Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 53 - Evidence
OTTAWA, Monday, May 6, 2002
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 9:00 a.m. to examine the state of the health care system in Canada.
Senator Michael Kirby (Chairman) in the Chair.
[English]
The Chairman: Senators, today we will begin hearings on volume 6 of our health care study. As most of you are aware, the study for the first five volumes began with some background material and some options; and then, in the volume we put out about two weeks ago, we outlined a series of principles for restructuring the hospital and doctor system in Canada.
We will hear from a panel of distinguished people from across the country, literally from one coast to the other, who will speak to two broad issues: development of a plan of action from the set of principles that we put forward; and, since we have made it clear that the health care system as we know it is fiscally unsustainable, their suggestions and thoughts, from a federal government point of view, as to how the additional funding can be injected into the system and the options for Canadians in helping to pay for improved health care.
Our first witness is Mr. Jack Davis, who is the Chief Executive Officer of the Calgary Health Region and former secretary to the cabinet in the Government of Alberta.
Mr. Jack Davis, CEO, Calgary Health Region: As a Western Canadian, I must say I feel I have achieved a certain status in life in appearing before this committee and I thank you for the opportunity to comment on health reform in Canada. As we all know, it is a hot topic these days, with a number of committees and commissions at both the provincial and federal levels reviewing the health care system, its sustainability, its future, et cetera. I will provide you with a quick overview of the major issues facing us and how best to approach them from my personal viewpoint, but also in terms of some of the discussions that are taking place in Alberta and in the Calgary Health Region.
We see three major issues facing the health system in Canada. The first is building a sustainable and predictable revenue stream. The Mazankowski report, recently tabled in Alberta, was the first major review to focus on cost containment and cost efficiency in the health care system and to put the revenue issue on the table. We need to get our heads around how to put together a revenue stream that is both sufficient and predictable.
The Mazankowski report, and our own thinking in Calgary and Alberta, is leading us to conclude that government cannot be the only answer. There need to be other revenue streams, and we are currently looking at what those options might be. That includes everything from an insurance-based system to different ways to raise revenue, and even whether we could potentially sell some of our services internationally by bringing patients to Canada or by providing services in other countries. We must be very innovative on the revenue side. That is not to say that governments should be allowed to abdicate their responsibility for coming up with a more acceptable way to provide funding and resources for health care in Canada. That touches on a very key issue.
We are committed to what we call ``spending smarter,'' which means continuing to look not only for efficiency gains, but also for productivity gains within the delivery system, and we think they are there. They may require some additional investment. There is much discussion about the electronic health record, master patient indexes and ways of using technology to improve productivity. However, we think there are still some opportunities in system organization and inter-regional and interprovincial collaboration that should be aggressively pursued, and we are committed to that. Spending smarter is a key component of our strategy as we move forward.
The final component is referred to as ``managing demand.'' This means working with the public on how to encourage Canadians to take more responsibility for their own health, focusing on wellness and the prevention of illness and disease. We think this is a tremendous opportunity, and we have not attacked this problem in an organized and coherent fashion. We have not yet provided the needed resources, but we are committed, in Calgary in particular, to moving forward aggressively in this area. This was the first recommendation of the Mazankowski report. It is a high priority in Alberta and I think we can really move forward on those recommendations.
I will speak later to the role of the federal government in this area, but we would certainly like to see the aggressive use of tax incentives to promote wellness behaviour on the part of Canadians. When we look at health care, we see that the ``sickness'' part of the system is almost completely funded or free to the user, whereas on the wellness side of the agenda it is almost the reverse. Individuals are responsible for all of the costs and there is very little government incentive to promote wellness behaviour. Those are three key areas.
The Chairman: That will be an interesting topic to come back to. Our next witness is Dr. Les Vertesi, Medical Director at Royal Columbian Hospital in Vancouver. Interestingly enough, his medical specialty is dealing with emergency rooms and services. Dr. Vertesi has written a book on the health care system that the committee found absolutely fascinating. It is not yet published, but he was kind enough to share it with the committee. We found that very helpful.
Dr. Les Vertesi, Medical Director, Royal Columbian Hospital: Ladies and gentlemen, thank you for the opportunity to appear before your committee. A few weeks ago, I had a discussion with one of my colleagues about the problems we were having with our health care system. Being an optimistic person, and having had a preview of the reports from this committee, I mentioned that, in just a few days, the next volume of the report of the Senate committee would be published and available and that it would have some interesting and useful information. However, his response surprised me. He said, `` Oh no, not another report from another committee on health care.'' Those words came with me to Ottawa and have troubled me.
On the whole, Canadians are tolerant and trusting. Some might think that perhaps they are a little too tolerant. However, Canadians are not stupid and they are tired of listening to the same arguments about health care. They are tired, I think, of listening to people who insist on turning a question of delivery of services into a battle between good and evil. They are also tired of listening to governments, and others, telling them what they think is good for them.
My impression is there is more at stake here than just our health care, as if that were not enough. The credibility of our own government and its institutions are also on the line.
As a physician, not only was I trained to make a diagnosis, but to look for clues before doing so. Our health care system is in trouble, that much is clear. I think only the most rigid diehards will continue to deny that. The problems with our health care system seem to be widespread throughout all the provinces, no matter what the political jurisdiction or institutions, or the resources with which we are dealing.
That tells me that whatever we are doing wrong, if anything at all, we are all doing it. As I do not think someone is deliberately trying to sabotage health care, what we are doing wrong is also something we think we are doing right.
That brings up a disturbing question: What if we are doing something that we think is right but is actually wrong, and it lies right within the principles of health care that we cherish so much? One of the questions we will have to face is what would we do if it became evident that one of the serious problems with our health care system lies within the very principles we have sworn to defend?
Many people ask me what role the federal government can legitimately play in health care, since health is a provincial jurisdiction. However, if it is true that one of the problems with health care lies within the core principles we have established for medicare, then who else but the federal government is in a position to identify that and do something about it?
I sincerely hope this meeting is not only about one more report on health care. Those disenchanted people out there who tend to vote with their feet and wallets will take care of themselves and their families by looking at private clinics or the United States if they have to, and they will eventually judge us. If we fail them, then we will be feeding that black market for health care services.
The fact is, regardless of how important we think the meeting here is today — and I believe it is important — the public is not exactly waiting with baited breath for our words of wisdom. We need to do something more than just generate another report. We need to do something that really counts, and I am here in Ottawa to help make that happen.
The Chairman: Next we have Graham Scott, a corporate lawyer. However, that is not why he is here today. He is here because of his background in health care. He is a former deputy minister of health in the Province of Ontario, and until very recently, was the chief executive officer of Cancer Care Ontario, which is the organization that links together all the cancer facilities in the province.
Mr. Graham Scott, Former Deputy Minister of Health, Province of Ontario: Honourable senators, I want to thank you for inviting me to participate in this event. I am very impressed with the quality of work of this committee to date, and while the most difficult decisions lie ahead, you have prepared a very solid base.
I support the three fundamental realities you set out in volume 5 and remain convinced that government can and must continue to be the single source of funds for essential health services and responsible for the establishment of health policy.
There is one thing I want to urge in your final report. I urge you to clarify and define the terminology around public and private participation in the future health system. Most Canadians want quality, affordable, accessible and efficient health care and, frankly, will not be concerned by the actual mix of for-profit and not-for-profit providers if they get it.
The public is completely confused by the lack of a clear differentiation between the private provision of health care within the publicly funded system and the private funding of components of current or future health care services. The committee will do a tremendous service to Canadians by clearly articulating the differences in the final report. This would also be an essential context for the committee's recommendations on the respective roles of public and private sector providers.
The best way to determine the potential of the private sector and help Canadians achieve their health goals within the public system is to avoid the strident and destructive debate that equates anything private with advocates who argue for a U.S.-style health care and sterile formulas for the ratio of for profit to not for profit within the system. Debate between the polar extremes prevents the examination of the potential role for the private sector within a public system. We must be prepared to examine where the creative use of the private sector will help Canadians achieve their societal health goals. Tired, inflexible absolutes on profit versus non-profit arguments may deny the public system valuable options.
The subject of sustainability often generates more heat than light, and much of this is due to the proposition that when you lack a reliable system of information, all opinions are equal. The health system currently requires more financial support, predictable funding and solid information. Funding is needed to help make up ground lost in the last decade, to address the required continuum of care through consistent and reasonable access, partially publicly fund home care and drugs and, of course, to develop effective information and management planning systems.
To become sustainable, the system requires more than additional funding. We are building on an outdated and unsustainable structure. We could accomplish a great deal more with a realignment of incentives within the system, something you noted in your report. Realignment of incentives, however, requires political courage in guiding both providers and purchasers through considerable change while ensuring predictable funding to support long-term planning and organization.
Between 1996 and 2000, in my practice with McMillan Binch, and together with my colleague, Maureen Quigley of Maureen Quigley and Associates, I was privileged to participate in mergers involving some 36 hospitals in Ontario. There were many lessons learned, and few are unique to Ontario. The crucial lesson for me was that hospital reform, on its own, can only have a limited impact if not matched with reforms to other parts of the system. There was no mandate to ensure that physicians, nurses and other professionals were positioned to work more effectively within reformed institutions. We do not even come close to making optimal use of the professional health talent we have in this country. The problems in primary care reform expose the often artificial but powerful limitations on effective use of our professionals.
With regard to how additional health funding may be raised, if we are to develop sources beyond general revenues, there is substantial merit in identifying specific funding methods in order to encourage accountability and transparency. Such new revenue sources should be focused on the specific needs of the system, and I would target health information systems as our greatest priority, as without it, and without some dedicated funding source, it is unlikely ever to be properly funded. Premiums and copayments are acceptable approaches, provided there are safeguards for individuals with lower incomes.
As to broader financing reforms, the utilization of the tax system, as proposed some years ago and revived this month in a different form by the C.D. Howe Institute, should merit special attention from the committee. It provides an effective approach to many of the issues in revenue generation. Finance ministries will not like it, and while we are on the subject of what they may not like, even an add-on to the GST might be a useful vehicle. It would certainly test people's commitment to spending on health care.
As to administration and management, in an ideal world, an arm's-length administration would be desirable. However, as it involves the expenditure of a large portion of provincial budgets, it is problematic to expect a provincial government to be comfortable with so much budget spending beyond ministerial control. However, the idea of specific authorities clearly focused on management of certain aspects of the system and reporting to the health minister has much to commend it. This can enhance both concentration of expertise and accountability.
Finally, there is little mystery involved in health reform. The challenge is one of change, and change is always threatening. We have many disparate and influential voices in health care, combined with very nervous Canadians who fear for their future. It will take political courage, federal-provincial cooperation, clarity and determination to bring about the needed reforms.
The example of your committee to date in working together to tackle this difficult issue provides encouragement that this just might happen. If it does, it will ensure that Canadians have quality, affordable and sustainable health care.
The Chairman: Our next speaker is Sister Nuala Kenny. In addition to being a member of a religious order, she is also a doctor and a professor of pediatrics at Dalhousie Medical School. She is the Chair of its Department of Bioethics and is also a former deputy minister of Health for the Province of Nova Scotia.
Dr. Nuala Kenny, Professor of Pediatrics and Chair, Department of Bioethics, Dalhousie University: Thank you for inviting me to participate today. Let tell you, first, of the lens through which all my comments today will be made, as it is the lens to which I am irrevocably committed. It is one through which I think the issue of Canadian health reform must be focused, and that is, the manifestation of Canadian values.
I want to summarize what has been a fair amount of work on my part, soon to be published, and which will be quite different from the perspective of Dr. Vertesi. I hope that, through the course of the day, we will have an opportunity to compare and contrast views, looking in a very respectful way at different interpretations of the issues before us.
The lens that I want to bring is really a summary statement of the values that have been incorporated into the development of Canadian health care until now. If we look at the history and get beneath much of the rhetoric about the principles of the Canada Health Act themselves being a manifestation of values, I have concluded that in fact there are four fundamental values that have shaped where we are today and which constitute the lens through which we need to look to the future.
The first value is that of solidarity, or collective responsibility. It has become clear that the Canadian approach to health need is that ``we are in this together.'' Health need has been seen as a particular kind of need that requires a collective responsibility, a kind of social solidarity that has been very powerful in our history.
The second value, aligned to that but distinct from it, is that Canadians have attributed particular importance to the value of fairness. Being fair has been extraordinarily important in our history. In health care, fairness is understood as equity, and what I now believe to be a unique Canadian conception of it. Canadians understand that, in health care, fairness, understood as equity, means treating persons the same but taking into account substantive differences.
We have in fact believed and understood that health need is a substantially different kind of need from other human needs. We have taken it into account by providing a collective response, with shared risk.
Those two values — solidarity and equity — have meant that in the arena of health need and response to it, we have understood that assumption of shared risk means that there will be a redistributive agenda. Of necessity, the people who are sicker — and the poorer who are sicker — will require resources from those who are wealthier and healthier in order to provide for their particular health need. I will return to that in my summary analysis of what I hope we will debate in detail today, because it becomes important.
The third value I want to emphasize is that of compassion. Canadians have always understood that in some way, this is not simply a collective responsibility for the sake of a kind of efficiency, but rather, mixed with our particular approach is an understanding that health need in all its complex forms — not simply acute health care — requires a certain kind of identification with those who suffer; that we have a sense, not just that they are sick, but of trying to get underneath what it must be like to be carrying that burden of illness, disease or disability.
Therefore we have solidarity, equity and compassion, and one final one I want to mention. I believe that what is at stake here — and you will see it in my specific comments on your report — is a different way of understanding the value of efficiency. I would suggest that equity is being challenged.
I give you great credit for the courage shown in volume 4 in stating upfront a different articulation of equity: That is, not whether we are being fair to the poor, but whether we should redistribute to be more fair to those who have resources. That is a fundamental question and we should address it head on.
Historically, we have valued a universal, single-payer accessible health care system because it has been more efficient. It has been more efficient precisely because government most efficiently delivers public goods, not market goods.
Of course our administrative costs, compared to any system that understands health care as a market good, show more efficiency. My point is that our understanding of efficiency is intimately related to the understanding that health care is not a market good like others; it is a public good. I then look at your report through that lens. There are a few points that I hope we will discuss in a very succinct fashion through the day.
First, I will say that your conclusion that the present system is unsustainable is problematic for me, not because I am a Pollyanna failing to understand the pressures, but rather because of the interpretation, which is that there are grave inefficiencies in our system. However, not all of the focus is placed on fixing the inefficiencies. You have done a very good job of focusing still on a single insurer and then attempting to look at ways to have a better mix of private-public delivery. I greatly appreciate that you are trying to focus on that because I agree completely that one of the things we have to do is spell out more specifically the distinction between public-private payer-insurer, and public-private, for- profit, not-for-profit delivery. We must make those distinctions. I think you have begun to do that.
However, I will say that the inefficiencies rampant in our present system should always be our first focus before we engage in anything that may alter those fundamental values that I mentioned. I will speak now of one other, then I will list five comments.
It is not just true that every province in this country is under pressure; every health care system in the world is under pressure. Every mechanism, every combination of public-private, including mechanisms that are profoundly market based, are under stress, because the question of expectations is not a simple one. We are rooted in a most complex society that has medicalized every aspect of human life. We are rooted in a science and technology that can do wonders, but which then partly create an enormous cascade of requirements for further dependence on health care and health technology.
Our expectations of health science and technology and, therefore, a health system, are deeply rooted. Thus the question of rationing, of unavailability of essential services, is not a wartime question. Our decision-making issue is that we have an abundance of opportunities for earlier and earlier intervention in a wider range of diseases and conditions. We will always have to make choices about the best way to use resources. That is so for private insurance just as much as for public insurance.
The issues of expectations and inefficiencies are deeply rooted in the problem.
My comments on what will work and what will not work, and what I like in what you have done so far and what I think is problematic, can be summarized this way.
First, you need to be clear in volume 6 about the goal of your reforms. We need to be clear about the goal regarding the maintenance of universal access for the poor, or medically necessary services, or however that problematic distinction might be identified. What is the goal of cost containment? What is the goal in relation to quality and outcomes, and what is the goal of a different interpretation of equity or fairness? Are we now in a different place in Canadian society and do we need to rethink that? It is only when the goal is clear that I can answer the question of what will work or not work. I need to be more specific that way.
Next, I will say that your emphasis on a single funder is extraordinarily important to me. It is a highlight of your report and I commend you for it. The only hesitation I would voice is that it seems to be limited to the doctor and hospital system. We have yet to engage in that second set of reforms that were at the heart of the vision for Canadian medicare. However, I absolutely commend you for identifying the central importance of a single funder.
Your key concept of an unregulated monopoly is truly problematic for me. I believe you contradict yourselves in volume 5 by indicating quite clearly early on in the document that there is a huge range of people who provide private health care. Doctors and most hospitals deliver the system in an unregulated way, and then you talk about the insurer and provider roles being the same. I do not understand what you are talking about. I did not understand it when I saw it in the Mazankowski report, and I have not seen it in a very extensive review of the literature on health systems over the last year and one-half.
Incentives are important. I would ask that we look at hospitals in detail. Global funding is a cost-containment mechanism. The movement to separate out functions, which I know we will discuss in detail, seems to me to be a formula for providing specific boutique-type interventions rapidly and efficiently, while real sickness and complicated patient care is being potentially put at risk. We need to address that question. I agree completely with the incentives around physician care, and I would commend you for the essential place you give to primary care reform and the absolute need to rethink scope of practice. I would say, if anything, you have not identified deeply and strongly enough how problematic that will be. This is a fundamental question in the reform of the system, and I believe it is far more at the level of philosophy and power sharing than it is at the level of remuneration, though remuneration and incentive become important.
Finally, on the issue of gaps in the system and the proposals that you have looked at here, I believe that national pharmacare and home care programs should be incorporated into our coverage. When you look at competition, you are into a market mechanism that does not serve health care well, except in the case of clear, designated specific services that can be delivered almost on a conveyor belt. Complex care requires integration, not competition.
With the greatest of respect, I wonder whether any of you looked at the question of competition from the perspective of any place other than downtown Toronto. To answer the question of competing and buying and fund holding, and from whom you are going to buy it and who is going to provide it most efficiently, please visit me in the Maritimes.
Finally, I would emphasize your commitment to public involvement in future coverage issues. There will never be enough under any kind of plan for all persons to receive all potential health benefits. Decisions will always have to be made, and I have concluded that the process is the most important question, and the most difficult part of the process is to develop an educated public. The hype about health care, the benefits of new drugs and untested, improperly assessed technology is so great that a truly educated public and, at times, truly educated colleagues in medicine, can be hard to find. We have not appropriately assessed it. Public education becomes an important issue for a public policy such as health care.
I commend you greatly for your work. You are trying to do something different here. I am only cautious because in your commitment to a single funder, which I applaud, and in your attempt to look at mechanisms to make this work, you have a mix of things I love and things that, through the lens of solidarity, equity, compassion and efficiency, I have to stop and think about.
The Chairman: Our next speaker is Mr. Lozon, the President and Chief Executive Officer of St. Michael's Hospital in Toronto and a former deputy minister of health in the Province of Ontario.
Mr. Jeffrey Lozon, President and CEO, St. Michael's Hospital: I thank you for the opportunity to be here with you this morning. I am looking forward to our discussions, and particularly the interchange between committee members and colleague panellists. I expect there will be some differences of opinion on this side of the table, as there probably are on yours, but thank you nonetheless for the privilege of taking part.
Secondly, I congratulate you. When I appeared before your committee in Toronto, I congratulated you on the work that had been done to date, and I would echo that on the basis of volume 5. As I have said before, this should be required reading for all students of health administration. It provides a nice historical background and good international context, a clear description and some cogent recommendations for the future. You are on the right track.
My opening comments are delivered from two perspectives. One is about scope and timing, and the second is about content.
One of the difficulties in talking about health care reform is the question of scope. How deep should you go in your suggestions or recommendations for change? If you stay at too high a level, they become superficial platitudes that everyone can buy into, which means that they give no direction. If they become so in depth and detailed that people can pick them apart on the basis of it does fit here and it does not fit there, it becomes impossible to implement them. The committee will have to be careful in its specific recommendations in report no. 6 about how deep you want to go in stating your recommendations. You do not want to be platitudinous, but at the same time, you do not want them to be so detailed that they are only intelligible to people like us who have spent our lives in the system.
The second question of scope that I would caution the committee on is the breadth in your report. In volume 5, I saw proposed changes to the fee-for-service structure, an in-depth look at research, how funding is to be changed, concerns about health human resources, how is the health care system of the future to be organized in the right way, and how to make the necessary and important investments in information technology. I would encourage you to priorize what you have to do in your next report. The breadth that you have covered is, as I said, a good model for students of health administration. It is not necessarily the right model for governments that have to implement this and need to know where they should go, and where they should go first.
The second thing is, the next time you want to release a report, you should set a date and then change it 48 hours before, because every time you have a date, something untoward happens and no one pays any attention.
The Chairman: We should explain to our viewers that the options paper put out by the committee was due to be released on September 12, and the paper that we released on April 18 occurred three days after the unfortunate bombing of Canadian troops in Afghanistan.
