Proceedings of the Special Senate Committee on Aging
Issue 8 - Evidence, May 12, 2008 - Morning meeting
HALIFAX, NOVA SCOTIA, Monday, May 12, 2008
The Special Senate Committee on Aging met this day at 9 a.m. to examine and report upon the implications of an aging society in Canada.
Senator Sharon Carstairs (Chair) in the chair.
[English]
The Chair: Welcome to the meeting of the Special Senate Committee on Aging. This committee is examining the implications of an aging society in Canada. The complex issues relating to aging have preoccupied governments for many years. They have become more prominent, however, as the number of seniors grows as a result of both longer life expectancy and the aging of the baby boom generation. The public programs and services offered to seniors are essential to their well-being, and it is our duty as governments to ensure that there are no gaps in meeting those existing needs.
We are here in Halifax, technically Dartmouth, today to hear from interested parties on the impacts of an aging society and more specifically to hear their views on our second interim report, which we tabled in the Senate on March 11 of this year. The interim report focuses on active aging; older workers; retirement and income security; healthy aging; supports to aging in place of choice; and the regional distribution of health costs associated with aging.
This is the second stop of our cross-country Canada travel, and we look forward to today's testimony. We have been a bit delayed because we were at Camp Hill this morning. We wanted to take a first-hand look at the veterans' programs offered there.
This morning we have three witnesses and witness groups appearing before us. In our first group, we have Pamela Fancey, from the Nova Scotia Centre on Aging; Deborah Dostal, from Spencer House Seniors' Centre; and Sandra Murphy, from Community Links. Welcome to all three of you.
Pamela Fancey, Associate Director/Research Associate, Mount Saint Vincent University, Nova Scotia Centre on Aging: Thank you for the opportunity to share some thoughts with you this morning on the interim report. The Nova Scotia Centre on Aging at Mount Saint Vincent University has been in existence for 15 years with a focus on research, education and community consultation.
This morning, time permitting, I would like to speak about four areas of the interim report: volunteerism, lifelong learning, healthy aging — just a few areas within that particular chapter — and informal caregivers.
I will start with volunteerism. In Chapter 2, ``Active Aging and Ageism,'' your report suggests that one reason senior Canadians are less likely to volunteer is that they are involved in informal support to others. This is an important factor that, in view of two trends, is only likely to escalate in the years to come.
One trend is the need for older kin to support younger, two-person, working households and the growing single- headed households that we see in our society today. Older persons are filling a huge gap because of minimal social policy on child care in this country. It is suggested that the Special Senate Committee on Aging include some statement to this effect and options that speak to working with other levels of government to raise awareness around the situation and the role that seniors are playing given the minimal child care policy in this country.
The other trend is informal support to other seniors, whether relatives or not. Much of the centre's work on caregiving demonstrates the important role that seniors play in peer support in their communities, especially rural communities. Moreover, we recently completed a discussion paper for the Public Health Agency of Canada on the role of older spousal caregivers; they are the population of growing interest. The options listed within the report are narrow and do not address well the situations of older spousal caregivers, whom we are seeing more of and whom we feel have distinct needs.
Options such as providing publicly funded respite for caregiving seniors to continue with volunteer commitments, for example, would fit well into this particular section and also could be cross-referenced in section 5.2 on informal caregivers. As mentioned in the report, keeping seniors engaged in the normal activities is important to active and healthy aging, and this would be one mechanism to support that.
On page 11, the first option you list is to provide tax credits for volunteers as an incentive to promote volunteerism. That should be expanded from recognizing their time to also include the direct expenses that they incur as a result of volunteering. The cost of volunteering continues to increase, especially with gas and other transportation costs. Some seniors may be hesitant to ask if compensation is available, and some organizations may just not have the infrastructure to support and cover those kinds of expenses for them.
Moving on to lifelong learning, this is an important concept as we continue to hear more about its role in keeping us intellectually stimulated and engaged with others in our society. There is and continues to be growth in this area. I am unaware of the scope of the seventh option that is listed on page 12, but I wanted to bring to your attention that already there exists a national network of lifelong education providers. It is called Catalyst, and it engages about approximately 50 different organizations responsible for lifelong efforts across the country. Therefore, rather than duplicating effort, you may wish to find out the scope of this organization's work and their capacity for further promotion and development of lifelong initiatives throughout the country.
Associated with the options you have identified in this section, I would suggest that there is an opportunity also to support university-based centres on aging such as ours and other existing education providers to develop new and to market existing programs to older adults. Particularly in view of declining university enrolments, there is great opportunity to build on existing resources and capacity at centres like ours. Also, we are hearing a lot about the number of faculty that will be retiring in the future. Those retiring faculty are a great resource and can offer academic and non-academic courses or general interest courses to adult learners.
Moving on to the discussion about social isolation and the recognition of the recent work on age-friendly communities, I would suggest that another option to be offered here would be to adapt the New Horizons for Seniors Program around age-friendly communities to be used as a vehicle to promote the notion of age-friendly communities.
The New Horizons for Seniors Program has great visibility and stature and usually requires the involvement of seniors in the design and implementation of its projects. What better way to turn into action the age-friendly communities' guides and checklists than to have seniors engage with other sectors to make differences in their communities?
The final point I would like to comment on in Chapter 2 is section 2.2 on ageism. Without a doubt, ageism is a key barrier to facilitating active aging in our society. How we view seniors and the messages we hear about them do little to counteract ageist notions. To me, the issue of ageism is broader than what is contained in Chapter 2, and, in fact, tenets of ageism exist throughout the report.
In Chapter 3, there is a suggestion that we support ageist notions through our existing public policies with respect to labour force participation and income security practices. In Chapter 4, ageism should be included in a discussion on abuse and neglect but is not given air time there. There is also a point that ageism could be woven through the mental health and mental illness debate, because those illnesses layered with ageism have great negative impact on seniors.
Rather than having ageism as one small subsection, I suggest it really warrants its own chapter throughout your document to be more fully developed, to broaden terms to cover a number of angles and then also to develop more options to help combat this important issue.
``Healthy Aging'' is always such a large and unmanageable title because of the interdisciplinary and multi-faceted nature of aging, and this is also evident in your report. There is an eclectic group of things under this heading in Chapter 4; it has everything from falls prevention, nutrition and oral health to palliative care and direct services to veterans and First Nations, your target populations — quite a hodgepodge, as we would say on the East Coast.
What concerns me most about this section is the slant on abuse and neglect and the weight given to situational factors as opposed to the larger frameworks for understanding abuse and neglect, such as capitalism and, again, ageism — essentially, issues of power and control in our society.
Without a doubt, caregivers and staff in health care facilities face significant challenges in their caring work due to changing context, such as increasing care demands and fewer supports. Without a doubt, we should be supporting these caregivers for a host of reasons, including the value of their work to society.
As you probably are aware, Human Resources and Social Development Canada, HRSDC, is hosting an expert round table next month, and the paper that our centre has been commissioned to work on as well as the other papers would not necessarily accept the current framing of abuse and neglect in this micro-situational context. Again, a separate chapter on ageism would better address the point here, which I raised earlier as well.
Moving on, option 41 supports capacity building projects for training in geriatrics and gerontology. This option is important as you recognize the growing need for health care professionals in medicine, social work and nursing. As you mention in the report, there is, however, equal need for gerontology training and education in a wider range of workers and professions including family educators and counsellors, program coordinators, researchers, policy analysts and even supporting budding entrepreneurs. At Mount Saint Vincent University, we offer a gerontology program at the undergraduate and graduate levels, but we struggle with enrolment. The challenge is getting the message out that this is an important field and that these education programs are valuable, that it is not just about the applied health professions. Options to help promote the non-health professional programs could include marketing gerontology training more broadly and a special stream of money to support students by way of scholarships and financial assistance to draw them to these educational opportunities.
There is quite a bit here on housing, and our centre has done quite a bit of housing work in Atlantic Canada. I have reports with me, if you are interested. I will not go into them here. I would rather focus on section 5.2 and specifically options for supporting informal caregivers.
I would support the options contained here as most come from work that we have been directly involved in. I believe Dr. Janice Keefe presented to the Senate last summer. However, I am not sure how feasible option 63, which talks about a central point of contact for caregiver services across the country, would be given that not much exists directly for caregivers. What exists would be at a local level so it would be difficult to get a handle on and to keep updated. I am not quite sure of the manageability of that kind of option at the national level.
Otherwise, the recommendations are mostly aimed at working caregivers, primarily adult children. They do not recognize the growing concern that seniors care for other seniors, that we are seeing a lot more older spouses and we need to think about these other types of caregiving arrangements. We recently completed a discussion paper on this topic for the Public Health Agency of Canada; they recognize this population as being distinct from other caregivers.
Finally, in order to develop the programs and services needed to support caregivers as well as offer them services, caregiver assessment is needed. Health care professionals need to discuss with caregivers, apart from the care recipients, their experiences, aspirations and expectations and help shape a care plan specifically for them. Just as you have recognized that seniors are a diverse population, so are their caregivers, and one size does not fit all. A menu of options to support caregivers is needed. Caregiver assessment is important to help shape that menu, and access to caregiver assessment earlier on in the journey can serve as an effective health promotion strategy.
This report could promote the need to advance caregiver assessment. An option to this effect would strengthen this section.
The Chair: Thank you very much. I did not introduce the senators before we began because I was expecting another, and she did indeed arrive. We have Senator Cools, from Ontario, originally from Toronto and now living in Ottawa; Senator Cordy, from Nova Scotia; Senator Mercer, from Nova Scotia; and I am a Manitoba senator, but I was born and raised in Halifax and certainly have a Halifax connection.
Our next witness is Ms. Dostal.
Deborah Dostal, Executive Director, Spencer House Seniors' Centre: Thank you for the opportunity to speak to you. I am a member of Seniors' Council, but my full time job is executive director of Spencer House Seniors' Centre, a centre that supports seniors living in the community. I have been working in this area for 15 years now. I would like to speak to two issues that are very close to my heart.
One is volunteerism. Spencer House relies heavily on volunteers. In fact, I do not think we could offer the programs and services we do without volunteers. We use about 125 volunteers a year, and at least half of our volunteers are seniors themselves. Two of our senior volunteers are 90 years old. Seniors have told me that it is very important to them not only to be able to give back to the community but also to feel useful and needed. However, as was mentioned earlier, it is actually costing some volunteers, particularly seniors, money to volunteer. At least two of our seniors cannot come to Spencer House unless they drive there. They are not able to use public transportation for various reasons, and rising gas prices particularly are costing them out-of-pocket expenses. I was interested to see that one of your points was tax incentives to support volunteerism. I am not sure how that would work, but there should be some financial support as well for seniors.
