Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 55 - Evidence
OTTAWA, Thursday, May 9, 2002
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 11:03 a.m. to examine the state of the health care system in Canada
Senator Marjory LeBreton (Deputy Chairman) in the Chair.
[English]
The Deputy Chairman: A few of our senators are on travelling committees today, so we have with us a few substitute members this morning. Welcome, Senator Léger.
I should like to welcome the young Parliament Hill tour guide trainees who are with us this morning.
I should like to introduce Professor Lawrence Nestman from the School of Health Services Administration, Dalhousie University. You have provided us with your brief, so please begin.
Professor Lawrence Nestman, School of Health Services Administration, Dalhousie University: I enjoyed reading the report of this Senate committee. I agree with much of the substance of the report, and I can see that your deliberations have evolved over the time period your reports have come out and that the major directions you are pursuing are appropriate for Canada.
I certainly agree with the strong role you have taken in terms of the federal government trying to be a steward of the health care system in Canada. I also agree with the other major role, namely, developing incentives within the health care system. That is an appropriate one. You must get the correct incentives in the system at this point in time. That will also help to, as you indicate in your report, increase accountability within the system. We are in an era of accountability.
The area where you will not quite get the pay off, as you indicated in your report, is developing the competitive internal market. There are limitations in terms of how you will develop competition within the system. I will elaborate on that later.
I also fully agree with the purchaser/provider and evaluator split in the development of the internal market. That is an appropriate way to proceed. Most health care systems in the world are continuing to decentralize, and more are realising the limitations of government in providing services and managing the systems.
I certainly agree with the issues of a national health care program. It is important that Canadians identify not only with their provincial health system — which they certainly do — but also with their national program, which is part of our national identity. It is important to preserve as much as possible the national characteristics of our health care system.
There are a couple of areas where I somewhat disagree. One relates to the issue of sustainability. I can agree with your definition. However, it is a definition that can become static over time. We know that western democratic countries can rein-in health care costs. Nearly all of the provinces and the federal government did it in the 1990s. If you look at what happened in Sweden, Germany and Japan during that time, all three of them were able to rein-in health care costs when they hit the fiscal wall. Of course, that had some adverse effects, but the power of democratic governments to rein-in costs, to manage the system, is still there. To say that they cannot is a scary proposition. It is within the powers of democratically elected governments to continue to rein-in and have a fiscally sustainable health care system.
While I agree with the three options we face in the health care systems that you alluded to in your report, the fourth option of improving the health care system and making it more efficient and effective is still a viable option. It is not the only option, we certainly do need more funding, but there are a lot of places where we are not doing things right. That is an important area.
I will close my remarks by touching on the issue of federal funding and its role in the health care system. In your report, I did not see an emphasis on a national home care, a nursing home program, or a national pharmacare program. If we go through health reform and all we get in this current round is an electronic medical record, better information systems, and a purchaser/provider and evaluator split the public will be sorely disappointed. They want something visible and they are looking for courage at this point in time to move this system in a new direction.
I heartily support you, and will give you reasons why, but I do think a national program for both nursing homes and home care, as well as pharmacare, is important for a number of reasons. One is cost control. Cost control and universality go together. That is an issue that, perhaps, you will want me to discuss later. In terms of public acceptability, improving access is an important area where these services are required.
I should like to leave it at that point in time, and I am open for questions.
The Deputy Chairman: I believe you sat through Ms Bégin's testimony yesterday. I think it is clear that pharmacare would be hugely expensive. However, home care seems to be something that the public will demand. Would you put home care as a priority ahead of pharmacare, or do you see them as being in lock-step with each other?
Mr. Nestman: You can choose to prioritize them. Pharmacare is a difficult issue because the costs of pharmaceuticals are zooming up. The only way we can make changes is to develop initiatives in that area. If we continue to ignore it, we will still face a cost-control crunch. I suspect that two or three years down the road you will have a Senate committee studying the issue of pharmacare costs.
In regard to the second issue of home care and nursing homes, the entire area of health care is shifting from acute care to rehabilitation and chronic care. We must shift our health care system in that direction. Unless we do that, we will not meet needs.
Germany and Japan have developed national home care and nursing programs with strong and positive results in terms of cost and accessibility.
The Deputy Chairman: What did you think of Ms Bégin's suggestion that, if these were new programs there would have to be some small user fee built into them?
Mr. Nestman: I should like to separate the two subjects, if I could.
In regard to nursing homes and home care, if you look at Japan and Germany, they have instituted national programs in these areas. Both of them have looked at additional sources of revenue to support those programs. However, they found out that when they instituted those programs, they were not as costly as they thought they would be because many costs have been absorbed into their health care systems already, either privately, where they shift from public to private pockets, or there is a certain amount of support in those systems that is already paid.
Many provinces are already paying the costs of home care. Many services are already covered in nursing homes, in particular. About 80 per cent of the costs in nursing homes are pretty well covered in Atlantic Canada by provincial governments.
If a national program is implemented in that area, if they do their calculations appropriately, they will find that the costs will still be there, but they will not be as high because some of the costs are already being absorbed by the system.
Additional revenue of some sort, and leadership by the federal government, is needed to move this along. How that should be done, whether through the tax system, through an ear-marked tax or through a component of the HST is another issue and debate. However, that is an important discussion.
In both Germany and Japan one sees clearly what is paid for home care and the national health care program.
The Deputy Chairman: Are those programs paid through a dedicated tax in those countries?
Mr. Nestman: Yes, that is correct. People accept that because they all know that at some point they will need these services, so there is an identification of it.
We have a different situation because our federal-provincial situation is very different from that in Germany and Japan. However, with some creativity we could pull off the same kind of arrangement.
Australia had difficulties in the past, before they instituted their national pharmacare program, in reining in the costs. Only when they introduced a uniform formula across the country, which is something that we are now working on in our federal-provincial relationships, did they tackle that difficulty. Some of the steps to a national pharmacare program are already starting to take place. It is now the coverage of those services outside the hospital that are crucially important.
Unless you have a universal pharmacare program, you are unlikely to have good cost control. It is only when you set up a universal program that you set up a structure to be able to do that. That is certainly what the Australians have found out.
In the United States, their public cost-control programs work well, but not their private programs, which are financed through employer contributions. The IBMs, Chryslers and Apple Computers are complaining about their programs because the private sector controls the cost. The problem is that not everyone is in the same boat. As a result, these private insurance companies are having difficulty reining in costs.
A universal, national program does not mean that we must pay all the costs ourselves.
