Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 44 - Evidence
FREDERICTON, Thursday, November 8, 2001
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 9:02 a.m. to examine the state of the health care system in Canada.
Senator Marjory LeBreton (Deputy Chairman) in the Chair.
[English]
The Deputy Chairman: Our witnesses this morning are: from Faculty of Nursing, University of New Brunswick, Dr. Margaret Dykeman; from the New Brunswick Healthcare Association, Mr. Robert Simpson, CEO; and from the Canadian Association of Chain Drug Stores, Ms Sherry Porter, Atlantic Canada Representative. I would welcome all of you.
Senators, since this is Thursday, this must be Fredericton. This is part of our cross-country tour as members of the Standing Senate Committee on Social Affairs, Science and Technology. As you know, we are taking an in-depth look at Canada's health care system and the role the federal government should play. As you have probably read in the newspapers, we are hearing many opinions of people across the country. Senator Robertson was quoted in the paper this morning as saying we have an avalanche of evidence and briefing papers that we have to go through before we come out with our report and recommendations.
I will ask the witnesses, as I did yesterday, when making their presentations, that they try to be as brief as possible, perhaps five to seven minutes, to allow time for questions.
Please proceed, Dr. Dykeman.
Dr. Margaret Dykeman, Faculty of Nursing, University of New Brunswick: I am here today from the Faculty of Nursing to talk about three or four areas. Hopefully, my remarks will not take too long.
The first area I will deal with is access. As I am sure everyone in this room is aware, we are presently lobbying hard to get nurse practitioners into the system in New Brunswick and have them classified as salaried care providers. That would open up access and decrease the waiting times for the large number of people who require health care. I recently heard that as many as 40,000 people in this province do not have family doctors. We believe that we must do something to alleviate some of the problems surrounding this issue.
We are not saying that nurse practitioners are the end all and be all for the health care system in New Brunswick. Indeed, that is not our goal. Nurse practitioners would work in collaboration with the doctors in the province and try to ease some of the workload. We recently heard that the doctors in New Brunswick spend longer hours in their practices than doctors in any other place in Canada. We believe that nurse practitioners would be a good adjunct to what our doctors do in the system and that they could help us through this very difficult period.
To do that, we need more funding for education. The Faculty of Nursing clearly recognizes that we require funds to pay for the programs that will lead to highly qualified nurse practitioners being in the workplace. They would require good quality education leading to advance practice certificates or degrees at the master's level so that they can offer a high level of health care service. That funding has not been forthcoming at this point in time. We are working on that. I suspect federal support is required to move that ahead.
It is no secret that nursing education is expensive. Once they are qualified, nurses require a lot of supervision throughout their education process. That, I suspect, costs a little bit more than most academic programs.
We believe that nurse practitioners can and will alleviate the situation.
Some of you may not know, but as well as having a Ph.D. I am a nurse practitioner, certified in the United States. I have worked there as a nurse practitioner for some time. I have recently returned to New Brunswick to work in the Faculty of Nursing. My experience has been in education and in the actual practice of this profession.
The second area we would choose to talk about is population health. We are pleased to see that the federal government is heading towards the population health route, which covers all of the determinants of health of our people.
New Brunswick, being one of the poorest provinces, has a high rate of poverty and children in poverty. We also have the most obese people in Canada. Many determinants of health need to be addressed in this province. Any help that comes from the federal government will be very well received.
I would like to congratulate the government on its move towards a harm reduction model of care. In this province, we have an increasing number of injection drug users. We have a growing number of HIV-positive people and Hepatitis C people, all because we do not have many of the basic necessities of life. Many people are homeless. Those are some of the determinants of health that are factored into that whole process.
The third area we would choose to address is research. Health research has not been very popular in New Brunswick. It has had a rough road partly, I suspect, because of funding, but also because we do not have a medical school in the province. Only now are we moving ahead in dealing with the health issues rather than the medical issues. Some of that must be addressed at the provincial level.
However, the federal government has not made it easy for us because most of the dollars are now ear-marked for health have to be matched, and there are no matching funds in this small province with its small population base. The result is that this has effectively locked us out of the research dollars from Ottawa. We are looking for some direction around that, and we are lobbying to find some way to better tap into the resources that are available.
From my experience of sitting on a couple of federal evaluation committees, I believe that we also need to start looking at what researchers we do fund because, at the federal level, we have a tendency to fund researchers with long track records. All of our faculty people and our researchers are the senior researchers in Canada. Most of us are ready to retire. If we do not start supporting the new researchers, the new faculty members, in 10 years we will find ourselves without research potential. I have stated this at other committee meetings and people said, "These people know how to do it." I recognize that those seniors probably do know how to do it, but we need to be advocating for the younger generation, so that they learn how to do it so they can take over. Personally, I cannot work forever, and most of my cohorts around this table will understand that.
It has been difficult to get matching dollars in New Brunswick because it takes almost all the cash we have to run a health care system. I hear some dire numbers of how much we are in debt for health care.
The last area we would put forward is a global health perspective. This is in part based on what has been going on in the last two or three weeks around the Cipro and the September 11th issues. We have, as a government and as a country, put our name on the line as being one of the countries that will support the World Health Organization and the global health network. However, when it comes to patent laws we are letting people in other countries die and that is not moral. If someone dies because he or she cannot have medicine that is available because of cost, that is immoral. That is an issue that all of us in this room and in the whole country should be looking at. Up to this point in time, we have been well respected globally.
Mr. Robert Simpson, Chief Executive Officer, New Brunswick Healthcare Association: Honourable senators, the New Brunswick Healthcare Association represents the eight region hospital corporations in our province, and is charged with promoting policies which lead to a sustainable, universally accessible health care system which is of world-class quality. On behalf of our members, I would thank the members of your committee for embarking on this travel schedule to allow for Canadians to appear before you. In fact, I did think you might not get out of P.E.I. last night, but I am glad you did.
Indeed, a public debate is needed as we contemplate the future. The NBHA believes that the public now realizes changes in health care are needed and that change will, indeed, come. We commend you for including a full range of options for debate. Clearly, the status quo should not be one of those options.
I will speak from the position of hospitals, since we are a hospital association.
If we will be talking about funds from the federal government, I think it is fair that the federal government should expect that those receiving the funds are operating as efficiently as possible. I want to speak to the organizational reforms that I believe would be appropriate.
With the advent of fully integrated health care systems, larger organizational units become the norm - larger in terms of their breadth. These broader units have the potential to provide a seamless system that can deal efficiently and effectively with the full spectrum of patient-client needs. These broader units can help dissolve the turf issues that hinder efficiency. Inter-jurisdictional issues disappear; and the needs and nuances of the various sectors of health care are more easily understood. The NBHA supports the concept of organizational units that address the full range of health care needs of our citizens.
Today, health care systems everywhere are experiencing manpower shortages in multiple disciplines. Combined with scarce health dollars, which some maintain is a myth, and an aging population, it makes complete sense to organize the delivery of services into speciality centres or centres of excellence. We cannot reasonably expect all speciality services to be available in each region. In New Brunswick, this means that the system must offer specialized services where the best outcomes can occur, outcomes that meet or exceed national standards.
It may mean that in New Brunswick not every service is offered in every regional hospital. It may mean that a particular speciality is offered in only two or even one hospital. We may have to travel further for specialized services. We may have to rationalize key support services into fewer locations. That is part and parcel of being as efficient as possible.
I will deal first with primary care. Reform in this area is urgently needed, but what models or combinations of models do we opt for? Some pilot projects are underway in Canada now and we suggest that more pilots are required so decisions on reforms are made with the best information possible.
NBHA favours a serious look at alternate payment schemes for physicians. We favour the team approach to patient care. We are aware that the skills of our professionals are not put to their best use and that there are disincentives to change. The reforms we adopt need to better match the skill sets of our health care professionals with patient needs.
We suspect that costs in primary care, if reforms are made, will not decrease, but we think that the rate of increase will probably be slowed.
Next I will touch on the issue of financing. When it comes to the financing of health care at the level of the hospital corporations, the trustees and CEOs do not debate which level of government should fund the system; nor do they debate how different levels of government should share the burden. Boards of trustees have a mandate to provide particular services as defined by the hospital system master plan at specific locations. The debate over who pays and how much, is for governments to decide. What hospital corporations have seen in recent years are demands to be more accountable, and they have delivered. Boards of trustees were told to cut costs, become more streamlined, more efficient, and to the degree that was possible, they did. Recent information from the Canadian Institute of Health Information indicates that the cost of operating hospitals as a percentage of the total cost of the health care system has been declining. In New Brunswick, cuts were made and more was done with less until boards of trustees became concerned about patient safety.
Hospital corporations have done their part to operate as efficiently as possible, as efficiently as the current delivery structure allows. Work stress is at a high level and there are shortages of virtually every type of health professional.
Health care in Canada, and hospitals in particular, desperately need adequate and stable funding for operational costs and for capital equipment.
Yes, the health care system should be organized in ways that provide reasonable access, that are efficient, and that can deliver outcomes that are of a high standard. All of that goes without saying, but after all of that, ongoing, adequate, stable funding is required. The federal government should not expect to take a health care holiday if it desires a high quality health system for its citizens.
When we speak of funding the system in an adequate and stable way, we do not exclude health care research, we do not exclude funding for innovative pilot projects, we do not exclude information technology investment for immediate and future needs. All of these are integral parts of a high quality health care system.
Your report examines a number of options for raising funds to ease the burden on government. They include user fees, income tax schemes, medical savings accounts and others. We respectfully submit that there are efficiencies yet to be had by making our delivery structure more efficient and by reforming primary care. If after these reforms are made we find we still cannot sustain the system, then look for creative ways to find additional funds. In the meantime, as these reforms unfold, we could continue to study some of the options raised in your report.
I had a difficult time coming up with just how to approach that because it is always dangerous to say that you should not look for a different approach. Some of those options are interesting. The income tax option, for example, is a good Canadian approach. It spreads costs out in an appropriate way, the way we pay taxes for every other service. There are a few others, though, that are not as interesting to me.
It is useful perhaps to ask, "What should an efficient system cost Canadians on an annual basis?" To answer that we need to compare the Canadian experience to that of other countries. Perhaps we should look at health care costs per person, or what percentage of our GDP we spend on health care. In Canada, we currently spend about 9.5 per cent of our GDP on total health care costs, compared to 13.6 per cent in the U.S., 8.5 per cent in Australia, 10.6 per cent in Germany and 10.4 per cent in Switzerland. It would appear to me that on a national basis we are not out of line.
The report raises the issue of private health care. The NBHA prefers not to enter the philosophical side of that debate. However, given the current shortages of health care professionals, we are concerned the public system would lose more of its scarce human resources to the private side if that option were expanded. The effect would be even longer wait times for access to the system. If wait times are unacceptably long, governments should be addressing that within the context of the public system. It should not use it as an opportunity to expand the private side without clear evidence that it would improve access overall at lower costs than the public system.
NBHA supports the further examination of a national pharmacare initiative with a view to preventing catastrophic drug costs for Canadians. This catastrophic drug cost is becoming more and more common. It is not a bit uncommon to find people having to find $30,000 from their own resources for health care. I think in Canada there is something wrong with that, and I think a national pharmacare initiative should be thought of, especially in that respect.
I was also disturbed to find that in New Brunswick about one-third of the citizens do not have a health insurance program. When you compare that with the rest of the country, it is simply not acceptable. I do not have any recommendations on how to address that, but it is disturbing. Perhaps a national pharmacare initiative, if it is studied, could look after that problem.
We support a national drug formulary for two reasons: there may be cost savings with a single buying agency; and it would eliminate differences in the formularies that now exist between jurisdictions.
The NBHA does not support the adoption of inflexible policies with respect to the mandatory use of lowest-cost therapeutically equivalent drugs. The nature and complexity of illness and the rapid advances in drug development make inflexible polices troublesome. That said, given the large increase in drug costs, hospital policies should reflect a culture that minimizes drug costs, but not at the expense of best practice in patient care.
NBHA supports home care programs and recognizes that the need for these services will increase dramatically. NBHA views the Extra-Mural component of home care as an extension of hospital services. The program should, therefore, encompass all medically necessary interventions. I am referring to the Extra-Mural Program as we know it in New Brunswick, which I think is a very good program.
Clearly, the federal government has a major role to play in health research. Further, doubling health research dollars to 1 per cent of health care spending is warranted. If we hope to decrease the demand on health care services, we need to have a healthier population. Research should include a focus on areas that lead to a culture of wellness in our Canadian society, including a sense that, as individuals, we should assume more responsibility for our own health.
On the topic of human resources, the current shortage of health care professionals is a very serious problem that cannot quickly be remedied. Hospitals are struggling to find needed professionals on a daily basis. Procedures are postponed, beds are closed, and admissions are delayed on a regular basis due to a lack of health care professionals. Indeed, it is a puzzle to Canadians how this situation could come about. Surely, we have the ability to more accurately predict our needs in this respect so our institutions of higher learning could better match the supply with the need. In the meantime, reforms that are taking place now or in the near future should emphasize the practice of using the skill sets of all health professionals efficiently. There are countless examples of doctors and nurses performing tasks that could be done by nurses or LPNs. This poor use of skills is costly and counterproductive.
In closing, the New Brunswick Healthcare Association appreciates this opportunity to present to your committee. While we believe we now have a good health care system, it is not without serious challenge. Those challenges can only be met with the full participation of the federal government, resulting in adequate and stable funding in the broad sense of health care. I do wish you every success.
The Deputy Chairman: Thank you, Mr. Simpson, for an excellent brief that followed along very nicely on many of the issues that we raised in our Issues and Options paper.
Ms Sherry Porter, Atlantic Canada Representative, Canadian Association of Chain Drug Stores: With me today is Ms Sandra Aylward, Vice-President of Pharmacy Service, Lawtons Drug Stores. She is a board member of our national board and will join me for any questions following the presentation.
You have a rather lengthy presentation in front of you. I will not read it but, rather, I will pick some highlights from the presentation. There are some very interesting appendices attached to our brief that I hope you will have an opportunity to look at in detail.
The CACDS has 19 members. We represent traditional chain drug stores, grocery chains, and mass merchandisers. The stores that you would ordinarily shop in are the stores we represent. We provide well over half of the nation's prescriptions. Each year, we employ 70,000 Canadians, including more than half of all the pharmacists in the country, and we represent well over 50 per cent of the pharmacies.
We are a relatively new organization, established in 1995. Since then we have been focussing on building the organization, putting the structures and systems in place. We are now able to take a more active role in the health care system, working with governments, and working on forming new health care partnerships.
We are a national association dedicated to supporting chain retailers and their pharmacists, and to providing accessible and convenient health care to people in Canada.
I want to take a minute to review the key goal of the association, that is, to contribute to the development of innovative health solutions.
We encourage governments and other health care partners to act in the public interest and make better use of the infrastructure available in the over 3,000 locations that we represent. We want to promote better utilization of our members, 12,000 pharmacists, as key health care providers in the prevention and management of health problems. We are there to protect the economic foundation of our members, to ensure continued access to high quality pharmacy services, and to promote growth and increased customer satisfaction by enhancing the relationships we have with our supplier partners. In the spirit of that mandate, we are here today to talk to you.
I have not had an opportunity to look over our submission, but I understand that it does provide a detailed review of our position on health reform, and our best advice and recommendations on how pharmacy can play a leadership role in providing higher quality health care.
It goes without saying that our health care system is undergoing great stress and change. We believe we are at a point in Canada where we must consider some fundamentally different health care models that not only build on the positives in the system but also improve the quality and responsiveness of our health services, including the quality of the outcomes.
Our members are uniquely positioned to play a more significant role in the health care system of the future. Our member pharmacists can continue to provide a high level of care, take pressure off other health care services and save the health system money if they are allowed to use their extensive training and play a much broader role in drug use management and pharmaceutical care than they do today. Pharmacists today are well prepared to play that much greater formal role in health care, a role that will truly make the best use of their education and skills and that goes beyond basic prescription dispensing and counselling. In the short term, this could include drug monitoring and compliance, drug therapy intervention, pharmaceutical care and patient focussed educational services. Over the long term, this could eventually include prescriptive authority.
We are collaborating with other stakeholders, including the Canadian Pharmacists Association, to enable pharmacists to provide these valuable services. A detailed overview of pharmacy services with reference to short- and long-term future roles is included in appendix A at page 15 of our detailed presentation.
In practical terms, pharmacists can also help manage drug use and costs by working with physicians and other health professionals in making sure people get the right medication and use it properly. In order to optimize results, consumers of pharmacy services should be encouraged to form an ongoing relationship with their chosen provider to ensure continuity of care. While this appears simple, when, over time, pharmacists come to play an expanding role in health care services, it will mean decreased hospital admissions, decreased emergency room visits, physician and special visits, and lower overall health care costs.
We have recently completed a research project called "The Fredericton Pharmacy Initiative," which was undertaken by CACDS and the Government of New Brunswick. It showed that, when pharmacists provided face-to-face advice and disease state education to patients with asthma and gastrointestinal disease, compliance with the drug therapy increased by 15 per cent, emergency room visits dropped by more than 80 per cent, and visits to general practitioners and specialists dropped from between 9 per cent and 47 per cent for both patient groups combined. These are very significant cost savings.
Our members also have a sophisticated health care infrastructure that is already in place, well managed, well used, and that can easily serve as a foundation to enable primary care reform in provinces across the country. In contrast to some models of primary care reform under investigation in the UK, there is not a need for public sector investment in pharmacy infrastructure as primary care reform proceeds in different parts of our country.
We are, through our existing pharmacy infrastructure, already providing the potential for virtual links between pharmacy and other members of the primary health care team. This infrastructure is already equipped to support pharmacists in playing an expanded role in many areas of health care, in particular, drug use management and pharmaceutical care, home care, diagnostic and screening services, health promotion and prescriptive authority. This gives pharmacy the ability to be an integral part of the primary care system.
Members of this committee need to know that realizing the benefits of an expanded role for pharmacists is definitely the way to go, but you also need to know that there is a significant challenge here. A recent Ipsos-Reid CACDS survey of retail pharmacists indicate that Canada needs over 2,000 pharmacists just to fill the existing vacancies nationwide, let alone respond to future health care needs.
As an industry, we are taking a leadership role in this and we are developing a strategy to deal with this important health care problem. We are collecting data, collaborating on labour market research and working with provincial governments in every province to expand enrolment at schools of pharmacy, as well as working towards making better use of pharmacists' knowledge and skills. We are using technologies and innovations today such as interactive voice response and robotic dispensing systems to improve accessibility and to free up pharmacists to provide more extensive valuable drug use management and pharmaceutical care services.
However, we do recognize that the complexity of the shortage issue is linked to a much wider health, human resource issue in general. In this respect, a comprehensive national cross-sector approach to resolving the health, human resource issues across all professional lines is clearly needed.
Our organization believes strongly in the importance of cooperation and partnership in developing those solutions. We have a lot of experience, we have a lot of initiative in those areas, and we are prepared to work with governments to develop the solutions to make the system more integrated and sustainable.
We have only touched on the fundamentals of our position and of our advice, but we are optimistic that, with further discussion and analysis, it will become clear just how much pharmacy can offer in terms of improving the health of Canadians.
Senator Robertson: Thank you all for such excellent presentations. There are so many questions to ask you about where you are coming from and where you are going, shall we say, in street terms, that we will have to use our time wisely.
I would start with Dr. Dykeman, if I may. Thank you for coming back to Canada. We know that we have a severe nursing shortage and that other medical classifications are in great demand.Can you offer us any advice as to how we can increase the number of nurses more quickly than the present methodologies allow us to do?
