Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 4 - Evidence - October 19, 2011
OTTAWA, Wednesday, October 19, 2011
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:14 p.m. to examine the progress in implementing the 2004 Ten-Year Plan to Strengthen Health Care.
Senator Kelvin Kenneth Ogilvie (Chair) in the chair.
[Translation]
The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
My name is Kelvin Ogilvie. I am a senator from Nova Scotia and chair of the committee. I ask colleagues to introduce themselves, starting on my left.
Senator Dyck: Lillian Dyck from Saskatchewan.
Senator Cordy: Jane Cordy from Nova Scotia.
Senator Martin: Yonah Martin from Vancouver, British Columbia.
Senator Merchant: Pana Merchant from Regina, Saskatchewan.
Senator Demers: Jacques Demers from Quebec.
Senator Champagne: Andrée Champagne from the province of Quebec.
Senator Seidman: Judith Seidman from Montreal, Quebec.
The Chair: This meeting is part of our examination of the progress in implementing the 2004 10-Year Plan to Strengthen Health Care. Today's theme is primary care reform. We have four witness groups before us today. I would like each of you to introduce yourselves when you are called to present. I understand it is acceptable that we proceed in the order that you are listed on the agenda in terms of presenting. On that basis, hearing no major objections, I will proceed. My witness list shows the Canadian Psychiatric Association as first on the agenda; and Dr. McGregor will present.
Dr. Fiona McGregor, President, Canadian Psychiatric Association: Thank you for inviting us to the committee today and providing the Canadian Psychiatric Association with the opportunity to discuss mental health issues and the essential role they deserve in the country's health care discussions.
First, I have a couple of introductory remarks that underline our concerns. As you are aware from the extensive media coverage, until the issue of stigma and discrimination regarding mental illness is addressed, any attempt at improved treatment will be hampered. Stigma and discrimination is a primary barrier to treatment and recovery. It has been demonstrated to result in delayed seeking of treatment, early treatment discontinuation, problems in finding housing and employment, and inadequate mental health care, all of which lead to adverse economic effects.
Second, I would like to make you aware of the discrepancies between disease burden and funding. According to the WHO, almost a third of all years lived with disability is due to a neuropsychiatric condition. This is quite disproportionate to the percentage of health funds spent on clinical care and research. In Canada these conditions are estimated to cost the economy $51 billion yearly. Another way of looking at the picture is that mental illness constitutes over 15 per cent of the disease burden in Canada, yet only 6 per cent of total health care funding is allocated for this problem. We rank almost at the bottom of the table in funding when compared to most other developed countries. When research funding is compared with the economic costs of disorders, mental illness receives proportionately eight times less research funding allocated than that funding allocated for cardiac disease or cancer. This discrepancy between funding and need seems to be evidence of structural discrimination. The Mental Health Commission of Canada will be coming out with their national strategy in 2012. This is the first step. The second step will be for the government to adequately fund the strategy.
We are here to present at today's committee because of the burgeoning interest in building patient-centred collaborative partnerships between primary care and mental health care providers. Mental health is an enormous problem for primary care practitioners. Collaborative models have improved access to mental health care and increased the capacity of primary care to manage mental health and addiction problems. Successful projects in Canada and other countries have demonstrated better clinical outcomes, a more efficient use of resources and an enhanced experience of seeking and receiving care. They are associated with reductions in health care costs, a greater likelihood of return to the workplace and the reduced use of other medical services, especially for people with chronic medical conditions.
The federal government has been helpful in promoting collaborative care models; however, there is a real need for initial investment in these new services if savings are to be achieved over the long term. Knowledge of best practices alone is not enough. The structure to allow adequate funding of interdisciplinary practice models and the information technology required also needs to be in place; and there has to be adequate manpower. In this country there have to be imaginative solutions that take into account the geographic disparities of its citizens.
There are other areas of concern. The 2004 accord promised significant reductions in wait times for five priority areas. Now other areas of health care need to be addressed. The Wait Time Alliance was formed out of concern for Canada's doctors over delayed access to care for their patients. In its 2011 report card, the WTA reports that it is unacceptable that there is no reporting of wait times for such important and substantial fields as psychiatric services, given that these areas provide a significant contribution to the overall health care system.
As you develop your plans for the next accord, I urge you to bring psychiatric conditions and other mental health services to the forefront of your wait times strategy. This is especially urgent for children and youth because we know that early, timely access to mental health care can make the difference between rapid recovery and a quick return to daily living and lifelong chronic illness. I remind you that 70 per cent of adults living with a mental illness say the onset occurred before age 18. Early intervention can make a dramatic difference in young people's quality of life.
Also, in 2004, the premiers directed their health ministers to develop and implement a National Pharmaceuticals Strategy. However, this has not progressed much, especially in the areas of developing a common national formulary for all prescription medications and a nationwide approach to savings in pricing and purchasing. The CPA supports a policy of equity for access to new medications for all Canadians with mental disorders based on individual needs rather than the cost of medication or location or the type of coverage. In the interest of all mental health patients and their families, the CPA requests harmonization of drug formulary policies across the nation to achieve optimal access to modern care and treatment for every Canadian with a mental illness. To ensure affordability and sustainability of public drug plans, the CPA encourages cost-effective approaches to treatment in mental health services without limiting access to effective new medications.
To conclude, the Canadian Psychiatric Association is asking that the federal government, one, ensure that mental health receives dedicated funding in the 2014 health accord and that the funds spent on mental health, mental illness and addictions are proportionate, or at least more proportionate, so the burden of illness in Canada. Two, we encourage additional investments in collaborative care models that will increase efficiency in the system and accountability of those care models. Three, we also urge you to bring mental health services to the forefront of your wait time strategy. Four, we want to continue to improve access to medications by harmonizing the drug formulary policies and accelerate access to breakthrough drugs for unmet health needs through improvements to the drug approval process.
The Chair: Thank you. Now we will go to the College of Family Physicians of Canada, Dr. Boulay, the president.
Dr. Robert Boulay, President, The College of Family Physicians of Canada: Good afternoon. As President of the College of Family Physicians of Canada and as a practising family physician, it is a privilege to be here with you today. Thank you very much for this invitation.
The College of Family Physicians of Canada, or CFPC, is the voice of family medicine in Canada, representing over 26,000 dedicated members. The CFPC advocates on behalf of its members to ensure high quality of care. Education is a key element of our mandate. We establish standards for the training, certification and ongoing education of family physicians. Indeed, we are responsible for accrediting postgraduate family medicine training in Canada's 17 medical schools.
My remarks today are focused on the health accord as it applies to primary care and family practice. They incorporate our vision for 2014 and beyond.
Primary care is clearly identified as a fundamental element of our health care system. We concur with the goals of the 2004 accord, including timely access, health human resource planning, prevention and health promotion, home care and a national pharmaceutical strategy. In particular, we found the statement about 50 per cent of Canadians having 24/7 access to multidisciplinary teams by 2011 to be very laudable.
Multidisciplinary primary care team models currently exist in certain provinces — Ontario's family health teams, Alberta's primary care network and Quebec's family medicine groups — but much remains to be done.
The CFPC encourages legislators to continue pursuing better access, ensuring that Canadians have their own family physician and access to nurses and other health professionals working in teams with patients' family doctors, and we applaud the significant progress in establishing models like this to date. It is of utmost importance, however, to further this momentum and do all we can to improve our health care system in the years ahead.
There is a better model for primary medical care emerging across the country. The CFPC introduced its vision for the future of family practice and urges our governments to join millions of Canadians seeking better access to family physicians and primary care by supporting the Patient's Medical Home initiative.
Patients' Medical Homes build upon the existing strengths of family practice and primary care. They recognize and seek to enhance the central importance of the patient and the doctor-patient, nurse-patient, and team-patient relationships. They reinforce continuity of care and effective use of resources. They offer a flexible model where innovation and response to changing realities in care are possible. They optimize the use of health professionals and their skills, and they reinforce the objectives of the 2004 accord, objectives we hope will be maintained and strengthened in a renewed accord.
