Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 9 - Evidence - November 30, 2011
OTTAWA, Wednesday, November 30, 2011
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:16 p.m. to examine the progress in implementing the 2004 Ten-Year Plan to Strengthen Health Care.
Senator Kelvin Kenneth Ogilvie (Chair) in the chair.
[Translation]
The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
I am Kelvin Ogilvie, a senator from Nova Scotia. I chair this committee. I would like to begin by having my colleagues introduce themselves, starting with the deputy chair.
Senator Eggleton: Art Eggleton from Toronto.
Senator Callbeck: Catherine Callbeck from Prince Edward Island.
Senator Cordy: Jane Cordy from Nova Scotia; a special welcome to our guests today.
Senator Merchant: Pana Merchant from Regina, Saskatchewan.
Senator Demers: Jacques Demers from Quebec.
Senator Seidman: Judith Seidman from Montreal, Quebec.
Senator Braley: David Braley from Hamilton, Ontario.
The Chair: Thank you, colleagues. To remind us all, we are continuing to examine the progress in implementing the 2004 10-Year Plan to Strengthen Health Care in Canada. This is the twelfth meeting of the committee. Today we are meeting with provincial representatives.
I will introduce our two guests. Thank you both for being here. We have Kevin McNamara, Deputy Minister, Health & Wellness, from the Government of Nova Scotia; and from the Government of Manitoba, we have Milton Sussman, Deputy Minister, Manitoba Health.
It is my understanding, Mr. McNamara, that you will begin with comments. You have the floor.
Kevin McNamara, Deputy Minister, Health & Wellness, Government of Nova Scotia: Thank you very much, Mr. Chair and good day, honourable senators. I appreciate the opportunity to speak to you.
Before my current role as deputy minister, I was CEO of the District Health Authority on the South Shore of Nova Scotia. I offer you my perspective as a former administrator and as someone who has overseen the provincial health care system for the last two years.
It is important that we take the time to reflect on the 2004 health accord and to have input on future priorities. Canadians deserve to know whether the agreement is working, how it is helping patients and whether the next accord needs to be different — and, if so, how?
I will touch on several themes and principles during the next few minutes — on accountability, equity, innovation and sustainability — in hopes that my comments will contribute to our reflections on the 2004 health accord and the shape of things to come.
Let me say at the outset that Nova Scotia agrees with those who say that we need to be accountable to taxpayers for the dollars entrusted to government to spend on health care. We invest billions of dollars on health care for families, on day-to-day care and to prevent illness. We must be accountable. It is our responsibility.
Certain areas of the 2004 health accord continue to benefit all Canadians, such as progress on wait times. However, there are other areas, such as health human resources that need further leadership.
The accord continues to be an important mechanism, based on the stable funding that sets out specific areas for investment, including information technology, wait times and infrastructure. Largely due to the 2004 health accord, the tests that patients receive in Nova Scotia are digital. They are sent more quickly from hospital to hospital, thanks to technology.
The Picture Archiving Communication System, better known as PACS, has been very positive for Nova Scotia physicians and their patients. As a small province with a large rural population, we welcome and encourage investments in health technology. Electronic records are helping patients in remote areas and there are more ways for patients to communicate with physicians. Further investment in health information technology is essential.
We need to consider how the electronic era can support and revolutionize home care and long-term care. At the same time, we need to be careful to ensure that the IT investment dollars are not offered in a way that provinces cannot afford to invest.
In Nova Scotia, we are establishing a drug information system that will allow doctors to see the current and past medication use of their patients. New Brunswick and Prince Edward Island are also using the same system.
We are not as convinced that we are on the right track when we talk about wait times, which we have monitored as part of the 2004 health accord. Dr. Brian Postl, from Manitoba, appeared before this committee. He called the focus on reducing wait times for hip and knee replacement, cancer treatment and cardiac surgery "arbitrary." That is an issue.
On the positive side, Nova Scotia has made progress in national benchmarks. We have one of the most robust wait time websites in Canada. We have worked hard to be accountable and transparent.
We have a high rate of heart disease, so Nova Scotians receive top-notch cardiac care. Currently, all patients who require surgery for bypass blocked heart arteries receive treatment within the 182-day national benchmark.
We also signed a memorandum of understanding in May 2011 at the Council of Atlantic Premiers. Under this agreement, Nova Scotia supports New Brunswick and Newfoundland and Labrador in their efforts to ensure that patients get treatment within the national wait time benchmark. Also, Prince Edward Island gets their treatment in either New Brunswick or in Nova Scotia, as they do not have a program of their own. Patients also have faster access in Nova Scotia to cancer treatment.
Women can receive screening for breast cancer more quickly due to linear accelerators and the availability of digital mammography across our province. New radiation bunkers are under construction, thanks to federal and provincial infrastructure dollars. These bunkers will open in 2012 and will reduce wait times further for cancer patients.
Nova Scotia meets our wait time guarantee to cancer patients. They receive radiation therapy within eight weeks of being ready for treatment. Collaboration among the Atlantic provinces is positive. We support one another by having the option to transfer patients to facilities within the Atlantic provinces if an eight-week guarantee cannot be met within our home province. It is a safety net and an important regional partnership. Through collaboration, we can deliver better care for patients, but we must do so based on evidence rather than clamouring to measure wait times based on what is making the headlines.
Addressing some wait times is proving to be challenging for our province. Is it reasonable or fair to measure orthopaedic waits, for example, when the measures do not take into account the rising volume of work to meet the needs of our aging population and the high incidence of chronic disease and complex needs? We also question why we set benchmarks for cataracts.
For those reasons, we think it is essential that provinces have input into the choice of future targets. We know from seeing the testimony of others that there is a strong desire to earmark specific health care performance targets. Going forward, we believe in performance targets, but based on evidence; and we believe that jurisdictions need some flexibility for implementing new targets.
For example, British Columbia has one of the youngest populations, while demographics show that Nova Scotia and Atlantic Canada has one of the oldest. The same model may not easily apply to all 10 provinces and territories.
With regard to federal funding, I do not believe it is appropriate in this setting to delve too deeply into the discussion of health care funding, other than to say that a new accord must address equity of needs. The Council of the Federation has these issues on its agenda for discussion in early 2012.
Regarding the sustainability of our public health system, we are proud of the work under way across Nova Scotia to make our system more efficient. It is not easy. In the next fiscal year, we have asked our hospitals to reduce our expenses by 3 per cent, following a current year of 0 per cent growth. We must ensure that we are good managers of the system in order to protect and improve patient care now and into the future.
The most recent CIHI report on cost drivers is further evidence that hospitals, physicians and drugs consume the largest share of health care funding. Like Ontario, British Columbia, Saskatchewan and Alberta, we have moved toward generic pricing of drugs in our public drug plans. Health Canada plays an important role in deciding which drugs, so I would ask you to consider how the agency may play a part in deciding which drugs get reviewed for funding.
As it currently stands, a drug can only be reviewed for safety if the pharmaceutical company recommends it. As CIHI found, there are too many public dollars being spent on expensive drugs. We need new ideas at the table.
I would also ask this committee to consider recommending that Health Canada examine whether certain drugs have the benefits touted by manufacturers through expensive marketing. As an example, I think of Lucentis for wet age- related macular degeneration. We know that Avastin, which is an off-label drug used by both British Columbia and Nova Scotia, has almost the same effect but is very inexpensive.
Innovation is also essential, and the next health accord must encourage and support that among the provinces and territories. That does not mean privatization.
In Nova Scotia, we are encouraging access to the right care provider for patients. We cannot be stuck in the 1960s model of health care that encourages people to be in hospital. In fact, one of the best things we could do is encourage more services on a needs basis in the community and at home, where they are easier and cheaper to provide.
Through our plan "Better Care Sooner," we are making best use of the time and skills of our doctors, nurses, paramedics and our 24-hour nurse line. They all provide care in a more effective 24/7 emergency care system.