Mr. Lozon: My second set of comments concerns the content of your report. These are high level, and I expect they will be fleshed out in the discussions. I refer specifically to principles 1 and 2, which talk about stability. As I indicated in my previous meeting with the committee, I am a strong proponent of an arm's-length agency in the provinces to deal with the issue of health care.
I know that this requires a leap of faith by provincial politicians, who are on the firing lines day in and day out; it requires a leap of faith by departments of finance, which worry about the money going outside their control — it requires a leap of faith on the part of many people. However, it is not something that has not been tried before because that is where our system started, particularly as it related to hospital and medical care. If people could have foreseen the situation in 2002 when they decided to make it a core function of the department, they might have rethought it.
I envisage a board of directors, appointed for five years, renewable for one year, with the responsibility for organizing and delivering the health services within the province. It would be supported by an expert staff, paid commensurate with their responsibilities. They would receive a multi-year funding commitment from the legislature. That multi-year funding commitment would go up or down on the basis of provincial revenue or a more complex formula — I will leave that to the mathematicians and statisticians.
Ministries of Health and Ministers of Health would not be sidelined in this particular activity. They would have responsibility for developing parameters for care guarantees. They would have important roles in continuing to look at health human resources and at how technology is introduced into the province. However, they would be out of the firing line, as best they can be, in terms of the day-to-day operation of the system.
Implementing reform of hospital funding and fee-for-service changes in a cogent, clear and timely fashion would be highly problematic the way the present system is set up. With respect to the previous panellist's comments, I think many of the inefficiencies in the health care system reside in the provincial ministries of health — not in how the ministries themselves operate, but in how they operate vis-à-vis the health care system.
The second principle I want to speak to relates to principles 5 and 14, one concerning technology and the other concerning health human resources. It also relates to the chapter on health care research in volume 5. These three areas are intensely intertwined with the future of academic health sciences centres in this country. Academic health sciences centres are where new technologies are most often introduced, where the bulk of health research funding is expended and where health human resources challenges are on the ground.
The committee might want to spend some time thinking about a national approach to the building and development of academic health sciences centres across this country. In that way, you can move closer to self-sufficiency in health human resources planning; you can have a more formalized locus for where technology is introduced; and it is consistent with the broad innovation agenda promoted by the federal government.
My last comment is with respect to principle 15, the electronic health record. As many of you know, I am the vice- chair of the Canada Health Infoway. I am not speaking on behalf of them, but I do know that the significant provisions that have been made already for Canada Health Infoway are only a first step in the creation of a pan- Canadian electronic health record.
Most experts estimate that the cost will be $4 billion to $6 billion. Presently, Canada Health Infoway has funding from the federal government of $500 million. It will take some time to do this. Notwithstanding the Auditor General's comments, I personally think the model is a good one. It provides for some nimbleness; it takes it away from the twisted world of federal-provincial relations, but it does not divorce it from the realities of the roles of the federal and provincial governments. Over time, it will allow us to put in place patient and provider registries and pharmacy and laboratory systems that we think are at the heart of the electronic health record.
I thank you for the privilege of addressing you this morning. I am looking forward to our discussions.
The Chairman: Our final speaker is Mr. Forget. He is both a former deputy minister and a former Minister of Health in the Province of Quebec. Some two years ago, he co-authored an outstanding book on options for health care reform in the Canadian context entitled, Who is the Master?
Mr. Claude Forget, Former Minister of Health, Province of Quebec: Thank you for your invitation to join in today's discussion. I join with the panellist who preceded me in congratulating you on a fine set of observations and recommendations. Your obvious care in looking into the facts of life of our health care system as well as the experience of other countries is a breath of fresh air. I heartily concur with many of the recommendations that you make.
In my brief remarks this morning, I would like to address, at least in my understanding, of where you are at in terms of the best way to approach implementation of this set of recommendations. I am drawn in particular to the collective title of all those reports, ``The Health of Canadians — The Federal Role,'' as an inspiration for at least the first two of my remarks.
Through your examination of the forces underlying the growth of health care costs in this country, you certainly lead one to the impression that the current system is not sustainable with its present level of funding and that something will have to be done. The present cash contribution by the federal government to the maintenance of the system is very substantial. However, at roughly 16 per cent of gross outlays by the provinces, it is not sufficient to give the federal government a role in transforming the system, beyond simply maintaining it.
There is a need to come to terms with the gap between the implicit promises of the system and the reality. This certainly requires, among other things, an increased commitment for an extended period of time. Very substantial additional sums of money will be needed to effect a transformation. I believe that most of this extra funding should come from the federal government in one way or another.
There is a stark choice for the federal government. It is between having an increased role in transforming the system, or maintaining its current, relatively modest, financial participation while looking at the interest, motivation and the political feasibility of maintaining that level over the long run. Should the federal government's choice be to increase its contribution, I believe that is the first prerequisite for addressing your recommendations with any hope of implementing them.
My second point is that increased funding by itself would not be a solution, which you and others easily recognize. For those who live the day-to-day reality of the health care system, there is a large political risk because of a lack of confidence that government promises of increased funding will be honoured, in any other way than in the breach, if push comes to shove from the economic perspective or if government priorities change. This has happened in the past and it has hurt the credibility of any attempt at reform and of the underlying health care system itself.
To strike a constructive note, I can envision Ottawa inviting the provinces to join it in the commitment of financial resources for the health care system, for example, by allocating the proceeds of earmarked taxes to an agency along the lines of that which Mr. Lozon was describing — an arm's-length agency for each province to which the federal and provincial governments would commit funds on a long-term, predictable basis, and in a way that would be transparent and accountable. We would know which funds are being funnelled where, and such an agency would, of course, be accountable for its use of those resources.
Transparency would be enhanced, and certainly we would have a basis for a legally enforceable claim if an arm's- length agency were the recipient of such a grant. We could envisage a legally binding contractual arrangement that would provide security consistent with planning for development and transformation, with some assurance that the rug will not be pulled from under the feet of those who are trying to change the system, or even maintain it.
Under such a system, Canadians would clearly know why they are paying more taxes than Americans. In a world of labour mobility across borders and free trade agreements, Canadians have become increasingly critical of and dubious about the weight of taxation. We all know that some of that weight is the direct result of our commitment to maintain a public health care system. However, that is an abstract notion. Most people cannot relate that abstract concept to the cheque they just wrote a few days ago at the end of April, which they feel is too much. Canadians believe that the government can do better with the huge amount of money that taxpayers are handing over each year.
The third point is that adding money, even secure sources of money, will probably not be enough to dispel the growing sense of failure of the system. Polls indicate Canadians believe that the system is no longer delivering on its promises.
Increasing resources over time may help to resolve some of the problems. The gap is created by the health system's implicit rate of growth, which some have estimated at 4 per cent per annum, and an average economic growth rate of 2 per cent. This gap can be bridged for a time by increasing public commitment, which I suggest we should do, but only for a time. Therefore, there is a need to tone down the health care rhetoric. There has been tremendous carelessness, in a moment of political euphoria, in describing the system as able to do everything for everyone, to the ultimate degree of perfection and availability. Even the current talk, which is not unjustified, of drug coverage and home care adds to the notion that, if only we make a final push, we can have 100 per cent coverage of everything. That is not true, as we know today, and has never been true. I submit that we have to recognize that it will never be a possibility, and perhaps it will never be desirable.
This has developed through a process of creeping health insurance coverage in this country, where we have been more concerned about supply-side driven expansion than with patient-oriented priorities. First we insured hospitals, then we insured doctors, and now we are talking about insuring drugs or providers of home care. In fact, we should look rather at insuring Canadians against health care risks.
Is that just a rhetorical point? No, it is not, because if you ask Canadians about their needs, they will recognize that they are not all equally important. They could envisage first-priority needs receiving 100 per cent coverage while lower- priority needs do not. At present, those either have 100 per cent coverage, by accident, or zero coverage. There seems to be a fanciful distinction between levels of coverage, for which there are at best only historical reasons. However, I am saying that the rhetoric has to be toned down to a realistic level by reassessing priorities. That is a painful and conceptually difficult process, and also politically dangerous. In my view, the role of the federal government is to help the provinces move jointly in this direction. I do not think any one of them can muster the courage to do it in isolation because of the political pitfalls of such a process.
The federal government, acting as the coordinator, could help the provinces to develop and harmonize an approach to the problem of redefining priorities. There is an urgent need for this — not that it would upset everything. I suppose the resulting pattern would match, in many ways, the existing system, but the rationale would be different and there would be significant differences. Certainly it would be easier to communicate to Canadians why certain items are covered and others are not. It would not be a reference to a system built over 50 years, but rather a current and relevant distinction.
If your recommendations are to be implemented, it is important to create an environment whereby health services managers are allowed to manage. Governments have helped to create a widespread notion, not entirely untrue, that the health system is not as well managed as it should be. It is a convenient excuse to restrain financing. It is sad, because the same government that said the health system is not well managed has not done much to improve it.
We have a health system that is unique in our economy. It is a mixture of a quasi-medieval guild system and a socialist command and control approach. I do not think you could find another example that mixes two systems so alien to good management. However, they coexist in the health system. As a result, health managers have almost no say over the crucial factors, which most managers anywhere else in the world and in other industries need to be effective. In most provinces, they have no say in the working conditions of the people with whom they work. They have nothing to say on the way capital equipment is made available or facilities are improved, because governments, right from the outset, have denied them the use of depreciation reserves, and they are judged on their use of inputs, as opposed to on the basis of what they produce. Therefore they have little incentive to be cost effective or cost conscious, and little incentive to buy the IT systems that would help answer those questions. Even if they knew the answers, it would do them precious little good in most cases, as this is not an argument that would improve the funding of their institutions.
Various recommendations you make in your report are pertinent to that. They certainly will help, but only if they are not another example of a top-down management command and control system. All our provinces have gone through several reforms that have, in most cases, changed nothing and are typical of the bureaucratic command and control reforms of the former countries of the Soviet bloc. They had reforms every five years and their economies went nowhere.
This is not the way to implement change. Let us make sure that in all the good intentions that are presently being debated, whether it is coverage of drugs or home care, both of which are quite desirable in themselves, we do not build additional silos. The management of health programs should be seamless. There should not be a question of disparity in coverage for the various resources that are complementary in delivering health services.
Bear in mind that one of the arguments in support of our health care system is the presence of a single funder, but we seem in practice to deny the raison d'être of the single funder because we put everything in separate boxes, watertight compartments that prevent good administration. Good management is a question of tradeoffs. Most of the time, you have to be able to choose A versus B, but if these are isolated through separate administrative structures and financial envelopes, it makes it very difficult, if not impossible, to do so.
In implementing recommendations, let us try not to build other boxes and other silos, because we have an abundance of them at the present.
The Chairman: We will now open the meeting to questions, comments and an interchange of dialogue between our panellists and members of the committee. I suggest that, since we are going to be here for most of the day, we group our discussion around particular themes.
For the next hour, we could focus on picking up the themes some of you raised, specifically with respect to patients. Let me just put a couple of issues on the table.
Mr. Davis suggested we ought to look at tax incentives on the wellness side to encourage people to do a better job of taking care of themselves. Mr. Forget raised the issue of limits on how much one can cover, even if one thinks for the moment of only the hospital and doctor system. The other side of the coin is, a number of organizations have commented that while our report talked about incentives for doctors, governments and institution administrators to change behaviour, we did not mention incentives for patients to change behaviour or use the system responsibly. That was because we could not think of any practical way to do that, but it could be useful if anyone has thoughts on that front.
Let us focus for the next hour on the patient-oriented issues and leave the organizational issues, and perhaps even funding issues, until later.
Senator LeBreton: Thank you very much for the excellent input this morning. That changed the focus of my questions.
Mr. Scott, you talked about incentives in the system and how there will have to be a lot of political courage. Mr. Forget talked about toning down the rhetoric in health care reform.
If we were starting with a clean page in trying to educate the public, so we could avoid this excessive rhetoric, how would you engage the public in this debate and get them focused as patients on the complexity and scope of this problem? What would you suggest we do in order to ensure that people are properly informed, that they are getting all the facts without getting caught up in the existing rhetoric?
Mr. Scott: I am glad you started with such a simple question. I have struggled with that, and I do not think there is a particularly easy answer.
In cancer care, for example, there are many very solid preventive activities in which people could engage. Getting their attention is difficult. On the other hand, there has been some considerable success with cutting smoking rates over the years. It takes something fairly spectacular to work.
The greatest problem I see — and I do not have the answer because I do not quite know how to get the public's attention — is dealing with the love affair between patients and their local hospitals, even though on issues such as critical mass their local hospital may be as much a threat to their health as an advantage. In attempting to talk about hospital rationalization or coordination of services, it does not seem to matter whether it is a sophisticated health science centre that has problems or a small rural hospital. How to get the message across that better health does not equate simply to bricks and mortar is a huge question.
As we look at the complexity of health care, where even large health science centres should arguably not be in some of the highly sophisticated businesses they are, it is a very difficult issue with which to come to grips. It is not aided by the fact that most hospital administrators, or politicians, as the case may be, do not want to get into the issue, as they see it as such a large mountain to climb. I am sorry that I do not have a nice, clean answer to that. I wish I did. It is just the kind of thing you have to keep pounding away at.
Dr. Kenny: Senator, I concluded with the issue of public education and anticipation. It is our issue. It is a citizens' issue. It is the primary question. How do we get Canadians to better understand what actually works and does not work in health care, and what ``works'' means when we are talking about interventions?
I would say that it is not unrelated. That is why the emphasis you have put on outcomes in your report is so important. I am not sure how the electronic health record is a fiscal tool, but as an educational tool, as a record of use of the system and an opportunity to analyze outcomes, it becomes an important part of the absolute requirement for information.
I would like to say two things. First, the challenge is how to educate people about the evidence of benefit from human health science and technology in a world where, whether we prohibit it or not, everyone receives direct-to- consumer advertising every night. You can see the skating grandmother with her new arthritis medication or the dancing Viagra man.
This issue is extraordinarily important because it means that, in the information age, we have a new kind of patient, one who comes for health care having surfed the Web. After 25 years in pediatric practice, you have parents coming in with reams of things from the Web. The quality is so variable. The opportunity to manipulate them with the ``one-only person in Houston who could save their baby'' is enormous. There is not only the range of information, and the inability to be clear about what is good and bad, but direct-to-consumer advertising is now influencing all of us.
Let us make it very clear. Advertising creates a need and then says, ``I have the answer.'' It is not about education, and it is creating an environment in which expectation about the health care system is a problematic and complex issue. It is deeply rooted in our dependence on science and technology in the 21st century and in the way in which information reaches citizens who then do or do not become patients.
Secondly, if we are to grapple with this significant issue, how do we help individuals understand what scientific evidence is? The headlines make it look as if we advance in such a way that today there is a disaster and tomorrow there is a cure, when in fact the physicians around the table will tell you advancement is decimal point by decimal point, showing that this is better than that. However, the expectations are phenomenal.
The flip side of the challenge is, health professionals, and particularly my own colleagues in medicine, tolerate variations in practice that are in fact quite frightening. They go to the fundamental nature of the responsibility of physicians to bring the best evidence to the value choice of the patient.
I think this issue, whether it is related to outcomes in general or primary health care reform, or the issue you will address in volume 6 of specialist utilization and reimbursement, goes to the heart of incentives that move us further from the good use of evidence as compared with finding ways to better educate the public. However, both professionals and the public are grappling with badly used information, and expectations about what can be accomplished by either medications or technology for which there is no evidence.
Mr. Lozon: I have several comments. First, I agree our expectations are higher than they have ever been. I think that is actually a good thing. We can do more than we have ever been able to do in the past. We all have increasing lifespans and increasing expectations of good health, some of which are attributed to the health care system, and a lot to our personal behaviour.
Generally, Canadians are a little more attentive to their behaviour than they were before Lalonde's report, ``A New Perspective on the Health of Canadians.'' It is a slow process.
However, I think high expectations are good. By the way, we cannot prevent them, even if we think they are bad.
We know a few things about patient incentives that do not work. We know that itemized statements issued by provincial ministries of health do not work. We do not know whether linking payment to service would actually help. We accept that as Canadians we will never do that, so I will move on.
Interestingly enough, ministries of finance have come to some conclusions on this one. Most recently released provincial budgets have increased taxes on cigarettes and alcohol. Presumably, they are doing one of two things: either helping us be more healthy or creating additional revenues. I will leave that to the committee to decide.
Public hearings that suggest that Canadians should get more from the health care system without understanding the costs are not helpful, which is part of the problem now.
We must accept that when we talk about ``adjusting'' consumer expectations, we are actually living in a world of ratcheted-up expectations that show no sign of abating. Frankly, that may be a good thing. Second, we are better educated and can do things in terms of information about health behaviours and medications that we could not in the past. That would be a very slow-change process. It will never happen as long as politicians say that we can give you everything that you need or want, and by the way, it will not cost you anything.
Mr. Forget: Very much in the same spirit, when is information useful to those for whom it is intended? First, it is only useful when they are attentive. If they do not pay attention, any amount of information you produce will have no impact.
Attention span varies from one problem to another. For instance, if we look at consumption patterns in this country, and most other Western countries, of red meat, sugar and tobacco, we see that dramatic changes have taken place over a long period of time. We do not quite understand how it happened. Certainly information was made available, and somehow it struck a chord. It would perhaps pay to study retrospectively what was so effective about the limited information available at the time compared to what is available on the Internet now. That was long before the Internet.
Patients become very attentive when they get sick, as do their families. Certainly, we have discovered that providing high-calibre information about treatment to patients and their families has been underplayed in the past, and it should play a much greater role in the future. It has a major impact.
There is another way, apart from being sick, in which people may pay attention. That is when the information is important in terms of decisions they must make. As Mr. Lozon said, if we say everything is free just for the asking, without limit, why trouble yourself with a lot of information? You can go with the publicity you have seen in a magazine and trust that the physician or the system will say, ``No, you do not really need that. It will be bad for you.''
However, nothing is ever so clear-cut. There are shades of grey. Studies of medical technologies often reveal cases where it is not so clear. I remember about 10 years ago, and Dr. Morin will know far more about this than I, a new contrast medium emerged that was very expensive. It was mostly for neurological work, I believe, and non-ionizing and so on. The indication seemed to be that it would reduce problems. A small percentage of people who were treated with the old contrast medium would become slightly nauseated, but not otherwise indisposed. There was no statistical evidence that there was any more severe problem. Some hospital systems in this country switched en masse to the new, more expensive contrast medium. You can say, ``Let us blame the consumer,'' but in this case, let us blame ourselves. We did not look at this very critically and say, ``Well, no, the small extra benefit is perhaps not worth the extra expense, or else let us charge a fee to the patient who insists on it use.''
There are other applications of this idea. There are tradeoffs when there are no life and death issues, or there is a little more inconvenience, a slightly increased risk of some mild adverse effect. Our system prohibits charging those who express a very strong preference not to endure the risk of being slightly nauseated. Is that right? This is a consumer incentive?
The information, while of no interest to the general public, would be of much interest to patients who are confronted with this choice. It places people in the position where they have to make a choice. If they do not have to make a choice, why should they bother their heads with all that information?
Dr. Vertesi: This is a very interesting question, and much of what I was going to say has been said, but I still have a few points to emphasize.
Educating the public is one of our most overstated, inflated expectations. First, the public is not uniform across Canada. We have rural and ethnic groups. We will always have special interest groups that we will never be able to educate or satisfy. No matter how small they are, the press will always give them prominence. The key here is not to try to educate all those people so they all come to a uniform consensus, but rather to ensure that the government is not paralyzed by what is going on in the public media.
Although public expectations are a factor, and I agree with Dr. Lozon that they are rising — as they should — it is because we really do have more to offer, and people should want more. It is not a buffet. It is not a situation where people can say, ``I think I will have this and I will have that.'' Sometimes it is portrayed that way. We allow people initial contact with the health care provider, usually a physician, and then things roll from there. The cost of that initial contact is not very great. The real costs are behind the scenes in what the physicians do. The real costs are in the hospitals, with the cancer care, heart surgery and so on. People do not choose these procedures because they have heard about them. Certainly if they do, the physician should be there to give them better advice. Here I would like to emphasize what Ms Kenny said. We should be targeting the variations in medical practice by the physicians. That is what really influences a great deal of the costs.
There is a common perception that people abuse emergency rooms. The scenario we use in lieu of the public abusing medical services is that they come to emergency too often and use hospital services too often. As someone who works in emergency, I have a lot of trouble with this allegation. The fact is that people who come to hospital emergencies but do not have anything seriously wrong do not consume significant resources. They are quickly identified and turned around. The ones who use significant resources, and plug up the system, are those who do require treatment in the eyes of the health care professionals. That is where the real problems are.
When I ask these people why they came to emergency, invariably they will give some reason that in fact does make sense if you follow their logic. Consider that they are in a crisis situation at the time. Imagine how you would feel with abdominal pain or something similar. This is not a time when people are apt to exhibit rational judgment about anything. No matter who you are, even a professional or someone who really knows a lot will not exhibit rational judgment at a time of panic or fear, especially when family is involved. The job of the hospital emergency department is to sort this out very quickly and identify whether something needs to be done. It is not the job of the patient to do that.