Better access, better coordination and delivery of a more comprehensive basket of services are possible when the core elements of a Patient's Medical Home are implemented. For example, research has shown that patients with their own family doctor and a consistent team of primary health care professionals working with their family physicians have better health outcomes. Same day scheduling strategies being used in medical home practices offer timely appointments with either the family physician or another member of the practice team. My own experience as a family physician in small town New Brunswick has reinforced for me the overwhelming concern that Canadians have regarding access to their own family physicians when they have questions or concerns regarding their health or the health of a loved one. Furthermore, electronic medical records, once fully implemented, could facilitate information flow and consultations and are an essential part of continuous quality improvement.
Primary care reform is indeed a long-term objective. The CFPC recommends that the health accord must be extended for at least another decade and there must be increased accountability for the use of funds to achieve the goals defined by this accord. Importantly, the accord must include sustained support for family practice and primary care.
A critical objective for the future of health care in Canada, and an essential goal of the Patient's Medical Home initiative, is the enhanced focus on prevention, health promotion and the care of those with chronic diseases, including mental illness, cardiovascular disease, diabetes, respiratory diseases, arthritis and cancer. A renewed accord must include significant commitments to improving individual and population health through illness and injury prevention, a focus on the social determinants of health and augmented support for home care and prescription medications for all Canadians.
Evidence shows that better access to ongoing family practice and primary care leads to better population health outcomes. Supporting primary care is the most effective way to sustain our health care system, prevent illness and deliver optimal care to all Canadians. Well-supported patients' medical homes where family physicians, nurses and other team members work together to provide patient-centred care will open the door onto a pathway leading to sustainable, high quality care. The 2014 health accord must give all Canadians the chance to be part of this experience. I thank you for your time.
The Chair: Thank you very much. I will move to the Canadian Medical Association. We have two members of the team here, Dr. John Haggie, the President, and Stephen Vail, Director, Research and Policy. Dr. Haggie will be making the presentation.
Dr. John Haggie, President, Canadian Medical Association: The Canadian Medical Association appreciates this opportunity to appear before this committee as part of your review of the 10-year plan to strengthen health care. An understanding of what has worked and what has not since 2004 is critical to ensuring the next accord brings about necessary change to the system. On the positive side of the ledger, the 2004 accord provided the health care system with stable, predictable funding for a decade, something that had been sorely lacking. It also showed that a focused commitment, in this case on wait times, can lead to improvements.
However, little has been done on several other important commitments in the accord, such as the pledge that was made in 2003 to address the significant inequity among Canadians in accessing prescription drugs. Along with the lack of long- term, community and home-based care services, this accounts for major gaps in patient access along the continuum of care.
We also know that accountability provisions in past accords have been lacking in several ways. For instance, there has been little progress in developing common performance indicators set out in previous accords. The 2004 accord has no clear terms of reference on accountability for overseeing its provisions. What the 2004 accord lacked was a clear vision. Without a destination and a commitment to getting there, our health care system cannot be transformed and will never become a truly integrated, high performing health system.
The 2014 accord is the perfect opportunity to begin this journey, if it is set up in a way that fosters the innovation and improvements that are necessary. By clearly defining the objectives and securing stable, incremental funding, we will know what changes we need to get us there. Now is the time to articulate this vision and to say loudly and clearly that at the end of the 10-year funding arrangements, by 2025, Canadians will have the best health and health care in the world.
With a clear commitment from providers, administrators and governments, this vision can become our destination. As a first step to begin this long and difficult journey, the Canadian Medical Association has partnered with the Canadian Nurses Association. Together we have solicited support from over 60 health care organizations for a series of principles to guide health care transformation in Canada. These principles define a system that will provide equitable access to health care based on clinical need, care that is high quality and patient-centred, and focuses on empowering patients to attain and maintain wellness.
They called for a system that provides accountability to those who use it and those who fund it and that is sustainable — by which I mean adequately resourced in terms of financing, infrastructure and human resources — and measured against other high-performing systems with cost linked to outcomes.
Based on our experience working within the provisions of the 2004 accord, we would like to suggest three strategies to ensure the next accord leads to a sustainable, high-performing health care system. They are: focus on equality, support for system innovation, and the establishment of an accountability framework. I will touch briefly on each one.
The first strategy is the crucial need to focus on improving the quality of health care services. The key dimensions of quality — and by extension the areas that need attention — are safety, effectiveness, patient-centredness, efficiency, timeliness, equitability, and appropriateness. Excellence in quality improvements in these areas will be a crucial step toward sustainability. To date, six provinces have instituted health quality councils. Their mandates and their effectiveness in achieving lasting, system-wide improvements vary. An integrated, pan-Canadian approach to quality improvements in health care, one that can begin to chart a course to ensure Canadians have the best health and health care in the world, is missing and is urgently needed. Canadians deserve no less. With the resources at our disposal, there is no reason why this should not be achievable.
The CMA recommends that the federal government fund the establishment and resource the operations of an arm's- length Canadian health quality council — with a mandate to be a catalyst for change, a spark for innovation and a facilitator to disseminate evidence-based quality improvement initiatives — so that they become embedded in the fabric of our health systems from coast to coast. To help expand quality improvement across the country, the triple aim of the Institute for Health Care Improvement provides a solid framework. Our health care systems will benefit inordinately from a simultaneous focus on providing better care to individuals, better health to populations, and reducing the per capita cost in doing so.
There is ample evidence that quality care is cost-effective care. When adopted and applied as a pan-Canadian framework for any and all structural changes and quality improvement initiatives, this approach will not only serve patients well but will also enhance the experience of health care providers on the front lines.
The second strategy revolves around system innovation. Innovation and quality improvement initiatives are more likely to be successful and sustainable if they arise out of commitment by front line providers and their administrators to the achievement of a common goal. We need to shift away from compliance models with negative consequences that have little evidence to support their sustainability.
Innovative improvements in health care in Canada are inadequately supported, poorly recognized and constrained from being shared and put into use more widely. This needs to change. With a focus on improving Canadians' health and health care, the 2014 accord can facilitate the transformation we all seek. Based on the success of the 2004 Wait Times Reduction Fund and the 2000 health care accord Primary Health Care Transition Fund, the CMA proposes the creation of a Canada health innovation fund that would broadly support the uptake of health systems innovation initiatives across the country.
The third strategy is that there needs to be a working accountability framework. This would work three ways to provide accountability to patients. The system will be patient-centred and along with its providers will be accountable for the quality of care and the care experienced. For accountability to citizens, the system will provide and — along with its administrators and managers — will be accountable for delivering high quality, integrated services across the full continuum of care. To provide accountability to taxpayers, the system will optimize its per capita costs and — along with those providing public funding and financing — will be accountable for the value derived from the money being spent.
We have done all of this because of our profound belief that meaningful change to our health care system is of the essence and that such change can and must come about through the next health accord. I thank the committee for its efforts and I would be happy to answer any questions afterward.
The Chair: Thank you very much.
Now we will move to the Canadian Nurses Association. We have President-elect Dr. Barbara Mildon and Chief Executive Officer Rachel Bard. I understand you will share your time together.
Barbara Mildon, President-elect, Canadian Nurses Association: On behalf of Canada's 250,000 registered nurses, we are pleased to thank you for the opportunity to bring the perspective of the nursing profession to your review of Canada's 10-Year Plan to Strengthen Health Care. We are pleased to acknowledge and thank our colleagues on this panel, with whom we are engaged in health transformation policy initiatives designed to bring forward our individual and collective expert advice for a strong, patient-centred system.
The 2004 health accord has made progress in reducing wait times for a range of health situations; tet, we can do more to address the root causes of a health system that has not kept pace with the health needs of our nation.
The CNA feels that we can gain maximum benefit from the time and resources remaining in the current accord by laying a solid foundation for patient-centred, strategic and integrated health care system transformation.
We recommend accelerated investment in two key and linked areas: a primary health care system that begins with prevention and promotion and continues along the full continuum of care, and inter-professional teams to enhance access to the right provider in the right place through multiple access points.
As many of you know, a comprehensive primary health care approach embraces promotive, preventive, curative, rehabilitative and supportive care, and recognizes the importance of a broad range of social and environmental determinants of health. A focus on primary health care contrasts the way we have currently set up our system in Canada. It goes beyond doctors, hospitals and illness care as the centre of the system.
