work, particularly with respect to the determinants of health.
In Prince Edward Island, we have begun to address some of the barriers that you have identified in your report and we have had increasing success with this. We have begun to develop inter-ministerial responsibility for healthy child development. This has not been an easy task, and we continue to nurture those relationships and partnerships among the five departments, with our health regions, with RCMP, community groups, municipalities, service organizations, and the list goes on.
Our challenge is in moving the resources. It is not merely a lack of political will, as was described in your report, and it is not just that some services are entrenched. I recently heard a Minister of Health from another province talk about political will, and he described political will as not being the will of politicians but the will of the people, and I am fairly confident that most of the people in this room today would agree that it is important that we move our investments from the high-end needs and into those early years, so that we begin to reduce our need for those high-end services. However, our attitudes would quickly change if we had a parent, a child or if we ourselves needed the services of the health care system, and that is where we are in the middle of the flight.
The federal government does have a role to play because provinces cannot do it alone. Provinces need funding to make those transitions. Provinces need to maintain their health systems in order to respond to the health needs of their citizens, but at the same time they need to invest in health promotion and prevention strategies to reduce the need for those expensive services. Funding needs to be long term and stable. We will not see that shift in the need for services for a number of years, and funding for those transitions should be integrated with long term evaluation to demonstrate the effectiveness of population health approaches.
I would like to briefly touch on Canada's Early Childhood Development Initiative which was described, as I mentioned, in the first ministers communiqué on Early Childhood Development. This initiative is supported with substantial federal funding. There is an amount of $2.2 billion over the next five years to be transferred to provinces and territories. Funding is allocated to provincial and territorial governments based on the formula used for CHST transfers.
As part of the agreement, jurisdictions have agreed to report annually on progress. Per capita funding, however, does not recognize the core costs for developing programs, nor does it recognize the core costs for developing systems of reporting. Often, smaller jurisdictions do not have the community level infrastructure to support improvements at the local level. It will be difficult to demonstrate progress in improving child outcomes and access to programs without a base funding level to support significant change.
There is a federal precedent for a different approach. In the early 1990s, the federal government introduced the Community Action Program for Children. Funding was available to develop community based programs for young children and their families. However, this program recognized that there are core costs associated with mounting successful programs that were not dependent on population size. The Community Action Program for Children, or CAPC, is managed by Health Canada. This program developed a funding formula that provided a base amount to each jurisdiction, and the balance of available funds were then allocated on a per capita basis.
In P.E.I., this program funds seven family resource centres, each of which have numerous outreach sites in small communities. This would not have been possible if funding were on a per capita basis. The Atlantic regional evaluation of this program demonstrated that these programs are very effective, and in Prince Edward Island the programs were so successful that when Canada introduced the Canada Prenatal Nutrition Program a few years later, it was decided jointly with Health Canada that all the available funds would be directed to those existing CAPC programs.
Right now, P.E.I. receives more funding through CAPC than it does through the Early Childhood Development Initiative. While the ECDI funding is scheduled to increase over the next five years, because it is tied to CHST funding allocation formulas it may actually decrease in Prince Edward Island in years three to five. Prince Edward Island is not the only jurisdiction to face the prospect of decreased funding for this program over the next number of years.
Thus the recommendation that we are making is that funding formulas need to address the realities of smaller jurisdictions in developing programs and accountability and evaluation systems. The funding formula used by the Community Action Program for Children is an excellent example of a formula that enables jurisdictions to mount programs that will actually make a difference.
I have a couple of comments on the federal role in research and evaluation. In 1998, Health Canada's Health Transition Fund provided funding to Prince Edward Island for the Autism Integration Project. This was jointly sponsored by the pediatric clinic of the Queen Elizabeth Hospital and the Child, Family and Community Services Division of our department. The sponsors of the project determined that the development of and a rationale for an integrated provincial model of service delivery would provide useful information to other provinces faced with the same issues.