I feel the focus right now should be on volunteerism in the community. A lot of research has been done on volunteerism. We have received information on screening, procedures, management and so on, but really what is needed, in my view, is more within the community. For example, shortly after the UN International Year of Volunteers in 2001, we had a volunteer resource centre that shut down because of lack of funding. I think that has happened quite a lot because there is no central place where people can go to be matched with volunteer jobs. Perhaps there could be a database or some other mechanism that would make it easier for people to be matched with volunteer opportunities in the community.
Our agency is funded by the United Way, and the United Way has what they call ``A Day of Caring,'' where a business will send their workers out to a volunteer agency for a day. I could see a lot more of that happening, or perhaps there could be tax or other incentives for employers to allow their employees to spend more time in the community doing volunteer work.
The second issue that I want to talk about is aging in place. The whole focus of our agency is helping seniors remain independent in the community. We offer recreational programs and home support programs. Spencer House Seniors' Centre is a place where seniors can come and be safe and where they can meet their peers. There is not a lot of recognition for what is available in communities to help support seniors outside of institutional facilities. There should be more recognition and more grassroots organizations that are helping seniors. Ms. Murphy can vouch for that since she also works for a community organization.
Among the services we offer, the one closest to my heart, and one that has not been mentioned much, is meal programs. Meal programs are crucial for helping seniors to stay independent in the community. There was some mention of nutrition, and certainly information on nutrition is important, but I find that often seniors just do not want to cook meals; they just will not do it. I know from studies I have read that malnutrition is one of the major causes of seniors' ending up in hospitals or long-term care facilities; they do not eat properly, and that leads to a host of other health difficulties. From my perspective, a meal program is crucial — and not only meal programs. In our case, we offer a meal in-house so that seniors can come to Spencer House and have a hot lunch. It is a social occasion. They really enjoy it and they get a nutritionally well-balanced meal.
Of course, our Meals on Wheels programs are extremely important. I do not know how it works in other parts of the country, but in Nova Scotia, Meals on Wheels is volunteer-driven, particularly in rural communities. Therefore, if volunteers are not available, there is no program, and that is a big problem. To my mind, it is essential that there be consistent programs throughout the province and throughout the country for providing meals to older adults who need them.
The Chair: Thank you very much. These meetings never cease to amaze me. We have been hearing testimony for two years, and we come to Halifax and we hear new ideas we have never heard before.
Ms. Murphy, please give us your new ideas.
Sandra Murphy, Executive Director, Community Links: Well, that is quite a challenge. Community Links is a provincial organization of over 180 seniors and senior-serving organizations as well as individual senior members. A lot of our work is in rural Nova Scotia; we have focused over the years on rural issues of seniors, although we have projects in urban Nova Scotia as well.
One of our major initiatives is ``Preventing Falls Together,'' and we have 13 coalitions across the province working on health promotion around falls prevention. We feel that we have been fairly successful in the efforts we are making around preventing falls among seniors, which, as you know, is one of the major causes of seniors being hospitalized or ending up in nursing homes or, in fact, dying.
We also do a lot of work to encourage seniors to be engaged in healthy public policy and to have some say in what is happening at a public policy level that will have an impact on their lives. Particularly, here in Nova Scotia we have the Strategy for Positive Aging, which is a marvellous document. If it were all enacted, then Nova Scotia would be the best place in the world to live as a senior. We are very concerned that the strategy be implemented and that seniors be engaged in that implementation and in the monitoring of that policy document.
We are concerned with issues around volunteerism as well as seniors' issues. Going back to Ms. Dostal's point, we also are a co-host of the Nova Scotia Volunteer Forum, which is a site where organizations can register their need for volunteers and where volunteers can be linked with volunteer opportunities. The site is fairly new, but we have not yet done our promotion as well as we might have.
Because I heard about this hearing only late on Friday afternoon and I was out of town for the weekend, I did not have much time to prepare for this morning. The board of Community Links, which includes seniors from across the province, spent a lot of time at one board meeting reviewing your first interim report so that we could make a response to that report. Unfortunately, we have not had time to review your second interim report, but I did feel that I would like to come today to reinforce some of the issues that we addressed in our first submission to you.
In our submission, we addressed every issue that was covered in your first report, but I will not do that this morning. In prioritizing what issues they felt were of most concern to seniors, the board members saw financial security as the key. They also wanted to say that they did not see that financial security for seniors should be different than financial security for all Canadians. A guaranteed annual income for all Canadians would perhaps be the way to address the needs of seniors, but also there would be less of a feeling that perhaps seniors had more than other Canadians who are poor. We are very concerned with the growing income gap between the very rich in Canada and the very poor in Canada. Among the very poor in Canada who are not necessarily being served by current income structures are single women who fall just below the age when they can receive Old Age Security. A number of people on our board are working in the community and trying to address the issues of those women almost on a daily basis, so this is of concern to us.
In general, we see that a number of seniors are well-off, but we are very concerned for low-income seniors, and you can see low-income seniors in our country and that the gap is growing. Also, seniors are concerned about poverty among other age groups in this country, and we feel that the issues of poverty should be addressed for all Canadians, not just for seniors.
Another area that was identified as a priority for our board was around seniors and caregiving. I think Ms. Fancey has addressed that issue very well, and the Nova Scotia Centre on Aging has done some terrific work on caregiving and seniors. Our board feels that caregivers are vastly over-burdened and under-supported in this country, and as Ms. Fancy said, there are not only the working caregivers, who perhaps have given up jobs to become caregivers for an aging parent, but there are also many seniors engaged in caregiving for other seniors, both family members and friends in their community. They are not being supported as they should be.
We feel that a lot of good work was done around the caregiving issue by a previous Government of Canada. Now we have taken some steps back. We seem to be poised on a national strategy for caregiving across the country, and that this has not moved forward has been a real setback.
Non-governmental organizations have a key role to play in support of caregivers, and they need support to undertake this work. I was at a caregivers' luncheon organized by Caregivers Nova Scotia just this past Friday, and they honoured five wonderful caregivers in the community. The work that Caregivers Nova Scotia is doing needs to be supported more than it is. Caregiver support groups are needed across this province, but that requires infrastructure support, which is not always available. We need to do more around caregivers, and we need more adult day programs for seniors as well.
Another issue that Community Links is extremely concerned about and involved in is transportation. We are particularly concerned for seniors in rural areas who lack of transportation. Not having transportation reduces the options seniors have around aging in place. Community Links is working closely with the Nova Scotia Community- Based Transportation Association, which is working to have a continuum of transportation options available for seniors but also for the economically disadvantaged and for the disabled across the province. We are also working with the environmental lobby around the transportation issue. Transportation is not just an issue for seniors: it is a poverty issue and an environmental issue, and we feel that more needs to be done at the federal, provincial and municipal levels to support the types of transportation options that are needed.
At one time, the federal government had a regular program for funding vans that were used by community-based transportation associations. Just recently there has been more infrastructure funding from the federal government for transportation issues, but there needs to be consistent support from the federal level for transportation at the community level in Canada.
We also had some concerns around diversity issues and the needs of seniors from immigrant communities, which are not being addressed. I think this will be a growing issue in Canada. Nova Scotia is not always seen as the place where we have the majority of immigrants. We are working hard to bring more immigrants into Nova Scotia, and if we do that, we have to realize that perhaps the needs of immigrant seniors are different. Often immigrant seniors are totally dependant upon their children because they are not eligible for Canadian supports. This often isolates them and perhaps creates some potential for problems that other senior Canadians do not have. As we become a more diverse society, we really need to address this issue as we look at the future of older adults in this country.
Since at one time I coordinated a volunteer resource centre in Newfoundland, the issue of volunteerism is very dear to my heart. I feel strongly that more needs to be done to support seniors to volunteer and those who are volunteering. In rural Nova Scotia, we see a real burnout among seniors who have been carrying the can in their communities for so many years that they just cannot do it anymore. There seems to be a perception that the emerging seniors or the baby boomers will not be engaged in the same way their predecessors were.
The idea of tax credits has been around for many years. Since the 1970s I have been hearing about tax credits as a solution for encouraging volunteerism. I think the idea has some merits, but we also have to realize that tax credits do not work for low-income people. It is certainly true for seniors that tax credits work better for rich Canadians than for poorer Canadians. Moreover, tax credits for organizations could be an infrastructure nightmare, just trying to keep track of people's hours, and they may create more trouble than they are worth. I think giving organizations the capacity to cover out-of-pocket expenses would encourage lower-income seniors to be engaged in volunteering more than perhaps tax credits would.
The Chair: Thank you. Before I move on to other senators, I would like to stay on the issue of tax credits. Ms. Murphy, you have clearly identified the dilemma that our committee finds itself in. We have heard clear testimony about the need for tax credits, but more recently we have been hearing the counter-argument that the smaller the organization, the more difficult it will be to keep track of these things. It is fine with Camp Hill, for example, with its 400 volunteers and several full, paid coordinators. There it becomes an easy thing to maintain, but with smaller organizations it is much more difficult. We have also heard the argument that tax credits benefit those who have tax payable, but they do not benefit those who do not have any tax.
When we were in Welland, a man from the audience came up to see me just as I was leaving and said, ``Do you know that in Birmingham, England, transportation is totally free if you are over the age of 65?'' He thought that this might be a way of addressing the issue of getting volunteers out and more active. However, you indicated in your testimony, Ms. Dostal, that some people cannot use public transportation. Canada is a different community than Birmingham, England. In Ottawa this winter, we had I think 436 centimetres of snow. No senior could get over the snowbanks to get to the bus stops, and the bus stops were often the last places cleared. Help us out, please, and give us some ideas about where you think we should go.
Ms. Fancey: I would have to support the notion that tax credits should not be the only option, although I think they serve a role. They are easier to administer at a macro level. That also applies to financial compensation initiatives for caregivers. We have done quite a bit of work looking at tax credits for caregivers and have found the same kind of arguments that you are thinking about regarding volunteerism.
In terms of other options, would it be possible to provide support to organizations at the local level so that they have the capacity to manage and provide special transportation if that is required by individual clients? Even having sufficient accessible transportation throughout the province, especially in the rural communities, is still a challenge. We do have groups working on that, but we are far from having addressed that hurdle. I do not have many great ideas to offer on this particular problem.