Rather, primary health care sees Canadians and their health as the centre. We need a shift of resources towards multiple access points, aimed at keeping people well and out of the hospital. That shift requires bringing services into the community, such as mobile clinics, community health centres and home-based care. This places the emphasis on health promotion, disease prevention, and on meeting the needs of Canadians with chronic illnesses that are forced to rely heavily on hospitals — the most expensive component of our system — because they have nowhere else to turn.
Rachel Bard, Chief Executive Officer, Canadian Nurses Association: Just as infrastructure investments build capacity for sustained economic productivity, a timely strategic investment in community-based, collaborative teams of health professionals would promote better access.
Teams have proven particularly effective in the prevention and management of chronic diseases, giving Canadians the tools they need to stay healthy and remain at home, reducing use of emergency departments, costly hospital stays and overall easing pressure on the acute care sector. This would save the system money and increase its long-term sustainability. Canada can do much more to integrate registered nurses in a more responsive system of primary care.
An example can be found in the collaborative model of primary care nursing and physician practice created at the Family Medical Centre in Manitoba to increase access to primary care services. The successes of this model are attributed to a recognition of the nurse's skills, which allows her or him to work to their full scope of practice. While the nurse provides routine care, health promotion, health screening and other preventive care, the physician's time is freed up to see patients with more complex needs. This model from Manitoba and other examples in other parts of the country have resulted in dramatically shorter wait times.
There are also compelling examples that illustrate the cost savings and system efficiencies that can be realized in the area of surgical wait times. One comes from a study at the Toronto Western Hospital, which showed that patients who were screened by a nurse practitioner in a surgical spine consultant clinic had a significantly shorter wait time: an average of 12 weeks rather than up to 52 weeks before initial examination by a spinal surgeon. The nurse practitioner was able to determine which patients were appropriate surgical candidates and refer them accordingly. Of those examined by the nurse practitioners, only 10 per cent were candidates for surgery. The diagnosis provided by the nurse practitioner was the same as that of the surgeon in all cases.
These are two examples, and there are more.
Ms. Mildon: Indeed, those are but two of the examples where we need strong federal leadership to make these successes commonplace across the country. The CNA believes we all need to be accountable for real change in the design and delivery of health care. As the 2004 accord concludes, we need governments to work together to design and implement the next agreement. A new accord should provide the road map to the best health system and the best health we can probably achieve. If the next health accord is to have teeth, it will need to be no shorter than 10 years; it will need to include an accountability framework that sets out clear targets and indicators that can be used to gauge progress; and it will need to set the tone for pan-Canadian collaboration and move best practices into common practices.
Senator Eggleton: Thank you for all of the presentations. I realize that you have covered a wider range of subjects than the specific subject before us today. We are all dealing with those things in different meetings. For example, we dealt with home care at the last meeting and wait times at another, et cetera.
I will focus my question on the matter of multi-disciplinary teams. You all talked about that today. Back in 2004, when the accord was signed, the first ministers said they wanted to ensure that 50 per cent of Canadians had 24/7 access to multi- disciplinary teams by 2011. We do not seem to have done that. According to the Health Council of Canada in 2008, we only got to 17 per cent.
What has gone wrong? Are you people not cooperating with each other? Dr. Boulay has a specific plan relevant to Patients' Medical Homes. How does that work in conjunction with what some other provinces are doing, such as the family health teams in Ontario, primary care networks in Alberta and family medicine groups in Quebec?
How do we get this team thing moving faster than the 17 per cent reached in 2008? What should the next accord say about it?
Dr. Boulay: Certainly, I do not think it has been for a lack of trying in terms of our organizations working together and seeing that this is truly the way that we are going to save our health care system in the long run. We have to continue to push forward on team development. What happened since 2004 is multi-factorial. There were no targets set for where the funding would go. Although it was a laudable goal, as I said in my introductory remarks, that we would achieve this 50 per cent by 2011, there was no accountability placed on that funding.
Certain provinces have seen the light, given what has happened in Ontario, in Alberta and more recently in B.C. where they have experienced quite a huge take-up in terms of team development. We would like to see that become a pan-Canadian reality, however; and I really think we can make this work. Actually, we have to make it work.
Ms. Mildon: I know my colleague has some comments as well. Basically, my thinking is that integrated care needs integrated funding models. When you separate funding into various pockets whereby home care has a fund and primary care services have a fund, it creates a barrier to the kinds of inter-professional teams we are seeing. Where we have seen successes, there have been ways to make that funding across the services. My thinking is to be sure to look at funding models and how they can enable the kinds of inter-professional practices that you named as examples.
Senator Eggleton: Can you give an example of how that might work? How might we write that up in the accord?
Ms. Mildon: I am sure my colleagues would have an example. The example I am most familiar with in Ontario is the nurse practitioner-led clinics that have a funding model that enables a pocket funding. The nurse practitioners have physicians on staff with them, and they bring in other health professionals as well. It becomes an integrated, inter- professional model that is funded globally.
The Chair: Let us hear from one of your colleagues, Dr. McGregor?
Dr. McGregor: It does come down to dedicated funding models. For example, the way in which psychiatrists are funded creates a great challenge to integrated care when you do not have face-to-face patient contact. There must be more creativity and imagination about how you do that. Sometimes it can be much more helpful if you can consult with a primary care practitioner, give them advice, and help them. What my CNA colleagues are saying is exactly right: the funding has to follow.
As a personal example, I work in Vernon, British Columbia. I cannot model primary care, but one of the things we have is a catchment area of responsibility. We have responsibility for acute, hospital and community services together. When you have a blended model and blended responsibilities there are far fewer barriers to care. If people have responsibility for the whole continuum of care, they will be responsible for it; otherwise it becomes a mandate for barriers.
The Chair: What does the CMA have to say about an integrated funding approach?
Dr. Haggie: You are looking at a different kind of silo — a knowledge silo. There are areas of excellence. The primary care transition fund was originally intended not to fund pilot projects but to actually change primary care. However, because of the way it was written, it did not have details of what was in and what was out; and it did not have any kind of timeliness. There was a lot of fuzziness around it. There are some pockets of excellence but to disseminate those pockets of excellence so the uptake can be enhanced requires one of the things that we talked about: the concept of an innovation fund, which would not be to fund pilot projects but rather to take best practices and seed money so they could start up.
There is a lot of ignorance in Newfoundland about what happens in Alberta. Their primary care networks are a superb example of what has gone well out of what was intended from the primary care transition fund. The silos are dissemination and knowledge as well. We do not have a framework to do that so one of our recommendations would deal with that.
Ms. Bard: I would add to what my colleague said. I agree that we need some seed dollars but we need to avoid creating another project approach. We need to find a way of integrating the concept throughout the continuum of care. We need to broaden the medical services covered under medicare so that we can look at a variety of funding models that capture more than acute care services have captured to date. We need to look at where community care fits into that.
Senator Seidman: The College of Family Physicians of Canada and the Canadian Psychiatric Association produced a position paper in late 2010 that presents a vision for collaborative partnerships between primary care and mental health providers, including the integration of mental health services within primary care settings. I would appreciate your comments on this, specifically with regard to the following: To what extent are mental health services integrated with primary care across jurisdictions? What are the barriers to interdisciplinary collaboration between mental health professionals and primary care professionals? How could a future health accord address challenges in this area?
In speaking to these issues, I would appreciate it if you could include some reference to child and youth mental health, which is a special area.
Dr. McGregor: We have all heard that it is quite spotty across areas. British Columbia is only just beginning to start on that, which is the field that I am most familiar with. Much more work has been done in Ontario and Alberta with their primary care networks, although I am not able to give you exact figures. I do hear that there is much greater satisfaction with services; that they are much more economically viable; that they actually cost less in the end; and that they are more responsive.
