Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 57 - Evidence
OTTAWA, Wednesday, May 29, 2002
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 3:35 p.m. to examine the state of the health care system in Canada
Senator Marjory LeBreton (Deputy Chairman) in the Chair.
[English]
The Deputy Chairman: Honourable senators, I should like to welcome to our committee Dr. Ken Gardener and Dr. Ruth Wilson who, by the way, is the daughter of our recently retired colleague, Senator Lois Wilson.
Dr. Ken Gardener, Vice-President, Medical Affairs, Capital Health Authority: Thank you, Madam Chair. For the clarity of members of the committee, I wish to inform you that I am Vice President, Medical Affairs for the Capital Health Authority in Edmonton. I make that clarification because we have a Capital Health Authority in Victoria and Halifax as well.
I would like to express my appreciation for the opportunity to appear before your committee today. I have circulated some brief highlights of my speaking notes. I will provide the committee with a full briefing document at a later date.
I would highlight three issues that I see as historical barriers to the implementation of primary care reform. I will quickly go over where I think primary care reform has the best opportunity for return to the system, and outline some key factors to the successful implementation of primary care reform.
In terms of barriers to implementation, the first thing I have outlined is the profile of the generalist. Historically, over the last few decades in medicine, we have seen a tendency to go from a system of generalist-based medicine to a system of specialty- and subspecialty-based medicine. That has occurred within our hospital system and, to some extent, in family medicine with the development of specialty areas in family medicine around care of the elderly, palliative care, sports medicine, et cetera. Typically associated with this trend to specialtization and subspecialization has been a perception of increased value to the system of these special foci.
As a result, we have seen some decrease in the number of individuals choosing to go into general specialty areas, such as general internal medicine and general surgery. The perception of lesser value to the system has had an impact on community practice.
Associated with that is competition for resources. These resources are financial, technological and human. When the funding is on the table, it has always been a challenge for primary care services to compete with acute hospital-based services.
The other point relates to public perception. Generally speaking, when you talk to the public, they are quite happy with their primary care system. They may not like doctors in general, but they like their own doctor. Following on from this perception, it is unusual, for example, to see a front page headline which reads, ``Patient Waits Five Days to Access Family Physician.'' What we will see instead is, ``Patient Waits Five Days in Emergency to Access In-patient Bed.''
The profile of the higher perceived value of the specialties, the effect that has on the competition for resources, and the fact that there has not been a significant public driver, have historically led to less focus on rolling out reform within the primary care system.
The primary care system provides a lot of service. For the sake of simplicity, I have outlined them as health promotion, disease prevention, acute episode management, chronic disease management and interface management. By ``interface management,'' I mean managing the interaction between the primary care system and self-care on the one side and secondary-tertiary care on the other. Over time we have seen a blurring of the margins of these interfaces. Much of what used to be standard now involves interacting with the system. As well, what used to be quite typically hospital-based medical care has now been brought into the community and the primary care environment.
If everything were working well, we would not be meeting. Where are the problems in terms of these particular roles?
Most people would say that the acute episode management and the interface between secondary and tertiary care has not been seen as an issue. Chronic disease management, when you look at national statistics around diabetes care, for example, which is often quoted, and the areas of health promotion and disease prevention have been highlighted as the areas where, if we made changes to the system, we could enhance the role in those areas. Those, along with the self- care and primary care interface, would be the areas where we would look for the largest return on investment.
How do we make that happen? Many initiatives have been suggested, and have brought forward three. The first relates to information management in three areas: public information, practice information and system information. We know that the public has a thirst for health information. The explosion of health-related Web sites and publications has produced a much more informed public and a public that wants to take additional responsibility for their care. In order to support this, we need to ensure as a system that we provide them with reliable and credible health information.
At the practice level, we are speaking of electronic medical records. I can go to an oil change franchise outlet where they type in my licence plate number, and they know my name, the service I had last time, what they advised and what I did not accept. That level of technology is not currently available in many of our community practices.
How does that change quality? It does it by allowing us to build in, as part of routine practice, the evidence-based medicine and the decision-support tools that are available. If a patient with diabetes comes in and registers, irrespective of what the patient is coming in for, the system will flag that he or she has diabetes. We will have in place programmed check marks to register whether they have had their hemoglobin A1C recently, their urine test for protein, their eye examination, et cetera. If those have not been done, a flag will come up, and that will prompt appropriate management.
The second involves formalizing the relationship between the consumer and the provider, the rostering concept. It is usually described in association with alternative payment plans. If we are going to move to a system where we set performance targets and accountability, we need to have a formal relationship between the providers and the consumers.
The last component is team practice. This has been talked about in many forums. From the patient perspective, they deserve to have the services of the skill sets of the various health professions in the community, as they do in the hospitals. From the provider perspective, there needs to be utilization of the full scope of practice. This is the evolution of reform that encourages physicians to form groups, encourages moving to alternative payment plans to allow the full utilization of other providers, and allows the appropriate distribution of work.
Dr. Ruth Wilson, Chair, Ontario Family Health Network: Thank you very much for the opportunity to appear before your committee. My mother briefed me beforehand so that I would show the appropriate amount of respect to your committee.
As a practicing family doctor, I know that the science of medicine is always changing. Every day, doctors have access to more information, better medicines and more advanced techniques. I also know that, no matter how sophisticated the procedures and medications become, no matter how deep our understanding of the origins of disease, a person's relationship with their primary caregiver, their family doctor, is essential if they are to benefit from these medical advances.
I agreed to chair the Ontario Family Heath Network and to work to implement its goals because I believe that family health networks support that relationship. The Ontario Family Health Network is a new provincial agency in Ontario, charged with implementing primary care reform, not on a pilot basis, but on a province-wide basis in Ontario.
I became involved for three reasons. The first is that, for the last 10 years, I have been the head of the department of family medicine at Queen's University. I was educating young family doctors to run a full-range practice, but, as I was with them as they learned how to deliver a baby, I felt that I was wasting my efforts because I knew that, when they graduated and went into a practice environment, it would not support them with practice infrastructure, financial incentives, and teams that would enable them to practice that full range of care that I had been training them for. As a result, I was feeling increasingly frustrated in my educational role. We were producing well-trained family doctors who were attractive to the States and other places but were not well supported here in Canada.
In my work at Queen's, over the last five years, I have been involved in a project in Bosnia to help them develop their primary care system. When I am in Europe, I am very aware of how well regarded the Canadian health care system is. Fifty per cent of our doctors are family doctors. We have a good balance between the generalist and the specialist to whom Dr. Gardener referred. There are many strengths in our system. We do not need a revolution. However, we need increased support for the work family doctors do. I am particularly concerned about the decreasing level of interest in family medicine as a career.
Finally, I have a personal level of interest in primary care reform. Some of you know my family. We have faced some health problems in the last couple of years. Family members have good relationships with their GPs, but some GPs, including some who serve my family, have Monday to Friday office hours. If someone is sick after hours, short of breath wondering what he or she should do, the alternative is to call the doctor daughter or go to the emergency department. I think we can do better in providing access to care for citizens.