Dr. Dykeman: I would start by introducing Dr. Cheryl Gibson, Dean of Nursing, University of New Brunswick. She will also be pleased to answer any questions. In fact, she might be able to answer some of them better than I can.
From my international experience, I recognize that this is a complex problem. Currently, we are engaged in one research study of life issues involving nursing in New Brunswick. We are hoping that, in coming years, CHSRF will fund a more detailed second study for which we have already entered proposals. Hopefully, the information that will come out of those studies will be research based. I understand that "evidence based" is the jargon being used these days.
One problem is that we have yet to recognize the enormity of what nurses offer to the Canadian system. I heard it said today that we are not educating enough people. I stand to correct everybody. We are educating all kinds of people, but we are not retaining them. Half of my classes leave for the States before they graduate. Why should they stay here? There is no continuing education. The wages are about the same, but the workplace is much different. I have colleagues who would not think of coming home because they get all of their continuing education free. They get time off to do it. They have lots of perks. If they want to move from one place to another, they get moving bonuses. We are beginning to think about those issues now, but we are not very good at it yet. For instance, we are not offering our nurses in the United States full-time jobs if they will come home. We are offering to pay for their moves, but we are not guaranteeing them positions and we are not guaranteeing them the status they might hold in the U.S. There are many complex issues within the educational issue that we must consider.
Our preliminary data from our research indicates that nurses want continuing education but they are not getting it. They want support in the workplace, but they are not getting it. Those are some of the major issues.
Senator Robertson: Do you see a role for the federal government in continuing education for nurses?
Dr. Dykeman: Yes, I see both an advocacy role and a dollar-and-cents role. We need some supports in place to do these things. I suspect that universities should be doing them, but universities are not getting the support to provide ongoing, continuing education. We keep saying that learning is a lifelong issue. We talk the language, but we do not support the infrastructures that can bring that about. We need to research how we can run those programs efficiently and cheaply. Web-based information is good, but for clinical situations it may not be the way to go because students need to be able to use all of their senses to learn a skill.
Nurses also need to be aware of various community issues, know how they can advocate within communities, and know how they can support population health issues. They must know what their place is in all of that. That has not been where nurses have been best utilized in years gone by. I am a diploma nurse who qualified within the system. I worked for 25 years in the institution before moving on to higher education. Community issues are important issues, and we need to be able to move out of the box we have created, and view the issues as part of a bigger picture.
Senator Robertson: You raised the issue of the restructuring of responsibilities, I will call it, of the different health professions. We have heard a lot about this subject. A major problem in doing that is that you must break down the existing patterns and encourage a cooperative approach. How do you think we could break down the barriers between doctors, nurses RNAs, pharmacists, et cetera? What responsibilities could your nurses take on now or with further training? How could they take some of the load off the doctors? What responsibilities would you assign to RNAs? Have you every broken down the responsibilities that these groups could take over?
Dr. Dykeman: We have done some of that, but it needs a lot more work. It would require all the team members to sit at the table, and that is difficult to do. It is much easier for team members to say, "It is been done this way forever," rather than to say, "Let's brainstorm and see how it can work."
The nurse practitioner/physician model works very well in a collaborative practice setting. I worked at that for seven years. I worked in an HIV clinic where I saw people from diagnosis to death. They were my clients and, unless I needed a lot of help from somewhere, I did not have to consult another medical person.
We do not know at this point what the parameters are, but we certainly know that we could do a lot of things in collaboration with each other. That would take the onus off any one profession. However, it has to be done as a collaborative team. We have to start looking at doing it. We have to consider doing it at a community level where the team works together and where more than one service is offered. I understand we cannot all have technology in every region, but we certainly can have primary health care that is efficient in one region so that people do not have to go everywhere to get it. The fragmentation to the system could be fixed if we could get team members to work together.
Senator Robertson: Dr. Haddad, the president of the Canadian Medical Association, advised us in Halifax on Tuesday that they were quite ready to cooperate. I found that to be a most encouraging expression. It renewed some faith I had that it might be possible to break the responsibilities down.
This question, I suppose, could be for all of you, in a sense, because everyone is interested in population health. Would it be helpful if the federal government could provide something like a surgeon general or some sort of a health commission that would be responsible for national education and the national delivery of services, through the provinces, with a view to improving population health? Would that be helpful?
Dr. Dykeman: In our brief we suggested that we need some kind of a standard for health education in Canada. I think what you are suggesting is an even broader concept. A major recurring problem is that we have not standardized what we teach people to assist them to take care of their own health. I must be very honest. One thing that makes me very angry these days is that, at many of the meetings I go to, I hear that people want more health care than we can provide. I do not believe that. I think people want health care that keeps them healthy and takes care of their problems. I do not think they are asking for the Cadillac plan; I think they are asking for something of quality that is very basic. I have a slight philosophical difference of opinion. What you are suggesting, I think, would level the playing field so that we could do something in that respect.
Senator Robertson: Mr. Simpson, I know your organization as the "New Brunswick Hospital Association." I am sure that ages me, does not it? We are all familiar with the problem of long waiting lists for hospital care and of the waiting lines in doctors' offices. In fact, some people cannot find a physician. My question, however, relates to equipment in hospitals that is not fully utilized because of the inability to get sufficient staff. Medical equipment is very expensive and some people feel it should be used almost 24 hours a day rather than from eight until four or whatever. This is contributing to the lengthy line-ups waiting for various treatments. How can we get more value from the expensive medical equipment that we have?
Mr. Simpson: That is a tough question. We have such a shortage of professionals that, if the organization and the staff were in favour of operating 20 hours a day, using equipment that was commonly needed, it is a question of whether we have the manpower and the support staff to do that. If we take one step ahead and say that we do have the manpower and the support staff, then it would make sense from a patient care perspective because the waiting lines would get shorter and people would get well quicker. I think it makes sense to do that. However, within the culture of our practice, there are obstacles to overcome. The professionals would have as much difficulty with change as I would or as would any other group of Canadians. It is like the previous question about making changes. It does seem logical. In some part of New Brunswick there is equipment in hospitals that is being used only a half a day a week.
Senator Robertson: That would be very expensive.
Mr. Simpson: Yes.
Senator Robertson: Are you familiar with Dr. McGowan's project at Sunnybrook?
Mr. Simpson: No.
Senator Robertson: I think it is important for the committee to get as much input from the witnesses as possible regarding the future financing of health care.
The McGowan project is very simple. It is a private health care delivery system. It is for profit. They have made an arrangement with the oncology department at Sunnybrook when their regular work day is over at 4 o'clock or 5 o'clock then the McGowan organization brings in a team of oncologists and nurses, et cetera, and all the technicians that are required, and they treat all the oncology patients from that time on until 9 or 10 o'clock at night. As a result of this, they have greatly reduced the waiting lines for this sort of treatment. The interesting thing is that they are doing this and only charging the Ontario government the same rate per patient as the day patients who are looked after by the hospital staff. Do you see anything wrong with that if that can be done at the same cost, that is, without charging more to the province? What would be your opinion on that?
Mr. Simpson: On the surface of it, it seems to be a very effective way to shorten the lines. However, if it is a private system, then it is only people who can afford it who are able to take advantage.
Senator Robertson: No, no. They are treated in exactly the same way as the patient who goes in at 3 o'clock in the afternoon.
Mr. Simpson: Did you say it was private?
Senator Robertson: Yes, it is a private group. They treat the patients in exactly the same way patients are treated earlier in the day, and they charge the government exactly the same amount as the hospital would charge for the treatment of a patient during regular hours. Do you see anything wrong with that?
Mr. Simpson: I wonder why that just does not happen under the public system.
Senator Robertson: They say they cannot get the staff. Dr. McGowan has gone to the community and found staff. They are mostly people who do not want to work full time. I was very impressed by it.
Mr. Simpson: I do not have a big problem with that. We cannot deny that there are private sectors to the health system as it is now. If it does not cost any more, if it does not affect the type of patient who receives the treatment, then it is just a more efficient way of shortening those lines.
Senator Robertson: As long as it does not cost more?
Mr. Simpson: Yes -
Senator Robertson: Fine. Thank you.
Mr. Simpson: - and you do not address a specific subset of patients because of where they stand on the socio-economic ladder.
Senator Robertson: Dr. Dykeman, would you have problems with that?
Dr. Dykeman: No, I would not, as long as there is equity.
Senator Robertson: That is what I think impressed us about that particular model.
Dr. Dykeman: It sounds to me as if there is some agreement between the hospital and this group because otherwise they would have to pay rent on this equipment.
Senator Robertson: No, there is an agreement with Sunnybrook.
Ms Porter, pharmacists are some of my favourite people and they are so under-utilized. How do you educate the physicians, nurses and patients to use the best drug for whatever condition is being treated?
The Deputy Chairman: That is a loaded question.
Ms Porter: I will let Sandra Alyward, who is a pharmacist, answer that question.
Ms Sandra Aylward, Vice-President, Pharmacy Services: Is the question: How do we educate not only the consumers but also all the providers to use the right drug options?
Senator Robertson: Yes.
Ms Aylward: I think the key word, and you hit upon it, is "educate." People have to understand why we want them to do something before they will do it. That is the bottom line.
Senator Robertson: How do you educate?
Ms Aylward: We need to show them that it works. We need to show them real examples based on some of the existing research data. There are some good examples in your brief about projects that have shown outcomes are what we all want if we take a more rational, best practices approach. I think there is a balance between structures and policies that gives people an incentive to follow a best practice approach. There is a balance between that and some of the policies that other people have made allusions to that are perceived to be heavy-handed or arbitrary or restrictive. I think the key is, and pharmacists deal with this every day, to try to help people understand the reasons behind the policies or behind the rules or behind the practice, and we find that when you can explain that to them, they are much more cooperative. The education that you are talking about can occur at a high level. There are lots of mass communications vehicles that we can use to get the message across, but education is also incredibly effective one-on-one.
When you recognize that a certain strategy or a certain drug is the most appropriate choice, it helps for the pharmacist and the physician to tell the patient that they support that strategy or drug. They should tell the patient that they agree with the recommended treatment and that they are not just following the rules as defined by the drug plan.
Senator Robertson: Do you have a view on prescription drug advertising? Do you think that helps to educate or not?
Ms Porter: We all know that we are inundated with information that comes across the border to us, and there is no question that it is confusing at the pharmacy level. There is a need for some Canadian protocol to be developed surrounding prescription drug advertising. We have lots of examples where customers come into the store and say, for example, "This pill is supposed to be green." That is because they saw the ad in an American newspaper or magazine where the pill was green. In Canada the pills are pink. There is a need for some sort of consistency to be developed and some standards to be put out.
Senator Callbeck: Dr. Dykeman, how many provinces in Canada have facilities to graduate nurse practitioners?
Dr. Dykeman: Right now I think there are five. Most provinces are working toward graduating nurse practitioners. In approximately four provinces, there are nurse practitioners, and their designation is legislated. Some of those are at a diploma level of nursing; and some of them are at a master's level of nursing. As this whole process works through there will have to be some standardization of the certification.
Everybody knows about NAFTA, and under that agreement you cannot preclude anybody from working anywhere. I think the potential to educate is Canada-wide. Whether or not the funds or the desire are there is a different story. We are so short of people to do primary health care, that we need the extra bodies. I think that will push it over the hill.
Senator Callbeck: Are you making good progress? Has the number of nurse practitioners increased tremendously in five years?
Dr. Dykeman: It has increased. In places like Ontario it has increased greatly in five years. The University of New Brunswick program has started. It is not funded at this point, but it is certainly off the ground. There is a new program at the diploma level in Newfoundland. There will be a new program at the University of Newfoundland beginning in January or September. As of next year, there will be a program here in Moncton to educate French-speaking nurses. Each province is going through this kind of integration process. Shortly, educating the nurses will not be a problem.
The problem, as I see it, is how they are integrated into the system. Currently, about 65 per cent of the nurse practitioners educated in Ontario are not working as nurse practitioners because there have been no job opportunities for them. In New Brunswick we have been lobbying very strongly that it should be an integrated system, that they are salaried and not fee-for-service, so that they will fit into the new system after all the restructuring is done. We have been promised that will happen in the next year or so. Hopefully, we can circumvent some of the problems that Ontario is having, and have them actually doing the job they have been educated to do.
Senator Callbeck: As part of the restructuring in this province will you integrate social services such as the programs that deal with addictions and housing?
Dr. Dykeman: From reading the newspaper in the last couple of weeks it appears that we will be putting health care back into communities. We are hoping that there will be a collaborative team community approach incorporating, pharmacy, nursing, doctoring, social work, and case management because that is so much more cost-effective. It cuts down on the duplication of services and it also provides service to people who do not have a support system in place who need to get their health care some place else.
Senator Callbeck: Yesterday in Prince Edward Island we heard from several witnesses about the integrated system. I think it is proving to be very effective.
I certainly agree with your comments on research. It is difficult for the smaller provinces to come up with the matching dollars.
Mr. Simpson, in Toronto we had a witness who talked about the importance of getting information out to the public; that there will be no increased public confidence in the health system unless the public is given more information. He talked about a report card on the hospitals in Ontario. The various outcomes are listed on the various facilities. What is your view of that?
Mr. Simpson: I welcome that question. I think it is important that the public be able to look at their system, be able to make comparisons and have confidence. I believe that the boards of trustees have confidence in the services that we provide now. I would welcome the development of a report card system. I believe that is in the process here in New Brunswick, that the government is working towards that. That is another step in accountability. Hospitals in New Brunswick have no difficulty in that kind of approach. We would certainly support that.
Senator Callbeck: In terms of bulk purchasing for hospitals, equipment, drugs, et cetera, are we cooperating more in the Maritimes or less than other provinces?
Mr. Simpson: As it stands now in New Brunswick, there are two buying groups. I think there is room for more. In my remarks I mentioned a national buying agency. I am not convinced that you need to go that big to get the best possible prices. When you go that big, you need a big administrative network to make it happen. I certainly believe that we need to be able to buy in bulk and have larger orders to get the best possible price. Like any business, health care has to pursue the processes to operate as efficiently as possible, and that includes the purchasing of all of those items.
Senator Callbeck: Would you say that in the last five years bulk buying has increased or is it about the same as it was?
Mr. Simpson: I do not have evidence that it has increased in the last five years, but I know that, in that time, in this province there have been two buying groups. Three or four hospital corporations got together and formed a buying group, and others have followed. There is a hesitancy to buy from one organization. You need a little bit of competition to get the best price.
Senator Callbeck: A witness in Halifax told us about buying a new piece of technology through a buying group and he told us that the savings were tremendous.
Mr. Simpson: Was that a Nova Scotia buying group?
Senator Callbeck: No. Some hospitals from Ontario were involved.
Ms Porter, could you tell us a little more about the Fredericton Pharmacy Initiative?
Ms Porter: The organization believes in evidence-based research. Not a lot of true Canadian research has been done. A project was put together with a controlled group. We approached the Province of New Brunswick in the Fredericton area to look at government employees who suffered from two disease states, asthma and gastrointestinal disease. We coordinated with every pharmacy provider in this region who signed up those patients who agreed to go ahead with this. Of course, the members of the controlled group had to sign the forms. It was a two-year project with the research being completed late last year. There were some very dramatic results from that research on what can happen when proper compliance programs are put in place, when everyone is educated about their particular disease states, and follow-ups are done with those people. There was an 80 per cent decrease in emergency room visits. There was a very big cost savings.
Senator Callbeck: Does the pharmacist do the follow-up?
Ms Porter: Yes. Perhaps Sandra could walk you through the specifics.
Senator Callbeck: Were they paid for this?
Ms Aylward: That would have been nice. The pharmacy got a lot of value out of this project. It was on that basis that we came forward to do it. However, it was not a transaction-based reimbursement scheme in the way that we would normally think of it. It was understood that this was a research project. Pharmacists provided, not as someone said earlier the Cadillac version of what we could do for people, but something more reasonable, more of a Honda Civic version, but with a lot of gas in it.
In these two disease states we tried to address what we thought were the most basic needs of people: understanding their disease and trying to get at some of the obstacles that people face in complying with drug therapy and with some of the lifestyle issues around these diseases.
The conversations took place when people came in to get their regular medication. They were usually five- or ten-minute conversations. There was a standardized approach to follow-up, and a lot of it involved using processes and programs that were already in place. For instance, our company has a standardized approach to telephone follow-up. We identify people who benefit most from it, and it is done in a very systematic way. It was just a way of standardizing, within this project, the way that 20 different pharmacies would proceed. Many of them had no corporate or business affiliations. We all did it the same way and then we measured the results. As Sherry said, the payoff for us was a validation of what we hoped we could achieve, and the result was unprecedented.
Senator Cook: Ms Porter, do you think the Patent Medicine Act, which determines the licensing of patents, is relevant in today's world as far as your profession is concerned? Is it due for a review?
Ms Porter: That is another loaded question.
Senator Cook: It reared its head when Cipro came on the scene.
Ms Porter: I am not trying to avoid your question. When that issue came to bear, as an organization, we saw that the easiest way to determine the supply of Cipro in the system was to ask the people who sell it, but we were not included in the discussions on that. We probably could have answered the question within 24 hours of asking how much product there was in the system already. That did not happen. It was done by the backdoor by a company called IMS which has no idea what is in the system because it only does transaction-based tracking and not distribution tracking.
Senator Cook: The industry minister did indicate that it was probably due for a review. I wondered if your industry had picked up on it and considered it in light of the patent act.
Ms Porter: I believe all those kinds of things should have to come up for review on a regular basis. This is not unique to our industry. We have a lot of interaction with the various manufacturers, both on the brand side and the generic side, and we have benefited from some of the cost control measures that have been put in place because of that in the last few years, and I am sure there will be future opportunities to benefit even more. A constant review is always welcome.
Senator Cook: In your role as a pharmacist, do you feel that you are underutilized? If so, if we could broaden the concept, that is community and health, do you see a role for the pharmacist in that multi-disciplinary team?
Ms Aylward: I love that question. I think the most important word you used was "community" because, like some of the other people here today, I think the big opportunity is at that grassroots level. We talk about our role and enabling pharmacists to do the most they can for people. There are probably two issues involved in this. One is information sharing. Whether we are talking about patients in hospital coming back into the community or patients who will see their physician or their nurse practitioner or their specialist, there must be an opportunity for all those people on the team to have access to the same information and, therefore, we can reinforce what each of us is trying to do. That is critical. As Sherry mentioned, we in pharmacy are probably able to lead, at least in the private sector, a lot of the information technology initiatives that allow that kind of information sharing.
The second issue is: The pharmacists I work with are all salaried - which in some ways is an ideal set-up rather than paying health professionals by transaction or piecework - and that leads to an environment where they are motivated to do the best that they can for a patient in a way that is independent from being reimbursed. That is ideal. However, we do have situations where the reimbursement does not link well with the activities that are performed. That issue also has to be addressed.
The two major items in terms of the opportunity at the community level are information sharing and a better match to incentives or reimbursement to outcomes.
Senator Cook: Dr. Dykeman, as a Newfoundlander I am well aware of the role and the need for nurse practitioners. To the best of my recollection, the CEO of the Canadian Medical Association in Halifax told us that, while there was agreement that partnerships were desirable, they have not been shown to be cost-effective. Have any studies have been done on that?
Leaving that aside, I tend to think of rural situations rather than urban ones, because I am from the country. I believe that, if we move away from an illness concept to a wellness concept, that has to begin at the community level. If we do not meet basic human needs, then we must look to the federal government to show leadership of provide some kind of funding. I believe that health care providers and people with commitments such as you will have to show them the way. Every step of the way we will spend dollars trying to convince people of the worth of along the way we will spend dollars convincing of the worth of educating people on how to stay well. Where do we go from here?
