Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 8 - Evidence - November 24, 2011
OTTAWA, Thursday, November 24, 2011
The Senate Standing Committee on Social Affairs, Science and Technology met this day at 10:31 to examine the progress in implementing the 2004 10-Year Plan to Strengthen Health Care.
Senator Kelvin Kenneth Ogilvie (Chair) in the chair.
[Translation]
The Chair: I would like to welcome you 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 will ask my colleagues to introduce themselves, starting on my right.
Senator Seidman: Judith Seidman, Montreal, Quebec.
Senator Eaton: Nicky Eaton, Toronto, Ontario.
Senator Martin: Welcome, minister. Yonah Martin, from Vancouver, B.C.
[Translation]
Senator Demers: Good morning, Madam Minister. My name is Jacques Demers, from Quebec.
Senator Verner: Good morning, Minister. I am Josée Verner, from Quebec City, Quebec.
Senator Champagne: Andrée Champagne from Quebec.
[English]
Senator Cordy: Welcome to the committee again, minister. I am Jane Cordy from Nova Scotia.
Senator Merchant: I am Pana Merchant from Regina, Saskatchewan.
Senator Callbeck: Catherine Callbeck, from Prince Edward Island.
Senator Eggleton: Art Eggleton, Toronto, and deputy chair of the committee.
The Chair: Thank you, colleagues.
Minister, we will welcome you officially in a moment. I will say up front we are delighted to have you here today. I will first, however, remind us that we are, as a committee, continuing to examine the progress in implementing the 2004 10-Year Plan to Strengthen Health Care in Canada. This is our eleventh meeting and it is overall with the Minister of Health and departmental officials.
We are very fortunate to have the Honourable Leona Aglukkaq, the Minister of Health, with us this morning. Accompanying her in the first part of this meeting will be Glenda Yeates, Deputy Minister; and from the Public Health Agency of Canada, we have Dr. David Butler-Jones, who is the Chief Public Health Officer and no stranger to this committee.
I remind my colleagues that the minister will be departing from our meeting at 11:30 and on her way to the provincial and territorial meetings with the ministers that are occurring in Halifax on this very health accord, in fact. I will simply alert you to the fact that we will be suspending the meeting to allow her to leave, and then we will have a couple of other people joining us at that time. Ms. Yeates will be leaving with the minister at that time as well.
With that, minister, I would be delighted to give you the floor, and we await your comments.
Hon. Leona Aglukkaq, P.C., M.P., Minister of Health: Good morning. Thank you, Mr. Chair and distinguished members of this committee. I am pleased to be here with you this morning.
I want to start off by thanking your committee for undertaking this very important review of the 2004 health accord. Given the significant investments supporting the accord, it is very important that parliamentarians have an opportunity to assess what results have been achieved to date. I look forward to receiving your sober second thoughts in terms of this accord and reviewing what has been accomplished in the last 10 years.
Since this committee's focus is reviewing the accord, I would like to outline where we stand with the implementation of the federal commitments under the accord. In particular, I will focus on federal funding and program initiatives. Then I will offer a few observations on where I think progress was strongest and where there is still room for improvement. I will wrap up with some of my thoughts about the future and how we might be able to make our country's health care system even stronger and better positioned to meet the evolving needs of Canadians.
Diving into it, let me first turn to the federal funding commitments under the accord. We will be joined by Finance officials today to handle detailed questions, but I think it is also useful to start with the financial overview.
In 2004, a commitment was made to transfer an additional $41.3 billion to the provinces and territories over 10 years to support first ministers' commitments in the 2004 health accord. The funding includes $35.3 billion in increases to the Canada Health Transfer, $5.5 billion in wait times reduction funding, and $500 million for medical equipment. Since 2006, health care transfers have been growing at the rate of 6 per cent annually.
We will be delivering on our funding commitments in 2011-12. We will provide $27 billion to the provinces and territories in support of health care through the Canada Health Transfer. With the annual 6 per cent escalator, the CHT will reach over $30 billion in 2013-14, an all-time high.
These commitments represent a significant federal reinvestment in health care after the challenging fiscal environment of the 1990s. Despite the recent economic downturn and need for fiscal restraint, we have stayed the course on accord funding commitments.
Over the past few weeks, I understand the committee has received detailed presentations on a range of federal initiatives under the accord. At the risk of sounding repetitive, I would like to highlight some of the key investments and achievements.
A cornerstone of the accord was to improve access to care and reduce surgical wait times in five priority areas. The federal government is investing $5.5 billion in the Wait Times Reduction Fund, which in turn has allowed the provinces and territories to invest in a range of initiatives. As a result, eight out of ten patients now receive priority procedures within appropriate wait times, and citizens across the country are able to access wait time information for their home province. In fact, our government went a step further on wait times, beyond the accord commitments. We invested more than $1 billion in wait time guarantees to give Canadians greater certainty that they will receive the care they need, when they need it.
Addressing the gaps in the supply and distribution of health care providers is an important part of improving access to care. Over the last few years, all jurisdictions made investments to increase the number of health care professionals. For its part, our government invested $20 million per year in the Pan-Canadian Health Human Resources Strategy and $18 million annually in the Internationally Educated Health Professionals Initiative. Evidence suggests that the combined efforts of all levels of government and stakeholders are paying off. Enrollment in many health education programs has gone up. The number of doctors has increased by 12 per cent, and the number of nurses has increased by 11 per cent since 2004.
Although the number of doctors in Canada has reached an all-time high, numbers alone are not enough. That is why this government has introduced initiatives to increase the number of physicians where they are most needed. For example, Health Canada's Family Medicine Residency Initiative will support the training of over 100 family doctors for remote and rural communities.
Building on this investment, Budget 2011 announced Canada Student Loan relief to new family physicians, nurse practitioners, and nurses who will practice in rural and remote communities.
Another key element of health system renewal is the implementation of the electronic health technologies such as electronic medical records, telehealth and e-prescribing.
Our government's investments in Canada Health Infoway, which now add up to $2.1 billion, have accelerated the development of these technologies across Canada. More recently, our government earmarked funding designed to get more electronic records into family doctors' offices, hospitals, walk-in clinics and laboratories.
We are also committed to improving the health of Aboriginal Canadians who tend to experience significantly poorer health outcomes than most Canadians. We are investing in improvements to health promotion and disease prevention programs, as well as training for Aboriginal health professionals. This directly benefits individuals and communities.
This government also followed through on its commitments to improve access to care in the North and bolster our efforts on prevention and public health.
Health system pressures and the priorities of Canadians have also evolved since the accord was signed in 2004. In response to this, our government has gone beyond the priorities of the accord in two key areas.
In 2006, the Canadian Partnership Against Cancer was established to bring together knowledge and expertise from across the country to help take our fight against cancer to a new level. Its goals are to see fewer people dying of cancer and enhance the quality of life of those who live with this terrible disease.
Our government also established the Mental Health Commission of Canada in 2007 to develop a national mental health strategy. We expect that strategy to be completed next year, and we expect it will inform and guide decision making for years to come.
What does this all mean? I have provided you with a list of funding initiatives and programs that support the 2004 accord, but, ultimately, a review is about measuring results.
What did all these investments of time, money and energy give Canadians?
After years of restraint, both levels of government began reinvesting in health care. This helped stabilize the system and restore public confidence. Federal funding levels for health care have never been higher. Coupled with significant investments from provinces, this means, in plain language, more doctors, more nurses, more MRIs, and Canadians can easily access important procedures like heart bypass surgery and cancer radiation treatment.
This is important progress and these things matter to people when they think about health care. All jurisdictions have started paying more attention to measuring health system performance, as we did with wait times under the accord. While there is still work to be done, I am encouraged to see that we can now compare wait times across the country for key procedures.
Several provinces have begun expanding their performance measurements to other types of services, like emergency room wait times. Most provinces now have quality councils that play an important role in driving improved health care performance.
The more partners we have pulling together on these issues, the more progress will be made. We can also make more progress when we are clear about what we are trying to achieve. Wait times is a good example. We chose five priority areas, set benchmarks and targets, and now we can see the results. It is much easier to track progress when you know what you are measuring.
Of course, governments have received a lot of assistance in meeting their accord commitments from third party organizations like the Canadian Institute for Health Information, the Health Council of Canada and stakeholder organizations. These organizations have an important role to play in supporting government efforts and holding us all to account.
Although there has been good progress in many areas, I would not want to leave the impression that the job is done. In fact, there is a lot of room for improvement.