I will outline what we now offer to all family physicians in Ontario. Since the end of January, we have been able to offer the ability to form family health networks. I will go into some detail for you, and I also have handouts you may take away and study. I will focus heavily on family doctors in my remarks. However, I do have a vision for primary care reform that goes beyond family doctors. We absolutely need to work with other professionals in networks of providers to support our patients. We are expecting and hoping the relationships with other professionals will grow as we put family health networks in place.
In some ways, I apologize that I am not going to speak more about other providers; but in other ways, I am not apologetic, as I do think we need to fundamentally support and network our family medicine practice group in Ontario.
In Ontario, the support that I have spoken of partly lies in the funding model that was negotiated by the Ministry of Health and Long-Term Care and the Ontario Medical Association. When you talk about barriers to moving forward in primary care, in Ontario the fact that the OMA and the ministry have jointly agreed on this funding arrangement, has been a tremendous source of strength to me as an implementer, as I go out to explain it to doctors.
The payment system provides rewards for full-service family medicine and there are payments for meeting preventive targets in areas such as pap smears, mammograms, flu shots and immunizations, and there are targets for comprehensive care and taking advantage of CME, continuing medical education.
There are also premiums for caring for patients outside the office. This is something that family doctors are well able to do. The financial incentives have not been there for a number of years. There are financial incentives for doing house calls, and for palliative, prenatal, obstetrics and hospital care. This encourages doctors to be with their patients when a baby is delivered and in the nursing home when they grow old. It encourages the cradle-to-grave care that they know how to deliver.
I mentioned preventive care and that family heath networks encourage continuity of care and the doctor-patient relationship. When patients enrol with a physician in a family health network, they undertake to seek primary care from that network first, unless they are in an emergency situation or on holidays, travelling somewhere. Patients sign a form saying that they will undertake to receive their primary care through the network in the first instance. That is the difference between seeing ``the'' doctor and seeing ``your'' doctor. It fosters a personal relationship.
As well, family health networks will receive funding for information technology. You have heard about the enormous clinical potential of information technology. Significant funding is going into providing software and hardware for family health networks.
I see a lack a of data standards in primary care. In that regard, I would mention that I enjoyed reading your fifth report with its recommendations. I was particularly struck by the analogy about who would provide the diagnostic service if a person says that his light bulb is burned out. In your report you posed the question of whether it would be cheaper to call in an electrician, who changes light bulbs at great cost, or an electrician who could make a diagnosis. You dance a line on that, but you point out that, from the perspective of the person with the problem, the only difficulty they recognize is that it is dark. Our national current coding systems will code the burnt out light bulb, the fuse box problem, the major wiring problem, but we do not have good coding systems for ``dark.''
As a family doctor, I see lots of patients with symptoms. They are tired, depressed and dizzy. They are not sleeping and they are run down. Sometimes I cannot make a diagnosis for quite a while, and sometimes I never make a diagnosis. A multiplicity of factors contributes to that.
We do not have a way of coding or making sense of many symptoms in our IT systems. Our IT systems are heavily influenced by the hospital sector, which is good at coding appendicitis or arthritis. Some leadership needs to be taken in establishing data standards for primary care — standards to which family doctors, nurses and nurse practitioners can contribute. There may be a potential federal role to be played in that area.
I will speak about some of the advantages that physicians and others have found in the family health network funding model. For the last number of years, we have been undertaking pilot projects in Ontario. We have now moved beyond the pilot phase. The pilot projects have given us important information about some of the advantages of our funding model.
In particular, a significant portion of the funding is capitation or base rate payments. That gives equity in health funding so that the funding is the same for each network for the patient population covered. It also gives doctors in the network some stability. They know there is funding coming in on a regular basis that does not depend on a fee-for- service treadmill to ensure they are remunerated properly. It frees them up to practice in a different way, to give advice over the phone and to work with a nurse practitioner to provide care. They like the fact that they can take a vacation and know that their overhead costs will be covered. They get a better balance between work and lifestyle. We need that to stabilize the physician workforce in Ontario.
Finally, I would draw to your attention the issue of access to care. In the family health network model in Ontario, we ask networks to provide access to care through a combination of regular office hours and extended evening and weekend hours. When the office is closed, the phones are answered by a nurse who performs a teletriage encounter with the patient. The patient can either be sent to the emergency department, given some advice about self care or, in our model, if the nurse is not sure what to do, she has the ability to phone the doctor on call for that network, and he or she has access to the patient's record. Between them, they can figure out some advice for the patient or see the patient, if required.
I am very optimistic about the success of family health networks. We received serious requests for information projecting revenue analyses for over 500 physicians in Ontario. My staff and I held meetings with more than 520 interested physicians. On May 16, the Honourable Tony Clement opened the first family health network in Ontario, the Dorval Medical Associates Family Health Network, in Oakville. We expect other openings soon.
For some physicians, this has been a difficult decision. We are asking them to move into a group practice to be paid in a different way, to consider collaboration with other colleagues and to take advantage of information technology. It takes them a while to get used to that idea. We have provided them with a workbook — and I have provided you with that as well — that outlines the funding model and an information kit that gives some basic information on it. I have also given you a patient brochure which outlines what we are asking the patient to do.
I would suggest that you take a moment to read the few paragraphs written by Dr. George Southey, the lead physician in the first family health network. We did not write his remarks for him. He came up with a list of the reasons patients and physicians would be well served by family health networks. I will read the last paragraph which states that:
One of the great defining characteristics of our society is our collective decision to care for each other through our health care system. What a great reflection on us as a country.
The Deputy Chairman: How has the Telephone Health Advisory Service that is now being offered in Ontario working? Is there any system of tracking the success rate when calls come in?
Dr. Wilson: That is a good question. There are currently two systems operating in Ontario. One is the system that is open to everyone. That is the one to which you are referring. It provides similar advice to the advice that family health network patients would get. However, it cannot link you to a doctor.
If you call the nurse for the provincial system, she will give you self-care advice, direct you to emergency, or advise you to seek medical advice. She does not have the ability to link you to your doctor or to a doctor to get that advice. There is slight difference.
We have evaluated both systems to some extent. Our Web site has some information that the committee might want to look at. It shows good results in terms of decreasing the demand for emergency services. When patients are asked what they would have done if they been unable to speak to a nurse, many say that they would have gone to emergency but, they say that, having spoken to the nurse, they will take another course of action. We are pleased to hear that. That is why we are making it part of the roll-out.
The Deputy Chairman: Is it taking pressure off 911 responses?
Dr. Wilson: Our numbers indicate that a small percentage of people would not go to the emergency department. The nurse, however, may advise the patient not to ignore, say, a that chest pain, and offer to call 911. That is a more appropriate use of the 911 service.
Dr. Gardener: In Edmonton, in September 2000, we launched Capital Health Link, a 24-hour-a-day, seven-day-a- week health information line. The board had identified that providing information to the public was a key business of the regional health authority. This afforded us the opportunity to coalesce what we discovered were over 40 different health information lines that were operating in the region.
We set the line up to do two things. One was to provide advice to the public on how to navigate the complicated system. Knowing how to access Home Care Services for a relative or finding out where prenatal classes are held, is information that the public wanted.