Dr. Dykeman: I try not to say that it will save the country money.
Senator Cook: Unfortunately, the minute you say that, taps go off.
Dr. Dykeman: That is very true. If we can teach people to stay healthy, which is what nurse practitioners do very well, then 10 to 15 years down the road - and there will have been two elections in that time - you will see a difference in the system because we will have slowed down.
Another one of my beefs is that I keep hearing that I am getting closer to being a senior. We keep saying that, because there are so many more seniors in the system, we need more money. That automatically leads to us looking at seniors as hazards. We are not utilizing what seniors can do for society, nor are we trying to keep them healthy so that they will not get into a rut. It is a very complex issue.
We can do all sorts of things at the community level. However, I think it will have to be a "show and tell" type of situation.
As an aside to the last question, there was a pharmacy in the community clinic where I worked, and I would send all my patients there. I would give them pharmaceutical information, but then I would tell them, "He knows more about it than I do. Go and talk to him, too." The pharmacies would reinforce what I had already said. It did cut down on the return visits. It cut down on the incidence of patients taking the medication incorrectly. From my experience, that was worthwhile. It worked.
Senator Cook: On a personal note - and I am still dealing with the monetary aspect - I have a niece with two little kids who is pursuing her nurse practitioner certificate. At the same time she is trying to pay a mortgage. Would it help if there were a line on the income tax form that would allow her and others like her to be exempt from a certain portion of taxes? If she needed to quit her current job in order to pursue her further education, do you think she should be able to make an employment insurance claim?
Dr. Dykeman: That would certainly help, but those may not be the only options. What we are asking the government to do - and they probably will not - is to provide some support for people who complete their education and then work in the province. We are asking the government to support them through the education process, perhaps even on a contractual basis. Nothing has been said to this point as to what that will look like. Perhaps, once qualified, the nurse practitioner would have to work for an organization that the government sets up. That organization may need a person for, say, two years. Presently, we only offer part-time studies because all of our students are working in full-time positions. With the shortage of nurses they cannot leave their jobs. In fact, many of them cannot even get the time off to take the classes. They are going to class after working a 12-hour night.
All of those issues have to be addressed if we believe in it and we want to do it.
Senator Cook: Do you think that, as a first step, you have to demonstrate to governments that there is a need?
Dr. Dykeman: I would hope that government already recognizes that there is a need. There is lots of American literature out there that says it is cost-effective. There is no Canadian literature, of course, because we have not had nurse practitioners here long enough. In the States there has been study after study after study that says nurse practitioners provide effective health care at a reasonable cost and that most people using that health care would just as soon go to a nurse practitioner as they would a medical provider. The research is very sound in that area.
Senator Cook: Have you costed out the program per person?
Dr. Dykeman: We have. It is very expensive. I cannot tell you the figures because I do not have them off the top of my head, but because of the clinical time it takes to support them through the clinical process, it is a fairly expensive educational process.
The Deputy Chairman: I have a comment to make on nurse practitioners. You used the Ontario example, and I am from Ontario. I found it rather shocking to hear it said that there is such a high number of nurse practitioners who are not being utilized; that they are doing other things. This is in a province where we have remote and rural communities that do not have even basic primary care. It is a pretty shocking commentary.
With that, I would thank all of our witnesses for appearing. The discussions could have gone on much longer because I had some questions. However I will keep them for another time. I may even get in touch with you personally.
I would assure you, and especially you Ms Porter, that the addendum to your brief is very helpful. All of the briefs we receive go into, as Senator Robertson has said, the avalanche of information. Be assured that, even though you cannot orally present all of the information you have provided in your briefs the information will be read and noted.
Once again, thank you all for coming this morning. Your attendance was most appreciated.
Our next witness, colleagues, is Dr. Russell King, the former minister of health for the Province of New Brunswick. I am sure honourable senators will have a lot of questions for you, after your presentation, Dr. King. We are always curious as to how, when they meet, Ministers of Health are able to reach a consensus, if that is the case.
Please proceed, Dr. King.
Dr. Russell King, Former Minister of Health, Province of New Brunswick: I appreciate the invitation to appear before the committee.
The world is a little different. I do not have an executive assistant nor my trusty deputy and officials with me; this is life after a public-sector career. It is good to know that there is a life after the public sector.
I should like to indicate that my comments are based on observations made during my time in public life and after. They are not based on a survey or anything else. I do think there is a need right now to reflect at a macro level on the Canadian health care system. I am responding to the request to respond to the "Issues and Options" report in a general way. At the end of this, I hope the committee will have some appreciation of how I look on their options.
I will paraphrase what is in the brief I gave you, and then go from there. I really do welcome this opportunity.
At least since 1991, there has been a call in Canada for a review of medicare after, at that time, 25 to 30, now 35 years since it came. There has been a need by many people to reaffirm, perhaps modify, perhaps make major changes, in order to reassure Canadians that their health care needs will be met in the future. I hope there will be some degree of predictability about our health care system.
I take the position personally that the health care system is under stress. I do not think we are in chaos, actually, but I do think that it must be secured by our collective thoughts and not dismantled in order to provide care for Canadians. I take the position that it is decision time. There has been study after study. I do not know of any, however - and obviously I have not seen the Romanow commission's deliberations to date - that have gone to the depth that this Senate committee has.
I have had an opportunity to look at the first volume, and I have gone through this volume, and it is my hope that in the end those who are responsible will articulate a vision so that Canadians have a reference point - if you like, the chart on the wall or the overhead on the wall.
There is a context in which this debate is taking place. I have just indicated some things that make it very confusing for those people sometimes. We operate in a sea of buzzwords. The buzzwords I refer to are words like "privatization," whatever that means, "multiple tier, two-tier, one-tier" - there is a big debate on tiers. Other words include "deregulation," "decentralization," "devolution of powers," "inclusiveness," "empowerment," "Charter of Rights," "tax cuts," "wellness versus prevention versus illness," "control of costs," "federal-provincial turf," "national identity," "cost versus the value of things." There is also a lot of talk about leadership versus "actively looking into," whatever that means.
While we tend to talk about the Canadian health care system, it has never been designed as a system. I think that is alluded to in the document. It has evolved in an ad hoc way to work in the manner in which we find it. There is, however, a need to think about our health care system as a system. Even though we may not attain a closed-loop system, at least those that are charged with the responsibility may think or should think in terms of continuity of care, that there is a beginning and an end to challenges. They should begin to think about the interdependency of one part of the system to another.
Any study of the future of health care in Canada must consider Canadian values, the relationship of one part of the country to the other, the sustainability of a health care system over time, which is what your document spends a lot of time on. It also has to look at the practical barriers to change such a health care system. The ability to do a procedure is not an indication for doing it in surgery and the ability to make a change is not an indication for doing it, necessarily. We do not necessarily need change, but we do need change in many parts of the system.
I have organized my comments under five headings. They are unusual headings, but they are as follows: Canadian goals for health care; things we must recognize; requirements we must consider; organizational considerations; and last, funding issues.
I believe the Canadian health care system should be a national program and should be understood as such as part of the national essence. We need to consider that. All Canadian residents should have access to a basic level of high-quality health care, regardless of location or financial means. These are not new concepts. Barriers between the health care receiver and provider must be removed as much as possible - not a new concept, going back to at least Tommy Douglas. The national health care system should be a non-judgemental system, and that is an important point in my view. A Canadian resident should not be excluded because of pre-existing problems or illnesses or particular patterns of behaviour. If you smoke, you should be treated. If you drink excessively, you should be treated. Why? Because you are a Canadian resident, that is why. I think when we talk about public and private and insurabilities we have to think about those things and ensure that we do not lose a thread there.
There are a few things to recognize in dealing with this problem. The health of Canadians depends on much more than obviously the health care system. It depends on our attitudes as Canadians. It depends on the physical structure in which we live, the social milieu in which we operate, the pollution in our harbours, the income support, as well as the availability of health care. A Canadian health care system should be designed to include the physical and mental needs of Canadians, and these needs include prevention.
Prevention is not a separate thing. I have difficulty with the fact that we will get into prevention rather than illness. That, to me, is a copout on the one hand and a misunderstanding on the other. Of course, the two are part of this interdependency. It would include active treatment, of course, and a restoration to appropriate recovery for people who have chronic needs.
A health care system should be designed to reflect public policy and accountability and function in a sustainable manner. If we consider medicare as a type of insurance plan that ensures and assures Canadians, the financial stability must be in the form of an insurance plan consisting of public and private components. However, as with any insurance plan, one must articulate in general terms what is insured, or at least provide some kind of comprehensive definition as to what might be included in what it is that would be covered. That basic element has been lost, as governments across the country have provided more and more services with taxpayers' dollars and the health care system has come to mean different things in different parts of the country. There is a basic core that we need to have.
Under the heading "requirements," the number one requirement in Canada right now, over and above all of the other things, is Canadian leadership. Number one, there must be a clear delineation of roles and responsibilities, in my opinion, or a clarification of the roles between federal, provincial and territorial governments and the private sector as it applies to health care to reduce overlap and duplication of the Canadian health care system. This is not new material, obviously. It has been called for in various ways for at least 10 years, and I am sure long before that.
While support of the principles of the Canada Health Act, in my view, is required, the Canada Health Act would need to be broadened to ensure access and sustainability in the future. Canadian leadership will require a problem-solving approach to Canadian health care concerns and challenges rather than an application of a particular dogma or a fragmentation of effectiveness by the leadership endlessly following the trail of various health care interest groups. There are many - and that is not a derogatory comment - interest groups, but leadership involves doing your homework and making a decision at some point.
There is a requirement to obtain agreement in Canada that medicare will be sustained by effective change and not simply by adding money on demand by the provinces to the vortex of, at times, program fragmentation and ideology. We do need more money in many parts of the system, but that cannot be the total means of looking at the health care system.
We need to increase the flexibility of the principle of universality, in my personal view, in the Canada Health Act to include the concept of universal inclusive coverage. I think I said in the first paragraph that we want all Canadians to be covered by the health care system. There are parts to the health care system. Every person being covered is different than universality, as I understand it, in the Canada Health Act. In that respect, we need to lighten up, in order to get the job done. It would be helpful in further considerations of portions of the health care system to consider pharmaceuticals and home care, which are not now considerations per se under parts of the health care system under the Canada Health Act.
The second from the last point is organizational considerations. We need to delineate and develop the health care and income support components of one's general health. That is very important as we think of home care, which I support.
Senator Robertson, your contribution to home care with the Extra-Mural Program lives on. As a family physician, every day that helps New Brunswickers. Canada has something to learn from this program, in my view.
A health care policy should be developed on the basis of need, not simply on age or disease entity or specific disability. There is a tendency to fragment people with needs into various categories. As such, programs get developed for various categories of people, and there is overlap and duplication of support. I think that needs to be reviewed.
The living needs of the disabled, regardless of age or challenge, require consideration of income support measures - there is an income support issue that follows every disability - and cannot be expected to be funded by a health care budget. There needs to be clarification of what it is the federal government would be supporting a little more clearly when they provide funding for "health care."
I support the five distinct federal roles in health care as outlined in your document. I think they are very helpful, particularly the follow-up to that for those who would chose to make a decision about these matters in the future.
The federal government's role has to be one of setting the tone on all kinds of issues, but particularly in health care. Examples of the federal role could be found in the promotion of wellness. ParticipACTION has gone by the wayside. I say that only to make the point that if you have public policy and you are pushing wellness out of one side, is there a real case for dropping ParticipACTION at this point in time? I just throw that out for reflection.
I think the federal government role could be enlarged in public health - for example with respect to immunization standards, food and drug directorates, which it does, immigration and travel issues, which go together, national blood standards, and in particular health care human resource forecasting or dealing with supply and funding thereof. Interesting that student aid is a national program. It has been. There is the area of health care professional training, and how many we have in Canada and how many are we likely to have in Canada. I think this is an appropriate role for the federal government to enlarge itself. It is related to student aid. It is also related to predictability of a health care support system.
The provinces and territories, in my view, would continue to be responsible for an integrated delivery system in individual communities in Canada. We need to look at that, in particular, as it applies to some Aboriginal issues or health care, which you have outlined in the report.
Universal health care coverage for all residents in Canada should be provided, in my view, through a public-private system. The public-sector - I think I found the definition of that in your earlier document, Volume 1 - would include various levels of government. For example, workmen's compensation boards are included in public spending. Private-sector spending, which is about 30 per cent in Canada, includes out-of-pocket costs and expenditures by third-party insurers.
The public system, I think, needs to consist of health care relating to hospital, community, and home physician services. It would include nursing, social work, occupational therapy, physiotherapy, respiratory technology, dietetic, and ambulance services, being part of a clearly defined program. It would also include pharmaceutical services necessary to support those publicly funded endeavours. Of course, public health care services would be subject to Canadian guidelines and standards.
I strongly support the creation of primary care teams consisting of multi-disciplinary integrated teams. These teams could be developed as a replacement for some fragmented services in parts of Canada. These teams would provide 24-hour coverage in health care, and this is very important. The primary entry to the health care system is very important. I think we need to look at ways in which we can make that happen. Your discussion on the primary health care team, I think, is helpful in bringing that to the fore.
The private system would consist of supplementary support and coverage for the above programs. I think in the area of development of technology, as it applies to the health care system, there are all kinds of opportunities for a greater federal role, in my view, to avoid overlap and duplication of individual provinces attempting to create specific systems. As a country, we can streamline this.
The funding of a health care system has to have some consideration of organizational things, some of which I have mentioned, before we can really deal with the funding. We have to know what it is in general terms we are funding, particularly from the public sector. There has to be some kind of uniformity across the country in terms of what is covered. You have to have that and you have to have the principles enshrined before you can work out the funding.
While funding cannot continue to be open-ended, it has to be a national priority. Therefore, the national challenge is to articulate what it is we would fund as a national priority. Accountability depends on all kinds of things, including efficiency, quality, integration, and the relevancy of services at the point of delivery.
At a macro level, governments need to begin to think in terms of healthy public policy when considering environmental, economic and foreign policy issues, particularly in world trade agreements. Health departments within governments - and this is something we cannot decree here - must be looked upon as key players, not just as departments with insatiable demands for public funds. It has to be a key player through a public policy structure within government.
In terms of simplifying the national debate, I think it would be helpful if the CHST funding were separated, such that funding for health care were defined separate from post-secondary education. Certainly health ministers do not need to be in front of a microphone defending how much went to health care; there are other things to do. Perhaps there are reasons why that funding could not be separated, but I cannot think of any.
Let me just address the sustainability of the non-hospital service portion of health care system. There is a continuity of care between prevention, lifestyle, all of those things that are health issues. An individual who was in an acute care situation but who no longer requires acute may require home care. The individual may have needs at home that did not exist before. Some of them might be physical needs. They may not relate strictly to health care, but they support the individual at home. The sustainability of non-hospital services should be sustained by a variety of methods of payment - co-payment, premiums, private insurance plans - to support that part of the health care system that is not currently in the Canada Health Act. This needs to be done, and it needs to be systematized so that people understand that it is part of the health care system. It does need publicly funded dollars, but it needs to have contributions from users on a base. I think that we can do this without, if the will was there, to get the job done for people.
I continue to believe that extra-billing over and above the established fees for any health care service under the Canada Health Act should not be permitted.
One thing I think that needs to be stressed is that federal funding to provinces and territories, in my view, should be conditional on their providing established levels of service and not just conditional on compliance with the Canada Health Act.
The Canada Health Act has served us well. During the time I was in public life, it was one of the main factors that prevented the fragmentation of the system into chaos. The Canada Health Act does not provide care for anybody. It is the system that the Canada Health Act would protect that is under stress. It is not the Canada Health Act itself. The Canada Health Act becomes irrelevant if there is no system to defend. I say that only because some of my elected colleagues, past and present, make the statement that they defend the Canada Health Act. They wrap themselves in the Canada Health Act, and then there is a tendency to walk away and say: "Well, I have dealt with health; I am for health." It allows people not to have to really think about things or be answerable. It is not good enough any more. The Canada Health Act is something that is there; that is not the problem.
In closing, I support a national pharmaceutical and home care program, but I do not think they can be covered by first dollar payment under the Canada Health Act if we are to sustain this system with some kind of responsibility. If we apply the principle that all Canadians should be covered somehow, or universal rather than universality, I think a pharmacare program and a home care program, realizing that income support issues should be separate from health care issues, can be achieved. I think we have the ingenuity to do it. It is needed, particularly with respect to pharmaceuticals, which represents a significant portion in this part of the country of people who are working but do not have a support. I think we can do this if we want to really work together.
If one of the major responsibilities of the federal government is to bring us together, the time is right for a practical, functional federal vision, a reference point, if you like, in order to provide the national health care debate. The success of the health care system in the future will not be measured through a ballot box, as we know, but by Canadians and their families who know that their needs are being met. That is the criteria. The fear of the future needs to be removed by decision making.
The Deputy Chairman: Thank you, Dr. King, for a very thorough and insightful presentation.
Senator Robertson: Dr. King, your most enlightened presentation gives us a lot to think about. We shall be studying your document carefully. Unfortunately, there is not enough time to put all the questions we would like to put on the table, so one has to be selective in certain areas. As you said, it is a very complicated issue. We have to be very careful as we progress with the task before us.
Dr. King, from the many issues you have identified, I will touch on just a couple.
I think you are one of the first witnesses to emphatically state that, as we move into home care and pharmacare, there has to be some private expenditure in there, some private coverage. Many people want total coverage, and it would be great if we could have total coverage of pharmacare and community health. It would be great if we could cover them and they could be wide open, free to everyone. In a practical world, I am not sure how we would get there. The wish list is very long, but the resource list is not that long, so we have to be careful.
I will start with the Canada Health Act. The five principles are almost like a national anthem, like a prayer that we say at night before we go to bed: "I pledge allegiance to the five principles of the Canada Health Act." You mentioned there are certain things that you wanted to look at there, I believe, if I understood you correctly. Tell us again, please. The delivery of medicine is not the same today as it was when that at was established. We are moving in a changing world. Could you please tell us more precisely or give a little more explanation on how you look at the five principles and what needs to be done with them?
Dr. King: The five principles have served us well, but they still need to be thought about. There are certain things that we have become accustomed to that are under the Canada Health Act. I think you need to think about how they work rather than just recite them. Your document has talked about and expounded on the one of public administration. There is some flexibility on the public administration, as your document outlines. I think that in itself is a modification.
Accessibility as part of it is a very key thing. It is the part that Canadians probably complain about the most, and that is "I cannot get to the services that exist." We need to realize, rather than just talking about accessibility, that sustainability and defining and dealing with organizational issues that I have tried in the short time to indicate will give meaning to accessibility.
Portability is a Canadian value, one that is very important to us. Again, just reciting it, it will come to mean less if we cannot get the same services in various parts of the country that you have right now.
Comprehensiveness refers to what? That is part of the debate, what we included.
Universality implies that everyone is really entitled under the same circumstances with no cost and that no fee is assigned to that, and I think that is still an important principle, providing you can assure sustainability of the system and providing that you are able to make it predictable.
Universal, to me, is different, in the sense that if there is a part of the health care system under which you want everyone to be covered you have opportunities for a little more creativity in determining how they get the coverage. Hence, universality has implied no first dollar coverage. Universal means you are supporting everyone having coverage, giving the flexibility that does not have.
Senator Robertson: Do you feel, with your experience, that the great arguments that go on between provinces and the federal government so often erupt because of the particular interpretation of those five principles or part of them?