Ms Bégin astutely noted that European countries do have user charges. The German program for home care in nursing homes does not pay all the costs. There are cash contributions, contributions to pay services, and contributions that are paid for families to support them during the time when they are taking care of their loved ones. However, the programs are not expected to bear all the costs. One must remember that, with home care and nursing homes, there is a housing element where people want to make a contribution. That should be recognized.
The German program is such that the levels of contribution by the families meant that the program did not impinge on the lifestyle of the spouse, who is well. It did not strip people of their resources, as now happens when you go into a nursing home. The Germans confronted that issue before they implemented their program.
The public contribution must be set low or high enough so that it does not impinge on family lifestyles in a detrimental way. The contributions are significant and accepted both in Germany and Japan at this time.
That is one of the lessons that Canada could learn from those two countries, which have developed universal programs in their area.
It is the same with pharmacy; you can expect a user charge.
We forget that, historically, before the Canada Health Act in which we removed user charges, the 1957 Hospitalization Act and the 1968 Medical Care Program provided for user charges. It did become an irritant. That is why we ended up with this system.
Perhaps you can look at this as an evolutionary thing where you can develop these programs and user charges and see how they develop by the year 2010 or 2012, and then decide in which areas you can reduce user charges, leave them where they are, or increase them.
We must learn how to do this to adapt these systems to a Canadian model. We cannot just take the German or Japanese programs. We should not look at developing this program as the final program, but rather as an evolutionary phase of development in Canada.
Senator Robertson: Mr. Nestman, I read your testimony in Halifax and I read again a circular that was put on my desk this morning. There are three areas I wish to discuss.
You are the first witness who has put these issues on the table. I come at this from an Atlantic Canada position. You spoke about funding on a per-capita basis, and that is going on now. That is the first thing I wish to discuss with you.
The second issue is the arm's length management to which you referred. We have heard witnesses speak about arm's length management. In fact, two days ago we had a long debate on that subject.
I agree with your comments that people are fed up with the continuing political argument.
In one of our 20 recommendations, the committee stated that we feel strongly that we should look at this in such a manner as to come up with a recommendation that would be more patient-oriented instead of politically-oriented.
Third, I should like you to talk about visibility and credit. By that, I mean the federal government being more visible. Some may call it ``visibility,'' I would call it ``getting credit.'' It seems that regardless of which government is in power, it is difficult for them to get credit for anything they do in the health field, especially when the funds are lost in the big conglomerate of funding. It is just there. It is very difficult to provide service with the limited resources that the federal government contributes. This morning the figures indicate that 14 or 16 per cent of the funding comes from the federal government. A large amount of cash was put in not that long ago. However, for my province — and I looked it up this morning — it represented about two weeks of health care. As a result of the methodology that is applied, that is all we got out of it. Hopefully, we will have a debate on the per-capita issue.
Those are the three issues I should like to discuss with the committee and with Dr. Nestman.
Mr. Nestman: I will start with the arm's-length issue. I should like to bring that into the funding, because it is important. They are tied together, as I see them.
The arm's-length issue is important when considering the issues that we have been confronting in the latter part of the 1990s and as we go on to the year 2010. We must remember that we have gone through a number of regulatory cycles within the health care system where we had arm's-length administration put into our health care system in the past. It is good to briefly review it.
Many of these issues were decided in the 1962 doctor strike in Saskatchewan, when 90 per cent of the physicians withdrew services because the Saskatchewan government at the time was trying to implement North America's first state-sponsored compulsory medical care insurance program, which is the coverage of physician services. Lord Taylor was brought in from England to mediate this dispute. The physicians had many concerns.
There are four issues that are germane to the issue of arm's length. One is that physicians were concerned about their clinical freedom and their autonomy — that is, their ability to diagnose and prescribe treatment to patients, which they felt was most important, and not have a civil servant in Regina checking over their prescribing habits. You only have to look at their concern in relation to HMOs in the United States today. It was a valid concern, considering the history in the United States. This was one of their major concerns. They did not want civil servants involved in their professional autonomy issues.
The second concern was about their entrepreneurial discretion. Every profession has entrepreneurialism in it. As you can see here, the chartered accountancy and auditing professions in the United States — as a chartered accountant, I can speak to this — are now going through a terrible time trying to sort out their entrepreneurial discretion issues and professional public obligations.
The medical profession in 1962 was also concerned about its entrepreneurial discretion, in terms of making enough money to reflect the high clinical training and the esteem that physicians felt they had in the community. Much of the concern was the perception of what happened to the medical profession in the United Kingdom, when the state- sponsored health service was instituted.
Physicians were also concerned that the only basis of payment they would receive would be from the provincial government. They wanted a program where they could have user charges over and above what was paid by the provincial government. That was another issue concerning them.
The third issue they were concerned about was patient records. Their concern was that, if it were a public program, the patient records would be reviewed by civil servants. As a result, confidentiality between the doctor and patient would be broken.
The fourth issue that became important was the role of the College of Physicians and Surgeons in the province, which was negotiating on behalf of the physicians with the government. It became evident during their negotiations that the College of Physicians and Surgeons was arguing for and negotiating for rates of pay, but it also had a mandate to take care of the public interest. There appeared to be a conflict within the college in trying to do these two things at once. The aftermath was that the College of Physician and Surgeons split and the Saskatchewan Medical Association was organized. That eventually became the pattern across the country.
These issues are important in terms of any arm's length discussion.
Eventually there was an agreement in Saskatchewan that the medical care commission would be set up with as much arm's length as possible from the government. There would be physicians on it — one from the medical school and two from the College of Physicians and Surgeons — and the appointments would be approved by the College of Physicians and Surgeons and the Lieutenant Governor. They felt that having this board of directors to administer the physician program would be as much arm's length as possible.
The Minister of Health sat on that commission ex officio. Usually the deputy showed up to do it. The idea was that it was an arm's-length transaction.
This model became accepted and also became instituted. Hospital commissions were formed in the same way. By year 1972-73, almost all provinces — and there are a few exceptions — had a medical care commission that was as much arm's length as possible administering the program. There was a hospitals commission administering the hospitals program; there were public health administrators in the departments of health; and another department, the Department of Community Health and Social Services, was administering nursing homes and home care, or however it was organized at that point in time. By 1973, we saw that pattern.
As we moved through the 1970s, 1980s and up to the 1990s, the whole scene started to change. Health care reports across the country indicated that this structure was not good for the coordination of services. Hospital and medical services should be coordinated. Nursing homes in another department did not work either. Public health was marginalized at 3 or 4 per cent of the public expenditures.