Over the course of the project, interest in autism and its treatment increased considerably across Canada, and in fact across North America. We face many challenges over the course of this project. The nature, extent and cost of training required to increase provincial capacity was grossly underestimated. The need for training to a broader range of people was not anticipated. The expectations of parents for intensive interventions beyond the preschool period has had a significant impact on many of our services. However, without the funding from Health Canada to begin that journey, we would never have learned or had the opportunity to experience and meet those challenges.
Our experience with this project gives us an opportunity to reflect on the federal role in funding health research and evaluation, and we would like to suggest that provinces need to have some discretion in determining the nature of the research needed at the provincial level. We needed to explore approaches to early intervention services for children with autism. We were able to frame this within the structure and priorities for the Health Transition Fund, that is, integrated service delivery systems. As Ms Fraser mentioned in some of her comments, funding for such projects needs to consider the period of time required to successfully mount a pilot project, implement evaluation frameworks and conduct meaningful evaluation. In the case of this project, 18 months was a very short period of time to be able to successfully monitor improved outcomes for children. While we were able to use anecdotal evidence and a review of parent records, we were not able to scientifically measure child outcomes with pre-imposed testing.
We are also involved quite closely with HRDC in a province-wide research project called Understanding the Early Years. This project research examines developmental profiles of five-year-old children, and then analyzes those results within the context of their families and communities. The research provides P.E.I. not only with some good baseline data on indicators of readiness as we launch our own strategy but also this data can be broken down to be relevant at the community level. This means that communities from Souris to Montague to Charlottetown to O'Leary are able to look at how some of their community factors and family relationships affect children in those specific communities.
The availability of this information is an extraordinary step for P.E.I. Because of our small population size, often research findings are not statistically significant for Prince Edward Island, and so we often need to rely on aggregated data for the Atlantic region. This type of research not only provides us with good data but also allows us to look at some of the predictors of health and good development, and look at the relevancy of those for P.E.I.
The data from this project has some surprises. In your report, you talk about many experts agreeing that socio-economic status constitutes the most powerful influence on health. We agree, and we can see the impact of varying levels of socio-economic status within our own province and the impact on children and families. However, the data from this research has shown that socio-economic status can be mediated by other factors.
One of the other components of this research project was a community mapping study, and this study confirms many of the things that we have already known about Prince Edward Island: that, compared to the rest of Canada, family income, educational status and employment are not as high as in other provinces. Our low scores on socio-economic status would predict that P.E.I. children would not do as well as children from other places with higher levels of socio-economic status. However, P.E.I. children have, on average, scored significantly higher in all areas of development that are measured by this research. Thus in health, social competence, emotional maturity, language and cognitive development, communication and general knowledge, we have scored higher than children in each of the other sites that are in place across Canada to do this research.
Because this research is multi-faceted, that is it considers not only those children's developmental scores but also within the context of family influences in the community context, we have learned that P.E.I. has also scored significantly higher than any of the other sites in social cohesion. It appears that P.E.I.'s high scores in social cohesion and community safety have had a positive impact on our children and how they develop. This is important information for us to know because it demonstrates that we have strengths to build on, and these findings are also borne out in the NLSCY data on a national level.
Your report underlines the complexity of the determinants of health and in taking a population health approach. This research with Understanding the Early Years that is managed by Health Canada's Applied Research Branch is an example of how we can begin to address that complexity. A study that examined any one of those individual components on its own would not have provided us with the richness of the information that we have learned.
One of the things that has also come out of this research, and it supports some of the comments that you have in your report, is that our Community Advisory Committee, which is supporting this research, has identified that this research data would only be important if communities were able to use it, and that we needed to understand how communities respond to that type of information. This began a series of discussions with HRDC, with the result that our provincial Early Childhood Development Association continues to be funded by HRDC to disseminate the research to Island communities, and also to evaluate how communities respond to that research data.
We believe that the federal government should be commended for taking this comprehensive approach to this research activity, and we would like to highlight the importance of ensuring that research activities address the complexity and multiplicity of factors inherent in a determinance of health approach, and also the need for a comprehensive approach in order that the research data is useful for communities, and supports both policy development and community action.