Ms. Dostal: I am a little stymied as well. I wonder whether it would be workable to provide organizations with funds to enable them to reimburse senior volunteers for their expenses. It should be fairly easy to monitor those expenses; business and government keep track of mileage and so on all the time, but we just do not have the funds to do that. From a community perspective, funding is always an issue.
Ms. Murphy: Better transportation systems are certainly key. Community Links and Nova Scotia Community- Based Transportation Association are looking at a continuum, everything from active transportation, which is getting there by Shank's mare, to Dial-A-Ride Nova Scotia, where you can phone a transportation system that picks you up at your door and delivers you. Some of those systems are limited as to what they can provide service for; they can help for medical appointments or shopping for groceries, for example, but are not available for recreational activities. Others are not restricted because they have managed to get more resources, so they will pick up people for anything they want to go out to do.
We also need Dial-A-Ride systems to link to public transportation, to get people from their homes to the public transportation system. This is especially needed in rural areas for people who do not live along the transportation route, but it is also true in urban areas.
I do not know what we can do about the Canadian winter. Maybe we just abolish it. Maybe we just get a rope and pull us down a little bit further south. We will probably never be able to get people who have some mobility problems out in all Canadian weather. We just have to make sure that there are systems in place so that most of the time they can get to the programs they want to attend. We have to provide for more sustainable, consistent transportation services.
In terms of supporting volunteers, we really, for many organizations, it would be a big help to have some core funding that they can count on from year to year. Even if it is not a great deal, if they can count on core funding and they do not have to spend all their time and effort raising funds for next year, that might allow them to put more effort into ensuring that they have some of their funds available to support their volunteers. There are no simple solutions, I am afraid.
The Chair: We did not think so, but thank you.
Senator Mercer: Thank you all for being here. As Senator Carstairs has already acknowledged, we should have come here first today, because then we would have gotten all these good new ideas quickly. I will leave my questions about the program at Mount Saint Vincent to Senator Cordy, but I am impressed that we have the program there.
Regarding the volunteer resource centre that was shut down due to lack of funds, I want you to refresh our memory. Who funded it, when did funding stop, and how long did it take from the time funding stopped to the time that the resource centre had to close?
Ms. Murphy: It closed in December 2001.
Ms. Dostal: I think the funding was provincial, was it not?
Ms. Murphy: I think it was provincial.
Senator Mercer: Would that have been the previous government? The current Nova Scotia government has been there for a while in various incarnations, whether the end of Premier Hamm or Premier MacDonald. Was it before Premier Hamm?
Ms. Murphy: In 2001? Yes, it would have been Premier John Hamm.
Senator Mercer: He would have been there in 2000. I am curious, in the context of the politics of everything, that within in the same government a program that was working sort of disappeared.
I am interested in the Strategy for Positive Aging document. I would like to make sure that we have a copy of that so that I can have a look at it.
Ms. Murphy told us that previous governments made some progress, but there have been steps back. I want to get the right benchmarks here so that we do not miss an opportunity. When that progress was made, was that when the secretary of state position was designed for seniors and for volunteers? Is that the era you are referring to?
Ms. Murphy: The last government had a minister for seniors who did a lot of work and brought together key stakeholders from across the country around caregiving issues. Work was being done on a caregiving strategy for the country, and there was a lot of hope in the caregiving communities that this would finally address some of the issues that had been plaguing caregivers for a number of years.
Senator Mercer: That would have been Minister Ianno, I believe.
Ms. Murphy: Under Ken Dryden, yes.
Senator Mercer: He was the junior minister, right?
Ms. Murphy: Yes.
Senator Mercer: It seems to me that we were headed in the right direction. We did not have the answers, but we were moving in the right direction.
Ms. Murphy: We were heading in the right direction. However, governments change; you take a few steps back, and then you hope that we will move forward again, but I think it was a real blow, especially to the people working in the caregiving field. One of our board members was very involved in the process, and she was quite discouraged after so much work had been done that it all seemed to drop off the radar again. It does not mean it does not get back on the radar, but it is frustrating.
Senator Mercer: No, it does not. Government does work in slow ways. As Lenin said, it is two steps forward, one step back.
Ms. Murphy: Yes.
Senator Mercer: Now we have got to take those two steps forward again.
Everywhere we have gone we have heard about the transportation issue, and Senator Carstairs spoke about the Birmingham example in England. In Welland on Friday we heard about public transit.
What would you think of our recommending a program where all GIS recipients would be given a free transit pass in all municipalities so that they could hop on the bus to wherever whenever they want? Of course, we recognize that in most rural areas there is no public transit. The exception is the Annapolis Valley in Nova Scotia.
Ms. Murphy: Yes, Kings Transit.
Senator Mercer: Kings Transit goes down through Digby, which is an exception to the rule. Do you think this would be a positive thing? Would it help remove the transportation barrier for seniors?
Ms. Murphy: It would support seniors in urban areas, but as you said it would not address the issue of rural seniors. Halifax is talking about having routes within the core of the city that will be free for everybody; that service exists in the summer now, mainly geared at tourists. They are thinking of expanding the number of routes, and I think that probably will happen more in metropolitan areas. In Portland, Oregon, for instance, there is free transportation in all the downtown core. That does not address our problems of snowbanks and so on, but it would be worth looking at.
Senator Mercer: Yes, I think we will have to live with the snowbanks no matter where we are. My son is a student at Saint Mary's University, and as part of his registration he gets a free transit pass. That seems to work well for the university and for the students. Why would it not work well for seniors? It seems like a logical leap from my point of view. We do have to recognize that urban dwellers have an advantage over rural people, which might suggest a transportation tax credit focused on rural Canadians as opposed to people who have access to public transit.
Senator Cordy: Thank you all very much for coming bright and early on a Monday morning. My first question deals with the guaranteed annual income that at least one of you mentioned. Ms. Murphy, you mentioned also your board saying that poverty for all ages should be addressed, and I agree with that. If you are poor at ages 40 and 50, then you are likely to be poor at ages 60, 70 and 80.
We have heard people propose a guaranteed annual income, and you made reference to it this morning. I am on another committee studying urban areas, and we have been looking at poverty, in particular. We have talked about guaranteed annual incomes. I believe Conservative Senator Hugh Segal has a motion to talk about replacing all of our other social network programs with a guaranteed annual income. However, on the other committee, we heard from the National Anti-Poverty Organization, and they were greatly concerned by this idea that the guaranteed annual income would replace all other programs, because there would be no Employment Insurance for people off on sick leave or no parental leave, and the mother or father might not be entitled to receive benefits under a guaranteed annual income because the family income would be above the cut-off point.
How much have you looked into a guaranteed annual income? At face value it sounds very good, but has your board looked beyond the face value at the implications it could have for other social programs?
Ms. Murphy: No, I will not say that we have. I think the board's main concern was trying to address the issue of poverty. Whether a guaranteed annual income is the best way to do that, we have not done enough research or given it enough thought. When we were discussing your first report, the guaranteed annual income came up as a possibility, but obviously there are all kinds of implications that we have not thought through.
The real issue is poverty. As you said, people who are poor at age 20 are often likely to be poor when they are elderly. Also, we really have to deal with the issue of disparity between the rich and the poor in this country. That gap is not getting better; it is getting worse. We have not even dealt with the issue of child poverty when we said we would do that by the year 2000. We are a rich country. There has to be some way that we can deal with the issue of poverty for all ages.
Senator Cordy: Ms. Fancey, did your centre look at all at a guaranteed annual income or just at dealing with poverty overall for seniors?
Ms. Fancey: We have not done much work on that area, so I do not feel comfortable commenting.
Senator Cordy: Ms. Murphy, I have heard of your program ``Preventing Falls Together.'' I have seen it advertised, and I think it is pretty successful. My question is not specifically about that program, but about programs overall for seniors. How do we educate seniors about the programs that are available to them? I am currently working on a speech for the Senate on the number of seniors who are not aware of their eligibility for Canada Pension Plan and the related Guaranteed Income Supplement. How do we ensure that seniors are aware of programs that are available to them? For instance, I thought everybody was aware of CPP, but then we hear about people who are not aware that when their spouse dies they are entitled to their spouse's benefits. In Welland last week we heard about a community group that talks to seniors individually about programs, which seems to be one way of dealing with it. With respect to CPP in Quebec, there is a theory that almost no people are not picking up CPP, in other words everyone is, because Quebec has a five-year retroactivity clause, so that if you do not received it and you are entitled, then you go back for five years. In all the other provinces, if you are entitled to CPP but have not been receiving it, the retroactivity is only 11 months. If government has to go back five years, maybe that is an incentive to make sure that people are aware of what they are entitled to. I know your program is working, but how have you made it work?
Ms. Murphy: We have taken a population health approach. We are doing small things in the community, working with groups that work with seniors, and we are trying to get them to change what they do; we are not working directly with the seniors. Our program works with organizations that work with seniors. Our coalition members would be Victoria Order of Nurses, seniors' safety programs, and community health boards. We are asking them to change what they are doing and to get the message out in their own programs around falls prevention and to make changes in their own facilities and how they deal with safety issues within their own programs. That is the approach we are taking. We do not see it so much as getting information out as changing society a small step at a time. We try to get municipalities to put more lighting in places where seniors might trip or to fix sidewalks, for example. We try to get groups that are going into seniors' homes anyway to look at them from the falls prevention perspective, so that they are making changes around falls.
I believe Ms. Dostal is on the coalition here in Halifax.
Ms. Dostal: No.
Ms. Murphy: I thought you were. We are getting malls to put in seniors' parking spaces. Those are the sorts of things we are doing in our Preventing Falls Together program.
The fact that seniors do not know about their entitlements to programs was raised at our board meeting. I think that you can work with the groups that work with seniors to make sure that those groups have the information so that they can let people know individually about their entitlements. However, there are infrastructure needs there. Ms. Dostal cannot do it all within her facility. There may be seniors groups in the community that would be happy to do it, but they might need a bit more infrastructure and support to make sure that they can get the information out to the seniors they work with.
Also, we all struggle with getting information out to isolated seniors. They do not come to programs. We have no way of getting them to come to programs, and they are the ones who are probably not getting the message.
In all the 30 years I have been working in the community, I have been asking about how we get through to isolated seniors. We have still not come up with the answers for getting information out to seniors who are not connected through community groups, churches or other organizations.
We should use churches more, because a lot of seniors still go to church. We should get the churches doing more around getting information out to seniors. Some of them do it, but it is a struggle to get that information. People listen to information only when it seems important to them.
The Chair: Colleagues, we have come to the end of our time. Senator Cools, do you have a quick question?
Senator Cools: I will keep my questions for later. I will just make a little statement. First of all, thank you to the three of you for serving your community as well as you do and for making the effort to appear before us today.