During the 1970s, 1980s and 1990s, these commissions collapsed and their functions were absorbed into health departments. The idea was that there would be better coordination. Most people would argue that by the 1990s we did not see the coordination; we saw a lot of shuffling of chairs. The arm's-length issue was taken out of the system.
From the 1990s to the present date — and we see this in all health care systems in the western industrialized world — we have seen a whole new shift in ethos of how we should regulate health care systems. The issues of accountability, choice, impartiality and evaluation are becoming the major issues in regulation. We are also continuing to decentralize health systems, which had started in the 1990s in a major way. It is amplified in your report, where you indicate a purchaser-provider split, which is a form of decentralization. That is decentralization. However, the role of government has changed.
In the 1990s we said that governments must start steering the health care system. I am sure you have heard this concept. We must change the role of how federal and provincial governments provide direction in the system in more of a steering capacity. As a result, the regulatory regime must reflect this new environment.
What has become evident in western Europe particularly, which has now implemented many of the concepts of the internal market, as indicated in your report — which is a good thing — is that when we move to an internal market, it becomes evident that we actually increase the amount of regulation in the system. Markets must be regulated. As you see in the United States, the Securities Exchange Commission regulates markets. If there is poor regulation in CA firms, you have difficulties; no information gets through; poor decisions are made; and people lose money. Internal markets require regulation also, and it is much more difficult to regulate a market than to be in a command and control situation, because you must relate to bouncing off the various entrepreneurial professional kinds of discretion that are within the system.
We have moved into this environment now where we must look at arm's length in a much different way. It has become evident in the literature — certainly you are seeing it in western Europe — that a portion of the health care system should be more arm's length. These include the licensing of physicians, the setting of capacity limits to the hospital system, capital equipment requirements, and the planning of long-range human resource issues at the regional level. These issues form the day-to-day operations of the health care system and they require continuity, both at the federal and provincial levels.
Part of the current problem is that deputies and ministers revolve so quickly that policy continuation is just about impossible. Usually when deputies leave, the infrastructure below leaves as well. Institutional memory disappears. We have chaos. As a result, we need some impartiality in a core continuum to continue.
Regulatory regimes are changing. If you go to London right now, you will see the regulatory regime of the internal market with the purchaser-provider split and hospital trusts. It is much more sophisticated steering the system than it was in the old days of providing. The new terminology is not just ``steer'' but ``steer and channel.'' In other words, how can we manoeuvre the system by sending signals at the senior level so that it moves in certain directions in a broad way but leaves the details to the fund holders, the primary care groups or the family networks, as we talk about them in Canada, to make the decisions at the local level?
The question yesterday was: How can we deal with Timmons, Ontario, vis-à-vis Toronto? Decisions must be made locally. You set broad parameters, steer and channel, and let some of the decisions be made by local councils, regions or however you want to do it. There is a need for impartiality in the system, but for reasons different from those we had in the 1970s. That is why I recommended that in the report I gave to you earlier. This is not only at the federal- provincial level but also at the federal level.
During the 1960s, we had a body called the Dominion Council of Health, which was a permanent secretariat where deputies and ministers liased with a number of health commissions that were federally oriented and provincially oriented. There was a permanent secretariat staffed by highly skilled people who related to permanent people in the provinces. As a result, there was a continuity of policymaking and more coordination of federal-provincial relationships in that era than we have in the current situation, which is unfortunate.
There is real breakdown. If you say there is not, then you are choosing not to see it. We need the kind of infrastructure I just mentioned to do that. However, it must be done cleverly. You do not want to add more bodies. The concept of a revised Dominion Council of Health for the federal government as well as some kind of permanent infrastructure in the provinces would improve federal-provincial relations and provide continuity as well as some arm's length input for the day-to-day operations.
We read about the parliamentary system and how ministers of health report to the legislature, so accountability must be there, eventually. I suspect that, if departments of health are smart, they will get into areas of steering and channelling rather than the day-to-day operations.
The Deputy Chairman: in certain parts of the country different people suggested an almost surgeon general kind of model, although not specifically like that in the United States.
Senator Robertson: Coming to the funding of the system and the visibility of the federal government, the per capita funding was removed not that long ago. In one of your presentations, you spoke to that. I would like you to explain further the difficulty that some provinces had with per capita funding and the difficulty, I believe and a lot of others believe, that the federal government has with visibility or being given credit.
Mr. Nestman: The role of the federal government is absolutely essential in our health care system. I worked for the WHO in Copenhagen for a while. I also worked with the European Union. After living in France and reviewing the health care system, what struck me is that some of those countries have regarded their health system as national in scope. The Swedes regard their health care system to be national. The same applies to Germany, because the federal government has a strong visibility in terms of how they are steering the system.
When I compare it to Canada, where we are starting to Balkanize with our provinces and territories, I see that it is a major concern not only for national unity but also in terms of the importance of getting coordinated services across the country. The role of the federal government in national kinds of agencies is absolutely crucial.
There are two arguments here. First, there is the role of the federal government in this. Many arguments can be made that the role is absolutely essential from an economic point of view, a political point of view and a social point of view. This role is important.
Second, it is essential because various parts of our country do not have the same fiscal capacities as some others. If you look back in the history of the last 100 years, you see that some wealthy provinces were once have-not provinces. Their status may have switched back and forth between the two. Alberta was not always as rich as it is. In the 12 years I was in Alberta, it was starting to look fiscally sound, but it was struggling. Nova Scotia, where I currently live, was the top economy in the early part of the 19th century in Canada. We must view this from a long-range point of view. Currently, the four Atlantic provinces as well as the territories, Saskatchewan and Manitoba — and we are starting to see B.C. falter a bit — are the parts of the country that need some help.
A cost-sharing formula that recognizes these inequities is absolutely crucial. If you go back to the history in the old cost-sharing agreements, which were interesting in terms of visibility and credibility, the medical and hospital programs both had, within their funding arrangements, a cost-sharing agreement with a built-in equalization factor. Canadians could see every year in the newspaper how much Newfoundland was getting vis-à-vis Ontario because it was reflected in the equalization payments. The federal government's role at that time was as a social leveller — that is, it tried to view its role across the country as a social leveller in terms of economic resources and health care access. That was an important role because it was visible.
When we moved to per capita funding, the federal government lost that role. If you now try to explain to Canadians the cost-sharing agreement you will be met with a glazed look. Most experts have difficulties understanding it at this point in time. The visibility has gone, as has the credibility. We hear, ``The share has dropped.'' There is a big fight over what the share is. People do not understand it. Before, it was very visible.
From an accountability point of view, visibility and credibility must be restored. I would strongly recommend that the committee consider recommending a new cost-sharing arrangement with equalization built in, one that recognizes some of the different parts of the country having more fiscal capacity and some having less.