In conclusion, I would just like to echo some of the comments that have been made earlier, that P.E.I. presents a unique opportunity to the federal government for piloting some innovative practices. Because of the size of P.E.I.'s population and the geographic proximity of our communities, our province provides a unique opportunity and advantages, both to the province and to the federal government. Our university has a very active Children's Health Applied Research Team. They have been partnering with us in a number of initiatives. I would like to say that we encourage you to consider the opportunity that this presents not only for our province but also for the federal government.
In closing, I would like to thank you for the opportunity to present to your committee today.
The Deputy Chairman: A lot of this information, as my colleague Senator Cook has said, is very valuable to us, and it supports much of the testimony that we have had, not only today and yesterday in Halifax but also in other parts of the country, that there is a unique P.E.I. example that we can perhaps apply to other jurisdictions. I would like to thank the witnesses on behalf of my colleagues, and invite the presenters for the next session to come to the table.
Ms Elise Arsenault, Coordinator, Evangeline Community Health Centre: I would like to thank the Standing Senate Committee on Social Affairs, Science and Technology for the opportunity to speak to committee members on Canada's health care system. My presentation will be made in English, but I invite committee members to ask questions in the language of their choice.
I will start by giving a very brief description of the Evangeline Community Health Centre, its philosophy, our experience with primary health care, as well as how we see this multi-disciplinary model as a catalyst in a population health approach.
The Evangeline Community Health Centre is part of the Child, Youth and Family program of East Prince Health, one of P.E.I.'s five regional health authorities. The ECHC works in partnership with the community to promote individual, family and community health and well-being. We serve a community of about 3,000 people, over half of whom are francophone Acadians. The bilingual staff provides services to clients residing in Lots 14, 15 and 16 in the Prince County area. We are physically located in Wellington.
A public health nurse, a speech and language pathologist, a mental health counsellor, a receptionist-secretary and a coordinator form our multi-disciplinary team. The centre has become the access point to health information and resources. Our multi-disciplinary team works with the community to provide programs and services with an increased emphasis on health promotion and illness prevention. I have circulated to members of the committee a three page hand-out which describes the centre model in more length.
The idea of a health centre for the Acadian community originated from the Coopérative de santé Évangéline in the early 1980s. The Co-op wanted to increase health services in the area. They put forth a proposal to the provincial government for a pilot community health centre project. Although the province seemed interested, it was East Prince Health that began implementing the Evangeline Community Health Centre. In 1995, a steering committee was set up to develop the community needs assessment. In 1996, the Evangeline Community Health Centre came into being.
The Community Health Centre's Working Group endorsed the following three philosophies for the implementation and the day-to-day operations of the Evangeline Community Health Centre. These philosophies include: community development, primary health care and a community health centre. Copies of these philosophies have also been distributed.
Here are a few examples experienced by the staff at the centre that reflect these philosophies: First of all, I will talk about this beautiful little four-year-old girl who presented herself to the public health nurse for assessment. Her speech was very hoarse and hard to comprehend. The public health nurse refers her to the speech and language pathologist. The assessment by the SLP showed enlarged nodules caused by voice abuse. The parents of this young girl were going through a divorce, and the child began showing anger. She was referred to the mental health counsellor, who addressed these emotional issues with the child. Within six months, her voice returned to normal and the SLP services were closed. A year later, she was no longer on the mental health counsellor's caseload. If this little girl had not come into this multi-disciplinary service delivery model, her health outcome could have been very different. In a case such as this one, the child would normally have gone through surgery. The nodules would have been removed but the overall health outcome of this child and her family would have been very different. This is a great example on how we see primary health care reform.
Another example of how we work with that philosophy would be the community addressing the needs for CPR courses for parents with young children, as well as parenting sessions. Those were identified by the community. The health centre became a catalyst and began providing the service. Today, these are being provided by other community groups. Our current programs reflect the community development philosophy, as well as the community health centre philosophy. We are currently undertaking partnerships in the area of prevention of Type 2 Diabetes, teaching skills of empathy to pre-schoolers through the Fair Play Project, working with the local crime prevention group, addressing areas of early childhood development, et cetera.