Since we are in Halifax, I would like to highlight the fact that there are three senators at this table who have natal ties to Halifax; obviously, Nova Scotia is well represented in the Senate of Canada. I want to thank those senators for their good service and to reassure the witnesses as they go back to their daily work that they can rest assured that there are people in the Houses of Parliament taking their interests to heart and beating those drums on their behalf.
I will end there for now. I want to carry on some of the points on elder abuse and so on, but we will have ample opportunity. I think it is important that we do stay on time.
The Chair: Thank you, Senator Cools, and thank you Ms. Fancey, Ms. Dostal and Ms. Murphy. Your comments have been very helpful to our deliberations.
We now welcome Dr. David Martell from the Lunenburg Medical Centre, and Dr. Chris MacKnight and Dr. Ken Rockwood from Dalhousie University. We heard about Dr. Rockwood earlier today because we were at Camp Hill; he is already infamous.
Dr. David Martell, Lunenburg Medical Centre, as an individual: Good morning. I will preface my remarks by saying that it will be difficult to hold me to five minutes, so please feel free to cut me off.
Incidentally, a reference was made earlier to Kings Transit. This is one of the mandates I was given to come here. Kings Transit actually goes all the way to Weymouth. It costs $3 for a ride that can bring you hundreds of miles. We are trying to model what we have envisioned for the South Shore on Kings Transit. It has been a great success.
What the heck do I know about aging? I have to say that at the outset. I am 36 years old. I am a family doctor practising in the wonderful little town of Lunenburg. It is nice to see Dr. MacKnight here so I am not the only fresh face. I have a child, a four-year-old. I have parents in their early 60s. Both my parents have had life threatening illnesses in the past 10 years, and I am anticipating the day when their caregiver will be one of their six children, perhaps me. That leads me to reflect on what it might mean to my child when I become aged.
In my own practice, I have interest in addictions. I am the medical director of the addiction unit at Fishermen's Memorial Hospital in Lunenburg. We have individual practices, but we are envisioning collaborative care. Primary care reform is one of my interests, and we have registered a proposal with the health department to develop a community health centre model to that end.
For three years now I have been pursuing an interest in electronic patient records and office efficiency. I sit on the Lunenburg County Community Health Board and have sat on that board for two years. In my spare time, I am a volunteer. I run an international charity.
I would like to relate briefly some personal stories about aging within my own family. In 1984, my grandfather passed away suddenly. He was a very unhealthy man. He was 65 years old. He had been retired for two weeks. The fortunate thing with him was that he died suddenly and unexpectedly. He did not burden the health care system very much. When he died, my grandmother came to live with our family. There were six children; both my parents were school teachers, but my mom stayed at home to take care of kids for 10 years. I think at that time that was the norm, though I do not see that very much these days. I do see caregiver burden at a distance, but not within one's own home, and even in my lifetime I have seen that change.
My grandmother lived to be 70 years old. She, too, died suddenly of a heart attack and was absolutely no burden on the health care system. If we had not had her in our own home, I do not know whether that would have been the case. From a cultural standpoint, I think things have changed very much.
On the opposite side of my family, things were very, very different. My grandmother developed Alzheimer's in the early 1980s and struggled for the better part of 10 years deteriorating with Alzheimer's. My grandfather refused to have her anywhere but the home, and he and everybody around him failed. The caregiver burden was overwhelming. He himself is now in a nursing home, and there is a struggle to help take care of him. He needs extra care that the staff in the nursing home cannot provide.
My other experience was in my practice, and it is rather delicate to talk about. I have had direct experience with a case involving the international abduction of a demented patient, which has been brought to light in the province.
The work of this committee is fantastic. I did not know about this committee, and that is part of what I would like to discuss in my remaining 30 seconds. I would like the work of this committee to be well-known. I think it is important. I think it is probably more important than anything else happening in this country right now. Whatever name is given to the report generated by this committee, I would like to see it as flashy and as sexy as Romanow or Kirby. I think that would go a long way.
Part of the mandate of this committee is to spread awareness and understanding of the issues. I do not know that we are completely unaware of what happens in this country from the standpoint of aging, but it is so all-encompassing. It is overwhelming. We do not spend much time reflecting on it.
I do not know who else has given testimony to this committee. If I were to invite people to a table like this, I would invite academics, philosophers, ethicists. These people are a lot smarter than I am. They have given a lot of thought to the problems we are facing, whereas I can speak only from experience.
I will end with the one statistic that always sticks in my mind. As a family doctor, the main focus of what I do is directed toward disease, which is aging gone bad. I have been told that 97 per cent of all health care dollars are directed at disease treatment, picking up the pieces after things are broken. Only 3 per cent is put toward prevention and the idea of health. I think we need to flip on its head how we think of health care. It should be health first.
The Chair: Thank you. I hope it will give you some comfort to know that we have heard from academics, philosophers and ethicists.
Dr. Ken Rockwood, Professor of Geriatric Medicine, Dalhousie University, as an individual: Thank you for the opportunity to talk to you today. At the moment I am attending on the general interim medicine ward. The 16 patients on my list this morning ranged in age from a person in their fifties to people in their nineties; the median age of people on the ward this morning was 79 years. Right now I am immersed in the details of aging and illness. However, it seems to me that I would do best with my time if I tried to paint a big picture about population aging and the demands it puts on health care.
I have looked over some of your prior testimony as well as the first and second interim reports you issued. Clearly you have heard two very different takes on this. One view has been the ``grey tsunami'' — the sky is falling and we are going to hell in a handcart, so let us privatize this as quickly as we can, as if that would do anything about it. The other view is ``Don't worry, be happy''; it is only 1 per cent, and it is just a matter of technology. Neither view has much to say about the messy clinical bits in between.
In general, I am fairly sympathetic with the second view. I think that aging will necessarily be an issue the public system has to come to grips with. However, apart from some gentle murmurings about the need for more palliative care, the second group does not offer a good portrayal of what is happening in health care right now.
It simply does not ring true to say that we do not need to worry about aging. Even in the 20 years that I have been in practice, the face of health care has changed. You need only go into any emergency room to see that the bulk of people there are old.
That is not what is putting the stress on the system. The problem putting stress on the system is that those people are old and frail, and we have not built a health care system for them. In general, we have conceived of the issue poorly. We have built a system based on people having only one thing wrong at once.
I will use the example of cardiac surgery, but you can take any specialty at all and people will come forward and say something like, ``The need for heart surgery goes up with age. The population is aging. Therefore, it is urgent that we train more heart surgeons now.'' That sounds plausible, and then the lung people come by and the kidney people come by and the thyroid people come by and so on. If you look at it from that standpoint, there are not actually enough old people to go around, because if 60 per cent have heart disease and 80 per cent have arthritis and 40 per cent have kidney problems, you are at more than 100 per cent of the population right there and you have only dealt with three things. It only works if the old people double up and triple up and double up again on the illnesses that they have, which they do. When they do that, they are frail. When they are frail, no one wants them — or at least our health care system, as it is conceived of right now, does not want them. That is the big gap, with the private system advocates on the one hand and the public system advocates on the other fighting over something which does not ring true to anyone in health care.
There is a lot of frustration in health care right now. Many front-line workers are very frustrated. Unfortunately, 80 per cent or more of the time they take out their frustration by blaming the old person for being there. If you want to get people who provide acute care in a real lather, ask them about the number of beds they have that are blocked, which is an official term. They will say, ``It is one in four or one in three or one in six,'' and they talk about it as though it is the fault of the patients, or they say, ``We need more long-term care beds.''
We have built a system based on doing one thing at a time, and we have not learned how to accommodate people who have many things wrong at once. That is where the sticky part of health care comes in. We will not make it better until we adapt the system to respond to the needs of the patients who are actually there.
The one-thing-wrong-at-once approached has been extremely successful for understanding how disease works and for understanding for the most part how to treat illness, but it is falling down in its ability to treat actual patients with the real problems they have. The standpoint I am trying to bring forward is that health care needs to face up to frailty. Frailty is what happens when people have multiple, interacting medical and social problems. It is a highly age-related problem, but it need not be so. You can find 50-year-old diabetics who by any account would be frail. However, for the most part, the older people are, the more likely they are to be frail. When they are frail, they do not need the same style of health care that we offer, which is to treat one problem at a time.
If you go to the emergency room at any place right now, you will find someone trying to get his or her ticket in. Who will take this patient? Do he have a kidney problem? Maybe the kidney guy will take him. Do he have a heart problem? Maybe the heart guy will take him.
We need more comprehensive care. Here I find myself without much sympathy for the ``Don't worry, be happy'' group's position that the issue in health care cost is technology. Often we are doing technologically inappropriate things to people. What we do would be appropriate if the patients could withstand the technological intervention, and they could withstand the intervention if they had only the one thing wrong with them. However, we have done a very poor job of understanding and risk stratifying for the people who have many things wrong.
From my standpoint, we have a conceptual problem in how we have organized health care, and we have a system problem in how we try to provide care. The issue now becomes how do we reform health care. Over the years I have come to the conclusion that the major problem is accountability.
It is obvious that some people are extremely poorly served by the health care system, yet if you try to solve their problem, if you try to do anything for them, a huge number of people line up with varying reasons why nothing can be done for these people. However, no accountability that attaches to the problems of those people. We are willing to let people fall through the cracks. We are willing to say that a person is too sick for program X, but not sick enough for program Y. There is no accountability to attach to the problems that individuals have.
I think that if we are to make things better for people who are frail, we need to change the accountability. When we do that, I think we will see a change in what we can afford to do. Currently there are many things we say we cannot afford to do. We cannot afford nurse practitioners. We cannot afford to pay doctors to look after the complex needs of older people. We cannot afford to do house calls. We cannot afford to do team conferences. We can afford to do MRIs. We can afford to do bypass surgery. We can afford this, but we cannot afford that. Obviously, we can afford things, but we have to organize the system in such a way that accountability is attached to the outcomes that would be improved by nurse practitioners and home visits and geriatricians and things like that.
It is a time for a big-picture account of what goes on, but as we paint the big picture, we need to root it in the everyday experience of elderly people facing health care and finding out that the system that they have counted on is not there to help them with the needs they have.
