Proceedings of the Subcommittee on Population Health
Issue 4 - Evidence - April 1, 2009
OTTAWA, Wednesday, April 1, 2009
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:14 p.m. to examine and report on the impact of the factors and conditions that contribute to the health of Canada's population — known collectively as the social determinants of health (topic: community- level population health model; and child health).
Senator Wilbert J. Keon (Chair) in the chair.
[English]
The Chair: Some more senators will be arriving, but we will begin.
We have two outstanding witnesses. We look forward to much information coming forth.
Dr. Cushman, you are going first, I understand.
I have known Dr. Robert Cushman for 30 years. He has had a long-standing career in the public health domain. Even more exciting now is that he is the CEO of the Champlain Local Health Integration Network, which I believe is a great thing for Ottawa.
Dr. Robert Cushman, Chief Executive Officer, Champlain Local Health Integration Network: It is a pleasure to be here. I will try to be short. I notice the questions and the answers. Could they be adapted? The answer is "definitely.'' Can they be adapted? That is the question mark.
There are some examples out there — the local community services centres, CLSCs, particularly in Quebec; and the community health centres, CHCs, across the country — but we are now in 2009 and we have to update what is out there and perhaps have more. The other question was about having the one-stop-shopping principle and having many resources under one roof. That certainly makes a lot of sense for the consumer, for the clients and the patients, and it also promotes integration amongst the services.
Now that I have answered the questions, I have more time left. I thought I would share with you some of my challenges so that you can better appreciate how this might help. I have titled my talk "Getting Out of Hospital and Closer to Home.'' It is looking at how we plan clinical services in the Champlain Local Health Integration Network.
There are now 14 local health integration networks, LHINs, in Ontario. I have provided you with a map. In terms of population, health care resources and the academic health science centre, we compare with six of Canada's provinces, not the big four, but with about six in terms of planning.
As to what we are all about, I have shown you that with the planning piece, the funding and allocation piece, the accountability and performance piece — that wheel you have there. What is interesting here is the community engagement piece, trying to engage the public. As a physician, I always ask people about their chest pain, but I never ask them about their voyage in the system. We have been doing that recently. I can tell you I am getting an earful. This is very helpful. We need to incorporate this as we plan.
As you see, this is what integration looks like. It gives a more seamless experience and improved match between what is provided and what folks need, and hopefully things are more effective and efficient at the end of the day. That is the philosophy.
I have provided you with a pie diagram that shows you where the resources are: 73 per cent are in hospital and 12 per cent in long-term care. That is already 85 per cent in the institutions. Our home care organization is very much a hospital in the home these days. You can probably take about 4 per cent of that and say it is either institutional or acute care service.
My message to you is that we do not have enough resources in the community. We have to shift into the community, away from the institutions. Our budget is over $2 billion and we have 206 health service providers. In fact, the Ottawa Hospital with the Heart Institute by and large consumes about 55 per cent to 60 per cent of the budget. That gives you an idea of some of the challenges we face.
I have given you our six strategic directions. What could be done in a polyclinic? What could be done in a community? What could be done anywhere and not necessarily in a hospital? Certainly, primary health services could. You notice we call it services, not care, because we understand how rounded it is. It may include snow shovelling or neighbourhood watch, as well as checking cholesterol.
In terms of chronic disease prevention and management, we now have major problems with diabetes and other chronic diseases. Addictions and mental health have been brought out because they are the poor orphan of diseases. We wanted to put mental health and addictions together because there is so much comorbidity, and yet the service providers tend to be in one silo or the other.
I think the elderly with complex conditions are the biggest challenge facing health care today. It is how we take care of people in the last 10 years of their life, and having our resources concentrated in acute care in hospitals is certainly not the way to do it. Of course, eHealth with electronic records is an enabler in health.
I have listed these five elements. The sixth is "access,'' on the next slide; it is the right service, the right place, the right time and the right people. By and large, if you look at what we are trying to do, the question is still where could it be done best, how close to home could it be done, and who can provide the services.
I have a quote, which is mine, on the next slide. However, it is basically on observation from the research I have looked at. When you look at how effective health care services are in any Western country around the world, international comparisons will show you that those who do best have a very strong primary care system. That is why the United States lags in terms of all the expenditures they have. I will share with you today some of my concerns about primary health care and primary health services in this country.
My next slide is a quote from Don Berwick: "Every system is perfectly designed to get the results it gets.'' In other words, we have to go back to the design stage. The problems we have today are a result of how we design things.
Do we have patient-centred care or provider-centred care? I will leave that with you. I will not answer the question.
You can see I think we need a migration away from provider-centred care to patient-centred care.
I will venture to say that I represent only part of Ontario here today, but I have worked in three provinces and in many countries. I am originally from Montreal. I think primary care in Canada is failing. That is one of our problems. I referred to that earlier in terms of impact — how you have to have very strong primary care. I have listed some reasons on the next slide, including professional turf wars between the various disciplines and a solo practice philosophy that is prevalent even though folks work in groups.
As I alluded to before, primary care is not primary health services. We need the social services and the other supports included. This is where the polyclinic comes up in another respect: the generalist-specialist medical care interface is very weak. We need to strengthen that. Finally, there is an absence of the eHealth record. That is my 90- second rendition on primary health care.
Now I will move to the hospital sector. Most solutions to hospital problems in Canada are, in fact, outside of the hospital. Hospitals need to develop a foreign policy — policy, practices and relationships outside their four walls as well as within. The H needs to stand for "health care'' more than "hospital.'' I love this quote about how the railroads went out of business because they thought they were in the railroad business. They forgot they were in the transportation business 100 years ago.
This is what we are seeing with health maintenance organizations, HMOs, in the United States. I ask you: What percentage of hospital work could be done anywhere — in a polyclinic, for example? I suggest to you the answer is quite high: easily 50 per cent and maybe upwards of 70 per cent.
I had a good friend from Boston, which is the most over-hospital-bedded city in the world, who came to Ottawa at the turn of the century. He came to a conference on the future of the hospital in the 21st century. I asked him what he learned. He replied, "They said there would not be one.'' That is interesting. For the type of surgery Dr. Keon used to do, it is clear you need a hospital. However, much of the ambulatory services could be done anywhere.
When I was a medical student, had you told me dialysis and MRIs could be done in a strip mall and that heart attack patients needed to go right to the Heart Institute, I would have been dumbfounded. I would have disagreed with two of your points and I would have asked you what an MRI was. As you can see, there has been an enormous change over the years.
What does the H stand for in 2009? Is it a regional hospital that offers tertiary and other care services? Is it a district hospital? Is it a local hospital that may in fact be an urgent care centre with long-term care and not be fixated on the current hospital model?
That is where we get an opportunity for polyclinics. Again, we have to think, not only the care and the quality, but also the economics — the economies and diseconomies of scale.
On the next page, I have a slide that is hard to interpret. Renfrew County is about an hour away and with 100,000 people is the largest county in Ontario. Here we see that we can transfer 28 per cent of the ambulatory surgeries back to Renfrew. That is 3,500 surgeries a year or more than 10 surgeries a day. Moving those back, if we could, would help three or four people out there. In fact, we can.
As for planning architecture — and I think this is in tune with your polyclinic concept — one of our themes is geography. We want to bring local providers together, build solid primary health services and customize services to the needs and realities of various communities. This is very much in tune with the work you have been doing and what you are proposing.
My next slide deals with the determinants of health. You all know downtown Ottawa. It is a tale of two cities: Dalhousie ward and the Glebe. They are separated at a diagonal by the Queensway and Bronson, and, of the 60-some odd neighbourhoods in Ottawa, the Glebe always emerges as one of the three richest and Dalhousie as one of the three poorest. Heart disease and diabetes, for example, are two- to four-fold more common in Dalhousie ward.
To me, this emphasizes the point about why we have to drill down to these communities of care and why we need to have local health interventions. This nudges us toward your polyclinic concept.
My next slide deals with communities of practice, and this is more about the medical model, which I am familiar with. How do we treat asthma in our region? How do we treat stroke in our region? How do we address the obesity problem in our region? The effort here is to guarantee a standardization of care. As I said earlier, so much can be done away from the large hospital centres. However, we need to use the virtual world we are in to see that asthma treatments are the same for a five-year-old child everywhere.
When a mom, in the winter in Barry's Bay at the edge of Algonquin Park, takes her asthmatic child in to the hospital, she may panic, and with an expensive tank of gas in an old car on winter roads drive to CHEO because she wants the best for her child. However, we know that with modern technology and clinical pathways we can provide the CHEO standards in Barry's Bay. With television hook-up we can tap into CHEO, if that child is not doing well. That gives you an idea of some of the potential.
We have looked at a number of community practices to have a standardized lab for hospitals in the Champlain area and to have a cancer surgery hub-and-spoke model. This deals with the repatriation of ambulatory surgery I was talking about earlier. We have looked to have a standardized health system and to get rehabilitation services. Rehab people already have access problems and here we bring them into the city centre. Therefore, how do we get this out to the community? We do so by providing venues like the polyclinic and by moving professionals out.
My next slide looks at maternal newborn planning. Here again, historically, we have had so much of a focus on labour and delivery that we have forgotten that we are thinking of conception on to the first year of life. Again, we are exploring how we can look at standards and provide quality care wherever a person is in this LHIN.
I will conclude with the last slide, which is a map that shows the number of hospitals we have here: 20. What can we move closer to home and, as we move into smaller hospitals, what can be worked into a polyclinic model? My answer, without quantifying it, is "a lot.''