I can safely say that the Evangeline Community Health Centre is consistent with the vision of primary health care as described in the Senate report. We are strongly integrated within the community and are becoming more integrated within the larger health care system. We believe in the multi-disciplinary approach and its benefits to both the clients and the staff. Health promotion and prevention activities are our best low-cost investment for increased health outcomes.
By working as a multi-disciplinary team, we become more client-centred and treat symptoms in a more holistic way. With a community health centre model, primary health care services are delivered in the community based on community needs. Thus, this model has implications beyond primary health care since the centre quickly becomes a catalyst for partnerships and new initiatives which strengthen community capacity and health.
To further enhance the population health approach through community health centres such as the Evangeline Community Health Centre requires increased surveillance, enhanced outcome measurement and further integration of medical service providers within current multi-disciplinary models. We need improved measurements in reporting of health trends and indicators of sub-populations: cultural, linguistic and geographic communities, especially in rural and remote areas. These are vital if we are to succeed in our population health approach. We cannot effectively monitor the health of our population if we do not have a clear health profile of those that we serve. For the Acadian and francophone population, this is vital for identifying the needs and measuring the outcome of our health promotion and illness prevention activities.
The role of the federal government is crucial in reforming the health care system. We must give health regions more data on the health of our population. Sometimes, sample sizes for P.E.I. are not very relevant when you look at the population as a whole. The federal government can play a role by increasing health surveillance and data collection.
I share the views of the standing committee on the role of the federal government as described in chapter 4 of the report on issues and options. However, I would like the federal government to make sure that French-speaking Canadians throughout Canada can have access to French services. The Consultative Committee for French-speaking Minority Communities has released in September 2001 a report to the federal Minister of Health that looks at the comprehensive intervention strategy to address access to French language health services in Canada. The federal government has a very important role in the implementation of this strategy. If we look at the determinants of health, we can assume that this population is more at risk for health problems than the population at large due to high unemployment, low education, high illiteracy rates, lack of health services, et cetera.
The Deputy Chairman: Thank you very much, Ms Arsenault. That example of the four-year-old girl was very revealing.
Mr. David Riley, Chief Executive Officer, East Prince Health Authority: Madame Chair, on behalf of East Prince Health, I would like to welcome the committee to Prince Edward Island, and also take the opportunity to respond to the report and to your work. The comments in the paper that we have presented is really a look at your work from ten thousand feet.
As indicated in the documents that we have provided to you, our region employs approximately 1,100 people delivering service to approximately 30,000 residents with an annual budget of about $52 million. We provide a wide spectrum of health and human services, and I am sure that you have heard through other presentations that we are a completely integrated health and social services system.
Essentially, regionalization was regarded as the essential aspect of health reform and health care in Prince Edward Island, and you have probably heard about this, but many of the goals of regionalization have actually been achieved. Services are more integrated, many silos have been removed and a number of efficiencies have been found. However, there are some observations in your report that are particularly challenging to us: Outcomes measurement and evaluation of services, which implies room for improvement in accountability and evidence-based decision making; health human resources, including shortage of clinical practitioners, as well as the requirement for evidence-based decision making and health system management skills; population health and primary care design that would overcome existing predefined scopes of clinical practice for health professionals which limit their ability to do work for which they are trained.
As well, and others have made the same comment, the sustainability of the public funded health system appears to be at stake. We would point out that the sustainability of the system will hinge at least as much on its response to the requirements for evidence-based decision making, accountability, human resources, population health and primary care reform as it will on finding new mechanisms for funding. Without improvements in the former, it is not likely that changes in the latter will improve current results. Rather, it is probable that costs will continue to escalate, spiralling beyond our ability to pay.
Your paper has thoroughly identified many options which might contribute to the sustainability of the system. In order to rank and prioritize these options, however, we must be clear on the fundamental purposes of the publicly funded system. In your paper, you indicate that the primary care sector should become more like the 21st century service industry. We agree that there is much to be learned from the private sector. However, we must not confuse operational processes with fundamental purposes, for this tends to confuse an already complex discussion.