The line was also set up to provide health advice. This is done through partnering with software-based nurse triage algorithms developed by the Cleveland Clinic. In the first year of operation we had 250,000 calls. The public response was overwhelming. The evaluations we did were very positive. The independent firm we hired indicated that they had never seen satisfaction levels in an evaluation of a call centre at that level in any other area of the industry.
Similar to what Dr. Wilson indicated, the purpose of this is to help patients manage that interface between self-care and primary care. The new mother who wakes up in the middle of the night with a baby who she thinks has a fever is often not sure whether she needs to go to emergency or not.
When we followed this, we immediately noticed that the increase in the number of non-urgent visits to emergency was going down. In the last quarter of the last fiscal year, we saw an actual decrease in the number of non-urgent visits to emergency for the first time in years.
Reducing non-urgent emergency department use is great in that you can save some money. However, the key here is the appropriate use of the resources. A number of people can avoid going to an emergency department. However, if one or two people, who are uncertain whether they need to go to emergency — and they do need to go — and they are advised to go to get the appropriate blood thinning medication for their stroke, for example, and as a result they end up with a slight or no residual deformity, then that is where there is significant impact.
The Deputy Chairman: I should like to hear both of your comments to my next question.
Dr. Wilson, in your paper you acknowledge that we are asking family physicians to change the way they are paid and move from the present system to a primary care team approach.
You have had this experience in Edmonton, Dr. Gardener.
What kind of incentives would you suggest? How do we get there? Do we target new, young doctors coming out of medical schools? Have you given that some thought? Have you put into practice some devices or proposals to get doctors into primary care without a lot of personal stress?
Dr. Wilson: My work now involves exactly that. You will see how we do and what works best.
We believe that financial incentives are important. The financial rewards for physicians moving into family health networks are there. I tell them that I do not expect them to move into a new form of practice unless it makes sense to them financially. There are some financial bonuses and incentives. In particular, they are targeted to the full-spectrum comprehensive care that we want to see as opposed to the episodic care where the rewards have been centred recently.
Beyond that, you are right, senator, in that more needs to be done. We are putting in place some courses to help doctors in the kind of team building and group work that they will have to do, both with other physicians so as to establish a level of trust if they are not used to working in groups of doctors, and also to help them work in collaboration with other providers.
There was an interesting study done here in Ottawa by Dan Way and Linda Jones, which indicates that, if you take time to teach family doctors and nurse practitioners how to collaborate, they end up collaborating more. If you do not teach them how, they end up talking to each other less. The situation does not stay neutral, it deteriorates. Those sorts of educational opportunities for doctors are important.
In practical terms, we have medical consultants and site co-ordinators, staff people from our network, who will meet with groups of doctors and work them through, step-by-step, what is required to form a family health network. We will do as much of the paperwork and administration for them as we can. For example, if they get to the point where they want to form a network, we will do the mailings for the enrolment of patients. We do this so as to take as much of the administrative paperwork from them as possible.
The Deputy Chairman: Dr. Gardener, do you have some comments on that evolution?
Dr. Gardener: It is a significant challenge. If you were to look in most environments at present, you would clearly see three groups of physicians. There are physicians who are ready to go. They know that they want to change the way they practice. They are happy to look at alternate payment, and they are pushing to make it happen.
At the other end of the spectrum there are physicians who are perfectly happy with the way things are.
Then there is a group in the middle who are interested, and they get the information and might look at it, but they are not ready to take the leap.
Historically, we have been working diligently with the first group. We have been trying to get a critical mass of individuals practising in an alternate environment and becoming the champions who will tell others how good this is. That has been how we have been trying to approach this.
There are challenges. Dr. Wilson mentioned the change management process. In the northeast project that we set up in Edmonton, we quickly discovered that you cannot just put doctors, nurse practitioners, rehabilitation specialists and other people in place and expect a team to form instantly. A significant amount of work is involved in that.
One of the challenges of alternate payment plans is to ensure that you do not have the relative value guide wrong again. As evidenced by the work done by Dr. Wilson and her colleagues, much effort has been put into ensuring that you do not give up necessarily the good points of one system simply for another. Each system has its own pluses and minuses. If you end up getting the relative value guide wrong on a pure capitation system, you can be in for more trouble than you anticipated.
We are working through the critical phase, getting critical mass and building on success.
Senator Callbeck: Dr. Gardener, I want to ask you about something you have not touched on today. Last year, I believe it was, the Edmonton authority won an innovation award for setting up councils to act as a communication link between the board and the community.
How were those councils set up? How many are on them? How were the people on them chosen? Are they volunteers? How do they communicate with the community?
Dr. Gardener: The community health councils were set up initially at the time of regionalization. I am not sure of the exact number of members on each council, but it is roughly 10 or 12. A notice went out to the public calling for interested individuals to sit on the community health councils. Individual applications came in. A combination of board members with support from members of the administrative team worked through the selection process of choosing from the list of candidates. Now, some of the current members of the community health councils participate in that as well by identifying members. They are all volunteers.
An infrastructure within the administrative framework of the capital health authority coordinates their activities. The councils have different ways of getting community input. Some hold public meetings, public forums.
On a formal basis, there are interactions with the Capital Health Authority board in terms of getting the input from the community to the board.
Senator Callbeck: If you were to make a major decision, would you consult these councils for input?
Dr. Gardener: Certainly, we ask the community health councils for their opinion on issues that may be coming down and evolving through the system.
Senator Callbeck: You would not consult on every issue that may arise.
Dr. Gardener: That is right. The focus for them is fairly high level. In particular, we do not look to the community health councils to deal with operational issues. We look to them for visioning and strategic directions, ensuring that, if there are community needs, we are setting the path to meet those needs. The Northeast Community Health Centre is an example of this. There was a tremendous amount of community input in terms of the unmet needs of that particular community that led to the development of that program.
Senator Callbeck: Are there any problems associated with these councils? In other words, do you think this is something that should be adopted elsewhere in Canada?
Dr. Gardener: We must ensure that we have adequate input from the public. The primary care reform scenario is an example. It is a challenge. If we were to move to a requirement that individuals must register with an individual physician, practice or provider, that would be the kind of requirement that could create major problems if the public were not onside.
Every jurisdiction needs to have some mechanism to obtain input from the public and to seek their advice on particular issues. Whether the community health councils are the only way to do that, I am not sure. However, that function is necessary.
Senator Callbeck: You have found it to be a positive experience.
Dr. Gardener: We have. When new councils come on, there is a learning curve in that some individuals who come on have a particular interest they wish to drive. However, they have been a valuable source of community input for us.
Senator Callbeck: Dr. Wilson, will the Ontario Family Health Network be implemented across Ontario? Will it apply to rural areas?
Dr. Wilson: I practised in northern Canada for 12 years — Northern Newfoundland, Northern B.C. and for six years in Northern Ontario. I am confident that this model will also work for rural communities.
We ask family health networks to have a minimum of five physicians. If there are communities that have fewer than five physicians, this particular model does not apply. They need another form of funding and other supports. It will work very well for those communities that have a minimum of five physicians and a small rural hospital.