Nova Scotia now has trained advanced care paramedics to immediately give life-saving, clot-busting drugs to Nova Scotians who are having heart attacks. They can do it on their front lawn rather than waiting until someone arrives at the hospital.
We are hiring paramedics to work at nursing homes to treat seniors in a place where they live, rather than making the frail and elderly wait for ambulances in an ER. We are developing collaborative emergency centres tailored to the unique needs of our communities.
Finally, we would like to see a greater emphasis on prevention in the next accord. Chronic disease and aging populations are forcing us to look at different health care approaches. We need to invest in preventing people from becoming sick in the first place. Innovation should be encouraged, with community based services based on the needs of patients.
Indeed, at their meeting in Halifax last week, health ministers confirmed that they will continue collaborating to put in place guidelines and actions that will lead to healthy weights. In Nova Scotia, our strategy aimed at reducing childhood obesity will be in place in early 2012.
Another area that was missing from the last accord was addressing the mental health of Canadians. The next accord needs to reflect this important health care issue and the growing need. We must recognize the effect mental illness is having on our public. Nova Scotia will soon release its first ever mental health strategy.
If there is a 10-year accord again, we believe it needs to have a midway check in at least five years, because our health care system is evolving quickly and must be able to adapt to the changing needs of our jurisdictions. As we demonstrated last week at our PT and FPT meetings in Halifax, there is a real opportunity for collaboration as we approach 2014. There is reason for optimism as we reflect on successes of the past and needs of the future.
Milton Sussman, Deputy Minister, Manitoba Health, Government of Manitoba: Thank you for inviting me here today to present on the existing health accord and its impact on Manitoba. This is a timely presentation following the meeting of health ministers in Halifax last week.
At that meeting, all ministers agreed that the partnership provinces and territories have with the federal government on health care, namely the 2004 health accord, has contributed to the significant improvement in health care achieved over the last decade.
I was deputy minister when the last accord was developed and signed in 2004. After working with the Winnipeg Regional Health Authority for a few years, I have returned as Deputy Minister of Health, and I share the ministers' conclusions about how the partnership with the federal government has contributed to improving health care services.
I would like to take a few minutes to discuss what this has meant in Manitoba.
One of the most important components of the health accord has been stable, consistent, appropriate and predictable federal funding for provincial health care delivery, with the 6 per cent escalator. Most importantly, this has helped to sustain and improve our health care system in Manitoba, ensuring that we are meeting the requirements of the Canada Health Act, including being accountable for the principles and services it mandates.
The other significant benefit of predictable funding is that officials are not devoting significant amounts of time every year to anticipating and negotiating federal health transfer payments. Instead, they have been able to focus on innovations in our system to improve care for patients and to improve efficiency in the system. This includes streamlining administration, developing more effective pricing and procurement strategies, and implementing lean management and other process-improvement methods. These efforts have saved an estimated $50 million last year, in Manitoba alone, which we were able to redirect into frontline health services to better meet patient needs.
Consistent federal funding has supported, in part, the recruitment and retention of record numbers of health providers. Manitoba now has more doctors, nurses and nurse practitioners than it has ever had before. Those frontline professionals contribute to reducing wait times and improving patient care.
Aside from stable federal funding for the Canada Health Transfer, additional federal investments were made in specific, targeted areas which have contributed to making a real difference in Manitoba.
Wait time funding has helped cut wait times and improve access in all of the five priority areas: cancer, cardiac, hip/ knee replacement, cataract surgery and diagnostic imaging. In fact, Manitoba now has the lowest median wait times for radiation therapy in Canada, at less than a week. With support, in part from the federal government, we are keeping wait times low, with a wait time guarantee of four weeks or less.
Because of this progress and strong foundation, Manitoba was able to take the next step earlier this year by launching a $40 million cancer patient journey strategy. It is the most aggressive and comprehensive cancer wait time plan in Canada. Our initiative will cut wait times across the entire patient journey, from when a family doctor first suspects cancer, through all of the testing, referrals and diagnostics, to when treatment actually begins.
Federal wait time funding has also supported innovative initiatives such as bridging general and specialist care, which supports family doctors in referring patients to the right specialist, with the right information, the first time. This eliminates unnecessary referrals to wrong specialists and the back and forth that happens between a specialist and a general practitioner. It also helps accelerate care by streamlining the referral process.
The Federal Medical Equipment Fund was a major support for Manitoba to acquire new and upgraded specialized medical equipment such as ultrasounds, CT scanners and MRI machines. This has helped to reduce wait times and improve quality. Unfortunately, this funding was not renewed and ended in 2006-07. Significant and ongoing federal financial support of Canada Health Infoway has been critical to Manitoba in terms of introducing innovation and increasing productivity in the health care system. This is one of the most concrete ways that the federal government can contribute to improving performance, health outcomes and innovation. There is a continuing and vital role for Canada Health Infoway into the future, as technology provides more options of bending the cost curve and enhancing Canadians' access to timely and quality care. We have launched eChart, Manitoba's electronic medical record. It, along with other hospital information systems and health information, is helping to improve patient care by allowing their providers to access up-to-date information from all across the province.
Primary care funding has helped to support pilot projects in Manitoba to improve access to family doctors and other primary care providers. Manitoba also took steps to train and recruit more doctors, nurses and nurse practitioners, to build more clinics and to support innovative primary care initiatives. These efforts have built a strong foundation, on which the province is now taking a significant next step. We are launching an initiative to ensure that every Manitoban has a family doctor by the year 2015.
Federal funding and support for research has been a vital and ongoing need. Of particular note, funding in support of CIHI has established and maintained a broad range of health databases that provincial health systems can use to look at other provincial health systems. We have the ability to look at and adapt best practices.
Since the signing of the 2004 accord, the impact and awareness of mental health has only grown. At last week's health ministers meeting, federal, provincial and territorial ministers of health expressed a strong consensus on the importance of this issue. Manitoba is very supportive of the ongoing federal funding for the Mental Health Commission of Canada. To this end, Manitoba, as announced by the Council of the Federation, will be hosting a national mental health summit, "Mental Health Promotion and Mental Illness Prevention For All," on February 15 and 16, 2012.
The Canadian Partnership Against Cancer, CPAC, while not specifically part of the 2004 accord, has become another avenue of successful collaboration by all the different components of health system. Federal funding and leadership has allowed provinces to access research and initiatives into best practices and to share this information widely.
The national role of CPAC is even more critical with the lack of a national pharmaceutical strategy, which was to have included new cancer medications with positive health outcomes. Manitoba was disappointed at the lack of federal engagement, in 2006, on the 2004 accord commitment related to a national pharmaceutical strategy.
The province, through its Department of Healthy Living, Youth and Seniors, has also committed to the priority of health promotion, illness prevention and investment in early childhood development in Manitoba.
The existing health accord played a pivotal role in not only sustaining, but also improving health care in Manitoba.
Looking forward, the Government of Manitoba has proposed some priorities for consideration in renewing this accord. First and foremost, continued stable funding from the federal government. We would recommend maintaining the 6 per cent escalator over the long-term, perhaps for another 10 years or more.
Like 2004, we would recommend federal-provincial partnerships in priority areas. The challenges and opportunities today in health care are different than they were a decade ago, and, therefore, Manitoba would recommend the following priority areas: First, a national senior's care strategy is critical as we face a significant increase in the number of seniors in Manitoba and across the country in the years ahead. This plan could include building more nursing home beds, as well as alternatives such as home care, supportive housing and initiatives that would focus on wellness among seniors.
Second, resuming federal funding for advanced medical equipment is also a recommended priority. This would help provinces to acquire new, advanced technology more quickly, to deliver better care and to reduce wait times.