Secondly, we have created a new disadvantaged class out here. It used to be that the people who were not able to get health care were the poor, and we all identified that problem. In fact, the origins of the Canada Health Act were focused on poverty as a barrier to care. That is much less the case now. We have created a new class of disadvantaged, what I call the ``conscientiously vulnerable.'' It is the people who can be persuaded not to use a hospital's services or other legitimate services that they need, at least for access to information, out of guilt. This is exemplified by the lady I see in the middle of the night with chest pain. When I ask, ``How long have you had this chest pain,'' she responds, ``Well, I have had it for three days.'' ``Why did you not come in?'' ``Well, I did not want to bother you.'' In fact, she had a heart attack, and it would have been much simpler to treat her earlier. Now she has created not only a problem for herself, but also costs for my hospital. She has converted a relatively simple problem into a much more complicated one. She will go on to have a lot difficulties and it will cost a lot of money. We have created a class of people who are too conscientious to access the care they need when they need it.
I would like to emphasize also Dr. Lozon's comments about the targeting of education. We first need to target education to the physicians who control the majority of the resources that cost money, and second, to the public at the time they need that information. That is the time when they potentially can use it to the best advantage.
Mr. Davis: We are in danger, from time to time, of looking for a perfect solution in a very complex environment.
People do respond to incentives. We know this. The entire world, with the exception of the Canadian health care system, builds incentives into its operations. I think we do need to take a serious look at the use of incentives, especially in promoting healthy and lower-risk behaviours. There is a role for the federal government there because it controls the income tax system, and that system is one of the major ways to influence the behaviour of people and organizations. Governments have used it since the beginning of time in some very positive and very curious ways to encourage different types of behaviours. I would encourage you to continue to look at that.
When we talk about educating the public, we have to be careful not to do so in a paternalistic way. The public is being educated every day. Whether it is through the popular media, the Internet or some serious research, it is happening. The question is, what role do we want to have in educating the public?
One of the advantages of regionalized health delivery systems is that they have the ability and mandate to take on public education and information. Governments need to look at this where health systems are not fully regionalized, because it is more difficult for them to do it.
I ask the question: how many hospital systems or regionalized health systems see public education and public information as one of their major priorities? Again, most systems are grappling with delivery of illness care, managing hospitals and the so-called ``sickness system.'' We have to put a major effort into providing information to the public. It is not so much public ``education'' because you cannot tell people what is right or wrong and expect them to passively accept it; you have to create a situation where reliable information is available in a user-friendly way. It must have an interactive component and, as I say, it must be focused on credibility.
We are struggling a little with this issue in Canada. We are still of the belief that if the government puts out a bunch of brochures, that will somehow impact people. We have to get into the contemporary media and start talking to both children and adults in the same way as a variety of other sectors in the economy. We can lament the fact that all kinds of high-powered advertising are influencing people; we need to get into that game, although in a slightly different way.
We must be in the popular media, but we must establish ourselves as a credible source of information. We have to win that battle, and then people have to feel comfortable in coming to us for information on how to minimize unhealthy behaviours and how to access the system when they have an issue. It is very difficult right now to access us for information and direction. As Dr. Vertesi pointed out, during a medical crisis is not the best time to look for a rational way to interact with the system. However, even there, we make interaction with the system difficult from a user's perspective. There is much to be done. We have done a poor job because we have not seen it as a priority. We must get on with this expeditiously.
Senator Morin: I understand we are dealing with patient-oriented issues. I have a number of specific questions for the panel.
Mr. Davis, I was intrigued by your comment about tax incentives for the wellness agenda, as opposed to raising taxes on tobacco, for example. I was wondering whether you had any specific examples of that. Would we pay less income tax if we were not smoking? That is in intriguing idea.
This is for Mr. Forget and deals with the coverage of medicare services. If we could reduce the coverage of services, we could save resources. I read your recent paper with great interest and care. If I understand it, you are saying that we should remove coverage for those procedures or techniques that are not evidence based.
To that, I will say that most of the new cost drivers in our system are evidence based. We spend most of our money on the last half of our lives. With new drugs and new technologies coming out, there are more random clinical trials now than ever. Looking at the expenses, it is not so much that we are getting older as a society, but that we are introducing new procedures that were not available before. There are now more bypass surgeries and it has now been proven to be effective after 80. We never thought of doing that before. Another example is that renal dialysis has increased by 14 per cent in the last three years and costs $50,000 a year per patient.
Therefore, this is where the expense is incurred. There is certainly no reason to deprive elderly patients of procedures that we do on 40-year-olds. Mr. Forget used the example of a dye that is used in urological procedures, but this is relative rare.
This comment is to Ms Kenny and concerns the dissatisfaction of Canadians with our system. I think it is specific to Canada. Poll after poll has shown that Canadians are amongst those who are the most dissatisfied with their system. However, we have been classed 30th by the World Health Organization. France is number one, and all of the European countries are way up on the list. Generally, the Europeans, with the exception of the British — and even they do not reach our level of dissatisfaction — are satisfied with their health system. There is something wrong with our system.
Finally, I agree with Dr. Vertesi's comment that over-consumption of services by patients is a myth. A good definition of what is an emergency is what the patient thinks it is. There are very few patients who want to submit themselves to procedures and so forth. The problem is more under-consumption. You gave an excellent example of patients not going to emergency when they have chest pain because they have been told repeatedly that they are using precious resources and so forth.
Mr. Davis: We need to do more thinking in the whole area of incentives, both positive and negative. The current bundle of incentives for wellness is largely negative — higher prices for tobacco being the best example. You could imagine a situation where there were tax incentives related to the purchase of specific services that would promote wellness, such as fitness training and things of that nature. That is one area that needs to be looked at.
Why not take a more radical approach and imagine a system where individuals registered with the regional health authority, and if they met certain fitness or wellness targets, they would receive tax incentives. It makes perfect sense when you think about it. We take a lot of money away from people in order to fund the health care system to deal with them when they are sick. Why not put cash incentives back in their hands — not just to purchase services, but real cash back in their pockets — if they are meeting certain targets, whether cardiovascular or weight related? There are all kinds of good evidence out there as to what constitutes ``healthy'' and ``good health,'' but we have not spent much time focusing on that because we have been so preoccupied with the sickness side of the system.
In a publicly funded system organized the way we are, we probably have an opportunity to make progress in this area. We could even become the gold standard for the world in this particular area if we focus on it. It is exciting, but we are still having a difficult time getting the attention of governments in the area.
Dr. Vertesi: Perhaps I can make some comments that do not follow normal expectations, because it makes for a livelier discussion. We all talk about incentives. There are two reasons for incentives: one is to change the utilization of our health care services and the other is to prevent illness. We talked about utilization earlier so I want to spend time on the incentive to prevent illness.
We have to be clear on what it is we are trying to achieve when embarking on prevention.
There is no question that we can affect disease patterns through prevention, but does it save money? We assume that it does because, if we prevent a car accident, then we have saved money. I will suggest that prevention does not save any money, but it does change disease patterns.
As evidence, let us look at the last 20 years of preventive action, when we have had successful seat belt legislation, anti-smoking laws, child vaccination, public health, sanitation, laws against drunk driving, et cetera. Many of these laws and programs have been successful, but if they saved money, then we should be awash with money now. However, we are not; we have simply changed disease patterns. We have allowed a person who might have died in a car accident and to get a little older, so he might have a heart attack or be susceptible to cancer or to other problems of old age, which we know to be expensive. We improved life satisfaction and I would not argue against that. I am not saying that we should not practice prevention. However, I am saying that we should stop assuming that it saves money. It does not necessarily save any money at all.
Mr. Forget: Senator Morin raised a question about whether it is right to suggest linking coverage to the quality of a medical or surgical procedure. I believe his question suggests that most of what we do that generates costs springs from the utilization of well tested and evidence-based procedures. If that is the case, so much the better. However, I question that. I see much of what is occurring in our acute-care institutions, certainly those we call ``tertiary institutions'' or ``academic health centres.'' I also see what is happening in a number of other institutions, which do not have that function, in developing variations or improvements to established procedures in a very informal setting. The analogy that I draw in my text includes the rigorous methodology, adopted in most countries quite some time ago, whereby we test drugs before commercialization is allowed. We know this is an expensive process, but it is done rigorously, not only by the manufacturers, but also by the governments, who play an active role in monitoring the details of this limited testing.
Imagine if drugs developed in the way other components of the health care system have developed, such that a doctor who has a concept, or an association with a chemist, has found a new molecule and wants to try it because it might produce some good results. Thus, the doctor attends a medical convention and tells his associates what he has done and they are inspired to try it also. It is done informally. That is a conceivable scenario. If we did it this way, we could see rampant use of new, untested molecules or a variation on existing molecules, and we would have huge costs and many accidents. When it comes to developing variations on, or totally new, medical and surgical procedures, we go about it in a more leisurely way.
For example, and I may have told the committee this at a previous appearance, we have known about the use of stents in angioplasty procedures for some time. It is a tested procedure but, in the last two or three years, some surgeons have begun to use three stents instead of one or two. This use has become generalized at a considerable cost.
Is this a tested procedure? It would seem that the data we possess indicates that, of the 100 patients to whom three stents are applied at a total cost of $200,000, only three would be prevented from returning for remedial intervention. Let us put that at $5,000 per case that would be readmitted because one stent is insufficient. In effect, we have taken a decision, on cost-effectiveness terms, to spend $200,000 to save $15,000.
This has been done informally and the application has been widespread, not unlike wildfire. Even though we now have the test results and the evidence, the habit has formed, and it would be difficult to change it because this has become the accepted way of doing things.
We need far greater discipline in the introduction of new procedures through testing in an approved setting on a limited scale and, if indeed they prove to be not only good for the patient but also cost effective, then they might be generalized. Drug testing involves four phases. Phase one would not apply because it involves volunteers, and no one will undergo surgery on that basis. Phases two, three and four involve a rigorous, step-by-step widening of the circle of those who receive the treatment and are monitored for effectiveness. We need to do this.
In step with stronger discipline in the introduction of new procedures, there are other issues of procedures being used in an environment where, for example, for reasons of critical mass, they should not. That is all part of making available, far more widely than is needed, procedures that are not tested and proven to be effective. I have no problem with evidence-based medicine, but the problem is that by the time you get the evidence, the procedure has been applied widely and for a long time to thousands of individuals. It is the process of moving from the concept to an evidence- based result that occupies so much of the time, effort and energies of our tertiary care institutions. That process has to be looked at closely, not to prohibit anything, but to determine the conditions under which a public system will pay for the procedure. If those conditions are not met, and the physician can persuade patients that it is worth proceeding, in spite of having to pay and with no guarantee of evidence-based results, well, let them have it.
Dr. Kenny: I will respond to Senator Morin's comment about my perception of health systems worldwide. Mr. Forget is absolutely correct. There is an interesting paper, a classic on health policy, entitled, ``From `promising report' to `standard procedure': seven stages in the career of a medical innovation.'' It shows that over the last 10 to 15 years, we have moved from a ``promising report'' in a headline to claims that evidence-based medicine is essential. In philosophical terms, it is necessary but not sufficient. You still have to make a judgment on the evidence and the appropriateness. However, Mr. Forget is pointing out a remarkable discrepancy between the way in which drugs, for example, move through development to approval and widespread use as standard care, and procedures and technologies. It is an important issue.
With respect to Senator Morin's comments about my contention that Canada needs to understand that every health system worldwide is in crisis, you were either putting me in my place or chiding me; and I will give it right back to you. I actually need to say two things:
One is that Canada's drop to 30th overall in the World Health Organization ranking was due to the percentage of private money in our health care system. We still wound up either seventh or eighth in goal performance. It is problematic for the system as a whole.
Finally, on this issue of wellness incentives, et cetera, I believe the Mazankowski report did a good and important job of highlighting our need to focus on health and health maintenance.
Again, through the lens of those values I think are important, let us be clear that the wealthier are healthier, and poverty and illness will not simply disappear in lower socio-economic groups if we put our minds to it.
We have to be careful about what seems to make eminent sense when dealing with the complexity of the socio- economic determinants of health and well-being. I am fully behind the encouragement to accept responsibility for our health and well-being, but we need to recognize that the socio-economic status into which we are born is not something we choose or intellectually accept. It is more complex and problematic than that.
Mr. Lozon: Firstly, I agree with Mr. Forget. The system we use for drugs is not mirrored in other procedures. It is more of an innovative system for bringing things into the health care environment, much of which is not evidence based.
One aspect of incentives we have not talked about is the fee-for-service medical system. There is interesting work being done in the Province of Ontario on alternative funding plans for primary care physicians and practitioners. One view would be to incent the practitioner to do patient education as opposed to dialysis treatment, for example. There may be some merit in looking at a different type of physician payment system that provides incentives for education as opposed to treatment.
The Chairman: You are saying we should change the method by which general practitioners are compensated in the current fee-for-service system to something that rewards or pays for both preventive medicine and public education.
Did you say there are experiments ongoing in Ontario? I am looking to the other panellists for alternative ways of doing it elsewhere in the country. Are there any successes or results yet?
Mr. Lozon: It is too early.
The Chairman: Are there experiments going on in B.C., Alberta and Nova Scotia as well?
Mr. Davis: Actually the results are positive, but again, the issues around changing the culture and practice patterns make it difficult to implement some of these new strategies.
The Chairman: You mean changing culture among physicians?
Mr. Davis: Yes. Where that change has taken place, and we have one major project underway in Calgary, we have seen some very positive results. That is our strategy and direction going forward.
Dr. Vertesi: We also have some projects in British Columbia, and whether they are successful depends on whom you ask. Generally, the people in favour of them to begin with look for the positives. There is no question there are some successes, but this question has been around for a long time.
We think of the United States as a place where the system is all free enterprise, but of course that is not true. The United States has a huge variety of different systems, all somehow coexisting. Depending on where you look, there are many systems in the U.S. that have tried this and have done a lot of research on it.
Looking at the meta-analyses of these trials, the consensus seems to be that when you make this kind of change to the way doctors are paid, sometimes there are efficiencies to be gained. Sometimes, certain patients get better service. However, it does not seem that there are any overall cost savings. The costs turn out to be the approximately the same.
The Chairman: Are you saying that regardless of the method of compensation of physicians in the primary care sector, the costs are the same, but the health of the patients may be significantly different?
Dr. Vertesi: Yes, depending on the sub-population you are looking at. There are rural populations and populations of people where the rate of HIV is high, so you have to look at each separate group, as it is not ``one size fits all.''
The Chairman: There may be reasons for changing the system beyond merely saving money; you may actually change it to help patients.
Dr. Vertesi: At a meeting I attended recently, the registrar of the College of Physicians and Surgeons of British Columbia maybe put it best when he talked about looking at ways of influencing physicians' behaviour. He commented that no matter what, 75 per cent of physicians try to do a good job and 25 per cent try to find a way to milk the system. If you change the rules, you will still find that 25 per cent trying to milk the system.
The Chairman: As we go on in this series of hearings, we will move into areas of funding and getting new money into the system. Everyone seems to agree, in some form or another, that a variety of new funding methods, or at least new funds, will be required for a number of things, including health information systems and technology.
We will need to look at what is the most effective method of doing that, and pick up on Ms Kenny's point about the fairest and most equitable way for individuals to contribute more to the health care system in the Canadian context.
Four weeks from today, we are holding another special session, where we will question experts from a wide variety of perspectives on the funding question. We want to lay out all the alternatives.
The Chairman: I will now turn to Senator Robertson. For those who do not know, Senator Robertson, before being appointed to the Senate, was the Minister of Health in the Province of New Brunswick for many years.
Senator Robertson: With all these interesting people here, it is difficult to know where to start, because there are so many questions. We have expertise at the table of which one should take much advantage.
I think Mr. Lozon talked briefly about simplifying what we are doing so that the public can better understand.
My first question would be for all of you, but perhaps Mr. Lozon and Mr. Forget would start it off, as they mentioned these matters in their remarks.
The thrust of everyday politics has always been a curse. The issue is discussed under principle 2 in chapter 2 of the fifth report. I know it is regarded by several members of committee as one of the most important principles for us to look at.
I would like your views on the management of the health care system if it were transferred, as it was originally thought of, from current provincial health departments to provincial arm's-length agencies. How do we get around the political ramifications of that move, still keeping the political arm involved without having it interfere? It would be helpful to have a discussion on that issue.
We will have witnesses later in the week with whom I will also vigorously pursue this issue. It is frustrating. A government changes, and all the work goes down the drain, and then it gets back on track, and then the government changes again. It is a treadmill. It is wasteful and very frustrating for the patient.
I would like a further discussion on the public and private delivery of health care. The people with whom I speak on a regular basis do not seem to care how they get the medical services, as long as they get them. I would like to hear your thoughts on that.
We were off the patient-oriented issue, but one thing I really worry about is that given the way our system is structured now, we have almost removed the patients and their families from any involvement. We are ``warehousing,'' as we all know, whether it is seniors in special care homes or wherever. There is no encouragement for the family to become or to stay involved. To make a silly comparison, if I cook dinner for my family every night, it is a lot better for them because I am a good cook, but it is also cheaper than dragging them out for dinner every night. We seem to have removed the interest of the family in helping, and somehow I believe we have to get it back. To add to that question, do you know of any jurisdictions internationally that are doing this successfully?
Mr. Forget: With regard to the political ramifications of setting up an arm's-length agency, first, I wonder if there is not a danger of overstating the obstacles to doing this in the current context. As I observe the fate of health ministers, and even deputy ministers, these are very exposed positions, which probably explains the high turnover. It is not as gratifying, for some reason, as it used to be. There might even be some relief for the political class in taking a more arm's-length role. Now, that is only a thought. It may not be sufficient.
In your recommendations, you suggest splitting off the evaluation role from the responsibility for service delivery, and certainly that provides a good way of working into a contractual arrangement with such an arm's-length organization, with sanctions for non-performance that would be based on evidence of failure, and the ability to remove the people from their positions and try to find more effective office holders.
You need a framework of accountability. These are public monies. There is no doubt that politicians, or our political institutions, to put it more broadly, should not walk away from health and say we have settled the problem once and for all. We need a contract or a statutory set of obligations targeted to sensitivity to patients' concerns, and there are ways of ensuring this is monitored, measured and evaluated. A series of performance requirements would not be very different from the performance requirements that some institutions in this country have developed for themselves. Monitoring those regularly would provide a sufficient basis to pass judgment from time to time, annually or somewhat less frequently, as the need may be.
I think that the politicians could feel that they are in charge. They could always modify legislation that affects entitlements and so on. It is not beyond our imagination to devise a set of obligations, constraints and controls that, in essence, keep the politicians as the masters, but prevent the micro-management on a huge scale that we see today and the lack of continuity that is so damaging.
On the question of public and private delivery of health care, I assume that you really mean delivery as opposed to financing. My point about managers having space to manage would certainly apply to that. The question of doing something yourself or contracting someone to do it is a management issue. It does not raise any fundamental question of entitlement or fairness as it applies to categories of beneficiaries. It is just a question of what works best in one circumstance or another, and that should not be specified by the system, but left to managers to decide. That is one of the options they might have to choose. If they had the power to choose it, it would enhance their authority. By denying choice to managers, you reduce their role to that of executors and not real managers.
On the question of patient and family involvement, I do not see this as a problem in short acute care episodes. If the family exists, and sometimes, as we know, it does not, and there is an acute episode, unless it is a very strange family, it does get involved. It is a crisis, and is perceived as such. It is of short duration, which perhaps facilitates involvement, because after all, life goes on.
Long-term care is all too often an all-or-nothing proposition, and if it is institutional, then the family can easily lose interest, and if it is nothing, you can literally kill the family with the burden that they have to bear. There must be ways of blending this approach, and indeed there are. Home care, respite services and so on are all pertinent to this issue. However, I am not a specialist in this area.
The Chairman: I wonder if Mr. Lozon and Jack Davis, both of whom are managers, would care to respond to this point.
Mr. Lozon: I will try to frame my response in the context of Senator Robertson's questions.
When I talk about an arm's-length agency and the capacity to manage, that does not imply that the role of the Minister of Health in health policy is marginal or superfluous, particularly because in my scheme of things, the setting of provincial health goals would continue to reside with the ministers, who may have whatever processes they think are required to develop those goals.
In my opening remarks, I mentioned that a care guarantee could very well be the legitimate outcome of a minister's thinking about the matter. I am suggesting that the capacity of ministers to actually organize and deliver the health care system is marginal at best. They do not have the ability — I do not mean that individually but institutionally — to organize the system on a continuous, progressive basis or to reorganize the system, as may be required, based on a whole series of new demographic and technological imperatives.
A body such as an Ontario health services corporation or Ontario health services commission would be one possibility. One of the most cogent comments made during our period of intense restructuring, which was from 1996 to 1998, came from one of the elected politicians, who said that the government wore every change made by the Ontario Health Services Restructuring Commission, but they could never have made most of the changes themselves. Although that may seem somewhat contradictory, there is a very real set of constraints on elected officials.
One could see an Ontario Health Services Commission as the actual purchaser of a series of services from institutional or community-based providers. The government may end up being the evaluator of how well that system works and the long-term goal setter. That is some further elaboration around that issue.
There is no question in my mind that, over the last seven or eight years, as health care has become increasingly the most important issue facing Canadians, the natural inclination of governments is to get more involved. Their natural process is: If we have a problem with emergency department access, we will move in and manage that access; if we have problems with extensive waiting lists in cancer care, we will move in and manage the waiting list issue, et cetera.