Although we saw increases in the quantity of several important health care services, we did not see as much structural change as we had hoped for. By this, I mean changing the way we do business to improve the quality and sustainability of health care. Our system is still very much illness focused and relies a lot on expensive care in institutions. As you have heard from several witnesses, it still tends to operate in silos. This tends to make it harder to coordinate and deliver high-quality care that is focused on the needs of individual patients.
Another issue is that we still do not have good data for many areas of health care. Better information would help us better understand where the gaps are and what can be done to improve the system. We also do not have enough comparable indicators that would help provinces and territories compare their results and learn from each other.
As we look towards the future, my view is that the fundamentals of Canada's health care system are sound. Canadians access medical care based on need, not on their ability to pay. We also have a single-payer model that is administratively efficient, but there is still room for improvement.
Provinces and territories are currently innovating in various ways within the parameters of the Canada Health Act. Later today, I will be flying to Halifax for a meeting with provincial and territorial health ministers. Part of our agenda is to hear about what is working across the country.
While I cannot speak on their behalf, I am always encouraged when I hear how provincial and territorial governments are finding ways to operate in more cost-effective ways.
As the population ages, there are more people living with chronic diseases. This will put more pressure on the system to adapt to make sure we are meeting people's health needs.
Care must be better coordinated and integrated around the needs of patients. Provinces and territories are finding many innovative ways to help patients navigate the system. Not only does this benefit the patient, but it helps the system operate more efficiently.
Electronic health records can also play a role in ensuring no vital information slips through the cracks as patients move from one health care setting to another. Whether it is the use of technology, preventative measures or home care that reduces strain on hospitals, these are steps being taken that will strengthen the system.
In a nutshell, senators, I believe we need to shift our focus from increasing volume to increasing value. It is about getting better results by changing how we deliver care so that we can get better care and better health for our investment in health care. I am not saying it will be easy, but it is the challenge we must collectively address as we move forward.
With a fragile global economy, a tighter fiscal environment and rising health care costs, there is broad recognition for the need to improve efficiency. This is key to ensuring long-term sustainability of the health care system.
We are in a good position to achieve this goal. Just last month, I was in British Columbia to sign an historic agreement that will streamline how health services are delivered to First Nations people in that province. I see this as an example of how innovation in the way governments work together can improve health care.
The recent isotope shortage also demonstrated how we can come up with more efficient ways of doing business when we need to. Innovation in both the science and the management of health care services is key.
Of course, common sense changes in the way care is delivered are beginning to transform the system. For example, several provinces and territories are making greater use of nurses, midwives and pharmacists instead of relying on doctors to do everything.
With over two years remaining in the accord, there is still time for more progress. After years of significant investment, I believe the system is more ready than ever to adapt and become more sustainable.
As we progress, we celebrate our successes and check in regularly to make sure we are still on the right track. That is what we are doing here today, and that is the important job the committee has undertaken. Again, I thank you for agreeing to do this.
In closing, I think we have taken some encouraging steps towards these changes, but obviously there is still work ahead. I look forward to continued engagement with my provincial and territorial counterparts to learn more about their priorities for transforming health care.
Improving accountability and demonstrating results for Canadians remains a priority for the Government of Canada. Improved performance measurement and reporting will help ensure that Canadians see progress and enable the provinces and the territories to learn from each other. After years of reinvestment under the accord, I think we are collectively ready to find innovative ways to make the system both better and more sustainable.
Senators, I hope my remarks this morning are helpful as you conclude your review of the accord, and I am prepared to take your questions.
The Chair: Thank you, minister.
Colleagues, I have a fairly lengthy list from those who wish to put questions. Let start with one key question each, go around and see if we can get to each of you. Then, if possible, we will go to a second round.
Senator Eggleton: Thank you, minister, for your presentation and your confidence in this committee in doing the work of reviewing the health accord. Reviewing the health accord of 2004 is important to measure how well we have done, but it is also important to determine where we go from here and what the next health accord will look like.
Your government has committed to a 6 per cent increase over two years after the current health accord expires — I believe, into 2016. I hope you will be able to use that money to bring about some of the changes you talked about in your remarks this morning, not just transfer it but use it to bring incentives to change. You said here in your closing comments "to find innovative ways to make the system both better and more sustainable." I agree 100 per cent.
There are so many areas that I am sure my colleagues will cover, but I want to cover the area of social determinants of health. It has been mentioned a number of times by people who came before the committee, and it is something this committee is familiar with because when Dr. Keon was deputy chair he led the effort to produce a report called A Healthy, Productive Canada: A Determinant of Health Approach. In fact, the Health Council of Canada said they found this report to be inspiring.
We have heard from people that have come here — Aboriginal communities and people from the North, for example — who have said what they need for better health is to have clean water, housing and to deal with poverty issues. These are not issues that normally come out of the health care sector in terms of dealing with them, but they are vital to a person's health. I think that was also recognized in the recent Rio World Conference on Social Determinants of Health in October that the government participated in, which resulted in a declaration.
Will that declaration be implemented? What is the government prepared to do in putting on the table with the provinces the social determinants of health?
Ms. Aglukkaq: That is a very broad question. In terms of my thoughts on the social determinants, given that it is so broad, there are a number of areas covered under that. You mentioned housing and early development. I recall when I was in the territories as a health minister, we fought very hard to include housing in determining social determinants. Now that is part of the equation that is talked about.
In terms of health care and determining how we move forward, each jurisdiction, by different ministries, covers those social determinants. Housing is one example. I can say our government has made significant investments in areas like housing and nutrition in Northern Canada to deal with the issue of poverty, for example. There are a number of government investments.
Going forward in terms of what we can look at under the prevention agenda, certainly some of the social determinants by jurisdiction would be a consideration that jurisdictions would need to consider in moving forward in looking at their priorities after the renewal of the accord.
From 2004 until now, we have focused on wait times in a number of areas. There is certainly a conversation to be had with the provinces and territories. Collectively, the discussions need to occur in terms of what those priority areas will be, how we can innovate and what we can do to improve the health of Canadians.
I am quite proud of the work that went on last year in the signing of the declaration with the provinces and territories on keeping Canadians healthy. The declaration was the first of its kind in Canada.
One area we are looking at as a priority is obesity and the impact it will have on our health care system down the road. There are a number of opportunities now, or since, that have occurred, where we are having conversations around what prevention agenda we can move forward to keep people from getting into the health care system in the first place, which is equally important to the whole thing. Part of that will be the social determinants you talked about.
How it will roll out by jurisdiction will differ. For example, we talk about an aging population in Canada. In Nunavut, we have the reverse problem; we have a very young population. To look at a national strategy for aging is not national in that respect, in that it is not very applicable because of the differences in age and population within jurisdictions.
We have to be mindful of that. We have to respect that jurisdictions will differ and will have different challenges. The conversation will be with the health ministers in terms of what those priorities will be.
Senator Seidman: Madam Minister, thank you for the confidence you have shown in us by giving us this mandate and thank you for being here today. I know you have a very busy schedule. I will try to ask my question without a long preamble.
There is an ever-increasing body of scientific evidence that mental health and physical health are inextricably linked. Daily, we are confronted with much data about the overall health challenges our children and youth face growing up.
Beyond the 10 priority areas in the accord, mental health challenges are emerging as issues of concern to Canadians. Could you tell us a bit about what steps you and your department have already taken to address these concerns, and if you believe mental health should be included among the top priorities of the next health accord?
Ms. Aglukkaq: Our government recognized the importance of mental health by establishing the Mental Health Commission of Canada. They have important work to do. In fact, I invited the commission to meet with the federal- provincial-territorial ministries at the FPT meeting to present their draft report in terms of what will be rolled out in the new year that we will be responsible for rolling out once it is implemented.
It is important to us and our government recognizes that. As I stated in my comments, over and above the accord, we made that investment to start the work on what we can do in Canada to address this issue.
Again, the presentation will be made by the commission to the federal-provincial-territorial ministers' meeting tomorrow. We will be receiving the update from the commission. By next year, once it is finalized, we will be rolling that investment out.
I am also pleased that we had a debate in the House of Commons on suicide; and, collectively, all parties recognize this is an area we also need to address.
I have recently written to all the provincial and territorial health ministers to determine what is being delivered on the ground by provincial and territorial health authorities in the area of suicide to get a baseline in terms of what is happening in Canada. That will be linked to the work we are doing around mental health. There is progress there, and I am looking forward to receiving the final report from the Mental Health Commission in the New Year.
Senator Callbeck: Welcome, minister, and thank you for coming today.
I want to ask about the National Pharmaceuticals Strategy. In 2004, a ministers' task force was set up. The federal government was very much involved in that. In fact, the federal minister was the co-chair. That also included catastrophic drug coverage. The task force was to develop, assess and cost various options. My understanding is that they completed their report in 2006. I am wondering what has happened since that time. Did you get a report?