For years and years we have tried to get more young doctors to do geriatric medicine, and one tries various ways to attract them in. When they are still quite young I tell them that if they want to save the world, they should do geriatrics, and here is how it works. If we think about all of the problems in health care in Canada right now, to my mind, frailty is the one that is most likely to undermine the public provision of medical care, because everybody is frustrated, and not knowing what to do they say, ``Well, we will just turn to the private system.'' That is perverse for reasons that we could go into, but if you think about it, medicare is one of the great unifying themes in Canada. Therefore, if we cannot get this right, what hope is there for the country? With everything that Canada has, if we cannot keep the country in place, what hope is there for the world? So I tell people, ``If you want to save the world, do geriatrics in Canada.''
Dr. Chris MacKnight, Associate Professor, Department of Medicine, Dalhousie University, as an individual: Thank you for inviting me here today. It is nice that you are talking to doctors. Often people in officialdom do not like talking to doctors because they think all of our interest is in our right hip pocket, but it is not necessarily there.
I would like to apologize, first of all, on two fronts. One is I might come across as angry at times, and that is because a lot of people are suffering needlessly because decisions have been made to do one thing and not look after them. The other thing is that, you are quite right, we need to take a bird's eye view of things, but I have more of a worm's eye view since I am down in the dirt all day.
You have heard from quite a few people, as Dr. Martell mentioned. Very bright people like Marcus Hollander, François Béland and Jeanne Desveaux have told you many sensible things. I am not quite so sure that some of the things other people have told you are sensible. Do you really believe that the next generation of seniors will be healthier, as a person from Health Canada told you, with the epidemics of obesity and diabetes? In my generation it is asthma. There is no evidence that compression of morbidity is happening — the jury is still out — but there is a lot of evidence that expansion of morbidity is happening.
Do you believe that the next generation of seniors will have more discretionary income to spend on private health care? Will people really save more? Will they make wise decisions with their money, human nature changing? Will the people who provide private health care not increase prices to match the buying power? Dr. Evans told you that the changes in the population aging will have little impact on health care and health care costs. That is probably true if you look at it from an annual change in percentage costs. The economist from the University of New Brunswick, though, I think made the case about the massive impact that it will have on a province like New Brunswick and other provinces that have more than their share of older adults.
You liked Dr. Evans' metaphor, the zombie, but then health care is still lurching and staggering, and if you use a different metaphor, the prism, from his end of things he has the clear ray of light and it is quite simple to look at. Then, on the other end of the prism, there are all the shades of colours, and that is looking at the frail elderly and the elderly who are demented and the patients that Ken was talking about who do not fit into any of these neat pigeon holes and are much more difficult for the health care system to look after. It is not just growing older, but it is growing older and adding more difficult patients.
I will tell you a little story — I hope not giving away too much confidentiality — about something I have been dealing with in the past week or so, including this morning, and I do it on a regular basis. There is a patient at home alone who is severely demented and cannot dress, feed or toilet himself. Family members are trying to provide care but need to earn a living as well. Home care will not go in and provide services because this person is verbally and physically aggressive. He talks loudly and quickly and bangs his hands on the table when making a point. He has not actually hurt anybody, but home care services will not go in because they are afraid. Adult protection workers will not place him in a nursing home because the family has power of attorney and can make arrangements for his care, so he is not an adult in need of protection. Continuing care will not put him in a nursing home because he is too aggressive. No nursing home in the province is able to provide behavioural management for somebody except for the veterans' building that you visited this morning, but that is a federal program and has different resources. No acute care facility has the ability to provide behavioural management to somebody with dementia, so that is not an option.
The only option for this man is the emergency room, where he will be strapped into a bed and heavily sedated, and then he will spend the rest of his life in hospital. It is very sad.
It is no secret that there are people like this. It is no secret that many people like this are coming through the system. The only secret is to the families when they come looking for help from the health care system and discover there is none. That is because people over the years have made decisions to not look after this problem and instead to buy MRIs.
The Chair: Thank you. I do not think you are angry enough, Dr. MacKnight.
Senator Cools: I would like to begin by thanking all three of you for your extremely thoughtful and scientific testimony. You have articulated the magnitude of the question this committee has undertaken to study. I thank you for doing that.
The questions you have put on the table are large, so maybe I could begin with Dr. MacKnight and the particular case that he articulated or cases like it. There are dozens of these cases. I spent much of my life working in social services. The problem quite often is that the difficult cases fall off the table and are neglected, whether in youth work, juvenile delinquency or counselling services. Human beings quite often just do not want to deal with the difficult cases, and those difficult cases just get compounded over 20 years. I am not sure that the committee has had a careful look at the science of these conditions and the differences, because there are many dementias that aging people get that are not necessarily Alzheimer's. Do you have any information on the number of people in Nova Scotia who are in that set of circumstances?
I am a little older than all three of you, I think. I grew up in the days of home visits, when medical care was not what it is like today. For example, as a baby I was delivered weighing 15 pounds at home by the local doctor. He had relationships with the other doctors, so if a situation at home got too complicated he would run gather up one of the others. Those doctors were known to arrive at three o'clock in the morning in their pyjamas to serve patients.
Can you tell us how many individuals are in the circumstances that you described? In other words, is this an isolated person, an isolated event, or is this symptomatic?
Dr. MacKnight: We know that 8 per cent of the population over age 65 has dementia. In Nova Scotia, that works out to about 14,000 to 15,000 people. You can compare that lymphoma, for example, where there might be 100 new cases a year in Nova Scotia. Dementia is quite a huge problem compared to other things we hear about.
I could not tell you how many people are in these circumstances, but there must be dozens at least in Nova Scotia. I have dealt with three or four individuals in identical circumstances in the past couple of weeks.
Alzheimer's disease is by far the most common causes of dementia. There are other, rarer causes. It is often not so important to be able to distinguish them precisely because we do not have many therapeutics that are different depending upon the diagnosis. The approach is based mostly upon assistance for the family and training for the family and expert caregivers, and the approach is similar for each disease, though it needs to be individualized for the person. The health care system has difficulty individualizing what it does. For example, in the best of all possible worlds, that person at home could have expert, trained caregivers in for a few hours a day and an expert nurse practitioner who could help train the family how to provide his care and who could provide backup for the caregivers. We do not have that, but we should be able to have that.
Dr. Rockwood: I would like to comment, referring to the principles I outlined. It is not that we do not know what to do. Dr. MacKnight has pointed out that there are programs of expert care that could deal with this person. There are studies showing how those programs would be structured. He has made the point as well that this is a common problem; I am sure there are dozens of people at any one time with an acute problem like this. They have not commanded the attention or the resources that patients with other illnesses have. That is one of the fundamental issues we have. It is hugely frustrating that we see people all the time in great need, and yet there appears to be no clear advocacy voice for them.
It is not that we do not know what to do, it is that typically the sorts of things that need to be done for them are not technologically intensive. They are expensive from a resource standpoint because of the labour attached to them. From the standpoint of innovation, we have tended to spend the most money in health on technology and drugs. We need to step back from that and find a way to prioritize their needs. That is why we made the claim about accountability. If someone was accountable for this patient in a meaningful way, there would be a means to solve this.
When I came to Nova Scotia and began practice in 1991, there was a rule about who would be responsible for the costs for that person, and the costs were attached to the social services at the municipal level. Social services would have a strong incentive to provide care for that person because they would otherwise somehow be penalized. I do not know if this actually happened, but the idea was that if that person wound up in the acute care hospital, that the per diem cost would come back to the social services budget.
This may not be the best answer, but we need to bring forward the idea that these patients have costs and that accountability goes with them. We do not do that now. We could get an MRI for that person in a flash; it would add nothing at all to the person's management overall and it would cost a lot, but we could do that because we are set up for that, but we are not set up to provide care for that person. That is how we should conceptualize the problem. These are not unsolvable problems. However, we do not organize ourselves in a way that makes it effective for anyone to solve them.
Senator Cools: Do you have any idea how that accountability could be encouraged or supported? Doctors frequently voice to me the same concerns you have raised. I am sure it happens to every other senator. If you find yourself having an X-ray or other test in the hospital, the people who work there are ready to tell you the huge problems they are facing, and years and years ago the management of health care used to be in the hands of doctors and nurses, actually. Much has changed, but I am just wondering whether you have any concrete suggestions for how we could address. That is the devil, the monster in this matter.
Dr. Rockwood: I would say three things in response to that question. First, in general doctors have not been champions of accountability because we have tended to favour professionalism, for good and bad reasons. In my view, the pendulum has swung too far the other way in terms of patient autonomy, which for many cases we deal with is a complete fiction that allows people off the hook where professionalism would be a reasonable remedy. I cannot imagine that any bioethicist would agree with that, but I did not want to miss the chance to say it.
Second, it is a big thing for a geriatrician to call for more accountability because the few accountability standards we have now work systematically against our patients since they are based on the one-thing-wrong-at-once approach. Famously, it is the length of stay.
I imagine a cost-based accountability that would take a population perspective and would say that the cost of dementia in this community would reasonably be X and the standards we would expect to be met would reasonably be Y, and I would expect some sort of adjudication mechanism to see whether we are spending X to achieve Y. The standards would actually have to be related to the needs of the population you are attempting to serve. I do not imagine that would necessarily be an easy thing, but you would make an investment, not run into it half cocked. You would need to do studies and trials. We need that kind of systematic, fundamental change to get us off the one-thing- wrong track that we are on now.
Third, regarding the nature of the accountability, in geriatrics we hold many things to be sacred cows, and they would probably change under a strict accountability mechanism. For example, if we think about the provision of in- home care here, the public home care agencies have got themselves in a real box because you cannot sweep the floor without a floor sweeping certificate, and you cannot give a pill if you are not a nurse. You cannot turn the kettle on without a nutritional degree. They have over-professionalized and over-standardized the service. Dr. MacKnight will know for sure.
I am not sure whether in your area you have the Newfoundland Ladies, a group of women from Newfoundland who work here two weeks at a time. They move in and do everything, and their major qualification, as near as I can tell, seems to be that they are middle-aged women who have raised big families and they can take on any task that needs to be done.
I know professional home care people will have the heebie-jeebies, but I will bet that at the end of the day the real solution on a population basis will look a lot more like the Newfoundland Ladies than it will look like the multi- certified, ``multi-teamified,'' inter-professional group that would provide care otherwise.
Dr. Martell: I like that thought. Thank goodness for the Newfoundland Ladies. They come from a different era, but they are life saving. It meant the difference for several cases of mine that had no solution, cases similar to the situation that your patient was in, Dr. MacKnight.
Senator Mercer: Somebody out there this very moment is trying to figure out how to professionalize those Newfoundland Ladies so that they will have to have a certificate to do what they do.
Dr. MacKnight, you indicated that you might come across a little angry. I did not think you came across as angry at all, but I think that collectively you all have a good deal of anger and more frustration. You all want to do good work, but the system is not helping.