On polyclinics, we even have used the term "health villages'' here, thinking of co-location. The Carleton Place hospital is looking to co-locate and they are looking to include the Children's Aid Society on the same piece of land. This is public health, Children's Aid Society, you name it.
I have provided a list of what one might do. As I said earlier, co-location is not only good for the client in terms of one-stop shopping; it fosters system building because people meet each other at the coffee urn. Even though they might be working within their silos, that interchange is healthy.
I think this is a wonderful idea that needs a Canadian flavour to it. One of the weaknesses is the interface between primary care and secondary care — the generalists-specialists interface — that the Cuban model has. However, Cuba is Cuba and Canada is Canada. Some of the models we have, the community health centres and the CLSCs, need a bit of an update in terms of where we are 25 to 40 years after their genesis.
I think there is a lot of opportunity here. I commend you for the work you have done. My favourite slide is the rowboat: we are all in this together unless we sink.
Getting back to your questions that I answered at the beginning, my answer would be let us look at this. Thank you for studying this. Let us bring it on, but let us recognize we need a Canadian flavour. For example, what we put in Orleans is an interface between the Montfort Hospital and the general practitioners in Orleans, which has a population of 100,000 people and no hospital. That is very different from what you would put in Barry's Bay.
Jodi Mucha, Director, BC Healthy Communities: It is both my pleasure and my honour to be here this afternoon to speak with you about population health and reducing the health disparities.
My aim today is to share with you the integrated model we are using in B.C. specifically to link the multiple determinants of health at the community level. This model is known as BC Healthy Communities.
First I will give you a snapshot of the initiative to provide some context for the initiative and some history. Then I will share you with you some considerations based on the options that were presented.
BC Healthy Communities is a provincial initiative that originated out of the B.C. Ministry of Health in 2005. Our core funding was received initially by the B.C. Ministry of Health. It is now the B.C. Ministry of Healthy Living and Sport, when that new ministry was created. The overall intention is to engage governments and community organizations to link the multiple determinants of health through connecting thinking and planning, actions and programs, both interdepartmentally and intersectorally.
The initiative is based on a five-year core funding commitment by the B.C. Ministry of Healthy Living and Sport. The steward of the initiative is the Union of B.C. Municipalities. The foundation of the initiative is built on the World Health Organization's four identified success factors for healthy communities, which are political commitment, community engagement, multisectoral partnerships and healthy public policy.
We have developed an integral capacity building framework that incorporates four categories that categorize the determinants of health. Those four categories are physical and behavioural; systems and structures; cultural; and psychological and spiritual. There are some overarching actions we use to interface and work with communities to think about those alternatives. Those are learn, engage, expand assets and collaborate.
This framework guides how we engage with communities to think about and make the links between the determinants of health as well as informs thinking and planning for the future. The framework actually reflects aspects of the health goals for Canada, which include basic needs, belonging and engagement, healthy living, and a system for health.
While BC Healthy Communities is provincial in scope, we recognize there is no one-size-fits-all solution. B.C. is split into five health authority regions, and we have a regional facilitator who lives and works in each of those regions. They are responsible for working with the municipalities and communities in that region. The work is primarily focused at the local level and there may also be sub-regional clusters.
I will not go into detail on how we do this work, but we begin by offering a shared platform for a common vision and purpose through community dialogue and community capacity building. We use participatory platforms to influence and facilitate change. We carve out a space, provide opportunities to inquire about world views, and encourage reflection on action, with the focus being on people, place, and potential — the whole person in the whole community.
A key underpinning of our work is that we look not only at the determinants of health but at the determinants of health with a focus on human development. Any of you familiar with Dr. Trevor Hancock's work will know that is common to how he speaks of this type of work.
We take both individual and collective health into consideration, as well as the interior and exterior of the individual, with the emphasis placed on healthy human development, which is development that serves humans. All of our planning always looks at how this might actually serve human development — considerations such as housing, food security, economy, health and community services, et cetera.
Bringing an understanding of human development into our work allows us to understand human diversity — different views, needs, tasks, capacities, guiding principles, problems and pathologies. With this knowledge, we have a better idea of where people are coming from and what is important to them. We have more information to guide us, a better idea of where to begin and what will motivate people to join in.
With this in mind, our role is to ask, from both an individual and a collective perspective, how the determinants relate to and influence each other, and how our values, thinking and actions might impact and influence our communities. How might we support positive change that improves the overall health of our population, looking from a holistic approach at body, mind and spirit, and beyond that, at policies, the systems and supportive structures? How might we go about improving the health disparities in communities that are in many cases faced with dire situations?
Speaking to this from the community level, because all the work we do is grassroots, local-level work, I will outline a few key thoughts. Again, some of these build on comments contributed by Dr. Trevor Hancock in earlier sessions.
First and foremost, we are hearing from communities that there is a need, a readiness and a willingness to link the determinants of health. They see the opportunities. They see they can leverage more; there is more bang for the buck when they can collaborate with other organizations and work closely with municipal governments.
Part of the challenge right off the bat is that many of them do not have the capacity even to start. They are underfunded and under-resourced. Our mandate is to provide the service to go in and work with them, to take a holistic, integrated view and start thinking about some of the planning in that way.
However, there are no funds or resources to support them. Essentially, they are left spinning their wheels. This is one of the challenges we are faced with as an organization. It is a provincial initiative, but what is lacking are a long-term vision and commitment and the funding and resources to support it.
There was a healthy communities initiative in B.C. in the early 1990s, but with the budget cuts in 1992 it fizzled out. In some cases, that really has more of a detrimental effect on communities. You go in and work with them and build trust, and then there is not a continued and sustained effort.
If it were possible to have a coordinated effort between the federal and provincial governments, with support to municipal government as well, using a bottom-up and top-down approach would be very effective. I know it was suggested previously, perhaps some sort of multi-sectoral committee linking population health and human development. I strongly agree that that would be a valuable structure to put in place, again acknowledging that one size does not fit all; it would be valuable to have an overarching structure to build in the flexibility, maybe some generic criteria or guidelines, but leave room for communities to address community complexity using local-level solutions.
In working with communities, we have an overall mandate to support, make links and build capacity, but that looks very different in each of the five regions, and it looks different in the various communities in those different regions.
In some cases, we have official partnerships with the health authorities, and they are responsible for delivering 21 core programs, some of which overlap. There is a focus on food security and healthy communities, so in some cases in those regions we work closely with them and have partnerships to build capacity jointly to deliver on some of those initiatives. Those are the regions in which we are very effective, and there is a lot of momentum and we are able to leverage a lot more resources and make a longer-term difference. If it were possible provincially to coordinate efforts in a fashion, I think we could get underneath each other a little more and cover all the bases, coming from top down and bottom up. Improving population health also requires focus on the settings where people live, where they work, where their children go to school and taking all of that into consideration.
Regarding measurement and evaluation that reflects human development:, if there were a little more emphasis on human development within the population health model and coordinated commitment and an overarching accountability structure with measurements for evaluation, there would be more of a closed loop system to continually inform and build upon. I think we need a long-term vision to sustain the efforts.
Another option outlined in the document is health impact assessments. Also, as suggested by Dr. Hancock, what about human development assessments? In some ways, this four-quadrant model we are using is somewhat of a human development assessment and a health impact assessment. We are using it with communities for them to identify what their existing assets are and where the gaps are and to identify local solutions to address the complexity in their local communities.
The other important aspect of the work we are doing is to incorporate other policy fields and have multi-sectoral groups, so as to not leave this work up to just the health practitioners and health promotion people. The criteria when we work with communities is that all the initiatives are multi-sectoral. We include planners, local government and the private sector so that everyone comes together and can start making those links and see that, from 50,000-foot view, they actually have more leveraging opportunities.
That is all I have to share with you at this moment. I am sure I will be able to shed more light on these points during the questions.
The Chair: Thank you both very much. Before turning to senators for questions, I must say that having the two of you before us is an interesting opportunity, because British Columbia is pretty much running better than anyone else in this field. Ontario got into regionalization very late, and they did not get into regionalization, or into links, so there is a tremendous opportunity for creativity there. I remember interfacing with Dr. Cushman on a number of other LHINs about a year ago on this whole subject, and we are very glad to have you here today, Dr. Cushman.
I will try to focus a little. We pretty well know what our report will say now — an all-of-government approach with strong community development. It will have vertical and horizontal integration, as you mentioned, Ms. Mucha, and try to get everyone involved in the field. The important thing is not to reinvent the wheel.
From an Ontario point of view, Dr. Cushman, there are approaches to doing the community model, including the polyclinic, but including the resources that are necessary to deal with the determinants of health. There would be no question that to expedite this in Ontario now, it would have to go through the 14 LHINs. There is no question; that is a fact of life. They are there to stay for quite some time, and that is the way it will be. We would have to build on that. Would it be enough for our recommendations to go at the LHIN level, or should there be more refinement? Should it get down to postal code and that kind of thing? Can you have sustainable community development at the level of postal code, or does it have to be something as big as an LHIN?
Dr. Cushman: That is an excellent question. I sort of straddled the line in my presentation because I mentioned Orleans, which has 100,000 people, and the polyclinic they need there is actually the sort of polyclinic that Don Beanlands described to me 10 years ago, which is a primary care secondary care interface. A hundred thousand people is really a city, even though it is part of the city of Ottawa, compared to Barry's Bay or a neighbourhood in Orleans. I referred to the difference between the Glebe and Dalhousie wards; you can walk the diagonal from one to the other. You can walk from Lansdowne Park to the river in less than an hour, and you cut across two neighbourhoods in Ottawa, one of the richest and one of the poorest.