Ms. Aglukkaq: Thank you for that question. I was on the other side when that whole process was happening. I can tell you from the PT side of things that, yes, there were commitments to start that work on a go-forward basis. The challenge we had at the time was that in order to have a national plan there had to be a national agreement. There was not always consensus around what that would look like. That was the challenge of getting an agreement in terms of what it would look like.
Provinces, as you know, determine what will be publicly covered through their drugs, by jurisdiction. They have their formulary to determine what they will cover and what they will not cover, and that differs by jurisdiction, as we have seen in some media of late. At the same time, we have increased the transfers to jurisdictions for them to determine what that would look like.
Some of the jurisdictions are doing innovative things around that. Since there was no agreement on the national plan, from the west side, three or four jurisdictions put plans together to do bulk purchasing to reduce the cost of managing pharmaceuticals. They are working together on innovative things on how they will manage the program.
Most jurisdictions, I think with the exception of two, have catastrophic drug plans, so there is still work being done on that. Given that this was part of the priorities within the accord, we have to be mindful that the accord is not over yet. We are in 2011, so work is still progressing in areas that had been identified by jurisdictions. In a nutshell, that is where that program is at.
Senator Callbeck: The task force actually completed its work in 2006. You could not reach an agreement, is what I am taking from that.
Glenda Yeates, Deputy Minister, Health Canada: Yes. In some ways, as the minister said, there were so many priorities in the accord that the work began, the analytic work was done collectively, and I think many of those analytic pieces we see in subsequent things that provinces have done, some of the issues on generics, some of those issues. There was no agreement at that working-group level to move forward, so in a sense the work is suspended. We have said as a federal government we are willing to continue to talk on the national pharmaceutical strategy, but in the sense that was not the consensus that made moving forward something that anyone pursued. It is essentially just suspended at this point.
Senator Eaton: Minister, thank you for coming.
As you perhaps remember from a report we did a couple of years ago, we spent a great deal of time dealing with our vast geography and the isolation of many communities. It is certainly a barrier and makes giving health care more difficult. What do you think you have done to improve access to services in the North and to First Nations communities?
Ms. Aglukkaq: Thank you for that.
In my opening remarks, just on the First Nations Health Authority, I mentioned that we signed an historic agreement in British Columbia, the first of its kind in Canada. I have to congratulate the Province of British Columbia and First Nations leadership in B.C. on their willingness to break those silos down in providing services to all of their population and work together in delivering health care to First Nations on and off reserve. We signed that tripartite agreement. Our government initiated the discussions. Ultimately, at the end of the day, this arrangement is to ensure that First Nations are involved in health and are making decisions in health for First Nations, by First Nations, for better outcomes for First Nations. I am quite proud of that, and our government took leadership in getting that agreement through. This is one example of jurisdictions working together in innovating and breaking down silos to provide better health outcomes to its population.
In terms of the isolated territories, our government also signed an agreement, and the Prime Minister extended this agreement to the territories this summer, and that is the Territorial Health System Sustainability Initiative. Within that program, our government supports the territories in looking at ways to reduce individuals from isolated communities having to travel out for care and trying to build capacity within the community levels to deliver a health care system.
For whatever reason at the time, when we signed the accord, the provinces' accord ended at 2014, and the territories ended three years before, which did not make any sense to me. Our government, through our officials, extended the three territories to be in the same timeline as the provinces. Again, our government committed to that to make sure that we did not disrupt what was within the accord itself. In order to have a discussion on the future of the accord, it was important to make sure that the agreements for the territories were in the same timeline as the provinces.
As to some of the investments that we are seeing in the North, the rural and remote communities, I mentioned the announcement we made of 100 more doctors to do their residencies in rural and remote areas, and the programs for doctors and nurses for loan forgiveness that we voted in the house the other day to promote more individuals to be in the field. We have invested in nursing programs at the community level in the North and midwifery training in the North. We have made a number of investments as a government that support the North in delivering care in the community.
As you know, the North has many small, isolated communities. My riding alone is larger than the province of Ontario, with 25 isolated communities that span three times zones, and one hospital. We need to build the capacity, and our government has made significant investments to build the capacity at the ground level.
[Translation]
Senator Verner: Good morning, Madam Minister. I would like to join with my colleagues in thanking you for being here this morning.
There are a great many things to be said about the health care accord, but I am particularly interested in accountability. What is your assessment of how effective the accountability measures aimed at the provinces and territories are, and how do you think these mechanisms could be strengthened so that Canadians are, of course, more aware of the progress that has been made?
[English]
Ms. Aglukkaq: Thank you for that.
In addressing the question on accountability, the previous accords have created a strong foundation for measuring performance of the health care system and reporting to Canadians. As you know, through the accord, we established the Health Council of Canada to monitor how jurisdictions are doing in terms of rolling out their commitments within the accord.
Since 2004, most provinces and territories measure how they are doing within their health care systems — like wait times — and report those. I think there is always room for more improvement in terms of how and what we report to Canadians. Tonight and tomorrow, I will be having a conversation with the provincial and territorial health ministers to discuss with them ways that governments can work together in addressing priority areas, while at the same time reporting to Canadians what results we are achieving with the investments we have made to health care.
I think Canadians are expecting that discussion on accountability. With the amount of money that we are investing in health care, Canadians want to know how this is improving health care systems. The flip side of things that is not often talked about is how this money is keeping us healthier. The prevention agenda is not often talked about. Over the last couple of years, equally important to when you fall ill is to keep you from getting ill in the first place. What are we doing in that respect on the issues around tobacco, obesity, and the number of preventative measures we need to take to keep people from the institutions?
Accountability is not just about measuring where the dollar went. I think accountability is also about what we are doing to keep Canadians healthy.
This is an exciting time. It is an opportunity for our provinces and the territories to get innovative about that conversation. I strongly believe that the condition is ripe for jurisdictions to start thinking innovatively, given there is commitment for stable funding. There is certainty that they are able to innovate, as opposed to always responding to the pressures of cuts and restructuring. This is an opportunity for provinces and territories to really start thinking about how we can do things differently, as opposed to always responding to patient needs.
The environment is very different from when I was at the table at the foreign affairs office until the wee hours, coming up with a financial agreement. There was no talk about population health during those conversations. This time around there is a real opportunity.
There are jurisdictions that are doing very innovative things. I look at Quebec, which is doing great things within their health care system. These are examples that we do not often share well with each other. We need to do more of that — on what we are doing to put the efficiencies in place — to be accountable to Canadians on how we are delivering health care.
Senator Merchant: Minister, my questions are regarding Infoway. According to a 2004 study, 24,000 Canadians die annually from errors that e-records could help prevent, such as doctors prescribing drugs that react dangerously with prescriptions undisclosed by the patient. Critics say that Infoway's focus was on hardware and software. The salaries of hundreds of federal e-health officials and computer engineers consume over $22 million annually, which is not far from the $30 million New Zealand spent to connect all its doctors permanently.
Also, critics say this may have been avoided if doctors had been engaged in driving the process. With only one doctor on the agency's 13-member board of directors, physicians feel they have been just taken as a token.
Could you tell us what has been done to help physicians acquire and utilize these systems to provide efficient treatment, especially considering our aging population and the chronic disease tsunami on the horizon which risks crippling our medical system?
Ms. Aglukkaq: In terms of the accord commitments, in my comments we saw the importance of investing in electronic health records across Canada. That work is still under way. The health care system is not just one area. It is not the doctor's office. A whole number of delivery agents are part of delivering health care. When you look at putting and connecting all those organizations into a system, it is very complex and complicated, but it requires partnerships and the engagement of many sectors.
I will use the North as an example, with 25 isolated communities. We have nurses who deliver front-line services. The pharmacist's office is miles and miles away and the doctor's office is in Ottawa. It is a whole different system.
There are some challenges, but given that it is important to start that process, you have to start somewhere. Through these investments, we are making progress in developing electronic health records across the country. It is not completed yet, but our government recognizes it is important and will continue to invest in that.
If you want more details, I can have the deputy minister respond to the details of your question.
Ms. Yeates: As the minister said, it is a very large undertaking. The question was where to begin. The first few investments were focused on what people call the electronic health records. They tended to be more of the back office, getting a patient registry so we could make sure we are talking about the right Mr. Smith, a provider registry, some of the lab, X-ray and drug systems, which are typically in institutions. For example, I think the country now has about three quarters of X-ray film replaced by digitization. It is a huge savings and an important early win that many jurisdictions chose to concentrate on.