Governments are reasonably blunt instruments, in that they can either fund or not fund; they can regulate or not regulate. However, they have neither the capacity nor, regrettably, the expertise to actually manage the system. Ultimately, they have choked the management of the system. I am not suggesting that the management of the system is totally pristine. Hospitals have budget overruns and sometimes do not manage their affairs; doctors may prescribe more than they are required to — those types of things occur. The fact is that there is not much management in the system, and it is declining. It is more government management, which is dictated or heavily influenced by departments of finance, premiers' offices or cabinet offices.
It is not an exaggeration to suggest that health care policy may actually be set in the premier's office, as opposed to in the office of the Minister of Health. The question is not whether the Minister of Health's office should set health care policy, but whether it should have a continuing role in the organization and management of the system.
The Chairman: If I look at the evolution of the federal Department of Transport over the last 25 years, when I first came here it ran airports, harbours and all kinds of things. Now the Department of Transport is essentially a policy department. Airports and harbours have been spun off, VIA Rail is now a separate Crown corporation and so on. The policy and safety controls rest with the Ministry of Transport, but none of the operational parts. Is that a correct analogy?
If I am right, in addition to ``letting the managers manage'' — which was the phrase 10 to 15 years ago — it would also mean a significant downsizing of the number of people in the provincial departments of health. You would not need them. Are both those conclusions correct?
Mr. Lozon: Yes. One of the real ironies of the system is that most of the expertise in the health care system is not in the ministries of health. Most of the expertise resides amongst the provider community, et cetera. In effect, you could create not only a smaller entity, but also a more expert one.
Senator Morin: I would be interested to hear the comments of Mr. Davis. Mr. Lozon is recommending an arm's- length board that would actually manage health care. Ontario does not have the regional authorities that some other provinces have. I do not think you are going down that avenue, and I know you believe that there is no evidence that regional authorities have increased the efficiency of the system. What about a province with regional authorities — I look forward to hearing what Mr. Davis has to say about that — where the authority and responsibility is actually decentralized? Do you still need a board of that type?
Mr. Lozon: I will let Mr. Davis answer that. You could, because — Alberta might not be the right example — in British Columbia, for example, patients could decide whether they wanted to go to the Vancouver Coastal Health Authority or the Fraser Health Authority, after considering questions of access, quality and that type of thing. A purchaser at a provincial level would purchase services from those particular regional authorities. One comment I would make about Ontario is that it would be much easier to set up regions if it were done by a provincial health authority rather than by the Minister of Health.
The Chairman: Since everyone is commenting on how regional authorities work, and since you run one of the biggest in the country, Mr. Davis, go ahead.
Mr. Davis: I agree with much of what Mr. Lozon has said, but with a couple of caveats. In Alberta in the early 1990s, when the government entered into its major restructuring under Premier Klein, it was part of a fundamental rethink of the role of government and it boiled down to some very straightforward, not too simple items. Government's role was seen to be that of legislating, setting policy, allocating resources, measuring performance and reporting to the public. Clearly, under those broad categories, the role of ministries of health is to set policy and standards. Mr. Lozon talked about health goals as a government responsibility.
However, government has to have some responsibility on the resource side, and this is where it gets a little tricky. While government has a role in the macro allocation of resources, in my view, it would be preferable to make the allocation decisions more systematic and organized and provide a buffer between that process and the government. To some extent, the population funding system in Alberta does provide for a more non-politicized way of allocating resources. I would not have a problem with some of the resources being allocated by an arm's-length commission or body, because that makes some sense. Measuring performance clearly should be done by an arm's length, credible organization.
The Chairman: Nationally?
Mr. Davis: It could be done nationally, regionally or provincially. The key is that it cannot be done politically. I do not think that is difficult to set up.
The Chairman: The only reason I have favoured a national one is that the cost to the smaller provinces of operating their own evaluation system would be a high, or it would be a poor evaluation. It seems to me that running it nationally would provide real economies of scale.
Mr. Davis: My 20-second comment is that I would be careful about setting up a national commission. I think a national ``virtual'' commission, drawing from the various regions, would make sense. You have to be careful not to create a system that is too big or bureaucratic.
Reporting to the public can be done through data from arm's-length organizations, but ultimately, it is the government that has to report. I would be careful about setting up a single, integrated commission to oversee the management, resource allocation and performance of the system. That has the potential to become a large, bureaucratic instrument — a political organization. These things have not generally worked well in the transportation area, or other areas where we tried to centralize everything in one regulatory body.
We do not want to inhibit local innovation and we do not want a situation whereby we have to consult with the commission on almost every decision. Eventually, because of the pressures in the health care system, the tendency would be to delegate upwardly. It is not just the fault of ministers and premiers; the system loves to give the problems of regional health authorities to the government and declare, ``These are your problems, not ours. Give us more money to do this and to do that and all will be fine.''
I would say that a regionalized system does give you more opportunity to manage and allocate your resources, pick priorities and move away from merely managing the sickness care side of the business, which is the most regulated side. I talked about communication, information to the public and wellness. There is much action in the non-regulated part of the health care community that needs to be integrated into and managed within the overall health care system. There is no easy answer, but generally, I believe that depoliticizing the day-to-day side of the system is crucial. There are several different approaches to that, although no one has the right balance entirely figured out. You could be breaking some new ground with your recommendations.
Mr. Scott: With this comment, I give up any possibility of ever claiming the role of ``philosopher king.''
I concur with Mr. Lozon's comments, notwithstanding my comments at the beginning, as long as it is clear that policy remains in the hands of the ministry. We would certainly be far better off at the provincial level, and I am heavily influenced by Ontario, of course. I believe it would lead to a much better operation in the medium term, and perhaps in a longer term of 10 years.
This is where I blow away all my claims to broad philosophical concepts. I want to do it because I do not believe there is a ``silver bullet'' for most of these situations. One of the ways to eliminate a mess is to come up with a new structure. That structure may, in 10 years' time, be another mess, so you revert to the structure you had 10 years earlier. That is the philosophy that is driving my thinking in this matter.
Mr. Lozon's description of Ontario is absolutely correct. Most of the very experienced people are outside the Ministry of Health, and I do not think this is unique to Ontario. If you look across the country, you see that there are extremely well paid professionals in the health care system. That level of pay is not reflected in the public service. Over the years, you encourage people to leave the public service to participate in other aspects of the system.
As far as I am concerned, that is unfortunate. Establishing a new administration would create an opportunity to correct some of these mistakes and develop a more coordinated approach.
Mr. Lozon referred to the former Health Services Restructuring Commission. It attracted some good people. It took a comprehensive view, because it was new and at arm's length. The problem was, and still is, that the ministry has not been geared to taking a comprehensive view because of its many sub-departments. While the people are high-quality, hard workers, there is no one pressure that pulls them together into a coordinated team to address the broad, interconnected aspects of health policy. For that reason, a strong case can be made that an arm's-length authority would make a great deal of sense in the current situation.
I will quickly deal with the other questions that Senator Robertson raised. I also believe there is no silver bullet as it relates to the public/private debate. To me, the only issue is to ensure that we do not close the door purely for philosophical reasons. I suspect that in many cases, the private option will be more relevant in the large centres and not at all relevant in the small centres. However, I do not want to prejudge. Rather, I want to keep that door open, so we can look at how a public system can ensure that every aspect is handled as efficiently as possible and that the money is spent as directly as possible on patient care.
As for patients' families, the real crisis is in the chronic care of patients with acute episodes of illness, of which cancer is probably the most common. Some useful experiments are underway in a number of the cancer centres in Ontario at the moment whereby the patient is assigned a dedicated nurse. That nurse is available to the patient and to the family, on a 24-hour basis, to provide options, advice, et cetera. However, the system is far from where it should be, and there is no question that we need to make a major investment in this area. A very sick patient with an unclear view of the treatment options can create other sick people in the same family because of the pressures. This issue needs to be addressed.
The Chairman: That intrigues me. Is there anyone who can talk to us about how that system could work? I am intrigued by the notion of a nurse dedicated to a particular patient on a 24-hour basis. Could you suggest the name of someone who could appear before the committee to tell us how that experiment is progressing?
Mr. Davis: We can give you some evidence on it, but it is still early. The best non-empirical evidence is the reaction of patients and their families when it works.
The Chairman: That is good evidence.
Senator Robertson: Mr. Scott, as we know, when an illness strikes a family, it is usually the female who takes on most of the work. She may often have been the second earner before the illness, especially in low-income and medium- income families.
Once the patient was professionally diagnosed, perhaps a federal program could help that person stay in the home. Would a small stipend help to compensate for the needed help that could allow the patient to remain at home for longer? That could make it possible for the family to be more involved with either the mother or another family member staying at home. A small stipend could provide some relief to such a family. Is there any possibility of that, rather than just bringing in a designated nurse who would still have to call to keep the family involved? It seems to me that would be an opportunity for real savings, but not at the expense of the health of the patient.
Dr. Vertesi: One of the fascinating things about health care is that it is almost impossible to stay on topic, because if you talk about one part, inevitably you will wind up somewhere else. That is natural, as these things are interrelated. It is like a chain of dominoes; if you push at one part, the effect will be felt elsewhere. This particular topic of why we are not operating at arm's length is an excellent example of that.
What Mr. Davis was saying about the role of government as the evaluator, designer and maintainer of overall objectives is correct. No one would disagree with that. Yet, there is an inherent conflict of interest in being the auditor and acting as a public advocate while managing the system itself.
Why does the obvious not happen? Why do governments not move to an arm's-length relationship, concentrate on what they are really set up to do and let the management be handled by someone with the expertise to do it? It is a great mystery.
I will suggest a reason, and it is my own theory. The present funding model for acute care is so labour intensive and requires much government management, because otherwise, the lid seems to want to come off. The government is sucked into micromanaging these affairs and cannot get out of it.
Why is that the case? It is largely because we are using an archaic funding model. I suggest that the global funding mechanisms that all of us use do not work, and that they are highly bureaucratically intensive. They are historically pegged, so change is almost impossible because you are looking at what happened last year. They cannot accommodate changes in population or management style.
This is a mouthful for governments to swallow. To move away from global budgets to a more service-based system will be a leap of faith because global budgets are designed to control costs.
What is the problem? Global budgets are effective in controlling costs only on a short-term basis. On a long-term basis, they lay the groundwork for many other problems. In fact, they are now consuming more money than ever.
However, in the short term, as soon as you abandon global budgeting, there will be an increase in utilization and cost. It is this short-term spectre of rising costs and the uncertainty about control that keep government in the micromanagement field, instead of in management, where they should be. We will have to get our heads around this. There are ways to control costs outside the global budget system, but they are not tested and governments are afraid to make that leap.
Dr. Kenny: I would like to return to Senator Robertson's comments about the family and incentives for their involvement, and the appropriate balance between family caregivers and professional caregivers.
Although, on this discussion about arm's-length control, I would like to say, after 10 years' experience of trying to help the Province of Nova Scotia as a deputy minister, you must indeed depoliticize it. This is not a criticism of politicians. I learned how difficult it is to be a morally good politician, because you are pulled at from every extreme position all the time. Good policy requires some kind of decision making in the middle ground.
I would like to return to the issues of incentive, support, family balance and questions about things such as the cancer model, which are back on the table.
If you look at the ethics literature dealing with health reform and negative consequences, generally in the English- speaking world, there is no question that health systems reform seems to have disproportionately increased the burden on women caregivers at home.
Any of us around the table involved in discussions in the last decade about provincial health reform know that one of the difficulties is that we tried both to contain costs and reform the system at the same time. Because we did not have the money to carry out reforms at the same time as we dealt with the fiscal crisis, we downsized faster and dumped patients onto home care when we had no support for the caregivers.
There is an extensive literature of ethical reflection around the question of what we have done to help the public understand these issues when we have placed burdens on them that create both fear and anger, as they seem to have been given tasks with which they thought someone was else was dealing.
This ``dumping'' that people perceive, when matched with the closure of small hospitals and their social meaning, has been a powerful force in the resistance of the public to seeing new things as possibly leading to improvements.
Your group should be able to say something very important about how we can rediscover the balance between familial and community caregivers and professional care givers, particularly given the consequences of hospitalization. How can we find a better balance between home care that is a follow-up to acute care and long-term care? People seem to think it is either/or; in fact, it is the two together.
Incentives would be appropriate in that area, even tax incentives, which I worry about in other areas. It seems we have no mechanism for family members, particularly women, to receive some kind of recompense for what becomes a significant emotional and financial burden.
The country has six centres of excellence in women's health. They published a report in the last year about the effects of privatization and health reform across the country on women and families.
I recommend it to you because it is important. It contains a number of examples of places where different things have been done to support the burden on the home of accepting different kinds of care, or where small projects such as the assignment of an individual nurse as a contact person has been tried. I absolutely agree that chronic illness, with acute exacerbations, is the real burden. Families, communities and parish groups are trying to offer long-term support, but with acute exacerbations that are very worrisome.
There is some evidence out there, and I would tell the Senate that this is an issue that I see as having been lost in many other areas.
If you people could bring this to the table, this is the kind of involvement of families, community and professionals that maybe will help us restore the balance. It is a major issue.
Senator Pépin: I agree with you on the issue of health care and women. The committee will have a special session on women and health care.
The Chairman: Senator Keon, in addition to being a member of the Senate, is also the Chief Executive Officer of the Ottawa Heart Institute.
Senator Keon: I would like to focus on several areas, in order to pick a couple of low-hanging fruits. I would like to point to a couple of areas where we might be able to make a real difference. I would very much like to have the comments of you all.
I will preface my questions with a few remarks. The two areas I will ask you to address are, first, a new generation of health professionals — and I emphasize a ``new generation'' of health professionals — and, second, the health ecosystem, which Mr. Lozon alluded to, and with which all of us have been involved for most of our lives.
I became convinced about 10 years ago that we cannot solve the problems in these two areas without regional health authorities. Also, we cannot have a single model of regional health authority in a province or in the country if we are to solve the problems.
Let us address the new generation of health professionals. You will all recall that a number of years ago, the federal government made a huge investment in the medical schools with so-called ``health resources money.'' I will never forget that, because I came back from America on that money, which built the Ottawa Heart Institute.
This really solved many problems at that time. It was a tremendous initiative and it allowed all of the medical schools across the country to grow and develop. It allowed places such as McMaster to grow from nothing. It could never have happened if that money had not come along.
We are now in a situation where we say we are short of doctors, nurses and technicians in this country. Every discipline that has come before us has emphasized its manpower needs. I believe there is a bigger problem. I think we have too many doctors doing what nurses should be doing. We have too many nurses doing what nursing assistants should be doing. We have too many technicians doing what clerks and administrators should be doing. There is a lack of proper integration and understanding between management, administration and delivery of services.
That is why, even though I believe there is room here now for a huge national — and I will emphasize ``national'' — federally funded initiative, we have to look at the regions and ask, ``What do we need in this region to deliver primary care, to deliver institutional care, to deliver hospital care, to deliver convalescent care, to deliver homecare, to deliver chronic care, and to deliver hospice care?'' Then we have to make the investment and try to provide the appropriate personnel.
I would like to hear all of your comments on this, whether you think this is reasonable or unreasonable, and how it could be done.
Mr. Scott: I will live dangerously and start off. You talk about a new generation of health professionals, and that does provide an opportunity for us. Today's health professional is more inclined to engage in teamwork and to take a fresh look. On the other hand, that is probably true of all new generations, but if we allow them to be influenced too much by the generation before them, we will not realize those potential opportunities.
As deputy minister in 1982, I launched a review of health professions in Ontario. We set this up with the obvious intention of expanding the number of health professional groups so that we did not have second-class professionals and first-class professionals. It seemed like a wonderful idea at the time.
It took 10 years to complete the review because of the intense lobbying that went on among the various groups as to whether they were going to be given a professional designation and their own legislation.
I only raise this to show that we have a monster out there. We have a very well-funded, well-organized and powerful monster in the form of each of these health professional organizations.
Senator Keon, you are right on target when you make reference to the problems. We are misusing people because of the incentives built around those health professions. It is interesting to see what happens in practical terms, how quickly those barriers break down when it makes financial sense.
Some years ago, when I was conducting the study in Northern Ontario on the use of emergencies, the doctors who were working together in groups, sharing funding and responsibility, were not only the happiest, they also wanted to know why we were not bringing in and training more nurse practitioners. They felt that specialty trained nurse practitioners — and I remember psychiatric skills was one area of interest in particular — could really supplement family practice in these rural and sometimes remote communities. Their enthusiasm was enormous.
You then go to another community, equally remote and equally rural, built around a small hospital where the doctors were not working together, and they talked about the threat of nurse practitioners, that if they were allowed, it would drive the family practitioners away.
In fact, depending on how they were funded, they were absolutely correct. Many of the existing fee schedules encourage doctors to ``dumb down'' their skills and, therefore, because they tend to be at the top of the professional food chain, others further down the system dumb down their skills.
When we talk about what kind of coverage we ought to have, about efficiency, about having time to talk to patients, if we want to help patients be better focused and help them with their problems, then we have to do something about the artificial protections that are in place. That is the kind of change I was referring to earlier. It is perfectly logical and there are ways to do it, but it is scary if you have been making your living on the margins of one of those protected areas.
The Chairman: I will ask a follow-up question. Is a change in legislation or regulations related to scope of practice required?
In other words, I understand it would be desirable to negotiate a solution to that problem. If a negotiated solution is not possible, how can it be done by force? ``Force'' may be a strong word. How can you do it other than through a negotiated solution?
Mr. Scott: The only way to do it independently of a negotiated solution is through legislation. Certainly in Ontario, and I think in a number of other provinces, the legislation exists.
The Chairman: You are referring to scope of practice legislation?
Mr. Scott: Scope of practice is included within the legislation.
The Chairman: Then that is the piece you have to change.
Mr. Scott: That is what you have to change, so perhaps an emphasis on the need for a re-examination of this, with the eventual threat of forced legislation, will persuade the parties to come to the table.
The Chairman: I ask because one of our principles deals explicitly with the need to change scope of practice.
Mr. Scott: It is intensely provincial, and it would be very hard to deal with on a purely national conference type basis.
Mr. Davis: On this huge issue, the senator is correct in what is implied by his question. One of the intriguing things about the Canadian health care system, the publicly funded system and the view that it is centrally managed, is that physicians are not centrally managed. They are largely individual players, and many of them form professional corporations and bill the government independently for their services. A large part of the system is outside what you would call the ``publicly managed'' portion.
The new health care workers want to be competitively remunerated in the context of the North American economy. Even though we do not want a market-based system, our manpower or ``person power'' wants to be paid at market rates within the North American economy. The large health care unions have driven much of the cost escalation in health care in the last few years. I would not exclude the provincial medical associations from that description — even though they are not comfortable with it — in driving governments to compensate them at as close to the North American market rate as possible. Most of the large health care unions have gotten into major standoffs with governments across the country over the last few years on quality of care issues, but also on compensation issues. Settlements are always something of a give-and-take process, and some of the politics involved in those settlements has not necessarily been in the best interests of productivity and patient care.
This is more than changing legislation, because we have changed legislation in Alberta. We have a lot of flexibility in the scope of practice legislation. There are many models throughout North America. I just had a look at the physician assistant model in Arizona the other day, and it is very interesting. These large unions and associations have a very strong role in influencing health care policy, and this will take more than a change in legislation. This will take a realignment of some incentives, a major reinvestment of money, some good thinking about what is the appropriate model, and a good deal of fortitude in moving towards it. If we are going have a system that is publicly funded and managed in an integrated way on the scale we want, this issue will have to be dealt with or we are just fooling ourselves.
Frankly, in terms of micro-management of the system, government takes second place to the large unions and professional associations that are exerting tremendous management control every day, sometimes for the right reasons, sometimes not.
The Chairman: The committee is concerned that if we, as we have said we will, end up recommending a specific means of raising additional money for the health care system, we would like to see it used to improve technology, to get the electronic patient record going, to do a variety of things that are of help to patients, and not simply swallowed up by changed fee schedules or contracts.
Mr. Davis: If we do move on some these initiatives, and we need to, they have to be financed and managed in a slightly different way from the global operating budgets of the regions and hospital systems.
Dr. Kenny: I was happy to hear Senator Keon say what he said. I am not happy it has to be said, but I am very glad that another very senior colleague in medicine is saying it. When I was making my initial remarks and applauding the focus that you folks have put on reform of primary care, I said, do not underestimate how difficult it is. While Dr. Keon was talking about the entire system in miniature, the issues we are dealing with in truly reforming primary care, not just primary physician practice, are the same.
I have three observations, because I have been researching the history of Canadian medicare and trying to write something on this.
The first is a very interesting historical observation, which really only struck me when I spent time studying the development of the system. Tommy Douglas was elected in Saskatchewan in 1944, the year I was born. I have markers for 1944, 1964 and 1984. God only knows what will happen in 2004, but the way that Canadian medicare moves forward is interesting.
If you look back to the beginning of the last century, you discover that organized medicine has not championed universal health care. There are only two periods in Canadian history when organized medicine — I do not mean individual doctors, but medicine speaking through the Canadian Medical Association or provincial associations — looked kindly on that development. They were both periods when doctors were at a disadvantage in terms of earnings. Of course, the Depression was the first occasion.