I make my second recommendation for pragmatic reasons. You will not get a deal on health care reform and health care cost sharing in this country between the federal-provincial governments unless some kind of equalization is built in. It is either the deal breaker or the deal maker.
I cannot envisage Atlantic Canada, Saskatchewan, Manitoba and the territories agreeing to some kind of arrangement between the federal-provincial government for pharmacare, home care and nursing homes unless some kind of equalization is built-in or is visible. If you look at the negotiations for the Canada Assistance Plan, the deal breaker was equalization. I do not see that changing. We are still living in a federal-provincial system. That does not go over in some quarters, and it is not politically astute to mention this in the current prevailing sensitivities between the federal and provincial governments. As a national program, however, it is important to do that.
Senator Fairbairn: Thank you for staying yesterday afternoon.
You say in your paper that one of the difficulties in our country is that there is always such a movement within governments of people who are involved in these issues, particularly at critical times. They go off somewhere else and we lose the continuity. One of the good things, at least for this committee, has been that we have someone like Monique Bégin, who got her teeth into the health issue a long time ago and has never really let go. She is a continuing source of information and thoughts on how the system has evolved.
You heard yesterday from her, from others and from myself, concern about home care and pharmacare. It is reflected in a different way in your paper, but she discussed the notion of reopening the Canada Health Act, which, of course, makes people's hair stand on end at the mere thought of the kind of negotiations and angst that might entail. One difficulty with it would be the desire to retain what is there and in some way add, whether it be a principle or some other name, the notion of a national home care system that would, in concert with the National Health Act, be universal.
When you talk about opening up the act, there is no illusion in anybody's mind about how difficult that would be. However, if we get a new kind of national program that is fair to Canadians, we would have to take either that course or some adjunct to it.
Two things jumped out at me from your paper were your view on the question of an equalization component and the suggestion that it would have to be part of this. I am not sure I have seen it stated this way before, that is, recommending that the provincial governments legislate into the mandates of regional authorities five principles of health care.
I come from the province of Alberta. It is an active province in the field of health care in a variety of ways, and because of the way Alberta has shifted ground in its health care system in recent years, it has brought to the fore some of these issues that people in other parts of the country and, indeed, in the Province of Alberta itself, sometimes find difficult. One that you mentioned is user fees. It does have, on one level, a logical rationale. On another level, psychologically, in the country, because of how people see our medicare system, they see user fees as a controversial concept, to put it mildly.
It is a fascinating thought for a discussion. I am trying to think at which level —through the social union route, perhaps — the provinces, as the beginning of change in our system, would legislate into the mandate of regional authorities and, presumably, into their own mandate overall, the five principles of the Canada Health Act. That, in and of itself, should that debate take place, would open up the Canada Health Act.
This is something that would have been a boon to the development of our process probably, had it happened at the beginning. It was difficult. I was a young reporter in those days. It was pretty hard, as I recall covering this issue, to get the provinces to even come to an agreement regarding the National Health Act.
What are your thoughts on understanding the accountability issue? How would you see a process developing, and what would it be? Would it be this council you are recommending that might be set up to bring forward these kinds of ideas? Would these two recommendations on equalization and on legislating the five principles be a federal initiative? How would you envisage that being done? Perhaps it could be a mutual initiative, if there were a body or umbrella under which both federal and provincial people were talking, as they did — successfully, it turned out — with the social union. Many people did not think that would ever happen, but it did. Do you have a vision as to how this will come about?
Mr. Nestman: With respect to user charges being contentious, I was asked by WHO to make a presentation about the Canadian health care system in Moscow and I was introduced by a prominent sociologist in Moscow University who spent a month in this city. He introduced the three major problem areas in Canada. One was user charges, the second one was hockey and the third one was national unity.
Senator Fairbairn: That about sums it up. It is right up there.
Mr. Nestman: With respect to the list of five items for discussion, I do have a vision on some of these issues.
The home care issue is important. I can remember some of the discussions I sat through in Germany when they were considering whether to set up a separate national home care nursing program or incorporate existing sickness funds.
Senator Fairbairn: Just to interrupt for a moment, we are discussing not just nursing home care but home care.
Mr. Nestman: The Germans felt nursing homes and home care had to go together. We have to consider that. The relationship between nursing homes and home care is very central. We, in Canada, institutionalize our elderly at twice the rate the Western Europeans do. We have to think of that. The Germans at that time were at 3.4 per cent, and they wanted their number to drop. We are close to 8 per cent.
To have only the home care program, you will encounter dysfunction in having the nursing home separated out. You will marginalize it the same way as mental and public health have been marginalized in this country. You have to consider them together. They go together. The new area of chronic care and rehabilitation fits nicely between those two.
When the Germans were deciding whether to separate the two, their concern was how to relate home care, with such a social component, to the hospital sector, which is acute care. The cultures are totally different in terms of delivery of services.
The second germane issue to us is the Canada Health Act which covers medically necessary services. How do you incorporate and change that definition into home care, which is such a large component? No country in the world has been able to define ``medically necessary.'' Hilary Clinton in her commission spent almost a third of her resources trying to define ``medically necessary'' and was unable to do it. The private insurance companies have done it. They just decide what is in and what is out. It is quite arbitrary, based on risk factors and income. We do not want to do that in Canada. If we look at Western Europe and ourselves with the ethical and social issues which we incorporate in trying to define what will be provided, ``medically necessary'' is very difficult to define.
The Germans and the Japanese decided to leave it as a separate system because of that definitional problem. They did not want to open up their sickness funds to this intervention.
The second reason they separated it, which I think is important, is that they felt that hospitals and acute care had so much momentum in the system that any new money would be expanding their mandate and marginalizing home care and nursing homes.
You only have to look at the $23 billion we put into the agreement two years ago. Did we get an expansion of home care and nursing home services? Did we change the structure of the system by that? They were concerned about that.
They also felt that home care and nursing homes had not matured enough in terms of their delivery capabilities to be able to compete for resources within the system. They decided to have separate systems.
I was a guest at several of those discussions in Bonn and Ingelheim. My reading of it is that we should not try to open the Canada Health Act for home care and nursing homes. We should try to develop a separate national home care program and nursing home program that could be combined. You could also discuss primary care in that if you wanted. That would provide visibility. You could put in equalization factors with visibility and accountability to federal governments for their portion.
The one disadvantage is the lack of integration. Home care and nursing homes are not ready to compete for the hospital budgets to support their piece. I do not know of a system where that happens. Regions have been mandated to increase home care. Acute care hospitals eat up the funds because their demands are unlimited. We should separate them and have a separate national program.