The last investment the federal government was really focused on recognized precisely the point raised about electronic medical records. We now want to reach out to physician offices. That is another important part of the system. The latest investments focus a bit more on involving physicians. I know that Infoway — not only through its board, but through advisory committees and other mechanisms — is very much working to engage physicians about how to ensure they are participating and take advantage of these new technologies. It is a big change for people who work in hospitals and in their offices. Sometimes it is a change for consumers. That engagement will be key.
Senator Cordy: I appreciate your being here. We only have one minister in the Senate. When we are doing bills and studies, it is important we have a minister. Thank you very much for that.
I have a short question, but will tie that in with my general question.
With the exception of Quebec, will there be only one agreement? The current agreement in 2004 was one agreement between the provinces and territories. Will it be one of agreements?
Second, I would like to deal with the structural aspect of the health care system. You mentioned it in your opening remarks. We certainly know we have silos. We know it is a doctor-hospital model. I think you referred to it as an illness- focused model, which is not necessarily the best model. We look at health care providers — other than doctors and nurses in the hospital settings — such as psychologists, physiotherapists, nutritionists and pharmacists. We could go on and on. Some provinces are doing a good job of making structural changes with their primary health care models and having all these people in one location, or easy access to it. This committee itself — in another report when we had Senator Kirby as the chair — said that unless we make structural changes, the system is not sustainable. I believe that. I also believe if we make structural changes to include a lot of health care providers, it will be better care for Canadians.
What incentives should there be in the new accord for structural changes? I am going back to Senator Verner's comments, about what accountability should be in the new accord to ensure that — it is the carrot and stick aspect in terms of ensuring — there will be structural changes. First there is the small question about the one of agreements or one agreement, and you could then talk about the structural changes necessary.
Ms. Aglukkaq: Thank you. That is a good question.
The conversation with the provinces is key to what areas they will focus on. I have to say that each jurisdiction, in terms of addressing priorities for health care, may differ a bit. I have to be respectful of that as well. One priority for all of Canada may not make a difference here, as much as priorities for what we can do to prioritize by jurisdiction — the aging population, as an example.
In terms of an agreement in priority areas, putting aside the financial part, it has to be broad enough so that jurisdictions can focus on areas that they need to address by jurisdiction. I say that respectfully, that they do deliver health care.
Senator Cordy: Would it be one agreement with broad parameters?
Ms. Aglukkaq: It would be broad enough. If you want to make a real difference in that, it has to be broad enough that it is making a difference by jurisdiction. I say that because jurisdictions have priorities that they are trying to tackle within their jurisdiction.
On the issue of the silos and better utilization, you could not have this conversation in 2004. I think the conditions today are ripe for jurisdictions to be moving forward to talk about how we look at some of the silos that are in the system; how we look at health care personnel broadly and utilize the skills that are before us, as opposed to focusing in one area — the hospital, the drugs and the doctors.
There are a lot of other players within the health care system that we can better utilize. I use myself as an example often in that when I was pregnant with my son, I did not see a doctor for the nine months. I saw a public health nurse and a midwife. To go and get your blood work, to get weighed and to talk about your nutrition, many other professionals can do that. We need to question the kind of care a person needs and the right kind of care provider. That kind of conversation needs to occur.
I do not believe that spending money and injecting it into the current system is sustainable. We need to look at when a person goes into a hospital and what kind of patient-centred care we are delivering to that person, or are we going into a system that is structured around the professions that are in that institution?
When you are sitting in a hospital, you do not know that this person is not a nurse practitioner; it may be an LPN that can do certain things only, but from the receiving end as a patient, you do not know that. All patients know is the kind of care they are getting. This kind of conversation has to occur in putting the efficiencies in the system, and it is happening.
Again, jurisdictions are working to innovate in how they can better provide services to patients. At the end of the day, the focus should be on the patient, as opposed to running the machinery.
What incentives are there? I think the incentive should be to make sure Canadians stay healthy. The incentive should be better care. The conversations over the next three or four years will be critical in terms of how we position our system to better respond to the needs of Canadians.
The Chair: We will only have time for one more questioner and then we will wrap up with the minister. I will start the next list when the officials arrive at the table with those who are still on the list. Senator Champagne, you will be at the top of that list, but we will have to move in that direction.
Senator Martin: Madam Minister, I wish you well in the meeting that you will be leaving shortly for with the first ministers.
Everything you have said demonstrates the vision you have and the leadership you have shown. One of the things you mentioned in one of your answers regarding the social determinants of health is looking at preventative measures. You talked about the need to refocus this whole system toward a more preventative approach that is less reliant on expensive institutional care.
I know that you have talked about a national focus on childhood obesity and nutritional programs in schools and so on. Would you speak about sharing that vision regarding what the government will do in refocusing on the preventative system?
Ms. Aglukkaq: I could talk about this subject all day. I have been around now for six or seven years in this portfolio, provincial-territorial, and the conversation is quite different from then until today. Back in the day, it was just getting through running what you have. Now you can innovate; there is time. However, at the same time, we need to focus on what is really important, which is keeping the population healthy and out of the institutions, and what we are doing. I say that our systems are focused on when you fall ill. Equally important to that is keeping you from getting ill in the first place and what we can do.
The conversation started about 2006, and we got an agreement last year. That is how long it takes just to get an agreement on what we can do collectively in the system to build on that. I am proud of the ministries of the provinces and territories to come together to agree to this collective agenda.
The World Health Organization has stated that obesity is the next epidemic. Our children today will not live to our age because of obesity. What are we doing about that? With the declaration that we signed over the summer months, we have travelled across Canada and engaged in a dialogue on what that would look like.
Of course, obesity involves many factors: the family, the school systems, the municipalities, the parks and incentives like the Child Fitness Tax Credit. There are a number of things to educate Canadians on what they can do to keep healthy, and on the impacts of obesity.
When we talk about wait times on knee and hip replacements, there is the assumption that it is because there is a lack of surgeons or doctors to provide care. Working through one of the institutions in Manitoba, there is a long list of people who are waiting to get operated on, but they have to lose weight to get the surgery.
It is not that the system is not there; it is that in order for the surgery to work well, you have to lose weight to get that procedure. It is all tied to some of those challenges that we face in the system.
The work that is coming forward from the dialogue on some of those preventative measures on obesity is well received by jurisdictions, and we will be doing the rollout of that. It is the first one that we are engaged in with Canadians on the prevention side of things, amongst other areas we have invested in — tobacco, consumer production legislation and a number of other things.
Obesity is one that will be a big challenge. There will have to be many partners — the health care system, the food industry, family, schools. It will involve many sectors.
It is really not up to the institution to keep you healthy; it is up to you as an individual to keep yourself healthy. What can we do to assist in that? That is a question being raised through jurisdictions, and I am really looking forward to the feedback from those discussions.
The Chair: Thank you very much, minister. We appreciate your frankness in responding to the range of questions that have occurred. Certainly, the questions today and those that we have been dealing with illustrate the complexity of the situation, all the way from where you wound up with the responsibility to the individual, through to our responsibility as a society in finding ways to deal with these complex problems.
We will be reporting to you at sometime early in the new year. In the meantime, we wish you and your colleagues well at the meetings you are leaving here to attend.
Ms. Aglukkaq: Again, thank you to all of you for this very important work. I am looking forward to receiving the report and your findings on where we can improve. I say that on behalf of the provincial and territorial ministers as well who are travelling to Halifax. They are looking forward to your findings through this review.
This will help us going forward. Unfortunately, it is not done for this FPT, but nonetheless it will be very important for the jurisdictions to review your findings. It is critical in terms of how we move forward on our priorities or what have you. Again, thank you for your important work.
The Chair: Thank you also, Ms. Yeates. I know you have to leave now as well.
In addition to Dr. Butler-Jones, who is with us through the whole session, we welcome Abby Hoffman, Assistant Deputy Minister, Strategic Policy Branch at Health Canada; and Chantal Maheu, General Director, Federal- Provincial Relations and Social Policy Branch with the Department of Finance Canada, who will be making a presentation to us. You have the floor and then we will open it to continuing questions.
[Translation]
Chantal Maheu, General Director, Federal-Provincial Relations and Social Policy Branch, Department of Finance Canada: I would like to thank the committee for inviting me here today. I will be speaking about the support provided to provinces and territories through the Canada Health Transfer to help finance health care in Canada. That transfer is in addition to direct spending by Health Canada.
[English]
The Minister of Finance administers four major transfers that provide significant financial support to provincial and territorial governments: equalization, territorial formula financing, the Canada Health Transfer, or CHT, and the Canada Social Transfer, or the CST. These transfers are legislated through the Federal-Provincial Fiscal Arrangements Act and all together amount to $56 billion in 2011-12.