It has struck me as a profoundly serious issue for myself and my colleagues in medicine that in actual fact, the key players in getting patients into the system, discussing with them and their loved ones what is appropriate care and helping them make choices really seem to have had this historical reluctance. This is not unique to Canada. This is a generic physician issue. The folks who are central to getting you into the system and to what happens to you there have never really been comfortable with that system. It is what that masterly text on the Canadian health care system calls the ``founding bargain of Canadian health care.'' It was a universal system, but it was not fully socialized because we allowed this fee-for-service negotiation by doctors. We allowed doctors, in this otherwise single, unified system, to be entrepreneurs.
Secondly, if we look at this from a system perspective, there is actually a principle of Roman Catholic theology at work. It has to do with working towards justice issues for workers, and it is the principle of ``subsidiarity.'' Many of you know it, and it is adopted in many other ways, but it was initially enunciated in a theological justice context. It goes like this. A system works best when functions are performed at the lowest level of competence. When I say that, you think, ``Lowest level of competence? What are you saying?'' Think of it. It is the lowest level of competence. Health care violates that principle every day. I am right on with what Dr. Keon is saying if I am saying it clearly.
We have a mindset, even within the practice of health professions, that you have to keep going up before you get a competent opinion. Somehow or other, we have developed a system that reinforces this inappropriate utilization of time and talent that Senator Keon is talking about. I think it is a crucial issue at the heart of primary care reform.
I was chief at a children's hospital. People would come to the hospital because they did not want to see someone in the ER, with great respect to the ER folk, and they did not trust their own pediatrician back in their hometown. We have created a system that has pushed up expectations, but at the same time, we wind up with people not maximizing their talent and ability and not appropriately utilizing and respecting others.
The context I am trying to set here is that we have this historical anomaly in doctors' involvement. We have this founding bargain whereby they were both in and out of the system, yet they are key to it. We have a strange way of respecting talent and ability and we actually violate subsidiarity all the time. Then you look at why we cannot make a difference.
My final comment is that we are stuck now, because my colleagues in medicine are the most demoralized that I have ever seen them, and this coming year will be the 30th anniversary of my graduation from medical school. I am doing some grant-funded work on role modelling in the development of new doctors. Our faculty members are demoralized. They are tired, stressed and unhappy with medical practice. That is true not only in Canada; it is a generic problem.
The point I am making is that, while we are burdened, we seem incapable of getting out of this situation. This is not just a matter of financial incentive, though that is key; it is not just a matter of legally changing the scope of practice, though that is essential; it is about sharing power and authority in a different way, while at the same time trying to provide new ways to support physicians, who are at the strangest place I think they have ever been in history, with this fundamental ethical commitment to individuals and the practice of requiring whole teams of people to do the simplest thing with a patient.
I do not know how to summarize this in one line for you, but what Senator Keon just said about that kind of ``inside the system'' inefficiency goes deeper than a structural change can fix. However, it is key to some of our problems and our inability to move forward.
The Chairman: Would you say about nurses everything you have just said about your colleagues, that they are demoralized and so on?
Dr. Kenny: Yes. I have just supervised a graduate student who has done her master's thesis on the experience of moral distress of nurses in neonatal intensive care units. Neonatal intensive care units are very high-pressure places. You experience a huge degree of moral stress when you have to participate in something that is not right. It is not a moral dilemma or a conflict; it is an experience of distress. There is now an abundance of literature on nursing. Nurses have described what moral distress is. This is not just being demoralized; this is being distressed because their talents and abilities are not being well used in the system. It is a very serious issue.
Mr. Lozon: Most of us in the health care system do not know whether we are good or bad examples of subsidiarity. I am not sure whether I am living proof of a good or bad example. I have a couple of comments on Senator Keon's observation and then I have a challenge.
My first observation is that the health professionals in this country have been the single biggest contributors to the high quality of our health care system, and that the professional groups themselves may be one of the single biggest challenges to reforming it.
Second, I do hold out some hope. The face of medicine is changing. The incoming class at the University of Toronto is 52 per cent women. Some studies suggest that women are more inclined to work in a group practice as opposed to as a solo practitioner and more inclined to be members of a team than their predecessors — all of which are signs of something good to come. It makes the training environment a little more challenging, simply because they do not want to do the old type of training with 36 hours on the job and so on.
Turning to Mr. Davis's comment about competitive pay, we have a supply and demand mismatch right now. Physicians and nurses currently have a lot of leverage because demand is greater than the supply. That is quite true.
My final comment comes from my days as a deputy minister. I was never more disappointed than in the efforts made provincially and nationally to deal with health human resources. Governments were so far out of touch on this issue that they were not even in the same decade. They said, ``We have corrected the physician problem; we have the nursing problem just about licked.'' Nothing could be further from the truth. It is partly because there is no insight into what the new physicians and new nurses are looking for. Having said that, I have no idea how this relates to regionalization — and that is the challenge.
The Chairman: You mean that the human resources problem exists under any scenario, regardless of how things are structured, and it does not necessarily relate to regionalization?
Mr. Lozon: Exactly.
Senator Keon: I would like to respond to Mr. Lozon on that. I have known how he thinks for quite some time and I truly admire it. However, I am afraid that if we do convince the federal government to bankroll an infusion of health care personnel, we will get it wrong again. If we do get it wrong, it will be because we have not looked at the regions. The health care team needed to take care of North Bay is drastically different from the one needed to take care of Metro Toronto. North Bay is not a very good example, and maybe I should have said Mattawa, a smaller community. We have to get input from the grassroots, from the regions, as to what they need in the way of health professionals to deliver the services that are required.
Mr. Lozon: I would agree with that. That speaks to not so much provincial, national, regional — because those can be, although not necessarily, loaded terms — but to a need for integrated human resource planning. Right now, governments do it largely in isolation from employers, schools and professional groups. The Health Human Resources Advisory Committee has until now — maybe it has changed somewhat under its current chairman — largely been a committee of federal and provincial government officials and has not had input from the various nursing —
The Chairman: I am sorry to interrupt, but are you telling me that the health human resources intergovernmental committee did not include people who actually train the personnel, such as deans of medicine or of nursing?
Mr. Lozon: Correct.
The Chairman: Pardon my incredulity.
Mr. Lozon: It speaks to the need for more integrated processes, because there are two or three solitudes. It is important to have an integrated process that includes the academic health sciences centres, which are national resources, so that individuals trained at Dalhousie in Nova Scotia can work in Cape Breton or Saskatchewan or the lower mainland of British Columbia. There needs to an integrated human resource planning that brings all the players to the table.
The Chairman: On that score, and because he has been both a minister and a deputy minister, I would like to ask Mr. Forget a question. Given that we always get into this issue that education and training are provincial responsibilities, but people graduate from medical school or nursing school in one province and work in another, do you think it is feasible to have a national, not federal, plan? Should we look at how many doctors, nurses and technicians the country needs, as opposed to the needs of smaller provinces such as Nova Scotia and Newfoundland? I chose those two provinces because they are small but have sizeable medical schools. Is it possible to determine the national requirements and develop a national planning scheme?
Mr. Forget: I understand the implications of your question. Yes, it is possible to conduct a study and try to estimate the requirements. Manpower forecasting in any field and for any industry, especially an area such as health, which is experiencing a great deal of change in spite of the rigidities, is a very difficult exercise. I remember that 25 years ago, there was a massive, Canada-wide study of the training requirements for health professionals. It took years to complete. Everyone in the medical schools and the health facilities was canvassed. They tried to project the need for physicians by graduation time. If you are to increase enrolment in medical schools, as Dr. Morin said, you have to project 10 years into the future for the exercise to be at all useful, and no one knows how to do that well. The margin of error is such that it may not be worth the paper it is printed on, and that is the big problem. The sector is not unlike a medieval guild system, in the sense that it is rigid and does not permit you to move someone over from another, related profession when you find yourself in a deficit situation. This is arranged in rather tight compartments. The problems of overshooting and undershooting will always be with us. I have observed that there are empty training places, not perhaps for physicians, but certainly for nurses. In Quebec there are many available spots that are not being filled. Why is that?
This is not the world of 50 years ago, when there were only two basic career choices for young women — teaching and nursing. Now, there are plenty of other opportunities. When they read almost daily in the press that people working in emergency rooms are experiencing nervous breakdowns, they wonder why in the world, for a salary that is not very high compared with other sectors, people would engage in such an occupation where, according to some reports, they remain the underdogs. Working shifts and weekends is part of the job. What kind of lifestyle is that? I think we have a basic problem there. There is another problem that affects women working in the health system. The relationship between physicians and nurses in certain areas, departments and institutions has reached a state of total breakdown. This relationship was predicated on physicians being mostly male and nurses being mostly female. That reality has not totally changed, although new registrations in medical schools predict that the balance will be different 20 years from now. Currently, there are few male nurses — you can count them on the fingers of one hand in one institution.
The other problem still persists and is embedded in the culture of the profession. It is very hard to break that down. In the institution with which I am currently associated, we have had dramatic examples of that breakdown and surveys of the respective attitudes, which are lethal. If it came out in the open, people would be horrified at the lack of respect, and it goes both ways. There is a lack of respect from physicians for nurses and from nurses for physicians. They have a long list of motives and reasons why they withhold that respect.
All this exists and it will only change very slowly. A new piece of legislation is not the solution. Certainly, Ontario has gone through the process and the lobbying effort is intensive. About 30 years ago, Quebec went through a massive overhaul of its legislation. The problem with legislation on professional fields of practice is that it replaces an antiquated set of constraints with an updated set of constraints. The problem is the constraints, and the accompanying lack of flexibility in an industry or sector of activity. Therefore, flexibility should be at a premium. Everything is predicated on the basis of this antiquated way of looking at the roles of professions.
Look, for example, at the internal bylaws of the council of physicians for any major hospital. That is a medieval document because it consists almost entirely of issues of status. Status is important to all of us, I suppose; it is part of life. In this case, however, it is legislated status. I counted no fewer than 11 categories of status among the medical profession in one institution. Everything is defined in minute detail — category 10 is higher than category 9 because it has specific privileges. I cannot understand why, in the 21st century, we enshrine status. We want people to work as teams, but we have antiquated legislation and bylaws in which everything is solidified and the remuneration system singles out one member of the team.
It is a marvel that teams manage to work at all. Whether they like it or not, all these people have to work together, in most instances, and they manage to do it fairly well. However, there are cases of breakdown, and that is tragic because the patient suffers as a result. We tend to hide our faces and deny knowledge of this when it happens. That is why the difficulties are so great.
Even if a way could be found to eliminate the rigidity and positively encourage team-building and the lowering of barriers, de-emphasize status and eliminate changes in the remuneration system, this fight would be too big for any province to take on by itself. Imagine one provincial ministry making an arbitrary health care decision that is not followed in other provinces. The lobby groups would be asking why in one province and not in the others. It must be a coordinated effort because that is what makes ``the shoe hurt.''
Dr. Vertesi: I would like to add a few comments here. Senator Keon started by saying that too many doctors are doing what nurses should do, and nurses are doing what nurse's aides should be doing. I agree with that, and would add that too many people are doing what no one needs to do.
To a large extent, we are dealing with a natural human phenomenon, which is protecting our own turf — jobs, lifestyle and income. We will not change that. It is tempting to come in with a set of laws to level that out. I do not think it will work, even though it looks attractive, because when government tries to do that, it becomes itself the biggest target. It has the resources and the political vulnerabilities and it is the payer, et cetera. We are seeing lobbying directed at government. If government were removed, these groups would not know where to lobby.
The fee-for-service system was brought up, and yes, it is a problem, but it is also a mixed blessing. It has advantages and disadvantages. The biggest problem is not that it is used, but that the doctors were left to control what the remunerations were and where the money should go.
The best method of dealing with these issues that we talked about, instead of legislation, is probably market competition. The best method for dealing with the guild mentalities is simply to lower barriers and let the associations deal with real people making real choices. I do not suggest it will ever be a completely free market in Canada.
The other question has to do with regional input. I work in an area that has gone through several changes, and I have some thoughts about it. I am a manager as well as a physician, so I deal with both sides of the equation.
Regionalization offers many potential advantages. The emphasis is on the word ``potential.'' There are no real advantages unless other things fall into place. Flexibility of funding, management at arm's length from government, some manpower and so on, must be there.
Although there are many examples of regionalization out there, none is allowed to operate freely. Some of it comes down to the size of regions. Big regions have more clout, but the management is more difficult because part of the advantage of regions is you can get more personal — you know your people and build on those relationships. The way to break this down is to allow them to look at inter-facility issues and needs and make contracts and arrangements with physicians that break out of the fee-for-service mould.
For example, in my region we have begun using ``hospitalists.'' We are able to integrate the hospitalist programs. These doctors are not on fee for service and are paid to stay in the hospital. As they are a small group, their expertise can increase with time. We can expect an improvement in both service quality and efficiency.
The Chairman: Is the hospitalist a general practitioner who does not have a practice as we normally think of it, but is rather a full-time employee of the hospital?
Dr. Vertesi: That is correct. The work of the hospitalist is to manage the patients in the hospital, regardless of who the physicians are, and make sure that when patients are ready to move out of the hospital, the continuity of care is better maintained.
That is one example of an inter-facility program. Since all facilities are not the same — some are small, some are large, some have heart surgery programs and some have trauma while others do not — this lets us go beyond each hospital's individual interests.
Senator Keon: I do not want to create the impression that I think regionalization can solve all the problems, but I have seen the gaps. We cannot supply the health professionals that some of the regions need and we currently have no way of addressing this. We can send people through medical or nursing school or technical college, but we cannot get the right blend of people to supply the services.
The Chairman: We will recess for lunch until 1:00 p.m.
I want to ensure we cover two topics when we come back and before we adjourn at 3:30: What are some of the funding options you think would make sense for the federal government to introduce, given the fact we are committed to putting some options for raising additional federal funding on the table. Also, what conditions should be attached to that funding such that it ends up in the health care system.
The next question is what is the broader federal role, given the fact it is an issue of provincial jurisdiction? How does one exercise federal leadership, given the constitutional constraints?
The committee recessed.
Upon resuming at 1:00 p.m.
The Chairman: For the information of people watching on television, in Senator Callbeck's previous incarnation, she was Minister of Health and, subsequently, Premier of Prince Edward Island.
Senator Callbeck: I would like to ask about health care funding. As you know, this committee has concluded that the system is not financially sustainable without increased funding. Certainly, many other committees have come to the same conclusion, such as inquiries into health care in Alberta, Saskatchewan, Ontario and Quebec.
From the comments you made earlier, I think that all of you, except maybe Dr. Kenny, agree there should be increased funding. Assuming that, where are we going to get it?
There are all kinds of proposals on the table. The latest one was that of the C.D. Howe Institute, referred to by Mr. Scott, which indicated Canadians should pay a new tax based on the cost of their medical services for that year; that families with an income of $10,000 or less would not pay the tax; and that there would be a cap of 3 per cent of one's income.
I would like to hear your comments on the whole area of funding and particularly on the C.D. Howe Institute proposal.
Mr. Davis: The first point I would make is that we always frame this in terms of the system not being sustainable at the current funding levels, and I would agree with that. However, I would like to frame it differently and indicate that I think that the system is inexpensive right now. We need to reflect upon the notion that we have an expensive health care system. By most international standards, we do not. Certainly in comparison with the United States, where access and technology standards tend to be at the high end of their system, we are very inexpensive. It may be that we do not have enough money in the system. At the end of the day, you get what you pay for.
The belief that some magical efficiency will come along that will generate productivity levels in our health care system that are beyond anything that exists anywhere on this planet is naive and unrealistic.
As for where this additional money is to come from, as people say, there is only one payer. In Canada, the people who generally pay the freight are the middle class. Low-income Canadians do not pay for much in this country. We have a good safety net program that insulates them from most of the cost of programs and services.
The question is whether it will come through general income tax, through dedicated taxes, or through some attempt to link payment to utilization of the system.
There is one other option, which is whether we have some ability to use the system as a revenue generator. For example, could the Ottawa Heart Institute generate significant revenues for the system if it looked outside Canada and had a different business model? All of those things need to be looked at.
The notion that higher levels of income tax are required to pay for the system will not fly. There is a sense that Canadians do not want higher levels of taxation. They probably do not have enough faith in government to believe that that higher level of taxation will translate into improved access to health care services.
Dedicated taxes and revenues make sense. I would like to see an incentive in that package that focused on the wellness and health side of the agenda.
There is a lot to gain, although not perhaps in terms of savings to the health care system — I agree with my colleagues' comments on that — but in terms of increased productivity and the avoidance of pain and suffering and human misery, I think there is potential benefit.
To some extent, we are the victims of our own success. We are doing more and achieving more than ever before in the health care system. We are spending more money, but the results are there. It is not necessarily a bad thing. The discussion is about the right priority for those resources.
In terms of the dedicated tax and dedicated revenues, I would like to see some opportunity for those dedicated revenues, at least, to be raised and managed at the local level. I am always concerned that we look for provincial and national approaches to solutions. The framework needs to be national, and provincial, in some cases. However, we want to ensure that we do not block local innovation and flexibility with large bureaucratic enterprises, whether they are arm's length from government or government themselves. It is difficult for them to be nimble and responsive to the local community.
I think Canadians would pay dedicated taxes and would accept the raising of revenues at the local level, as long as they can see them going into health services and producing very tangible results such as improved access.
The Chairman: Would you give me some illustrative examples of revenue raised at the local level? In your opening statement, as I recall, you made an oblique observation that, for example, one could build a new institution and pay for it by having some portion of the procedures carried out there service people who did not live in Canada. Is that what you mean by raising revenue at the local level?
Mr. Davis: There is a combination of things we have not looked at. Again, as Canadians, we are generally happy to give away whatever we have of value. Sometimes we even ``buy the stamp,'' as we say. There are things that we have to start doing. We provide a great deal of training and expertise internationally. We should be charging for that.
The Chairman: In terms of training foreign doctors?
Mr. Davis: Foreign physicians, health care providers. They are in Canada all the time, learning from our expertise at very little or no cost, and that is often not reciprocated, especially south of the border.
There is a lot of opportunity to move into the wellness area. It is unregulated now. I know it is controversial, but I think there is a big opportunity in the area of wellness scanning and programming associated with wellness. There is a big opportunity to work with companies and corporations in the mental health area. We must move into some of those fields. We cannot leave all the revenue generation to the private sector. We have to start joint ventures and get into some of that action ourselves in order to raise revenue.
We need to look at some of the more complex areas. Clearly we have a superior system in terms of quality, so why would we not look at providing services to uninsured individuals, probably mostly Americans, in a way that would generate revenue both for our providers and for the publicly funded system? We need to get full cost recovery from our WCBs. We have largely allowed the insurance industry a free ride at the expense of publicly funded health care.
We need to have full cost recovery. If we are to run this thing more like a business, we have to shore up the revenue side. Most businesses, while they look at cost cutting, also look at revenue when they develop their future business plans. Our focus in health care has traditionally been on cost cutting, productivity gain and efficiencies. We must take a more balanced approach.
We may also have information that has the potential to generate revenue. We have to look at that again. We cannot be giving everything away. When you give something away, you sometimes send a message that it does not have much value, so why would people be interested in it?
We have to look at a range of things. There is a market for many of these products and services, and the credibility of regional health authorities and regional hospital systems that put their name on this information and these services gives us a competitive advantage. Whether we deliver something ourselves or through a joint venture, we need to look at the best business model for whatever location happens to be looking at the options, but they are there.
The Chairman: You are saying that in looking at some of the non-insured services, wellness services and so on, a fitness centre brought to you by the Ottawa Heart Institute would have greater credibility than some others?
Mr. Davis: Maybe not a fitness centre per se, but a full wellness work-up, including some high-end diagnostics, and then a referral to a group of fitness centre trainers who have been approved by the Ottawa Heart Institute. That kind of package is attractive. We know that kind of package is being sold now. Do we want to share in that revenue? Do we want the publicly funded health care system to benefit from that? We should only be raising revenue as a return on our capital investment to improve the system. We are not raising revenue for profit or for shareholders, but to benefit the public.
The Chairman: You are raising the revenue for reinvestment in the system, and therefore it would be important that it not go back to provincial coffers.
Dr. Vertesi: I agree with much of what Mr. Davis said, and in fact we have discussed some of this. We have to be careful not to use words such as ``profit,'' but rather words like ``surplus.'' That implies that it is not our money to keep. We reinvest it.
I agree we need more money in the system. I think almost everyone agrees with that. It is useful to look at extra money in two different sectors. One is money for capital investment, and the other is money targeted specifically for operations related to work done. We are under-capitalized in health care in Canada, and it is largely because in the public model, we are trying to cut back, and these are big expenses.
At the same time, we do not necessarily do a good job when we do invest capital. We still have a vacant building in Vancouver 10 years after it was built for Vancouver General Hospital. That was a huge amount of money.
The Chairman: Why is it not used?
Dr. Vertesi: Because once it was built, we went into a cost-cutting phase, and could not afford to staff and run it.
The Chairman: Ottawa once bought a machine that sat around in a crate because there was no money to operate it.
Dr. Vertesi: This is a huge eyesore in Vancouver. It is a testament to the fact that government does not always get these things right.