Adjustments have been to accommodate the rural situation. In communities where family physicians are working in a rural hospital, if they have hospital privileges and are actively participating in the hospital work, then we waive the requirements to provide extended office hours and weekend hours.
Having worked in the North I recognize that it makes no sense, in a community with eight doctors, to have one staffing the emergency department on a Saturday morning and another one staffing the office. That would be too much of a drain on your human resources. We do say in rural areas that they can provide after-hours care out of the emergency department or outpatient department. We have made some adjustments in that regard. There are also modest financial incentives in the model for rural practice.
Senator Callbeck: I come from Prince Edward Island where most rural areas would not have five doctors.
Dr. Wilson: I do know some of the family doctors in P.E.I. One of our pilot sites is operating in the rural area north of Kingston. It encompasses the communities of Sharbot Lake, Sydenham, Tamworth, Verona and Newburg. From one community to the other would be about an hour's drive. None of the communities has more than two family doctors. The population in each small village would be about 1,000 or 2,000. Since it is a pilot project, two nurse practitioners have moved into that network.
The doctors have formed a network. The first thing they did was to share call. At first they were reluctant to do that because they were used to being on call most of the time for people in their own village, many of whom were their neighbours. They were reluctant to have weekends or nights off when the doctor in the next village would be on call. Last summer, they did all their call as a group, and they enjoyed it. Over the winter, they have come together as a call group.
In rural communities, that situation offers the doctors some stability from a lifestyle point of view, and it gives them an opportunity to take some time off.
They also enjoyed the implementation of the teletriage system to deal with the calls for advice that would come in at any hour from people in their small towns. Because they saw that their doctor's porch light was on, they would call. Those have dropped dramatically.
The addition of the nurse practitioner has been very popular, particularly in one practice that had no female providers.
We are confident from that pilot experience that small communities — and I think this could work in P.E.I. where driving distances are reasonable — within an hour of each other, with one, two or three doctors in each community, could form a network and offer care.
[Translation]
Senator Pépin: As a follow-up to the question from senator Callbeck, I would like to know if there is a significant difference between the response of doctors in rural areas and those who work in an urban environment or who participated in the pilot projects?
[English]
Dr. Wilson: I would say no. Interest has been expressed in the pilot projects by city, urban, suburban, rural and remote physicians. Last month we had requests from Dryden, Sioux Lookout, Haliburton, Guelph, Oakville, Ottawa, Thunder Bay, North Bay, Sault Ste. Marie, London and Kingston. It is all over the map.
Young doctors are interested because, when they graduate, they want to move into a set-up where they do not have to put lots of time into administration or setting up a clinic. They like the idea of a network. Semi-retired or older physicians like it because they are in a call group and they can share call and perhaps work part time and their patients are looked after. Female physicians like it because they can work part time and know their patients are looked after. Doctors who provide comprehensive care — obstetrics and hospital work — welcome it for the financial rebalancing of incentives. Doctors who are interested in information technology welcome it.
I cannot categorize the interest as being just rural or just urban. I have seen interest from all age groups, from both sexes, and from a wide geographical area.
Does it appeal to everyone? Not at all. Not every doctor wants to work in a group or provide comprehensive care. Many doctors are not interested in information technology. However, I have described the kind of doctors it has appealed to so far.
Senator Pépin: Some patients have told our committee that they feel much more comfortable with a team because, if one doctor is unavailable, another doctor from the team will see them, and the doctors are familiar with their files.
In some pilot projects, it appears there was difficulty regarding traditional nurses. Are you aware of the problem between some nurses and doctors, and has anything been done about it?
Dr. Wilson: We have a new role in Ontario, the nurse practitioner role. Not every province has nurse practitioners. Those nurses have an expanded scope of practice. They have the ability to diagnose and treat common ailments, to prescribe medications, to order x-rays and to apply casts.
Some are nurses who are operating within that scope of practice in smaller, remote communities. Others are nurses who have taken a formal training program in our universities and colleges to achieve that classification.
Currently, there are approximately 400 nurse practitioners in Ontario. However, there are not a large number of funded positions for nurse practitioners. Some of them are available in community health centres and in northern communities. We hope that, in the future, there will be additional opportunities for nurse practitioners in Ontario.
Senator Morin: How many nurse practitioners are included in the family health network system? If none, why not?
Dr. Wilson: I skated around that when I started. Let me describe the process in Ontario. We are determined to do this in Ontario province-wide. We are moving beyond pilots. We want to move the mainstream model in Ontario to become a network model.
The ministry and the Ontario Medical Association were key in negotiating the model. They successfully negotiated a compensation and practice model for family physicians. With the agreement of the OMA and the ministry, that is what is on offer now.
That is not enough. We would all agree — myself, the OMA and the nursing associations — that we need more practitioners to be added to family networks and the government is committed to seeing that happen. However, as of today, I do not have the exact mechanism for how that will happen. I am confident that announcements will be mad. Right now, what is being offered is being offered to family physicians.
The Deputy Chairman: Some time ago a witness told us that 40 per cent of the trained nurse practitioners in Ontario were unable to get employment as nurse practitioners and were off working in, say, Wal-Mart. You are trying to address the issue of having them properly integrated into the system.
Dr. Wilson: I saw some testimony to the effect that they were underemployed, and I also saw something about them being in retail.
My information is that many of them are underemployed in the sense that they are working as nurses, but not to a full scope of practice. I am not aware of a large-scale movement of nurse practitioners out of the field of medicine, though there may be some.
I am as desirous as you are of seeing the model expanded to include other practitioners, and I am that confident it will happen. Having said that, we must start somewhere. We have a large process of change to introduce if we are to convince the thousands of family physicians in Ontario to accept this model. This is the first step that is on offer.
The Deputy Chairman: It is a big hill to climb.
[Translation]
Senator Pépin: I would like a clarification on one point. For now, in the Ontario system, patients have to register. Their family doctor can refer them to a specialist. And they can change doctors up to twice a year. However, if they see another general practitioner regularly, the doctor they are seeing in the network can take their name off his list of patients.
What is the difference between a patient registered with a network and one who is not? If I decide to leave the clinic where I am registered because I believe I will be better served elsewhere, if I shop around, in other words, do I run the risk of ending up nowhere?
[English]
Dr. Wilson: First, we ask family doctors who form family health networks to offer the ability to enrol to all of their current patients. We ask them to do that because we do not want them to choose only the healthy to enrol and not enrol the sick. Since part of the system is capitation based, there is a potential incentive to roster the healthy, for whom you get a monthly payment whether you see them or not, and avoid the sick, who need to be seen more often. We want to ensure that that situation does not evolve. We require the physician to offer the ability to be enrolled to all patients.
Patients sign an agreement that they will undertake to receive their primary care through the network. They are not at all stopped from second opinions or from consultant opinions. We hope and expect that the family doctor will coordinate that for them.
We do not want patients to feel tied down. If the doctor-patient relationship does not work for them, we do not want them to have barriers to moving to another family doctor. We say that patients can change their doctors twice in a year. We do not lock them in and specify that they must stay with a certain doctor forever.