These transfers help address fiscal disparities among provinces and territories and support national priorities such as health care. In addition, the federal government provides tax transfer support through the CHT.
[Translation]
Federal support to provinces and territories for health has evolved over time from cost-sharing programs to block funding transfers. The block funding approach gives provinces and territories greater flexibility in designing and administering programs. To give you a sense of some of this history as it relates to health care, the Established Programs Financing, or EPF, was introduced in 1977 as a block fund to replace the cost-sharing system for hospital insurance, medical care and post-secondary educational programs. The EPF and the Canada Assistance Plan, which funded social assistance and social services costs, were replaced by the Canada Health and Social Transfer, or CHST, on April 1, 1996. It was a block fund transfer for health care, post-secondary education, social assistance and social services that was a combination of cash and tax point transfers.
[English]
The CHST was restructured in 2004 to create two new transfers: the Canada Health Transfer and the Canada Social Transfer.
The CHT is now the primary instrument through which the federal government provides long-term, predictable funding to provinces and territories to assist them with financing their health care services. In addition, provinces that receive equalization, and the territories who all receive territorial formula financing, may spend these unconditional transfers in any priority area of their choosing, and that includes health care.
The CHT supports the five national principles for insured health services legislated through the Canada Health Act: universality, comprehensiveness, portability, accessibility and public administration, as well as the provisions relating to prohibiting extra-billing and user charges. Provinces and territories must fulfill the conditions in the act related to these principles in order to receive their full federal cash contribution under the CHT.
More generally, it also contributes to providing health care to Canadians and to making information about the health care system available.
[Translation]
Moving now to financing amounts, as part of the $41.3 billion investment in support of the 2004 health accord, the federal government announced $35.3 billion over ten years to establish a new CHT base of $19 billion in 2005-06, with an annual escalator of 6 per cent beginning in 2006-07. These total CHT cash levels are set in legislation until 2013-14, providing predictable, sustainable, and growing funding to provinces and territories.
[English]
All provinces and territories receive equal per capita total CHT support through a mix of cash and tax point transfer. Because the value of tax points differs from province to province, different per capita cash payments are required to achieve the same total per capita CHT support.
In Budget 2007, the government announced that it was moving the Canada Social Transfer to an equal per capita cash allocation starting in 2007-08. It also announced its intention to do the same for the Canada Health Transfer. To respect the agreement achieved with provinces and territories in the 2004 health accord, the move to an equal per capita cash allocation for the CHT was delayed until 2014-15, the year after the 2004 health accord ends. This commitment was legislated in the Federal-Provincial Fiscal Arrangements Act.
Total CHT cash and tax support to provinces and territories is at $40.7 billion in 2011-12, representing about 30 per cent of total provincial and territorial public health care spending, which was about $128 billion in 2010-11. Of this amount, $27 billion is in CHT cash and $13.8 billion is in tax transfer support. The cash support will continue to grow to over $30 billion in 2013-14 as a result of the 6 per cent escalator. The value of the tax point transfer, of course, grows in line with the economy.
Thank you for your attention. I would be pleased to answer any questions you may have.
[Translation]
Senator Champagne: Good morning. This is a question I had expected to put to the Minister, but it turned out to be too late and she had to leave before I had a chance to ask it.
In the 2004 accord, a number of sectors were designated as priorities. I would have liked to know — and I am sure you are also able to answer this — in which areas we have been most successful and, secondly, which areas should be priorities under the next agreement?
[English]
Abby Hoffman, Assistant Deputy Minister, Strategic Policy Branch, Health Canada: I could start, and Dr. Butler- Jones may want to add to this.
I think there is probably some sense among all jurisdictions of, in their view, which areas were the most successful. From a federal perspective, we would point to several. Given the enormous focus on reducing wait times, which was a lot of the inspiration for the commitments that were in the 2004 accord, and thinking about the fact that benchmarks were set in four of the five areas that were identified and that those benchmarks have, by and large across the country, been achieved and reported on, that work on wait times has inspired work in individual jurisdictions on addressing other areas where there have been significant problems of access due to excessive waits. We would certainly say that the reduction of patient wait times has been one of the most important areas of success.
The minister and deputy minister, Ms. Yeates, spoke a bit about eHealth in response to questions in the earlier section of the meeting. While many people may still express some concern or even some frustration about the pace at which electronic health records, electronic medical records, and so on, have rolled out across the country, I think the general feeling is that we are making good progress and that platforms have been built and are starting to be operationalized quite effectively so that both Canadian providers and individual patients will receive better treatment and have more access to more information about their care. As I say, this is a federal perspective.
Finally, I think the work that has been done on health human resources has been very effective. Certainly at the time of the 2004 accord, there was a concern about the lack of pure numbers of physicians and nurses across the country. Again, I think statistics have been cited earlier today and in some of your earlier meetings about the growth there, so I will not dwell on that.
In addition to simply growing the number of nurses and doctors, both practising and now enrolled in medical and nursing schools, there have been a number of other important innovations. Many provinces have their own health human resource plans. There has been a lot of work done to revamp both medical and nursing education to address some of the issues we talked about earlier with respect to continuity of care, appropriate provider providing care, and so on. Those are the three — eHealth, health human resources and patient wait times — that we would reference.
As far as going forward, as the minister indicated, the conversation with provinces is beginning. Work in virtually every area that was in the 2004 accord needs to continue, but I think it will be a matter of jurisdictions working together to identify what they think is most important.
I will underscore one of the messages from the minister this morning, which is that if we focus to a degree on volume under the 2004 accord — more nurses, more doctors, more medical equipment, what have you — there will be a much stronger focus on value received from those investments as opposed to simply having more of all of these inputs to our health care system.
[Translation]
Dr. David Butler-Jones, Chief Public Health Officer, Public Health Agency of Canada: There is something that is not well understood in terms of the organization of the public health network, the National Immunization Strategy and collaborative strategies between the provinces, the territories and ourselves.
[English]
It is less about cost, not large investments but very strategic investments that promoted a collaborative approach to public health, whether on immunization through the Public Health Network or a range of activities and strategies that allow Canada to respond effectively to each one and to move into the declaration of prevention.
As the minister clearly indicated, all sectors are looking at how we can better move upstream going forward, how we can incent and support that. A lot of it is better ways of doing business, not simply resources. If we do not get primary care and public health right, we will have a challenge dealing with the rest.
Senator Eggleton: The minister, in her presentation this morning, talked about structural change being needed. She also mentioned that care must be better coordinated and integrated around the needs of patients, and greater use of nurses, midwives and pharmacists, instead of relying on doctors to do everything.
I want to ask you about primary care reform. I wanted to ask the minister about it, but I could only get in one question this morning.
In 2004, the first ministers agreed that 50 per cent of Canadians should have 24/7 access to multidisciplinary teams by this year. The health council reported back in 2008 that 17 per cent of Canadians had that kind of access. In 2009, they said 32 per cent of Canadians had access to more than one health care provider. It sounds like some progress, but it also sounds like a long way to go.
The committee has heard in its deliberations on this that one of the key barriers to the integration of health care providers into primary health care multidisciplinary teams are the funding models, including payment schemes for physicians, such as fee for service, capitation models and blended models.
What role could the federal government play in fostering discussions on best practices related to different payment schemes for health care providers to promote the development of team-based care?
Ms. Hoffman: I am happy to start with a few comments. First, I would agree with the diagnosis of the issue, that funding models, incentive regimes and so on are an impediment to team-based care. There is no question about that.
Having said that, I think we all know that the relationship among various provider communities, with each other and with their respective provincial and territorial governments with whom they negotiate on a recurring basis, their fee structures and remuneration systems, is not something that the federal government readily enters into that picture.
However, I think everyone recognizes that this is a critical issue going back now more than a decade, back to initiatives such as the Primary Health Care Transition Fund. We tried to — and I think succeeded in this — support provinces with a whole array of pilot programs related to the modernization and renovation of primary care.
We have seen over the decade that a lot of successful models have been rolled out in many provinces. It is fair to say that, by and large, people know what works. The question is: Is there the will to move forward on some of these changes?
This is an area, given the extreme sensitivities in terms of the relationship among providers, the relationship with provincial and territorial payers, where we almost have to stand by and see whether jurisdictions actually want us involved in some way. Is there some manner in which they would say, "We can be helpful"? It is certainly not for the federal government to say, "Here is the best remuneration model" or "Here is the best means by which to move family health teams," who may provide coverage in a jurisdiction for, say, 10 or 15 per cent of the population, to tell them how best to move that to the 50 per cent benchmark. That is just a milestone, not the complete picture.