The goals of private and public sector enterprises are fundamentally different. In the private sector, resources are invested by or on behalf of the owner or shareholders in order to realize a profit. In the public sector, resources are invested on behalf of citizens to achieve some commonly held public good. Social goods are not as easy to define as profit, especially when they involve such intangibles as individual and community health and their determinants. Even worse, it is sometimes easy to confuse the investment with the result. For example, investments made in quality - such as shortened waiting times, efficient service, knowledgeable and courteous staff - is a means to achieve the fundamental purpose or result of the organization. In the private sector, investments in quality are made to achieve market advantage and, ultimately, profit. In the public sector, investments in quality are made to improve the public good, or health outcomes for individuals and communities.
There is obviously a close link between quality processes and good results. However, the distinction between means and ends is critical, for their confusion is a central aspect to our dilemma. As governments and public servants, our expertise is in improving systems and processes. We keep building better processes without asking how - and whether - these processes contribute to the best and most desirable results. Ultimately, when we get to the point where we must make trade offs, an inevitability in the face of finite resources, we have little or no basis for assessing the merit for competing interests. In the absence of an agreed-upon fundamental purpose, and quite often an absence of facts as well, ensuing debates, by necessity, are at best informed by ideology, and at worst by personal and professional self-interest.
A number of perceptions are widely shared by the public and many service providers concerning crisis points within the medical health care system. These may or may not be valid. What we would suggest is that Canadians need to have a discussion about the fundamental purpose of the health care system - what good, for whom, at what cost? With no clearly articulated statement of purpose or desired results, and in the absence of facts, options for improvement can only be based on assumptions and will be directed towards improving processes rather than results.
Many examples of high public concern are outlined in your report. I will use two examples, user fees and waiting lists, to illustrate some of the implications of trying to make decisions in the absence of facts and without agreements on intended results. We believe that similar implications are true in other areas.
With respect to user fees, there is an assumption that the adoption of user fees will stop waste and ensure better use of the system. However, research does not support this, and we have indicated that in our paper. It would appear that patient abuse is not the primary cost driver of the system. Research does show that user fees do not affect the cost of hospital services but they do affect how people access services. In areas were user fees have been applied, physician visits decreased for all people, with the largest decline for those with the lowest incomes. We would submit that user fees would not contribute significantly to the sustainability of the health care system and would tend to work to the detriment of the poor and the ill. Paradoxically, adoption of user fees could achieve results which are the exact opposite of those intended, wherein the system is faced with higher costs occurring as a consequence of treating increased acuity of conditions arising from delays in seeking treatments.
There is very little data currently available on waiting lists which can be used for good decision making. There are no standards in place for defining and measuring waiting lists, and as a result there are a variety of opinions. The publicly funded health system, like any service enterprise, must respond effectively and appropriately to client/patient needs. However, we must balance consumer expectations against our responsibility for delivering a public good on behalf of citizens. In a publicly funded health system with finite resources, we must base our decisions on what constitutes acceptable waiting times against the fundamental purpose of the system. This implies that standards should be established for each service with timeliness of access defined against acuity and immediacy of risk for the client/patient. If health outcomes are an essential result for which the health system is to be responsible, then the system must ensure that client/patient waiting times do not negatively impact this result. Waiting lists for some services may require drastic improvement. However, waiting times for other services, where there is no direct negative impact on health outcomes, may be entirely appropriate. In either case, sole reliance on public perceptions or consumer demand does not constitute good evidence for decision making.
While we recognize that it may be necessary to put in place new funding arrangements, we believe that without fundamental reform of the system such new arrangements may not improve current results or achieve sustainability. In short, if we base our decisions on perceptions rather than evidence, seek to improve processes rather than results, and not address the fundamental cost drivers, we condemn ourselves to a system that will continue to spiral financially out of control regardless of mechanisms for funding. We would agree that there may be a few steps required prior to settling the ultimate funding structure for the publicly funded health care system.