You definitely need to drill down to the postal codes. These are true neighbourhoods. I think the City of Ottawa has identified 60 neighbourhoods it has been looking at within the city. We did the early development instrument, which looks at how prepared children are when they hit Grade 1. This was done across Ontario. We looked at the differences in the roughly 60 neighbourhoods identified by the city.
I guess a polyclinic can mean a lot of things to a lot of people. I said we have to get the local in the LHIN, because this LHIN is actually as large as six provinces in the country. That gets back to the community of care concept. I think there are different definitions of polyclinics floating around. Much is what a hospital could do, which could be closer to home, but on the other hand, the other definition, which is the one I think you are bringing from Cuba, is more like the CHC and CLSC pieces, and they both have a lot of potential.
Having services collocated in the neighbourhood, so that we can actually reconstruct the personalities and flavours of neighbourhoods, which we have lost since I was a kid, and to have these organizations co-located, would do a real service. People would know where they were, would know how to get there, and it would bring some sustainable development back into the community.
To answer your question regarding postal codes, yes, drill down to neighbourhoods, because that is when you will get primary health services that make a difference. As Ms. Mucha said, that is when you will address the true determinants of health.
The Chair: Ms. Mucha, over to you. If there is going to be an effect at making Dalhousie equal to Rockcliffe, or to the Glebe, obviously the 50 per cent of influences that determine health outcomes and well-being and productivity — and I think we have to keep addressing all three because they are intertwined — 50 per cent of those are non-health issues, right? They are social issues or housing, all of this. When you sit down to plan in British Columbia, because you are up and running, who is around the table with you?
Ms. Mucha: When we sit down to plan? Can you expand on what you are asking?
The Chair: What is your working model? You do not run everything yourself, I am sure of that. Who are your partners? Who is around the table with you?
Ms. Mucha: We have a 15-member steering committee. Eight members represent provincial organizations and seven represent communities, so we have a range. We have a representative from the Planning Institute of British Columbia, someone from British Columbia Recreation and Parks Association, four local government officials, some mayors, some councillors. There are folks from Community Futures, so that is economic development. There is 2010 Legacies Now, which is focused on Olympics, youth and literacy. It is a multi-sectoral committee. Each of those organizations has a mandate specific to capacity building, community development and sustainability. For example, we will also have a member from the British Columbia Environmental Network, so that would be environmental sustainability.
Those folks are around the table. We developed our strategic plan, and then each year we get our operational plan approved by them.
We work quite closely with some of those steering committee members on side initiatives. They are very keen on the work we are doing. In fact, one of the member organizations has hired us to develop a framework for rolling out a program in schools. We use our integrated model to bring youth into the process to determine how to increase physical activity and healthy eating in schools.
While our initiative is not focused on any one particular issue, the integrated model can be used for any issue. It can be used for specific issues, but using the integrated model ensures that all the different stakeholders are around the table and that we are taking those four different categories of the determinants of health into account in all of our planning.
We have also developed an integrated evaluation framework so that we are using that same approach to evaluate all of the work we are doing.
Senator Eggleton: Thank you for coming. I have a couple of questions. The polyclinic concept in Cuba, as I understand it, has multi-disciplinary teams. It has doctors, nurses and psychologists. It has dentists. It has all the primary health care people, but it also has social workers, speech therapists and child care services. It even does scientific research and training of people. It is quite multi-dimensional.
Is there anything like that here in Canada? Is there such a facility here in Canada at this point?
Dr. Cushman: I think there are models — the CLSCs and the community health centres, for example — but what is there is very much a patchwork quilt, and not comprehensive. There is wide variation. Some may share a speech pathologist; some may not have one.
This is what I was alluding to before: the primary care is not primary health services. We need to go well beyond that. Even an organization like Meals on Wheels, for example, could be done out of these neighbourhood clinics.
The short answer is we have little that truly compares, but certainly, in terms of our sense of how we need to build better primary health services, there is much that could be done.
Senator Eggleton: Ms. Mucha, I take it that much of what you do is to bring about a coordination of different agencies that are involved in social services and things other than primary health, as opposed to trying to integrate all these services in one location, one-stop shopping; is that correct?
Ms. Mucha: Yes. We are more or less the organization that is at that 50,000-foot view. When working with communities we make sure they are incorporating or including people from the different agencies, that there are multi- sectoral committees and stakeholder groups. We do play more of that coordination role.
Senator Eggleton: Do you have one facility that has all the different services in it and deals with the social determinants of health in the broadest context?
Ms. Mucha: Yes and no. We work closely with the other organizations across the province that deliver on those different services. In many cases we have developed partnerships with those organizations, or we will develop joint initiatives with those organizations. However, we are pointing to and trying to link as much as possible to those other organizations to bring them into the planning process. We are trying to build provincial capacity overall and partnerships with those organizations out there. One example is the BC Healthy Living Alliance, which works specifically to increase physical activity, healthy eating and tobacco reduction. They have a capacity building strategy that provides capacity support for each of those three items. I said earlier that we have a regional facilitator who works in each of the regions. They were going to hire a facilitator for each of the regions. The northern region is the size of France. It is a very large region for one person. Because there was such an overlap and complementary mandates, we developed a partnership with them to hire two jointly shared positions, one of ours and one of theirs. They are using our integrated approach specific to the capacity that they are building for those three things: healthy eating, physical activity and tobacco reduction.
We are not all these people working out in the regions tripping over each other. We are also building communities of practice, so those professionals and practitioners working out in the field are actually coming together. They are learning together, sharing together, building together, and they are also able to sharpen their skills and work closely together in that way.
Dr. Cushman: If I might add, from your Toronto experience, Senator Eggleton, you would probably have as good a sense as anyone about what could be under one roof. Certainly, from my work with the City of Ottawa I learned more about the interrelation of services, including the social services, than I did from my time spent in an emergency room.
We need to know how much health and social services we can put into one neighbourhood. As well, interesting links need to be considered, and whether they should be embedded close to the schools, for example. We have so many different departments and so many different governments. At the neighbourhood level, there is great potential to co- locate many of these services that need to be at the local level.
Senator Eggleton: I appreciate your answer. I will explore one more question.
In your slide on health villages, which is our polyclinic concept for Canada, you have included a number of things, which you also referenced. What makes sense to co-locate? You would have to look at each situation, because one size does not fit all. What might be appropriate in Toronto would not be appropriate in Northern Ontario, perhaps.
How do you envision this? How far can we go? The biggest social determinant of health is poverty. How would you address that in terms of a clinic? Would you have social workers and welfare workers? "Social determinants'' is a pretty broad category. You could end up with a great deal under one roof.
Dr. Cushman: It is very broad. Health services have so little direct impact. The Somerset West Community Health Centre is about two or three kilometres from Parliament Hill. It has services with nurse practitioners and physicians and many social services. There is much effort to empower people, with everything from community gardens to the Quebec model of the eggs, milk and oranges, for example, which came out of the Montreal Diet Dispensary. These are food supplements for pregnant women. Again, to deliver that, you have to be in the neighbourhood, almost at the curbside.
To your point, one size does not fit all, but if we are to address the social determinants of health, drilling down to the neighbourhood level is primary. The whole empowerment piece is very important too. For example, in Ottawa, the public health department is using youth facilitators to go into the schools because they figure the kids would rather hear from kids a few years older than from someone their parents' age.
There are all kinds of things you can do. A key issue at the local level is having the resources on hand and good solid communication among all the players so that you can manage and address the top one or two problems in a given neighbourhood, which Ms. Mucha alluded to. It is important to have things like job training on site at the local level. The Cuban model is wonderful. As you said, senator, poverty is the number one social determinant of health. It is hard to find a country poorer than Cuba, so they have really addressed the issue. When we think about poverty, health care and determinants of health, we tend to be a little existential. Cuba has put poverty on its heels in terms of health status, so they must be doing something right. We need to learn from them.
Senator Eaton: Dr. Cushman, I loved your presentation. I started off my volunteer life at the age of 16 by working in the Montreal Diet Dispensary taking down ladies' bios before they were admitted.
I certainly agree with Senator Eggleton's comments. If you had your way and we put polyclinics in place at the grassroots level, what role would you see for the federal government? Would it be responsible for setting uniform health standards across Canada? Would we have accountability?
Dr. Cushman: That is a tough question, senator. I have worked for the City of Ottawa. In terms of population, Ottawa is fifth or sixth in the country. When the surrounding cities amalgamated with Ottawa, we lost that neighbourhood flavour. There were good reasons for amalgamation, such as public transit and infrastructure. However, at the true community level, we have a problem. We need three levels of government in this country: the first is neighbourhood; the second is regional; and the third is federal. Some things are best decided in your backyard; some things are best decided as a region; and other things are best taken care of at the federal level. If the federal government is to invest in this, it wants a return on that investment.
Senator Eaton: It is not so much a return, but if we believe that the neighbourhood is the best model, then do we not want the same standards of health for people living in B.C. as we want for those living in New Brunswick?