That is a conversation we are prepared to have with provinces and territories and national provider groups, but it is not something that could be mandated from the federal side.
Senator Eggleton: You can say that about a lot of other things in here, yet in 2004 the federal government did provide incentives in things like wait times and other areas as well to the provinces and came up with an agreement with the provinces. It was a partnership. It was not being imposed by the mighty federal government. I am concerned when you use the words "stand by," because if we want to see structural changes and improvements in how this system helps people out there, if we want to see a patient centre, I think we have to be part of that partnership approach.
Not only that, the federal government is itself a major provider of health care. We sit with the provinces also in that regard, such as the Aboriginal community and the military community, as examples. I would hope the federal government could put this on the table for discussion on how we can come to a partnership arrangement with the provinces and how to reform the primary care system.
Ms. Hoffman: When I say "stand by," what I meant was as you described: We will not dictate to the provinces in how to move forward. If provinces have ideas that extend beyond their own jurisdictional borders, I think, as you said aptly about wait times, that collective effort will move things forward. There is no question we are prepared to be part of that. Part of the frustration of the last decade is that with all the focus and attention on primary health care, all the experimentation and pilot projects that we endlessly supported, as you remarked and as the health council reported, there is progress but it is not happening at the pace it should. The consequences are not just with respect to the quality and accessibility of care, but also cost. We are not delivering primary care in the most effective and efficient way. We know that.
Dr. Butler-Jones: In terms of the federal government and models of multi-disciplinary care, whether it is First Nations using different levels and different kinds of health providers or in the military, good models, as Ms. Hoffman identified, there are a lot of good models out there. It is more about the issue of application. That is a question in terms of whether there are incentives that will assist that in practical ways.
I think I mentioned this the last time, one of the biggest barriers I had to primary care reform in Saskatchewan was an agreement between the government and the medical association that you could not actually come into the province or graduate and start out in a multi-team practice. You had to build a fee-for-service practice first before you could do that, which meant you did not do that. That was a government-instituted structural barrier.
The other thing I experienced is some of the faculties of these multi-disciplinary teams did not want their students studying with students from other faculties because they did not want them, in effect, in my view, contaminated by the views of other professions. We have to train them together in order to do that.
Whatever the incentives, whatever the benefit, if we do not have professions that want to work together or governments and professional associations that minimize the barriers to working together, that is what it is. No federal government can do that. It requires a common cause, a common view and application strategies.
One thing we can do is sharing best practices and ensuring people are aware of what works, why and how.
The Chair: We will move on but, before I do, you have been following the proceedings so you know this issue has come up of the many silos and many jurisdictions that all point to somewhere else are saying this is a key issue. I think they are, as Senator Eggleton suggested, looking to someone taking the leadership role to do that. We do hear, on an ongoing basis, that there may be a role for that federal player. We will not prolong that discussion now, but it is fair to say that is an issue for us.
[Translation]
Senator Verner: Earlier, I had an opportunity to talk about accountability with the minister. What I wanted to ask was this: although Quebec has a separate agreement, how do you think we can approach the question of accountability with that province so that it is more accountable under a renewed accord?
Ms. Hoffman: Thank you for your question.
[English]
I will not comment in any depth about the agreement with Quebec or, for that matter with the provinces collectively, on this front. The government has said there will be, as there was in 2004, a separate agreement with Quebec. I think it is fair to say that in any conversations around the accord, as the minister indicated earlier, the issue of accountability will be very much front and centre.
If one reflects on the 2004 accord, there were at least half a dozen places in the accord, and this would have had general application to all partners in the accord, at least a half dozen references to the development of indicators and to reporting. Some of that reporting occurred, some of it did not.
Just from a purely personal standpoint, gauging the mood across the country and what kind of opinion leaders and decision makers in the health system are expressing, the entire environment around accountability and reporting is much stronger than it was before. It goes back to this issue I raised earlier, and that the minister touched on, on the volume versus value perception.
What will it look like? We cannot say. Will accountability play prominently? I think virtually everyone wants that to happen.
Senator Seidman: I suppose I might be continuing this whole conversation about integrated care which keeps recurring.
Dr. Butler-Jones, you talked about, as the minister did, prevention-oriented models of care and how important it was to move from an illness model to a different kind of model. You yourself talked about the necessity of going upstream, that we better look at that, it is the future of having a quality health care system.
I would like to ask a question about home care, actually, which in many respects is a prime example of good integrated care, if it works well. It must be integrated into a primary care system in a way and can certainly help keep seniors out of the hospital system.
I am trying to remember if we heard about this in our hearings. I know as part of the 10-year plan, the first ministers agreed to provide first dollar coverage for certain home care services based on assessed needs by 2006. Those services included short-term acute home care, short-term community mental health care and end-of-life care. Although they were supposed to report under the 10-year plan, the health ministers were supposed to report to the first ministers on a staged implementation of the home care commitment by December 31, 2006, it appears no report has been published and none is publicly available.
I would like to know if there was indeed a report on the staged implementation of home care commitments, and, if so, what were the findings?
Ms. Hoffman: I can regrettably give you a short answer to your question. There was not a report filed as called for in the accord. That was largely because jurisdictions could not really come to terms on what they thought the appropriate measures and indicators were. Unfortunately, it will be after the Senate files its report on progress under the accord, but the health council, in early 2012, will be issuing a report on home care and progress relative to the 2004 accord commitments, among other things.
What we do know is that the access to short-term, post-acute home care is not uniformly delivered in precisely the same way across the country, but considerable progress has been made there, and also with respect to some home palliative care services.
The mental health home care commitment that you spoke about has been less well accomplished at this stage. Just thinking about the future, there is no question that pretty well everyone is talking about trying to move care to places where, first, it is better suited to patients and is also more efficient and/or integrated. That means for most people, particularly those with chronic disease or elderly people with multiple, chronic disease situations, care in the home. I think we can expect to hear more about that, going forward.
Dr. Butler-Jones: In one of my previous lives in a couple of regions I actually ran home care. One of the challenges goes back to something we talked about previously, which is the system of care. Not just in a medical way, but the kinds of supports to individuals, families, et cetera, that allow them to stay at home when it is appropriate — it is not always appropriate — to get out of hospital or institution earlier, to have the appropriate level of care.
Even in home care, I remember when the only time the home care nurses would talk to a family about smoking in the house was if there was oxygen. Now that is a teachable moment and opportunity, saying this in the clinical setting.
It is thinking about what the supports are to do that. When we built up home care, it is not in and of itself. It needs to be part of a linked system of care and it needs to be appropriate to the needs. Again, because it grew out of the health system, in many jurisdictions the criteria are based on health needs. If you do not have a bandage that needs replacing, there may not be other supports.
Sometimes it is simple. I remember when the veterans administration in the United States had a program for vets living isolated or at home, elderly, et cetera, and they would get a phone call every couple of weeks from a nurse who would ask them how they were doing, if they were taking their medications, if they had any questions, et cetera. What they found was they had less hospitalization, fewer visits to emergency, better management of their conditions, and they loved the system because someone was paying attention. That is low cost and simple.
Again, it is about balancing the interventions. Sometimes we give, to who is eligible, everything, and then when you only need a little support you are not eligible because you do not have this level of acuity. It is thinking more comprehensively about the system moving forward.
Senator Eaton: Following on my colleague's question to you, Dr. Butler-Jones, do you think the next health accord should have a health management system in place for our aging population? Are you taking that into consideration?
Dr. Butler-Jones: Again, one of the struggles for us, as federal public servants who are part of a system where there are federal and provincial responsibilities, is the accord is obviously a political agreement at the end of the day and what will determine that. The accord is a piece that can facilitate change or not.
Clearly, the issue, as Ms. Hoffman alluded to earlier, and the minister did, different jurisdictions will need to respond differently, based on their situation. Having said that, one of the things that will be critical is that we are contemplating and thinking about the aging population, the nature of the population that we are facing, and in rural areas there are very different challenges than in urban ones. Sometimes it is just a matter of access to bus service as a key component of health for the elderly, or some way to access transit, et cetera.
Those must be key considerations of the implementation of whatever we do, whether it is in the accord or not.
Senator Eaton: Following up on my question to the minister this morning about providing health care in isolated regions, are you putting more resources or are you building on? Do you see telehealth as being something that will be used more and more in isolated regions so people can access the best care and not have to move?