Dr. King: Great arguments do go on. They erupt because of dogma sometimes, and that is why I alluded to that point in my remarks. If provinces would take a problem-solving approach to what is in the Canada Health Act and do their homework around it in organization and sustainability issues, then we might get somewhere, but arguments do happen, and there is a refusal to look at anything other than covering first dollar for everything that is under health care. Of course, we know that is not the case, that provinces pay for many things, and they include them under the health care budgets that have nothing to do with the Canada Health Act. The Extra-Mural Program in New Brunswick is one of those. It is such an important part of our life that it is included under the health care budget. It is hard to determine where it all starts and ends.
Senator Robertson: There are two schools of thought that we seem to run into all the time. A percentage of Canadians tell us that there are sufficient deficiencies that could be had in the system now that would pay for expanded services such as pharmacare and home care. Others tell us, and I think you are one, if I hear you correctly this morning, that we will have to look at a different form of funding or consider participatory action on the part of the citizens as we put home care and pharmacare in place, and anything else that we add to the system.
Look back at the start of medicare. At that time, most health care services were delivered in hospitals or doctors' offices, but now that figure is down to 40 per cent. Sixty per cent of services are out there in the other world. Can you reinforce your position on those two positions that we hear quite often? Can you reinforce your position on that split of ideology?
Dr. King: There are savings to be made from an efficiency point of view if we were to make some organizational structures, and this is what I alluded to at a macro level. If we avoided overlap and duplication between federal, provincial and territorial services, we could save dollars on a macro level. I will give an example of wellness.
Provinces are getting into "wellness," which is good, but there is a national tone. A lot of the wellness, the support of Olympic teams, ParticipACTION, stay healthy, run faster, let's clean up our harbours, because it is part of wellness, fits into the federal role. The federal role also can be seen in immunization, travel clinics, immigration. All of those things naturally flow. There is the area of human resources, because the universities and health departments across the country have had difficulty determining how many health professionals are needed in a particular time. That could be done nationally. Hence, there are macro savings to be done there.
There are things that would be done at the provincial level that I do not think you have to do at the federal level, as to the mix of health care professionals and how they are used. Those are management issues and common sense issues.
In spite of those things, in spite of those organizational structures, changes, if we are to have pharmacare, with its enormous costs, I think we can have it if we ensure that all Canadians are supported, but those that can will have to contribute to make it happen.
I am not trying to sit on the fence. I think you need it all that way if we will sustain it over time at all, and home care will require far more work, in my opinion, on the income support sides of government than it will on the health care issues.
I know I am beating the drum for Extra-Mural here, but I will give you an example. Let's take the case of a disabled individual, who may be disabled because of a genetic problem or simply frail, elderly. That person is in the home, with a whole set of needs in order to live at home. The health care dollars that I think should be funded under the Canada Health Act would flow with the nurses who are essentially nurse practitioners, by any definition. They are very highly trained, the ones that are in the Extra-Mural, who provide the health care service, the pharmaceuticals. We have people on intravenous medication at home. Most of the palliative care in New Brunswick is done in homes, supported by this. That part needs to be funded, and I think should be under the Canada Health Act because that is the Canadian way. However, the lift for the steps, the modifications of Aunt Suzie's bedroom, the extra support for someone around the clock, the strong back, the mature adult, not the nurse, needs to be funded out of some other budget than health care.
Hence, if the provinces and the premiers and the Prime Minister or the health minister, federally, are talking about accountability, that if we give this extra money, we have to have accountability, it means nothing if you do not define the organizational structures. You need to take the income support, because living a long time requires a lot of income. It requires a lot of income support and it requires more if you are disabled, whatever it may be. There needs to be a clarity of thought in organizational structure that will go a long way to defining the sustainability of the health care system, which is what your committee is focussing on. I hope I have answered the question; however, I am not sitting on both sides of the fence.
Senator Robertson: No.
Dr. King: I think they are both interrelated.
The Deputy Chairman: You mentioned in your presentation the lack of uniformity across the country, that some things are covered in some provincial jurisdiction and not in others. Do you think that that is a contributing factor to people not understanding the five principles of the Canada Health Act, and that with respect to accessibility and portability it is causing major problems for governments on the expectation level of people?
Dr. King: I think if we do not clarify it, yes, accessibility and portability issues will become more dominant than they are right now. During the 1990s, when governments had to really think about how to fund health care, various provinces de-insured various things, some more than others. The Province of Ontario had de-insured some things, I believe, that we did not have in New Brunswick to start with. I used to hear these kind of stories.
In the terms of seniors' physician services or seniors' pharmacare services in New Brunswick, for instance, when the Province of Ontario brought in co-pay, New Brunswickers had been paying two or three times that for some time to have the privilege of paying a premium. Hence, there is a great variety of things across the country and the discrepancies become greater.
I use the word "basic" level of high-quality care. There has to be a general understanding of what is care. If you are dealing with the technological part and if you are a province that can afford an MRI for every 75,000 people, then I do not think that is a major problem for the rest of the country as long as the rest of the country, through the national effort, is able to have reasonable access by definition of what is appropriate. I think we can do it, but we have some really tough decisions to make.
We will have to define the envelope of what is under the Canada Health Act, I think, and that comes to various health care providers. I have listed people that I think are an integral part of it. There are a group of health care providers or increased quality-of-life people that I am not sure that we can cover as a first dollar payment. For instance, with every single endeavour that increases quality of life, someone will have to say, "No, you are not in because of such and such," as miserable as it sounds.
Senator Callbeck: You mentioned in your brief workmen's compensation, and we all know that people that are on workmen's compensation get priority in the system. If there is a certain test, they are bumped to the top, as I understand it. If they need a certain medical procedure, they get it ahead of the general public. Do you feel that that is fair and just?
Dr. King: I am not sure that that happens all the time, but that is the pressure. I personally was involved with trying to grapple with that situation. I mentioned it in this document.
I think that there needs to be a revamping of that aspect by having within the health care budget, a separate program that would involve workmen's compensation issues. That would avoid competition in the system, where someone elderly with cancer is bumped because an individual has a sprained knee that occurred on the job. You get around that by organizing it. I think we need to do workmen's compensation different. I think it has to be part of the health care system, but defined in the same way that you may put a capsule around a cardiac surgery program.
You do not hear the debate, "Well, so and so went for cardiac surgery, but I could not get an x-ray because I have something in my bowel." It is understood. People understand about a cardiac surgery program. It or other programs can be delineated. I think for workmen's compensation, you do that and you fund it, and I think you have all kinds of opportunity. I do not think you can totally bring that under the Canada Health Act, but I think you have to fund it in collaboration with the public sector and the compensation to do that a little differently. That will become a bigger problem if we leave it just like it is.
Senator Callbeck: You say it would become a bigger problem if we leave it as it is or if we change it?
Dr. King: If we leave it as it is I think it will become a bigger problem over time. With the demographics of the population, with some feeling that there is a finiteness to at least the acute care budget, I think unless you put it under a separate program that that will become the commonplace which you defined.
I must say that I have not found precisely what you said to be the case, but it definitely happens sometimes.
Senator Callbeck: Well, we certainly have heard it before from witnesses, and I understand it to be the case.
You mentioned the CHST funding, about dividing it so that the public would know how many dollars a province got for health and how many dollars for education, and that it should be for specific types of health care. Are you saying that the federal government should be specific in the services that that money will cover?
Dr. King: What I hope will be the end result of this committee's deliberation and the Romanow commission - and I am hoping that decision will be made on the clarification of the kind of services, not the specific procedures, of course; that is a local thing - is the kind of services that would be covered. I think that has to be done at some point. I think that funding should be given to provinces to ensure that the services are there rather than just the tenants of the Canada Health Act being supported. If you continue just to deal with the Canada Health Act, it becomes greyer and greyer as time goes on, and more confusion ensues.
Therefore, yes, in terms of clarity, once you have determined what you are giving the money for on the federal side, it would be helpful if you simply separated it. It helps to clarify things for Canadians, to reassure them.
Senator Callbeck: In some provinces, for example, chiropractic services are covered under medicare, while in others those services are not covered. You would have the federal government set out what services are covered and what services are not covered; correct?
Dr. King: What I think should happen is that the federal government, as a result of this committee, as a result of the Romanow commission, needs to articulate something itself that becomes a reference point. For instance, suggest the kinds of services that would be included, yes. Then in the typical Canadian way, if a time frame for implementation were set, there could be modifications, but modify something that is more concrete rather than just having a debate over dollars, which we seem to be having now. We need to be a little more sophisticated than that.
Medicare was set up following the Hall commission. Medicare is much broader today than it used to be, and so someone has got to say: "Well, we would remove the barrier between providers and indicate what the providers are rather than letting it all just develop in an ad hoc way." That is what I am saying.
Senator Callbeck: What about follow-up by the federal government as to how the provinces spend the money?
Dr. King: You cannot follow-up if you do not have a position to start with. I would leave that to people who know how to do these things. The Canada Health Act, with some modifications, not to destroy it, could deal with that. You would incorporate those kind of things through the act, would be my feeling.
What are they? I do not know at this point just what they would be, but people with much more expertise can find a way, if they know what it is they are trying to defend.
Senator Callbeck: We had a witness in Halifax talk about the CHST, which is based, as you know, on a per capita formula. His suggestion was that that should be changed, that rather than us looking at how many people live in a province, we should be looking at the need, for example, how many senior citizens live in the province.
Dr. King: I certainly support your discussions on population health. This is part of my simplistic terms of problem solving. I think you have to look at demographics trends. People are changing places in Canada. It is traditional, for economic reasons.
If you have a national system, funding needs to follow on considered demographics, again, by appropriate formula, which is beyond me as to how you would do it. It needs to take into consideration what it is you have that you are trying to provide care for.
Senator Cook: In your brief, Dr. King, you talk about non-hospital services. Would you share with me what some of those services are, and how do you see the co-payment for those services being implemented?
Dr. King: Non-hospital services involve at this point a larger and larger part of what we do. It involves a lot of physician services. It involves ambulance services, which I think most areas are considering is part of the continuum of acute care. It involves pharmaceutical support for keeping people in their home. It involves nursing services. Actually, in New Brunswick, it involves occupational therapy support and physiotherapy support, and that can be enhanced for a variety of services that I mentioned in my document, dietetics. It is dependent on, of course, the human resource potential. While I say we have physiotherapists in the Extra-Mural Program, we do not have enough, but we do have them. Those are some of the services that are health care services. It also involves some palliative care services.
Senator Cook: How would you implement the co-payment?
Dr. King: It would depend on where you draw the envelope for the services that would be under the Canada Health Act. You can have everyone covered by indicating that certain people with lack of financial resources to be determined would be covered because they need to be covered. As we do with other things, there would probably need to be some kind of financial accountability of your ability to pay. I think you have to do that if you bring in a co-pay, for instance.
As you have indicated in your document, you can do it as co-pay, you can do it through the income tax system, which I think is very complicated and I tend not to support, or you can do it through user fees. I tend to support either a co-pay or a premium for those parts of the health care system that are not directly at this point covered under the Canada Health Act.
The implementation of this and how you do it, I think, is an administrative thing. I think we first have to decide what will be considered to be the part of the publicly funded system that we would support.
Senator Callbeck: Non-hospital services could also fall into the category of off-site from the primary building, if you were, when you talk about physiotherapy and occupational therapy, and those kinds of things. They could be as a result of one piece of the program being done in primary care, and then moving to a home situation.
That is why I asked you to help me with a definition of non-hospital services.
Dr. King: A lot of those things are part of the continuum of care and are being done more in the home now, with support from nurses and others, to make up for the fact that hospital beds have been decreased and not everyone has to be in a hospital bed. It is part of that changeover that occurred, in particular during the 1990s.
Income support issues associated with staying in the home when you have a disability need to be taken out of the health care sphere and incorporated into income support departments.
The Deputy Chairman: Dr. King, I would like to most sincerely thank you on behalf of the committee for appearing. You bring a unique perspective to the table because of your background as a family physician, and also working on the public policy side. I would sincerely like to thank you for appearing.
Colleagues, we will now call our next set of witnesses to the table. I would like to welcome Bryan Ferguson, Daniel Theriault and William Morrissey.
I will start with you, Mr. Ferguson.
Mr. Bryan Ferguson, Partner, Applied Management: I am a principal in the firm of Applied Management, which has been working extensively in the field of drug insurance in both the public and private sector in recent years. Our firm, and I in particular, led a study for Health Canada called "Canadians' Access to Insurance for Prescription Medicines." This is, I believe, the most comprehensive study of the situation in Canada.
Just for some background, that study was commissioned by Health Canada to provide a common base of data to facilitate exactly the kind of discussion on a national drug policy that the Senate is engaged in today. The Senate has used some data from the study in the report and made some other observations. I feel that the interpretation is perhaps perpetuating some myths that are not supported by the data, and I wanted to take advantage of the opportunity today to try to clear up some of those. I know that the time is limited, and so I have chosen to focus on three things and make myself available, obviously, for questions if there are any.
The three things that I wanted to focus on in my presentation are dispelling some myths about drug coverage in general; talking about some of the issues with regard to public drug plans, and finally, to give you my views on the options that you have put forward in your discussion paper.
If I can start with drug coverage in general, the first thing that I would like to address is what I call the myth of the 3 per cent. The Senate has used the number of 97 per cent as the proportion of Canadians with some form of drug insurance. In the very strictest sense this is true, as it is only in Atlantic Canada that there are individuals who are uninsured at some point for drug coverage.
It is important to keep in mind that unless you are a senior or receiving social assistance, drug expenses would have to be very high to elicit reimbursement from government. In B.C., for example, only about 5 per cent of the residents outside of the above categories, i.e. the universal program, would receive any reimbursement from government, even though everyone in the province is covered.
Most important, the 3 per cent masks an important gap in coverage in Canada, and that gap is the working poor. Close to 20 per cent of those who meet Statistics Canada's definition of "poor" would pay 3.5 per cent or more of their income for fairly routine drug costs, and much more if their drug needs are higher. Income tax credits for these individuals do not help much. If I am facing a $100 drug bill this month, it is of very little comfort to know that I will get it back at tax time next year.
The message that I would like to impress on the committee is that high drug expense is a relative term, and the number of Canadians facing these high expenses is more than the 3 per cent number would indicate. By my estimate, and the estimate of the team that worked on the project for Health Canada, the percentage of individuals who are underinsured or uninsured, using a combined measure of cost relative to income, is probably closer to 10 per cent. These individuals are found across Canada, and not just in the Atlantic region.
One related issue is the fact that there are a small but increasing number of private plans that are moving to limit coverage by imposing lifetime annual maximums or, in some cases, delisting expensive drugs. There are not very many, but it appears to be a trend that is starting to grow, and as we track this with private employers, we see more of these types of plans emerging.
As well, where plans do not have out-of-pocket limits, even those with good coverage may face high drug costs. For example, if you have a plan with a 20 per cent co-pay, for most circumstances this is a very adequate plan. It would be typical of many of the plans in Canada, but 20 per cent of a big number is still a big number, and I think the example in your report of the individual facing those kinds of costs was in exactly this sort of situation.
These developments fly in the face of the principles of insurance. I believe we need a fundamental rethinking of private plan design and, in some cases, public plan design as well to avoid situations in the future where it is the individuals who need help the most that get penalized.
I agree that the priority for improvement in drug plans is to ensure that there is some form of coverage to protect individuals against high drug expense, whether it is the result of individuals with good plans who have extremely high expenses or poor individual who just need basic drugs.
Some of the other myths that I was disappointed to see in the report include the following: Myth number two is that the uninsured are mostly poor. The uninsured are almost equally divided between low income and high income individuals. Many higher income individuals, such as professionals and small business owners, choose not to buy insurance, or the cost of individual insurance is very high and so they take their chances.
Myth number three is that the uninsured are primarily working age individuals. The uninsured are not only working age people, they cut across all age groups and include children as well as adults and seniors.
Myth number four: Very few private plans cap the exposure of individuals. It is not a small minority of private plans that cap the financial exposure; the Health Canada study found that the proportion with out-of-pocket limits is closer to 50 per cent. All of the plans in Quebec, for example, must have a $750 maximum limit, 13 per cent of employees pay no deductibles or co- payments, 15 per cent pay a deductible but no co-payment, and in B.C., Saskatchewan and Manitoba, once the employee has met the government's deductible, the government takes over. Therefore most private plans do provide good protection against high costs. The exception would be, as I said, those that are moving to start to implement annual and lifetime maximums, and in some cases, plans that have co-payments but with no limits.
Myth number five is that Atlantic Canadians have poor private coverage. Private plan coverage is actually more common in Atlantic Canada, not less. If we accept the CLHIA figure of 57 per cent as the percentage of Canadians who have private coverage, the corresponding numbers for Canada are Newfoundland, 64 per cent; Prince Edward Island, 67 per cent; Nova Scotia, 65 per cent, and New Brunswick, 65 per cent. When you realize that the level of public coverage in this region is so low, it is natural to expect Atlantic Canadians to protect themselves with private coverage.
Finally, I have a concern about your emphasis on the impact of sales and premium taxes on private plans. All employer contributions to the drug plan represent, in effect, a tax-exempt salary payment, whereas an uninsured individual must pay for his or her drugs out of after-tax dollars. Thus the greater the employer contribution, the greater the income tax benefit to the individual. Even after paying sales taxes or premium taxes, this still represents a good deal for the employee and the employer, so I cannot foresee the removal of taxes as encouraging more participation in private plans. I think the federal dollars would be better spent in addressing the gaps in coverage, as I will explain later.
Turning to public drug plans, there is a tendency to focus on variability in out-of-pocket costs to beneficiaries in these plans. It is true that a senior in the Yukon, for example, would pay nothing for drugs, whereas the same senior in Newfoundland could pay 100 per cent of the cost himself or herself. Provinces have devised their regimes with different philosophical approaches to co- payments, deductibles and premiums, and I believe that finding any common program that will be acceptable to all will be a major challenge for policy makers.
There are two issues, however, where some federal intervention could make a big impact. One is portability. As it stands, anyone covered by a public plan loses coverage upon leaving a province, and must reapply and wait for three months for coverage in the new province. For those who are more familiar with the rules under medicare, for example, or hospital insurance, the provinces have arrangements to provide a continuity of coverage, and indeed it is one of the pillars of medicare.
The other issue is access to specific drugs. While the Senate speaks of "log rolling", the evidence to support such a practice is not strong. Any analysis of new drugs released in the last five years or so will show that provinces are very different in their rate of approval of a drug, and indeed on whether the drug is covered at all.
While a national formulary could help standardize the disparity, I suggest a better approach would be to operate as most private plans do and pay for any drug requiring a prescription with very limited exceptions, but the caveat that I would add is that we create a well-developed set of guidelines for use, based on evidence, which are communicated to all physicians and with penalties for inappropriate prescribing and inappropriate use. Would it not be a better use of resources to ensure appropriate use rather then denying access to needed therapies?
Finally, as we move toward models of integrated health care delivery, there needs to be better communication and sharing of information, and I think a few of the speakers this morning have spoken to the same issue between private and public sectors. If an expensive new drug will result in reduced hospital stays or lower physician visits, we would want employers to be motivated to pay for the drug, and this is less likely to happen as long as the cost stays with the employer and the benefit accrues to government.
Just a comment on the options. The first priority, in my view, is to provide coverage for those with high drug costs relative to income, and I suggest that option four would be the easiest and least disruptive way to accomplish this. Individuals could opt into the provincial plan if they had no coverage. This would provide them access to the drugs they need and would solve any issues of cash flow. They would have the drugs when they needed them, and not have to wait until tax time to recover the funds.
Provinces would provide the individual with the equivalent of a T4 at the end of the year, and bill the federal government for the expenditure. The federal government could then claw back the amount of the T4 if the individual's income was over a predetermined amount, or if expenses were under a certain threshold, say 4 per cent of income. Higher income individuals with very high drug expenses relative to income would pay income tax on the amount over the threshold, but would still receive some relief from their very high drug costs.