Dr. Cushman: Right, and we have that problem with respect to heart surgery. Rest assured that in terms of dietary supplements in pregnancy, it will be even more difficult. We need to make a series of interventions available, almost like a menu, from which you would choose according to the drivers in your community. I would hope that these would all be based on best practices so that you would know the cost-effectiveness equations and the evaluation formulas. The accountability piece would be worked out.
Senator Eaton: Yes.
Ms. Mucha, we have pilot programs with best practices but we do not seem to share them. When you sit at 50,000 feet and look down at all the communities, your steering committee helps. Do you see pilot programs being used or developed in communities that could apply to other communities?
Ms. Mucha: Absolutely, but we would not necessarily call them pilot projects. These communities are in their readiness and willingness emerging as leaders. We see what they do with our process and the results. We can then take that information and use it as a mechanism for informing and sharing with other communities to help them learn how to proceed. In some cases, we might even link them directly so that they develop relationships with sister communities to learn from each other.
I am not sure a community would like to be called a pilot project community. Many of the communities we work with are smaller, and many of them have been researched to death. There is a level of cynicism toward being a research specimen. Again, we see what emerges as they use this process, and we then use that as an opportunity to share our learning.
Senator Eaton: You share their experience.
Ms. Mucha: Yes. As I said earlier about the quadrant model, we interact constantly to learn, engage, expand assets and collaborate. There is a constant feedback loop in the learning. We simply facilitate the process. We are not going to teach them anything. We are learning with them and guiding a process of asking questions and providing a map, if you will, for them to start seeing the links between the determinants.
Senator Pépin: Do you mind if I switch to French?
[Translation]
If I have understood correctly, Ms. Mucha, you have five regions, several partners and five groups around a table. Obviously, that is very good for community work. How are the working relations of the groups and the regions? Are their mandates complementary? You say that you are in a learning phase and that there is overlap. How is it working in general?
[English]
Ms. Mucha: When our initiative began, we travelled around the province and introduced ourselves. We started by looking at where other healthy community initiatives where. We went to them to find out what they were doing and how we might build from that. We are linked to the Union of British Columbia Municipalities and therefore municipalities know about us. How we work is that communities approach us. We do not go to them. We tell them this is our program; you should use it; this is how it should look. We are selling a process, an integrated and holistic way of thinking, which links those determinants of health.
The communities we are working have a level of readiness. They approach us and ask us how we can do business in a different way. Is not the definition of insanity doing the same thing over and over and expecting a different result? The model we are using allows them to start to go beneath the complexity of the issues in their community and see them from another perspective, see that there is another way of doing business.
We may work in specific communities or sub-regions. I have not yet experienced any strong difficulties or distance between communities in the regions. They are happy to be learning. There is a strong sense of solidarity in those regions.
There are differences between the regions themselves, such as the northern region and the Vancouver Island region. Part of it is a perception that we in Victoria are making decisions — just like those in Ottawa are making decisions — for local communities. That is part of our conversations and raising awareness to allow them to start to see their world views and how those can get in the way.
[Translation]
Senator Pépin: Do you have a group that looks after seniors? We hear more and more about seniors' problems. Do you have a group that is examining this issue in particular?
[English]
Ms. Mucha: We do not have a specific group for anyone. It is all integrated. We are asked to sit at the table and hold seats on committees that may have a specific focus on seniors or youth. However, I think the interest of people to have us present at the table is to bring this integrated perspective. For example, in an initiative we are working on now with a steering committee member who hired us, we recommended that the committee should be 50 per cent youth and 50 per cent adults. It is very successful. We are rolling out the initiative.
[Translation]
Senator Pépin: Doctors and nurses work in your polyclinics. We talked about Cuban clinics. They have dentists, psychologists, psychiatrists, dentists, speech-language pathologists and psychotherapists. Do you provide or do you hope to provide these services? Is there a way to integrate them?
Dr. Cushman: The possibilities are vast. There could be dentists, child protection and welfare services, unemployment services and many others. The challenge is to determine what kind of polyclinic you want to have. We are focussing first on basic services and there are some problems that persist. Not all services necessarily need to be provided solely in hospitals. There are a great number of possibilities for establishing polyclinics, for example, in Orléans. It is a question of definition.
Dr. Beanlands, Dr. Keon's former colleague, explained to me that with the polyclinic concept there is extensive collaboration between general practitioners and specialists and this reduces wait times for patients. The model we are describing today resembles a CLSC or CHC, where we focus on neighbourhood services. A particular neighbourhood may need a doctor rather than a specialist.
Senator Pépin: Or nurses.
Dr. Cushman: You can add a whole host of services. The important thing at each location is to emphasize cooperation by focusing on the needs of the neighbourhood. That is the underlying principle of primary care, not just in health but also in social services and all that it entails.
Senator Pépin: Does that include nurses?
Dr. Cushman: Absolutely.
[English]
Senator Callbeck: Thank you for appearing today. Ms. Mucha, I am interested in the B.C. model. How many years have you had the health authorities?
Ms. Mucha: The health authority is a separate initiative. I believe it started early in 2000. I am not sure exactly.
Senator Callbeck: How do BC Healthy Communities and the health authorities work together? Do the health authorities elect people on the board?
Ms. Mucha: To be honest, I am not sure.
Senator Callbeck: They would have an appointed or elected board that develops a plan for how they will fight poverty in that area. You are a completely separate group with 15 members on your committee; you are in Victoria, and you are making decisions. You said there is a facilitator. From your budget, do you pay for the facilitator in each of those regions?
Ms. Mucha: Correct. We have a facilitator who lives and works in each of those regions. It is completely up to us whether we interface with the health authority. There is no mandated structure for us to plan or interface with them because we are out there working at the local community level. It depends on how the health authority is set up in each region to deliver its core services. In as many cases as possible, we work with those who are working out in the communities and with some who may be based in the research departments.
The effort to integrate the planning between the health authority and our initiative is up to us in each of the regions. It is not a provincial activity necessarily. It is developing a relationship with the health authority in the region. We have a partnership with Northern Health in the North. They provide funding to support the facilitator that we have in that region because of the work that they would be doing out in the field anyway. With some of the other health authorities, however, it is more about lines of communication and sharing. We are not working as closely together.
Senator Callbeck: Anyway, it works.
Ms. Mucha: It has been working, but there are more opportunities to work together. The initiative began in late fall 2005, so it has taken some time to figure out what it looks like. We did not develop programs to deliver. It is more a process to find out what communities need and how can we support them. Now that we have been out there for a few years, we have been able to use some examples. Senator Eaton asked earlier about the pilot communities. We can actually see how we use this process in this case. What we have learned from this, we can now present as an opportunity to work with other people. In some cases, we are doing that with the health authorities.
Senator Callbeck: That is good.
Dr. Cushman, I have one question. What would you say is the minimum number of people for an area for a polyclinic and what is the maximum?
Dr. Cushman: That is a good question. If you use the traditional medical definition, it would be quite a bit bigger. This is what we are looking at in Orleans, which is an interface of about 20 family physicians, many specialists, an MRI and mental health and addiction services, mammography, and so on. It could be a mini hospital. That is one side. The other side is what we have been talking about today: what you need in your neighbourhood. To be at the neighbourhood level, I think you will see that the health care piece diminishes while you increase the other pieces, which are more the social services and the community development piece.
You need some primary medical care, but, further down the line, there are advantages to coupling the primary medical care with specialty care. The Somerset West Community Health Centre, for example, has visiting specialists. They may have four days in a week where they have visiting specialists of different kinds, such as psychiatry or paediatrics. Much of what they are doing there is based on the social services, addressing community gardens, and job training.
To ground this the way the Cubans have done it and the way I understand you folks are thinking of it, this would be in the neighbourhood. You might have a centre of health care people, but it must be broader in terms of the social services and the community development piece, which is what Ms. Mucha alluded to.
That is a long answer to tell you that I do not really know and it depends.
The Chair: Building on that, whether they are large or small, for example, the Orleans model, one of the things they lack — and having been there to look at it I am familiar with it — is an integration with public health and social services, which I think could occur at that level also. The Montfort Hospital unloads the sophisticated health care delivery stuff, so to speak.
Do you see a possibility of getting some of those social determinants of health integrated into the Orleans clinic?
Dr. Cushman: That is a good question, because the Orleans clinic will serve 100,000 people. It will be a mini hospital. You can either have a hub-and-spoke model, where you address it in various neighbourhoods in that community, or you have people in a suburban community where there is a lot of travel. People come and go, but, one way or the other, people have to get out. There is the whole business of the travelling public health nurse, visiting home nurse, and so on. You must have equilibrium of this equation.
This is why what Ms. Mucha is talking about is so important. You must understand your neighbourhood and the needs of your neighbourhood. If you are living in a suburban neighbourhood where everyone uses their car every time they go get a litre of milk, you might locate the clinic in a mall and people will come to you. If you are in an urban or rural neighbourhood, you might do it differently. Think about downtown Ottawa and downtown Toronto. They are very different.
I am having trouble with the question because it is hard to see the future. I emphasize that there is the whole sense of quartier and community and neighbourhood. We cannot lose the sense of that. One of the determinants of health is isolation. In this fast world in which we live, we have lost our sense of community. I think back to my nostalgic days as a kid. We fended for ourselves because we had a community that nurtured us. It was a different environment from the one in which I raised my kids. We are paying for this. This is a negative determinant of health that we have created with our material riches. One of the ways to get around that is to go back and drill down in the communities to ensure, for example, that our schools are not being used only from 8:30 a.m. to 4:30 p.m. They are a community resource. We are now selling schools because of the demographics. Yet, they are a resource that belongs with the community. We need to nest these things together. What you nest depends on where you are; whom you are serving; and access, meaning how easy or difficult it is to get the next level of services.