Dr. Butler-Jones: Even in non-isolated regions, I would argue these technologies and approaches — for example, nurse practitioners, when I was doing primary care I did not argue that you need a nurse practitioner because you do not have a doctor. You need a nurse practitioner because they are actually better for a number of things than a physician. Having an appropriate team approach should be in the urban centres as well as in rural centres. The ratio of what kinds of expertise you will have will be different.
The same is true for telehealth. If you are a physician practising in Toronto, you have access to modules, tools, expertise, et cetera, without actually having to go across the city or to another city. Often in small urban areas, such as Saskatoon, they will never have the level of expertise in all specialties because it is not appropriate and they cannot maintain their skills. You still need access in Saskatoon to the pediatric neurosurgeon and their expertise in Edmonton, for example, without having to fly or drive the patient there. I think these tools will be essential, moving forward.
A quick example is the Isle of Skye, in Scotland. Someone I was travelling with fell off the bed and broke her hip. She was able to be diagnosed in the little clinic on the Isle of Skye, the X-ray electronically seen in Inverness, and she was able to be evacuated out for the diagnosis and appropriate treatment. That is the kind of thing we should look forward to anywhere in this country.
Ms. Hoffman: On the subject of telehealth in rural and remote areas, a large component of what we are doing with respect to First Nations health is providing services and developing telehealth systems for Aboriginal communities that are very remote and operating in much the manner that Dr. Butler-Jones describes.
Senator Eaton: Will you use the B.C. Aboriginal health accord that the minister was talking about as a model for other provinces and other Aboriginal communities?
Ms. Hoffman: That remains to be seen. There were certain preconditions in B.C. that made that tripartite arrangement feasible. We are having preliminary discussions with some other jurisdictions, but that really requires the federal government, provincial government and First Nations health authorities to be at a point where that is a viable subject to bring forward. That will evolve over time.
Dr. Butler-Jones: It has huge potential.
Senator Merchant: My own inquiry is about the difference in quality of health care in lesser populated and remote areas. For example, in British Columbia, they have multi-tier hospitals. If there are pregnancy problems, the required standard is to have a specialist at the mother's side in nine minutes. This means a specialist in the hospital. The next tier is a specialist in 30 minutes. That means an immediate call to drive to the hospital. Women with high-risk pregnancies are sent to these first-tier hospitals.
You mentioned, Dr. Butler-Jones, that lesser populated areas, like Regina and Saskatoon, can neither afford or maybe cannot attract a sufficient number of specialists to have these kinds of first-tier hospitals as they have in British Columbia. I am not suggesting that people everywhere can get the highest level of Canadian health care. It may be too costly and too specialized. I have in mind the statistics that we see in the media about the high rate of First Nations and Inuit infant mortality where people live in remote areas.
My question is the following: Is it possible for you to provide us, perhaps in general terms now and in writing later, any insights by statistics on the difference in quality compared to the difference in cost of medical care, both in Canada and comparing Canada?
For instance, Switzerland provides the best health care in the world and many of the cantons are remote, but at what cost? Do you chart quality by nations and by areas in Canada? How is quality of health care, not quantity, tracked? This refers to getting wait times down, which you have heard over and over again, is quantity, is more operations.
How is quality tracked, statistics on success of health care, and can you correlate that cost by region?
Dr. Butler-Jones: Perhaps Ms. Hoffman can speak to that, but if I may start. One of the things is being careful about what we mean by quality of care and looking at outcomes. For instance, Saskatchewan, in the early 1990s, closed some 40 rural hospitals and converted them to long-term care facilities and local clinics, et cetera. When it was studied some time later, the health improvement in those communities surpassed the general population, and the worst data was in the communities wherein if you were able to close or convert the hospital, they actually had the worst outcomes.
Therefore, having a hospital and having doctors locally does not necessarily translate into health. We have models around the world where we see it is really about appropriate capacity. It is not about having all the specialists but appropriate care to deal with the majority of issues and a system that can get you to where higher level care is required. The vast majority of the things that kill us do so in a chronic way. It is not just about emergency situations. You need that capacity, and just having a hospital does not necessarily guarantee that capacity.
It is about appropriate levels of care and a steeped approach that allows the appropriate things needed to that level. Having more, for example, obstetricians, at least in the past, has translated into more caesarean sections, not necessarily better outcomes.
Ms. Hoffman: In response to part of your question, which is whether people are paying attention to comparisons within Canada or internationally, yes, we absolutely are. Senator Ogilvie might be interested to know that the OECD issued their report entitled Health at a Glance. It is not really at a glance; it is a bone-crushing set of data. It provides insight.
We all know that there are different measures and different ways of collecting data. You can interpret that and draw conclusions in general about the appropriateness of the care, about outcomes, about the efficiency, about its accessibility and timeliness. You can learn something. Whether or not you can actually say that a region, as you suggest in Switzerland, compared with a health region say in Canada spending more or less, looking at the results on whether these parameters are delivering better care is quite difficult to determine. However, quality councils in provinces, the Health Council at the national level, the Canadian Institute of Health Information and all kinds of academics and other observers spend a lot of time looking through that data trying to figure out what we can learn there that might have application.
If you look at the per capita spending in different age groups across Canada, it varies quite dramatically. People would also observe that the spending and ultimately the health outcomes and the appropriate interventions are not linked to spending, in some cases not at all.
There are conclusions to be drawn and things to be learned, but there are not really internationally agreed-upon comparable measures.
Dr. Butler-Jones: For example, when cataracts were reviewed in Vancouver, one quarter of cataract surgeries ended up with worse vision. How can you end up with worse vision if you have cataract surgery? It is because you did not have a bad cataract, you were quite functional, but because you had a cataract, you had access to the surgery, so you had the surgery. It was not a disability, but now because of the consequence of surgery, your vision is worse.
It is not about not needing the specialists; we need the specialists and a system that has access to them when we need them at the appropriate time.
Senator Callbeck: I want to come back to the question that I asked the minister with respect to the catastrophic drug plan.
In 2004, the task force was set up, they came in with a report but could not reach an agreement between the provinces and the federal government. Am I to take it, then, that it is off the table? Or has the federal government given any thought to taking a leadership role in developing a national catastrophic drug plan?
Ms. Hoffman: I am mindful, incidentally, that just yesterday the New Brunswick government, in part of its Speech from the Throne, indicated that it would be instituting — parameters still to be determined — a new drug program for non-insured individuals living in that province. I am reminded of the fact that we are now at the point where I think there is just one province and one territory that actually do not have a catastrophic drug program in place.
It will be up to the provinces to determine whether or not this is an issue they want to bring forward. My sense is that they have moved on to other issues beyond, say, pharmacare or extended coverage of a catastrophic drug cost nature or of any other form, and they are more interested in some of the issues that were actually part of the original National Pharmaceuticals Strategy, on which some progress has been made, such as formularies, generic pricing, appropriate prescribing, things of that nature.
I do not want to predict. I cannot forecast whether there would be interest in a discussion about coverage, but I will just say that the undertaking in the 2004 accord was for costing models for catastrophic drug coverage to be developed. That was the commitment, among others. There were eight other elements in the National Pharmaceuticals Strategy.
When ministers reported in 2006, they had these models costed in considerable detail for catastrophic coverage. Some people presumed that meant the logical next step, required under the accord, was for a pan-Canadian funding arrangement to be concluded. That might have been something people may have hoped for, but that was not actually a commitment under the accord.
In the aftermath of the ministerial task force reporting, there was not an outpouring of demand from provinces to move to some kind of pan-Canadian universal drug coverage regime. That issue had come up in the lead-up to the accord in 2004, but it did not come back on the table subsequent to the ministerial task force reporting in 2006.
Senator Callbeck: I take it that the federal government has not really given any thought to taking a leadership role here. This is a big issue. Depending on where you live determines what drug coverage you are going to get.
Ms. Hoffman: I do not want to say there is no interest and no concern about the variability in drug coverage. There is. What I am saying is that the things we have been working on, we are one of the principal funders, for example, of the Common Drug Review. The 80 per cent funder of the Canadian Agency for Drugs and Technologies in Health does a lot of work on prescribing, formulary listing and so on. It is the Federal Competition Bureau that did a lot of work on the business model for generic drugs in Canada, which has caused a huge decrease in the cost of generic drugs.
We are doing many things. We are not at the moment focused on the change in moving from coverage regimes managed by individual provinces and territories to something that would operate at the national or pan-Canadian level.
Senator Cordy: It is nice to have all of you back again. You are always very open and helpful to us. Thank you very much for being here.
Ms. Maheu, you talked about how the Canada Health Transfer supports the five principles of the Canada Health Act, but I will have to argue with that because the emails I receive from people with MS would argue that the system is not really accessible to them, but that is an issue for another day.