We might have a situation where the patient has agreed to enrol with me, perhaps, and then she persistently uses walk-in clinics, that is, she double doctors and sees a variety of other providers. The contract would allow me to say to her that she is not living up to her obligation, which is that she will seek primary care through the network. I could de- enrol her. She could still be my patient, because I would not be ending the doctor-patient relationship, but I would not be paid for her in the same way that I am paid for enrolled patients. That does not matter to the patient, but it matters to the physician. The physician can retain that patient on a fee-for-service basis.
The patient, theoretically, ought not to have access then to the telephone triage system, and she would not receive the reminders that we would send out regarding preventive care that we would offer to enrolled patients. She might not be reminded to have her mammogram or her pap test. However, she can still enrol as a patient of that physician.
Senator Pépin: If there is an emergency, can she still attend your clinic?
Dr. Wilson: She can still attend for her regular health needs as well. If the doctor decides, and the patients agrees, that the patient cannot live up to the obligations in the contract, she can still be a patient, but not an enrolled patient. The doctor will not be paid a capitation rate but, rather, a fee for service.
Senator Pépin: You would be penalized money-wise; is that correct?
Dr. Wilson: Potentially, I would be penalized. I would lose some financial incentives if she went outside the network for care. If I de-enrol her, I will be paid fee for service the way most doctors are currently paid.
[Translation]
Senator Pépin: The health system is under provincial jurisdiction. What could the federal government do to facilitate the primary health care reform, apart from offering financial support, of course? Could we also establish conditions?
[English]
Dr. Wilson: I am going beyond my scope of expertise now.
Senator Pépin: Perhaps Dr. Gardener can reply.
Dr. Gardener: That is beyond my field of expertise as well.
Senator Pépin: I am sure you know.
Dr. Gardener: Much of the dialogue around your question about whether an individual actually needs to identify with a physician or with a practice involves the following: What is the accountability from the public perspective and what are the expectations from the public perspective? These are critical points when you talk about primary care. When you talk about hospital care and acute care, there is not that relationship over time. It is sort of the difference between choosing a hotel room for one night or choosing a resort place to which you will return year after year. You probably put more time and effort into the one with which you have that familiar relationship.
There must be some sort of guidance in terms of what, from the public perspective, are reasonable accountabilities in terms of the system. Somehow, we need to remove primary care from being directly in competition for scarce resources with the acute care system.
Any assistance from the federal government, either in setting expectations or with funding, which would allow the development of information systems infrastructure, setting guidelines and so on is important. We must determine what those should do, so that we do not have different systems that cannot link up with each other.
We also must determine the appropriate percentage of our investment in health that should be going into primary care versus the other sectors.
Senator Morin: What you are saying, Dr. Gardener, is very important. If I understand correctly, your first priority for primary care would be a truly national information system. I am not sure about your second priority. Are you saying that the federal government should tell the provinces what percentage of their funding should go to primary care? I fully realize that there is a need for resources for primary care. What is your second priority?
Dr. Gardener: I apologize. I cannot wade into the politics of what the federal government can tell provincial governments to do. I would be in too far over my head to do that.
To be successful, we need some system that will allow the investment in primary care, recognizing that the return on that investment is not immediate. There are additional costs to be assumed up front. We clearly need to put in place the processes to monitor and evaluate the longer-term investment in health promotion, disease prevention and chronic disease management by avoiding the development of complications related to what would currently be seen as not best practice in many of these areas.
I am not sure how that will happen. If there is a role for the federal government to assist in ensuring that primary care is viewed in an environment that does not continually put it in competition with the wait lists for joint replacement, cardiac surgery, the emergency rooms, et cetera, that would be very constructive. Exactly how that would be done, I cannot say.
Senator Fairbairn: I applaud the efforts you are making with the network in Ontario.
Dr. Gardener, as you began your presentation, you talked about the decrease of generalists in today's society because, with the expansion of technology, a lesser value is placed on pursuing that particular form of medicine.
I come from Lethbridge, a small city southern Alberta. The area is a major focal point of activity and marvellous, small towns surround it. You talked about a family health network in small communities having two or three doctors. How can we adapt our health system in this country to be able to provide service in our smallest communities, which are a fundamental part of our history and our society? It is sometimes difficult to attract one doctor to those small communities, and it certainly would not be a specialist. That has happened in my area, and psychological impact that has on a community is profound. It affects the very survival of a community in which people would wish to raise a family.
Dr. Wilson, perhaps this is not the kind of problem that is as obvious in Ontario as it is in my area. How would you suggest we build a health network to fulfil the needs of those small communities?
Dr. Gardener, you are probably aware of some of these concerns. These are attractive communities which offer a good quality of life. A few physicians are coming from other countries to take these jobs that will not be filled by Canadians. How can we deal with better understanding and also advising on this particular phenomenon in our society right now? It is critical.
Our committee has spent a lot of time talking about the differences between rural and urban requirements. What I am asking about now is the different definitions of the word ``rural'' in various parts of Canada. It is difficult to encourage young people who have just completed their university training to practice in those communities. How can we attract them?
Dr. Wilson: I know Dr. Gardener will have lots to say, but I wish to respond to that. In so doing, I am taking off my family-health-network hat and donning my professor-of-family-medicine hat.
At Queen's, we have a mission to train family physicians for small, remote and rural communities. We have a good track record. Since its inception in 1975, 25 per cent of our graduates have gone into communities of populations under 10,000. I am very proud of that.
From an educational point of view, I know that some things work, and I suspect you already know them. However, I will remind you of them. It works to recruit into medicine young men and women who are born and raised in rural communities. They have a comfort level about going back there. It works to give them early exposure to rural medicine in their training.
We see a tremendous amount of badmouthing and denigration of rural practice in our urban medical centres. If medical students have an opportunity in their first, second, third and fourth years to spend some time with a rural GP, they see a scope of practice and rewards in that practice that they will never see in a liver transplant unit. They also see the patients that the GP failed to take care adequately. They form a different view of rural medicine. Early, repeated exposure to meaningful role models of practice makes a difference.
We know that postgraduate training in the role they are to assume also makes a difference. I personally know of two GP anaesthetists who wanted to practice in rural communities and trained to do GP anaesthesia. Both quit on their first day in rural communities when they realized that they were the only anaesthetists in town. They did not have someone to back them up when they ran into trouble. Training people so that they practice the role in a safe way before they have to assume it also works. Some of the other things are harder to engineer. The role of spouse is really important. If the spouse has a job in a small rural community or has roots there, that helps. Of course, we cannot engineer that in medical school, but we know that makes a difference.
As well, the remuneration must be adequate.
There are a number of factors to consider. For a number of years I recruited doctors for rural and remote areas, so I know that it make a tremendous difference if doctors can be recruited into some sort of organizational support, for example, an organization that will arrange for locum coverage for them, arrange for CME for them, look after them and ensures they get regular breaks — that is, a network or some form of support. We know that makes a difference in recruiting. Sometimes, it is the support of the community that makes a difference.