The Chair: You sat in on many city council meetings here in Ottawa in your life as public health officer. I suspect the subject we are talking about, population health, was never addressed. Was it ever addressed?
Dr. Cushman: We looked at it through the health department and working with social services. The City of Ottawa has looked at 60 neighbourhoods. I say 60, but I could be wrong about the number. They are making an effort to concentrate services to move forwards this model rather than provide the same menu of services for all communities. Steve Kanellakos and his group are starting to look at this. Public health, social services, parks and recreation have all played a part. The United Way has also been instrumental. Again, that reminds us of the importance of the non- government and the NGO sectors.
The Chair: It is my impression that the Public Health Agency of Canada, particularly with the clout it has now, is very interested in population health. We will be recommending a major public health node in PHAC to link to the nodes in the provinces. Hopefully, public health would get linked to communities through the polyclinic concept and so forth.
I can tell you I have raised that with public health officers and it is not necessarily a popular idea. I have asked why there would not be a public health nurse. You cannot have a public health doctor in every polyclinic because the numbers are not there, but you could have a public health nurse there either part time or full time. Why has that concept not caught on?
Dr. Cushman: That is an excellent question. I have been working in population health for most of my career. I am not quite sure I understand it. It is great for the halls of academia. It is wonderful to discuss because it is so meaningful and elegant. I read the Black report when it came out 25 or 30 years ago. Historically we average but, as you know, it worked on the quintiles and we saw the differences in terms of diseases.
One of the problems with respect to poverty, as I said earlier, is that so many of the determinants of health are overwhelming and outside the jurisdiction of our health professionals. Therefore we have to rethink this. As a public health physician, I have looked at a number of these issues. Certain links of the chain you can break with conventional intervention. We have done well on tobacco, but now we are down to 18 per cent of people who smoke, which is so nested in the last quintile. Then we need to get into this community development piece and neighbourhood engagement in getting the services down there.
As Senator Eggleton said, how will we take on poverty? How will we take on education? The isolation is something we can take on. There are a number of things we can take on in terms of building better communities and building the resources. Certainly the late Dan Offord and his group looked at children at risk and there was a sense of resiliency there that we have to tap into.
It is not easy. We have to be flexible, agile and smart. One way is to get into the neighbourhoods, have a dialogue with the people who live there, listen to them and empower them so that we come up with a menu of services they can access.
What bothers me is that we are existential about poverty, and those of the left persuasion talk about it differently than do those of the far right persuasion. I do not care whether you are a bleeding heart missionary or a hard-nosed, calculating accountant; at the end of the day, we cannot afford it. It bites us.
Look at how much money we spend dealing with the consequences of poverty. I suggest it would be cheaper to attack poverty head on. Some of you have been to Cuba; I have not, but to me the real learning piece from there, which I will repeat, is that Cuba has put poverty on its heels. It has addressed the social determinants of health even though the country remains poor. Clearly there are lessons there.
The whole notion of drilling down into the neighbourhood and making the services there, involving the community engagement piece and empowering people, is what will give us the answers we need.
Senator Eaton: To pursue what you are saying, Dr. Cushman, I could not agree with you more. Your idea is right and wonderful, but there is a whole part of this country where there are small communities in the North. We almost have to have one system of health for people who live in urban centres or villages or where there are enough people to support a polyclinic and all the attendant neonatal services and whatever you want. Do you see the same system working in the North or do you see another system?
Dr. Cushman: As background, I spent a year working along the Quebec side of Hudson's Bay and James Bay, so I know the Cree and Inuit villages there quite well. They are very small. Some of them are 300 to 400 people. I am showing my age here, but that year was before Hydro Quebec, and some of those villages were isolated. They were fairly self-contained and had traditional ways of doing things. You can compare that with what was on the news recently about the baby who died of meningitis. I did not hear what province that was in, though.
Senator Eaton, you are right on. We see this even within the Champlain LHIN. What is cost-effective in downtown Ottawa will never be cost-effective in Barry's Bay. There is an equity piece there.
Senator Eaton: Maybe we should not worry about it, because there is one pot.
Dr. Cushman: I do not want to wax here; I had better be careful. We all have opinions, and that is not why I am here. However, I was surprised when I heard about this village. I did not have all of the information. I heard a bit over the news. We have to stop learning by our mistakes. If a village is big enough to be a village, maybe it is big enough to have some of these services in an organized way.
I will stop there. However, it gets back to what we said earlier that one-size-fits-all does not work.
Senator Eaton: I have been reading Dr. Leitch's statistics about suicide and diabetes. It is absolutely frightening that we are not addressing this quickly.
The Chair: We are trying.
Ms. Mucha, I have been waiting to get at this. You were the only one today who mentioned the spiritual dimension of determinants of health. I want you to expand on it for two reasons. First, you have a mixed population of native people living on-reserve and native people living off-reserve. We have had the privilege of dealing with them.
I will lead you because I will tell you where our report is right now. We have a different report for the Aboriginal communities than we have for the non-Aboriginal communities because we think they are different and have to be organized differently. Then there is the complex problem that 60 per cent of Aboriginal people are now living off their native lands or their native communities, off the reserves if they are First Nations.
We will be making recommendations around the polyclinic, which embraces all of the determinants of health and is not that different from what you are doing already. How are you getting application of your ideas and methodologies in both of these dimensions, in dealing with Native people off-reserve and Native people on-reserve?
Ms. Mucha: I would like to suggest there is even more complexity than that. In B.C., we are experiencing that is it is not just non-Native and Native, but the reserves also have a great deal of diversity in cultural backgrounds. There are different cultures within the Native populations, as well. That brings in a whole other dimension to how we do our work.
In our model, we talk about this upper left quadrant as the psychological and spiritual, in which certain determinants are categorized. Depending on the groups we work with, we may never use the word spirituality. We are really talking about values. I was saying earlier that the focus is the whole person and the whole community. The whole person is multi-dimensional; it is inside and who I am and what views I bring to the table. It is also what I take away from each of you in my experience. It is the interior and the exterior of the individual, and this plays into the human development piece.
We have worked with several First Nations groups. Again, depending on how we work with communities, we may come to the table right away and share with them a model that we can use for a process to work with them or there might be a time when there is an entry point to begin talking about it. They are already leading us along the way. People are saying, "You are actually showing me a model that represents what I am already trying to talk about and I have not really had words or a way of communicating it.''
The First Nation group I am speaking of were quite excited when they did see our model because it resonated with them and was similar to their medicine wheel. They took the two and basically revised the medicine wheel for decision making in their community to incorporate some aspects that were not there previously.
In those cases, there is a strong indication and acknowledgement that, "This rings true; this makes sense; this gives our philosophies and our thinking some legs.'' Again, the groups coming to us are groups that are interested in taking more of an integrated, holistic perspective.
I am not saying that all are willing. However, the ones we work with are the ones that approach us. I think if you can create critical mass that way, word gets out, interest is piqued and people start seeing the results: financial results, community results with crime prevention, where community safety is increased, and intergenerational connections are formed, and so on. Communities are very interested. They want their community to be like that.
The Chair: I want to know what your interface is with crime prevention, because that is also a huge dimension of population health. Since you have only a couple of minutes, I want to know how you are linking with Health Canada and Indian and Northern Affairs Canada to deal with Native people.
Ms. Mucha: We have had some preliminary conversations, but we have not been working closely with them yet. There are many organizations and agencies we need to be talking with to expand on what we are doing and communicate the results. We are evaluating our initiative now using this integrated evaluation framework and we can communicate the results so that we can show more.
We are working with communities to tell their story. As you know, it takes time to be able to illustrate the quantitative results. Qualitative results in the case of community develop work, in particular, are very important. There are "Aha!'' moments—those moments when the community will never be the same; they realize that there is another way of doing things and now an opening occurs.
Therefore, we are working with them to tell their story through the means of digital storytelling. This is a way that we can more concretely provide some results of the work that we are doing when we do approach and dialogue with other agencies in terms of what we are doing and what it actually looks like on the ground.
Again, we do this because we are selling a process, not a program. It has taken a few years to start seeing some themes and some different results out of how that process unravels in the different communities.
The Chair: I visited the Vancouver Aboriginal Friendship Centre on Hastings Street and I got the impression that the Native peoples using that centre had pretty well fallen through the cracks. They did not have anyone to look after them because they were off-reserve and they were not part of the other system in Vancouver, although it was impressive. We brought in by teleconference the authorities from the Vancouver —
Ms. Mucha: — community project?
The Chair: Regardless, they are truly impressive people, so I am sure that the Native people could find their way into that dimension and network. However, if you walk through the friendship centre and talk to some of them and ask them who is looking after them, they fundamentally say that no one is.
Ms. Mucha: We do have a First Nations representative from a provincial First Nation. That brings the provincial scope to the table in our planning and thinking. As I said earlier, we are working with First Nations groups; they are approaching us. We do not have a mandate to target certain populations. However, again, it is to ensure that those different populations and those sectors are at the table and involved, that their voice is heard and that we are engaging with those groups in communities we work with.
The Chair: Thank you both very much for coming to speak with us.
We will now hear the testimony of Dr. Kellie Leitch, who did an extensive report for the Minister of Health at the time. It has been widely circulated in Canada and has been the subject of much discussion and many compliments. Please tell us about it.