A second approach, used in addition to the first, would be the public-private partnership option, and I stress that I see this as being a second approach and not one option versus another. Governments and employers together could create a pool to pay for defined high cost drugs. Employers would participate in the pool in proportion to their total plan enrolment, and this would provide employers with some reassurances that they will not be hit with unexpectedly high costs due to one or two or a small number of employees incurring some very high drug expenses, and this would be shared by the pool. I believe that options 1 and 2 would be unnecessary if the first two approaches were followed.
The only remaining financing issue is for individual who move from province to province. This is a gap that could readily be filled by a federal contribution to finance the bridging coverage for use in the participation in other parts of the program as a basis for requiring provinces to provide the bridging program. However, if, as we suspect is occurring now, individuals are stockpiling in anticipation of the move, provinces could probably formalize their rules with very little financial impact.
I will be very happy to answer any questions as they come up.
The Deputy Chairman: I will now turn to Daniel Theriault, the Director General of the Society of Acadiens of New Brunswick.
[Translation]
Mr. Daniel Thériault, Société des Acadiens et Acadiennes du Nouveau-Brunswick: Madam Chair, allow me to offer special greetings to Senator Viola Léger, a gifted figure of the Acadian arts scene. She is known both nationally and internationally and we are certain that her presence in the midst of your honorable assembly will contribute a particular and noteworthy approach and point of view. Senator Léger, let me congratulate you on your appointment. I have not had the pleasure of encountering you since.
La Société des Acadiens et Acadiennes du Nouveau- Brunswick, the Society of Acadians of New Brunswick, wishes to thank the Standing Senate Committee on Social Affairs, Science and Technology for organizing this public consultation on Canada's health care system. We are pleased to have this opportunity to add our comments to what has been and remains to be said.
The SAANB's 20,000 person membership ensures its presence throughout the province of New Brunswick. Since its foundation in 1973, the goal of our Society has always been to champion and maintain the rights and interests of the Acadian community of our province and to ensure its advancement. To speak of the Acadian community is, of course, to speak of the francophone community. For us, the two terms are synonymous.
The Acadian population of New Brunswick comprises approximately 240,000 people, and accounts for about a third of the total population of that province. I should say directly that we do not feel like a minority. We are simply one of the two official linguistic communities of New Brunswick.
French-speaking people are found throughout New Brunswick. The Acadian communities are more preponderant however in the northern part of the province and along the eastern seaboard.
Three years ago, the Société des Acadiens et Acadiennes du Nouveau-Brunswick decided to focus on health as a priority issue. Small wonder. The expectation that they might be able to obtain health care services in their own language remains, for the Acadian community, a matter of the greatest concern. Language is not for us an ancillary but a primordial issue with regard to health care delivery and even, I would say, with respect to the organization of the health care system in New Brunswick and, indeed, in the rest of Canada.
The commitment we have made in this most important matter reflects a feeling broadly shared by the whole Acadian population concerning the need to reconsider the issues of health and health care, and to make them one of the fundamental objectives of society.
Our appearance before you today shall focus on three points: an outline of our views on the main aspects of the draft legislation; the expectations and concerns of our members and of the whole of the Acadian population with respect to the present state of our health care system; and also our expectations concerning what the federal government should do in response to the particular needs of our community.
Our Society is presently involved in an extensive research and deliberation project, which is attempting to analyze the current state of health of the population and the changes that have occurred since we last examined the issue in 1985; a study of the health care system and the way it has evolved since 1985 and an analysis of the survey conducted by a public opinion firm on French-language health care delivery in New Brunswick.
This research initiative should allow us to compare the data compiled in the course of this study with the data derived from the 1985 study our society undertook under the conduct of Mr. Jean-Bernard Robichaud. This study not only revealed the considerable disparities existing between northern and southern areas of the province, but also at the time enabled the Acadian community to promote the reorganization of the hospital system and the establishment of regional hospitals. Based on this study, we set up a program that allowed us to make up for some of the lost time. We hope, in the light of the current data, to obtain the resources we were granted at the time.
Our present research also has a proactive side to it. We wanted our ponderings to include also the active participation of the francophone community and in particular of staff representatives from hospital corporations, health care facilities, health care professionals and volunteers, community agencies as well as patients. We have already completed phase one of that initiative.
From the start, our intention was to achieve an analysis of the situation sufficiently comprehensive to enable us to embark upon several projects relating to the health of the population and the health care system, and to give expression to the voice of the francophone community in these matters. The preliminary results were provided by the regional forums that we organized throughout the province in the spring of 2000 before convening a provincial forum.
These consultations brought out a clear need for a very thoughtful reconsideration of the health care system. It is true that budgetary constraints have these last years brought about a drop in the quality of health care services delivered through the system, to the point where today we can say that health care is in serious jeopardy. All we have presently are the services provided by an inadequate number of nurses and doctors. The scarcity of resources is evidenced in a number of ways including professional exhaustion.
The forums also brought out the problems experienced by the francophone community in areas served by a bilingual or anglophone hospital corporation. It seems that the attempt to deliver services in the French language rarely goes deeper than the linguistic abilities of receptionists. I'm speaking here of course of areas that are either bilingual or mainly English-speaking. It is clear, however, that the way health care services are structured impact on their ability to serve the province's two linguistic communities.
Looking to the purposes of bill 88 and of the Official Languages Act, and considering the social and demographic importance of the francophone community in our province, we believe the time has come to develop, within the department of health and well-being, a space where francophones might take their own affairs in hand so as to plan and manage in the interest of the French-speaking community, the delivery of French- language health care services.
I know that here I am addressing the federal government whereas the recommendations we are putting forward are mostly intended for the provincial authorities. But since the first part of our brief describes the reasons underlying our needs and our expectations, we have included them in the text of our presentation.
At the forums I spoke of a minute or two ago, many people deplored a dearth of information, as well as lifestyles detrimental to health.
We recommend that our governments apply, in concert with federal educational agencies, a strategy aimed at disseminating useful health information.
Our Society has organized for the French-language community of our province a round table in order to debate the health issues that seem most pertinent. This will allow the SAANB to draw upon the expertise needed to launch the initiatives we have planned in the field of community health.
The SAANB has also launched a project intended to articulate a comprehensive vision of what is required to ensure the proper delivery of health care to the province's francophone community. This vision focuses on the prevention of disease and the promotion of a healthier state of being. Our society's aim in this matter is to see to it that the equality of both linguistic communities is reflected, not only in public pronouncements but also in the very delivery of health care services.
Third, the SAANB is committed to a political strategy designed to ensure the development of a health care system by and for the French-speaking population. Experience has shown that to correct the type of problems we are experiencing, the francophone community must rely mostly on itself.
Fourth, the SAANB is exploring the various means of clarifying minority rights in regard to health care. Our position on this stems not only from the present difficulty in securing French-language health services, but also from a number of government decisions that have put the Acadian community in serious jeopardy.
We are referring here to the merging of the medical laboratories of French-language and English-language facilities in the Moncton area. We intended to clearly signify that the merging of these two facilities in the Moncton area was unacceptable.
We support a very broad definition of what health care should be, including in this concept an enhanced well-being, disease prevention and having people take a greater hand in ensuring for themselves a healthy state of being. Experience has shown that when the community gets a chance to take its own affairs in hand it can achieve results consonant both with its own needs and with practical realities. Let me cite as an example a program designed to improve the recruitment of French-speaking doctors in New Brunswick. The Acadian community got involved in a program called Acadie-Sherbrooke, bringing together French-speaking medical facilities and Quebec universities. This program has been a clear success as the 80 per cent rate of return of doctors to our province clearly shows. This is a higher proportion than in other programs. These results point out not only the need to provide French-language medical services but also the need to take things in hand and set up our own programs because that is the best way to get results.
Our position in favor of having the French-speaking population of New Brunswick assume responsibility for health care delivery is based both on considerations of language and on regional differences. The situation varies according to whether one lives in the south, which is mostly English-speaking, or in the north which is mostly French-speaking. There are considerable economic disparities between the two and, it is worth noting, the suicide rate is significantly higher in the north. Recent experience has shown that the best way to improve these problematic situations is for the Acadian community to develop its own structures. This seems preferable by far to simply having bilingual projects whenever justified by population ratios.
Let me recall, for the sake of example, how just recently the province set up a training program for suicide prevention counselors. The program was offered solely in English since, it was claimed, numbers did not justify offering it in both languages and that, in any case, the knowledge base came from Alberta.
Considering a phenomenon which, like suicide, has considerable cultural implications, and the fact that within our own community, as in other French-speaking communities such as Quebec, the suicide rate is very high, there is no doubt that if we had had the necessary resources to provide that type of training, it would have been made available in French.
Let me stress, in conclusion, that on the health issue we fully intend to work both with your committee and more broadly with the government but, also, that the Canadian health care system must take into account our nation's linguistic duality.
We believe that in New Brunswick a French-language health services network structured around a French-language tertiary institution and facilities serving the mostly French-speaking regions - including facilities in minority areas - would be a step in the right direction. The establishment of this kind of French-language network will improve health care delivery to the French-speaking community, and facilitate the recruitment of doctors in the various regions as it will enable them to network with other French-speaking teams of health care professionals in the province. This would also better satisfy constitutional requirements, and more specifically article 16.1 of the Canadian Charter of Rights and Freedoms, according to which, in New Brunswick, English and French do after all have equality of status.
In view of the conclusions outlined in the national report on French-language health care delivery, following the forum that took place in Moncton on November 3 - just recently - the SAANB urges the federal government to take up the issue and facilitate the establishment of a French-language network of health care services adapted to the needs of the French-speaking community of our province.
The report that came out of the forum organized by Health Canada's advisory committee of minority francophone communities recommends the adoption of a comprehensive strategy to improve access to French-language health services; the setting up of provincial and territorial networks as well as a national administrative office to strengthen links between the various communities, health care professionals, educational institutions, health care facilities and French-language professional associations, and recommends that the government support the creation of a pan-Canadian consortium to train French-speaking health care professionals.
Considering its role in Canada's health care system, we feel it is time for the federal government to invest extensively in the health care system so as to foster the advancement not only of the French-speaking community of New Brunswick but of the Canadian population as a whole.
[English]
The Deputy Chairman: Thank you very much, Mr. Theriault.
I will now turn to Mr. William Morrissey, who is representing himself here as an individual, but will bring to the table his experience as a former Deputy Minister of Health in New Brunswick.
Mr. Morrissey, welcome to the committee.
Mr. William Morrissey, Former Deputy Minister of Health, Province of New Brunswick: Having read some of the material that you published, I am not sure I have anything new to offer, but I think there are a couple of points that should be reiterated, especially in view of the fact that Senator Robertson was Minister of Health in this province when the Extra-Mural Program was conceived and born. For fear that she might not like to blow her own horn, I thought that I would review for you how that concept came about, and that was in the late seventies, early eighties. I think those concepts are still valid today, and are worthy of being copied.
Despite the fact that, in the interim since 1980, there has been some erosion of the program, it is still a valuable service, and I propose to move very quickly through my comments. One of the reasons I would like to talk about this is I recently heard the Federal Minister of Health making this statement that we need to study home care as an alternative to acute care treatment, and my reaction to that is that there is no need to study; it has been put in practice in New Brunswick in the 1980s and 1990s.
How did the concept come about? It basically started with the fact that somewhere between 35 and 40 per cent of our acute care hospital days were being taken up by people with chronic conditions, and who were, for the most part, over 60. We set about to determine the significance of that, and it was determined that, if we continued on the same wave, by the middle of the nineties we would need almost 1,000 more acute care hospital beds than we had. Clearly we could not afford that, either in terms of capital cost or operating cost, so we set about to find a solution that did not include acute care hospitals.
I suppose what came out of that was that if we cannot use the acute care hospital, where then do we provide service? We took a look at the fact that people are either at home, in school, or at work, and we decided to try to move the service centre to the home, to begin with. Traditional home care programs have been used, and still are in some instances, by acute care hospitals as a way of moving people out the back door after they have been subjected to the first four or five days, which are the highest cost days, of their hospital stay, and to move them into their home for three or four days early. What we did was we took the Extra-Mural route, and we said, "Let's reverse the traditional view of home care. Instead of using it to move people out of acute care hospitals, let's use it to prevent their entering the hospital in the first place." That, in many ways, surprised a lot of people.
Basically, we set up the hospital with a board of directors. We set up policies and procedures not unlike a traditional hospital, where physicians had to apply for privileges, and certain services were made available. The reason we put emphasis on the physicians was that this was an attempt on our part to give physicians, especially general practitioners, the ability to command resources in the community.
One of the problems that GPs run into all the time is that they can only command resources when they manage to get a patient into an institution. We said, "Very well, we will create a context in which you can create and command resources in your own time." Of course, the word "extramural" meant that you could command resources outside the walls of an acute care hospital.
What are the advantages of this? First of all, it is cheaper. Why is it cheaper? It is cheaper because you take out of the system the hotel cost. When you take a person into an acute care hospital, you have to house and feed them, which is basically not part of the health care cost. You have to maintain a very expensive physical plant, and if you have a third of it occupied by people who can receive service elsewhere, why not do it? It is flexible.
The Extra-Mural Program was influenced in the first five years more by the creativity of people who were involved in it than certainly anybody who was involved in the planning, because whatever service is needed can be provided. It is not programmed by some sort of constitution of an acute care facility.
The Deputy Chairman: Mr. Morrissey, pardon me for interrupting for a moment. How long will your presentation be? We would like to ask you some specific questions about this subject-matter.
Mr. Morrissey: I can finish any time.
The Deputy Chairman: If you could, that would be fine. Specifically, we were interested, because this is the only example in the country of a program such as this. If you were able to summarize what you are saying so that we can allow some time for questions, that would be grand, because we are against the clock a little bit this morning.
Mr. Morrissey: Very well. I will not say any more about the Extra-Mural system.
I have one more point to make. Your terms of reference spend a lot of time talking about the federal role in the health care system, which is a bit of an oxymoron in that, constitutionally, health care belongs to the provinces, and presumably the federal government does not have a role. On the other hand, the federal government has the taxing power and so it comes into the system as the financier, but its role has never been defined. That role has bounced up and down since 1967.
I think that we need multi-year funding on the part of the federal government, and we need a definition of its degree of responsibility. In other words, will it provide 25 per cent, 30 per cent, 20 per cent? In 1967 it was 50 per cent, and that was the intention. It has now gone down to as low, I am told, as 11 per cent in some provinces, and I do not think you can ask people to run institutions if you make the federal involvement subject to yearly political decisions. That is what we have now. You can imagine the absolute chaos in the country if we had the same approach to OAS or GIS.
Senator Robertson: My observations are more general, shall we say. I think it would be important for this committee to really look at the Extra-Mural Program. It has not been looked at. I would submit that if this program had been identified and developed in Ontario, by now it would have spread all across the country, but when it comes from a small province, nobody pays a bit of attention to it. It is sort of fly-by-night thing in someone's mind. It has been in place for some time now, so my overview here is more of a speech than a question, shall we say, because I know the answers to any questions that I might ask of Mr. Morrissey on this subject-matter, and I would like to leave the question period, perhaps, to some of my colleagues who have specifics to ask of this witness.
The Extra-Mural Program is a process that has been around for a long time now, as you know. It is the most popular political program or government program with which I have ever been associated, in any department of government with which I have been involved. The people today still stop and say thank you, and as Viola knows, it is not hard to copy. We made it look easy. Forty per cent of our patients were coming directly from the doctor's office instead of going in, and we know that the money is spent when you go through that door. That is where the money is spent. You can go in and get some tests done, and then get the heck out, and we have a coordinated home care. You can come directly from your doctor's office and be facilitated into the care system.
Palliative care, what have you - it is all under one roof. There is no silo there. It is all under one roof, and it is a comforting program. Most people want to be in their own homes. Who wants to die in a cold room in a hospital where they do not know anyone, where all these strange people are coming in? It is cheaper to have the nurses, to have physiotherapists, to have the speech therapists, et cetera. We gave the management of the homemakers out to the Red Cross and they trained all of the homemakers. You just call the Red Cross and they come.
Now there is an unfortunate part - and perhaps Mr. Morrissey could answer this better than I, because I have been removed from the scene for a while. As you can tell, and I have never spoken about this matter before on this committee, but I think it is about time I did because I am hearing of a lot of garbage happening in a number of areas that could be easily resolved if the proper approach was used. I see people nodding their heads there, because we went through all that garbage before, with no success, but we got there with Extra-Mural. We started with one provincial board. It was set up separately and we included it in the New Brunswick Hospitals Act so that it would not be starved of funding.
In any event, Mr. Morrissey, would you tell what happened to the system, because you know better than I what has happened to it since I was there. It is in a weakened form now, but the original form was very strong.
Mr. Morrissey: Two things: It was set up province-wide. In other words, it was defined as a service to be provided at the same level all across the province. It was under one board, and the reason for that is we have economies of scale and we have consistency of service. It was also set up under one board specifically so that the acute care hospitals could not get their hands on it and start reversing the role back to the traditional way.
I will not go into who did this but since then, in the name of economics, the centralized board was abolished and the extramural hospital was divided into eight parts under the board of our eight regional acute care hospitals. While there is still a very valid concept of service there, it went totally against the original vision of the hospital. It is interesting to note that our Auditor General, a year after that was done, included in his report a note which said, "I could find no evidence that a cost-benefit analysis was done prior to this decision. I can find no evidence that there has been any savings of money, and I can find no evidence that there has been an increase in the quality of service." Those, of course, were the three reasons cited at the time for making those changes.
The Deputy Chairman: Mr. Morrissey, has there ever been an attempt since to kind of unscramble the egg and put it all back together again?
Mr. Morrissey: Other than people such as myself haranguing the minister, no, I do not think so.
Senator Léger: I just want to make a comment that I hear wonderful things about that Extra-Mural Program. I do not know of its evolution, as you have just mentioned, but even as is, the people can get that service. I am not saying it should remain minor at all. It is greatly appreciated. That is all I wanted to say.
The Deputy Chairman: Actually, Senator Robertson and Mr. Morrissey, for the purposes of the committee, are there still extensive documents from when that system was set up and the process it went through, that could be retrieved and submitted to the committee?
Mr. Morrissey: Yes, in the legislative library.
The Deputy Chairman: Senator Robertson is being a little modest here. When the committee was getting into this whole home care area of study, it was amazing the number of times that Senator Robertson had to kind of stick up her hand and say, "But there is an example in the country." Even though she did not get into the speech she made today, she has, in her own way, made us very aware of this program in New Brunswick.
Senator Cook: Mr. Ferguson, in your brief you say:
More important, the 3 per cent masks an important gap in coverage. That gap is the working poor. Close to 20 per cent...Our report says that some 3 per cent of the Canadian population appear to have no insurance coverage at all for prescription drugs. Are you suggesting the figure in that document should be 20 per cent rather than 3 per cent? I seek some clarity on the two pieces.
Mr. Ferguson: Yes. The document that the Senate has produced uses a 3 per cent number. As I have said, technically that is correct. If you are a resident of Ontario, every resident of Ontario has coverage from the Ontario Drug Plan, the Trillium Program, at some point, but that point is so high that, in fact, the number of people who actually receive the benefit from the program is very small, or they are people who have very specific conditions that the Trillium Program would apply to. Therefore while technically they are covered, the reality is that, particularly for people who have relatively modest drug needs but whose income is low, there is not a program for them. They never achieve a ceiling that would provide any sort of coverage to them.