We know there is also a role for critical mass. Once, for four days, I was the only doctor in the town of Bella Coola, B.C., which had a population of 2,500. I remember the terror I felt for the whole four days. I had wonderful nursing colleagues and nothing bad happened, but I felt the weight of the world on my shoulders as solo GP in that area. We know that doctors in rural practice need the support of nursing colleagues and the support of other doctors.
I am sure you have heard a great deal of testimony on the current physician human resource problem in this country, the declining number of physicians and the declining interest in family medicine. One of the things that will solve the problem of rural and urban medicine is that more doctors, period. An increase in supply would sure help, along with all these other things.
I apologize for that rant, but it is a favourite topic of mine.
Dr. Gardener: I agree with Dr. Wilson. Certainly, from the training perspective and speaking for Alberta, we now have a rural family physician training program in our two medical schools in the province that specifically utilize a rural training program in their curriculae.
The infrastructure support necessary to retain physicians is very important. The rural physician action plan does provide locum support and CME support, and that is really important.
We can provide system support to individuals. We have set up a critical care line in Edmonton. This is a 1-800 telephone access line specifically set up for rural family physicians in central and northern Alberta, north-eastern British Columbiam the Northwest Territories and parts of Nunavut. If a rural physician requires critical life-saving advice or immediate transportation of a patient to a referral centre, by phoning that number, they will be able to speak to a consultant specialist within four or five minutes.
The technology allows us to link up to 30 individuals on the phone line without any loss of tone. While someone is locating, say, a neurosurgeon or a cardiologist, the provincial flight coordination centre is arranging fixed-wing aircraft transportation. If the distance to be travelled is within a certain range, the ambulance service will be contacted. They can be listening in on the line and getting the information at the same time. Perhaps they may be rolling the helicopter out of the hangar so that there is no delay. The advice is given; the decisions are made.
Approximately 10 per cent of the calls end up with a consultation and the referring physician is comfortable enough managing that case without sending the patient to an urban hospital. However, 90 per cent do come in. In the situation where we do not have the resource, we can link in Saskatoon, Calgary, Red Deer, Grand Prairie, or any number of other places.
When we evaluated project, the rural physicians told us that the technological link was a significant support to them. Their comfort level while practicing in the smaller towns, particularly in northern Alberta, went up considerably. Knowing that they could contact someone within minutes, irrespective of the problem they faced, was a significant factor in retaining physicians in those regions.
I will say nothing more on the educational side because Dr. Wilson is the expert.
Senator Fairbairn: I was touched by Dr. Wilson's comments about how she felt while she was in Bella Coola. I can relate those to some comments I heard in a remote community in my area. People come, perhaps lured by a genuine interest in rural health, but they do not realize that they will have no support system. They have no nurse practitioner and they are not near a hospital. They just simply burn out. Perhaps we will never solve this problem. Technological support is all well and good, but these rural physicians need more than that. I can understand why some do not stay. Perhaps if you entice couples to serve these rural communities, it would be more likely that they would stay
Dr. Gardener: There is no easy answer. The challenge is to match supply with demand and how to identify where to best deploy the individuals. Many communities across this country do not have a physician. Ensuring that transportation — whether it be an ambulance service or whatever — is available to transport patients to somewhere they can get help in a timely fashion, is clearly a high priority for those areas. There is no magic solution to the problems faced by isolated communities that believe that they have a critical mass and require resident practitioners.
As Dr. Wilson indicated, if we had more doctors and more nurse practitioners, we would potentially be in a situation of being able to deploy them in ways other than we currently do. In the absence of those numbers, putting in whatever supports we can from the products of our medical schools, our nursing schools, our other health professional health training programs, and trying to balance the supply with the demand, is the objective here.
Senator Roche: Dr. Wilson, you talked about shortage of doctors and you told us that more doctors would help in making medical services available to people. Does the family health network compensate, in a qualitative sense, for the shortage of doctors? Would you recommend that we put a lot of money put into the system to acquire more doctors?
Is the family health network a good thing by itself because of the manner in which you have been able to extend health care without reliance on a greater numbers of doctors?
In your opening remarks you told us that you were training doctors in how to deliver babies, but that they left and you were not sure where they were. Is that contributing to the shortage of obstetricians? Is the fundamental problem we are facing a shortage of personnel as a result of the cutbacks in funding and, thus, there is a need for an injection of funds into the system, as distinct from the qualitative changes that you are making through innovation and the family health network?
Dr. Wilson: Your question is also my question. I do not think there is an either-or answer.
We know from our pilot experience that almost all of the networks have been successful in serving more patients than we expected they would serve when they were set up. Some of that efficiency comes from being able to have nurse practitioners working with physicians. In some cases, because the funding model is different, they are able to give lab results over the phone or renew prescriptions over the phone and not be required to physically see the patient to generate income. In Paris, Ontario, the network was able to enrol not only 100 per cent of their existing patients, but they also enrolled an additional 15 per cent by becoming a network. The networks hold some promise, but they are not the whole solution to improving access.
Whenever you ask the question: How many more doctors do you need, you must answer by asking: What do you want them to do?
Some of my new graduates from Queen's who have been well trained to do several things, find it financially and lifestyle wise attractive to work two shifts in Belleville emergency, two shifts in the Trenton emergency department and one shift in the walk-in centre at the mall. They work a 40 hour week and they have no ongoing patient responsibility. They have very adequate remuneration. Those doctors are lost to comprehensive care, and their skills are being lost as well.
In a way, we do not need more doctors. In another way, we do, because we need them to staff the emergency departments. An estimate I saw yesterday suggested we were short 3,000 family physicians in the country. That is probably not far off the mark.
I would suggest we do need more family doctors, and we do need different supports and organizations for them so they can serve more patients. We need to rebalance the financial incentives to attract them back to comprehensive care.
Your question was complicated. I think the answer is complicated. We probably need some of both.
Senator Roche: Are we dealing with a motivation factor for doctors? I have the old-fashioned ideal that doctors are more than people who work a 40-hour week. I do not know what Senator Morin thinks of my old-fashioned ideal of doctors being available for lengthy hours. I think many Canadians believe that many doctors are called to human service through the application of medicine. It is a calling. You are disillusioning me, as have others.
What can we do to strengthen the motivation factor so that doctors will not, in the numbers you are talking about, go off into the marketplace and search out ways to contribute their special skills to the human condition?
Dr. Wilson: I would agree with you. For me, medicine is a vocation. Others would frame it differently, but an aspect of the professional role is an altruistic role. Whatever language you want to use, secular or not, many people would acknowledge there is an element of altruism or vocation in the profession.
I am a bright, caring, altruistic young physician with a calling. How can I contribute my skills? The first thing any young physician runs up against is sleep deprivation.
When Senator Fairbairn talked about couples, I smiled because my husband is a family doctor. We have sometimes been two of three family doctors in a community. That means the phone rings two out of three nights. I was smiling because I was thinking of couples I know who are doctors and how they arrange their phones. Some doctor couples have phones on either side of the bed. They have their own rings. In some families, the phone is passed over. Either way, your sleep is frequently disturbed. Part of the burnout is the simple biological need for sleep. If you are up delivering babies or looking after sick people, you run up against that square in the face.