Dr. Kellie Leitch, as an individual: Thank you very much for having here. I will start with a statement with respect to the report, and then I am happy to take questions.
Mr. Chairman, honourable senators, thank you for allowing me to speak to you today. I will share the principal conclusions of my report on the health and wellness of Canadian children and youth, entitled Reaching for the Top. I think it was circulated to you, in both English and French, so I hope you had an opportunity to see it.
In March 2007, I was asked by the then Minister of Health, the Honourable Tony Clement, to provide advice to the federal government on improving the health of Canada's children and youth. It is both an honour and a privilege to help shape public policy when it comes to the health and wellness of children. It is also something I take very seriously, largely due to my day job. I work as a pediatric orthopaedic surgeon, encountering children with illness and primarily injuries from falling off swing sets and such every day.
In writing this report, I traveled to every province and territory in the country. I learned that getting the health and wellness of our children right is an absolutely essential ingredient to the success of our country. Nations like India, China and others in Southeast Asia and Eastern Europe are investing tremendously in health care and education for children and youth. They are investing because they get that the number one source of long-term sustainable competitive advantage for their nations is investing heavily in the health, education and training of their young people. In Canada, we must take a similar perspective, not only because it is good social policy to invest in the health of our children, but because it is good economic policy.
We have the resources and wherewithal to succeed, but, as I have stated in my report, Canada has significant opportunity to improve. My report contains a total of 95 recommendations on how to help children to be healthier so that they can live better, happier and more productive lives.
Throughout my research, I learned that we need to invest in the health and wellness of our children and youth in the same way we invest in infrastructure, science and technology. They are our future, and they are fundamental to the nation's economic success in an increasingly competitive world. For a nation that prides itself on being prosperous, generous and enlightened, we actually must do much better.
Today I would like to talk to you about three key issues and opportunities that I identified in my report: injury prevention, childhood obesity and mental health.
The first of these three issues is injury prevention. Preventable injuries are the number one cause of death among Canadian children and youth. I encourage you to think about that. Injuries to children cost the Canadian economy $4 billion per year. Clearly, there is significant progress to make in preventing injuries among children.
In my report, I recommend that the federal government establish a national injury prevention strategy, a five-year national strategic plan following in the footsteps of the United Kingdom, the Netherlands, Sweden and many others that have done exactly the same thing with excellent results. I also make recommendations on issues like supporting helmet use, eliminating toxic toys, and promoting booster seats and other protective equipment for children and youth. We need to put the large national injury prevention strategy in place first, but follow it up and support it with initiatives that tackle specific problems. That is how we will actually get these numbers down.
The second issue I will speak about is childhood obesity. The percentage of overweight children in Canada has tripled in the last generation. Today, 15 per cent of Canadian children are overweight and obese, and another 30 per cent to 40 per cent are at risk of becoming that. In fact, obesity is the new tobacco for Canadian children in this generation.
There are a number of causes, and I think we all know them. They are all interconnected, including bigger food portions and, quite frankly, too much PlayStation and not enough playground. Overweight children are at risk of diabetes and cardiovascular disease and will continue to have these chronic comorbidities into adulthood, putting even more pressure on a health care system working as hard as it can to accommodate aging baby boomers. Many of these children will actually die of these chronic diseases.
In my report, I recommend the establishment of a centre of excellence on childhood obesity. This centre would bring together experts in fields like nutrition, physical activity, child care and others to establish national standards and programs to help fight childhood obesity. I have also recommended that the federal government establish an obesity target. We need to get the rates of childhood obesity down from 8 per cent to 5 per cent by 2015.
The last issue I will touch on is mental health. Children with mental health problems are often identified and referred into this system way too late in this country, and their problems worsen with time. They are simply not getting the opportunities that other Canadian children receive. The good news is that if we catch pediatric mental health problems early enough, we can help these children lead happy, productive lives, but if we do not, their problems actually become society's problems.
A major recommendation in my report is the establishment of a pediatric mental wait time strategy. Right now, we actually do not even know how long children are waiting for mental health services in this country, let alone how effective they are or what type of access they have. We need to identify problems and bottlenecks in the mental health system and focus our efforts in ensuring timely access to care.
No country in the world has the resources we have in health, nor the talent and potential that Canada has. It will take planning and a desire to change long-standing systems, but most importantly it will take a commitment from all of us to take some action on these items. My report provides a path and points a way for Canada to become a global leader in child and youth health. For each of the key factors I talked about this evening — injury prevention, childhood obesity, and mental health — there are actions that can and must be taken in order to make a difference.
No great achievement was ever accomplished that had a timid goal. I would encourage us to have the same goal together in establishing Canada as the number one place in the world for a child to grow up.
Thank you very much for your time. I would be happy to take any of your questions.
The Chair: Thank you very much, Dr. Leitch. A number of senators would like to ask you questions.
[Translation]
Senator Pépin: I will speak in French but you can answer in English. When you spoke about having a wait time strategy for children suffering from mental illness, I did not realize that the wait times were so long. I knew there were problems. You believe it is one of the main causes. If we could provide care earlier, could we help some of them?
[English]
Dr. Leitch: Yes, the statistics in Canada are that one in five children has access to mental health services in the time frame they should be received — only 20 per cent. For the majority of children, we do not even know the time frame, nor have the benchmarks been set for when they should be seen. What we have done in this country, which I think is commendable, in my own field of surgery, is establish a national pediatric surgical wait time. We have set the benchmarks and the time frame, and now all of us working in child surgical health are working to achieve those, and we are driving numbers down. For dentistry access, or access for children to get tubes in their ears, we have decreased wait times in this country from 18 months to 12 months in most provinces. I believe that we must set the benchmarks for mental health access for children, and then we must implement a plan to drive towards it so that the 80 per cent of children who do not have timely access actually receive it. We know that the 70 per cent who receive it when they are young lead productive adult lives. It makes a huge difference, and we need to tackle that.
[Translation]
Senator Pépin: I am somewhat disturbed by the fact that the leading cause of death among children is related to a preventable injury. Can you tell me more about this? What kind of injuries are we talking about?
You stated that Sweden and the Netherlands have a law or regulations to that effect. Could you elaborate on that point?
[English]
Dr. Leitch: As a pediatric orthopaedic surgeon, I see children every day who have been in severe accidents. The numbers astound me. Canada ranks 22 out of 29 countries in the Organisation for Economic Co-operation and Development, OECD, for preventable injuries causing death. I have outlined in the report the details of what I have termed the 15 killers of kids.
The number one killer is motor vehicle-related accidents, which may involve a booster seat or car seat; teenagers who are driving early and unsafely; or a pedestrian hit by a vehicle or a child on a bike hit by a vehicle.
The second leading cause after motor vehicle involvement with a child is drowning and suffocation. It is astounding that in this country one in 230 children who are admitted to an emergency department, and not just because they broke an arm or had a small fall, are admitted overnight. Twenty per cent of those have head injuries that leave them with lifelong disabilities. These are astounding statistics in a country like ours. They should not occur. We do a great job once children come through the door at academic teaching hospitals like my own, but we should not be seeing them. I would quite happily be put out of business.
As has been done in many European states, we need to put in place a national injury prevention strategy that focuses on a number of things, one being leadership. We have done a great job in this country on smoking, litter and other things where the nation has shown leadership and the Government of Canada has shown leadership in driving change.
We need good social marketing. We need to educate parents and children on what the problems are and how they can fix them. We need to provide national standards in that strategy of what we need to achieve. We need to collaborate not only among academics, but among industry and NGOs like the YMCA and the Boys and Girls Club. We need to ensure that our colleagues in the NGO world are communicating and that we have the appropriate research to back what we are doing in an evidence-based way.
In the report I tried to detail those components that have been used in other jurisdictions that we could implement here to have a resounding impact on changing the dial for kids.
Senator Eaton: Dr. Leitch, this is a wonderful and very interesting report. One thing that comes out of this report is that we have process and government, but none of it seems to be working or interconnecting. It is all very siloed.
Before your appearance here today we were talking about polyclinics in communities that would look after primary and maybe neonatal health and, if it was an elderly community, having special things for the older generations. Do you envision a polyclinic-type model that could do childhood care or deal with obesity prevention? Could we use schools or workplaces to teach people prevention and nutrition care?
Dr. Leitch: There are a few mechanisms that could be utilized very well to have that comprehensive care approach. Canadian parents were adamant with me about what we need to focus on, that being these three big items: injury prevention, obesity and mental health. I was astounded at how consistent this was across the country. In our online, five-day survey, 7,200 parents said exactly the same thing.
I think you can create a mechanism that focuses on kids that is like the polyclinic you speak of, but I think the best way of accessing children is through the school system, because they are a captive audience. They are there all the time and they are a ready audience.
For those kids who are more challenging to reach, and also for parent education, I recommended in the report an annual national report card similar to the immunization record, that yellow card that every parent has on which they check all the boxes. There are certain things that every child should have — optical care, dental care and certain other things, such as those you are talking about in a polyclinic. If we provided that tool to parents, it would empower them to help their kids. We have to provide the resources and services to do that.
Much of that sits with the provinces. In the case of First Nations and Inuit health, it sits with the federal government. There are very few mechanisms that tie them together. The first part is empowering parents, giving them the checklist of things they need to do for their kids so that they know, because many of them do not.