Third, improving health and health services on reserves for First Nation communities is a priority. Currently, there are remote communities with thousands of residents that do not have a hospital, diagnostic services or, in many cases, a doctor. Of course, health services are only part of this issue, and we must focus on addressing the other determinants of health and well-being, including: clean water, better housing, education and employment.
Finally, as mentioned, Manitoba is making significant progress in primary care, but federal partnership could expand and accelerate our plans. We believe that a comprehensive accessible primary health care system in which every Manitoban can access services close to home when they need them is key to a sustainable public health care system. It will help avoid more costly services like hospitalization and emergency room visits for non-urgent issues while helping to keep families healthy by preventing chronic conditions and complications that result from them. When patients require more specialized care, primary care providers will be able to coordinate this more seamlessly and quickly.
Thank you for the opportunity to present today. Provinces, the territories and the federal government have made significant progress together on improving health care services. There is clearly more work to do, and continued strong partnership will help to keep this work moving forward in the years ahead.
The Chair: Thank you both very much. I will open the floor to my colleagues for questions.
Senator Eggleton: I will start with wait times. There were five areas identified for the 2004 accord, and both of you have talked a bit about the progress that has been made there and the development of benchmarks. You have given statistics that have indicated some success. Some of the reports we have received suggest that, while there has been some success, there is still a long way to go.
What specific strategies were successful in reducing wait times in your provinces? Are there other evidence-based benchmarks that you have established in the province for other health care priorities that perhaps we should consider as part of the next accord? A number of suggestions have been made by others as to what might be included in that. I would like to know whether you think the list should be expanded.
Mr. Sussman: We have looked at a number of other areas in Manitoba. I mentioned in my comments our focus on cancer treatment. We have launched a significant initiative that targets the whole cancer journey. What is important to Manitobans, and I think to Canadians, is not only the length of time between being referred by a specialist and receiving a certain test or treatment, but also the time between when your physician thinks something is wrong and the time you actually start treatment. That is an area in which we are investing significant resources. We are trying to set a two-month time frame from suspicion to treatment.
We think that other benchmarks can be achieved. I want to reflect a bit on Mr. McNamara's comments. There is always a downside when you focus on specific targets, and the evidence on setting those benchmarks was not always as clear. As Dr. Postl said, sometimes it can be somewhat arbitrary.
Having said that, I think there is value in setting the targets, because it certainly focuses efforts in jurisdictions on that work. That can be at the cost of neglecting other areas with priority areas getting significant focus while other areas that may be equally as important may not get quite the same focus. There must be a delicate balance. You should not set so many targets that you cannot spend resources on the other kinds of wait times.
Senator Eggleton: Are there any particular ones you would add to the next accord?
Mr. Sussman: I would be more focused on cancer again.
Senator Eggleton: Cancer is one of the original five.
Mr. Sussman: Yes, but it is a very limited target and I think it can be expanded. From my perspective, there are targets on access to family physicians. It will be important that Canadians have timely access to care providers. Those are just a couple of areas.
Mr. McNamara: I talked about orthopedics. In our case, we have done 16 per cent more surgeries in the first six months of this year than we did in the first six months of last year. At the same time, our wait list has increased by 30 per cent. It is very difficult to achieve a target when you have those types of demands.
In trying to address the wait list we have also put in orthopedics assessment clinics which do pre-assessments and identify individuals who do not need orthopedic surgery. There are other modalities that can be used, such as physiotherapy, to divert people from surgery. Obviously, if you go to a surgeon, he or she will cut, in the same as if you go to an internist they will give you a pill. That is the way they are trained. It is not that it is bad; it is just how we provide service.
With respect to the future, I would look at access to a health care provider, although not necessarily a physician. There are many other providers including nurse practitioners, family practice nurses and even pharmacists in some cases. We have to think differently about how we provide service. If we measure everything by a GP, it will continue to create problems and we will never have enough of them.
An addition to the list that I would like to see is access to mental health and addiction services. Those are things we could set targets on. In our province, and probably in many of our provinces, we are not doing a very good job in that area. Even though a number of us are developing strategies, I do not think we are there yet.
Senator Merchant: In our hearings we constantly hear about improvements in timely quality care, about reducing wait times. What are your departments doing to track quality? Completing more surgeries is not necessarily a measure of quality.
Last week the OECD gave Canada not very good marks in some areas. Last week Dr. Butler-Jones gave as an example a review done in Vancouver. They tracked cataract surgeries and found that a quarter of people who had cataract surgery were actually worse off after the surgery than they were before. He asked how that could be, and he concluded that some patients whose eyes were still functional really did not need the surgery, but because they had cataracts they could have the surgery.
We know that many people go to the Mayo Clinic because they have the impression that they get quality service there. I do not know if you track it, but this must be quite a loss to our economy. Have you any idea how much money goes out of the country because people are seeking quality?
Mr. McNamara: In Nova Scotia, we were late to the game, but we have set up a quality team within our department. We have a chair by the name of Dr. Pat Crosskerry who is probably an international expert on quality and patient safety and has done a lot of work particularly in emergency medicine.
We have developed standards for emergency departments across our province. I think we are the only province that has a full set of standards, including the training, the equipment and what is expected. It will take us a couple of years to get there once you set up the training.
In terms of surgery, we know there are surgeries being done in our province that are inappropriate. We know that people are being hurt. We know there are people that are being treated inappropriately. We are using cancer as our guide. We will be changing, over the next year, how we do that, and we will stop doing some of those procedures.
We also have to spend time helping people understand that the treatment they see on television is not the thing to do. It is very difficult. We also know that everything we do in health care impacts the income of someone. When you stop doing something, individuals lose income, and it is hard to get them to come along. We have to find a different way of being able to pay or getting them to think differently about what we are doing.
If I use the example of rectal surgeries in our province, I know we are doing inappropriate rectal surgeries for cancer. We have to change that. I am sure we are not the only province.
Mr. Sussman: I think you are quite correct. All jurisdictions, and certainly Manitoba, are starting to focus more on quality. Each department has divisions or sections within them that are more focused on quality. The regional health authorities in Manitoba now all have quality committees as the major committee of their board of directors. We have a large focus on patient safety in Manitoba where we are tracking and posting critical incidents and trying to do learning summaries from them.
I alluded in my comments to a program we have called Bridging General to Specialist Care. That was looking at the requirements that a specialist would need before they get a referral from a family physician so they are sending the right information and they can make the right initial assessment. We have launched that in a couple of particular areas, and our intent is to expand that across the system.
We have also had initiatives that look at the wait lists for different types of procedures and tried to do an assessment on whether those people are appropriate for the service they are looking at.
It is clear, though, that this is a very large and complex system, and we are still at early stages when it comes to advancing a culture of qualities across the system. All of us are very conscious of the work that IHI does in the U.S. If you go across the country, you will see significant initiatives in those areas in every jurisdiction.
I agree that it is something we have to continue to focus on.
Senator Callbeck: I have a couple of questions, and one is about the drug information system. New Brunswick, Nova Scotia and Prince Edward Island are using the same system, but what about other provinces? Do they have different systems? Is the aim to all have the same system, or are we going to have apples and oranges?
Mr. McNamara: We have apples and oranges. It depends on the different direction given in different provinces. Sometimes it is based on the vendor and who does the best job of selling a product. Sometimes it is based on the users who have a preference.
One of the struggles we often have is going back to these systems are there for the patient and owned by the patient, but they are really not. They are owned by the provider in many cases. One of the things we have to change is it has to become more of a patient-focused system in everything we do, rather than provider-focused. Our biggest failure in Canada is that we are too provider-focused.
Senator Callbeck: Is there a role here for the federal government?
Mr. McNamara: I am sorry?
Senator Callbeck: Different provinces have different systems. Say someone moves from one province to another. Say I live in Prince Edward Island and move to Ontario. A doctor in Ontario will not have access to my drug information. Is there a role for the federal government to play in trying to get some consistency in this?