There is also the burnout that results from caring for sick people who die, and being involved in some of the tragedies that happen as part of the human condition. We can deal with that provided we have the supports to keep us going. One key is to have enough colleagues so you have enough rest and sleep at night to carry on. If you carry that 24-7 responsibility, you must have a way of getting relief during the night. You must be allowed to sleep.
The teletriage helps a great deal. It is a huge help iff the easy advice calls that do not need to keep a physician up at night are taken care of. If we are part of a group of colleagues who will take our calls for us regularly, colleagues we trust to look after our patients the way we would like them cared for, that keeps us going.
Do we have to school our new graduates in altruism? I do not think so. I think there are as many bright, young committed people as there ever were. I want to make sure that the practice supports are there to keep them going.
Dr. Gardener: In reality, the situation our new graduating physicians face is different from what it was 20, 30 or 40 years ago. The hours that we put in as resident house staff, et cetera, are no longer acceptable or appropriate. We see a different attitude amongst doctors these days, and it is not necessarily a bad attitude. We must acknowledge it.
The sacrifices that physicians made and continue to make do take a toll. Within the current medical community, frustration arises when they feel that resources are not always available to allow them to do their jobs in a timely fashion and in the way they would like to do them. Combinations of issues like these lead to concerns about physician morale, a shortage of physicians in certain areas, and increased workloads. It is a reality.
This does not mean that physicians do not care. I do not believe that. We must do whatever we can to make it easier for them and our other health professionals because they face the same issues.
Senator Pépin: You talked about attitude and the role of doctors' spouses. We know that the number of female doctors who are registered at university has increased. It is 60 to 65 per cent now. Do you believe that will help? Will it cause a major change? If a female doctor has to go into a rural area and her husband is not a doctor, do you think he will be able to follow her? Have you considered that?
Dr. Wilson: The predominant female registration in medicine is a phenomenon in Quebec. It is 50-50 nationally, but Quebec contributes a disproportionate number of women. In the anglophone schools, including McGill, there is still a larger a percentage of men than women.
Senator Pépin: Obstetricians and gynecologists nationally.
Dr. Wilson: Yes. You are quite correct. We are seeing an increasing number of women entering medicine. We know from studies that women spend more time with patients, are less likely to do after-hours care and emergency room work, and more likely to do preventive manoeuvres.
There is conflicting evidence on how many years they work on average. They tend to work fewer hours during the childbearing years. That may or may not be borne out; I read different things. They tend to work longer at the end of their lives.
Some recent data that the CMA will be presenting to Mr. Romanow this week suggests that women work, on average, eight hours a week less than men. That was a surprise to me, and I do not know where that comes from. I do know about family medicine because family medicine has had more women proportionately in comparison to other specialties.
Once women get into family medicine, if they are interested in rural medicine, they are just as likely as men to go to small towns. I am sometimes told we do not need more women in medicine because they will not go to the rural areas. However, there are good numbers to suggest that women physicians will do that as frequently as men.
The spousal issues are the same for men and women. The doctor needs a spouse who is supportive of moving to a rural community, and he or she needs spousal employment. Some communities that are trying to attract a doctor have worked hard to find employment for the spouse. It is a piece of social engineering, and it is difficult to know how to influence except person-by-person and community-by-community.
Senator Roche: There are not enough doctors. You have told us that we need a considerable number of family doctors. That brings us back to money. In your experience, do you think that what we need is not so much concentration on efficiencies and innovations that will happen in any event, but, rather, an infusion of money into the system. Is that the key that should drive our thinking? Would either of you agree with that?
Dr. Gardener: No. That is a simple answer to a complex question. However, we need to know what we want to produce. We need outcome measures and performance targets and we should hold people accountable.
Recognizing that we have a shortage in the number of providers, our solution will not be found in physician resource planning, it will be found in health force planning. As Dr. Wilson has indicated, the number of physicians you need depends on what they are required to do and with whom they must work.
It is unacceptable in this country that significant numbers of women develop invasive carcinoma of the cervix and have never had pap smears. We must solve our demonstrated problems by managing chronic disease. However, we will not solve the problems if we simply put in more people who will do the same thing they are doing today. We must develop a new system. These people are not doing a bad job on purpose. It is important to have many providers in all of our health disciplines across this country who do an excellent job in all aspects of primary care, in health promotion and disease prevention, in acute disease management, chronic disease management and managing those interfaces. However, we do not do as good a job as we should.
We need to move to a system that provides the supports they require to do a proper job. They need the support tools that are available that would, for example, automatically check for allergies or drug interactions if the physician is prescribing a new medicine. They need to follow recognized care protocols.
Thousands of clinical practice guidelines have been developed, but many physicians do not use them because they do not have a forum that forces them to incorporate those into the regular way they do business. They have binders on the shelf full of guidelines. Those need to become an integral part of how they manage their day-to-day cases. Patients and providers deserve to be able to utilize the variety of skill sets that we have in the professions.
If you are unfortunate enough to be an in-patient in a hospital, you are certainly getting service from your physician or a group of physicians. You are also clearly getting the support of the nursing staff, the pharmacist, the social worker, the physiotherapist, the dietician, and so on. They are all there meeting your needs.
These individuals are in the community, but it is difficult to pull them together. They are often hard to access. In most environments, they do not work together as a team in the way they would in an acute care environment.
The patient does not benefit from the expertise of that group of individuals. If we do not look at how we provide these services, by using evidence-based medicine, the performance indicators, the outcome measurements, and hold people accountable to achieving them, we will not end up with the result we want.
Senator Morin: These are two success stories in Canada. The Ontario Family Health Network is the first network of family care reform. We had pilot projects. I know it is starting slowly and it has growing pains. It has not been easy, but at least it is off the ground. I have been going through these booklets and I must say that it has been remarkably well done. I certainly wish you the best of luck.
The Capital Health Authority is known around the world. When you go to international meetings and people talk about regionalization, they cite the Edmonton Health Authority as an example. When we think of reform, we immediately thing of regionalization and primary care reform. We have with us today representatives from these two areas.
Our committee is to report in October and we must make recommendations as to what should be the federal role. I should like to return to Dr. Gardener's two priorities. We all agree on that an information system is important. You have described the medical record as a decision support system for practitioners. The federal government has an important role to play here. I would be surprised if that were not one of our top priorities.
The other issue is funding of primary care. There are two issues here, as you point out, namely, funding and reform. Reform has a cost. In addition to that, there is the primary care team.
Dr. Wilson, there is a budget attached to this Ontario Family Health Network. What is the budget and from where does it comes?
Dr. Wilson: Ms Donna Segal, CEO of the network, has come here from Kingston.
Senator Morin: I should like a ballpark figure. Where does it come from and who took the decision to implement it? I am coming to the point that is it important for the federal government to use it for primary care. You started down that road without the federal government telling you to do that.
The Deputy Chairman: Would you like Ms Segal to come to the table?