Senator Eaton: You were talking about smoking and litter, and I absolutely agree. Do you foresee us beginning, for example, a national campaign on diabetes, eye care or prevention? Does a grassroots national campaign with ads work?
Dr. Leitch: On the preventive side, the federal government can have a huge impact in that way, but I would not pick a disease entity. I would pick obesity components or injury prevention, because if we are ahead of the curve in ensuring that children are not injured and therefore not coming to the emergency department, there will be huge savings. The saying is, "Look a little ahead, my friend.'' If we look a little ahead and work on the preventive side, we will save both economically and in social infrastructure.
You can have national campaigns. The federal government has a huge impact. I have said at many tables where I have met with ministers, and I will repeat it here, that you have a huge opportunity. The country will follow you. You did it with tobacco, and you have done it with other things. Pick the big items you can move, because you can do it. Invest in them and move the dial.
This country should never see a child at the emergency department because they drowned. In this country a child should never come through the emergency department and be diagnosed with type 2 diabetes at age five. Those things should not occur in this country.
You have the capability, as a national body, to drive that forward. We did it with tobacco. The numbers have come down astoundingly. You can do it with the new tobacco, obesity; you can do it with injury prevention. You absolutely can do that, particularly on the social marketing side by showing national leadership.
Senator Eggleton: Thank you very much for coming, Dr. Leitch.
Dr. Leitch: I will try not to be so passionate. I will contain myself.
Senator Eggleton: Congratulations on your excellent report. I hope you have had a chance to meet with the new minister of health, and I hope there is an interest in seeing your report fulfilled as much as possible.
My first question is whether you can give us any information about how well it is going through the system.
I will ask a couple of other questions. You speak passionately about our having the ability on a national level. It takes more than ability; it takes will and it takes working things out within a constitutional framework where there are shared responsibilities. Much of the responsibility for the delivery of these kinds of programs is at the provincial level. Some of it is carried out at the local level. Have you given any thought to how all of that might work better? National strategies in areas that involve the provinces require a fair bit of coordination. I am not for a moment suggesting we do not go that route; I am a fan of going that route.
My third question: in your key conclusions, you note that Canada ranks twenty-second when it comes to preventable childhood injuries, twenty-seventh in childhood obesity and twenty-first with children being included in mental health. These are OECD rankings. There is another one the committee dealt with recently: in a study of 14 OECD countries, in terms of early learning and childhood education, we came last.
I cannot recall all five recommendations, but in the specific areas you dealt with, you did not deal with early learning and childhood education. I noted that you did have very good comments in the appendix, where you said, for example, that if we want Canadian children to be successful and competitive later in life, we must do everything we can to stimulate their early development. You even pointed out the business case, as I might call it, that it has been repeatedly demonstrated that investments in early childhood education pay off in a better life and health outcomes later in life. Research estimates that every one dollar invested in childhood development is worth $3 to $18 later in life.
Why did you not get into this whole area of early learning and childhood education?
Dr. Leitch: To start with the third question, I had a very specific mandate letter that asked me to answer three questions. I probably stepped outside of my mandate letter more often than I probably should have, to begin with.
My mandate letter was very specific: to look at the programs of Health Canada and PHAC. Early childhood development and many of those other social determinants of health on the list were not addressed. They are addressed at HRSDC, INAC or Transport Canada, which is not to say they are not exceptionally important. For an orthopaedic surgeon, it was exceptionally educational to learn about these things, and it has definitely changed my practice.
The scope of the report was based on the mandate letter I was given. It is not that early learning and childhood education are not important; I think they are exceptionally important and they should be taken in totality when they are dealt with, but the report speaks to the letter that I was given.
I think there would be huge value in something similar to this being done, looking at the 12 social determinants of health, how they can affect children and youth across the country and how they can best be integrated appropriately to address broader health needs, particularly on the preventive side.
With regard to the system here in Ottawa, you people are probably more attuned to how it functions than I am. I was independent council, and how this world works is not my day job, albeit it was very educational.
Both the Deputy Minister of Public Health, David Butler-Jones, and the Deputy Minister of Health Canada, Morris Rosenberg, were exceptionally helpful in ensuring the report came to fruition, and their staff contributed a great deal to it. I continue to work with them.
I have been pleasantly surprised that this report has not gone to the shelf. I speak publicly on it at least once or twice a week. I know the Deputy Minister of Public Health is taking it seriously and is integrating many ideas from it into his own world, as is Morris Rosenberg at Health Canada. It was part of the strategic review process in a very straightforward manner, not that I know everything that happens with strategic review, not being from here, but it has been taken seriously, which is constructive. I have heard that not just from them, but also from the programs on the ground where they have been asked to change their practice to address the three big issues that Canadian parents came forward with.
With regard to implementation of national strategies, my third great learning was about federal-provincial- territorial relations on this. I think everyone in the country understands that we need to move the dial on these things. There are different ways of reaching the goal but, ultimately, I believe everyone thinks that we need to collaborate to make it happen.
One question I was asked was whether there should be a continuous voice in the Government of Canada on these issues. I talk about having an assistant deputy minister at Health Canada. Having spent the last year dealing with stakeholders in the space — and not just my academic colleagues but large service organizations such as the YMCA, which sees over a million children through its doors each year, the United Way and others — I believe there needs to be a voice for children and child and youth health in the country. However, probably the best way to interact with the provinces and territories and with other community service groups is to have that group outside of government, to have it function essentially as a think tank, a foundation outside of government or at arm's length from government so that the provinces more freely interact with it and it acts more as an independent voice, giving advice and good ideas in public policy development so that there can be a more collaborative environment than if it were housed in the Province of Ontario or within the Government of Canada.
My efforts had been focused on developing that entity as a non-governmental organization to represent child and youth health and the new ideas.
Senator Eggleton: You call it the national office for child and youth.
Dr. Leitch: That is how I outlined it in the text.
Senator Eggleton: Did you consider the possibility of a cabinet-level position, such as a secretary of state, which is a junior cabinet position? We have one for seniors; why would we not have one for children and youth?
Dr. Leitch: There were many options on the table. Ontario, for example, has is a minister responsible for children's services, the Honourable Deb Matthews. Different than in my own report, I have come to the conclusion that having an entity outside of government that acts as an independent voice on child and youth health and that interacts with all governments as well as all NGOs and others in the space could be far more powerful as an independent body than having something situated within the government.
Senator Eggleton: Would you see the mandate for this independent body coming from the federal government?
Dr. Leitch: Ideally, it would come from a national body, yes, and it would meet the criteria I outlined in the report of doing policy development and ideas development, ensuring there is a collaborative environment and a research evidence base for that. Ideally this body would be supported by the federal government but also have the opportunity for the provinces to more freely interact with it.
Senator Eggleton: Thank you. Keep pushing.
Dr. Leitch: I am working on it. Would you like to join the cause?
Senator Eggleton: Absolutely. I am with you.
Dr. Leitch: I will give you my business card at the end.
Senator Fairbairn: Thank you very much. Listening to you raises all sorts of memories, although not of myself.
Dr. Leitch: I hope good ones.
Senator Fairbairn: I think you mentioned it early on, but with respect to the advancement of children and the whole question of literacy and learning, not just that it is out there for themselves, but within families which themselves may not be high on that list, how much of a degree is that in elevating the opportunity for the earliest childhood chances, that they will be able to climb up that ladder and be able to reach out with others, and without that kind of centrepiece how hard is that as far as trying to build them for a future?
Dr. Leitch: The issues of early childhood education and literacy were outside the scope of the mandate for my report, albeit I heard a great deal about it.
As I said in the appendix of the report, which I thought was important, having a literate society is exceptionally important. It does move the bar. We may have all these social marketing tools, but having people being able to internalize them and, because of that, change their behaviour, is exceptionally important.
I am a product of a wonderful Canadian education. I spent half of my life in post-secondary education, let alone in primary school. I think it is exceptionally important that we as Canadians provide parents and children the opportunity to be able to function well within society by being able to read, write and participate.
Senator Fairbairn: Even though we are seen as a very proud and learned country, the statistics in this country on the number of adult Canadians with difficulty with literacy and learning seem to go on and on.
Dr. Leitch: One of the great programs the federal government participates in is the Aboriginal Head Start Program, which is tailored for children.
Senator Fairbairn: That is terrific.
Dr. Leitch: It is a comprehensive program dealing with many of the social determinants of health, in addition to those that are specifically health care oriented.
Senator Fairbairn: They have worked hard at it.
Dr. Leitch: They have done well. It is evidence-based. We have seen evidence of the dial being moved because of it, such as higher graduation rates. I have encouraged the federal government to invest in it in an effort to increase the capabilities of our Aboriginal population across the country. The federal government is involved in some programs that are definitely doing a very good job of trying to move that bar in literacy.
Senator Cook: I would like to look at the most vulnerable children in our society, and they are the children living in poverty. I look at obesity and the availability of food and what those children are provided with. Do you have any answers for that?
Children spend most of their day in the school setting. In my province, there are wonderful breakfast programs where they get proper, nutritious food. Then there is the cafeteria. I think school cafeterias are the worst perpetrators of obesity for children. I know you cannot legislate common sense, but is there any way that can be addressed? How much can you impose in a democracy?
Dr. Leitch: I cannot say I know the three ticket items you should implement in your province to make the dial change. However, I do believe that if we bring together the experts — not just in the academic world but also NGOs, industry and others — in a centre of excellence on childhood obesity to determine what those best practices are and how they can be implemented, I believe we can change the dial.