I can give you a personal figure. We do not do primary care relationships because we need primary care reform in my area first. However, we took a catchment area of responsibility in my local area and had ways in which GPs could fast refer to us and we could refer to them. That was a kind of collaborative care. I will compare us with our neighbouring community to the south of us. We have shorter waiting lists, half the number of psychiatrists and apparently the same quality of services, but it costs us less than half of what they are charging in the community for medical costs and psychiatric costs to the medical services plan. There are economies. How can we address those challenges? We have to look at primary care reform significantly. How do we look at child and youth mental health, which requires a much more integrated service?
For example, in British Columbia, child and youth mental health comes under the jurisdiction, apart from acute care, of the Ministry of Children and Family Services; and we have the Ministry of Health as well. It requires a real vision to have integrated child and youth services. Locally we have made those relationships, which of course integration depends on, where there are administrative silos; otherwise it is difficult.
How can you address it? We are talking about funding models. The way seems to be using the carrot to get people to focus and do it. We need some framework of accountability, which I think we are agreed on.
Dr. Boulay: I would add that many wonderful things are happening across the country in terms of collaboration. I have colleagues with psychiatrists who come and spend half a day each week in their offices doing shared care right on site. That is a great model, but our current funding models do not support it. Child and youth mental health services in Canada are bordering on a national embarrassment. We need to push forward in that realm. Targeted funding toward initiatives would truly help in collaboration not only between departments of health and child welfare but also between departments of education, which have a huge role to play in early identification and helping youth become all that they can be.
Dr. McGregor: There are other barriers, such as confidentiality agreements that stop parents from knowing what is happening to their children. We could look at the privacy laws in that regard as they relate to health care.
Senator Seidman: Is there anyone else? Perhaps Ms. Mildon might have something to say.
Ms. Mildon: My day-to-day work is at the Ontario Shores Centre for Mental Health Sciences, so mental health is a subject that is dear to my heart. I find myself turning to funding models. We have global funding but it is volume-based in our organization. When we have a surplus, we invest it. There is always fiscal year constraint in particular programs.
A recent program is expanded evidence-based education modules about mental health in education settings. We see the integration not only through health care but also through other sectors, such as health care and education. That is why we cannot deal with the health care sector only; the social determinants of health cover all those sectors. Again, there are funding models and innovation models, such as teams of nurses going into long-term care settings with a focus on psycho-geriatric needs. It comes back to two things: funding models that enable these kinds of services to be shared and the innovation to do it.
Senator Martin: I have so many questions. All of you mentioned common themes. I keep hearing about collaborative care models, which could be multi-disciplinary, interdisciplinary or trans-disciplinary. In terms of creating this effective team, are there criteria in print or understood by all various health practitioners for reference in developing very effective interdisciplinary teams? If these have not been articulated, should they be in the next accord? As a former teacher, I think about rubrics. When I asked students to do an assignment, we provided the specific criteria that allow them to succeed. I am curious about whether there are criteria. I am considering the importance of the number of times that a team would meet or intersect, whether via teleconference or in person, to interface about a particular patient. Electronic records might be a key tool to help create that continuum. What are the criteria for a very effective team within this system?
I know firsthand about the amount of exposure, face-to-face time and kind of care that we receive from nurses. When you talk about integrating nurses into the system, could you explain in greater detail how they could be integrated further into the current model so that they could reduce the burden on the overall system and we could maximize the services they are able to provide? I know you are already doing that, but how could you better be integrated?
Lastly, I wanted to just ask all of you to follow up, not so much answer today, regarding what these current barriers may be. What do we need to remove, as well as what sort of specific language must we put into the accord, especially when it comes to accountability? You all talked about it, and it would be great to get very specific recommendations about that.
The Chair: Before I turn it over to you, I want to pick up on what Senator Martin has just indicated and requested of you. We would welcome, following this meeting, you forwarding us additional responses to questions that you do not have time to fully explore, and there will be more of those come up. On that particular one, we will ask you to respond later.
Since the first question is one that would require you to think about your answer, we could go to the question to the nurses first, and then I will come back to you with regard to her first question and see who wants to start that one up.
Ms. Mildon: Thank you very much. I will certainly ask my colleague to join in. Your question raises for me the notion of public health nursing. Having been a nurse for more than 30 years, I have seen the continuum. Public health nurses, from infancy care to school health to elder screening, can make a big difference in terms of promotion of health and prevention of disease, yet those services have been eroded considerably throughout our country in almost all of our health systems. When you ask what we can do to further integrate nurses into our system to make the biggest difference, I would ask that we look at our public health nursing system and that we make sure that nursing is integrated into the public health system. We do have many examples of good, solid evidence that public health nurses make a difference in our public health system. That would be my first answer to that.
Ms. Bard: Maybe I could add, to supplement, when we think as well of primary health care and primary care, we need to create a system that will allow and transfer resources into those other setting environments. Right now, if I look at the data, while we promote the team approach in primary care, out of the 250,000 nurses that we said exist in the country, right now we have about 30,000 registered nurses that are working in a primary care setting. When we look at nurse practitioners, out of 3,000, we have 1,000 that work in the primary care setting. We need to try to find a way of shifting resources and supporting. Actually, I would start by answering as well that if we think of moving into the team approach, one of the criteria is that it starts with the patient. What is it that the patient needs? You create the team that the patient needs around the service, rather than right now we are all coming in as professionals and thinking here is what the services are. You start with the patient, when we talk about that, and look at his need and you create the team that the person needs. The team can vary, and the lead can vary, just because of making sure that you arrange the services that are needed. Again, it is timely services, the right services at the right time and at the right place.
The Chair: I will come back to the first question and ask Dr. Haggie to start that off.
Dr. Haggie: The first question really speaks to what services are needed. Ms. Bard has taken a patient-centred approach, which is what we have done. The team changes. If you have a diabetic patient who is stable, they may need an exercise regiment and physical therapy and these things rather than intervention on a medical level. If they are decompensated, you may need surgical referrals and those things. It changes, and it is not static. What they need on day one may be completely different than on day 365.
If you back up a little bit and ask, from a systems point of view, what services in general you need, we really do not have any idea. The bottom line is that the data has not been collected. You then ask, well, how do you deliver the services? First we have to find out what they are. We do not really have a good population-based needs assessment. We then do not know if we have the right staff in the right mix. Chronic disease is now the example or the paradigm for health care. Eighty per cent of health care in North America is chronic disease management. It is no longer acute care, yet medicare was designed for acute episodes delivered in hospitals by physicians, and that is still how it works. What do you need in terms of resident output from programs to staff a service that is chronic disease management? Do you really need 50 to 60 per cent of them going into specialties? How do you then inform the medical students of what opportunities there are for residency programs so you do not get someone who is an expert in the left ankle and cannot find a job because you do not need any more left ankle experts but need someone who fixes fractured hips but you have not passed that information on to people in a timely enough way? What will work this week may no longer be the case in five years time. It is a complex adaptive system.
The other thing, then, about the team is transitions. The pitfalls in care, the gaps, come when you move from primary carry to secondary care to tertiary care, the handover, the referral process. CMA actually has a tool kit for governments and stakeholders that is nearly ready to be launched. It will take two examples of referral practices and patients and then can be replicated for others in an attempt to try to minimize the gap in communication.
Underpinning all of that, if you really want to make sense of it all, you need an EMR, an EHR, from the ground up. There has been money for Infoway from the top down and the infrastructure and the big pipes to carry the information, but the issue is at point of care where it really makes a big difference. We have 14 health record systems in Newfoundland, with a population of 502,000 people. They were all bought from the same vendor. None of them speak to each other. We now have four integrated boards. They are still struggling to get two computer systems 60 miles apart to speak to each other. That is since 2005. It is not built from the ground up. It has been imposed. It has been subjective constraints where the views of the user, the person at the pointy end, were not really taken into consideration.
I have a quick answer to the accountability question. The answer may well be, and one of our suggestions is, a patient charter. It has been used in other jurisdictions. Alberta has one on the starting blocks now with some enabling legislation proposed. The difference is it has teeth. It makes the system accountable to the patient, not governments to each other, which did not work in the 2004 accord because you got into this jurisdictional fight about who was the senior or junior level of government. It is not about that. The system has to be accountable again from a patient point of view. What happens to the 82-year-old lady who runs into a problem? Where does she go to get that problem addressed? Not everyone can go to the Supreme Court.