I have one question. Dr. Rockwood, as Senator Carstairs said, while we were at Camp Hill this morning someone mentioned your name in a very positive light. You come with recommendations from patients, which is a great recommendation.
You have told us that there is a need for the system to adapt to the patient who is actually there. You have said, ``If you want to save the world, do geriatrics in Canada.'' What should our first and second steps be?
Dr. Rockwood: At the system level, they would be along the lines of what I have talked about. I do not want to come across as too partisan, but we simply do not have enough specialists in geriatric medicine right now, and we are not training enough. We put obstacles in place that defy common sense. Someone needs to say that there will be guaranteed training slots if you want to do geriatrics and there will be a reasonable prospect of being hired afterwards.
Our group right now has three people training in geriatric medicine, and we are probably one of the largest groups in the country from that standpoint. We currently have two specialists in geriatric medicine, and there is a big discussion about whether we can find a place for them in the bizarre practice plan arrangements that the Department of Medicine has engaged itself in. It beggars belief that we have two people in our grasp and we cannot figure out a way to hire them. We need on a national priority basis to get our act together to at least do that. Let us not turn away people who have come here and done the training or want to do the training. That must be the easiest thing in the world to achieve, so it is the first thing that needs to be done.
The second step, in my view, looks like this. It is clear that there will never be enough geriatricians to provide all of the care that should be provided, nor should there be. We have to think about what the appropriate role is for them. Presumably, the appropriate role for them is as a catalyst within the system to put exemplary services in place and then have arrangements whereby other people can come in and learn how to do it in this way and take it back to their home environment.
An example that is poignant and a bit frustrating for us is that in this province we set up a restorative care service and systems that have been emulated in many countries around the world. When the province came out with the restorative care program to go outside of Halifax, there was no consultation with us, and they put things out without standards, without accountability, without the routine processes of care that we could put in place. It is odd to me to be answering inquiries from Australia and Ireland, but I cannot get any traction 100 miles away.
Therefore, having brought more people like this on, the second thing we would do is to recognize the catalyst role for them. I make this point because the traditional thing we expect our specialists to do is to provide hands-on care, and we have not got a good model that allows them to do systems work. That cries out to be done to help provide for an aging population.
Again, if we change the accountability, we find that all these things would become cost-effective and reasonable to do overnight. Again, the point to make is not that we cannot afford it. We afford implausibly complicated things all the time. The point is that we have to structure ourselves so that we require this to be done and hold ourselves to that standard.
Dr. Martell: To echo Dr. Rockwood's thoughts about restorative care, the situation in Lunenburg is that roughly three years ago we lost one of the pillars of our community, a family doctor named Art Patterson. Part of his legacy was to build a restorative care unit within the community. Lunenburg is a small town of 2,300 people. The Restorative Care Centre was built and is functioning, and I think it is a model that can be replicated. It has been a smashing success, but it serves only a small, defined population. These are not the failing elderly with multiple co-morbidities. These are the elderly who have one problem that will improve and then they will be able to return home. A lot of thought was given to the construction, layout and staffing of that centre. It does not work perfectly and is evolving, but it is one of the successes.
Three years ago now, as well, we got together as a district with all of the stakeholders to develop a plan around aging. I was hoping to distribute that plan to this committee, but it was quite short notice. This initiative was driven by the district. It was not grassroots. It did not come from individuals from the community or even from the community health board. The initiative was from our district. It was called Aging Matters and was extremely comprehensive, with implementation plans and so forth. Born out of that committee was a seniors help team, a collaborative group of individuals, nurse practitioners, nurses, therapists of various sorts, who would go out into the community to find the people who were failing in various ways, the people who fell between the cracks, cases such as Dr. MacKnight came up with.
At the outset, this team was a fantastic safety net. As a family doctor, whenever I came across a case for which I failed to find a solution, I turned to these people to spend the time and the thought picking up the pieces, and they did very well. They were fantastic at making assessments. They would go into the community, find out what was wrong and find solutions. They would make recommendations that are realistic and will have outcomes.
However, the trouble with this team, which has since to a large degree disintegrated, was that they were not a sustaining team. There was nothing behind them. There were no caregivers to continue to giving you therapy in your home if you needed therapy to gain strength so that you do not fall or to manage your medication so you do not end up in the hospital with medication errors. However, I like to dwell on the successes, and this is one of our successes.
One other thought I had while Dr. Rockwood was speaking is efficiency. I think our health care system lacks efficiency and accountability. We have, believe it or not, enough family doctors on the South Shore. I am not sure about interims of full-time equivalence, but we are still looking for more. What we lack are other health care providers.
Also, we lack meaningful delivery of care. The family doctors that we have work every day at crisis intervention. The do not necessarily do much prevention. To a large degree, they do not work in collaborative teams. One of the simplest way to fix that, I think, is to make their pay contingent on their outcomes. That is part of the vision we have with our own collaborative practice. I think these things can be done.
Dr. MacKnight: Regarding the seniors' community health team that Dr. Martell mentioned, I just received two urgent referrals from them, but they were sent in November and somehow ended up on my desk six months later, and their patients has not been seen yet.
I am not sure what happened during those six months, but it is obvious that access to specialist geriatric medicine services for that team was lacking. That goes back to Dr. Rockwood's comment about how we do not and will not have enough geriatric medicine specialists and need to train people to work locally. They do not necessarily have to be doctors. I am not married to the idea of doctors doing it. Nurse practitioners could do it. Occupational therapists or social workers with additional interest in training could do a lot of that work.
It is not necessarily difficult to train these people, and it is not difficult to find people who are interested. It is just difficult to find the will to create a position for them.
Senator Mercer: Dr. Rockwood, you used the word ``accountability.'' I am trying to figure out how we introduce that into the system. Where does it start? Who has to drive that? Does it have to be driven from the top down or does it come from the middle or the bottom up? Does the federal health minister or the provincial health minister need to say, ``Here is how we will introduce accountability into the system?''
Dr. Rockwood: I am all in favour of things being as broadly supported as possible, but if the top does not buy in, this will not work. This needs to be top down. It is a role for visionary leadership. No doubt it will discomfort people who will imagine themselves disadvantaged under the new arrangement.
In 25 words or less, ultimately we want our health care system to achieve three outcomes: we want it to prevent premature death; we want it to relieve suffering; and we want it to maximize function. At the moment, we do not have effective accountability on any of those.
For example, when a patient has hip replacement surgery, the only outcome is whether the patient gets out in five days or eight days or whatever length of stay is attached to that procedure at a national level. That is really the only accountability we have. We do not have accountability about whether they can walk at the end of it.
This is how I imagine the accountability measures coming about. We would identify the reasons that we do things, and then we would hold people to achieving those outcomes on a population basis. What portion of the patients who had surgery X walked as a consequence of that, if walking was meant to be the outcome? Right now it is very process- based. As long as the hip surgery is done, it is fine. Clearly, there is some monitoring for the morbidity and mortality count. If patients have particularly bad infectious outcomes for their surgeries or their mortality rate is too high, somewhere in the system that will get picked up. However, that is a very distal outcome compared to the more usual state that people find themselves in for which they are able to express well-articulated preferences ahead of time.
In my practice, if I intend to put someone on a drug, I try to imagine what the goals of the drug are, and then when we follow up, we see the extent to which patients have met their goals as a consequence of the drug. We actually follow a fairly formal procedure for it, as we do with the Restorative Care Unit, which is a place people come to be rehabilitated after their acute hospital event has been dealt with.
At the unit, we have a formal process whereby we set goals for patients' outcome and we try to tie their discharge to those goals so that discharge arrives at the point they have met their goals. We do not say that someone with a hip fracture should require seven days post-operatively, because we know that there are two populations. People who do not need to climb stairs can probably go home in five days, and seven days is actually two days too long for them. People who need to climb stairs probably will have to take 10 days, so seven days is three days too short for them. We try to individualize the outcomes of care to the needs of the patient, but we are fairly idiosyncratic in doing that in a systematic way. I think an accountability mechanism should look more like that.
Senator Mercer: It seems to me, as a veteran of six or seven knee surgeries, that we treat patients to the front door of the hospital and then send them on their way. Excluding things like physiotherapy, health care seems a travesty passed to others.
Senator Cordy: The three of you have brought a different perspective than we have been hearing, which we appreciate.
When we look at accountability, I think you are saying that we should be looking at the patient and not the system. If we are looking at the patient, then we have to cross jurisdictional boundaries within government. We have had a couple of high profile cases in Nova Scotia. One of them was the one you referred to with the alleged abduction, and the other was the woman who had lived a very quiet life and suddenly was within the justice system and did not have a place to live and so on. I know there are hundreds of other cases that are not high profile that are not reaching the newspapers. Dr. MacKnight, you gave an example this morning of several. Are those cases making a difference? Are more silos being broken down? Are we seeing government departments like community services working with health care? Is justice working with community services and health care? If we are trying to meet the needs of our population, in this case specifically seniors, then we have to cross jurisdictional boundaries and we have to do what is right for the person.
Dr. Martell: Having some involvement with that one case, I will take a stab at this. The briefest answer I can give you, based on that specific case, is that there has been debriefing. There is a provincial initiative, and it is being taken seriously. I shared that case with a geriatrician, Dr. Carver, and I have been asked by a provincial committee to review some legislation that they are looking at implementing on personal directives. However, in my opinion this is reactive, not proactive. This comes about because there has been a failure in the system, and I do not know that that is necessarily a great way to go about developing policy.
Dr. Rockwood: I await the groundswell of people trying to fix the problems of the seniors from the senior standpoint. That is not in my experience. Sometimes you do not have to cross the jurisdictional boundary to understand what the problems are. The example I have often used is that if someone at this moment were to have a cardiac arrest, there is an extremely well worked out procedure for what needs to be done. Similarly, if there were an accident outside here, there is an advanced trauma life support protocol for what should be done, and it is really down even to the point of who stands where by the bedside doing what. Everyone knows what to do, and a case from Oregon and one from Ontario look about the same.
If an older person shows up and starts to swing at his or her caregiver, then it is catastrophe. No one knows what to do. We run around. There is no protocol. I would be more optimistic if we had things like an advanced geriatric life support or an advanced behavioural problem intervention protocol so that we would know what to do and it would not default always to trying to get the one-offs.
Part of the frustration that Dr. MacKnight and I share in trying to help manage these patients is that the things that you learn about for patient X might not help you at all for patient Y, because patient X was a veteran who lived in this postal code area and it was a Thursday and that day there happened to be someone available and so on. There really is no systematic approach to problems that are occurring in a predictable way, and that is very frustrating. Even within the system, we have problems getting our act together on that. Again, that is because there is no specific reward attached for doing it well or sanction for doing the job badly.