We will gain some experience of how this will work over time. Perhaps in 10 or 12 years from now, we will have another report from another royal commission with recommendations about how they should be integrated. However, we now need to find out how these would work on a national basis.
That was the case with the Germans and Japanese. Interestingly, Sweden is also considering a national nursing and home care program. The same issues are being raised, and they are going through the same kinds of thought processes. They are most interested in what is happening in Canada, as well as looking at what Japan and Germany have done. They are certainly influenced by those countries at this point.
You may want to reopen the Canada Health Act because there are certain areas that should be adjusted. The principles of that act have allowed a fair amount of flexibility in each one of the provinces in the delivery of their services as they see fit. The Quebec system is very different from the one in Nova Scotia and the one in Alberta. There is a lot of latitude to manoeuvre.
I wonder if Alberta has already adopted my recommendation that the provinces consider implementing and legislating the principles of the Canada Health Act provincially in their Bill 11. The provisions of the act state that no delivery capacity will be allowed unless it complies with the Canada Health Act. I wonder if provision for a provincial system is covered in that legislation. It will be interesting to see if there will be provincial litigation in that area. The Canada Health Act has not often been challenged in the courts. I am interested to see how the Alberta situation unfolds in that regard.
Senator Fairbairn: There have been no developments from that legislation yet to be able to judge it, but it was because of that part of Bill 11 that it was ultimately not judged to be legally in violation of the Canada Health Act.
Mr. Nestman: It is an interesting future issue. I am not sure how it will unfold.
Senator Fairbairn: It will be interesting to see how it gets down to the regional authorities.
Mr. Nestman: I am recommending legislation at the provincial level because regions are becoming very autonomous. For example, the regions of Edmonton and Red Deer are very different. That also applies to regions in Nova Scotia.
More autonomy is coming to these regions. The Mazankowski report recommends that. All of the reports recommend giving more autonomy to the regions. The provincial governments are more often playing the same role as the federal government plays nationally.
The Deputy Chairman: Exactly.
Mr. Nestman: If there is to be uniformity in a province, some agreements on principles of how health services will be provided must be developed. It would help federal-provincial relationships if there were a similar image at both the federal and provincial levels, particularly when we consider that Alberta may already have moved to that.
The key question is: Can you just take those principles in the federal act and legislate them provincially? It may require some articulation to bring them down to the provincial level. Some modification may be required. A federal- provincial council could review it to decide how this could be done.
It makes sense that we should be on the same page. That does not mean that Alberta's system will be the same as the Nova Scotia system. However, in the interests of visibility, the areas that are provincially legislated should be clear, and the areas that are federally legislated should be clear.
It should also be visible that there is a national system to which the provinces must comply. By extension, it should be seen that the regions must also comply. I think that would send a good message in the regions. They could then include in their mission statements their strategic decisions, reflecting on the provincial version of the Canada Health Act, so that they are steering their regions in a way that is in broad conformity with the overall parameters of the province.
Senator Fairbairn: I thank you very much for sharing that with us. These topics are fraught with angst and controversy. It is an interesting concept. I thank you for putting it on the table.
Senator Morin: I should like to address the federal pharmacare and home care programs. As you pointed out, Canada is unique in the world by being so decentralized. I agree with you that it is unfortunate. Every province is very jealous of its prerogative. I cannot see very well how we can change it, especially in the province I come from.
Everyone has been talking about pharmacare and home care programs. You remember that Minister Roche presented that topic at the provinces three years ago, and that proposal was unanimously turned down. Mind you, had that been accepted we would have national home care at the present time. The provinces wanted the money and ran away with it.
There are many objections coming from the provinces. They say it is very important that the health care delivery system be the responsibility of the provinces. It is very important that all elements be integrated. You alluded to that.
Having a federal program side-by-side with provincial programs introduces all sorts of vices and perverse effects. At least that has been the case historically. I want to commend you on sharing your historical perspective of our health care system. All health care systems are the product of their history.
Federal programs for mental health and tuberculosis resulted in all sorts of perverse effects. Currently, this is seen at the provincial level where hospitals tend to use pharmacare to save part of their budget. Imagine if this were federal. The provinces would have the patients order their drugs from the drug store while in the hospital. A problem results when you have two programs side-by-side and one is funded and managed by the province and the other by the federal government.
We should keep in mind that most provinces already have a pharmacare program. Some of them are quite extensive and others are not so generous. Alberta has one model based on the private insurance system; Quebec has a very generous program; and Saskatchewan has a catastrophic program. I am not sure if the provinces or the people living in those provinces would be prepared to abandon their programs. I fully realize that we are faced with a problem and the fact that there is no catastrophic drug plan east of Quebec. It is unacceptable that some Canadians cannot afford drugs because they happen to live in a certain part of the country. However, I am not sure that a federal program to solve one issue for one part of the country is the answer.
Similar circumstances apply to home care. Alberta has a good home care program, but should they abandon it for a federally-supported program? A federal program must be managed. If they simply give money to the provinces, it may get used for something else. As you pointed out about the $23 billion — we know what happened. There were strikes in your own province, illegal or otherwise. Instead of having a home care program, we had a strike. If we give another $20 million, we may have another strike. There is no end to it. It is a monopoly and no government can resist a strike by health care workers. However, I am sympathetic to federal programs, and that also applies to home care and nursing care.
Some issues are intensely provincial, for example, primary care, as you pointed out. Apart from these two programs, do you think any other federal initiatives could be taken? Do you have a ballpark figure for the cost of these programs? A figure of $6 billion has been mentioned for pharmacare, but perhaps you have an idea how much home care and nursing care would cost.
Returning to my other questions, some issues are intensely provincial. Have you considered any federal initiatives, apart from these two programs, that would increase efficiency, equality and accessibility of the system? Everyone is in favour of primary care reform and changing the system for physicians, but that area is intensely provincial. Our words here will not have much effect at the provincial level.
I found your comments about equalization and cost sharing to be most interesting. You mentioned all the provinces that would be in favour of having some form of share equation, but not those who would be against it. I am not sure that Ontario and Alberta would be in favour. According to Mr. Martin's figures, the feds pay 62 per cent of the health care costs in Newfoundland; 68 per cent in Prince Edward Island; 55 per cent in Nova Scotia; 53 per cent in New Brunswick; and 29 per cent in Alberta. You may not agree with his figures so I will give you the document if you would like to see it. Should we increase the federal contribution to Newfoundland to 80 per cent or 90 per cent? The percentage is already relatively high.