Ms. Mildon: I will be very brief. I want to bring a pragmatic answer to the question of the criteria for an effective team. One of them is that we have to understand each other's scope of practice. The federal government has invested quite wonderfully in inter-professional education for health care providers. We need to see how that fits and whether it is working. If there is an understanding of each other's scope of practice, the integration of services is truly facilitated.
Lastly, from my perspective, criteria for an effective team include that it is outcome oriented. It is looking at its data. How many patients is it serving, and what are their health outcomes?
Senator Cordy: These have been excellent presentations. I was going to talk about the mental health issue, but Senator Seidman did. I was pleased to see that you recommended that mental health receive dedicated funding because we find that, in hard, economic times, if it is not dedicated funding, it gets lost in other areas of health. I think that is an excellent recommendation.
I would like to continue with Senator Martin's line of questioning in terms of value for money and accountability.
This morning, Dr. Haggie, I heard you at 7:15. You talked about Canada being fourth or fifth in terms of what we spend, and yet seventh to twenty-seventh in what we get. I was not able to write it down fast enough but, in my own words, what we got for our money.
You talked about having a patient charter. I was on this committee when we studied the health care system. We said it is ironical that those that provide the funding and care actually evaluate themselves. You made reference to that earlier, which is a unique situation. How do we ensure that we get value for money? How do we make it accountable? You talked about patient charter. Some of you talked about clear targets, vision and a plan. Is that enough? What should we recommend to the minister be put into the 2014 accord to ensure there is accountability? Should we have the patient Charter of Rights? What should we do? If we are spending the money, we want to be reassured as Canadians that we are getting the best value, and not waiting five or six hours.
Dr. Haggie: It speaks to the idea of quality. Quality care is cost-effective care. It is good sense to spend the money on quality and do it right the first time. The system is patchy with that. We do not actually have good, hard outcome data. What we do is we pick things that seem like a reasonable surrogate or proxy, such as length of hospital stay.
There are several prongs to improving. There is no Harry Potter spell. To be very simplistic — because it is a complex system — you have to take a multi-pronged approach. On the individual level, you have to supply clinicians with data on how they are doing. As a surgeon, if I have a wound infection rate that is one third the national average, it is great. However, if my colleague has four times the national rate, it may not be so good. What is the difference? Why is that there? No physicians go to work wanting to do a bad job. I have not yet met one of them who wants that. They just do not know. You are at the ``workload,'' and you do not get positive feedback. You do not get positive audit and peer reviews. It is not built into the culture at an individual level.
The success of the Wait Time Alliance showed that if you pick things, decide on targets and use the background experience, you can make a difference. You can argue about whether the benchmark you have chosen is the right one. You can argue about whether or not you should have picked hip and knees rather than bunions or backs, but that is at a detailed level. You have to start somewhere. Let us pick some things that are different. Do you want to alter your definition a bit?
One of the issues with wait times is the time from when the specialist sees the patient to the time the specialist does the elective procedure. How do you measure wait times from a patient point of view? When a patient has a pain in their back, that is when their problem starts. It is not when they go to their primary care provider. How do you measure that in a way that is consistent?
One of the things with the wait time benchmarks has been that different jurisdictions have had a different emphasis on what they collected. Trying to compare it is a bit like apples and oranges, or chalk and cheese. You could not make direct comparisons. We made headway. There is not a revolution in that regard; there is an evolution.
Patient-reported outcome measures: What do patients feel from that point of view? They have been validated in other jurisdictions. We have not used that. Why not? We talk about a patient-centred system. What does the patient think? There are little threads starting with education, peer review and audit cycles. There is not one thing that will actually do it.
Ms. Bard: The federal government has a leadership role and needs to set some vision — if we want to make a difference — so that by 2025 we have healthy Canadians.
Where do we want to be as Canadians in terms of our health system? I would support some of the comments that my colleague Mr. Haggie made. We need to develop benchmarks and have some national outcomes that we need to strive for. For the dollars that are being transferred to the province, there needs to be some accountability or reporting mechanism. We can strive to achieve the vision that the federal government will provide as to what we want as a country in terms of the health of our citizens.
I think we need to come to grips. I have worked in government and I know from previous experience that provinces do not like to be compared. We need to move beyond that, set some targets that everyone buys into, and strive for it. Then we align our service response and services so we can ensure that we start to adjust. If what we are delivering is not making any difference to the health of Canadians, then we need to adapt our services. We need to have the flexibility to adapt our services, and that way we can start to monitor and adjust. It becomes a responsive system, based on patient needs and clear patient outcomes.
Dr. McGregor: I was going to say the same thing. The Canadian Psychiatric Association actually developed wait time guidelines a few years ago about mental illness. It is relatively easy to look at wait times — although it is a bit crude because there are arguments about it — but it is one of the ways to start to look at accountability.
Dr. Boulay: The issue of pan-Canadian outcomes is a vital one and can become part of something that can come forward as a proposal.
When I go to meetings, imagine the surprise of international colleagues when they ask me to describe the Canadian health care system and I cannot do that in a couple of simple paragraphs. It is because we have many health care systems. Our vision would be to migrate ourselves toward one health care system that is equitable for all Canadians. I think it is fair to say that there is a lot of disparity right now.
The Chair: On the issue started by Senator Eggleton — and all my colleagues have raised other dimensions of it and it has come up in earlier sessions — there seems to be a clear understanding from what we have heard from you today that the patient is the centre of this issue. The patient needs to be able to have access to the required treatment through a single approach in a continuous and timely fashion. It is delivered so that it helps the patient and moves the issue forward.
You have mentioned a number of aspects of this today, including integrated services, access across the system, and you have all referred to patient centres. There were suggestions about funding models that would bring people together, but that was identified as potentially another silo. We have heard silos a lot.
I think what it really comes back to are professional areas that have a long history, clear membership understanding of expectations, and objectives from a career point of view. You are within a turf and the issue is that there is not any single boss in this. Who is in charge? Certain key aspects of the medical care system do not report to the rest of the system.
All I would like to do at this point is ask you to reflect on the things that you have responded to in different ways today. See if you could come back to us with some written outlines of processes that you think might really work. One of the threads that comes through is ``follow the money.'' In fact, in most systems if you follow the money you get to the problem in a hurry. That is an issue here. How do we develop funding models? How can we recommend approaches to that issue? That is the issue we heard, but that will not work unless there is a mechanism to deliver the results expected in the patient charter that we come to.
Let us tie that in to how we would actually recommend issues that can be dealt with in an accord that might lead to that direction. I want to take a simple example that came up in one of the answers. You mentioned two electronic systems that do not communicate with one another. When one looks at the literature in the public press on these issues looking into various systems, you see we have spent huge amounts of money in each of the provinces and at the federal level on electronic systems that are reported to be colossal failures to this point. We have heard from other witnesses that they would love to have a system that gives them information within their own health care unit let alone getting information from B.C. to somewhere else. In my opinion, there is no excuse for electronic systems today that do not communicate with one another, but we know why people are very jealous of the system they happen to know how to use at the moment. One of the issues will be the information that is available to you as caregivers in these integrated models. They will not work unless you have the information you need with regard to the patient at a given time.
I do not want an answer now. I am entering into this now to simply try to pull together what I think my colleagues have been focusing on as a very substantial series of questions that relate together in terms of how we ultimately deliver that. I will leave it with you, if I could, and come back to my colleagues with regard to the ongoing questions today.
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Senator Champagne: As I listen to my colleagues speak, I am becoming increasingly aware that the place in Canada with the most limited access to health care professionals is still Quebec. We should not be surprised, as we have had a provincial government that, at some point, forced an unbelievable number of nurses into retirement. Now, we are rehiring some of them through an employment agency. The same thing happened with respiratory therapists. Almost at the exact same time, the number of admission spots in several faculties of medicine was reduced. Although our population is aging, access to health care professionals has become very poor.
For instance, a clinic doctor may have 2,000 to 2,500 patients. To be able to take care of everyone, he or she would need a full-time nurse. The clinic tells such doctors that, if they want a nurse, they will have to pay that nurse out-of-pocket, and it will not be covered by the clinic. That is a problem.