Dr. MacKnight: I guess it is sort of a not-in-my-backyard syndrome. Chronic care says that acute care will look after it, and acute care says that chronic care will look after it, so it ends up being the family, who do not have the time, training or resources, who try to do it.
Senator Cordy: I would like to talk now about family doctors. Dr. Martell, you are a family doctor. The reality is that the family doctor is the front-line person. You are the person seniors are most likely to go to unless they are within the system and have a specialist that can look after them.
We have heard today that when a senior goes in, very often there is not just one issue. You have go to look at the senior overall, so it will take more of your time. Most family doctors are being paid per patient. Do you get more money if it is a senior who is coming to see you? I was on the Prime Minister's Caucus Task Force on Seniors a few years ago, and I remember a lady in Victoria telling us the doctor is allowed 15 minutes, and ``at my age,'' she said, ``it takes me 15 minutes to get my clothes off.'' I am just wondering if you could sort of educate us on how you get paid as a family doctor.
Dr. Martell: I have patients who take 15 minutes to get into the exam room with the help of family, and these people living at home.
I am not motivated by money. I am forced to be a business person on the basis of the practice arrangement that exists, the only one that was available to me when I started my practice. I mentioned at the beginning of my remarks that we have a proposal to become a collaborative practice, a community health centre, and that is my dream job because would allow me the freedom to do other things.
You just said, ``Dr. Martell, you are a family doctor and seniors go to you when they have a problem.'' The ones I see come to me. The ones who are truly failing cannot come to me. I have to go to them or find some way to go to access them. I do not know to what degree elements of my practice are not doing well, if I do not see them. My availability is structured in a way that allows me to do business. I am a small business owner. I have to be conscious of that, and there are elements of my practice that are completely unfunded.
I am called upon constantly to sit in on case conferences to discuss difficult cases. I have got one in the hospital right now that is going very poorly — an aggressive patient in a place that is not appropriate for their care, and staff are frustrated. Most of the staff would say that ideally this patient should be sedated so that staff do not have to deal with the problems.
I have absolutely no reimbursement for that whatsoever. I am asked to take an hour out of my day to attend this and it is a necessity. I do it because I have to, but it is money lost.
The current master agreement that is in the midst of being voted on in the province addresses some of those problems, both with contingencies for complex care and with collaborative practice arrangements. To me it appears novel, if it works, but that is just here in the province. Not everybody is interested in doing it, but I think it would go a long way.
Senator Cordy: You are not getting paid for this morning. Is there something that we should be doing? You mentioned attending meetings, dealing with families, preparing for meetings, and so on. Should we be changing the way we pay family doctors?
Dr. Martell: That is a difficult question, and I do not know that I am representative of family doctors. I am motivated by the work I can do and not by the dollars it brings in, but I do not know that I am typical.
The Chair: That is not the motivation, but the reality is that we have established pay schedules that are reflective of the kind of technological medicine that we practice. For example, I know that the vast majority of palliative care physicians, which is a cause close to my heart, come from either oncology or internal medicine. They get paid less to deliver palliative care services than they would if they were practicing internal medicine or if they were practicing oncology, and I would suggest to you that is because internal medicine and oncology are high-tech deliverers of systems, whereas palliative care is very low-tech in terms of delivery of system. I would like to hear your comments on that, not to make it sound as if you yourself are asking for more money, but if we are asking about true accountability and we are saying that the accountabilities should be with the patient, are we not doing this all backwards?
Dr. Martell: Yes, but how do you do it the right way? In our district we have a full-time palliative care physician. He was a family doctor but got to a point in his career where he was burning out as a family doctor, so he went to pursue his passion, caring for the dying, for personal motivations. Dr. David Abriel is a great mentor in our district. I do not know that he knew he would live this long. He is not very old, but the work that he does I do not think is easily done by anybody else.
It is actually an interest of mine as well. I have given thought myself to going back to doing palliative care medicine, and the pay I would get from that would be whatever it is, but, in my vision, the value in doing that type of work is the value of life experience.
I made some notes while Dr. Rockwood was talking about the three goals: preserving function, relieving suffering and avoiding premature death. If these are our goals, then we want to tie the amount of available resources to those goals and list them as outcome measures, but they are not very easy to measure. There are ways to measure them — studies are done on these things — but they are all sort of pertinent negatives. How do you give an incentive for a palliative care physician? How do you measure a good death? It is not a tangible thing. How do you measure the suffering that has been alleviated? If you can tie incentives to the way these things are measured, of course more and more outcomes will come to you. It is a business model.
The other part of that is taking away the drive to earn income on the basis of outcomes. If we were all salaried physicians and happy with our salaries, then we would have the freedom to do work that we otherwise would not do.
Dr. Rockwood: I have two quick comments. One is that the money that gets paid out is a statement of values. There are technological things, and it is a statement of the skills required to master certain procedures, but after that it becomes a statement of values.
Internal medicine is not particularly technologically driven. It uses technology, but that is not procedure-based. The same with oncology. For Dr. MacKnight and me, the reality is that as subspecialists in geriatric medicine having done internal medicine first, we get paid less than the internal medicine doctors do. I am always nervous when I hear doctors whining about their salaries or their revenue shares, whatever the correct term is. What we could say is that the experiment of ``Is this a way to attract more people to geriatric medicine?'' has been done, and the answer is ``No, that is not an attractive proposition.''
I was recently in Ireland, where they had a very small number of geriatrics in the 1980s and they will have a very large number now. They are at 76 for a population of 4.2 million and they are aiming for 110 in three years time, and they will get there. They paid those doctors more than most other doctors were paid. Suddenly they found that the problem of where would those doctors come from went away. People were lining up to do the work. We could try that experiment here, too.
Dr. MacKnight: What Dr. Rockwood did not tell you is that he is attending in internal medicine right now and earning less than other specialists who are doing the same job just because he is a geriatrician who is intrinsically valued less.
I do not think most doctors are necessarily interested in money on its own, but rather they are interested in being able to do a good job and having access to resources to do a good job and being able to innovate and be flexible and try to put in place a practice that will meet the needs of their patients. So long as they are earning what they think they are worth, which is, of course, a different thing altogether, I think the lifestyle and the practice pattern for everybody is as important as the money that is attached to it. Dr. Rockwood and I, in an alternate funding plan from the Nova Scotia Department of Health, do have a fair bit of flexibility in terms of team conferences and phone calls and house calls and so on that physicians who are not in an alternative funding plan do not have. Some doctors prefer to be in a fee per service pattern, so it is hard to say that one size fits all, but there are different initiatives that can be done that can make it possible for people to work in a pattern that they enjoy.
The Chair: To put it in other words, it is not a terribly sexy aspect of practising medicine.
Senator Cordy: Nor should you be penalized for spending a lot of time with your patients, because you also have families that need things that cost money.
I would like to go back to the incentives. Perhaps one incentive is to pay gerontologists more money, but what are the incentives to get people involved in geriatric medicine? On Friday, a woman in Welland told us that she speaks to schools about the volunteer work that she does in aging. One of the young girls asked her, ``Why are you talking to us about this?'' and this woman answered, ``Well, I care about your future.'' She said the young girl sort of stepped back and said, ``Yes, it is about my future.'' How do we encourage health care professionals to enter this field?
Dr. MacKnight: I have been the president of the Canadian Geriatrics Society; we have looked at that question. Part of it you cannot do anything about unless you want to limit geographic mobility, but it seems a lot of people who do geriatrics had close relationships with their grandparents. I did, I think Dr. Rockwood did, and it sounds like Dr. Martell did. That is one way to do it, but we cannot tell people that they have to live in an extended family.
Exposure to geriatrics in medical school and in training is probably the biggest thing. I think you did that for palliative care by strongly encouraging universities to make that a requirement. In most medical schools in Canada there is no mandatory exposure to geriatrics. Students finish their four years in medical school not knowing that geriatrics even exists, so how will they choose that for a specialty? They have to decide on their specialty towards the end of their third year of training.
If the universities and medical schools establish more access to programs in geriatrics, not only for physicians but also for nurses, occupational therapists, physiotherapists and the whole range of health care professionals, that would be one way to attract people. Then having positions available is key. For example, I am the program director of the geriatric medicine training program at Dalhousie University; we had an applicant last year, but we did not have a position to offer her because we had to compete with all the other subspecialties and we were lower down on the priority list.
The Chair: Are you talking about a residency position?
Dr. MacKnight: Yes. There was no residency position to offer this applicant. She did get a position in Vancouver, and it is highly unlikely she will work here in Nova Scotia after training in Vancouver. Those are the main points: exposure during medical school and then access to positions when people are actually interested.
Dr. Martell: I am now nine years out of medical school. We were made to make decisions about our careers very early on. For the first three years of medical school I was gearing up for a career in general surgery; only in third year did I decide that that was not for me and I pursued something else. At the time of the match, many people still have not had any exposure at all to certain of the specialties, and that is an absolutely critical juncture.
Medical schools in Canada are autonomous bodies, and they are really not given specifics regarding what you have to do. However, they do receive funding, and putting incentives in place to make sure that exposure happens is one step that can be made to ensure that we have adequate supplies. I come from the time in the mid-1990s when there was a 10 per cent to 15 per cent cut in enrolment generally in medical school. Of course, now we are seeing the shortage. Somebody did not have vision.
The Chair: Health care economists recommended that.
Dr. Martell: Do you have a name?
Senator Cordy: Dr. MacKnight, I was interested in your comment. I have always taken it at face value when people say that the next generation of seniors will be healthier, but you are absolutely right. I was on the Kirby committee. We heard over and over again about childhood obesity. You mentioned asthma. I used to be an elementary school teacher. When I first started teaching many years ago it was rare to have a student with asthma. When I finished teaching eight years ago, every class had five or ten kids who had various levels of asthma or allergies.
I do not think Canadians are any different than I am. I think many Canadians are thinking that the next generation of seniors will be healthier and will live longer. How will we get the message across that we had better start preparing now if we want to have healthy aging?
Dr. MacKnight: Reading through your transcripts, I noticed that Senator Mercer missed a meeting because of a health issue, and I think Senator Keon mentioned a health issue once; even you are not what a colleague of mine refers to as ``geriatric astronauts,'' people who are in perfect health in late age.