The same is true of the provinces in the west. For example, in Saskatchewan and B.C. where we have coverage, we have extremely high deductibles. In Saskatchewan, you have a deductible of $1,500 in the drug plan. Thus, while everyone in Saskatchewan is covered, the number of people in Saskatchewan who actually receive a benefit from the program is very small.
In fact, in the National Population Health Survey that took place three or four years ago, one of the questions that was asked was, "Do you have insurance, either from an employer or from a provincial drug program?" The response rate in Saskatchewan, if I am not mistaken, was about 65 per cent who said yes. According to the program in Saskatchewan, everybody is covered, but the reality is, from the perception of the individuals who receive no reimbursement because their drug needs do not hit the $1,500 ceiling, they perceive themselves as being not covered. I think the use of the word "coverage" masks this issue, which is really people who are facing difficult financial circumstances because of their drug expenditures relative to income, and looking at it strictly from the perspective of whether they have insurance coverage or not is, in a way, a red herring, or takes us down a path that diverts the attention away from the real issue, which is the actual financial or out-of-pocket impact on those individuals.
Senator Cook: Do I understand, then, that for you, the word "coverage" needs to be identified more clearly in the report?
Mr. Ferguson: Absolutely.
Senator Cook: That it is, rather, 20 per cent, and the opening statement is adequate? It is inappropriate? The report says "Some 3 per cent of the Canadian population appear to have no insurance coverage at all." Would you advocate the 3 per cent staying in that sentence and a fleshing out, if you will, of the word "coverage"?
Mr. Ferguson: If I were writing the report, I would ignore the introduction about the 3 per cent altogether and try to tackle the problem from the perspective of individuals who are facing financial hardship because of their circumstances. I really believe this issue, and I know it is a number that the CLHIA used. In fact, in our own report to Health Canada, we have used the number as well, and I think the table that is included in the Senate report has come out of the study that was done for Health Canada, also accompanied by about 200 pages of caveats and explanations and trying to put it in this context.
In fact, we looked at it from the perspective of individuals in two different situations: individuals with very high drug costs and individuals who are facing what would probably be average drug costs in Canada, and approximately 20 per cent of Canadians have no drug coverage. They would receive no reimbursement from government, from employers, or from any other source for those drug costs. For someone who is facing $50,000 worth of drug costs, there are probably only about 3 per cent of Canadians who would not get at least $1 back on that $50,000 from some level of government. We are talking about levels and we are talking about the impact of the high cost of medications versus the other situation, which is relatively low income people who just have high costs relative to their income.
Senator Cook: Then if you suggest dropping the 3 per cent in the document and the report, what happens to the 20 per cent in your brief, when you talk about the myths and realities?
Mr. Ferguson: I would lay out the situation by saying that in Canada today, approximately 20 per cent of people who have routine drug needs have no insurance and receive no reimbursement from any source. Then I would start from there, and I would describe who that 20 per cent are. About half of them are well off Canadians who choose not to purchase drug insurance. They feel that they would rather accept the risk of facing potential high drug costs as opposed to what it would cost them to buy insurance for themselves. In that category we would have professionals, small business owners and a variety of people like that.
The other half of the 20 per cent, if I can use that expression, are people who are the working poor, the low income Canadians who work in part-time, seasonal occupations, or who work for employers who do not provide any drug coverage. They are the ones, in my view, who should be the focus of attention and the focus of any sort of program that will try to address needs.
The Deputy Chairman: Did you have a supplementary question, Senator Robertson?
Senator Robertson: Yes, I have. I stopped my questioning because I thought the others might have questions for Mr. Morrissey.
These two witnesses that we have right now, Madame Chair, are presenting almost singular positions that we have not heard before, on Mr. Ferguson's concerns and his expertise, or Mr. Morrissey's concerns with the Extra-Mural hospital project. I think we can always go back to them to get additional information in the near future.
I did not quite understand; I am afraid it went over my head when you talked about the tax benefit of insurance programs, if I understood you correctly, paid for partially or fully by the employer, and then they got tax benefits at income tax time. What was that all about again? I did not understand that. I am not a tax person.
Mr. Ferguson: Senator, we are mixing two concepts here. When I talk about tax benefits at tax time, I am really talking about those people who have drug expenditures that are high, and who would qualify for the health expenditure tax credit when they file their income tax returns, and would get a proportion of their expenditure back from the federal government because their health expenditures or drug expenditures were high.
The other point that I was trying to make is that for an employee who receives a drug benefit from an employer, the portion of the cost that is paid by the employer is not considered salary. It is a cost to the employer, but it is not a salary cost to the individual. Therefore, to the extent that the employer pays any share of the drug benefit cost, he is really providing a tax-free salary benefit to that employee. If I looked at another employee who was in the same industry, receiving the same salary but had no drug plan, then they have to purchase all of their drugs out of their after-tax dollars.
Senator Robertson: I think I understand it now.
I have one final question. You talked about portability, and we have a group here that will talk about portability this afternoon. Portability between provinces does not always work, as you know. What about the interpretation of the portability section of the Canada Health Act? One of the principles, when one is travelling - do you consider that the portability should still remain if one is travelling? From your study, what did you find there?
Mr. Ferguson: First of all, I think the most fundamental issue is that we do not have inter-provincial portability; in other words, we do not have inter-provincial portability, let alone portability when you are travelling outside the country. Unlike the situation with medicare where if you move from one province to another, the provinces have arrangements to ensure that there is no loss of benefits while you move, in the case of drug coverage, because they are not covered by the Canada Health Act, there is not any requirement for any sort of portability.
With respect to travelling outside of the country, there is no benefit coverage from your plan outside of the country. As you probably know, most people stock up as much as they can before they go. If their drug plan provides for a three-month supply, what they will do is try to get a three-month supply before they leave so that they at least have the main component of it covered. If you have the prescription filled outside of the province, your drug plan will not pay for it.
The Deputy Chairman: To say nothing of the information we got from some witnesses that some drugs are approved in some provinces and some are not. If you happen to move to a province where your prescription drug is not on the approved list, that can make things a little difficult there.
Mr. Ferguson: That is a whole different issue at hand.
The Deputy Chairman: I know, and we will not go down that road.
Mr. Ferguson: Certainly, if you wanted to look at it from the perspective of equity in Canada, that is a far bigger issue to me than the financing issue.
The Deputy Chairman: Yes. We had very good witnesses on that aspect in Toronto.
Senator Callbeck: Mr. Ferguson, on the example that you give of opting into the provincial plan so that they could get the drugs that they need and it would not cause cash flow, will the federal government end up paying for part of this? You say give them a T4 at the end of the year and they submit that with their income tax return, but the province also charges the federal government for the amount.
Mr. Ferguson: That is right. What I am proposing is if the federal government wants to play a role in gap-filling, or if they want to play a role in trying to solve the problem that is the most serious problem as far as drugs are concerned: it is trying to get at this relatively small group of individuals who are facing these kinds of problems. If there was federal government money to do it, the way you would target it to these particular groups is through some sort of a program like this. The way it was originally worded in the option paper still achieves the same ends, but it has the difficulty of not providing the money when it is needed to the individual. I think you need to have this other step in there that would allow the individual to essentially opt into their provincial plan, which gives them the card, which gives them access to the drugs at the time they need them. Then the other financial arrangements are sorted out between the federal government and the provinces.
Senator Callbeck: Fine, yes. I just wanted to make sure I understood that. That is how I understood it.
Mr. Morrissey, I certainly agree with what you have said about the Extra-Mural Program. Certainly, you and Senator Robertson deserve a great deal of credit for this program. It is, in my book, the best in the country.
You talked about the funding; that you need multi-year funding: In other words, you need stable funding. Then you talked about the percentage. Do you feel that the federal government should pick up a certain percentage of the total cost every year?
Mr. Morrissey: I do, in the sense that if you go back to 1967 when medicare was the Centennial project of the federal government, the feds bought into the program at roughly 50 per cent. That could vary a little bit, depending on what services came in what form. Since then, through political decision, that has decreased and decreased, and we now have a situation where the federal government, with the concurrence of the provinces, basically is dictating through the Canada Health Act conditions for the delivery of a service which is constitutionally that of the provinces, while, at the same time, the federal government's share is getting less and less. Since it has gone down to 10 per cent or 11 per cent, which was unthinkable in 1967, it could go as low as 5 per cent. My question is: What is the role of the federal government? I think we are in this sort of debate today because the federal role was never clearly defined. I think it was defined in the minds of the people who brought in the program in 1967, but it is not a definition that has withstood the test of time, and I think it should be a fixed percentage.
Senator Callbeck: No, I understand that. It is difficult, though, I suppose, for the federal government because they never know what they will be spending on health care until the end of the year.
Mr. Morrissey: They could say the same thing about income assistance programs, but imagine the chaos that would be created if they came out and said, " For the next year we have to save so many hundreds of millions, so we will cut all OAS pensions by $50 or $60." That is essentially what we are saying to people in need of health care. To me, health care is a public utility in this country.
Senator Callbeck: It is certainly a major problem for the smaller provinces, especially not knowing how much money you will get from year to year.
Mr. Morrissey: It is getting to be a problem for the bigger provinces, too.
The Deputy Chairman: Thank you very much, Senator Callbeck. Before we adjourn for lunch, I have to let you know that Mr. Theriault had a previous commitment and was not able to stay for questions, but Senator Léger would like to say a few words, just to follow up on what Mr. Theriault had to say. Please proceed, senator.
Senator Léger: Thank you very much, sir, for your presence, and I do agree that we are a different province.
[Translation]
Thank you, madam Chairman. Your presentation was assuredly a necessary plea on behalf of a linguistic community, since much needs to be done to make up for past shortcomings, but it is fair to say as well that much has already been done.
Following Jean-Bernard Robichaud's report, we do now have French-language regional hospitals. More needs to be done at the specialist level. I found it interesting that 80 per cent of our doctors who go out to Sherbrooke end up coming back to our province. That is the only comment I had but it does confirm our specificity.
[English]
The Deputy Chairman: I would like to thank you, Mr. Morrissey and Mr. Ferguson, and in his absence Mr. Theriault, for appearing before us. I found your testimony and your reports to be very useful and helpful. We may have to have you back, Mr. Ferguson, in order to get into that other issue that I almost raised.
The committee suspended its proceedings.
Upon resuming.
[English]
Senator Marjory LeBreton (Deputy Chairman) in the Chair.
The Deputy Chairman: I would like to introduce our witnesses for our afternoon session. We have Bob Jackson, President of the Canadian Snowbird Association; Helen Ladouceur and Eileen Malone of the New Brunswick Senior Citizens Federation; Sandra Keon, Secretary Treasurer and Vice-President, Clinical Programs at Pembroke Hospital, Catholic Health Association of Canada; and Michael Gallagher from the Miramichi Police Force.
Mr. Bob Jackson, President, Canadian Snowbird Association: Joining me today is our executive director, Heather Nicolson-Morrison. I will touch on all the points that are in the brief, which I have tried to summarize.
The Deputy Chairman: I should have pointed that out to the witnesses. It helps us if you summarize the brief and allow us more time for questions. I appreciate that, Mr. Jackson.
Mr. Jackson: The Canadian Snowbird Association has been in existence since 1992. In the beginning, our mandate was to find affordable travel medical insurance, but we soon realized that there was no association dealing with the specific needs that impacted on the Canadian snowbird or long-term traveller. Therefore, our mandate has changed from the early days.
In the first year, we managed to provide our members with savings of $25 million on their travel insurance. One of the reasons for the astronomical increase in supplementary insurance prices was that Canada's provinces were, and still are, breaking the law, specifically, section 11(1)(b)(ii) of the Canada Health Act.
The portability principle of the Canada Health Act is that the provinces are required to pay the same amount for emergency medical care out of country as it would for the same level of care in province. Prior to 1993, all provinces except British Columbia were in compliance with the portability principle of the Canada Health Act. In April and May of 1993, Saskatchewan and Alberta reduced out-of-country emergency medical payments to $100 per day. In July 1994, Ontario cut back to $100 per day. Quebec cut to $100 a day in 1996, and New Brunswick cut to $100 per day in 1997. All of this was in direct contravention of the Canada Health Act, which the federal government has jurisdiction over.
In your interim report, you recognize that the principles are not as strictly adhered to as many Canadians would like. The previous statement about the cuts is a growing example of the blatant abuse of the law by the provinces. That would never be tolerated from a private citizen because this is federal legislation that the federal government has jurisdiction over.
Those provinces that come close have not indexed the amounts to reflect the yearly absent tides of rates. British Columbia pays only $75 a day in emergency health coverage, which has not changed in over 25 years. Both this rate and the $100 rate are a joke.
The Canadian Snowbird Association entered into extensive discussions with the Ontario government, and when no reasonable outcome was reached, we took legal action. Two judges ruled on procedure stating that the association's actions were premature until a process of consultation between the federal and provincial governments had been completed. That is stipulated in the Canada Health Act.
The third judge wrote a scathing 18-page report in our favour that said it was beyond dispute that Ontario was breaking the law. Ten years later, the consultation process, as discussed by the Ontario justices, has not started. A legal challenge was also initiated in British Columbia and the judge there stated that it was a matter to be resolved between the federal government and the province.
I noticed in your report that you say that this has never been challenged in court through the federal government. We did go to a constitutional legal firm, Osler & Hoskin from Ottawa, who are supposed to be constitutional lawyers. They said that we would not get anywhere by challenging it under the constitution because it was not in the constitution that it had to be enforced. Therefore, we have taken the route of going through the provinces.
Prior to the 1995 provincial election in Ontario, we contacted the leaders of each provincial party and asked what they would do if elected to bring Ontario into compliance of the section 11(1)(b)(ii) of the Canada Health Act. The leaders of both opposition parties agreed that Ontario should be in compliance with the Canada Health Act. On September 1, 1995, Ontario's out-of-country emergency medical service per diem rate was returned to the previous level.
The charade that is carried out by five of our provinces should be no surprise to Minister Rock. The numbers are released in the Canada Health Act Annual Report, published by Health Canada, with a preface signed by the minister and tabled in the House of Commons each year.
Your report also mentioned that experts argue it might be possible to achieve a better return on the health care dollar by promoting healthier lifestyle for Canadians. An ounce of prevention is worth a pound of cure. Many of our members live frugally year-round to achieve their chosen lifestyle. They are being proactive. By going to a warmer climate each year, these seniors are actively taking charge of their physical and mental health.
Should a snowbird have an emergency illness while outside of Canada, they have taken care of the bulk of the financial burden through their purchase of supplementary travel medical insurance. Increasing the per diem rate will not eliminate the need for this extra and often costly insurance, but it may make it a little more affordable to assist Canadians in achieving a better return on the health care dollar by allowing for a healthier lifestyle.
We are not soliciting additional funds. We would like the funding referred to in the Canada Health Act to be delivered. We are having success in some provinces.
Experts argue that it may be possible to achieve a better return on the health care dollar by promoting healthier lifestyle for Canadians. In some provinces, we have had time limit regulations changed to allow a retiree flexibility of travel beyond the six-month-plus-a-day presence required within your provincial boundaries to keep your medicare. Although this is a provincial regulation, we feel that your report should encourage uniformity among the provinces as it pertains to a healthier lifestyle.
Another area of concern is vacation supply of prescription drugs. If a Canadian can travel out of the country for six months, then a person on long-term medication should be able to access prescription drugs equal to the length of time they will be out of the country. When he announced the change in that province, the Premier of Ontario said that it makes good health sense. To rely on mail for essential medications puts Canadians at undue risk.
We concur that prevention is the key. The federal government should enforce the five founding principles of the Canada Health Act, including section 11(1)(b)(ii), thereby eliminating the wide variances across the country. The federal government should initiate the consultative process with the offending provinces. If these provinces continue in contravention of section 11(1)(b)(ii), then the federal government should invoke its ability to withhold transfer payments.
There should be a uniform policy across Canada giving taxpayers the right to freedom of travel as long as a principal residence is maintained in their home province. It is fundamental that every Canadian be allowed, through their drug plans, to purchase prescription drugs equal to the number of days they are allowed to be out of the province. This should be uniform across the country.
On those two issues, we are making headway with some of the provinces, but it is hodgepodge because there is no uniformity to it.
The Deputy Chairman: I have a husband who is a snowbird, and I know how you feel. I will now turn to the New Brunswick Senior Citizens Federation, and I will ask Ms Ladouceur to make her presentation.
Ms Helen Ladouceur, Member, New Brunswick Senior Citizens Federation Inc.: I represent 24,000 seniors in New Brunswick. The senior population is aging and we would like to distinguish between acute conditions and chronic conditions, such as transplants, joint replacements.
Bypasses are very costly to seniors. Seniors should not have to be hospitalized for flu and allergies. Due to the early discharge from hospitals, our seniors have to pay more for home care, long-term care, palliative care, drug care, and need more equipment to stay at home, which is all out-of-pocket expense.
We would like to see a positive health care with seniors returning to work, volunteering and keeping active to stay healthy. We also would like to see more research done on senior women. We also would like to see our drug costs not as high as they have been. We have shortage of doctors, and the waiting list for special care is too long.
The Deputy Chairman: Thank you Ms Ladouceur. I am sure we will elicit more from you when the questioning comes.
Ms Sandra Keon, Secretary Treasurer, Catholic Health Association of Canada; Vice-President, Clinical Programs at Pembroke Hospital: The Catholic Health Association of Canada is the national voice for catholic health care. The CHAC represents provincial health associations, hospitals, homes, numerous sponsor organizations and health care professionals.
The committee is to be commended for having highlighted key issues concerning the state of health care in Canada. I will highlight five points from the brief we have submitted to the committee.
The first point is that without attention to values, there cannot be good policy. Chapter 7 of the report presents a narrowly defined discussion of the Canada Health Act that focuses primarily on a single question: "Are private health care provision and private health care insurance permissible under the act?" Such an approach overlooks an essential feature of the act.
The Canada Health Act embodies a set of values that Canadians hold to be important. The national forum concluded that the Canadian underpinnings of the health system include the premise that it ought to be government run and not for profit. It is the belief that all are entitled, as a matter of citizenship, to equal access to quality care, a commitment to compassion, to a sense of community and to a common purpose.
The committee's report sets out a wide-ranging list of proposal options. You are asking Canadians, "What values do we choose now?" This is where this discussion must begin. Any rethinking of medicare requires a reaffirmation of the societal values that give rise to the health system, a critical analysis of new and emerging values, and a change in the focus of the discussion from the marketplace toward a discussion of the core values.
In our brief, we present a list of those values that can provide a vision for health in the future, as well as a means to assess the wide range of alternatives currently being promoted for organizing funding and integrating health care services in Canada.
The second point is that health care cannot be treated as a mere commodity. Chapter 5 of the report acknowledges that health care is different from other goods and services, but it defines this difference in terms of market failures. Throughout the report, the essence of health care is reduced to a market ideology.
Central to our analysis of the strengths and weaknesses of the options developed by the committee is a conviction that health care is a service. It is first and foremost an essential social good, a service to persons in need. It is not and cannot be treated as a mere commodity exchanged for profit, to which access depends on an ability to pay. The strongest forces pressuring the sustainability of the health care system are linked to those values that view health care as a commodity, individualism and self-reliance, unlimited choice, economic competition, rapid service and guaranteed outcomes.
Our third point is that medicare is workable. In recent years, Canadians have been subjected to what sometimes appears to be an organized campaign designed to weaken confidence in the nation's health care system.
Chapter 8 of the report takes up the question of affordability and sustainability. There is a strong negative tone in this section of the report. It suggests that those who hold that medicare's problems can be fixed by increasing efficiency while still preserving the public health insurance system, are not being prudent and are avoiding the tough financial questions.
The committee does acknowledge that efforts to enhance efficiency and effectiveness have been hampered by the attitudes and behaviours of those with vested interest in the current health care system. However, the report fails to ask an important question: "Is there the political will today to challenge these vested interests?"