We have listed in our report, and I will not go through them, a series of steps that we would suggest should be implemented first before jumping to conclusions about what the solutions are for our system.
We have made some concrete suggestions to your committee, and I will just conclude by indicating that reform of the health care system is obviously a mammoth undertaking. Today, rather than preparing the dissertation presented here, it would have been far easier for us to have merely reviewed the list of options presented, and to have checked those which we favoured. However, this would have been a disservice to your committee.
In Canada, the fundamental purpose of the publicly funded health care system has not been clearly articulated nor, by extension, have its intended results been defined. In addition, we suffer nationally from a lack of sound information upon which to make decisions regarding the future of the system. This is not a criticism of the committee but is, rather, a statement of fact that became all too obvious to us once we tried to assess and prioritize the various options. Therefore, we believe that before we move too far down the road to selecting options, the basic foundation to support evidence-based decision making should be put in place, and additional investments in the short term should be made strategically to support this goal.
The Deputy Chairman: Mr. Riley, when you started your presentation, I wrote down the words "evidence-based" because it certainly is the hallmark of your presentation. Again, when you look at our first report on myths and realities, I think that is part of the problem, that we are dealing with myths and not realities.
Now, I will turn to Dr. Stan Kutcher.
Dr. Stan Kutcher, Head, Department of Community Health and Epidemiology/Psychiatry, Dalhousie University: Honourable senators, I appreciate the opportunity to present to you. I am the Professor Head of Psychiatry at Dalhousie University, the Clinical Academic Director of the Mental Health Program for Capital District, and I am the Associate Dean for International Medical Development and International Medical Research at Dalhousie University. I serve in a number of national roles including that of chairman of all the heads of psychiatry at all the universities in Canada. I am a member of the Institute of Advisory Board for the Institute of Neuroscience, Mental Health and Addictions for the Canadian Institutes of Health Research, and I serve on a variety of other national and international boards and committees.
I have also had the opportunity to either work or be a visiting professor in a variety of health care systems around the world, including the United Kingdom, the United States, Australia and the Middle East, so I have a little bit of an overview of how some other people are doing some other things. Nevertheless, I do not consider myself an expert in many areas.
It is nice to be here in academic medicine. We sort of humourously refer to "an expert" is someone who is from out of town who brings a PowerPoint presentation. I do not have a PowerPoint presentation to make to you today. Neither will I read a brief for two reasons: One is that I think you know how to read, and two is that I would bore myself silly. The real reason is that I do not quite have it with me.
I will talk about some areas of your report which I found fascinating, a number of areas in which I think there are some options that I would like to focus on and make some suggestions, and also on parts of the report where I feel more information or a slightly different understanding might be of value to the committee.
I would first like to start, however, with some mild criticisms of the assumptions that we often bring to looking at health care. My primary degrees were in history and political theory, prior to going into medicine. Looking at the historical context, I think, is very important. We as a society in the Western World are the healthiest society there has ever been in all of history. We are the healthiest there has ever been. You take any indicator of health, you take any measure of health, and we are at the top historically. This is something that we lose sight of because one of the issues that we have deal with is, where is the top?
The other large issue is that we have redefined in the last two decades our meaning of health and the concept of health. Going beyond the absence of the disease or the treatment of illness and to the very broad construct of wellness has had some profound implications for our health delivery systems. Our health delivery systems never were developed and never were constituted to deal with the concept of wellness. They were constituted to deal with the care and the treatment of the sick. To try to put a round peg into a square hole is an activity fraught with failure, and it is not surprising that many of the discussions that we are having at this table, in this country, and internationally, is our difficulty in understanding that we cannot squeeze the round peg into the square hole. We need to have a slightly different model.
The other thing that is important for us to understand, I think, is that health is not simply about health care and it is not simply about wellness. The primary economic driver in Canada in the next decade will be the knowledge-based economy and biotech industry. Therefore health and health care is a primary, essential player in the international economy, in our country's ability to be internationally competitive. We have to understand that there is a very strong relationship between the health of our population and the technological drivers of the biotech industry.