The number of nurses is so low that important surgeries are at times delayed — without, however, putting lives in jeopardy — because there are no nurses to assist in an available operating room.
Having a patient health charter would greatly help us. There are people who phone their doctor's office in June to get an appointment and are penciled in for November. That person may not have any mental health issues at the time, but they certainly may develop some once November rolls around, as they will have spent 24 or 36 hours on a hard chair, in a hospital waiting room in the meantime.
What else should be included in that patient charter, which may help get around those types of problems? What should absolutely be added to it to make health care professionals more accessible to people and this aging population?
Dr. Boulay: The province of Quebec is faced with some unique challenges in terms of human resources in health care. The patient charter could certainly provide us with information on this shortage and set the government on the right track. That would contain an accountability element as well. If patients were having a hard time obtaining services in a given region, or there were many complaints on specific types of access, the government or the health care system could certainly take it into account.
Senator Champagne: If you talk to people on the street, you will see that three out of five people do not have a family doctor, and the two that do have to wait four months for an appointment. With an aging population, I do not think that this is the right way to do things.
What you said about the patient charter struck a chord with me. I am wondering what needs to be done to ensure that we receive care on time and do not have to wait four months or more, at which point it might be too late.
Dr. Boulay: Quebec's lack of family doctors in particular has been a known fact for a long time.
Senator Champagne: It is terrible.
Dr. Boulay: However, some progress has been made over the last few years. An increasing number of young doctors are opting for family medicine throughout Canada and especially in Quebec. That does take time, but your province is certainly making progress. I hope that it will get better, but from the national perspective, implementing a charter that could be used in various provinces to help them better manage their health care resources would be a step in the right direction.
Ms. Bard: If we truly believe that a non-profit health care system should be maintained, we have to start looking at service delivery models to ensure that our resources are transferred to regions with a need. In Quebec, it is certain that we must really look at how we could transfer resources at the community level if we want to provide primary health care. We must also set objectives and change the current models. I had an example just recently of a Quebecker who told me that she had not seen her family doctor in three years because things were going well. At some point, she wanted to take preventive measures, have herself checked out and all that. However, unfortunately, the standards are not quite clear owing to a lack of resources. So, because the person had been inactive, her file was closed even though the doctor she wanted to see was her family doctor.
If we were to develop one system per team, with one nurse or another type of health care professional, the assessment could be made by the professional. Then, if the doctor needed to become involved, he or she would do so, but we need not put up additional hurdles. The same is currently the case in clinics, where the most serious cases take precedence. However, if we truly believe in a preventive approach, we have to ensure that people are seen. We also have to establish reasonable standards when it comes to wait times so as to avoid crisis situations and complex issues.
Nowadays, when we look at the number of people suffering from chronic diseases, it is clear that a lot of money has been invested. However, it is also clear that no one was able to ensure that the appropriate questions are asked and that services are organized to prevent the kind of situation we are going through right now.
Senator Champagne: When a clinic is created and 9 or 10 doctors share the office space, do they have a licence to open up a clinic? Before they are allowed to start a clinic, do they have to ensure that a pharmacy is near? Could we not force them to automatically have one or two nurses who could facilitate matters? Would that be a valid requirement?
Dr. Boulay: I do not think that there are currently requirements imposed on physicians who want to work together as a group. Of course, according to the traditional model, doctors are paid on a fee-for-service basis, and they hire whom they can afford with that salary.
Senator Champagne: Not everyone wants to do that.
Dr. Boulay: Exactly. That is not a sustainable model. I think that we must continue looking into different types of models when it comes to requirements for forming a medical group, groups of doctors with nurses and other health care professionals.
Senator Champagne: If there are 10 doctors in a clinic, they could pay a good salary to a nurse, who would be happy to receive it.
Ms. Bard: Basically, we must come up with a model that is not based on an independent practice. We must look into community clinics where the doctor is part of a team and a specific region is served. That would make it possible to provide fair service so that everyone could have access to it. The model must be changed in order to allow a cooperative community approach to thrive.
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Dr. Haggie: I spent a day with two primary care networks a couple of weeks ago. They have evolved a system that answers that need. It is a government-provided capitation fee to practitioners who fulfill certain requirements. They require a panel of patients and agree to work with other physicians rather than in solo practices.
I believe that there are four criteria. I can find that information and send it to the committee. If you fulfill those four criteria then for each patient on the panel of the group, you get a capitation fee each year from the government for non-medical services. You can hire a practice nurse without having to literally pay for their health care out of your pocket. You can hire a foot care specialist. In fact, 80 per cent of patients have chronic diseases. That is the burden that we are talking about. It is clear from the evidence that early intervention makes a huge difference.
There is evidence that with a diabetic population, one of the most important things you can do to stop me having to amputate someone's leg two years down the line is to provide someone to cut the patient's toenails. You do not need an RN to cut someone's toenails; you need someone who is appropriately trained. By putting foot care in place and using it on a regular basis, the system for that kind of care becomes much more efficient. I would not have to be technically superb at amputations with low complication rates because I would no longer have to see that patient.
Senator Champagne: Would you say that because the federal government pays for health care and the provincial governments administer health care, it creates a problem? You said that there are four criteria that doctors have to fulfill to receive the capitation fee. Would the fee come from the federal government or from the provincial government?
Dr. Haggie: That fee comes from Alberta Health and Wellness. It is a provincial initiative. They have opted for it on the basis that over the long term, it will reduce their costs. Certainly, it solved access to primary care with walk-in clinics; and emergency room visits have dropped. As well, it allows a mentoring process for people who come off a family medicine rotation with their ticket, new and inexperienced, in terms of working in practice because they can sample various ways of working. They can go on salary with the group if they want or they can have a capitation fee or a blended system with a fee-for-service model. They can learn business skills that are not taught in a residency program simply because of time constraints.
Then, the doctors working there are far happier and they have a core staff around them with skills that extend the ability of the practice to service the population that they are obliged to service or are responsible for.
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Senator Champagne: Could we not put foreign-trained doctors to good use by making them go through some sort of training with our Canadian-trained doctors? Would that not be a good solution in a place like Quebec, where things are so complicated?
Dr. Boulay: There are certainly several models throughout the country now where doctors with foreign credentials are trained and integrated into our health care system.
Senator Champagne: One or two a year?
Dr. Boulay: In some provinces, like Saskatchewan, over 50 per cent of doctors have foreign credentials. Once again, there is the example of Dr. Haggie and your own example that show the disparity between the provinces and our country's need for the widespread availability of centres of excellence. Again, financial incentives should be implemented to help in that area. There are currently many excellent initiatives in Canada, but they must be introduced throughout the country. Quebec needs to have access to models similar to those used in Alberta that Dr. Haggie described.
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Dr. McGregor: Three of the physicians here today are foreign medical trained. The first problem is the lack of residency posts. Some foreign medical graduates in this country come from systems so completely different that it would be difficult to generalize. There is an enormous lack of residency posts in this country for foreign medical graduates, which makes coming into this country a huge challenge so that you can be trained appropriately.
Second, it is not rocket science. Many countries around the world, particularly the ones that do the better value for money, use integrated teams as their primary way of delivering services. The evidence is clear that physicians prefer working in an integrated team where physicians do what physicians should do instead of what nurses should do, which sometimes happens. In the fee-for-service model, someone might come to see the doctor to have their blood pressure checked, which is an enormous waste of a physician's time. It does not have to necessarily be that the physician employs them because a community model can be pursued. There are a number of models around that will allow for more effective service.
Third, standards for the number of physicians per capita also need to be looked at as well as other professionals. That needs to be looked at in Quebec. You can have the best integrated service in the world but you need to have enough physicians to make it work. Whether we have enough, whether they are badly distributed or whether they are doing things that nurses or podiatrists should do, all should be looked at.
Senator Eggleton: The CMA did a series of town hall meetings this year. I have seen the report but I could do with a little refresher. Perhaps not all of my colleagues are aware of what came out of that. What do Canadians want in a health accord?