Mr. McNamara: The federal government can help us tremendously by at least doing the interoperability between systems. It could be different systems in different provinces. The interoperability is the expensive and hard way to do it. I would encourage that that happen, and not just in drug information but with other factors as well.
If we look at, for example, the electronic medical records, in Nova Scotia, we have one system. We are still having a battle because we are being resisted by physicians who want to have choice. If you are in some other province, and I am not sure of Manitoba, but in Ontario it is wide open and any vendor can provide a system. That is an issue for some of us. We are trying to hold the line on the one. Whether we will be able to do it or not, time will tell.
Mr. Sussman: I think it is hard to go across the country and have one standard system because each of us has different health systems with slightly different rules and slightly different coverage.
I do want to clarify that, with health information and some of the standards of what should be in the drug information system, Canada Health Infoway, if you access their funding, has dictated some parameters around it that I think will provide a standard quality of information. It may not be exactly the same information. The issue of interoperability between jurisdictions is a much longer term issue. I think there has been tremendous progress.
As I mentioned to you, I was a deputy minister in 2001 before this accord was signed. I can only speak for Manitoba, but investment in information technology was minimal. With the advent of Canada Health Infoway and its funding, but also its push to follow certain standards, we have seen rapid development of information systems and are making progress in all of those areas. I am more worried about us finishing that job. I do not mean it is not important to have interoperability, but I think it is vitally important you have all of those systems in place in your home jurisdiction.
Senator Callbeck: I want to ask the same question on wait times. When we talk about wait times and compare one province to another, are we talking apples to apples or apples to oranges? Is every province using the same definition?
Mr. Sussman, you talked about cancer. I understood from you that the wait time starts from the time the person sees the family doctor until they get the procedure.
Mr. Sussman: In our cancer journey strategy, that is the measure we are using.
Senator Callbeck: However, on the others where the wait times are being compared, province to province, is it a consistent definition?
Mr. McNamara: I would not say it is 100 per cent consistent. There is some consistency, but there are some differences as well.
It is the interpretation; it is the systems that are being used. It is how accurate the inputting of the information is and how well individuals input MIS data. It is a difficult system to code. Even when we talk about administrative costs in this country, because you will hear it is high, infection control and patient safety are included in "administration." It is not pure administration as you and I think about it. I guess we give misguided advice sometimes because of that.
Senator Cordy: It is good for the community to hear from the provinces who are the providers of the health care. You have both been excellent witnesses, so I thank you very much.
I would like to ask questions about mental health and mental illness. I was part of this committee when we did a study on mental health and mental illness under Senator Kirby. Things have come a long way because at that time I doubt that we would have had two deputy ministers from two different provinces coming in and both talking about mental health. We have made some progress in that way. One of you mentioned the Mental Health Commission. That was a recommendation of this committee, and Senator Kirby was the first chair and still is.
We have heard other witnesses who also talked about mental health and mental illness. What should we recommend to the minister be put in the new accord? You want to have something in it that is flexible. Mr. McNamara talked about flexibility because not all provinces are the same. However, you want some national standards that all provinces and territories are looking at in their treatment and wellness for those with mental health illness. One in five Canadians will suffer from poor mental health at some point in their lives.
Mr. McNamara: In terms of mental health, I would like to see access to at least a caregiver of some type when individuals need it. Sometimes individuals get sicker because they do not have quick access. It is looking at more the early intervention and how we can do that.
Second, think of those who have mental illness. What are the issues they are dealing with? They are dealing with homelessness, not having a house to live in and poor income. Even when we look at the accord, we have to ensure that the health accord is not at the expense of the other transfers. If we take housing away we will increase the problem for homelessness and health because it will end up being the last resort for many of these individuals. For me, it is early access and having the other determinants that can assist. To me, many individuals with mental health issues need a home, advice, support and a friend. I think we have to figure out how we do that.
Mr. Sussman: I would say that I agree with Mr. McNamara. In dealing with mental health issues, what I hear from family practitioners in Manitoba is a significant part of their patient case load deals with mental health issues. We have to find ways. There are models that support family practitioners, who are providing most of the mental health support in their practices. They are dealing with way more people than are psychiatrists or mental health workers. We have to find ways to support their practices.
I agree with Mr. McNamara. You need a wraparound type of service for people with persistent mental illness. There needs to be support for those kinds of initiatives. There needs to be housing. There also needs to be a focus on mental health promotion and mental illness prevention. We often do not really recognize that. It is still very much an under- reported issue.
I think the Mental Health Commission has been a significant first step in moving forward. I think it occurred at a time where it was becoming apparent to all jurisdictions how important this is. It has been a support to that.
Senator Cordy: Mr. McNamara, you talked about a friend or an advocate. It does not necessarily have to be the family doctor, which I think Mr. Sussman was saying. We need the wraparound services. You phrased that in a great way.
Mr. Sussman: I am not suggesting that it must be a doctor. I think there must be a broad spectrum of supports that are available. I do think it is critical that we support family practitioners.
There are some significant models. We have a shared care model where there are mental health workers and psychiatrists that are resources to a family practice clinic. The mental health workers spend time in the clinic seeing patients, and the psychiatrist is there to consult with the clinicians and, if necessary, to see the client. We will never have enough psychiatrists — certainly not in the short term — to provide the level of services that are required, so we have to find ways to maximize those services. It is based on a model that I think was started in Hamilton and is a hugely successful model.
Senator Cordy: Mr. McNamara, I like your comment that perhaps we should have a five-year evaluation. I look at when this accord came in, in 2004, and it does not seem that long ago, but look at the changes that have occurred within the health care field in that period of time. I think that is a great suggestion that you have made.
Senator Champagne: You both spoke about unneeded surgeries. In my home province of Quebec, it has been reported that in the last few years there have been a huge number of unnecessary Caesarean sections. Is that something that you see in your part of the world?
Mr. McNamara: In our case, yes, it is. We just did a look at that. We also looked at hysterectomies, and that is higher than it should be. We are taking a look at that to see how we can address it differently and reduce that.
Mr. Sussman: We are seeing some of that in parts of Manitoba. We have tried to address that. In one of our health regions, it is way out of whack with data from anywhere else in the province and nationally. We are addressing that specifically within that regional health authority as to why those rates are so high.
Senator Champagne: Surgery is surgery. It is very expensive. An OR is being occupied for something that maybe was not necessary while someone else is waiting for something that could be urgent.
Mr. McNamara, you said in your presentation that it is essential that provinces have input into the choice of future targets. What should be earmarked for targets or what should not be earmarked?
Mr. McNamara: Definitely cataracts cannot be there. That is one example.
Senator Champagne: Allow me not to agree, because I am next.
Mr. McNamara: We also know that individuals are getting cataracts younger and younger for obvious reasons.
One of the things we have to look at in working together is to use evidence based on the support systems we have in Canada, and ask what needs to be done that will impact the lives of individuals. How do we do it differently, whether it is prevention? In the last accord, many things were picked ad hoc rather than giving a lot of thought to it. We do have a couple of years to do this together. I think provinces have to sit down and work our way through it so we collectively can come up with some issues that we can suggest be part of the goals that we want to achieve together.
As I mentioned, it may be different. As Mr. Sussman said, we need an aging strategy, which is very important to the East Coast because of our demographics.
The other thing that was interesting to me in looking at statistics, if we look at individuals who are the most ill in the seniors population, it is on the East Coast and Alberta. That is kind of funny because the richest and the poorest have the worst record in dealing with seniors. It means our system is failing, so money is not the total answer.
What I am trying to get at is that we, as provinces, must sit down with the appropriate experts to say what are the things that we should put forward that we believe, with evidence, we can support and put the appropriate benchmarks in place?
Senator Champagne: You were talking also about the need for flexibility for implementing those new targets. Do you mean between the provinces, or in your own province or what?