I would like to share with you a graph - and I apologize because it is hand drawn but it has to start somewhere. On the vertical axis is the word "status," and that means the health status of the population. On the horizontal axis is the word "cost," and that means the cost of delivery of services to achieve the status of the population. Let us just assume for the time being that the delivery of services is somehow related to the status of the population. You will see that the curve is not, as many people think in our country, linear; that is, it does not go like this, or straight up. That curve is "s" shaped and I think it more clearly reflects the relationship between health status in a population and the cost of achieving that status. If you look at the lower left part of the curve, you will see that a relatively small increase in costs has a dramatic impact on the health status of the population.
That is why, when we look at developing medical services in developing countries, the cost increment to health benefit is exceedingly high. We put a little money in, we get tremendous return. If, however, we look near the top of the curve, you will see that the same amount of funding put into achieving health status outcomes gives very little return, and that is because the health status is so high.
This discussion has been missing from the entire debate, as far as I can see. I have not seen it in any of the reports. We are looking and thinking in a linear model, whereas the model, I think, is "s" shaped. We have to be very clear about what we expect. We have a very healthy population. Are we to expect what, for what input? I think that is a really important thing to keep in the backs of our minds. This is not a linear graph; this is an "s" shaped curve.
There are a number of fundamental issues to which we need to address ourselves in our discussion. Whenever we talked about the illness care system - and I prefer to call it an illness care system because, regardless of how healthy the population is, we will need an illness care system - there is another myth, and that is, as population health improves, illness decreases. This is not a teeter-totter. Putting more resources into population wellness is a good thing. This does not mean that illness will necessarily decrease, because there are other factors at play.
Within the large spectrum of concepts within the report to date, I have pulled out three of what I consider to be fundamental issues. One is responsibility, the second is accountability, and the third is evidence, and I do not mean evidence as evidence. The worst evidence that you can have in your deliberations is the opinion of experts. The best evidence that you can have is what we call "tier one evidence" - that is, information obtained from multiple controlled experimental studies. When we actually look at some of the expert evidence that we use to drive our concepts of health care, it is on the basis of experts' opinions; people like me. We are often very wrong. We are subject to the same pressures that you are: We have biases; some of us have prejudices; we have particular rows to hoe; we have professional identities; we have patches to water. Our evidence is all coloured by those things.
Please, when you write your report, give the weight it deserves to the testimony of experts, such as myself. Critically evaluate our comments with the data from experimental designs, and apply the same criteria to models about prevention, to models about promotion as we do to models of therapeutic outcome.
I would like to address a few sections very quickly. In each of these areas, I will only focus on what I consider to be the federal role. I do not intend to talk to you about our pilot programs and my own research, et cetera. I will just focus on the 35,000 foot level, and what I think the federal role should be in each of these areas.
Research and evaluation, particularly, has some very practical aspects which may be of use. With respect to health human resources, I want to identify an area that you have not discussed in your report but I think is fundamental, absolutely fundamental, to our health human resource planning in Canada. The financing role, I want to talk briefly on the concept of prescription drugs. On population health, I want to talk about some practical recommendations for dealing with population health, and no, I do not agree that the federal government should have a role in delivering population health, and I will tell you why. Then, I want to talk a little bit about some of the special populations found in Section 12.
First, with respect to the research and evaluation, I would like to start with a quote from The Global Forum for Health Research:
Health research is essential to the design and implementa tion of health interventions, health policies and health service delivery.
We have seen major improvements in the funding of health research in Canada in the last five to 10 years. We are now not last out of the G8 countries, it is lovely to know. However, we have a long way to go. One per cent of the total health care funding targeted for health research is, in my opinion, too low. Any large successful business which wants to be moving ahead does not invest one per cent of its gross return on research and development. They invest closer to 10 per cent, and unless we start investing seriously in research and development - and I am talking at the 10 per cent level, not the one per cent level - then we are will be constantly playing catch up. Research is essential because not only does it benefit health but also, as I said before, it benefits the economy. Health research can provide for Canada, and the federal role here, a regional anchor for improving regional economies and improving health in Canada. One of the biggest difficulties that we have is the regional disparities in health care and economic development. Through appropriate thinking about research and development in health, we can bring the two together, and we can use bringing the two together to improve regional economies and regional health through the concept of what I call regional anchors, which is, I guess, very maritime.