Mr. Nestman: Those are pertinent issues in terms of trying to implement anything in this country. They must be addressed.
I should like to address the first question, namely, that the role of the federal government is not one of running a federal program in home care, nursing care or pharmacare. Health is a provincial responsibility and the provinces would not allow a program to be federally run and centralized at the federal level. I do not think the federal government would want to be involved in that either.
I see a situation whereby the federal government would develop a national home care and nursing home act in which the principles of delivery are articulated for nursing homes and home care. It is quite interesting that the Germans and the Japanese found it liberating to develop principles for that area rather than change their sickness programs to accommodate it. Their principles are interesting to note because they are related to chronic care and rehabilitation, and long-term care and continuing care models. They do not relate to the acute care model.
That is the role the federal government promises to develop — the principles of delivery of nursing home care — and then develop an act similar to the Canada Health Act in which cost sharing would take place. The federal government could share the costs with the provincial governments. However, the provincial governments would administer those programs within those principles as they do with the Canada Health Act for hospitals and physician services. That is the only way it will work in our type of system.
For Alberta, which has a good home care program, it could mean making a few modifications. They may be able to make the accommodation right away without making changes. For example, when they implemented the medicare program in 1968 across Canada, Saskatchewan met the requirements immediately, and it was the first province in.
The federal initiative is more ``steer and channel,'' not to administer the program, but to allow the details to be taken care of by the province.
I did not indicate which provinces were against federal initiatives. We know Alberta's situation; we know the situation of the Government of Ontario; and we know the historical and cultural issues surrounding why the Province of Quebec has taken a different stand. You must look back to 1957 when Mr. Paul Martin, Senior introduced a national hospitalization program; and to 1968 when the Pearson government brought in the medical care program. The provinces were not happy campers. Earnest Manning of Alberta was dead-set against the 1968 national medical care program, as were Ontario and some parts of Quebec.
At some point, you can accomplish uniform agreement. Would you say that we should not have gone ahead with those? I say they were major, positive steps that took courage, and that is required right now. If you do not have consensus in a federal-provincial program, that does not necessarily mean that a particular province will not come in to the program.
The social union agreement that your colleague brought up earlier does not require uniformity of agreement to move ahead with social programs. That is an issue on which we cannot expect uniformity. Courage must prevail. When the medicare program was presented, the provinces had the option of joining or not. Eventually all the provinces joined. Throughout the process, you could sense the change in public opinion about the national medical care program. It is one of these political strategies that must take place.
It is the same with pharmacare. The national pharmacare program would be provincially run, but it would be run under federal principles of administration, cost sharing and implementation, and it would apply to those drug costs outside the hospitals. You may be able to incorporate pharmacare into the Canada Health Act much more easily than you could incorporate nursing homes and continuing care, because the culture is closer. That is where a modification of the Canada Health Act could take place.
You asked me about the costs, but I do not have that information.
Senator Morin: You seem to be familiar with the German situation. It appears to be fairly expensive. They actually pay cash to the family members.
Mr. Nestman: Yes, they do.
Senator Morin: If someone wants to stay home, they are paid to do that. I do not think we would go that far.
Do you know what it is costing the Germans? I know they have a higher percentage of elderly than we do, but how much does that program cost?
Mr. Nestman: I have the figures, but they would be difficult to express here. I can give them to you later in detail. For the first six years the program had a surplus. They now have a surplus of U.S. $6 billion in their long-term nursing home program.
We can lean many lessons from the development of that program. One of them is that the Germans considered good assessment to be the important issue when determining whether people should be placed in a nursing home or in a home care program.
Another one is that they tilted the incentives, which you talked about, to lean towards home care rather than nursing homes. The push was to keep people in their homes, which is part of the German family-oriented culture, but they also realized that they were making a change in that they would not have to provide money, cash contributions, to informal caregivers.
The third lesson we can learn from the Germans is that you must have good cost controls and budget limits. The Japanese did not have that, and their costs are going through the roof. The Germans kept below budget, which has resulted in them not having to adjust their fees upwards as much as they thought they would. They are also getting economies by central purchasing through their sickness funds — one system for all, a sole-payer kind of arrangement in the German sense.
Where they made their mistake in the German system is that they underestimated the number of patients that had dementia. They did not make adjustments for that. They also did not consider the capacity restraints for nursing homes and private home care. They brought this money on, and all of a sudden firms were getting into it. As a result, they have overcapacity at this point. That is another lesson we can learn from the German experience.
Their cost control has been good. I suspect we can do the same as the Germans have done. The total costs are laid out.
The important lesson is how they introduced payments for informal care. We should be entertaining that concept in Canada. We know that 25 per cent of patients are in home care right now in this country, and family members are having a ``doozer'' of a time dealing with that. That is a lot of people.
The caregiver has to give up his or her job in order to work at home. The Germans decided to make a cash contribution to those people and to pay their government pension plan contributions while they were providing care. They provide certified training for informal home caregivers, and they offer continuing education once a year. The government also provides respite care and relief for those informal caregivers.
That program has received wide-scale acceptance, but again they do not pay all the costs. If you are a senior citizen with modest means, your pension will cover it, and you will have some money left over for independent living. Currently, in my province, people in nursing homes are not independent; they are bankrupt. To get into a nursing home in Atlantic Canada means bankruptcy, not in the traditional sense but in a real sense, for the independent individual. The Germans faced the same issue and decided that they would not let that happen.
We should consider cash contributions for informal caregivers, but that would be a provincial matter where the federal government could only recommend principles. Hopefully, the provinces will cover some of those issues.
Senator Morin: I congratulate Mr. Nestman. He is the most knowledgeable witness we have had. His knowledge of historical matters and health care delivery systems outside the country is remarkable.
The Deputy Chairman: You say that the German system is in surplus. Is it funded through a dedicated tax? Are pensioners paying part of their pensions plus a small user fee? What are they using as the base? When you say they have a surplus, what are they using for the revenues?
Mr. Nestman: They have a different system. They have an employer-based kind of health care system where employees and employers pay for their hospital requirements through a sickness fund. The Germans have developed a separate sickness fund for long-term care and nursing homes. It is done in two ways. First, for those employed above a certain income level, the employer and employee pay 50 per cent into this long-term care nursing home program. Usually it starts at age 35 and goes up to 60. After age 60, pensioners pay their own premium into this and the federal government pays their half.
The Deputy Chairman: It is by premium, then?
Mr. Nestman: Yes. It is dedicated. You know exactly where it is going and who is to get credit for it. It has accountability and visibility. That could be done here. You must be creative about how we could develop a dedicated tax, both federal and provincial, that would be dedicated to this program. It requires some imagination to bring it to a Canadian reality.