We have all heard for years all the things you need to do to grow up and grow older healthier, and we all know those things from the ParticipACTION program and so on, but how many people actually do it? Then we look at the data about physical activity: people are not physically active. People are getting more obese and have higher rates of diabetes. To believe that the boomers are healthy and that healthy boomers will remain healthy at age 60, 70 or 80 is wishful thinking. We all know what needs to be done to get those messages out; it has been done before and it has been done successfully, and we just need to put more effort into doing what we already know how to do.
Senator Mercer: We have had some terrific observations, but there is an obvious question we have not asked: Is a system somewhere that is doing it better, doing it right, that we should examine and try to model ourselves on, or if we go down this road, are we inventing the wheel?
Dr. Rockwood: I think you will find components of systems everywhere. I have worked with colleagues in Sweden and I have always been impressed with their ability to have more age-friendly cities, for example.
In Canada we still do things like build houses with the steps outside, and that makes no sense whatsoever. We have treeless sidewalks where the wind would blow over a 25-year-old, never mind an 85-year-old. Basic things like that we do not do; they are not reflected in our building codes, and developers left to their own apparently will not do them, yet people still buy. Those elements are part of the big picture.
Regarding the provision of care, often by the time someone is frail, your ability to influence their outcomes in a dramatic way is much less than being able to have a safe and healthy environment for them. That being said, there are places, including Sweden and health districts within the U.K., that have put a lot of work into this and seem to be moving that way as well.
I have been intrigued to be invited to Ireland in two weeks' time to talk to a conference that has been brought about by the Irish government. The conference will include people at the highest levels and will reach broadly into the community as well, with architects, police, developers and so on attending. The title of the conference is ``What would it take to make Ireland the best country in the world in which to grow old?'' It struck me that that is a very different way to think about the problems of an aging society.
I was struck when I was speaking with people there a couple of weeks ago who have been through the experience of the Celtic Tiger. I talked to a man who said that he grew up in a day when it was inconceivable that by 2008 Ireland would have the success that it does, and yet here they are doing it. They see population aging as just another challenge that they will get around.
I often remind people that a lot of the challenge of the aging baby boom is because the parents of the aging baby boom got through the Depression and won a war. Compared to that, the challenge that we are up against is small. If we cannot lick this, shame on us.
Senator Mercer: It seems to me that when we talk about healthier aging, we have acknowledged that we will live longer but will not necessarily live healthier. It is more of an observation than a question. It is a sad reflection on where we have come after we have all learned about ParticipACTION. It is our lack of participation that will get us in the end.
The Chair: Just as Dr. Martell began his presentation with the story of his family, my engagement in palliative care and now in the greater issue of aging is of course also a family story.
My father had a massive stroke in 1970 at a time when stroke victims were written off completely. There was little in the way of physiotherapy, little in the way of anything. He died in 1980 after my mother looked after him for 10 years, and then she died seven months later because she had literally killed herself caring for my father.
That is a very common story still today. That is, I think, the need that you have presented, Dr. Rockwood, with respect to accountability, because we now have aging people looking after aging people, and the deterioration of the health of the caregiver is significant. What will we do to address those issues?
Dr. Martell: The silence is deafening.
The Chair: It was relatively easy when I championed the palliative care file. It was easy, relative to this situation, to find the dollars necessary for research. It was easy to put in a compassionate care benefit. Frankly, it was relatively easy to persuade the College of Physicians and Surgeons that there should be a core program in palliative medicine, and as of 2008 every student graduating in undergrad medicine will have one. It cost the federal government $1.25 million to give to the College of Physicians and Surgeons to initiate the curriculum.
I am afraid I am much more stumped by the question of what recommendations this committee can make to the federal government regarding its responsibility, because we are primarily focused on the federal government. What can they do to make this system more accountable?
We have heard some people say that we need to make a more caring medicine delivery system, whereas right now it is a curing medical system. I do not reject that idea, but I need to know the practical. If I became the minister responsible for seniors tomorrow, what would be my top three priorities as a federal government minister? I knew what to do when I became the minister responsible for palliative care.
Dr. Rockwood: I think you are right that ultimately much of what gets delivered is a provincial responsibility, but there is a big role for a morals equation here. There is a big role for identifying where the system fails and for pointing out that some of the systematic obstacles that people have imposed on themselves are functions not of not knowing what to do, but of putting in place administrative systems that do not allow them to do it.
There is then a role that has very much been a traditional federal government undertaking, which is to do the research that allows the examples to be worked out well so that one can imagine something going on from that standpoint.
From standpoint of the provision of health human resources, there is precedents as well for the government to prioritize certain areas and to look to train more people within those areas.
I think those would be three things you could do. Make the case in a way that is compelling; put in place programs that allow research to be done to allow the anecdotes to be turned into evidence; and help train more people who can provide the new models of care.
Dr. MacKnight: Dr. Rockwood gave my answers, while I would have said human resources, funding innovation and I guess the other thing would be community care — some sort of a national home care community care strategy.
Dr. Martell: My first intuition was to respond by saying make it sexy. In the very first part of my comments when I started I mentioned in passing about the Kirby commission and the Romanow report. I would hope that most people in Canada know what those are and know some of the content because of their successes in marketing.
Bringing awareness and understanding to the issue is a first step. I do not know how you go about doing that. Do you take some failing senior into the Senate chamber and say, ``Look here''? I do not know how to go about that. I am not a marketer. Perhaps you have a senator who is already sitting.
Senator Cools: When I came to the Senate, we had a very old, aging senator. She used to arrive with her wheelchair, and I remember with great vividness that any time people wanted to show a negative image of the Senate, they would show this very old woman. She must have been in her nineties. I am not too sure whether in today's community with a growing consciousness of aging, age and disability they might do that, but I wanted to let you know I have witnessed that sort of thing. I think your point is well taken.
Dr. Martell: On the point of trying to make it sexy, I think that is actually possible if you look at the complexity of the problem of aging. It is a massively complex problem, and yet it is yielding to inquiry. I would think that when people see the intellectual challenge and that strides are being made to address the intellectual challenge, that would be a way to motivate.
Certainly for some of the people you want to come on and be opinion leaders, persuading them of what an intellectually complex and appealing area this is would be one tactic. One of the highest paid specialties within medicine is gastroenterology. You cannot think that that subject matter is inherently attractive, right? Compared to that, we should have an easy sell.
Senator Cools: If there is anything else that you think of or that you have been thinking of but have not had the chance to say, you should certainly throw it in in the next few minutes.
My question is about the apprehension, fear or reluctance of caregivers to deal with dementia and the other pathologies of old age, their inability, basically, to confront or face agitation in patients — agitation, provocation, aggression, or whatever you want to call it. I am very sympathetic, because I spent a large part of my life working in crisis interventions. As I was listening to you, I was recalling a situation where we had to have a woman taken away in a straitjacket by hospital attendants. Now even that language has disappeared in today's community, but I remember how sensitive the individuals were when they came to take her. She was essentially having a psychotic breakdown right before our eyes.
In those days, any time there was any problem like that, as the captain of the ship I was immediately brought up on deck to deal with it, and I had developed a large number of techniques for calming. One of them is as simple as just placing your hand directly over the forehead and just giving the person some physical support. You will see the person's body start to calm down. However, I always remember that the skill they used this time was to talk to her very gently, very sweetly, almost like she was a little child; they calmed her down and then, low and behold, put her into the straitjacket and took her away.
What I am understanding is that in these huge areas of medicine, like cardiac arrest and cardiology, some of these processes and procedures are down to a science. You do this, you do that, you administer oxygen, and so on, but in other areas when you are dealing with unreason and, let us be frank, psychic deterioration, it is not so easy to develop strategies or a definite procedure. I wonder whether you have any ideas of such systems.
Is perhaps a literature needed? Do we need a literature to develop around how to manage those kinds of problems? Or is it just that those skills are a function of individual human beings who have those talents and sensitivities and who bring them to the case? I remember a particular case of a man who went on like this for many years, His death certificate stated, ``Cause of death: apoplexy.''
Do you have any thoughts about how some of those techniques or systems could be put into operation to deal with unreason and with individuals who are provocative and aggressive? Some of them have no insight whatsoever. That is a characteristic of dementia.
Dr. MacKnight: It is not really unreason. The person is still in there and the person will still respond to a warm and caring caregiver, which it sounds like you were.
You said that you had developed various techniques, and other people can develop techniques and you can teach those techniques. For example, difficult behaviours in dementia can be divided into four basic categories: verbal, physical, aggressive or non-aggressive. Those have a very defined set of underlying causes to rule out as simple, fixable things, and then they have a defined set of approaches, although each approach will not necessarily work for each individual, but you can test things in order. All that knowledge is out there. It just needs to have the experts who know it be able to translate that to the caregivers in the home and the family so that they can use it. However, we do not have enough people who know how to do that and know how to teach people on a one-on-one basis and in thousands of households in Canada how to do that.
Dr. Martell: Modern medicine has horrors, anecdotes and examples that we give from our cases in practice to illustrate points, and I have one that is relevant to this sort of situation. I have an aggressive patient who was hospitalized with family unable to care for him just at the end, and he was placed in hospital. Of course, in cases like this, usually caregivers are strained and have been failing for months on end. They actually have very good strategies for dealing with the problems as they arise, but they just get to a point when they have had enough. The patient is thrown into an unfamiliar environment, and of course the aggressive behaviour gets worse, but, beyond that, the new set of caregivers, the staff surrounding this person, have no knowledge about how these things have taken place at home, how the issues have been met. In this case I have it is very simple. Two years ago the fellow required a colostomy to save his life, and caring for him in his demented, aggressive state was an extreme challenge to the point where it was not unusual to enter his room to find he had torn his colostomy bag off and swung it around the room, if you can imagine that kind of nightmare.
We racked our brains and weeks went by without knowing what to do short of sedating him, and the requests were always, ``Please give him more medicine so that he stops doing this,'' and that was not necessarily the answer. The answer I got was from one of the geriatrics residents. I did a case conference over the phone and he asked whether they had tried putting something in his hands when they did his ostomy care. I suggested it to them, and lo and behold that was what was taking place at home. He was made to hold something while his ostomy care was being done, and as soon as they started doing that, the problem went away; the agitation went away to some degree. It was much more manageable. That is a skill, for the geriatrics resident to be familiar with the situation and say this is a simple thing. If somebody is aggressive, perhaps they have difficulty knowing what to do with their hands. If you put something in their hands, the problem is much less of a problem, and in this case it worked very well.
The Chair: I want to thank the three of you very much. It was an excellent morning. I know you did not get paid for it, but I hope you will see some worthy compensation in our final report.
The committee adjourned.