At any rate, the other problem with attracting capital is that the hospitals run on global budgeting, and global budgets never attract capital; service-based budgets do. For an example, I can cite the laboratory systems. In British Columbia, and perhaps it is the same in other provinces, we pay labs to provide the services, and therefore the government does not have to build all the labs. We attract a huge amount of outside money for building labs and operating the services. The government sets the rates and only pays for the services provided. Some private clinics are operating that way. Doctors' offices are an excellent example of a way that fee for service can attract outside capital to build facilities, and they can be operated independently. The services that government really wants and is willing to pay for are provided. We do not do this with hospitals, and we should.
The other side is public revenue in the form of general taxes that come into the health care system. I believe that the public is prepared to put more money into their public health system, but not into taxes that go into general revenue. It is a trust issue. The record on governments taxing people and then ensuring that money goes into designated services is not good, or at least certainly the perception is that it is not good. The trust has been broken. People do not want to give money to governments and have it just disappear. They are prepared to do so if they are assured that the money will go into health care, and especially into health care in their local area. This has not been sufficiently tapped.
This goes back to what we talked about earlier, which is an arm's-length agency that can be seen to be trusted with that money. That money is going where people can see it, and not into general coffers. It is another reason why such an arm's-length agency to run health care is important.
Even if we are successful in raising more money, let's not delude ourselves into thinking it will be enough. Even in the States, where they have a lot more money, they do not have enough. I think the important thing is not that the public perceives it to be enough, but that we are providing care to people. Right now, we are not just making people wait, we are actually denying care to many, and that is the truth.
Mr. Forget: I do not have a lot to add to what Mr. Davis and Dr. Vertesi have just said, because I agree with their remarks.
Earmarked levies are the only feasible way to raise additional revenue. I do not think I would use them just from the incremental aspect, because some of the basic funding could be done in this way as well. Otherwise, it creates a misleading impression that the entire cost of the health system is borne by a very small levy, which itself creates a problem.
One important issue of principle — it goes back to what Dr. Vertesi was just saying — is that even with additional money, the problem of scarce resources will not disappear. My approach would be that we have to look at our public commitment to health as finite — although perhaps greater than it is now. In other words, Canadians, through their governments, have to make up their minds — and this may evolve over time — that they want to put this amount of resources into health and no more, and then recognize the consequences of that.
In what way would that be different? Presently, the system is being driven the other way, with the implicit promises from governments that everything is provided; it is a universal system that is portable and comprehensive, which gives the impression that the resources are unlimited. The implicit promise is that whatever technology, new requirements or new expectations emerge, they are covered, and therefore, expenditure determines revenue requirements.
I believe we have to say that our economy and our collective will, in terms of devoting public resources to health care, has a finite limit. We need a system in which for some segments of health services, we do not necessarily say that we will not cover them at all, but we will cover them at a lower rate. In other words, the public has to share in the notion that there are certain things that you will not fund 100 per cent. That has to be made more explicit, otherwise I believe that the disparity between the implicit promise of the system and what it delivers will continue. That is, not only the resource gap, but also the credibility gap, will continue, undermining the entire system. Therefore, revenue must determine expenditure, and not the other way around. We presently have it the wrong way around.
Mr. Lozon: I agree with what everyone has said so far and I have a couple of other observations. The reason you would want a dedicated levy for health is, in part, to protect other public services from health care, because it is essentially swallowing up provincial revenue streams at a great rate. Not only do you want to be able to be accountable for the dollars that are raised, but you also want to ensure that people do not go wanting in areas such as higher education, public education, roads and social services because of the health care requirement.
Next, I would add that in Great Britain, most of the new facilities are being built under a private financing initiative, where they are actually built, owned and operated by private consortiums, and the regional health authorities, as occupiers, are essentially tenants.
I will take a divergent view here. When you take the notions of a private insurance system and user fees out of the discussion, you are left inevitably with the question of tax increases, whether dedicated or not. I would like to raise this: Why not allow individuals to purchase health insurance that would provide them with another level of care, as long as we Canadians continue to provide the social safety net of which we are enormously proud? The record of the organization of which I am president is 110 years of unrequited service to the most disadvantaged in our society. Why not allow individuals who have the wherewithal to say, ``I do not want to have to wait six months for my hip replacement,'' to buy that service?
The Chairman: That is a legitimate point of view. What you mean by ``another level of care'' is essentially a parallel system of some kind. Would you see that service being provided at the same institution that provides service to publicly funded patients, or in a separate one?
Mr. Lozon: You would have to be careful about how and where you provided it. To some extent, what Mr. Davis was talking about, providing excellent care and services to people from the United States, is not a fundamentally different concept. That would be offered to people from outside our country, while people inside would not be able to get it.
Senator Morin: I do not think Mr. Lozon answered the question. Would you have these services in separate hospitals? The British system has separate, private hospitals. The Swedes have private insurance, but 10 years ago they did not have private hospitals.
Mr. Lozon: I did not answer it directly because I do not really know the answer. I would proceed from the premise that all people should have access to care, and then where this other level of service is provided would be determined by what would do the least harm, or no harm, to the first principle.
Mr. Davis: One of the fundamental prerequisites for providing that enhanced level of care — and I agree with it, by the way, and I agree it is not dissimilar to selling services to third-party payers from outside the country — is there would have to be a guarantee of maximum wait times for the publicly funded system. If you want to get your hip done in a week and a half because you want to be ready for the golf season, that cannot be at the expense of somebody in the publicly funded system, who has to wait longer. We need to get our heads around moving to more open access or guaranteed maximum wait times, and then we can layer in enhanced levels of service and selling services to third-party payers.
I think a mix of private/public delivery facilitates those enhanced-level services to the third-party payers, because some of that private side, and even some of the public side, may be financed by the revenue generated. That will create more volume and more activity in the system. It would probably create a greater critical mass of providers. There is a great deal of benefit for the publicly funded system. To not consider that thoughtfully is probably a major error. I know the committee has touched on the topic and thought it through. I congratulate you on that.
Mr. Scott: I would not encourage any parallel private activity because the primary beneficiaries of that are also the people who drive the political system most effectively. They could then save money in health care because the drivers are well taken care of. That is not what I wanted to talk about.
The Chairman: That was simply an aside.
Mr. Scott: Absolutely. I believe that there ought to be a hierarchy, beginning with long-term, stable funding for what we are attempting to do now in the system. Then the next part is the catching up. I suspect Mr. Lozon has better numbers than I, but there is no question that we lost ground on many of the basics in the 1990s because of the substantial cutbacks and reforms that tended to put us behind in a number of areas. That may not be a long-term expense.
There are also items that I believe have not been dealt with, such as information. Mr. Lozon referred to the amount of money that has been set aside to work on the electronic health record. Management information in the health system is absolutely crucial. I see no evidence that any government has ever felt that it should invest any money in it. In fact, I presume that some have a policy somewhat like Ontario's, which is that there is no money for management of information — you have to find that yourself.
Thus, we remain in the dark ages on information. That will continue, without some dedicated funding, simply because there is absolutely no public appreciation of the value of information systems as opposed to an extra ambulance, a new wing on a hospital or a new cardiac catheter program in a certain institution. That thinking is so well entrenched in our system that we will never be able to learn many of the things we should know if we are to run a much more efficient system without dedicated money for information systems. I would put that as my highest priority.
My second-highest priority is to tackle home care and drugs because they are so interrelated with everything else. As long as there is no effort or coordination in that direction, we will have trouble working effectively with the traditional hospital-doctor mix.
As to the specific form of revenues, I already touched on that in my remarks. They have to be dedicated, and the GST is a very good test, because if people want to pay for it, they will notice it every day. I just read about the C.D. Howe proposal yesterday and am still dealing with it. However, I urge the members of this committee to look at it more closely. There are numerous instruments that could be used within that type of formula that might prove to be attractive, although I am not prepared to endorse it at this time. It is quite creative and provides the opportunity to address a number of the items on the list.
The Chairman: As an observation, the C.D. Howe proposal essentially says that at the end of each calendar year, you receive a statement from the government that says you are deemed to have had additional income that is equal to the total costs of the health care treatment you received during the year, up to 3 per cent of your income. It is interesting that the structure of the proposal dates back to 1961, when the idea of a national health care system was first raised. Subsequently, that feature was dropped. It goes back 30 or 40 years.
Dr. Kenny: I will say two things. On wellness scanning, I would like to ask a question of Mr. Lozon, if I may.
Let us be careful, when we find things to sell that are not covered, that they do not conflict with our deep desire to ensure that whatever we provide is evidence based. We can sell anything to anyone in the name of health care, and ``wellness screening'' is causing hives to break out all over my body. We have to be careful that in the name of one goal, we do not compromise something that is a much more fundamental. That is a small aside, but you can think of all kinds of things that could stem from that. Wellness scanning and other such activities are scary.
Mr. Davis: I would not disagree with that.
Dr. Kenny: The more active you become in that area, the more concepts there are that could compromise other things. That is all I am saying. Obviously I am not an entrepreneur.
I was extremely happy that, in contrast to the Mazankowksi report, volume 5 did not recommend medical savings accounts, user fees or a parallel private system. My reading of the literature is such that I would ask Mr. Lozon what goal he thinks parallel private insurance would achieve? I thought that the three kinds of goals we might look at were sustainability of the universal health care system, cost containment and the challenge to equity that I mentioned earlier. What goal would a parallel private system most likely achieve?
Mr. Lozon: I would think that a parallel private system might achieve enhanced access.
Dr. Kenny: — access to what?
Mr. Lozon: — to a system of health care services. It could achieve that enhanced access, but perhaps just for some. Should we say that it cannot be for all? That is the corollary.
Dr. Vertesi: We finally come to the crux of what has been nailing us down for 30 years. I am sure we could spend a whole day on this issue alone, and perhaps that is warranted, but we do not have one full day. I support what Mr. Lozon said, and I think a second level is also important. However, there are dangers and a second level would have to be kept in balance. Having said that, I believe that we are the only country in the world that still actively disallows any second level. That has to give us some kind of message. What would be the advantages?
There is an immediate apparent advantage in terms of attracting more money into the system. We talked about that already. The second is that those people who are willing to pay are taken out of the queue. We have looked at those issues before. Is that really better? Yes, and it is also better for others if the ones who are paying are paying more than their share. For example, if they are paying twice the usual fee for their hip operation, and if that extra money were used to help someone else who needed that operation, would it meet our objectives? Yes, it would. That depends on our knowing how much a hip operation really costs, which is another problem.
The real advantage to a second, parallel system has not been touched upon. A parallel system is the only way to provide us with a reality check, so our public health system knows when we are out of touch with what people really want, what the quality should be and what the cost should be. Otherwise, we are working inside closed walls and we have no idea. If I were a politician with a Machiavellian bent who did not want people to know that they could have something better, then that is exactly what I would do. I would say that I would not allow anything else, because otherwise, the people might get a taste of something better. We can get away with that for a while, but it catches up with us eventually. It has caught up with us after 30 years.
The problem is not so much that we are confining people, but that we ourselves no longer know what quality standards and pricing we should be aiming at and what is reasonable. The only way to find that out is by having an alternative, albeit it should be kept in balance, because we do not want a parallel system that is the same size as our public system.
I would like to see a dominant public system that provides for the majority, 90 per cent, for example, of the health care needs of our country. However, that ``market share'' should be legitimately earned by the public system, not legally inflicted on people who do not know any better.
Senator LeBreton: I was being a little facetious when I said ``for everyone.'' The way I read what you are saying, Mr. Lozon, by having a parallel system, you bring more technology and people into health care and therefore you provide better service in the public system as a result. Is that it?
Supplementary to that, what does that do to our goal of guaranteed access within a limited time period, depending on the procedure?
Mr. Davis: I will try to assist Mr. Lozon. He can correct me if I drift.
We discussed oversight of the system being independent of the political arm of government, at least. A crucial part of anything we do in this area is having a utilization commission process in place, or a commission that reports on access. If there is any sense of the resources in the publicly funded system being used for a second tier to do third-party work, there would have to be clear reporting that there are benefits to the public system, such as reinvestment, additional providers of technology, shorter wait times or better access. All of those would need to be part of that analysis. Some people say you can never determine that. It is disappointing if that is true. We should try to determine it.
We must look for new sources of revenue for the system, not just dedicated taxes. We must sell the value of the system for some of the reasons that Dr. Vertesi gave. We must demonstrate where that value is. It is complex and needs to be looked at carefully, but we should not rule it out.
We do need to recognize that we are very much in a North American-global economy, and there is a lot of Canadian money going south of the border to purchase health care. I hear people say that is fine, let it go there, but in an internationally competitive market, we want to keep that money here and bring some of their money up here for the benefit of our system, because otherwise it is a net loss to the country.
Along with the money, some of our providers are going south as well. It is amazing how many Canadians you bump into at the University of Texas, the Mayo Clinic or Scripps. We do not need to lose those providers either.
The question is do we believe we can become a force in health care worldwide and in North America, or are we going retreat and say we are only going to operate within a narrow, confined spectrum and let anyone else, provider or patient, who wants to go elsewhere for something different, do so?
Mr. Lozon: I realize what I said is quite controversial, but I said it quite intentionally. I would say to the Senate committee that if you decide, for good and valid reasons, that that is not what you want to do, there are many Canadians who would appreciate an articulation of those reasons.
The Chairman: Absolutely.
Mr. Scott: It is a difficult way to go about it if you are worrying about shortening lists or providing better service. Maybe everyone will come rushing back so they can deal with the high end of the market, and maybe you can entrench something in the Constitution to ensure that every dollar gets poured back into the public system.
There are other potential alternatives within the system, which we talked about earlier, that make more efficient use of services. You do not need a parallel system to do it. There are some good examples. However, there was the very controversial decision that Cancer Care Ontario made to repatriate patients from the United States by opening what the Toronto Star loves to call a ``for-profit clinic,'' because the doctors do work for profit, but it is hardly a multinational conglomerate.
The Chairman: Are all doctors not working for profit in that they are self-employed entrepreneurs?
Mr. Scott: That is right, so it is not terribly different from any other clinic. Because of the shortage of medical resources, which obviously was a substantial part of the problem that drove everyone to the United States in the first place, how do you handle enough patients to deal with the backlog when there was no increase in the number of people able to do it? They found innovative ways to do that.
There are all sorts of arguments for and against, but the bottom line is they found more innovative ways not being practised anywhere else within the system, for many of the reasons Mr. Davis raises: Standard practices, union thinking about not changing the way things are done. Before we rush off to build a parallel system, we should be looking at some of the more efficient and creative things we can do within our own system. All we have to do is a little mould breaking.
Senator Robertson: When the federal government refuses to allow me to buy private insurance, do I have a Charter issue?
Mr. Davis: I am not a lawyer, so I could not answer that. However, it is an interesting question.
The Chairman: The question was raised as to whether refusing an individual the right to buy health insurance in Canada to purchase services in Canada violates the Charter of Rights and Freedoms. Since you are not a Charter lawyer, are you passing on that one?
Mr. Scott: I do not have an answer to the question, except I believe the right to access health care has certainly been raised and the courts have determined that that right does not exist.
Senator Robertson: It is strange to see what the Charter has been allowing lately in different parts of the country.
Mr. Forget: You cannot prejudge what the courts would say, but to my knowledge, this has never been raised before the Supreme Court. One could assume that the court would find that restrictions on freedoms that are democratically adopted in a free society are valid limitations.
One must make a distinction between that kind of abstract denial of a right not related to a particular case, and how the Quebec Appeal Court has judged that denial of payment by one provincial medical board for a special form of cancer treatment obtained in the U.S. without prior authorization was wrong. Certainly, that was an affirmation of a right to seek treatment in a timely manner in a particular case.
I suppose one could suggest that perhaps if the courts were to become more proactive — and who knows, we have seen that in other areas — this question about the parallel system might become moot, because people can go to the U.S. in a number of cases when service is denied in a timely manner. We know it is not difficult to imagine cases like that. It would then be far better to have a parallel system in Canada.
I agree it is already going on. Let us bear in mind that it is not the only parallel system that exists. There is a ``moneyless'' parallel system. It depends on whom you know and how clever you are at working the system. Therefore, I believe we should not be too sanctimonious about this issue.
The real question is how to ensure that recourse to a parallel system does not hurt those Canadians who do not have the means or do not choose to avail themselves of that possibility. That is a real challenge, because it would not multiply the number of physicians and nurses. We might multiply the number of pieces of equipment and the facilities, but eventually, the same people have to deliver the service. As it takes about 10 years to train a physician, this is not an instant cure. It is another managerial issue. Certainly, if we monitor quality of care, there should be a way to spot deviations from the norm.
Senator Morin: Here we are with a majority of panellists supporting the possibility of parallel care. When we mentioned this as an option in our first report, consider all the pressure put on us and the insults we received! Here we are coming back to it. This is an interesting turn of events.
Senator Roche: I would like to thank all the members of the panel for wonderful presentations. Mr. Chairman, I have one essential question in trying to bring the financial issues into coherency. The panel has diverse views on this question, which in some respects mirror the diverse views in the committee itself.
I am interested in finding a consensus solution to the financial questions.
I want to direct the question first to Dr. Kenny, but also invite other panellists to pick up on the sub-themes that I will introduce.
Dr. Kenny has, in her opening statement, and several times since, insisted that we keep in mind what the goal of the sixth report should be, and the way in which we can approach the financial recommendations. I will ask Dr. Kenny if she agrees with me that the fifth report can be boiled down to a choice that the committee is asking Canadians to make: Either pay more for the health care system or allow people to buy their own insurance.
If that is the key question, and we have certainly come back to it in several ways here, then it does bring us to a discussion of the values in the medicare system. Without going back over any of the territory that Senator Morin just briefly referred to in his comment, we can say that in putting more money into the system, the first question is, how much is needed.
I was struck by the many comments with regard to the fifth report to the effect that perhaps the committee had overstated things by saying that the present system is not sustainable. Whether that is correct or not, let us move on and say that the system needs more money.
Dr. Sinclair, the former commissioner of the Ontario Health Services Restructuring Commission, came before the committee several days ago. He put some numbers on the table. He said that, looking at the whole system today, which costs perhaps $100 billion, give or take a little — 70 per cent public, 30 per cent private — the committee should perhaps think of adding 10 per cent to that for restructuring, improvement or efficiency to bring it to where we want it. That would be $7 billion.
Then we asked him how he would split that. He said 50-50 — $3.5 billion for the federal government and $3.5 billion for the provinces.
I would like to know what the panel thinks about those numbers and whether, Dr. Kenny, you could integrate what you said about home care and pharmacare — and it has been picked up by others also — into a restructured system. Would it cost a lot more?
I come to the substantive question of paying for it. Everyone seems to agree that some manner of dedicated taxes or a dedicated levy is essential, rather than increased taxes going into a general pool. Should this be done through health premiums, or could a levy be politically saleable? I think it was Mr. Forget who said that it is not enough to introduce a levy for the incremental costs, but somehow we have to show that the whole system is receiving dedicated taxes, a dedicated levy. How would we make a dedicated tax feasible?
Finally, I come back then to the political arena. It has been said here that we want to depoliticize the question. Surely we have to underline that when we get into the finances and who will pay what. Is there in fact an ideological struggle going on that is at the root of the financing question?
I am a layman here, which enables me to ask simple questions. I do not want to see this issue in terms of Mazankowksi versus Romanow. I said in my opening comment that I want to see us come together. Can the federal government and the provinces come together without having any sort of cooperation wrecked by an ideological struggle over who will control health care?
I am well aware that the federal government puts money into such national policies and the provinces deliver the program. In order to get this essential cooperation, we must understand where we are going together. I think that there is still too much diversity of opinion in the Canadian public, and the diversity of opinion expressed around this table is too much for me.
Dr. Kenny: Let me see if I can give an answer that is helpful but succinct. I recognize that the Senate had indicated that it wanted this discussion and debate to be non-ideological. I remind the senators that ``ideology'' is not a pejorative term.
An ideology is a system of beliefs, and we all have ideologies, both personal and political. The term ``ideology'' or ``ideological'' becomes pejorative when we have a sense that people are entrenched in a position and unable to even listen to a different perspective. I think it is in that sense that the committee wanted the debate to be non-ideological.
In fact, I think Senator Roche is correct. We are now at the heart of a conflict of ideologies, and it is a very specific one. Competing conceptions of fairness are now on the table.
There are perfectly legitimate differences in how people understand ``fair.'' We can use the U.S. conception compared to Canada, because it makes it distinct, and I will do it briefly. The Canadian conception of ``fair'' is communitarian or egalitarian. It fits with an understanding of equity as, ``Treat everyone the same, taking into account differences.'' People cannot buy their way. It is a philosophical approach to understanding ``fair.'' They cannot buy their way to special privilege.
In the American conception, the libertarian understanding — a deeply rooted one — fairness is, ``Treat everyone the same.'' Their conception is more about equality than equity. Treat everyone exactly the same. You do not take into account substantive differences; you just prevent restrictions.
We have now arrived at an issue that I thought was happily dispatched in volume 5. It is back on the table precisely because a different conception of fairness is now operating within Canadian society, and it will be at the heart of the decision about what we do next.
Let me make three other comments.