Senator Cook: I am intrigued with the concept of a Canada health services council and how that might be brought about. You talk about partnerships with both levels of government. You recognized the social union framework, which is probably some barrier to the system. The block funding per capita would be one. If I understand you correctly, you see it as a partnership with the federal government, the provincial government and regional boards.
When I am confused and need to get things back to their simplest forms, I draw a pyramid. It would make more sense to me if I saw somewhere in that mix the deliverers of the system — that is, the people who run the engines to take care of the client to make it work.
I am interested in your structure and the processes, and I am wondering how far out of the box we need to go to attempt implementation, given the fact that the regional boards do have mission statements. At the first two levels, you talk about incorporating the five principles of the Canada Health Act, that is, at the provincial level and at the regional board level. Would not the mission statement suffice?
I am overwhelmed by all the things we need to do with all the stakeholders within the system. You talk about pulling out of the current systems — whether they are provincial or federal — those that you desire to go into your council.
Could you help me with some of those theories?
Mr. Nestman: The role of the Canada Health Council must be feathered out and clarified. It is an important issue.
For my own vision or sense of it, I go back to what happened in the time of the Dominion Council of Health. That was a joint endeavour between the federal and provincial governments. They were the two partners in it. They had this common secretariat that would work up federal-provincial issues. That does not mean there was agreement, but they were articulated, ventilated, and many times the disagreements dissipated because they worked their way through the system. When they were brought to the policy level, you knew the positions where there was disagreement.
I talked to a person who was involved in that, namely, Fred McKinnon from Nova Scotia. He said that when we went through the Dominion Council of Health, it was good because we came to agreement on federal-provincial issues almost 80 per cent of the time. The council was a way of channelling discussion. We still had 20 per cent of disagreement on issues, but the council was a vehicle by which the total disagreement could be modified. We have total disagreement now because we do not have the structure to articulate it.
The issue is how it will be set up and who will be partners. The idea is to improve federal-provincial dialogue and discussion. As to the partners outside of the federal provincial government, how much impact the regions should have, is an interesting issue. Is this a federal-provincial-regional system? You can only take it back to the discussions we are having now in terms of federal-provincial-municipal. How much clout should municipalities have? This is a current issue in our Canadian system. How should the federal government respond to municipalities? This is a critical issue.
Looking at the regions as another level of government and whether they should be part of a Canada health council is an interesting issue. To me, providers — that is, doctors and nurses — have enough vehicles now to articulate their needs and interests. An impartial Canada health council needs to be a place because, otherwise, an endless group of providers would want to be involved. I do not see them as being central or participants in this council. It would not be a council to air all the views on the health care system; it would be to develop day-to-day management agreements on how the system should be administered and to discuss policy issues so that both sides understand one another and try to come to agreement or, where they disagree, allow some discussions to take place in a more impartial environment. That is my vision of it. The Dominion Council of Health did not have providers on it.
Who would be involved in this? I see it as being limited. The regions report to their departments of health. That would be their vehicle of input into a Canada health council. I can see the provinces possibly developing their own health councils within the province, although I have some difficulties with smaller provinces doing this.
Senator Cook: I come from a small province.
Mr. Nestman: So do I.
Senator Cook: I have been attempting to interface this in my home province of Newfoundland. As I look at it here, it is exclusive. We have excluded the deliverers of the service from the concept here. They need to be included at some level, whether it will be at the regional board level, because they know best. At the top, I can see policy and funding matters and some other components being important, especially when you pull out from existing agencies. We must be able to do a good piece of work outside the box. However, it is just as important to have the involvement of other piece, that is, the medical professions who are the deliverers of the service. I do not see how you can develop policy for a country as diverse as Canada if the other level does not have some input.
Mr. Nestman: When the Dominion Council of Health was operating, while the providers were not on the council, there were committee meetings where the physicians were brought in for a discussion. They would prepare a position paper and say, ``We better vet this with the nurses, doctors and lab techs to get their input.'' It was not a closed system; it was certainly open.
Senator Cook: That is how I understand it here. This is why I am asking you to help me walk through it.
Mr. Nestman: Their input was more advisory when they were asked to reflect on issues before the council. That is where I would see their input being brought in, rather than it being central to of the formulation. Who should be members of the council is an interesting issue. If you put too many people on a board, you will end up facing the same issues we face now.
Senator Cook: You define the job for the board and then you decide who will be on that board.
Mr. Nestman: To me, at this point in time, governments need a place to reflect, and I do not think they have that. They are in a hothouse environment; that is why deputies and ministers are turning over. Having permanency through a body such as a Canada health council would enable that federal-provincial kind of dialogue to take place. The deputy ministers have their council right now; the ministers of health have their councils now, so those functions could be rolled into a Canada health council. It is not a new invention. It is a matter of trying to bring everything together. I see the permanent secretariat as the important component that is missing.
The Deputy Chairman: This is just for clarification. What was the rationale at the time for the Dominion Council of Health being disbanded? Do you see there being a new oversight body much like we are talking about, an arm's length agency which would provide accountability? How do you see us getting this back in the box, so to speak?
Mr. Nestman: There are two issues there. The Dominion Council of Health started after Saskatchewan initiated its programs, and then the federal government and the other provinces became interested in that program. They realized that they needed a permanent kind of a secretariat to deal with federal-provincial issues and they saw it becoming a national body at some point in time. It grew out of a need, and then during Trudeau's era, it mysteriously disappeared. Those were the times of more difficult federal-provincial relationships. It was swept out then which, to me, was unfortunate.
Looking at impartiality from a provincial point of view is an interesting topic. I was talking earlier about the 1970s when they were developing these hospital and medical care commissions. The chief economist for the Hall Royal Commission in 1964, started a tremendous amount of thinking when he raised the question of whether health care in each province should be set up as a Crown corporation in which the day-to-day administration of the program could be taken out, providing some impartiality. Peter Meekison, a prominent political scientist from the University of Alberta, also started talking about this, as did quite a few people in Ontario. However, it dissipated because we went through an era of getting rid of these commissions in an effort to coordinate the system.
It would be interesting to consider whether such a Crown corporation could look after the day-to-day operations of the health care system. You saw remnants of that in Ontario when they set up the Ontario Health Services Restructuring Commission. They moved aside the restructuring model and said, ``Go do your job.'' You would not have to go much further to say, ``After you do the restructuring, make it a Crown corporation which will run the system.''