Mr. McNamara: I used the example of "young" versus "old" — like British Columbia versus Nova Scotia. That does not mean we do not have both groups in there; we know, for example, that many young people between 14 and 19 are using a lot of our health care services because of lifestyles and other things.
We can make that as a national basis to help the seniors, but we may say there is a greater target on the seniors in a number of provinces and greater one on the youth in another. That is what I am talking about when I talk about flexibility, but it could still be part of the big package.
Senator Champagne: Do you have anything to add, Mr. Sussman?
Mr. Sussman: When I hear from Manitobans, often the issues are how do I access some kind of care provider? I agree with Mr. McNamara that it does not have to be a family physician; it can be a range of practitioners.
The other thing that I constantly hear is I have a care provider but I cannot get in to see them when I need to see them. I end up going to an emergency room or to a walk-in clinic because either I cannot get in after hours or I can get in only in three weeks. Often, if you have something that is maybe not an emergency but certainly you are feeling ill, it may not be appropriate to wait three weeks.
I think access in a timely way to a care provider is one that provinces need to focus on. We are, but help in supporting some targets in that area might be appropriate.
The other thing is that every jurisdiction will be dealing with significant numbers of people with chronic health conditions. Right now, because we are not as successful as we need to be in managing those chronic conditions, we start seeing people coming into the ERs or being in hospital.
If a comprehensive primary health care system was in place, with appropriate measures for monitoring people's chronic conditions, those people would not be presenting to hospital. It is a huge issue in Manitoba, particularly in relation to our First Nations communities and our remote communities in the North.
Senator Champagne: Are you using e-medicine with those people in the North or people who live far from the big centres?
Mr. Sussman: We have a significant telehealth service, but it is still a huge issue. There are jurisdictional issues that come into play with who has responsibilities for providing health services on reserve. Is it the federal government or is it Manitoba?
What we are seeing, frankly, is an overrepresentation in our hospitals by First Nations, many of whom have chronic health issues, such as diabetes and other kinds of conditions, that are not managed as well as they should be.
When we see them in our system, they are sicker, they have had more amputations. It is a significant problem that we do not have the right indicators and right services to provide that chronic disease support and management before they become quite ill. It is not just in First Nations; I think it is a problem throughout. However, it is highlighted in Manitoba, particularly when you walk through a hospital and see the overrepresentation.
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Senator Verner: I would like to raise an issue which speaks to people who receive health care services from the provinces, and that is accountability.
I would like to know what you think about the measures which were included in the health accord regarding accountability. Do you think that changes should be made to paint a clearer picture of any progress which has been accomplished, in the interest of keeping Canadians better informed?
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Mr. McNamara: As I said in my opening remarks, we believe in accountability to taxpayers. It is important and it is our responsibility. I know not all provinces agree with that. Some would like more flexibility in how they use the funds; that is their prerogative.
From the Nova Scotia government's point of view, we are not afraid of accountability. We believe that if we are using taxpayers' money, we have to be not only accountable on how we provide quality care to the patient, but how we ensure to the taxpayer that we are using it appropriately.
Mr. Sussman: I would agree. I think there is a tremendous amount of accountability — much more so than I think people are willing to acknowledge.
The Canadian Institute of Health Information publishes information that compares the different levels of service and outcomes across the country. We post tremendous amounts of information now on public websites. We post critical incidents and the summaries of what happened in those critical incidents. We publicly post wait times. Everyone is moving to increasingly post and disclose information about their system. We are looking constantly at other jurisdictions.
If you are in a province, health care is the number one issue. It is in every single session of the house, daily in Question Period — multiple times most often.
I think we still have to continue to evolve this, but I happen to be someone who believes that there has been increasing accountability. Do we always have the right measures in place? I do not think we always do — we have to work between us on what are the right measures; but this is a very accountable system.
It may not always be doing the right things, but it is often the way the system has developed and you can report on that. I think we may have to define changes in what those accountabilities might be, but there must be some agreement and there is not always that kind of agreement on what and where those changes should be between providers and the families.
Senator Seidman: I was quite pleased to listen to some of the interesting things that you are doing in your provinces. I thank you very much for presenting that to us.
I would like to enter into the discussion from the vantage of "vive la différence," in a way. Provinces should have the ability to innovate and be creative in the delivery of health services to their citizens.
You have both spoken about ideas for innovative measures that you are engaged in, or preparing to engage in, in primary care, for example. I am pleased to say that in Quebec, just a week or so ago, the government passed legislation to give pharmacists the right to renew prescriptions and even to prescribe medications. The exact specifics are still being worked out, but I found that to be extremely inspiring. I thought, "This is a way to be more creative in the way we deliver services and, perhaps, in the provision of more timely access for something as simple as prescription renewal."
All of that is my preamble. Given the importance of innovation, how might the next accord encourage or promote innovation and experimentation in the provinces and territories that then, perhaps, could be shared across the country?
Mr. McNamara: Again, my personal viewpoint is that we frequently reinvent the wheel, province by province. I think we have to work smarter as to how we can utilize what is working well in one province in another. I think that is something that we, as deputies, can do. As there is more cooperation, we can talk about the good ideas. As a matter of fact, at the meeting last week, one minister suggested that maybe we should have a show and tell at our next meeting, to talk about the good things going on. Sometimes we do not get an opportunity to brag about the good things. You mentioned the pharmacists; Nova Scotia did that about a year ago, and we are really pleased that that is moving forward. There is still more to go with it.
We are also expanding, for example, the models of care, trying to get an individual to practise at the full scope of practice, at the lowest level, whether that is as an LPN, a nurse, a doctor, or whatever. That is a new concept. It is hard to get through because we are still dealing with unions and with others who are on term protection. It does take a while to get there. We recently introduced paramedics into our system, and we are fortunate to have a highly trained provincial system. It is the same system used in Prince Edward Island and New Brunswick, which is helpful. In getting that into the system, it has taken a while to negotiate our way through the colleges as to who could do what, how they could work together, who could take instructions from one another, could a nurse listen to a paramedic, et cetera. All of these things take time, but they have been advantageous in moving our system forward.
Any encouragement we can get to get into more innovative ways of doing things and to share these practices would help us all tremendously.
Mr. Sussman: I think, frankly, the best way to support innovation is through continued, stable funding. I think that has been a real catalyst to starting to look at innovation.
Sometimes when you get an indicator and you see that your system is not doing quite as well as another jurisdiction, my first question is, "What are they doing in those other jurisdictions? Can we learn from them?" I think having the stable funding, with a predictable escalator, allows us to do that. There is tremendous innovation going on, not only in clinical practice, but also in the administration. Saskatchewan is doing tremendous work in looking at how to heighten the efficiency and productivity in its system. It has focused heavily on that. We have copied their system, and I think they copied it from the National Health Service policy of "Releasing Time to Care," which allows nurses to spend more time with their patients. It really looks at how they do their work and allows them to focus much more on spending time providing care, rather than chasing down supplies or trying to find things. It has had huge impacts. We are seeing huge impacts in Manitoba. We just started it, on a much more limited basis than they have. Everyone is focused on the sustainability of the system. To sustain the system, we need to promote innovation. However, to promote that innovation, we cannot be looking at unpredictable funding. If we are, everything slows down.
On the one hand, tight funding forces you to innovate. I am not suggesting that it should be unlimited because it does force innovation. However, predictable funding is imperative.
Senator Demers: One of the things in the last accord is addressing the mental health system for Canadians.
More than ever, homeless people — and correct me if I am wrong — have mental health problems. I am sure you have statistics on that, which I do not have the opportunity to have. Why do we not look into that? I am not saying that you do not because your presentation is very positive on it. Every year, I serve at the Old Brewery Mission in Quebec. Everywhere, in the provinces, there are places like that that serve people who have those problems. You give them food, and they sleep on the subways or in the metros. This is a major issue in our society. Where are we going with this? How can it not be part of the major problems in our society?