Ms Donna Segal, CEO, Ontario Family Health Network: As Dr. Wilson mentioned earlier, the provincial government has provided additional funding to the coffers to provide added incentive and to create the infrastructure that enables physicians to participate in this kind of plan. The Ontario government has allocated $100 million towards the actual practice features. That is over and above the monies that they would have continued to fund to the physicians themselves, were they to maintain their ongoing relationship through the ongoing negotiations.
Senator Morin: How many MDs would that cover?
Ms Segal: The $100 million is intended to top up the monies.
Senator Morin: How many doctors are we talking about?
Ms Segal: The estimate is somewhere in the order of 6,000 physicians. In addition, the government has also set aside a new $150 million towards the development of the technology and the sharing of the technology throughout these practices.
Obviously, we are working on averages and estimates at this point. It is understood that, for the purposes of budgeting, the estimate was based on the notion of 10 physicians per practice. That being the case, they estimated approximately 600 practices to contain the 6,000 physicians. They are looking at over 600 units of physicians requiring additional top up support for the care they provide, including the bonuses and those features Dr. Wilson described earlier, as well as the $150 million towards the technology.
Senator Morin: Is the $150 million a recurring fund?
Dr. Segal: The $150 million is one-time funding over three years or so, at least as it is now understood. That was part of an agreement that was negotiated between the Ontario Medical Association and the Ministry of Health some two years ago. It was also contained in the budget statement made by the government subsequently.
At this point in time, we understand it to be an investment for developing the IT, and making the IT accessible and available to the physician practices. I do not know what will happen in the future as physicians bring these services onboard and begin to get used to them. As they are used more and more, these services have to be maintained and upgraded. Those issued, I am sure, will be the subject of future discussion between the profession and the ministry itself.
Over and above that, the government has also paid for our agency. There is an operating budget for the agency itself. It is made up of not just staff and the normal infrastructure that you would expect in a secretariat function. However, at our peak, we will have somewhere in the order of 120 staff members.
Beyond that, there are also provisions to help with some of the administrative roles that Dr. Wilson alluded to earlier. For example, after the evaluation of the pilot projects, one of the primary complaints of physicians was with the bureaucratic process that was required to enrol the patient with their physician. As a result, we will be using some of our budget allocation toward helping the physicians in getting that administrative role away from them, leaving us with the paperwork and letting them get on with the work.
At this point in time, our allocation for this year has not been identified. For last year, it was somewhere in the order of $50 million. The reality is that we will not be spending that full amount until we are fully blown. We are now working toward creating the capacity to meet our needs with that money.
Senator Morin: That is a fair amount of money. Again, to come back to it, this was a decision that the Department of Health of Ontario has taken to priorize, and that is very good.
Dr. Gardener, if I understand correctly, the Edmonton health authority has, more or less, a global budget that it effects to a given population for the chronic and acute care of that population. Am I right in saying that?
Dr. Gardener: Capital Health Authority is funded primarily by two mechanisms. First, it is funded by a population- based funding formula, as are all the regions within the province of Alberta.
Second, some of the programs we provide are funded through a province-wide services funding formula. This funds those programs delivered within Edmonton and Calgary which are designed to support the entire provincial population.
Senator Morin: What prevents your authority from effecting a portion of the budget to primary care? If I understand correctly, and correct me if I am wrong, you are not as advanced as Ontario is as far as primary health care reform is concerned. Am I right in saying that?
Dr. Gardener: We have certainly not progressed in the development of Family Health Networks.
Senator Morin: That was my impression. On the other hand, you are farther down the road than Ontario because it is non-existent in terms of regionalization.
What would prevent your authority from effecting part of its budget to primary care reform, as Ontario has done at the provincial level, if it is that important? I think you recognize its importance.
Dr. Gardener: Competition for resources. I return to my second identified barrier to implementing primary care reform.
With regard to the issues that face the region, I will use Edmonton as an example. We have been given provincial targets for certain conditions in terms of cardiac surgery, joint replacement wait times, MRI wait times, et cetera. As with all acute health jurisdictions across the country, we have significant pressures on our emergency departments and on our medical beds. We have significant pressure to develop increased capacity in community care alternatives for the elderly, not just traditional continuing care environments but home options for that population. It is a matter of where do you allocate the resources you are given.
We have invested in primary care. The development of the Northeast Community Health Centre was a major investment in primary care for a given community. Capital Health Link was a major investment in primary care. There is a recognition and willingness to move in that direction. However, it is a matter of availability of resources.
Senator Morin: Do you not think that Ontario has the same competition? It has just effected $300 million, which is a lot of money. You have heard Ontario premiers one after the other complaining and finger pointing to the federal government because they did not have enough resources. It is a remarkable decision to have taken $300 million of their own budget and effect it to primary care reform.
Dr. Gardener: Certainly, with the planned implementation of the Mazankowski report, the Province of Alberta will also be looking at targets, such as getting 50 per cent of physicians on alternate payment plans by 2005, as well as a number of initiatives rolling out that will, in fact, relate to health infrastructure, information infrastructure, et cetera. There is no question that the provincial governments will be committing resources to this.
Senator Morin: Do you see my point? We all believe in primary care reform. We all hope it will be extended throughout the country. To reach that objective, must the federal government actually earmark funds for it, as you are suggesting? There is a need for increased funds for the health system generally. If we do not earmark funds, will the same objective be reached through a conscious decision of either the regions where regions are in existence or of the Department of Health? That is my major question here.
Ms Segal: I do not think the province intends to foot the bill entirely on its own. It is counting heavily on health transition funding coming from the federal levels. In fact, it is making an investment on assumed priorities that ought to come and ought to be supported, at least in part by the federal health transition funding which is available through your good graces.
At this point the Government of Ontario has made that investment. It has these as the priority initiatives. It has decided to make the expenditure, but will request, and is requesting through your programs, some offset funding to support their initiatives.
In answer to your question, senator, it is not just Ontario that is doing it. It is a collaborative effort between the federal and provincial governments.
The Deputy Chairman: In allocating funding for this project, where did the Ontario government get it? Did they move it from another program? After all, that is a sizable sum of money.
Ms Segal: To be honest, I cannot identify that.
The Deputy Chairman: Is that part of the role of health care?
Ms Segal: Obviously, the budget for the Ministry of Health in the Province of Ontario is a large one. They have identified this as a priority issue, not only for primary care reform but for reform of the health care system in general. They have decided to ensure that certain funding goes toward these objectives. They have provided that kind of budget forecast.
Honourable senators must understand that the $100 million expenditure, as well as the $150 million expenditure, is by no means spent at this point. It will be spent as new entities come onboard. They are seeing it as an incremental investment, hopefully with incremental pay back and support through other funding sources, a primary one of which would be the health transition funding.
The Deputy Chairman: I suppose there are consequences because if this works it will take pressure off another part of the health care system.
Ms Segal: It does. I can honestly say that there are also areas of the ministry which say, ``You have a lot of money, and I do not have the amount of money I need this year.'' You are right, senator, it is coming from places. You see it both ways.
The Deputy Chairman: On behalf of honourable senators, I wish to thank our witnesses for appearing before us today.
The committee adjourned.