The model that we currently have in which matching funds obtained from provincial or other sources are used to offset federal monies, such as the Canadian Foundation for Innovation, is just not fair for smaller regions and smaller provinces. It does not work. The Canada Research Chair program is a brilliant idea. It has probably the potential of pulling most of the good talent out of smaller areas to larger areas because we cannot compete with infrastructure support. A university in central Canada can offer a Canada Research Chair to a professor and provide that individual with a large infrastructure to support their work. We cannot do that. You do not have to be a rocket scientist to figure out where you, as a Canada Research Chair, will be going.
Pilot projects from the Health Transition Fund have the same issues and they have a further issue, and that is that they are often not sustainable in small centres. Thus you have a nice project: it goes through, you manage to scrape together the matching funds, you get the project, you do the project, you show it works, and then you cannot sustain it. That is a terrible, terrible problem. The Health Transition Fund causes some problems. It has benefits, too, and I can clearly see the benefits, but it has to have some sustainability built in. It will not work in a regionally disparate country in which the economic viability of the regions is so desperately different.
The Deputy Chairman: Dr. Kutcher, due to the lack of time today, I will have to suggest that we call you back because you have obviously approached this from a completely different viewpoint, which I think is very compelling.
Dr. Kutcher: That would be appropriate, and I could meet with you at another time.
The Deputy Chairman: I would like to see your brief. You are the first witness that we have had who has actually raised these issues, and I think it is very important that you be given a much longer and better hearing. I would suggest that when we hold our hearings in Ottawa, we can invite you to come to Ottawa and you can make a full presentation to the committee there.
Dr. Kutcher: I would be pleased to do that, thank you.
The Deputy Chairman: Are there any questions?
Senator Callbeck: Madame Chair, I want to ask Ms Arsenault a couple of questions.
I am really happy to get the information on the centre and how well it is working. Do you have other health professionals who come in there from time to time?
Ms Arsenault: Yes. Being integrated with East Prince Health, we have a person who offers addiction services, and who comes in one afternoon a week and can see clients there. We also recently started working jointly with an occupational therapist who does come in. A dental hygienist comes in on clinic days when the public health nurse is seeing young families, and as well, we have someone coming in respecting hearing aids as a service to the community. Yes, we do occasionally have other people coming into the centre as well.
Senator Callbeck: Do you have a doctor?
Ms Arsenault: No. The initial plan for the centre was to have a doctor on staff but we could not recruit one. However, I think that would be an important element to add. It would give us a new role as well if we could integrate a doctor within the multi-disciplinary team.
Senator Callbeck: Are you open in the evenings or just in the daytime?
Ms Arsenault: Right now, we are not open in the evenings but we do hold clinics. For example, we had a well woman clinic one night whereby we invited the physiotherapist, the nutritionist and other people in. We held an evening for women from six to nine, a walk-in clinic, and at that time had physicians doing Pap tests and breast self-examinations. That was a one-evening clinic, and we repeated that clinic on four occasions, so we do bring in, occasionally, evening sessions at the centre.
Senator Callbeck: How many people have you provided a service to in the last year, do you know?
Ms Arsenault: According to the last statistics that I looked at, the mental health counsellor had 119 on her caseload, the public health nurse probably had 60 or 70 pre-schoolers, pre-natal visits and those types of things. We serve a population of approximately 3,000 people. I would say probably we touched close to 2,000 people in the last year.
Senator Callbeck: Thank you.
Mr. Riley, you had a well thought out brief and I look forward to reading it in its entirety. I thank you.
The Deputy Chair: Mr. Riley, in some of the questions asked of the other presenters in the same field as you, we probably covered most of the questions. When we have a chance to read the briefs again, sometimes we will follow up with some written questions.
The committee adjourned.