Mr. Sussman: It is a significant issue. In Manitoba, the frequent users of the ER system or the health system are often homeless people with mental health conditions. Interestingly enough, the Mental Health Commission has supported some research and service delivery based on a home first model, where you are providing a home for people and the supports to them. We actually have an initiative in Manitoba, the Chez Soi Project, that the Mental Health Commission has done in different parts of the country. They have linked it to research to actually see the outcomes. The idea is that we do find homes and supports for those people. We provide the home setting as the one stable starting point and add the supports around it.
In Manitoba, as I mentioned, we have had a cross-sectoral group, including the police, and we have identified some of the chronic users of the ERs and multiple ERs. Often it is mental health and homelessness that is an underlying piece of that. I think it is getting much more attention; I think it needs to get more. The challenge we are facing is that the funding for that program is running out. The provinces will have to look at strategies on how to pick up those costs. It is clearly a model that, at least initially, seems to be working very well.
Mr. McNamara: I have a couple of comments. I agree with what Mr. Sussman is saying. I think we do need to do more.
I have an interesting anecdote. We have a program, through one of our district health authorities, that works with youth, individuals up to 35. They all have mental illnesses. They had a banquet to honour the employers of these individuals. There were 85 employers in that room, many of them small businesses, who had individuals working just a couple of hours a day.
One individual who had nominated his supervisor for an award worked at a Tim Hortons in Cape Breton. He talked about how proud he was of his job cleaning the parking lot. He said that he did such a good job that they rewarded him by letting him clean the parking lot at the Tim Hortons down the street. He cleaned one parking lot, drank a double- double, and went down the street. He nominated his supervisor because of how good they were to him.
We have to do more to incorporate individuals with mental illness back into our community. The government is one of the biggest failures at doing that. The Nova Scotia government does not hire individuals with disabilities as much as we should. When I look around our table I do not see individuals who we could incorporate. It is partly due to seniority and other things, but we have to find a way to break that log jam. If we cannot be leaders, we cannot expect others to do it.
Senator Martin: I want to talk about the effectiveness of the 2004 accord in achieving its desired outcomes. I agree with much of what you said about the necessity to think differently about how health is delivered, including the use of different health practitioners and having a very integrated system. We have heard phrases from other witnesses such as "multi-disciplinary teams" and "trans-disciplinary," as well as "new models" and "innovation," which you have both mentioned.
We can look at the accord as either a vehicle to achieve the outcomes we want, that is, better health, a focus on health versus illness, and preventive measures, or a tool that allows provinces and territories to work together and to communicate.
What pieces in the current accord have helped provinces and stakeholders to achieve some of these outcomes, such as accountability? What can we add or improve in the next accord that will help us do even better? You spoke about accountability, but I believe we can do better. Do we need clearer language, clearer targets, specific mechanisms or templates?
Mr. Sussman: I do not mean to harp on this, but from a provincial delivery system perspective we are developing targets. I know that every jurisdiction is looking at best practices around the world and implementing models that work better in other jurisdictions.
I cannot overemphasize how important it is to have a consistent and predictable source of money to do that. In the areas of primary care, seniors and chronic disease we could have clearer language. These are areas on which every province and territory is focusing.
The accord can be a support and a vehicle. Again, it may not be moving as fast as many people want it to, but these are big systems to change. They have developed over many years. Changing the direction is a long and complicated process, and people have to recognize that.
The accord should be a supportive document that supports that kind of change, innovation and focus on the right type of care.
Mr. McNamara: I agree that we have to spend more time on prevention and dealing with chronic disease. It has been proven that if adults with the onset of diabetes did 30 minutes of exercise per day we could reduce the incidence by 30 to 50 per cent. How do we encourage that and move it in a different way? We are spending a tremendous amount of money on diabetes. That will be the next tsunami if we do not deal with it.
The Aboriginal community in Nova Scotia is not as large as elsewhere, but we do have a significant number of individuals. We have to figure out what the role of Health Canada is and what the role of the provinces is. There is sometimes confusion when we go onto reserves about who provides what. You get into the payer of last resort. It is unfair to that group of individuals not to straighten that out.
As an example, we were doing a home care program that was not provided in the Aboriginal community, and I met with Health Canada to get an agreement that they would not reduce funding to the Aboriginal side if we did home care on the reserve. We have to think about this differently.
We have to support the North and Aboriginal people, but each province has issues that need to be addressed at the same time.
Senator Martin: I understand the need for stable funding. We have talked about that at length and different witnesses have said the same thing. However, we have also heard that it is not only a matter of funding, that we need to understand how that money is being spent for greater transparency and improved accountability. I feel like I have not received clear answers on what can be articulated or included that will help us achieve greater transparency and accountability to ensure that the money is going where it needs to go and that there is clarity around that. I can see that it is a huge and complex system, and we learn about more complexities as we hear from more stakeholders. "Transparency" and "accountability" are two words that come up repeatedly.
Mr. McNamara: We have to look at the last accord. I think the provinces were outsmarted in some ways by those who got wage increases. Much of the money went to increased wages for the same providers rather than adding new programs. I do not mean that people do not deserve a raise, but we have to deal with the wage issue.
As an example, in Nova Scotia in 2006-07 we received $103 million in new funding, $26 million of which went to non- wage, $61 million to wage and $15 million to program. As part of accountability we have to put the money where it will give the most benefit rather than enriching the wrong sectors, be it administrators, doctors, nurses or cleaners.
Senator Braley: I believe we have a very good health care system overall, but I will challenge you with a number of things.
A 6 per cent escalator federally is impossible. Will we give up education or other social programs? We just do not have the money. How can the health care system take a larger and larger percentage? In some cases the provinces have another 2 per cent. It is impossible to continue to go that way without throwing other programs off the table. A percentage of GNP has to be used.
With respect to cost efficiency, I understand that we all settle, and wages are a big part of the thing. When doctors need more time to do something, they come and get more money from you, but what if doctors need less time to do something? There is a $300 charge in one province for cataract removal. It can be done in 15 minutes now, and $80 should be the charge, and it can be done by a technician with a laser. I do not understand why we still pay. Are we not managing our costs? Are we not doing things appropriately for the work done and the services rendered? Separate deal for each province is what you are basically saying, because they are all different. It is likely to happen if we continue getting these reports. I am sure the government will say, "Oh, my goodness, they think this is a bigger priority than that." They may make a separate deal with each province. We do not want that.
If the costs got out of line, the federal government could say, "We will take care of research and this and that, and we will cut our taxes by this amount, and you guys tax as individual provinces, and you need to tell the people that you are taxing why you are taxing for the amount of services they are getting."
In addition, you need competition. Maybe we should have private clinics. I was in the Mayo Clinic, the Cleveland Clinic, two clinics in Vancouver in the past week, the Cambie one and the Granville one, to see how things are happening. That would take a piece out of the system so you can supply more people.
I just threw a whole pile of stuff at you that will have to be challenged. We just cannot continue to have 6 per cent escalators in the federal government.
The Chair: Maybe we will focus that pile into two parts. One is the issue of where the funding levels may go, the realistic aspect of that. The other is the question of how you generate alternate possible suppliers for the services you need to provide your citizens.
Mr. McNamara: If I go back to the escalator, if we go back to the Canada Health Act, it was 50/50, and it is 22 per cent that the federal government pays now. I think that is the reason for the escalator, to try to get back some of what has been lost by the provinces, to be frank, honest and blunt.
In terms of dealing with other providers, as was said by a study done by an economist in Ontario, public health care can do the job well. What we have to do is be competitive amongst ourselves. Are there efficiencies? Definitely. One thing that has happened is it became provider-focused and not patient-focused. As we move more to patients and have better quality, you will see those efficiencies come out.