The idea is to move the day-to-day operations out of the Department of Health and develop an impartial system. You can never be totally impartial in this environment — no Crown corporation ever is. However, I think there are some defined tasks in each province that could be handled by an impartial organization. That, then, would still allow the departments of health to manage. I do not think they have done a good job steering, channelling or sending strategic messages to the system.
The Deputy Chairman: It was certainly the view of the people at our round table on Monday to retain the provincial departments of health. These bodies in the provinces would then directly link into the oversight body that you are suggesting now.
Mr. Nestman: They could, yes. You could develop a relationship there, because to me there are some linkages. I hate to recommend another layer in the system. That is why I am trying to ask in my paper: What areas of the health system could we absorb into these bodies so that we are not just duplicating functions?
My concern is that, currently, federally and provincially, we are starting quality councils and research institutes. These are all good initiatives, but I am afraid that by 2005 or 2006 we will be asking, ``How do we make sense of all these agencies? How will they be administered and coordinated?'' That is why you will notice I am asking: What areas could a Canadian council or provincial body absorb that we are already dealing with? With imagination, you could probably do some of that so that you are not just adding new money or creating other functions.
The Deputy Chairman: You are taking about creating another layer.
Senator Cook: Equalization is not a very nice word in my part of Canada. It was wonderful in the beginning. However, we believe the formula is punitive because it is per capita, and all of the Atlantic provinces suffer from out- migration for one reason or another. If we were to consider equalization in this scheme of things, we would have to walk far outside the box to see what was fair for Canadians.
Mr. Nestman: You are right in that it will require a courageous step. However, I think it should be done differently from how it was done in the past. It is interesting to look at the literature on the experience with cost sharing in Western Europe and even in the United States. Some changes in views are happening right now in terms of how cost sharing and equalization can be put together.
I have an interesting book here, which has yet to be published, which comes from the WHO observatory in Copenhagen. One of the conclusions is, if you have cost sharing with equalization, you have to recognize the costs of the system and a population health element.
People may ask: Why not use population funding totally? The problem is there is no existing risk adjustment system that takes into account the variations. The Netherlands and Germany found that they can only adjust for 30 per cent of the attributes of health between one region and another. They recognized that they do not have the technical capability for the other 70 per cent.
Actual costs equalization is still important because of the capacity of places like Newfoundland and New Brunswick which do not have the fiscal capacity. Both components should be in place.
When doing population health funding through equalization cost sharing, you must be careful of the incentives you send out in terms of population health. For example, if we know Cape Breton has a high obese population, should we reward them by giving them more money for that, or should we withdraw money so they reduce their obesity? That a crucial decision because the signal you send will set perverse or positive incentives either way. That is a crucial issue. The observatory found that we have to be creative. If we are going to send signals, we must make sure they are important.
Senator Cook: Population health is tied to the geography of my province, as it is in most of Canada. We need to look at where people live and what services we can realistically provide for in the area of population health.
We are an aging population. Workers move to urban centres where there are jobs. Population health and how we approach it are sensitive areas, given the geography of where we live. That is true of all the Maritime provinces.
The Deputy Chairman: That also applies to Northern Ontario.
Senator Cook: What other infrastructures are there? There is no point in having a good population health program if there is nothing to support the area.
Mr. Nestman: I am certainly sensitive to that in Nova Scotia. We are experiencing difficulties in Atlantic Canada, and I think Alberta and Manitoba share some of our concerns.
Certain services are difficult to provide in our provinces because they are high-cost services, for example, lung transplants. We have a difficult time staffing those procedures. A Canada council such as I am talking about could make decisions on national programs. We could finance a national centre where certain procedures could be done.
For example, in India, with a population of close to 1 billion, a major problem that arose was the incidence of cataracts. Cataract surgery was going on all over the country. It was decided that the surgeries would be performed in nine sites, and that they would pay people to go from their homes to the places where the surgery would be done. It became a national issue, because so many elderly people required cataract surgery.
That has improved the quality of care of delivery of cataract surgery in that country to the point where many of our ophthalmologists are travelling to India because they want to be involved in one of these specialized focus units. The volume of care moving through there, both complicated and easy operations, is so high, as is the quality of care, that they can get good training within two or three weeks because they run across every type of problem.
We may have to make the decision to centralize certain programs. They can be distributed. A council, such as the one we discussed, is the only body within which we will be able to reach that kind of agreement. That is where the trade-offs can take place. Alberta could get a centre and another province could get another one. That is the kind of manoeuvrability that could take place within a Canada council. We do not have that vehicle at present. Certain services are so costly and require such a high volume that we do not need them all over the country.
We may be able to help Newfoundland or Saskatchewan by giving them a centre for a particular service. Nobody likes to travel in our large country, but the pragmatics of the future may require it.
Denmark has centralized all their diabetics in a clinic in Copenhagen which provides three-quarters of the country's diabetic services. Nobody has complained about that. The quality of care at the clinic is internationally renowned at this time. It was a great decision to make 25 years ago.
Senator Keon: You just raised a very important point. I have had the personal experience of administering six national programs, and they are the only game in the country, so to speak. They occur by serendipity. What happens is you obtain research funding to try something, and when you get into the clinical arena, word gets out across the country that you can do this. Then you have to go to all the provincial deputy ministers of health to work out a funding arrangement to recoup the costs. I would endorse your idea, as there is no mechanism for dealing with this now other than many telephone calls.
Mr. Nestman: I would agree with what the senator said 100 per cent.
In closing, I would just say that your committee is at a historic time right now. Ernest Manning set up the first universal maternity hospital and child program in North America. It was a courageous decision. Tommy Douglas established the hospitalisation medicare program, another courageous decision. Paul Martin implemented some national senior programs. Castonguay in Quebec took courageous steps. He did not have all the information he needed to do it, but he made a major step to move the Quebec health care system in a new direction. There have been other leaders in Canada.
You are not going to get perfect information to act on home care, nursing homes or primary care. It takes courage. I would encourage you to be courageous and be remembered as the body that implemented national programs. We all have heard in the past that we cannot afford it. The provinces said they could not afford hospitalisation, medicare or Monique Begin's 1983 Canada Health Act. Hospitals in Quebec said they could not afford Castonguay's visions.
At some point in time you have to make a leap and move ahead. We know more about primary care now than we ever have. We know a lot about home care in this province, and a lot about nursing homes and pharmacare. Let us get on with it. Take a courageous step and write a bold report.
The Deputy Chairman: That is what the Canadian public wants as well. They want some leadership and courage to be shown in dealing with this issue.
On behalf of the committee, I would thank you, Professor Nestman, for a most interesting presentation. I am sure we will be calling you back on some of these issues.
The committee adjourned.