I have heard the term ``social determinants of health'' mentioned a few times today, with which this committee is familiar from its study when Dr. Keon was chair of the committee. It is a broad area that we know is relevant to health.
The health accord really deals with the health care system in the narrower sense. In the social determinants of health, you are getting into housing, education, poverty and a wide range of things that do affect people's health, legitimately. If we were to suggest to the government something with respect to the health accord and social determinants of health, how might that look? How would we work that in?
Dr. Haggie: Starting backward and going forward, I live in a province where there are 180 communities with boil water orders, 60 of which have had them for 20 years, and 40 per cent of high school students in Labrador graduate. There is a clear link between low education, poverty and health. That is a background to everything we discuss in the sense that a healthy population is where you want to start from and certainly where you want to end up with this process. Wiser minds than I can deal with that. I am a physician.
Going back to what we heard when we went from Halifax to Vancouver, we spoke to about 2,400 people face to face in these big meetings. They were packed auditoriums. We had another 4,000 comments online through a website. We asked three questions. One was about the scope of the Canada Health Act. Was it adequate? Was it too broad or not broad enough? One was about what Canadians thought value for money was from the health care system. The third one was about responsibility. Who should be responsible for what? What was the responsibility of the provider, the payer and perhaps even the patient, the general public, as well?
The big surprise was there was no surprise. Everybody was consistent from one side of the country to the other. They want a publicly funded system with access that is equitable across the country, based on clinical need and not the ability to pay. That was like a mantra from Halifax to Vancouver. There was no dissent about that.
The public has a really good grasp of health care issues. I was quite startled. The physicians we spoke to were very much with the nuts and bolts of the system, inside it, but the public had a very high-level appreciation of what they wanted. They wanted a values-based vision for what we do next. That is kind of where they started from. They wanted this publicly funded system, they wanted it equitable, and they wanted it based on clinical need. They also said that medicare was designed in the 1950s and legislated in the 1980s with an example of disease, and what they wanted was a wellness focus, a preventive focus, as you mentioned, with the social determinants of health, but they wanted something that filled in the gaps so that, from the patient's view, you got the right care from the right person at the right time, and ideally as near to home as possible in your own community. That was a very broad brush.
With the nurses and the other stakeholders, in actual fact, we have patient summits. We are going to try to take this back to the general public, if such exists, to try and fill in the gaps in this matrix so it looks little more operational rather than principled. That is where we are up to at the moment. If there is anything specific, I will try to answer that question.
Dr. Boulay: To pick up on the question about social determinants of health, I have been a family physician for 21 years in small town New Brunswick. In that time, I have seen some dramatic things occur. I have seen seat-belt legislation come into force, which has saved countless lives. I have seen legislation about public smoking come into force, which has done much more than all of my education in my office has done to have patients come in and ask for smoking cessation aids. Until we get serious about issues like childhood obesity, about the way we feed our youth, particularly in underprivileged communities, I think these issues are going to plague us for years to come. Those are true things that we can affect with legislation. I am speaking to legislators right now. This is my punch. We owe it to our children to take responsibility for that.
Dr. McGregor: I think there are other international ways of looking at it, what other jurisdictions have done. For example, I think, and I may not be up to date on this, in Britain, for example, when you do community work, you are funded with a model that also looks as disparities of income and social economic disparities so that the poorer people get greater funding, because you cannot just measure uptake of, for example, immunization in a nice middle-class area as opposed to where there is much less education level and it is much more difficult. That might be a way of looking at it as well.
Ms. Mildon: I will quickly add a couple of things, first of which is a tiny little story. In my organization, we have patients that have been hospitalized for many years. We feel they have reached their potential to go out into the community, but the housing system cannot accommodate them. It creates a situation where they are staying in hospital using very expensive resources.
Secondly, on the notion of an accountability framework, we all need to help you, with our written submissions, find a way to integrate into that accord some metric around showing integration across the system. I am sure that we can come up with some way to give you some recommendations around that.
Thirdly, I would add that on top of the very good work that my colleagues in the CMA have done with their town halls, we are embarked on a cross-country expert commission on the health care system. We will also be able to add more voices to this dialogue.
Senator Martin: I wanted to build on what Dr. McGregor alluded to in terms of some of the existing promising practices or best practices or models that do exist. Many of you have also talked about what is working well across Canada in certain jurisdictions. We know that we are looking at what we need to improve, and there are items missing in order to develop a cohesive pan-Canadian system.
My question is this: Where should this information sharing be done or how should it be done? Should there be certain templates or analyses of these best practices to look at the criteria or the determinants of that successful model? What kind of articulation should be included in an accord, or should this be a separate document of sorts? How would that information gathering be done effectively to try and create a pan-Canadian network? There are many jurisdictions, and there are many sectors. We have a vision and hope for a pan-Canadian health care system, part of which is coordinating this very valuable information. I am curious as to how we can define the parameters to do this and how it would be helpful to the overall process.
Dr. Haggie: Look at two of our three recommendations. A pan-Canadian health quality council would be like radar that would look at best practices, identify hot spots of excellence and be a disseminator or a repository and a resource for the entire country.
The flip side of that would be the health innovation fund, which could kick start with funding, not pilot projects, but examples where it has worked in Alberta and we will take it to Saskatchewan, or it works in Saskatchewan and we will bring it to Corner Brook or St. John's. The money for the health innovation fund could perhaps come, for example, out of the escalator. That will be $1.9 billion a year. You set aside some targeted monies analogous to the Primary Health Care Transition Fund but with a clear notion of what is in and what is not, timeliness and timelines, and then because it is part of the escalator, it gets rolled in as the years go by. The hot spot in Calgary with the PCNs suddenly bursts into flames in Corner Brook and grows. Other jurisdictions may say, ``For our geography or our particular demographic, we prefer the Ontario model.'' They would make an application; they would be within the notion of what is in and what is out, and there would be some clear deliverables. The evidence from the 2000 health accord with the Primary Health Care Transition Fund was that if you had those deliverables, it worked.
Ms. Bard: I would build on the concept, though, that we do have in the nursing profession some clinical practice guidelines that have been developed. You could start to find ways of transferring that knowledge, because we are all promoting that care should be provided and services should be based on evidence. We know that there are best practices, and therefore we need to be able to provide the best practises inside the system so they are applied and measured. You can see the deliverables and where they have an impact on patient outcome. We would like to try to address it from that perspective.
As well, we need to think about how we can strengthen the capacity of our human resource service to try to stabilize it and guide it around best practices to maximize the scope of practice of each individual. In that way, you can focus on improving the overall delivery of services.
Senator Cordy: A couple of you mentioned harmonization of the drug formulary. Should the committee make this recommendation for the 2014 health accord?
A few years ago, in its study on the health care system, the committee recommended that we have catastrophic drug coverage. We spoke to a number of Canadians with chronic diseases who were spending huge amounts of money on pharmaceuticals and were experiencing undue financial hardship. In his report, Mr. Romanow talked about a pharmaceutical plan across Canada. Should we have catastrophic drug coverage for Canadians in such situations? Should that be part of our accord?
Dr. Haggie: One of the good things in the 2004 accord was the national pharmaceutical strategy.
Senator Cordy: I thought there was one, but I have not heard anything about it.
Dr. Haggie: Neither have we, so we are in the same boat. It had elements of a catastrophic drug plan. It also addressed things like security of drug supply, because we have a drug shortage issue.
I work in a province where the average income is lower than the average across Canada as a whole. My area is probably lower than the average for the province. I have an 82-year-old lady who has to take diabetic medication every second or third day rather than every day because she has financial issues. She is unfortunate enough to have a certain amount of money in the bank so she falls below a certain threshold.
In terms of a national strategy to encompass those things, how you want to resource it and what its scope is, you could take the 2004-05 strategy off the shelf and implement it. You could go back to the Romanow report or Senator Keon's report because they contain such mechanisms. In fact, Quebec has a type of comprehensive safety net for drugs. Whether you want to term drug coverage as ``catastrophic'' in terms of one-off illness expenses or whether you want to look at it as an economic burden to the family depends on your perspective. Whatever you could do to alleviate that would be crucial.