Many of Canada's most respected health policy analysts have concluded that our country's single payer health system has worked. There is a tendency to overlook the success of our current system. John Ralston Saul has called this tendency, "one of our era's most dangerous failings."
Point number four deals with private finance and for-profit delivery. Chapter 8 presents an excellent overview of a range of new funding sources. However, the report's conclusion that user charges, medical saving accounts and contracting for private health providers and private insurance could be implemented in ways that would avoid the risks associated with these approaches.
This appears to ignore the research on these subjects. What evidence is there that private for-profit care is cheaper and more efficient than public health care? I quote health economist, Robert Evans, who says, "Hopes for increased efficiency through increased for-profit provision of care have no empirical support and face extensive counter-evidence."
There is strong evidence that the growth of for-profit care will increase costs and that it tends to decrease quality. We are especially concerned about the impact of some of these options on persons who are poor and vulnerable in our society.
The fifth point is that there is a need to build a more integrated system of services. The health system in Canada has evolved in a way that privileges hospitals, physicians and health care interventions. This reality must change.
The health forum proposes a system in which services are integrated and where the care, not the provider or site, is funded. The committee has identified home care and prescription drugs as two key areas for action developing such a system. As technology has allowed increasingly complex care to be provided within the community and in the home, provincial governments have allowed the associated costs to move outside of the publicly financed system. A move rightly termed by some as passive privatization. Prompt action is required to reverse this trend and to ensure that home care becomes an integral part of the publicly funded services.
Canada should begin taking steps to include prescription drugs as part of its publicly funded health care system. The committee, in its presentation of its main findings from phase three, appears to favour the participation of the private sector; either through the imposition of user charges or the involvement of private insurance, as the preferred method of expanding public health care coverage to include prescription drugs, home care and long-term care.
This approach differs sharply from the funding recommendations for home care and pharmaceuticals set out by the national forum. It said that public financing without deductibles or co-payment is the only reasonable way to promote universal access and to control costs of prescription drugs. We are surprised that the forum's extensive research in this area is not referred to in the committee's discussion for prescription drugs.
The Deputy Chairman: Thank you, Ms Keon. I notice in your report that you refer to Dr. Nuala Kenny. She was a witness in Halifax and she made a strong case for some of the points that you made.
Corporal Michael Gallagher, Drug Section, Miramichi Police Force: I am here today to speak about the problem we are facing in Miramichi with prescription drug abuse. We have seen a dramatic increase in crime, specifically, violent crime, home invasions, armed robberies and frauds, directly related to the abuse of the prescription drug Dilaudid. Following Dilaudid, morphine is the second most abused drug.
The Miramichi Police Force has joined our community to form a committee to look at this problem and to what we can do to stop the problem. We have looked closely at the medical system in the province of New Brunswick. We found there are problems with the system that we would ask that the federal government look at and perhaps implement policy for the provinces to monitor prescription drugs.
In New Brunswick, a patient can go to a doctor and be prescribed powerful pain medications that are similar to heroin in their makeup. They are morphine based. The addiction qualities are similar to heroin, and the trauma to the body and the need to get a fix is similar to heron. We have a very serious problem.
A person can see a family doctor and get a prescription for Dilaudid, get the prescription filled and then sell it for enormous profits. An eight-milligram Dilaudid is sold in Miramichi for $30, and I am told that in Fredericton they are being sold for $40. People are abusing the system.
There is no record of these drugs or who has them. The only record the doctor will have in his office is the bill he sends to medicare for payment. This only states that the patient visited the doctor on such and such a date. The pharmacist will have something in their database, but it is not shared with any other pharmacies.
We ask that the federal government assist the provincial government. We will approach them as a committee made up of doctors, pharmacists, youth care workers and addiction services people. As a committee, we try to implement a program to monitor these drugs to ensure that they do not end up on the street and cause the chaos that they are causing in Miramichi. I understand in Maine they have a similar problem. However, this problem is not limited to Eastern Canada and Eastern U.S.
Senator Robertson: The last testimony shocks me. I did not realize it was out of control like that. Are you doing something about it with the physicians and the pharmacists right now, or are you only working toward a model for the province?
Cpl. Gallagher: We are working toward a model for the province. On the committee we have incorporated the physicians and the pharmacists to put ideas down and try to come up with a feasible plan. We can then approach our provincial government with that plan to try to have it implemented.
Senator Robertson: What type of person gets this prescription? Is it a senior person or a younger person?
Cpl. Gallagher: Usually younger people are getting it. We did have one investigation last year where a person over the age of 60 saw eight different doctors in New Brunswick within a two-week period to get prescription drugs. I often laugh because we have some good actors in New Brunswick who can fool the doctors.
Senator Robertson: This is the first time that this problem has been brought to our attention. If it exists in New Brunswick, it must be going on in other provinces as well. The federal government would have a role in helping to structure something. There are many types of legislation that come into play. We are making progress in some areas, even respecting the privacy legislation that is necessary in some of these cases.
Keep up the good work and we will try to put a strong recommendation to the federal government on this particular issue. I did not know it was this bad.
Ms Keon, you want the integrated services, the pharmacare program and the community health program in addition to what we have now. The funds, even for what we do now in the hospital and the doctors' offices, are very scarce. Do you expect the federal government to pay for these, or help to pay for these? What type of financing are you recommending?
Ms Keon: One of the key issues is perhaps some redesign. The commission did speak to primary health reform and to some of the shifts or potential shifts in cost, if we are to have primary health reform in place.
I can speak from experience about these shortages. We are in a situation where we have a shortage of health care professionals, particularly physicians, and the timing is right to start to redesign the system so that we have a broader range of health professionals. That certainly has different cost implications.
Senator Robertson: I appreciate that, and the reconfiguration of the system runs through a lot of interventions that we have had. There are those that say to get the money out of redesigning of the current system and a better use of resources. There is another school of thought that asks if we cannot get it there, where do we get it?
The assumption is that the federal government will add more money to the pot. There is no guarantee of that. If the redistribution did not find the money for you that is needed for the other programs, then where would you recommend that we find additional money?
Ms Keon: It may mean that we have to increase our spending.
Senator Robertson: It is important that we understand that the reconfiguration may not do the trick. People do not want participation fees or something similar. You either pay through taxes or you pay through your own program when all else fails.
Ms Keon: I think that Canadians do value health.
Senator Robertson: Yes, they value it a lot. You can see that from the lineups all over the country.
Mr. Jackson, some of us are familiar with your concerns with the snowbirds. It is frustrating to know that your campaign has had few results in some areas. What can we do to help convince the federal government? How do you want the federal government to act and how can we help that?
Mr. Jackson: We have had meetings with the federal minister's office on different occasions over the years. We have gone back to the provinces because the federal government, in meetings that we have had with staff and the minister over the years, they will concur that the provinces are breaking the law, but they have bigger fish to fry and do not want to take a heavy club with the provinces and enforce this issue.
We have even been applauded for going after the provinces doing their job, but if they do not do their job, then it will all come down like dominoes and every province will be in the same situation. If it was not legislation we would not be going after it, but what we would ask of you is to try to save face.
Minister Rock will say that he does not want to upset the province and he wants to do it on a consultative process. All he has to do is say, "You are reporting to us every year and by the looks of it here you are not adhering to this section of the Canada Health Act and we had better sit down." The act says that the minister will consult with the provinces, and if he cannot get results from that, he can withhold transfer payments. However, it is discretionary in nature.
We would like to see the federal government take responsibility and enforce the section of the act, as they would if I was breaking the law. If I have a handgun that is not legal, I will be in jail and it is a criminal offence. They are letting the provinces away with it.
We have spent tens of thousands of dollars suing the provinces and trying to make this right. We knew when we took on those three provinces, the best we could hope for was a declaratory statement saying, "The province is not conforming to this section of the Canada Health Act, but I do not have anything to say about it and cannot do anything about it." However, they were not prepared to do that. Ontario is the only province where we have had success in all three areas.
Senator Robertson: That is interesting. If only the Minister of Finance would be as lenient with some of us when they start collecting taxes. The law is the law is the law.
Would it be helpful if this committee at some point asked Minister Rock and his staff to come before us and try to straighten this out?
Mr. Jackson: Certainly. Anything that you could do to bring it to their attention and to show them the importance of it would be helpful.
Many people have the misconception that because snowbirds travel and are away that they are not paying their taxes. The reason that I am a member of the Canadian Snowbird Association and have been on the board since the first month is that the Government of New Brunswick tried in 1993 to change the maximum days out of country to 90, after which people would lose their medicare. When you lose your medicare, you have lost everything. You can pay a few thousand dollars for supplementary insurance, but if medicare does not pay, then your supplementary insurance will not pay because your medicare is your primary insurance.
Senator Robertson: We have heard from many seniors' associations in our wanderings around the country. It is a group of citizens that we have the greatest concern for. There are other groups, especially the children living in poverty and sick children, but our seniors have given so much to the country.
We know the burden that a lack of pharmacare is presenting to many of our citizens. We will continue to work very hard to make a difference.
In our province and all provinces across the country, we have a large number of unpaid informal caregivers, and they often hold the family together. Most times, it is a member of a family who gives up work or gives up many things to care for another member of the family, usually a senior. The wages paid to the other caregivers who are reimbursed for something are very small.
Have you any suggestion how we could perhaps ease the burden of the unpaid informal caregiver in the home? Right now they are not recognized, except with a good pat on the shoulder. Could we better direct some of the monies spent to give them encouragement? I refer to a program a few years ago where the federal government had financial help for families who wanted to add a granny apartment. I do not know if that is still going on or not. Have you ever thought of trying to get some help for these caregivers who are not remunerated at all?
Ms Eileen Malone, Member, New Brunswick Senior Citizens Federation Inc.: No. There are tax deductions, perhaps, of some method, but there is no compensation at the moment.
Senator Robertson: Could you take that question back to your association?
Ms Malone: We certainly will.
The Deputy Chairman: Is there a ministry in New Brunswick responsible for seniors that you directly work with?
Ms Malone: The Minister of Health also takes on the state of the seniors.
The Deputy Chairman: There is no specific designation?
Ms Malone: No. We also lack an advisory council, as they have in other provinces.
Senator Callbeck: Corporal Gallagher, are prescription drugs a bigger problem in the Miramichi than other parts of New Brunswick?
Cpl. Gallagher: No, I do not believe so. However, Miramichi is unique in that we do not see a problem with crack and we do not see a problem with heroin. It is not readily available. Prescription drugs are available and there is a large supply of them.
We also have a problem with other people shipping in their prescription pills. There are suppliers shipping in from Bathurst, Fredericton, Saint John and Shediac areas. I have talked to the other drug sections around the province. They have been focussing on the problems that they see as bigger problems such as crack cocaine. However, they do have a problem with prescription drugs.
Senator Callbeck: This been a big problem for a while; is that correct?
Cpl. Gallagher: No, not to my knowledge. I have been in drugs for nine years and I did not see this problem until two years ago. I would not know what Dilaudid was two years ago. It has caught on quickly.
For the user, it is attractive because for the first time they really know what they will get. The heroin or cocaine that they used before was always cut with other things. Dilaudid is government approved. They feel good using it. Many younger people are getting into it because they feel it cannot be dangerous because it is a prescription pill. This makes the problem that much worse.
Senator Callbeck: Have you talked to any other areas in Canada that are having this problem?
Cpl. Gallagher: No, I have not. I have talked to some people in B.C. about their pharmacare project with the pharmacies and some doctors' offices linked on a database to monitor the amount of prescription pills and who is issuing the pills. Those are the only people I have spoken to.
Mr. Jackson: We had meetings in Ontario with the Canadian Association of Chain Drug Stores and also with the Ontario Medical Association on these issues. There are problems across Canada with this. We had meetings less than three weeks ago with both organizations in regard to privacy and what can be done.
Senator Callbeck: Ms Keon, assume that there has to be increased spending for home care and prescription drugs. Do you feel that Canadians would be in agreement to pay more income tax for this?
Ms Keon: After the redesign and after looking at all issues, if there were no other answers, then they would be in agreement because health is valued.
Senator Callbeck: Mr. Jackson, you mentioned about Canadians being able to take a six-month drug supply out of the country and the time limit regulation changed from six months. What are you looking for there in that time regulation?
Mr. Jackson: Prior to 1990, every province in Canada allowed their residents to be absent from the province up to eight months. Today, there are very few people who would be away up to eight months. In 1990 the provinces changed it to six months. Newfoundland did not change, so they still allow eight months.
Quebec allows 21 days as many times as you want after you have been out of the country for six months. We convinced Ontario to change what they did. They gave an extra month, so you have to be physically present in Ontario for 153 days, but it is not restricted to Canada.
In Alberta and British Columbia, we were able to convince them that it is not right to be restricted to their provincial boundaries. They are saying, "You guys are getting over the hill or you are almost ready to die, and you had not better leave the province and go see your grandkids or what have you or we will take your medicare away from you." We were able to get Saskatchewan, Alberta and B.C. to change their regulation to state that you have to be physically present in Canada for six months out of the year after having been away for the six months, as long as you can prove you are a resident of that province.
We had what we call letters of comfort from Prince Edward Island, Alberta, who has since changed the regulations, Saskatchewan and Manitoba, stating that medicare was never intended to restrict travel within Canada. We had a meeting in Manitoba just a couple of weeks ago with the minister, and he said: "That is not a letter of comfort. If a minister gave you that, then it is policy." We are only trying to get those governments to change.
There should be no restriction to travel within Canada for a Canadian citizen. We are promoting mobility, free trade and global economies, but we want to keep everybody home. That is not right.
The very least you could expect is that people should be free to travel in this country. There was never a problem with the eight-month timeframe because few people would do that or abuse that. If they have gone away for their six months, I can go on for great lengths of the value of that.
The most money I spend all winter is the money I send back to Canada in taxes. Even though I am not here, we are paying for infrastructure and things that we are not using. Nobody is complaining about that. There should be some flexibility.
No province is really enforcing this, but if there was a catastrophic situation with somebody's health and they ran up a big bill and the province has that regulation that says you cannot be out of the province over six months, then you have to squeal on yourself because you have to sign a form like an affidavit swearing this is the truth. The regulations could deny you the claim. That is right.
Senator Callbeck: Is there any province where you can get your prescriptions filled for six months before you go away?
Mr. Jackson: Yes, in Ontario. The reason we have had more success in Ontario is that we have a larger membership base, Ontario being the largest province in Canada, and they were not concerned about the dispensing fee. What they said was, "Okay, we will allow you a 100-day supply." They have changed their regulations to say this. You can access the second 100-day supply if you are going away. That is not a problem.
There are other provinces that do allow the person to take prescription drugs with them. New Brunswick, for instance, talks about a seniors' drug program. The only seniors' drug program that we have is for people on a guaranteed income supplement. Anybody else has to provide his or her own program.
Through our Blue Cross in New Brunswick you can access that second 100-day supply. You pay for it and they will reimburse you later. Manitoba will do the same thing. Every province has a little variation. There are some that are still sticking to the time limit out of the province and the prescription drug situation. We do not mean drugs like morphine and drugs like that. You will not give anybody a six-month supply of that.
I found out last year from a personal experience how important this is. I had what they call atrium fibrillation. I was in the hospital, and I had been taking Cumidin, which is a blood thinner, rat poison. I was on it for two months and my cardiologist said I could stop taking it. Four or five days later I had another attack of atrium fibrillation, not related to being off the Cumidin, and I was in the hospital for another nine days.
I was in there four days before my heart went back to a normal rhythm. They kept me in the hospital for another five days to get my blood down to a therapeutic level, and I said, "Why? It was at a therapeutic level. I just had it for two months right up until four or five days before I came in the hospital."The nurse told me that if you are without that drug for three days you have lost all the benefit it has gained. I am sure there are other drugs that work in the same way.
As Ontario said, "It makes good health sense to allow people to take the drugs with them that they have to have for their diabetes or heart or whatever."
Senator Callbeck: Your priority is to do more research on women. What particular areas of research will you focus on?
Ms Malone: Many of the research projects that have already been done, have been done on working men 40 to 60 years old. There is very little research done on senior women and the possibility of prevention of cancers and osteoporosis through various programs, for example, mobile clinics.
The University of New Brunswick is doing some research, and I work with St. Thomas on a research program that has both men and women. We are hoping that there will be more research to give us some indicators of the prevention of health conditions. We are finding that people are living longer and going back to work in their second phase of life, volunteering, and keeping active and healthy.
The Deputy Chairman: Corporal Gallagher, we have had people across the country speak on thi issue, and sometimes it is to address different problems. Your problem is the abuse of a prescription drug. There are other areas in the country where people are over-prescribed because they go to doctors and they get confused about what they will be taking.
An idea has been advanced by several witnesses that involves having, for lack of a better term, a health smart card that people would carry like they carry their social insurance number. It would have certain health information that would protect them. They could decide what kind of information was on there, but it would prevent people from going to four different doctors and four different sites and six different drug stores and getting prescriptions filled.
Has your police force looked into that model? There are examples in the United States where they have used that smart card process. Would that be of assistance to you in your work?
Cpl. Gallagher: Yes, it definitely would. We went public with this problem approximately two months ago. Since that time, we have had a public meeting in Miramichi and we have formed a committee. The committee met once this past week, and that idea was brought up at the meeting. It will be researched by some members of the committee and brought back to the table in two weeks' time for a report. It does look like a very good plan.
We also encourage continuing education for the doctors who prescribe these powerful narcotics. We have some people in the rural parts of the province who have been in practice for some time and perhaps do not know the seriousness of these drugs. With the smart card and some education, I think we can make a difference.
The Deputy Chairman: Mr. Jackson, in addition to the coverage, or lack of it, that is provided by some provinces, what is the average that a snowbird has to pay when they do not have other insurance such as Blue Cross? What is the average amount that you pay over and above?
Mr. Jackson: It depends on their age and health. The insurance program that we endorse has three levels: standard, preferred and preferred plus. The preferred plus is the cheapest. It would range anywhere from $1,000 to $15,000. Those people could afford it, and if they cannot afford it, they cannot go. That is my concern.
The things that I am arguing for on behalf of this association I could probably live without. If you have a government that will say, "You can only go out of the province 90 days or you lose your health care," it does not make any difference how much money you have. You are beat. The reason that I am arguing these points is for the people that cannot afford it. There are so many roadblocks.
When I was a young fellow there were only a handful of people in my community that could go to Florida for the winter. They were the more affluent of our society. In the last few years, anybody could go and that was great. They should go wherever they want to go. The pendulum is now swinging the other way where it is getting to the point where it will just be the affluent that will be able to afford to go. That is unfortunate because it should not be that way.
There are many other things aside from what we are speaking about that do not amount to much when you have the overall picture, but it only takes the last nail in the coffin, so to speak.
There is the exchange on the dollar, your high cost of your out-of-country insurance and the low interest rates being paid, so people are finding it more difficult.
The Deputy Chairman: It is only the last two years that my mother, who is now 91, has been in a care facility. Before that, she had at least 15 years of high quality life and I am convinced it was because she went to Florida.
We appreciate each of you taking the time to let us have your views. We have had an avalanche of information, but we read this all of this material and we have good researchers who, if we happen to miss some of it, point it out to us. It will all make its way into our report and recommendations.
I would ask the next set of witnesses to come to the table. We have a couple of familiar faces here, including, from the Canadian Union of Public Employees in New Brunswick, Raymond Léger. I think we saw him yesterday. We have Mr. Rex Guy, who is the National President of the Federal Superannuates Association. I saw him at the annual meeting in Ottawa. I actually addressed that association. From the Union of New Brunswick Indians we have Wanda Paul Rose and Nelson Solomon, director of health. We have Roxanne Tarjan, director general of the Nurses Association of New Brunswick.