I will repeat what I said with regard to money, because perhaps I was not clear. I am saying that because there are so many inefficiencies in the system — and you know them well — you cannot answer the question of whether more money is needed unless you fix the things that you are not doing right. I am not saying it is not true. I am saying the fixing needs to be done.
The Chairman: Do you agree with our categorical statement in volume 5 that it costs money to fix the system?
Dr. Kenny: You read my mind. Restructuring is a different issue, and that is what the senator has put on the table. I believe that we have never put the necessary money into the system either for infrastructure development or for restructuring. I agree. I am not debating that. In my understanding of the data and from my experience, that is so. That is the answer to restructuring. We need new money. We have never put money into that and attempts at reform have been disadvantaged precisely because of it.
However, the philosophic principle that now becomes important, going back to where we are in the intellectual argument, you enunciated clearly — single payer. I applaud that. I believe that is in keeping with the values Canadians have held and still fundamentally hold, although perhaps not to the same degree. We need to separate out the funder, the payer, or the insurer, from the provider. Within that, there is a lot of flexibility for discussion about private, public, for profit, not for profit. That is a separate question. You have done a nice job of attempting to make those clear, and you need to do that.
I would say that once the issue of parallel private is on the table, you now are saying something different and contradictory. You are now talking about multiple payers. If you are debating that, I am suggesting that you need to revisit your goals before you make that decision. The three fundamental goals we might consider are, first, actions to preserve universal health care; second, cost containment; and third, a different conception of equity. It may well be that we have outgrown that goal and now have a different world view.
I would suggest that Senator Roche is right. There is an ideological issue at stake here. It is about competing conceptions of fairness and allowing or not allowing private parallel.
I guess I am shaking my head, and perhaps Senator Morin is getting different advice because of the group at the table, because I would have thought, from all the reading I have done about every other system in the world that has fooled around with mixes of private and public, and two and parallel and one, that it would be clear that if you have a parallel private system, you erode support for the public system, especially among the middle class. You have a private parallel, and you do not contain costs. You have a continued escalation in cost, only now it is coming from this pocket through taxes and from that pocket through private insurance.
You have a distinct problem, as you identify well in your own volume, of doctors working in both parts of the system. Do you create a different conception of equity in private parallel? Yes, you do.
There is a deeply rooted ideological difference, and you will have to come up with an interpretation of where you think Canada sits on that today.
I would also ask you to take into account the evidence about what private parallel does or does not do if the goals of preserving universal public access and cost containment within a Canadian conception of equity are still at stake. If they are still at stake, look both at the value and at the evidence about what private parallel does.
Mr. Scott: Moving from the ideological to some puzzlement, this is the first time I have heard that the parallel system would actually enrich the public system. I am not aware of any evidence of that, but I would be interested in it.
I would like to look at it from an economic perspective. This sounds to me like a prescription for spending more money on health care, albeit with a different mix, rather than less money. Since part of this exercise was trying to get the most for the least, that is an interesting thought.
The moment you have a parallel system, the question is who is in it and who is not. One of the first groups in it would be the Canadian Auto Workers Union, because they would not want their members to have anything but the very best care. Any union that gets in there first will bring other unions in. As a consequence, you really are developing a parallel system that is driving up costs.
For a country that is part of the North American continent and highly dependent on the United States, regardless of the moral, ethical and principle questions that have been raised, there is a practical economic question of whether we want to continue to have the economic advantage that health care gives us as a nation, or whether we want to put that severely at risk through a parallel system that drives up overall costs, drives up the proportion of gross domestic product going into health care and lowers our competitiveness. This is why the Conference Board of Canada and others have been far more in favour of the single payer system than a parallel system.
Mr. Davis: I would be disappointed if we were going to approach our competitive advantage with the United States by saying, ``We should keep the Canadian dollar low and ensure that Canadians get marginal services in some areas because that keeps our cost structure down.'' That is a Third World approach to being competitive, and I do not think we want to go there.
If I could make one other comment, once you frame it as an ideological issue and get into fairness, equity and egalitarian notions, you make the argument into a debate between good and bad. All that is being discussed here is whether there are some ways in which we can raise additional revenues that can benefit the publicly funded system. That is the discussion. It is not about a full-scale parallel health care system, but whether there are ways to provide some enhanced levels of service to third-party players that fall within the publicly funded mandate — we are doing that now, by the way. There is nothing new here.
I also wondered whether there are some services in the uninsured ``basket'' that we could look at providing to generate some revenue for the system. We are simply looking for other sources of revenue as we move into a newer and more entrepreneurial age. I do not think anybody at this table, or anybody I have talked to, wants to undermine publicly funded health care. Everyone supports it. People are asking, ``What is the best way to save and enhance publicly funded health care?'' The debate is how to achieve that objective, not whether the objective is right or wrong. All of us, as Canadians, are egalitarian, and we do have a fundamentally different view of the role of the individual in society from that of our friends south of the border. It was important to put this into context.
The Chairman: I want to clarify a point that Mr. Davis made, because it has come up a few times today. WCBs across the country effectively operate in a two-tier system, in the sense that their patients automatically go to the front of the line. Doctors who perform services for Workmen's Compensation Board patients are remunerated not by the provincial health care scheme, but directly by Workers' Compensation. In those provinces that have caps on doctors' incomes, money that doctors earn from Workmen's Compensation cases is not included. That was the reference to WCB.
Senator Roche: I want to go back to the questions of how much money and how to raise it. First, I want to return to Dr. Kenny. We are all agreed that additional money is needed, but I want to fine tune it and ask, additional money for what? That is when the questions about restructuring have come up. I cited the $7 billion figure per year for 10 years given by Dr. Sinclair. A number of people say that restructuring should be given a high priority in the overall improvements needed to save and extend medicare.
The other part is what you, Dr. Kenny, and others have raised; namely, the introduction of home care and pharmacare as additional elements in the medicare program. Would the amount that I have cited be sufficient or insufficient, in your view, to integrate those two new elements into medicare and also pay for restructuring? Or would the total amount of money required for these three elements be more than the Canadian public system could stand?
Dr. Kenny: Senator, I am not an economist, so I am not going to give you dollar figures for anything. I do not have the expertise to do that. When I was on the National Forum on Health, we made a strong recommendation to the Prime Minister for a national pharmacare program. We believed at that time — so I am getting the information from experts who were looking at the issue — that people are paying for their drugs and the money is being expended. However, it is being expended in a way over which we do not have any control, whether of optimum formulary or best practices. These are problematic. The money was being spent, and we felt there was a way to make that expenditure more efficient. We must remember that pharmacare costs have gone through the roof in terms of percentage increases over the recent years, but I do not know the amount.
Again, I have no dollar amount for home care. Home care is variously covered across the country in a way that is random and confusing. I am saying that an integrated approach is required. If you could define ``medically necessary services,'' they would state that pharmacare and home care — home care as an adjunct to hospital care — should be under the umbrella, along with doctor and hospital services. However, I do not have any meaningful figures.
Dr. Vertesi: Your question about whether the ideological issue existed astounded me. This is the original ``ideological baby,'' and those of us who were here when it was born remember that. It has now grown up and turned into something different.
I agree with Dr. Kenny in one respect — that dealing with this is different from dealing with the other kinds of questions because of the fundamental ideology involved. What kind of vision do we have? There is an extent to which once we cross some line, we have crossed into another ideology.
There is another side to the question we have never considered, and that is, do we have a free choice here or not? Dr. Kenny put it as if we can choose whether we want this or we want that. There are some people who believe that there is no free choice, and that it is all an illusion that we got away with for a while. However, our costs have increased to the point where it is no longer going to be sustainable, which brings us to this conference. In other words, if we had a free choice, of course we would choose a publicly funded, single insurance system that would look after us. It is the same as, if we had the choice, we would choose a wealthy parent or a sugar daddy to look after us.
The problem is, does that really exist, or is it a fantasy that is not fiscally sustainable because of the way finances and markets work? That is the question. To go further, it is a question on which we have been unable to have a good debate because the ideology tells us that it is forbidden to even talk about it. That has been the case until now. It is difficult to talk about this in an open forum, certainly here in Ottawa. In this building, until now, no one could bring it up and get away with it. The fact that we are at least discussing it is a step forward.
Can we discuss it on its own merits and look at the evidence and the science? We will disagree, I am sure. For instance, I disagree with Dr. Kenny about the evidence on parallel systems and what they do or do not achieve. It would be a good thing to discuss this and ask how we interpret what happened in Australia. How do we interpret the U.K. experience, and so on. We should have that discussion, and out of that, some logic should say, ``We never really had the option that we thought we did and we had better abandon it, the sooner the better,'' or ``Yes, it is there, and yes, we can make it work.''
Of course we are going to decrease costs at the same time. It is not one or the other. It is not that we either attract more money or we decrease our costs. We can do both. In fact, having a different financial formula that brings money in is one way of also decreasing our costs internally, because it will provide feedback and incentives to the providers to decrease their costs. For example, if we want public hospitals to decrease their costs, I can think of no better way than to force them to compete with private ones providing the same services for money. It might be more effective than a bureaucratic solution.
I am sure that we will not be able to finish this level of debate.
I want to make an additional point about workers' compensation, which is a two-tiered system that pays hospitals and doctors more for the services and people go to the front of the line. That occurs not because the WCB likes to throw money away, but because they are charged with bearing all of the costs of the injury. In other words, if the worker is off sick, they have to fund that side of it as well. If the worker has to wait six months for surgery, they bear that entire cost.
In the other part of the public health care system — the more standard one in which we all participate — that is not the case. They push those costs back onto the private individual. If you cannot get in for an operation for six months or for one year, you bear the cost of the lost wages, and also that you cannot work and that you require the assistance of a home support worker.
The very fact that WCB is willing to pay for this is evidence that it is worth it in the long run — it saves them money. They are free to make the choice and they choose this because it saves them money over the long term.
Senator Roche: With respect to the figures I put on the table, the whole system costs $ 100 billion now, split 70-30. Dr. Sinclair says that 10 per cent is needed for restructuring — $7 billion per year, split 50-50 between the federal and the provincial governments. Is that viable? Each level of government would come up with $ 3.5 billion per year. Can we get out of this dilemma that we now face by having the federal and provincial governments put in $ 3.5 billion each per year for the next 10 years? What is your view?
Mr. Lozon: No, you cannot get out of it. First, it is highly unlikely that a province such as Saskatchewan would do that, and certainly it is clearly unlikely that Ontario, which would bear $1.5 billion of the $3.5 billion, would be prepared to invest more in a health budget that is currently at about $23 billion. I do not have the numbers, but on the smell test, they do not seem to match up.
Senator Roche: You think the provinces will not put in more money, even if we were to convince the federal government to put in more for restructuring the health care system?
Mr. Lozon: The provinces feel they are maxed out right now.
Senator Roche: Is it a dead end. Would it be a dead end for us to recommend that the provinces share in the restructuring costs for the medicare system?
Mr. Lozon: Even in the most recent history of this suggestion, in September 2000, when the first ministers reached their health accord, the number was $23 billion over five years, all of it federal. I would have thought that, if this were a fruitful line of thinking or discussion, it might well have been tapped then.
I am speaking as an individual —I am not representing any government agency — but I do not see the provinces coming collectively to the view that they have an additional $3.5 billion to put into the equation.
Senator Roche: Is that what leads you to think we have to explore the private route to obtain the extra money?
Mr. Lozon: The original discussion was whether there would be a dedicated stream of revenue, presumably flowing from the Canadian public, for increased resources. I raised the other issue because I wanted to see it debated and discussed. My own view is that, if you want to increase taxes, whether it is a dedicated tax or a general tax, then you are talking about putting substantial amounts of money into a system that, over the next six to 10 years, will inevitably grow and cost more.
The Chairman: The committee has not discussed the numbers. The point is that Dr. Sinclair was asked the question because he had worked on the restructuring proposal in Ontario.
Senator Keon: Mr. Davis has answered my query.
[Translation]
Senator Pépin: I am delighted that you agreed to share your expertise with us.
[English]
I share the preoccupation of Senator Keon with the issues of health care providers and information for users. I am taking you back to the issue of public education, which we discussed earlier.
Many of us are of the generation when the health care system was first implemented, in the 1960s. I was a nurse in the services and we worked as a team with the doctors. We even made house calls with doctors. We had our routine, but after that, the system changed.
I believe that public information is mandatory and we must make it a priority. We also need to consider public education about the new technology. We spoke about how important it is, and so we must use the new technology to create a better health care system.
The majority of the users of the system will be 65 years of age and over. This group is the most reluctant to use the new technology. I visit elderly people on occasion and I tell them about people who are trained to teach the elderly to use a computer. They refuse to try it, and they even refuse to use their Interac card because they do not want anybody to have access to their bank accounts. Much public information will be computerized, and so I am concerned, because the elderly have such high expectations.
You said that Canada is 30th in quality of care. That is because the majority are expecting top-notch health care across the board. Someone mentioned the love affair with hospitals. We know the difficulty that occurs when two hospitals are merged and people worry because they will have to use a facility with which they are not familiar — perhaps there will be new doctors and new services. We will have to find a way to encourage people to computerize their information, perhaps through tax incentives. That might be a good way with baby boomers. Right now, elderly people probably constitute the majority. However, only the wealthier people will accept this new technology, while the majority will remain blind to it.
When we are speaking about education, we are speaking about doctors, nurses and social workers. How do we educate the people about the new techniques the doctors and nurses are looking for? Who will do it and how will they do it?
We have spoken about technology, and what we have to do in funding. I agree with all the discussions we had, but one of the most important questions is how to address the situation with that group of people. Until now, we have talked about the practical things. The people's issues will be very difficult to deal with.
Also, if we want to have the people's support instead of their anger, because they do not understand what is going on, we must look into different ways that we could do it, such as through contemporary media. I agree with that, but I think we must spend as much time discussing fundraising and technology.
My problem is, if we organize everything and present it without explanation, people will be confused. The majority will also question the confidentiality if we do not explain what we are doing. We do not even speak about home care, and it is the same there as well.
Do you have good avenues to solutions? I believe that this is the secret if we want people to accept the reorganization. They must understand it; otherwise we will have a big problem.
Dr. Kenny: I think you are on a very important issue. I do not have the answer, but I would like to say that very often, and it is even in a few of your volumes, when we identify the drivers of health care costs, we identify the aging population. It is extremely important for us to be very careful about how we say that. First, we know that it is not aging per se that causes the costs; it is patterns of practice. Senator Morin was talking about how we are doing dialysis later or doing cardiac procedures on older people.
Yet, if you look at the empirical literature about informed decision making in the elderly, including things like the development of advance directives before there is a medical emergency, it is really abysmal. We do this very poorly.
As someone who is often involved with ethical conflicts at the bedside, I have seen cases where elderly people thought their doctor wanted them to have the procedure, thought their doctor said they needed to have the chemotherapy, when in fact, if they had truly understood, they would have made a different decision. They would have been prepared to make different decisions more appropriate for them — sometimes to use the technology, but sometimes to forgo it.
I would like to say two things in response to the senator's question.
First, please be careful in your report not to make it look as if the aging population, which is in large part a celebration of the advances of modern medicine, is a problem simply because it is aging. There is something deeply problematic and ageist about that.
On the other hand, the issue of respectful and appropriate decision making for precisely this group, as they move into their final years, becomes excruciatingly important. You are right that this is not a matter of information technology, though there are some very technically adept elders who have become really interested and sophisticated. However, the majority of them will certainly need members of the health care team to walk them through the evidence, the benefits and risks.
Therefore, I go back to the question of primary care reform, with which we were dealing in the beginning, and even the way doctors are paid. The average doctor, no matter how busy or what his/her style, agonizes over not being able to give the appropriate amount of time, communication and support, particularly to elders or those living with a terminal disease. Thus, we have this problem of tougher decisions, with more potential options being provided, at a time when the doctor and the nurse, or whoever the people closest are, but generally it is the doctor, have less time to actually help patients understand the information and what it might mean to them.
The recommendation that we give particular attention to informed decision making with elders and those with chronic and terminal illness should become an educational commitment in its own right. It is important, because there is so much inappropriate care at end of life, and failure to give good care. I have heard Senator Carstairs talking about the absolute need for proper end of life care. We do not do that anywhere near as well as we ought. There are a lot of inappropriate interventions. That is a good example of where nothing in our current system is helping us to do it right for the group of persons to whom I think we have a special obligation.
Mr. Lozon: You have raised a very broad area. Sometimes, when we talk about the health care system, we talk about adding money, adding technology, better human resources planning, and restructuring of institutions and community care. However, the essence of our existence, caring for people, is what we do well. The strength of our system is that it is based on, as Dr. Kenny said early on, compassion and understanding between one human being and another.
When we talk about building more information systems or doing some reorganization, it is against a backdrop, which we take for granted and perhaps should not, that the compassion in the system is what moves it forward, and that what we do can only be an add-on.
I am actually encouraged by the number of patients who ask me why there is not more information technology accessible to individuals.
The privacy concerns that you touched on are very real. As we move forward with better electronic health records, this question will become more and more delicate. After decades of waiting, I am cautiously optimistic, because information now seems to be a lot more accessible and in a form that is much easier to handle than it used to be.
Mr. Davis: I will comment on the teamwork issue that has arisen a couple times today, how to encourage health professionals to work together, as that working relationship does not seem to be what it once was. That is, more than anything, a management leadership issue within the delivery system itself. Things can and should happen at the government level in terms of removing some of the legislative barriers.
However, we do need to focus on finding and developing top-quality management and executive leadership for the health care system. It is such a large, complex environment that we should be looking for the best managers, who can lead effectively in this teamwork area.
This is not particular to health care. I was talking to the president of the University of Calgary the other day, who told me that when he tours downtown Calgary and talks to executives from the oil and gas sector and asks what they need the university to produce, they say they want more engineers, but they want engineers and technical people who can work in teams, think laterally, relate to the Aboriginal community, and have that broader range of skills. We have to look for that leadership in health care if we want to encourage this kind of behaviour.
It would be a mistake to think that scope of practice changes, in and of themselves, will automatically facilitate this. This really is a leadership management issue.
The Chairman: I would like to ask the panel two questions that are completely unrelated.
First, can you give us, since you come from five different provinces, a handle on what you see as the federal role in restructuring? One of the reasons I ask is, as you can probably tell from volume 5, we were extremely frustrated when the federal government put $1 billion into new equipment, which it announced in the September 2000 agreement, without knowing where the money actually went, or even if it went into new equipment. You can read between the lines in volume 5 that our view is, if the federal government is going to institute an earmarked tax, it would need some assurance that, first, the money goes into the health care system and, second, into the sorts of things that we have talked about today, such as restructuring.
The broad question is what kind of role do you see the federal government playing? Is it to contribute money and hope the process works, or is it to put strings, conditions, et cetera, on the money? That is one issue.
Second, as we made clear in the report, the rationale behind our principle 20, the care guarantee, which says to people, ``You will have a maximum waiting time for various procedures and the length of the waiting time will depend on the procedure,'' was to shift the pressure from the patient. Now rationing puts pressure on the patient by lengthening waiting lines and on front-line providers because they are overworked. We want to move that pressure back onto the people who created it in the first place through rationing and global budget control — provincial governments.
I do not think we put it quite that bluntly, but that was an important underlying rationale for the care guarantee, aside from the fact that it also dealt with the number one public complaint about the system.
If such a guarantee existed, several of you are in a position where you would either have to deliver on it or see patients go to another jurisdiction, or even to the United States. I would like your comments.
Senator Morin: Many panel members commented on the fact that certain issues were, to use your words, ``intensely provincial'': primary care reform, hospital funding and so forth. What do you see as the federal role? Do you have an order of priority for the issues on which you think the federal government could get a handle, as opposed to those that are so intensely provincial that even if we knew what the solution was, we could not really comment on it?
The Chairman: To give an example, on the technology issue, some of us have asked — not facetiously — if you wanted to put $1 billion into technology, why did you not give them the equipment rather than the money? At least then you would know where the money went.
Has anyone any comments on any of those issues? Most of you have served as deputy ministers at one time or another.
Mr. Forget, I see you are the only one who served as a minister. I will start with you.
Mr. Forget: Chairman, you are aware that in my earlier appearance before you, I tried to steer away from federal- provincial issues, but the question is put so directly. Eventually, I think it is critical to the success of your recommendation.
Ottawa and the provinces are in this boat together, so to speak. They can decide to play a cooperative game or they can decide to play an uncooperative game. Of course, we have examples of those uncooperative behaviours from the provincial perspective.
An uncooperative game is to blame all the things that go wrong on the federal government, because of transfer cuts, and to try to steer their own separate way on issues of political saliency. Those are not always the same, obviously.
I would say the federal government's uncooperative game would be to say, ``Let us carve out something that we can do directly without any agreement about fundamental health issues with the provinces and have isolated, self- contained federal programs.'' We have a few historical examples of those, also. I remember from my days in politics that there was something called a ``local initiatives program,'' which created a great deal of resentment provincially because it was seed money, and after three years, most of those grants ran out. Of course, the political problem was you-know-where, and it created distortion and political angst.
I believe it is more constructive to at least attempt a cooperative game. A cooperative game would imply doing away with this dissension that Dr. Morin was implying in his question. Is there something that we can parcel out to the total mass of health care programs, whether or not the provinces agree, and be sure that the money is spent for those purposes?