I think creating the right incentives and behavioural change among parents, as well as among children, is important. The children's fitness tax credit was implemented in first in Nova Scotia and then by the federal government as a tool to motivate individuals to be more involved.
Is there something similar we could implement that would draw behavioural change on the nutrition side of that equation, as well as on the activity side? I do not know whether we have the answer to that. Part of that may be incentives for industry for changing portion sizes and ensuring labelling is better so that people are better educated. These are things I outlined in the report.
Senator Cook: The industry loves to make cereals laced with sugar.
Dr. Leitch: I agree.
Senator Cook: Is there any way, given that we live in a democracy, we can dictate to industry?
Dr. Leitch: I give some industry leaders some credit. Through the course of the report, I had the opportunity to deal with one large industry leader that produces a lot of soda pop. They came to me and said we want to be somewhat socially responsible. I said then you actually have to prove it.
We have this problem on the obesity side of the equation, but one thing we do not have for children is after-school programs. After-school programs address a bunch of issues, not just the obesity issue. They ensure kids are safe and have a place to go in that witching hour between 3 p.m. and 6 p.m.
I challenged them: Why not fund after-school programs and have an incentive there for children? They are one of the companies involved with the torch for the Olympics. The children who improve the most and participate the most, not the fastest runners in the class but the children that who improve the most, would get to carry the torch.
To their credit, they have stepped up to the plate. They have invested $10 million; they are running after-school programs in 1,000 places across the country and the kids who improve the most will carry the torch.
It is not ideal. We have not eliminated soda pop, but we have created a degree of social responsibility for dealing with children, so it drives some change in what they do.
The other part is that they are interacting with children more, particularly working with ParticipACTION, so they are hearing more about how to have some behavioural change. That is exceptionally important.
Will we have one big leap? I do not think so, but I think baby steps like that will be constructive and useful. We need to identify more of them so that we can drive behavioural change.
Senator Cook: The stark reality in today's world is that mom or dad drops the kids off at a preschool or daycare centre at seven or eight o'clock in the morning and picks them up at the same time at night. All the children's waking hours are spent someplace else. Is there an opportunity to get into the daycare systems in this province and make it part of their licensing? Should healthy foods be made mandatory?
Dr. Leitch: I do not think it is just daycare. This spans children outside the 0 to 5 year-old age group. This also affects kids up until they are 16. That witching hour you are talking about, not just the early time but the witching hour between 3 p.m. and 6 p.m., is exceptionally important.
Eighty per cent of Canadian parents now work. Parents are wondering where their children are during that time. They are not that productive at work at that time because they are checking their watch to see when they have to pick up their children. Also, who knows where their children are.
If we create after-school programming that effectively deals with ensuring children are safe, that they are eating well, that they have activities to do that their parents are confident in, I think that will move the bar a long way in this country. That is not just about the 0 to 5 year-olds, but up to 16 year-olds as well — particularly the 6 to 12 year-old age group.
Senator Cook: I come from the province of Newfoundland where there is a fair sprinkling of after-school programs, but they cost money.
Dr. Leitch: I agree. There are many incentives that both the provincial and federal governments have invested in for the early years. I give them credit. There have been a variety of facets; the provincial governments have done some things and I know the federal government has done others. I am not an expert in that.
I would encourage both the provincial and the federal level to look at how to address that after-school programming time frame from 3 p.m. to 6 p.m. It may require asking the provinces for structural change, to change the time kids go to school; maybe they should go to school from 10 a.m. to 6 p.m.
Senator Cook: But mom goes to work at 9 a.m.
Dr. Leitch: I just throw that out there. It could be we are dealing with ensuring we provide an incentive for parents to utilize an after-school program. I am sure there are lots of mechanisms, machinery-of-government issues that I know nothing about, that definitely could incent the use of those. I agree with you completely that that 3 p.m. to 6 p.m. witching hour needs to be addressed, provincially and federally.
Senator Cook: Regarding mental health services, is there no screening for children age 3 when they are doing their preschool? Are mental health services a part of the screening for children before they enter school?
Dr. Leitch: Not in all provinces and not in all locations in all provinces.
Senator Cook: Would you advocate that?
Dr. Leitch: It is part of the report card that kids should go through to make sure they are reaching certain developmental levels so that we know early if they are falling off the dial and we can intervene sooner.
Senator Cook: I apologize I did not get to read your book. There was so much else coming at me. However, I will; you have sparked my interest.
I have one last personal question. We have three little kids; they are three, four and a half, and six and a half. They travel occasionally on a holiday. Invariably, we have to book the car seats and the booster seats. No matter how many contracts we sign with rental companies, we have yet to get the seats that we bought and paid for to put the children in to keep them safe. What can you do about the industry? My daughter would love to know that one. The last occasion was a couple of months ago.
Dr. Leitch: The number of parents who showed up to talk to me about how they did not know how to install their booster seat was phenomenal in the last year. I feel like I have become an expert in this area.
I was at a conference in June last year, called Auto21, with the 131 auto manufacturers in the country. They asked me to present regarding childhood injuries and what they could do.
I presented to them a whole series of slides and showed them in gory detail what I take care of when kids are ejected from motor vehicles. You could see they were stunned in the audience, thinking good grief, how can I have an impact on this? They can have a substantial impact by doing either of two things. They could build into their vehicles a booster seat. My Volvo has a booster seat built into it. I do not have to buy a booster seat. I just have to flip up the lid and set the kid in the booster seat. It is safe and meets requirements. Other industry leaders could do that.
The second thing is they could make booster seats easy to put in, such as by having a tiny sensor that changes the colour of the light so you know it is inserted properly. These are small things engineers could do that would make a huge difference for parents in either having a booster seat or inserting one.
The other thing we need in this country is booster seat legislation in every province. Currently we do not have that. It astounds me that only 28 per cent of the Canadian parents whose child should be in a booster seat actually have one and utilize it in their car. That is a result of not having legislation across the country that is equivalent in all provinces, and it is actually part of enforcement. There are definitely things on the legislative-regulatory side, both provincially and federally, as well as on the manufacturing-industry side, that we could change that would have a huge impact on ensuring that children are safe in vehicles. That is among the leaders of preventable injuries for kids.
Senator Cook: Something needs to be done in that area. Industry has some responsibility for providing some of those initiatives.
Dr. Leitch: For sure.
Senator Cook: That evening, I knew someone was going to jail. I did not know it was going to be my daughter or the fellow who came with inadequate equipment. We sat in an airport for four hours while he went and bought three car seats. There are horror stories out there for this kind of thing. Surely there is some way we can address it. In my province there is legislation. I think national standards might be the norm. Car manufacturers are having problems now. Maybe when they turn around they will build adequate seats.
The Chair: Just before we wrap up, I want to thank you for coming before us. I have had an opportunity to talk to you privately about this two or three times. It is wonderful to have you on the record.
I was intrigued in previous conversations and today with how you addressed organization to try to get buy-in from the various constituents necessary to move the agenda. The thing you shied away from was a silo by appointing some ministry or formal appointment or arm of government. Instead you moved to the side of government, which helps people to become more comfortable to participate.
In the determinants of health, which are much broader than your mandate was, we struggled with this also. For a while, we tried to envision where a minister of human development would fit federally or provincially. We discovered that it would not fit because it was too narrow, even though human development is the core of what we are talking about in population health. We have settled pretty well, because our report is in the process of being written now, unless something very unusual happens, on an all-of-government approach; in other words, cabinet committee, federally, provincially, in the cities, community organizations that fit in this kind of thing. This organization has worked in the countries that have moved the agenda on population health.
I just wanted to hear your comment on that and get it on the record.
Dr. Leitch: I am very much in favour of the whole-of-government approach. The place in the country that has had the most effective impact on moving the dial with respect to children has been the one province that has done that, which is Manitoba. In Manitoba, they have taken a whole-of-government approach to dealing with child health. All deputy ministers and all ministers are at some point in time in the process touched by having to put forward what part of their mandate they believe would affect child health. They actually do it in the cycle before the budget is determined so that those items and ideas are on the table, so the minister responsible for their whole-of-government approach on child health actually has that document in hand before the budget cycle begins.
It is quite a powerful position, and I think it has proven substantially progressive for moving the dial for child health in the province of Manitoba, particularly with their large Aboriginal communities that they have dealt with effectively, particularly in contrast to provinces that have not been able to deal with these public health issues.
I have been very supportive of the whole-of-government approach. I commented on it in my report and it would be of great value for dealing with these issues by the Government of Canada.
Senator Eggleton: What is the position of the minister that has the responsibility in Manitoba for the whole-of- government report? Is it specific to this children portfolio or some other portfolio?
Dr. Leitch: It is specific to this. There is an office of child health for the whole-of-government approach and the minister responsible for child health chairs that cabinet committee and also deals with several of the other health- related issues. It is not just children. They have a whole-of-government approach for other health-related items as well.
Senator Eggleton: Whether you have a human development minister or whatever, you have to have a minister at the cabinet level that will have responsibility for it. A whole-of-government approach involves many ministers, but someone must be the lead.
Dr. Leitch: I agree.
The Chair: Expanding on that, we are recommending that it be the Prime Minister at the federal level and premiers at the provinces. At the civic level it would be the mayor, I suppose. In communities where there are a lot of volunteers, we are still struggling a little bit but we will have to find a way.
Dr. Leitch: You could pick the chair of the YMCA.
The Chair: Thank you very much.
(The committee adjourned.)