Unlike in the 1960s when hospitals, doctors and surgeons treated infections and these kinds of acute illnesses, medication today is one of the defining modalities of chronic disease management. It is not the only one, but it is becoming such a big deal that you have to address it directly.
Dr. McGregor: There is also a preventive aspect. If people took their medication, maybe they would not need expensive hospitalization. It is also an economic thing. If we had a national pharmaceutical strategy, medications would be a lot cheaper because we would not have to negotiate the prices individually.
Dr. Boulay: There is also the matter of equitability from province to province. Certainly, we see a lot of inequity in terms of availability of drugs and access to certain drugs between provinces. I would hope that a national strategy would do away with that.
Ms. Mildon: At CNA we would say a vehement, yes, to both questions and that pharmacy vigilance is needed across the system. We need to look at clinical studies to ensure that they are effective and serving Canadians well.
Senator Seidman: Dr. Haggie, you referred twice to the fact that the health care system is designed for acute care. Yet, you said that the vast majority of cases, 80 per cent, are chronic care. Perhaps we need to deal with that. I would like to know what suggestions on orienting primary care services you might like to put forward to the committee for its consideration of the next accord.
Dr. Haggie: You need to go back a bit to the concept of the right care by the right provider in the right place. In my experience as a general surgeon, I have had my bed allocation reduced because of patients in hospital for acute exacerbations that could be reduced significantly, such as with early interventions in cases of heart failure. I read an article the other day that said using weigh scales at home would pick up indications of heart failure well before hospitalization would be necessary.
That kind of community-based intervention at a very early stage, often by someone who simply reads a weigh scale and then arranges for a patient to see a primary care provider well in advance, would prevent an acute admission to hospital. My analogy earlier was with diabetic patients. I have a vascular practice so I see a lot of people with dreadful feet. If you go back two or three years, a little bit of toenail clipping would have actually prevented me from demonstrating how clever and good I am through my results in amputation surgery.
Medication costs are an issue because the people I see in that situation funnily enough are not the elderly. They are working-age individuals who fall into that awkward gap because they earn a little more money than would qualify them for social assistance but not enough to pre-fund it with insurance. It becomes a tossup for them: have all their medication, some of their medication or pay their heating bill at the end of the month.
There will never be one magic bullet. You have to look at the whole system, which is why we have been calling for transformation rather than any sort of lesser tinkering around the edges or any kind of cherry-picking approach. It has to start and end with the whole system. The CMA has been informed by the Canadian public and we see the way as taking a principled approach. That keeps driving me back to the same old mantra of the principles we got from our dialogue. Our challenge is to work with groups so that we, the experts in disease management and wellness, can present you with some options. Then in turn, Canadians will ultimately decide which of those is right. It is not for me to tell you how to design or run the system. It is for me to offer some options based on my particular expertise, as it is for Ms. Mildon and Dr. McGregor to do so as well.
Dr. Boulay: We all need acute care at some time. When I had appendicitis, I was happy to go to emergency and have surgery; and I had excellent care. If we want to get at the issue, we have to look at funding primary care and community care more aggressively and at having targeted funding for that. As we look forward to a new accord, we need to really tunnel down into our communities and to fund things that will keep people out of acute care. It is not that we want to keep people out of hospital, because certainly hospitals are important places for people to go when they are very ill, but there is a lot of stuff that could be prevented out there. There are a lot of folks we could keep out of hospital a bit longer, and that all saves a lot of money in the long run.
Ms. Bard: If we want to keep our publicly funded, not-for-profit system, we need to look at the elements of the accord of 2004. The elements were there, but the commitment around the funding distribution was missing. We need to see in the next round a commitment that goes beyond the acute care system and really commits protected dollars, whichever innovative way that can come out, so that we have dollars for primary health care and dollars committed to home and long-term care and dollars that start to reach people where they are and start preventing people from going inside the acute care, the emergency care, when we know that is not where they necessarily need to have the services. We need to find a way of having another pot of money, if we can use that term, or another envelope of dollars, that will start to be committed and support the community and all of the different factors that I have covered, including certainly a pharmaceutical strategy, because we also need to make sure that is accessible and eligible to the citizens. It is shifting dollars and having the way to do it.
The Chair: A fairly good-sized elephant wandered into the room following Senator Eggleton's question on social determinants when we started coming back to the idea of preventive care. We hear a great deal that we should focus on preventing disease and education and all that sort of thing. It is very difficult to get one's head around that in terms of what it really means. The public can say those are words, but what do they really mean? You have given a couple of examples here. I met with some health care providers yesterday in my office. A simple example came up, kind of like cutting toenails to prevent amputation. That is a graphic kind of thing. An example was brushing your teeth. One provider mentioned that simply, if we could ensure that a significant proportion of the population that does not now do it were to brush their teeth on a regular basis, the following serious disease outcomes would be substantially eliminated, because it starts with the various wonderful microorganisms we carry around that respond well to other things we do and suddenly take over and cause us very serious things or long-term debilitation and so on.
I wonder again if I could ask you to think about the idea of education and prevention. It comes to the issue of diet as well. That is a huge part of everything. We heard another example where if, for example, you take someone who is obese and diabetic, comes in with serious knee problems, which would normally lead to an immediate response that there needs to be knee replacement surgery, but the physician will not consider operation until there is a loss of 75 to 100 pounds. Examples exist that show that if that is lost over the time period the physician demands, quite often the diabetes has substantially reduced, the medication is cut in half or to a smaller part, and there is not a need for the surgery.
When we talk about prevention in the public, we do not say those kinds of things. I am wondering if part of the strategy we need in this part of primary health care is identifying, like the image on a cigarette package, examples that our outstanding surgeon doctor — we can reduce his demonstrating his expertise on you by having you clip your toenails when you are in a given situation. I wonder if I could ask you to again take away and reflect on this aspect of it, not necessarily what I am saying here now. Are there aspects of a new approach to dealing with the idea of prevention and getting people to take better care of themselves to start with that might actually have an impact in that area? I do not want this to go on much longer. We cannot of course. Go ahead.
Dr. Haggie: The CMA actually has a module for physicians on what is called health literacy. Our aim with this is to actually try and develop skills in the general public, particularly at high school, so that when they leave school, they have the ability to read and educate themselves with the information that is out there about health and health issues.
You can only provide information, and it is a start. Changing behaviour is a completely different thing, particularly if you grow up in a community where it is cheaper to buy a can of coke and two bags of chips than it is a glass of milk and an apple. You are hungry, so what do you do? Education is one part of changing behaviour. If you look at one of the successes that Dr. Boulay alluded to about cigarette smoking, for example, it has taken over 60 years to get prevalence of cigarette smoking in the population down to 15 per cent from 80 per cent. The information has been out there since the late 1950s to the early 1960s, but just simply presenting the information alone did not by itself result in behaviour change. It had no longer to be cool to smoke before it worked.
[Translation]
Senator Champagne: I just have a comment, Mr. Chair. I do not want to make it seem like I am demonizing Quebec's health care and those providing the services. Once we are in the system, everything goes very well; diagnoses are excellent and the level of care is very high. However, getting into the system is the difficult part. As someone who has gone through some hard times, I can assure you that I am living proof of the excellent care that can be obtained in Quebec. Thank you.
[English]
The Chair: I thank you all on behalf of the committee for your very open willingness to discuss these critical issues with us today. I am going to repeat again my invitation to you on behalf of the committee to follow up with the specific areas we have asked. I would like you to think about this last exchange as well. Dr. Haggie, we do not have 60 years on this one. We need to use examples in a different way with regard to encouraging people to have the opportunity to take better responsibility for their own health care and to realize the outcomes in a personal way. To repeat an example you used of using the scales, if you could get people to use their weight scales, it might have a significant impact. Studies have clearly shown that those people who weigh themselves morning and night are in far better health than the general population. It is a remarkable kind of observation. These are really quite simple things. If we could ask you to think about that and reflect on your experience in this kind of light, I am sure you have far better examples that we could use that might be able to form part of recommendations.
With that, honourable senators and witnesses, this has been a very dynamic meeting today. I thank you for it, and I declare the meeting adjourned.
(The committee adjourned.)