On the contrary, and this is what I tried to say in my remarks, with regard to those things that are intensely provincial, Ottawa can, quite paradoxically, play a very significant role, but that implies sharing the political odium as a result of the major transformations that are needed. That will not take place unaided in individual provinces, or else it would have already done so. These problems have been known for a long time, but it is simply politically almost impossible to crack those nuts unless there is a concerted effort. The whole issue of professional corporations and the very compartmentalized unionization of all these groups superimpose another degree of rigidity. The question of which services are covered and which are not is very important. It is crucial. It is more important than equipment. Equipment would take care of itself if we had a well-functioning system, because there would be a demand, and perhaps a funding system through services provided rather than through global budgeting.
It is not logical, whenever an input is deficient, to say that the government has to intervene and solve the problem. These are managerial issues. Let us ask ourselves why the managers, who can see those problems, are not able to resolve them. They are not able to resolve them because they live in straightjackets. Let us change that and, in so doing, the federal government can take a leadership role in intensely provincial matters, not to replace the provinces or do things in spite of them, but with their cooperation.
It is like the prisoner's dilemma. Either you do this cooperatively and you achieve a greater good for all, or you try to optimize your position separately, then it will get worse rather than better.
You will solve one problem and create another one in the process.
It seems to me that the big challenge is not to try to separate federal from provincial concerns, but to attack the whole issue. I cannot believe that the provinces, if approached in the right way, and in spite of the past history of cynicism and so on, would not respond if they knew that the federal government was prepared to share the political cost of making changes. Let's face it, it is not just a question of playing Father Christmas and saying, ``Here is $1 billion.'' It looks nice, sounds nice and is nice, but it is free in political terms. You are doing something to the system that will inevitably make enemies. Too many forces have to be disturbed, so you cannot do this free of charge, politically speaking. People will hate you, but it must be done.
Mr. Lozon: It is always a bad idea to follow someone as eloquent as Mr. Forget, but I would echo his comments about a cooperative approach on this one, sharing in both the benefit and the pain.
I will speak about characteristics of what I would call an ``expanded federal funding role.'' First, it has to be full funding. It cannot be partial. It is not a matter of leveraging additional monies out of the provinces.
The Chairman: To be clear, you mean it is not a cost-shared formula where we pay X and they pay —
Mr. Lozon: It goes to my second point on targeted funding. If you target funding, it cannot be partial. It is fully funded, it is targeted, and most importantly, it is continuing.
There is a feeling at the federal-provincial table that the federal government will put money in when they have money, and take it out when they do not and can do both with impunity. I do not think that that is the spirit of what Mr. Forget was talking about. I would look at continuing and targeted full funding.
I would actually compliment the federal government, which I think has been quite strategic in some of its investments. The investment in the Canadian Institute for Health Informatics is a good one. The investment in health research innovation is tremendously important for this country. The Health Infoway is also a very good investment. They have done some things right, strategically. As Mr. Forget said, if approached properly, the provinces will be part of it.
I would like to add one point for your consideration, which is the future health and vitality of Canada's medical schools and academic health sciences centres.
Senator Morin: I was at the dean's meeting over the weekend in beautiful Calgary, and they mentioned exactly that.
Mr. Scott: I would agree with all of that. However, a serious credibility problem arises from not just a few years, but several decades of what the provinces might see as the federal government being in and out of various funding programs, as and when they feel like it. I am somewhat depressed to think we are at a point now where what we need to do first is develop a little confidence before we can restore the cooperation at both levels. I think the first step is some concept of stable funding, and you have addressed this.
The Chairman: Stable funding for the current system as opposed to a restructured one?
Mr. Scott: Yes, so there is a clear understanding that there is a longer-term commitment from the provincial and federal governments, and that they are actually in the same game in terms of paying for what they have now, even though that may not be enough. If there were some stable, longer-term perspective on this, then moving into dedicated funding in other areas would be much more successful.
Not to be too cynical about it, but if, for example, you granted my wish and created dedicated funding for speeding up the development of information systems across the country, I know that some senior provincial people would say we just want the information to show they are not doing a good job now because we underfunded them in these other areas. That kind of cynicism has to be addressed, and I think the first step is stable funding.
Mr. Davis: The federal government absolutely must take more of a role in the financial support of the health care system. When you control as much of the tax base as they do, it just flies in the face of logic that they would not participate more fully in the country's most significant social program.
If you look at what the federal government spends its money on, it pays interest on debt and it transfers money to individuals, but it does not really participate significantly in health care or education, notwithstanding the CHST. They have to get more into the game, and I would suggest a per-capita, age-adjusted amount that goes to every province, irrespective of the equalization system and CHST, a basic, floor amount. The interstate highway system in the United States would never have been built without some base level funding and dedicated revenues to support it.
I have already talked about tax incentives for encouraging wellness behaviour. There is a huge opportunity there, because the federal government largely controls taxation in this country. However, I would diverge from my colleagues over the idea that everything must be a cooperative venture between the provinces and the federal government, because it will simply not happen. There can be federal-provincial meeting after meeting at the ministerial or deputy ministerial level, and the current federal Minister of Health is probably as good at building consensus as anyone holding political office in that area anywhere in the country, but I still think it will be difficult.
It should be much like the CFI, which I think was a brilliantly strategic move, and is actually working very well. The provinces did not agree with it and objected vehemently when it was a —
The Chairman: CFI being the Canadian Foundation for Innovation.
Mr. Davis: Yes. It is doing exactly what it is supposed to do. It is focusing on excellence and research-capacity building, and the provinces are now supporting it because they can see the benefit.
The one area I see with real potential for federal investment is the electronic health record. If you want a national health care system, you need a national record. To say this cannot be done, or it has to be done in consultation with the provinces, with every health system in the country, is very Canadian, but look at the development of national and international information systems, of which there are many. You can put your Visa card in an ATM anywhere in the world and engage in a fairly confidential, complex financial transaction. I would encourage the federal government to simply build the national electronic health record, fund it, if they want, as a utility with a transaction fee attached — however they want to do it — and develop it with IT architecture that is sufficiently open that pieces can be added on at the local level. Notwithstanding that we are going to try to do some things with this in Calgary and work with Mr. Lozon and Canada Health, we have multi-region consortiums trying to put together provincial consortiums. This thing will be very complex if we do it that way. This is one area where the technology is available, and it just takes will and some significant financial investment. Go out and do it. That will do more to ensure publicly funded health care in a national health care system in Canada in perpetuity than any other single action.
Senator Roche: I am hearing several comments that express the same view: the additional money needed for the restructuring of the Canada health system should come from the federal government alone.
Mr. Davis: I would not say that. Rather, I say that they need to pick which horses to ride carefully and to stay below the level of high public visibility, putting in place the basic infrastructure for an electronic health record, even though it has controversial components. I do not think they should become involved in primary care reform or reforming the delivery side of the system.
They need to put the basic infrastructure in place. It would be nice if we had a good TransCanada Highway across the country, because that would have certain economic benefits for many provinces. It is the same with the electronic health record. That would enable primary care reform and cost-containment efficiency, and allow the provincial jurisdictions to move forward with restructuring and reform.
The federal government has gone down a poorly thought-out path, funding 10,000 pilot projects on every type of reform imaginable. It created a huge amount of work for people to prepare submissions and evaluate them. The provinces have created bureaucracies to manage both the federal government and us. It has placed a great deal of pressure on many of our providers, who have become better at writing proposals and evaluating them, or spend more of their time doing it, than at delivering care.
Senator Roche: If all this were done, would it obviate the need for the provinces to put money into reform of the delivery system? Would reforms flow out of the national projection that you have been talking about?
Mr. Davis: There is always a cost to restructuring anything. If you have that enabling infrastructure in place, it makes it easier and less expensive. What is the biggest part of the reform? There is much deep thinking going on throughout the country on how to reform the delivery system. We are missing the enablers, and one thing that has come up is information, which goes back to the electronic health record and the common master patient index.
Dr. Kenny: Until about three minutes ago, I thought I would jump up and down and say, ``I can agree with Mr. Davis today.'' Then he said something with which I can only half agree. Mr. Lozon indicated earlier that he was concerned about the scope and the timing of what you are doing. If, in fact, under the general rubric of improved information for good decision making by all partners, you are narrowing it down, we should pick the electronic health record. The power of that to help us think differently about so many other things is crucially important. I am able to go to Africa and put my Interac card from Scotiabank in a machine and it will debit my account in Canadian dollars as it dispenses South African rand.
If you were to begin to think about the scope and low-hanging fruit, go for that one. I think it is the key to a different mind-set about the use of information and evidence in informed decision-making.
I do not know how the federal government will do this, but I believe only it can. It has to do with the reform of primary care. I cannot walk out of the room today without saying what you have heard repeatedly and what you have identified very well. Our inability to accomplish substantial reform of primary care goes to the heart of this issue about medieval guilds, the sharing of power and the inflexibility of our unions. It is central. It is not that reforming primary care would reform all care, but you must get a better grip on this collaborative team issue and more appropriate use of expertise.
I am stuck on what to say the federal government might do, other than provide some kind of moral leadership. Perhaps I will wake up at 2:00 a.m. with a brilliant thought. I need to put it on the table.
It is so incredibly frustrating to live in a province that receives federal money for one of these pilot projects, and the description you heard of the time and energy that are put into these things was modest. They are small, and even when they are successful, nothing happens. The money stops after the project is concluded, even when you know it worked well. We used to call them the ``boutique programs.'' It is a serious issue, and if you are to recommend targeting federal money, you will have to see how it fits into a sustainable transformation. Otherwise, it is more trouble than it is worth. It has to be the full amount, because obtaining federal grants that have to be matched may be fine when you are sitting in Vancouver or Toronto. However, when you are sitting in Halifax, the fact that you have $500,000 in grant money means nothing if you cannot get the other one-half million dollars. It is so demoralizing. It has to be up front and targeted. Make it so that you can see the difference. You have to think about the central importance of primary care reform in all of this.
The Chairman: You emphasized that the funding has to be continuing.
Mr. Davis: Do not lose sight of the federal role that does not cost any money at all — the moral leadership, and getting out there with more solutions and a less adversarial approach. This is where I believe they could be helpful in primary care reform, by getting the three or four key issues on the table in a positive and constructive way to help provinces move forward rather than limiting them.
The current Minister of Health can help play that role. It is important to speak to Canadians with a single voice to indicate that we need to move forward. Positive groundwork could be laid for the electronic health record, which will be controversial at some point. Our political leadership needs to tell people not to be afraid of this. There are issues, but we will work through them. The overall benefit of this will be huge, so let us embrace it and move forward.
Dr. Vertesi: I agree with Mr. Davis's comments, especially about the electronic health record.
I would like to emphasize a few points. Just as important as what the federal government should do is what it should not do.
I want to raise an image of something as important as primary care reform. I agree with Dr. Kenny on how important it is, and I want you to think about how it feels to have your mother-in-law tell you how to do things, as well meaning as she is. It does not work. There are some things, such as primary health care reform, that have to be done by the providers, because the detail is incredibly important. The federal government cannot complete this and cannot look after the detail.
We need to allow some variation from province to province to permit them to try different processes that fit their local needs, and so they can try things with which they are not familiar to find out if they work. The federal government, as well meaning as it is, can disrupt that process.
I am surprised that no one touched on the Canada Health Act, which of course is the main source of federal intervention in health care.
It has been talked about a lot in the press. I do not sit at the ministerial table, but what I hear is that the federal government is inhibiting certain needed flexibilities. I hear of provincial governments not wanting to break the law, but who are willing to play right on the edge of the fence.
One role of the federal government is not to get in the way. If the Canada Health Act gets in the way, we need to do something about that. The main purpose of the Canada Health Act was to ensure access. That is fine; I am all for that. The question is, does it still ensure access? In the days when it was written, the inability to pay for services was considered a surrogate for lack of access, and it was used that way. Is that still the case? I suggest it is not, or at least it is only a small part of it.
If the Canada Health Act wants to ensure access, it should refer to that and measure it.
Senator Keon: I talked about low-hanging fruit, and I am happy to see there is universal agreement that an electronic record is a top priority and that the federal government should pay to get it done.
The other point I raised is more important. I do not want you to leave without addressing this again. That is, the new generation of health professionals. I suspect there will be strong support for another infusion of cash into the 16 medical schools to deal with medical manpower. However, I think that doing that in isolation would be a mistake. If we do not look at a new generation of manpower and simply infuse cash into the medical and nursing schools, it will stop there. I believe we need more than that now.
The hour is late, but I did not want that to fall off the table.
Mr. Davis: My only comment is the one I raised earlier, that all of these strategic manpower plans by governments generally fail because the time frames are too far out and the complexity of the issue is not fully appreciated before the plan is put in place. This does need to be thought through carefully. The whole labour market mobility issue is a big part of this. We have done little to restrict market mobility in the health professions area, and many people advocate that, but if we start doing it, what will be the implications?
We need to look at restrictions on mobility, the mix of professionals and who can do what where. That might be the kind of thing that an expert panel should look at to provide guidance to all governments. I think we can build the electronic health record. I am not sure you can solve that problem at the federal level.
Senator Keon: Do you think it would be worth proceeding with an infusion of funds into medical schools without a manpower plan?
Mr. Davis: Only if it was on a limited basis. We know enough about demographics, the aging population of physicians and some of the issues around specialists, such that we could inject some cash with very little risk. A major infusion with the expectation of solving the future physician supply issue would be a mistake. That must be thought through more carefully.
Senator Morin: Three years ago, Minister Rock offered complete federal funding for home care programs. The provinces turned this down. Instead, they got $23 billion two years ago. This money disappeared into a black hole, there were strikes all over the country and we have nothing to show for it. If the provinces had accepted this, we would have a home care program coast to coast.
With respect to pharmacare, drug funding by provinces is unequal. There is no ``catastrophic'' drug plan in the Atlantic region. Should the federal government get involved in these programs?
Mr. Lozon: No, I do not think they should.
Senator Morin: Despite the fact that the Canadian population east of Quebec is not covered by a catastrophic drug plan?
Mr. Lozon: The difficulty is that it has set the stage for further wrangling about ``You are not delivering what we told you to deliver.'' It is not the way to go.
Mr. Forget: I agree with that. Creating more envelopes for specific purposes in the overall context of delivering continuous care does not really make sense. It opens the door to all kinds of game playing. Even within Quebec's borders, that is now happening in the drug program. Some hospitals that are pressed for funds have found a way to invite some of their in-patients to get their drugs through the program.
The Chairman: They are using your outpatient drug plan to augment hospital funds?
Mr. Forget: That margin is essentially permeable. If you release a patient earlier, what happens to their drug coverage? Do they fall under the federal or the provincial program? It introduces another level of complication and another source of disagreement. Funding health care by targeting specific inputs is one way to minimize the ability of the system to manage itself intelligently. That is not the way to proceed.
Indeed, there are people who are not covered. I am sure the Atlantic provinces would like to provide adequate drug coverage if they had the wherewithal. The problem is not that they are oblivious to the need; they just cannot afford it.
It would also make sense to include home care because it is an extension of hospital care. Creating separate envelopes is a sure path to hell.
Please, let us not multiply these things. They are contrary to sane management.
To develop electronic health records is a self-contained, separate thing. Your committee has to consider that there are basically two ways to go. Self-contained programs such as this, or research, are valuable and precious. That means, and maybe this sounds strange coming from someone from Quebec, because that has not been the traditional line, the federal government is opting out of the main game in the health sector, and at the present time, judging from the comments I heard today, it is probably already too late to be in that main game.
There has been a lot of brave talk about changing the system and evolution and transformation, but if the federal government confines itself to self-contained, separate programs and says the rest is too complicated, I predict that the federal role, except for these isolated programs, will simply disappear in time. The funds or the tax points will be transferred and there will be no federal role. I think your committee should consider this.
Mr. Davis: First, I would say the $23 billion probably prevented a number of health care systems in various provinces from lapsing into total chaos. I think there was some value for that money.
I would like to end on a high note and get on better terms with my colleague from Nova Scotia, for whom I have a deep respect. Maybe because I come from a regionalized health system, I think the benefits of providing care in the community so outweigh the benefits of putting impediments to that care in place that we need to look at some way of funding pharmacare and home care that is more equitable across the country. Whether that is an insurance-based system or not, I do not know.
I would be nervous about proceeding with that prior to having the electronic health record in place. There is a huge potential abuse problem.
Senator Robertson: I want to come back to Dr. Vertesi's comment about the Canada Health Act. I assume you are looking at the principles. Where do you see in the Canada Health Act the restrictions on allowing the provinces to develop their systems properly? Perhaps I am wrongly reading into your original comment that you feel there is something restrictive in the administration of the act. When you look at the 20 principles that we have suggested here, can you pick out anything that you feel might be restrictive and limit the ability to act?
Dr. Vertesi: The restrictive elements in the Canada Health Act relate to the funding methods. Provincial governments are duly elected and responsible to their own electorates. Yet there is an element in the Canada Health Act that does not allow that. It treats them as if they were children. There are certain rules and you are not allowed to play outside those rules. Even if the public in that province is all for it, if the name of the game is access — and I believe that is what the federal government is trying to do and am in support of it — there is no measurement of that.
For instance, a province that levels a user fee, for example, on some services could be penalized, whereas a province that says ``No user fee, but you have to wait a year and a half'' — and that is the reality — pays no penalty. It encourages the provinces to deny care rather than looking for ways to improve access. There is no scorecard on access for the provinces at all.
It allows this huge hole in terms of access to open up, which is exactly what has happened in Canada.
The Canada Health Act has not in fact ensured access to Canadians. A woman called me last week in my office to complain that she had been waiting a year and a half for her disc surgery and how much longer did she have to wait. I looked at the waiting list and she had not moved. She was still number 86. I had to tell her the reason she was not moving up was that she was not sick enough yet. She said, ``I cannot work and I am in pain. Does that not mean I have a right to surgery?'' Actually, no, it does not mean, in British Columbia, that you have a right to surgery. You have to get sicker; you have to have nerve loss; you have to have damage that is irreparable and incurs some sort of legal liability.
I do not think that is right. I do not think that that is what the Canada Health Act was intended to do. She cannot go to the States. We have talked about people having options. We do not have a private insurance system here. That is wrong. She cannot go to the States, because there she would bear the entire cost and she cannot afford that. She would gladly pay a small amount so that she does not have to wait a year and a half. She could wait three months, for example, but that is not allowed.
Insurance systems take time to develop. They cannot be built overnight. If we have no private insurance at all and a public system drifting in this direction and the public needs going in that direction, we have a huge, unfilled gulf in the middle, and we do not allow insurance companies to fill that void.
If the public system collapses, as some people predict, there is no bridge. People will fall into the chasm. If there were a private insurance system, there would at least be some support in the middle. It is not an option for everyone to go to the States. The United States is incredibly expensive because Canadians cannot use their insurance system. They must pay the full cost. Even wealthy Canadians, if they had to pay the entire cost of their care, would pay a lot. I do not think they can do it.
The Canada Health Act does not allow insurance because it does not permit any other form of payment mechanisms to be explored or even experimented with.
The provinces want to be able to play with some of these other methods of funding, up to the point that their own electorates will allow.
Senator Robertson: On the same issue, Mr. Lozon, you said there was too much in the report, and that we should focus more and look at the main priorities. Would you like to comment further on that?
Mr. Lozon: I think 20 principles, none of which I can disagree with, are too many for any implementing government to swallow. I would encourage the committee to focus in its deliberations on some of the areas that you think are of the highest priority.
There are several ways of doing that. One is to consider what would be the most fruitful way to spend our federal resources. If you proceed from that perspective, I would go with exactly what Jack Davis is suggesting: funding an electronic health record. Perhaps, as Dr. Keon said, money could be put into academic health science centres, which are national resources.
Clearly, another way of proceeding would be to have a seminal discussion about a new or renewed direction. We spent an hour this afternoon talking about the pros and cons of a parallel system. If you wanted to proceed with the most controversial subject, you would come to a conclusion on that. You would say yes, with the following provisos and conditions, it makes sense; or no, we reject it for the following reasons. There are several ways to proceed.
I would have to leave it to the committee to decide whether it wants to start with what is the most useful role for the federal government, or what is most on the minds of practitioners and Canadians in terms of the future shape of our system, and then proceed from that perspective.
Senator LeBreton: Dr. Kenny and Dr. Vertesi have already commented on our recommendation 18 and the issue of primary care.
I would like to throw out the possibility, with regard to the federal role, of incentives for the provinces for phased-in primary care. You talked about a new class of disadvantaged people. We heard public testimony about ``orphan patients.'' There is clearly a need for some primary care structure.
I heard what you said about the provincial versus the federal role in this area. Certainly the public — the people we talked to as we went around the country — feels primary care reform is important. I do not think they will understand if we do not come up with a reasonable solution and simply say it is too much of a fight between the feds and the provinces. I think that at another time, we should deal with primary care reform and what role the federal government can play in this very important area in a lot more detail.
The Chairman: On behalf of the committee, I would like to thank all of you. I know you came from one end of the country to the other. We really appreciate it. If you have any further thoughts as we go through this process, drop us a line. I suspect most of you will hear from me one way or another anyway.
The committee adjourned.