Speaking for Nova Scotia, last year, our district health authorities were held to a 0 per cent increase. Next year, it is minus 3. In both of those times, they had to add a 1 per cent wage increase, plus the COLA, so in effect it is 3 per cent this year and minus 5 next year. We are achieving that and doing so by efficiencies. At the same time, we need the funds to be able to do the other side of it, as a province that is having a difficult time trying to get ends to meet.
Mr. Sussman: As Mr. McNamara mentioned, the federal government's percentage, even when the 2004 accord was signed, has still declined. Our increases in health care spending have averaged about 6.8 per cent per year over the last 10 years. Therefore, the percentage that the federal position occupies in Manitoba continues to go down, and I think that is the case in virtually every jurisdiction, and the number of services we have started providing has increased in virtually every single province as well.
I think you make a very valid point about cost efficiency. There is a huge amount of work to be done in all of our health systems, including Health Canada's, to look at cost efficiency and value for the money. We are starting to pay attention to those kinds of things.
Senator Braley: My preliminary look is 25 to 35 per cent that could be pulled out of the system if it were done properly. That is my preliminary look at the cost of health care. I do not know if it is true, and I cannot say it is true, but with my preliminary look, when I run across things like the cataract example and all the various things, it drove me nuts, only looking at it on an audit basis. I am very concerned.
The Chair: Today we do not get into a debate over the percentage issue.
Mr. Sussman: I clearly agree that large amounts can be taken out through productivity improvement and efficiency gains, and it is something that every jurisdiction is focusing on.
Senator Braley: Who is responsible for doing that?
Mr. McNamara: I would like to think we all are.
Senator Braley: In all provinces? Is there a system set up in each of your ministries to do that?
Mr. McNamara: For our case, we are starting to deal with that. One of the things that happens to governments is that when they are being lobbied, no one else stands up to support them. I talk about that in many of my speeches. No matter what the issue, when a lobby group comes out, the poor politician gets pummeled into the ground. None of the professionals or others come up. We look at the issue around liberation treatment, right or wrong, how we got there. Was there support for any of the ministers to say no? No one, including no professional group, stood up. One thing we need is help for governments to say no.
For example, every time a government says, for example, that emergency service becomes a priority, the doctors say, "If I do not get the extra dollars, I am leaving the province." I do not care which province you are in, this happens.
Senator Braley: Is there a mechanism in each of your provinces with regard to the cost effectiveness so that you could show me dollars or savings that you have generated? Why would you renegotiate cataract surgery with those distances between them and pay it? They are making a million dollars a year right now.
Mr. McNamara: We are going through that process, but it is not easy. It is a negotiating process.
Senator Braley: Nothing ever is.
Mr. Sussman: The dilemma, frankly, in the last 10 years is that we were still stabilizing a system that emerged from the 1990s in pretty rough shape across the country.
There are, in every jurisdiction now. I mentioned previously the initiatives that Saskatchewan has with regard to pushing lean initiatives throughout its system. Certainly we are starting to move in that direction and have a major focus on that. We are working with the Business Council of Manitoba, which are the senior leaders in business, the presidents of some of the larger companies in Manitoba, to work on how we can advance this more in Manitoba.
Everyone has tight budgets, so everyone is starting to focus much more on cost effectiveness. The issue of cataracts speaks to the complexity of it, because you are negotiating with physicians who are private practitioners, who are very mobile and have the ability, if they see a practice environment that is more attractive for them, to move. That may be less of an issue in a province like Ontario. It is a significant issue in a province like Manitoba.
Senator Braley: Then I would train a technician to do it.
The Chair: Before moving to the second round, I would like to summarize. We have heard many things today, but I want to summarize and touch base on some of them.
I wanted to follow up on Senator Braley's observation of your comment, Mr. Sussman, that you would like to see a 6 per cent escalator over the lifetime of the new accord. You mentioned in your counter to Senator Braley that, in fact, your province has seen an increase on an annual basis of 6.8 per cent. Surely, in today's economy, your province's economy, the national economy, you really do not think that kind of situation is sustainable in terms of an overall economic term.
I would like to touch base on the issue of the drug information and the idea of transfer, following up from Senator Callbeck's question. We have seen a number of examples of the idea of an individual patient, and there are places in the world where this is being done today, where they all had their own diskette, now a memory stick, that updates their information, and they take it with them. It does not matter that you do not have a system to transfer across. It comes to your point, Mr. McNamara, where you suggested that the information should be the patient's information so that they could transfer across the system. Then it does not matter so much that the communication among systems is not compatible because in fact most systems will translate data and information on a memory stick. It seems like that is something that we could move forward with. I do not want to get into a discussion now; I am just picking up on these things.
The issue of unnecessary surgeries, which we have seen many reports on, is an issue that the provinces should take on with a hammer. Not only is there the unnecessary initial expense, but every surgery involves a risk, and we know a significant percentage of them lead to further medical interventions and costs. It is an enormously important incentive for provinces to look at the issue. Not only the patients but we as citizens are also undergoing surgical interventions we do not need. The long-term impact is great.
Mr. Sussman, I liked the example you used, the idea of the paramedic as the home visitation doctor. In rural Nova Scotia when I was a kid, the doctor came to the house, but perhaps use the paramedics in a more action-oriented way like that.
Again, both of you pointed out the jurisdictional issues that come into play when you start to deal with those things. We should be able to work on and solve those things, if, in fact, there is a practical aspect.
Cataract surgery, as you both will know, has been a recurring example before us, where technology has reduced the time from an hour to 15 minutes, but instead of the cost for cataract surgery going down, apparently it went up. That then put additional pressure on other specialists who wanted to get in on the same game the cataract surgeons had just arrived at. Surely, there must be a way that the provinces, perhaps with the federal government involved, can stand up to what in previous days might have been called "extortion." Certainly, it has a dramatically increased impact on the health care system.
In the end, there is the issue of innovation, which you have both touched on. Mr. Sussman, I think you were quite enthusiastic about it. What we seem to be hearing is that innovative ideas are being developed in a number of areas. This seems to be a relatively recent occurrence. It is not that innovation has not occurred over time, but the volume seems to be increasing as a relatively recent occurrence.
We note that an innovative idea in one area is not an innovation until it is actually applied more broadly in the system. Some of the questions my colleagues were asking were to find ways we can use the new accord to incite and support the transfer of an idea that seems innovative in a given particular practice more broadly across the system so it truly becomes an innovation and a savings across the system. I wanted to summarize those points, not get into debate about them, and indicate if you have further specific examples, to follow up quickly with us on any of those issues. We would welcome them.
I would like turn to the second round, starting with Senator Eggleton.
Senator Eggleton: Mr. Sussman, you said that Manitoba was disappointed with a lack of federal engagement in 2006 on the 2004 accord commitment related to the National Pharmaceuticals Strategy. What we have heard, so far, about the National Pharmaceuticals Strategy has largely been around purchasing strategies, possibilities of federal involvement with catastrophic drug coverage. Both of your provinces have it, as I understand, and most provinces do, but there is not a national catastrophic drug coverage program yet.
Then there is pharmacare, a much broader national program. I would like you to comment on that.
I will throw in generic drug pricing here, because that has come up as an issue. With the patented drugs — the brand names — there is some federal control in terms of the prices review board. As for generic drug pricing, we are now being told it is quite high compared to what it is in some other countries.
On the question of drugs, I would like to hear from you with respect to the pharmaceuticals strategy.
Mr. Sussman: I think you are right that a number of provinces do have catastrophic drug programs. Not all provinces, as I understand, have a pharmacare type of strategy. While we have a common review for expensive cancer drugs, for example, that provinces are doing across jurisdictions, there is not any kind of provision for dealing with those very expensive and increasingly more targeted drugs. You are getting very expensive drugs that apply to a more limited population of people based on more targeting of the genetics of it. Those are both things we need a national approach to and where there could be a national support that could help the work that is ongoing.