Today, I would like to ask you about the human resources strategy. Numbers are not enough; I think that is what the minister said. In Nova Scotia, no province would ever say we have enough doctors or enough medical personnel, but we do have a reasonable doctor-patient ratio. The challenge is the urban-rural divide. While the population of Nova Scotia has stayed relatively stable, the population of Halifax is climbing, and the population of the rural areas in Nova Scotia is falling, which would be the same in every province.
I am wondering whether or not there are things in the accord that we should be looking at in terms of a human resources strategy so we get more people out to the rural areas to practice medicine.
Dr. Butler-Jones: Obviously, that is something for conversation and consideration. It is a challenge that has existed forever. Various jurisdictions have tried a range of things with really little success, though the federal funding around training and support for family physicians in more rural and remote areas, the new medical schools or attached medical schools in Northern Ontario, Northern B.C., et cetera, and an increased focus to ensure that people get practice and training in rural and remote areas so they can develop comfort with it is probably the best at the end of the day. Things like telehealth assist in that.
Therefore, that sense for physicians, nurses or lawyers is about having good work to do, being supported in that work and having a reasonable place to live, well beyond salary and financial incentives, that actually supports people to be there and to stay there. There are a number of things that do seem to work moving forward. Whether an accord can address that or it is just a matter of applying best practices and reviewing the experience we are having, I think time will tell. It is an absolutely key issue.
In addition, recognize it is not just about having a physician accessible but having appropriate care or a support for the basics, or if you have an accident, that you can be stabilized and transported quickly. A physician out there may not be that useful. We used to say you would want an ambulance with a tech to pick you up if you had an accident, not a doctor, because we require all this other equipment, by and large, and paramedics are trained to deal with emergencies in the field.
Making sure you have that system of care actually ensures that for the trauma, you have appropriate access, but that you also have the support for prevention on a daily basis, as well as promotion and good care management, which is critical.
Senator Cordy: There are some good programs. Dalhousie University has a good one, and they are trying to encourage people to go through it.
Ms. Hoffman: This is not strictly speaking related to the accord, although it is in keeping with the objectives of it, but a couple of years ago, the government announced its intent to support the cost of medical residencies, specifically with a focus on residency seats for doctors who would practice in rural and remote areas. We were curious about whether or not jurisdictions and medical schools who needed to be partners in this enterprise would be as enthusiastic as we were in taking that up. Pleasantly, we found there was huge enthusiasm for this.
This will create and is creating a situation where individuals who have a clear interest practicing in rural and remote and less populated areas get a very specialized kind of training that makes them better suited to practicing in those areas than in large urban centres. They are starting to move through that system, and we think it will work very well. Whether that program would be extended or enlarged, I am certainly not in a position to say, but I think those kinds of initiatives, along with Canada student loan forgiveness that is conditional on the graduating student or nurse agreeing to work in a less populated area, complemented by similar programs in some provinces, they are not the total panacea, but they are certainly very helpful in having individuals go and practice in rural areas.
Unlike some initiatives in the past, because of the nature of the training, once an individual locates in a less populated area, they are more likely to actually stay there because they have now found their training is suitable for that environment. If they like it, it is more likely where they would want to remain.
The Chair: I will intervene now for a minute or two and come back to three items that have occurred today in the minister's comments and either directly or indirectly in your responses to various questions. I will start first with the observation I intervened on earlier with regard to Senator Eggleton's question.
It is very clear that in much of the testimony we are hearing, there are certain areas that are considered to be very important to moving some of these issues forward in the ways you have talked about. It is not just money; it is how we move these issues forward. The federal government comes up often, not in terms of a heavy to go in and impose, but perhaps as the body that has the opportunity to interface with all the other areas and perhaps use a little bit of muscle to help encourage the other jurisdictions to move on them. I would like to take three of these.
One is innovation. Innovation comes up a great deal in what we hear. We are not talking about rocket science; we are talking about innovations in group practices that lead to better outcomes in community clinics, things of that nature, examples that then do not thrive perhaps because of the billing issue that we referred to previously, the way in which remuneration occurs. Even if in the end they do succeed in their own right, there is no mechanism to transfer those to other jurisdictions; that is, to spread the innovation more broadly, either in a province or across the country.
As we know, a good idea is not innovation until it is applied more broadly. There is a desire to see someone take a lead in moving the innovation agenda in that concept of innovation more broadly.
The second thing I would mention to you is the telehealth issue, and it has been referred to several times here today. There is no question that the distribution of electronic data, such as the radiogram, almost as an attachment across multiple systems, works very well. We are hearing that in spite of the fact that all people in an individual hospital network have access to a computer and an operating system, there are many different operating systems, and they do not communicate with one another even in the same hospital district. We have heard witnesses and practicing physicians say, "I am not concerned about getting that record from Alberta; I want to get the data on this patient from within my own hospital system."
Finally, I want to come back to this issue of accountability that we hear about many times because I think it is often brought up to us from the point of view of expressing frustration that certain things have not moved more rapidly in areas where people believe there are solutions and they are just not moving forward.
I want to quickly indicate that I do not want you to try to solve all that in the next few minutes. I rather wanted to get them on the record and you will be seized with these, so I will not ask you for further written input. You will hear more from us in one of your various responsibilities.
If you have any quick comments, I would personally welcome them.
Dr. Butler-Jones: First, thank you for the opportunity to meet with the committee. Ms. Hoffman and I are on a later flight than the minister to Halifax, so we were able to stay a bit longer, and hopefully it has been helpful to the committee.
One of the key things that the federal government has is convening power, and you can class it as leadership. We have a number of fora. Whether it is the federal-provincial-territorial ministers, deputy ministers, the Pan-Canadian Public Health Network or any of the committees on health human resources, we need the ability to come together and identify innovations because, as you say, it is only good in terms of the application.
There are a number of things that the government has recently initiated over the past few years, like the Canadian Partnership Against Cancer, looking at different fora, like the Mental Health Commission and the Pan-Canadian Public Health Network, that actually came out of the original accord, all of which helped to do the dissemination, the sharing of best practices and best ideas and where we can in fact make a common cause moving forward.
The investments in telehealth and Infoway more broadly have been critical in supporting the provinces and their work moving forward and having a common frame so systems can talk to each other. We clearly have a long way to go yet.
Accountability comes at many different levels. I think this is something that jurisdictions are increasingly more comfortable with. I will not say all. That is, you cannot really assess what you do not count. Therefore, finding better ways of surveillance in terms of whether it is diseases or risk factors, whether it is in fact identifying that we are matching severity of patients to it. Our waiting lists are judged not simply by when you arrived on the waiting list but the acuity, which is the main frustration for clinicians.
With respect to Infoway-related investments, for example, my daughter works with Manitoba Health on the whole wait time issue and with surgeons and others so there is a more integrated and effective system so the right people get seen at the right time, not just to reduce the amount of time but more appropriate time. Sometimes waiting is fine if it is not serious, but if it is serious, you want to be in tout de suite.
There are a number of things in place, and the federal government has played a key role and provided leadership, but the form of leadership will vary depending on the topic and the issue. In my view, that requires a bit of a conversation. The reflections of this committee and that of ministers over the next few days are all important.
Having watched this for a long time, I am never quite sure I absolutely have the right answer. However, in conversation, we often come up with good answers.
Ms. Hoffman: First, I will endorse everything Dr. Butler-Jones just said. Thank you for not asking us to resolve these three huge challenges in the health system.
I will say a word about the business of accountability. One way of thinking about this is that it is accountability, but a lot of it is about reporting and having indicators that are comparable, having indicators that measure things that are relevant and meaningful, and things that reflect the necessary change happening in the system. We have heard many people say, and Dr. Butler-Jones just said it as well: You cannot know where the best practices are if you do not have comparable data that allows you to determine properly who is doing what well.
Often when we have supported pilot projects, and initiatives have occurred across the country supported by us or by individual provinces or territories, we have had a good description of the initiative and some of the outcomes. However, we have not focused on what the essential political, economic, provider and payment dynamics are that allow that initiative to succeed. Absent that knowledge about the pre-conditions, it is not helpful for those who may want to replicate, as you have given an example, whether it is something in eHealth or interprofessional collaborations around primary care. Sometimes we have missed the boat in terms of getting at the pre-conditions necessary to make something happen. We need to focus more on that.
The Chair: Thank you very much. On behalf of the committee, I want to thank the three of you for being with us today. We know, at least in most cases, you will be dealing with this issue on a continuous basis from now and throughout the negotiations of the next accord. We certainly have appreciated having had the opportunity to have you with us today.
(The committee adjourned.)