I would ask each of you to briefly introduce yourselves and then we will go straight to questions. I will start with Mr. Rex Guy from the Federal Superannuates.
Mr. Rex G. Guy, National President, Federal Superannuates National Association: Madam Chair, as you mentioned, we had the pleasure of listening to you at our triennial convention this August. I am pleased to report that the membership was very impressed with your presentation and with the important work that this committee is doing.
I am the national president of the Federal Superannuates National Association. With me is our research officer in health matters, Roger Heath. Also present, behind me, is the regional director for Nova Scotia with several members of the local branch, so we are here in a fair degree of strength.
The association, as you are aware, represents those retired from the public service of Canada, the Canadian Armed Forces and the Royal Canadian Mounted Police. We have more than 120,000 members across the country in 80 branches. We are vitally interested in the matters under discussion here. I do have a presentation for you, which you have told me I am not allowed to present, but we will stand by for questions when our turn comes.
The Deputy Chairman: I should point out that I know some of you people spend some time in Ottawa and we will be having further hearings there. Many of you may, in fact, be invited back.
Mr. Guy: I might add that we have presented the committee with a brief.
The Deputy Chairman: That is right. I will now turn to Mr. Solomon and Wanda Paul Rose from the Union of New Brunswick Indians.
Ms Wanda Paul Rose, Coordinator, Union of New Brunswick Indians: Honourable senators, the Union of New Brunswick Indians represents roughly 10,000 Aboriginal people from 14 Mi'kmaq and Maliseet First Nations. Aboriginal people of those First Nations living off reserve also come under the auspices of the Union of New Brunswick Indians. The New Brunswick First Nations represented are Eel Ground, Indian Island, Fort Folly, Kingsclear, St. Mary's, Eel River Bar, Bouctouche, Woodstock, Oromocto, Madawaska Maliseet, Pabineau and the Red Bank. UNBI also represents Lennox Island and Abegweit, which are the First Nations from Prince Edward Island.
The activities of the Union of New Brunswick Indians are directed by the chiefs of these 14 First Nations.
The Deputy Chairman: I will now turn to Roxanne Tarjan, director general of the Nurses Association of New Brunswick. Of course, we do have your brief, Roxanne.
Ms Roxanne Tarjan, Director General, Nurses Association of New Brunswick: The Nurses Association of New Brunswick welcomes this opportunity. As the executive director, I am here representing 8,700 nurses in the province of New Brunswick. We have submitted a brief. While we have a variety of opinions on the reorganization of the health care system for the future, we have focused on three areas: primary health care, funding, and nursing human resources. I am sure you will identify the details and address any areas in which you are interested. Thank you.
The Deputy Chairman: Dr. Margaret Dykeman, from the Faculty of Nursing, University of New Brunswick, also made an excellent presentation this morning.
Last but not least, we see a familiar face from yesterday, when were talking about Prince Edward Island. Today, it is New Brunswick. Mr. Léger, would you please proceed?
[Translation]
Mr. Raymond Léger, Research Representative, New Brunswick Government Employees Union: The head of the New Brunswick Government Employees Union, Ms Susan Barton, was called away to Ottawa on urgent business. It is interesting to note the number of women senators on this committee. It would be nice to have a better balance in the House of Commons.
The health care sector of the New Brunswick Government Employees Union represents primarily workers in hospitals and health care facilities as well as ambulance workers. In some regions, this service is provided by private operators. We also represent workers in a dozen or so facilities for persons with disabilities.
Briefly, our submission focusses primarily on hospitals and health care facilities where funding and service delivery problems have been identified. We continue to be deeply concerned about the direction these sectors have taken as a result of these problems. The same phenomenon has also been noted in long-term care facilities for seniors. The workload continues to increase in these sectors.
Because this public sector is overburdened, a lack of adequate care has been observed. For example, in the section of our brief dealing with long-term care for seniors, reference is made to studies conducted in the United States which show that patients receive a minimum of 3.5 hours of care per day in that country, as compared to only 2.5 hours of care per day in New Brunswick.
Compare this to the criteria used by the Department of Veterans Affairs. The federal government allocates funds to the province or to hospital corporations like the one in Moncton where in terms of funding, considerably more hours of care per patient are provided.
In conclusion, we point to the danger of privatizing facilities. For instance, it cost $20 more to feed a patient at the hospital in Saint John because this is a private facility. The cost is significantly lower in Moncton, because the hospital is a public facility.
[English]
Senator Cook: I have a question for Wanda Paul Rose or Mr. Solomon. I notice on page 4 of your brief, where you talk about education for Aboriginal people, you say, "Our people should be able to benefit from the federal millennium scholarship program and at present they are not." Would you share with us why that is?
Mr. Norville Getty, Consultant, Union of New Brunswick Indians: The current problem is that the people who qualify for millennium scholarships are those who have student loans, and the millennium scholarships are credited against their loans. Aboriginal people do not usually require student loans in order to attend school. Therefore, they are not considered for the millennium scholarships.
Senator Cook: Are you saying that the only people who are eligible to apply for the millennium scholarship program are those with existing student loans?
Mr. Getty: As I understand it, the people who qualify for millennium scholarships have received student loans and scholarship funds are usually credited against those.
Senator Cook: Existing student loans?
Mr. Getty: That is right.
Senator Cook: I find that astounding.
Senator Robertson: I did not know that. That is an interesting piece of information on our Aboriginal students.
I have another question, either for Mr. Solomon or you, sir. One of the recommendations of the Royal Commission on Aboriginal Peoples is to develop a strategy to deal with health concerns. Are we getting anywhere? Are we starting to make progress with the recommendations that came out of that commission?
Mr. Getty: My understanding, Senator Robertson, is that the only department of the federal government that is doing anything about the recommendations of the royal commission is the Department of Indian Affairs. The Department of Health has not really taken the issue to heart.
Senator Robertson: Thank you very much for that. I have one other question to either of you. How many of our younger native people in New Brunswick have been trained and are involved in the delivery of health care? I am speaking of doctors, nurses, nursing assistants, lab technicians, et cetera. Do you have an approximate number if you do not have exact data?
Mr. Nelson Solomon, Director of Health, Union of New Brunswick Indians: We have one doctor and probably about a half a dozen nurses.
Senator Robertson: Do you think that your communities would be better served if there were a higher percentage of trained young people working with their own people?
Mr. Solomon: Yes, they would.
Senator Robertson: Do the commission's recommendations give you any ideas on how to proceed? If you have not heard from Department of Health, I assume that they have not suggested anything. Would that be correct? It seems to me that would be a logical step forward.
Mr. Getty: I do not think the royal commission's report really dealt with that to any great degree. It dealt generally with improving education and some of the education issues, but it did not zero in on one particular profession or health category.
Senator Robertson: Mr. Léger, we have met with a number of CUPE people in the last year or so. I think I know your views rather well from reading different position papers. I want to ask you the same question I asked someone else from CUPE. There is an expanded list of health care services that you would like to see in the communities, as I understand it, including pharmacare, community health services and others. There was a list in one of the proposals that we received. How do you propose to pay for those additional services?
Mr. Léger: How to pay for them is certainly a problem, since in some areas, if we do not funnel in more money we are in danger of losing what we have. In our brief, probably for P.E.I. and New Brunswick, we are saying some of the direct patient care is being eroded, so there is a real danger there. We even quote one of the ministers of health from this province saying that one of the causes is new technology. If you buy an MRI or some other new technology, there is a capital cost, but there is also a cost to running all of that new machinery. Therefore, we feel that the extra money should be provided, and it is a question of priorities, particularly for the federal government. We think that they have to play a key role.
Now there are other examples, such as the one illustrated in the table in our brief. It shows that when New Brunswick lost money from the federal government, they continued to increase the overall budget for health. You will see that in some sectors, particularly hospitals and ambulances, it went up quite substantially, while in others, such as care of older people in nursing homes, the budget basically stayed the same. In fact, when you take inflation into account, it was reduced. Some provinces, because it was a priority, replaced the money that they lost from the federal government. It had no devastating effect. We think that the federal government could also funnel a little more money to health. At the same time, we are opposed to the tax cuts, for example, that are happening everywhere. We think that those are not good at a time when we need money for health in particular, because this is the priority of most Canadians. I think it is possible to achieve a balancing act by putting more money into health. At the same time, we think there are other areas of taxation where it is possible to raise those revenues. We do not suggest that we go into massive debt, but at the same time, there is a balancing act that is always possible to achieve if you set health as a priority. I think that health has to be the focus and the priority.
Senator Robertson: Well, given that there used to be a 50/50 sharing between the federal government and the provincial governments when we first started out, and it is now down to an average of 17 per cent, and in some provinces as low as 11 per cent, what role do you see for the federal government? Has your union asked for a fixed position on federal financing? What role should the federal government play?
Mr. Léger: Our union's recent position has not been for a return to fixed financing. We opposed its removal way back, but then it became sort of an impossible task to bring it back. Certainly, we are really concerned about some of the work coming out of the Canadian Institute for Health Information, putting everything in terms of 1992 dollars. When you look at that, there is either a decrease, or the same spending pretty well everywhere, be it on the federal side or the provincial side. That makes it impossible to do what needs to be done in health. There has to be a formula to keep increasing the budget to at least keep up with inflation, and also to cover the losses. You will see, in some of the tables we have done for P.E.I. and New Brunswick, when there are a few years with big losses, even though it increases after, it is hard to keep up the same services without new money.
Senator Robertson: Almost impossible.
I have one quick question for Roxanne Tarjan. With the need for greater integration of health professionals, where nurses will do more of the work that the family practice does now, and perhaps nursing assistants will do more of what you are doing, there is a firm belief that a different structure would help to relieve the shortage of staff in some ways. Has your association had any success in approaching these issues, for instance, with the medical association or the RNAs? Have you moved in that direction yet?
Ms Tarjan: That dialogue goes on continuously. There certainly is progress. I believe the motivation of all health care providers in the system is to ensure the quality and safety of care for the clients. I think that if you separate the issue of evolving scope of practice from the concepts and the principles on which the health care system will be organized, it loses its flavour. We believe strongly that we will not have a sustainable health system in Canada unless we adopt the principles of primary health care.
If I can build on the comments of the other witness about financing, there is a large body of research out there that supports the idea that unless we are ready to invest in a system that moves away from expert-centred, illness-focused care to client-centred, wellness-focused care that includes a comprehensive cadre of programs to address health promotion, wellness, and restorative and supportive care, we will not get there.
We read your information, and the Senate committee has done an enormous amount of work. It must be commended. We were concerned about the balance of the outcomes from the National Forum on Health. Canadians, whether they were ordinary citizens or experts, participated in that exercise. They validated the principles of the design of a health care delivery system in this country and expanded on them. It is based on that one principle of who we want to be as Canadians. We want to live in a society where everyone has equal access, irrespective of ability to pay. We always come up against this barrier of how will we pay for it. I do not believe we fully engaged the citizens of this country in talking about what it will cost us to achieve that, and then how that investment will bring benefits, reduce the need for high-cost health care services, and create healthier Canadians.
The Deputy Chairman: We have heard that statement from coast to coast. It does not really matter what province you are in, that summarizes the viewpoint of a lot of people.
Senator Cook: Mr. Solomon, I am looking at your brief here where you tell us that you represent roughly 10,000 Aboriginal people, and yet I hear that out of that population has come one doctor and several nurses. I am wondering if you could share with us what some of the barriers are. Is it just by choice, or are there systemic barriers, and if so, do you have any suggestions about how we might remove them?
Mr. Solomon: Yes, I believe the barriers begin in the high schools, where a lot of our native students are being pushed towards lesser achievements and away from health programs and sciences. Therefore, that creates a problem when they want to go to university. They are lacking the courses needed to get in. Once they graduate from high school, they have to go back, if they are interested in those professions, and take their sciences and whatever. I think it is at our school level where a lot of our kids are just herded through lower achievements. How do we solve that problem? I do not know.
Senator Callbeck: It is unfortunate we are running into time constraints here, as we certainly would like to have heard your presentations. I just had a few minutes to briefly look through your briefs.
Mr. Guy, your first recommendation is "...governments promote informed participation by households and their organizations." Could you elaborate on that?
Mr. Guy: I would ask Mr. Heath to do that.
Mr. Roger Heath, Research and Communications Officer, Federal Superannuates National Association: The fourth report of the committee defines the health care system as including hospitals, doctors, and things that the government pays for. As has been pointed out, 30 per cent of the health care money comes from private individuals or their insurance programs. We remind the committee that the other 70 per cent also comes from households, through taxes. Most householders I have talked to are not too interested in whether it is federal or provincial taxes, although that seems to get an awful lot of attention. The point is that householders are not only important because they actually spend more than the federal government does; they are important because they participate in their care and they have to be brought into the discussion about their care. Households not only include the individuals, but associations such as ours, the pharmacists who supply us with drugs, and the insurance companies and employers who provide our health insurance and play a big role in population health issues. A lot of that kind of service is delivered from the workplace.
The recommendation says that if you want a national health program, you have to include all this expertise and experience in it.
The provincial and federal governments do not let this part of the economy, of the population, participate when policy is actually being made. Then our other three recommendations, which Mr. Guy might want to review, are all from the point of view of one health system for all Canadians. It includes some parts of the system that are run by the government and some parts that are paid for by the private sector. Once you recognize that we will pay taxes, we will pay money for purchases, then it does not matter who pays what. What matters is what is most efficient and most equitable. When you look at it that way, a lot of things change.
Senator Callbeck: Going back to that first recommendation, you are saying, "...recommends that governments promote informed participation$" How do you recommend governments do that?
Mr. Heath: First, by allowing some of the groups like those that have appeared before you today to take part in the forums where actual policy is made. Second, we would recommend that perhaps the government could arrange for community college or university part-time courses so that representatives from these associations could get up to speed and be able to press their point of view, which is different, I think, from that of government administrators, but with some of the background that the administrators possess. If all we can do is think about it one week out of a year because a committee such as this is doing yet another study, we will not have the knowledge and the ability to really understand the issues and make the contribution we should be making, which the system really needs.
Senator Callbeck: Ms Tarjan, I notice a sentence in the nurses' brief that says, "The Federal Government must show leadership and assist in the coordination of efforts to deal with the shortage of registered nurses." What would you suggest they do?
Ms Tarjan: We have focused our recommendations. There is a national advisory committee. Now there is a nursing sector study on which, I assume as we speak, the signatories are signing on to proceed. That will be a very extensive, two-year process. Significant research has been completed in our own country.
From a nursing profession perspective, we already have the evidence for what works and what investments are required. It requires investment in education, continuing education, control of the workforce, and enough supports to ensure that these knowledge workers can provide the value of which they are capable to the system. We have been challenged over the last decade, as this shortage has evolved, with the assertion that we do not have evidence. It is all American evidence. Well, that is no longer the case. Research centres at McMaster and in Toronto are producing the Canadian evidence that demonstrates the same thing. Everything is so connected in the discussion of health care services and their financing.
To go back to the other witnesses' comments about costs, we nurses have been accused of saying that spending has been reduced. In actual fact, there has been increased spending in health care across the country. With the focus on reorganization and the costs of high-tech care, those high-cost interventions, and the lack of flexibility in financing the system, where have they been able to cut? They have looked at the delivery of service, reducing five beds on this unit, four on another, closing this one and combining service. That has created a work environment that is producing almost the sickest workforce in Canada and high levels of injury, even higher than people working on our docks, and it is because of the massive change.
We believe we have made the right moves in health care. We have to move care out into the community. We have to allow people to maintain the best quality of life they can for as long as they can. What has that done to our acute care system? We have been accused of saying people are sicker, that they were always sick. The acute system does not have a balance of some people who are almost recovered and ready to go home, some who are in the middle, and some who are acutely ill. We have them all here. Lengths of stay have shrunk so intensively. Therefore, a lot of our dialogue and debate on health care focuses on the acute care system.
We believe there are ways to manage that better. There will have to be an investment in improving the work environment. One of the biggest issues in recruiting and retaining nurses is, if it is not a reasonable place to work, where people can feel challenged, that they are contributing, and go home satisfied, why would a bright young man or woman consider that career?
If I could build on the other witness's comments when you asked how the federal government could do that, primary health care provides the model. Delivery of health services is reduced to a micro level. You have population-based discussion in communities, identification of needs, and services that are uniquely designed to meet them and that the community is prepared to support. I would say that when it responds to their needs, they are more willing to pay for it. The problems in our acute system will not be resolved until we invest in creating better health for Canadians. If we do not, we will continue to see increased costs.
My husband works for another department in government, Natural Resources. When it comes to the budget each year, we have this debate in our house that as health costs continue to grow, where does the money come? It comes from other departments. Health cannot grow that way. If the pattern continues, New Brunswick will be spending almost all its resources on it. It will be very difficult to create that change, but it is the only thing that will make a difference.
Senator Callbeck: I understand what you are saying about primary care reform. I just asked that question because I wanted to see exactly where you were coming from on it.
Mr. Solomon or Mr. Getty, in your first recommendation, I see a new tax on financial transactions. Are you referring to the "Tobin tax"?
Mr. Getty: Yes.
Senator Callbeck: I am reading here that it would not be difficult, but I have always understood that it would be. Do you have any information to back up the idea that it would be easy?
Mr. Getty: The only information we have is that financial transactions are tracked now. When shares are bought and sold, highly computerized systems keep track of all this stuff. Logically, it just does not seem that it would be very difficult to keep track of this and make sure that you are collecting the tax.
Senator Callbeck: I do not know the ins and outs, but I heard this brought up in another meeting, and it was shot down because it was said to be too difficult to track.
Mr. Getty: Well, the government intelligence services can track conversations. I do not see what would be so difficult about tracking financial transactions, especially when it is all computerized, and it is now.
Senator Léger: My only question is for Mr. Solomon. I was just reading a statement here: "There is no provision for our elders and traditional healers or spiritual leaders to assist in the healing process." Now we talked a lot this morning about extra-mural care. Do you have access? I imagine it exists throughout the province. Given your specialty, elders, language and your healing process, does a formula like that provide you with what you are supposed to have?
Mr. Solomon: Well, I believe elders are used in hospitals in B.C. and they have proven that they do assist the clients, who seem to improve faster. I know the elders are not used here at all. I did have a meeting with Region 3 here two weeks ago to try to hire a native liaison person who will work with the patients and maybe also with the language and everything else. At least it is a step.
Senator Léger: Right. It is a step, perhaps, in this extra-mural concept that we discussed this morning. In other words, it is older people who receive care at home. I wondered if you had that.
Mr. Solomon: We do. As a matter of fact, the Union of New Brunswick Indians is holding training programs for home care workers, and the Red Cross is providing the training for these people to go back to the communities and work with the elders. Yes, we have made a beginning. It started last year.
The Deputy Chairman: As a closing thought, we did hear from witnesses in British Columbia that the elders follow their clients through the hospital and health care system and then back into their communities in helping them deal with it.
With that, colleagues, I will have to bring the meeting to an end.
Mr. Guy, did you want to say one last, quick word?
Mr. Guy: One quick word, Madam Chair. To assuage my disappointment in not being able to make my presentation, may I file a copy of it with you? It is supplemental to our brief.
The Deputy Chairman: Actually, we had your brief. Yes, you certainly can. We will put it on the record. We have had your brief since early this morning, which was really good, because most of us did have a chance to read it.
Senator Robertson: On that point, all briefs will be given to the head of research and will be analyzed very carefully.
The Deputy Chairman: Thank you very much, on behalf of my fellow committee members, for appearing.
The committee adjourned.