We are quite concerned about the high cost of generic drugs. In Manitoba, we have tried to engage in what we call a "utilization management process" with generic drugs, trying to bring down the cost and not only looking at what the business case is. We are using this in both generic drugs and in new drugs. Our process is a bit different than some other jurisdictions, where we are trying to see what the utilization of those drugs would be, what the business case would be and what the value of the drugs is. We want to ensure supply for Manitobans and ensure competitive costs with other jurisdictions. We have found it has been quite successful in reducing the growth in our pharmaceutical budgets, which before were one of the fastest growing parts of the health system and in more recent years have started to become much more manageable.
Mr. McNamara: With respect to generic drugs, we went through a process following Ontario, not the 25 per cent but 35 per cent, which has been effective for us in reducing costs. The drug utilization is something we have a team now going to follow some of the ideas Manitoba is doing.
With respect to the big pharma and generic companies, one of the concerns I have is a practice out of the U.S., which I am sure is following into Canada. It is called "pay for delay," where the big companies are paying money to generic drugs to slow down the introduction of certain generic drugs and splitting the difference. Taxpayers are paying for it.
The second thing is the issue of new drugs where companies are using vulnerable individuals to put the face on what they want in terms of a drug that has minimal impact, in some cases, but are very costly. For an example that I went through, an individual came in who had terminal cancer. The drug that the company had suggested to this individual may have provided a month at most. He comes in, puts pictures of his children in front of me and says, "What will you tell my children about not providing this drug?" That is the type of pressure that big pharma uses.
We have even had a case where they write letters. In one of the letters, they made a mistake and said, "Fill in the blanks." It was the drug company that had written it. In another case, we were dealing with one of our national charitable organizations that was pushing for a drug. They said they were putting on pressure. We called the charity and asked if we could get a copy of the press release. They said, "We have not gotten it from the drug company yet."
Where the federal government can help us is how to start changing these practices and make things more transparent for those individuals that are taking money out of taxpayers' pockets.
Senator Eggleton: What about an overall pharmaceuticals strategy in the next accord?
Mr. McNamara: In my understanding, in the last one, there was an agreement not to move forward. There was disagreement between the federal government and the provinces. I was not there at the time, but in reading the historical documents, it came down to the issue of money. When money was talked about, the federal government backed away, and then the provinces decided not to move any further.
Senator Eggleton: Would you like to see the federal government continue to play a role?
Mr. McNamara: Definitely.
Senator Eggleton: What would you like to see — a catastrophic drug plan or purchasing strategy, or a whole pharmacare plan?
Mr. McNamara: First, if they could help us change the rules so that we could put a drug on to be reviewed for safety — i.e. Avastin versus Lucentis — that could be very helpful in some cases. The second is to help us look at the efficacy of drugs.
As Mr. Sussman said, we deal with cancer drugs; but I want to know, when we have the opportunity to fund something, if it will make a difference to individuals. Are we going to recommend it to the minister? If it is only a drug with a new patent with very minimal improvement, I can use the old drug at a much cheaper rate. That is another way of helping us without putting a lot of money on the table.
Senator Callbeck: Carrying on with the same theme, the catastrophic drug plan was part of the National Pharmaceuticals Strategy that was in the 2004 health accord; there was a federal-provincial task force that did a lot of work on that and the feds co-chaired it. The minister was here the other day and she said a report came in back in 2006 and they could not get an agreement.
This catastrophic drug thing really concerns me, and I am sure it does everyone here. The price of drugs is going up and there are an awful lot of people who are having great difficulty in paying for their drugs.
My understanding was that after 2006, a lot of the provinces went on their own and most of them have their own catastrophic drug plan. I asked one of the officials about this that was here the other day from Health Canada — whether it would be part of the new accord. She indicated it is up to the provinces to determine the priorities that would be on the table.
Do you feel that the provinces will see this as a priority after what they have gone through and now that most of them have their own plan? Do you still feel that it will be there as a priority for the new accord?
Mr. McNamara: I see it as a priority. We may have catastrophic drugs, but not the same catastrophic drugs are covered in every province. There are differences.
I was looking earlier at the correspondence between Minister Tony Clement and the Honourable George Abbott, who were the two leads at the time when the decision was made not to proceed. It was because they could not agree on a process to move forward and it became a stalemate. I am not blaming one side or the other; I am just saying we have to get this back on the table and have some meaningful discussions.
Senator Callbeck: I agree 100 per cent.
Senator Cordy: I would like to talk about the issue of palliative care. No matter how many vitamins we take or how much we exercise, it is not if we are going to die, it is when. Also, it is not only old people dying, it is every age group.
Palliative care is certainly cheaper for the system. The vast majority of Canadians want to die in their homes, yet a very small percentage is actually doing so. Most are dying in the hospital. Should there be something in the accord?
Palliative care is not innovative; it has been around for a long time. In Nova Scotia, we have palliative care. Mr. Sussman, when I was reading your bio, I know that you were the COO in Winnipeg and palliative care was one of the things that fell under your jurisdiction. I am sure Senator Carstairs would have met with you at some point in time, since she is from Winnipeg.
Should this be part of the accord? It seems like it is sensible. It is what people want. It is inexpensive relative to keeping them in the hospital, and yet I do not believe it is happening as quickly as it should be happening.
Mr. Sussman: I agree with you that it is not happening as quickly as it should be. For anyone who has utilized palliative care, it is often at a very difficult time in peoples' lives; yet people are very grateful for palliative care and grateful to have this support to allow their loved one to die either at home or in a hospice. Sometimes it may be in a hospital because of the complexity of providing their symptom management, but it can be in a palliative care facility. However, most people die in hospital wards without access to palliative care resources.
It is something that needs to be expanded. It is particularly an issue in Manitoba outside of Winnipeg. We have a tremendous palliative care program in Winnipeg. It still needs some work in some of the community hospitals; especially in a tertiary hospital, it has not had the presence that it should in Manitoba.
We could go through a list and we could probably come up with 25 to 35 really critical things that require attention. I am a big believer that we have to do more palliative care, and that we do not actually ask the question and have the difficult conversation. We start treatments that will often have no real benefit because we do not have the conversation, and then we do not support someone in dying appropriately.
I do worry that the accord can become so diffuse with topics that nothing will be achieved. First, you will not be able to track all of those different things; and, second, the provinces will not be able to focus in that many directions.
If there are going to be specific targeted areas, they need to be focused. I think the seniors piece could deal with it; although palliative care is not exclusive to seniors, they are a significant portion of that.
Senator Cordy: It could fit in under that umbrella and not as a specific subset.
Mr. Sussman: Yes.
Mr. McNamara: Quickly, I differ a bit with Mr. Sussman on this. I think palliative care is important. One of the most costly times of service that we look at is end-of-life. That is extremely difficult.
We have expanded our drug program, or will be in the early new year, so that we will provide free drugs in the community to patients that are in palliative care. I know that other provinces have done it. It is a way to encourage people to stay home. Before, they went into hospital because otherwise they had to pay for the drugs.
Second, we have to do more at not letting people die in an orthopedic unit because staff there do not know how to look after them. It is not that they are bad staff; it is good people not having the correct training. We have to do a better job. For people that have done a great service to our communities, we have to figure how to provide that great service back to them at their end-of-life.
The Chair: On behalf of my colleagues, I would very much like to thank you for your frankness on the issues that have been put before you today. The range of answers that you have given have certainly broadened the evidence that we are hearing throughout this particular process and they have given us a real good sense of the provincial issue in this very important area.
A positive aspect coming out of it is you have both indicated that it is important for all the jurisdictions to now work together in moving forward. We will have the opportunity to see at least one of you again this week and perhaps have a more free-ranging discussion on some of these issues.
With that, thanks to my colleagues for the focus of their questions.
(The committee adjourned.)