Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology

Issue 13 - Evidence

OTTAWA, Wednesday, May 16, 2001

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 3:30 p.m. to examine the state of the health care system in Canada.

Senator Michael Kirby (Chairman) in the Chair.

[English]

The Chairman: Honourable senators, we are here to continue our study of the state of the health care system in Canada. We have with us today several groups who will discuss human resources. The witnesses are from the Canadian Medical Association, the Canadian Nurses Association and other health care professional groups.

The gentleman on my left, Mr. Steven Graham, is the Clerk of the Social Development Committee of the Northern Ireland Assembly. Mr. Graham is visiting to learn about our Canadian system so that he can take useful information back to Ireland. Mr. Graham, we are delighted that you are with us.

Senators, our opening session begins with the Canadian Medical Association, Dr. Peter Barrett. Dr. Hugh Scully from the Canadian Medical Forum, Task Force 1, and Dr. Thomas Ward, who is the Chair of the Federal/Provincial/Territorial Advisory Committee on Health Human Resources.

Dr. Peter Barrett: President, Canadian Medical Association: Honourable senators, as President of the Canadian Medical Association, I represent more than 50,000 physicians from across Canada. Our association has a twofold mission: to provide leadership for Canada's physicians, and to promote the highest standards of health and health care for Canadians.

The Canadian Medical Association has been following, with great interest, the work of this committee's inquiry into the state of Canadian health care. We are impressed with the committee's ambitious work plan and with the calibre of the representations you have already received. The CMA also commends the committee for scheduling today's session on what we believe to be one of the most important issues affecting the health care system in Canada today and in the future: namely, the state of health human resources.

When it comes to the issue of health human resource capacity, it is well known that the health care system is a labour-intensive service - whether it be physicians, nurses, technicians or other allied health care professionals, who are providing the patient care. In terms of proportion, it is generally accepted that over 70 per cent of institutionally based expenditures are allocated for health human resource requirements.

In the context of recent policy decisions taken by governments related to the funding of the health care system, physicians, nurses, allied health care professionals and administrators have had to make a series of very difficult choices so that they could meet specified budget targets. Health reform has had a significant, lasting and negative effect on all of the health professions.

Our presentation today will look at five elements of sustainability in connection with the physician workforce: the increasing workload of physicians; physicians practising in rural and remote areas of Canada; the challenge of access to physicians; the quality of life concerns of physicians and their families; and the issue of training and medical education.

The Chairman: I want you to cover all your points, but rather than take 20 or 25 minutes with a full presentation, could you present a summary? My experience has been that we find the question and answer session particularly helpful. We would appreciate that approach, if you do not mind.

Dr. Barrett: Certainly, I do not mind. We will start with the first element, which is workload.

We must ask if the workload that today's physician is contributing to our health care system is truly sustainable. The average physician in Canada is currently working 53 hours per week and an additional 25 hours per week while on call. Although many people may think that "on call" means that you are not at work, but you are close to work. Even though you may be at home while on call, the stress continues because there are things that you cannot do with your family; there are places that you cannot go; and so the stress continues.

For a number of physicians in Canada - almost 2,000 - there is no shared call. They are literally on call 24 hours per day, seven days per week, every day, every week, for years at a time.

I would like to mention one or two quotes from physicians. These will help to impart from the heart an understanding of the current status of physicians. The first one states:

I have practised family medicine for 10 to 12 years. Under the current health care system, I cannot possibly deliver the health care I am satisfied with. Most of my friends have a five-year plan to get out of medicine. It is a disgrace to see what is happening to the profession.

In short, it is difficult to be on the frontline in a service industry and have to be continually apologizing for the care that you can or cannot deliver. Almost every physician reports increases in workloads. They are seeing more patients; there are fewer physicians in their regions; they are doing more administrative work; there are more elderly patients and more complicated patients; and there is just more to do. We need help.

With regard to physicians in rural and remote areas, professional satisfaction is decreasing significantly, as you will see. We at the CMA are very concerned about the health care infrastructure in rural areas. The level of professional support is just not there. It is insufficient to provide quality care, and also to recruit and retain doctors who will serve to meet the needs of those communities.

We have, therefore, developed a policy that will be available to you. There are 28 recommendations in the policy. The three main areas of interest are: training, compensation, and work and lifestyle support. That policy reflects the needs and skills of physicians that will be practising in rural Canada, and it also reflects the needs of their communities.

To deal with the rural issue we need to see commitment and action by all stakeholders, including governments, medical schools and professional associations. We need to see that commitment urgently.

The third area concerns access to physicians. This is an increasing challenge. Most of the information is available for you to read, but I would caution you that this is not a rural problem. Most Canadians seem to have the opinion that the access-to-physician problem is a rural problem; it is not. As I have travelled around the country, I have heard about this in all areas. I have heard about it in the Yukon and in the territories, but I have also heard about it in Calgary, Toronto and right here in Ottawa.

The next one is a recruitment issue: access to everyday medical technology. I know that you have already had a presentation by the Canadian Association of Radiologists who emphasized that, so I will not repeat it. However, access to medical technology is a big problem here. That sort of frustration has led to physicians and other health care workers leaving Canada. Statistics Canada shows that health care workers have made up a disproportionate percentage of the "brain drain" to the United States. They tell us that for every 19 physicians that go south, one comes north. In the nursing profession it is almost as bad - 15 to 1. It is an increasing problem.

Right now, 24 per cent of the physicians practising in Canada are international graduates. In some provinces, such as my home province of Saskatchewan, 54 per cent of physicians are international graduates.

We have relied increasingly on physicians from other countries to meet our needs. That will be increasingly difficult to do. Dr. Scully will be talking about that. There is a worldwide shortage of physicians and health care providers.

The other thing I need to emphasize in this area is the entire issue of new technologies and expanding areas for treatment and the sort of services physicians can provide. Patient expectation is also growing, fuelled largely by information from the Internet. I keep warning people, be aware of baby boomers armed with information and attitude. They are about to hit us, and we are not prepared.

The Canadian Institute of Health Information has shown that per capita costs for patients or people aged 55 years to 74 years are 60 per cent higher than those of people aged 45 years to 64 years. We recognize that as people age, their health care needs rise.

It is not only keeping them alive. It is allowing them to live better. It is fixing their cataracts, giving them new hips, and that sort of thing. We realize that as the Canadian population ages, the need for health care services will increase.

In looking at the cost of medical services and what we as physicians will be providing, you cannot look only at today's numbers. Realistically, one patient now will be reviewed in terms of physician population ratios as 1.6 when we examine the needs of that older group.

In addition, the average age of physicians is increasing. We have been losing our young people. The Canadian Institute for Health Information also provides us with those statistics. By 2024, 40 per cent of all active physicians will be over the age of 55. The numbers of today do not reflect that. The physicians will not want to work harder, but many will be thinking about retirement.

The fourth issue is the quality of life concerns of physicians and their families. Doctors have spent their time telling patients and increasingly helping patients prevent stress and deal with increasingly stressful lives. In the meantime, we have not been practising what we have been preaching. We are increasingly discouraged with a system that we do view as resource poor, disorganized and, to a certain extent, overwhelmed.

Trying to balance a family life with the burgeoning demands of practice is adding to strain. Finding quality time for oneself and one's family is increasingly difficult. I would like to add that quote:

I can never make up the time I spend away from my family when my children were growing up. I would never have chosen another career, but I am glad my children have not followed in my profession.

Physicians traditionally were proud to have their children follow them in their profession. A recent study by the Alberta Medical Association showed that one in four physicians was actually actively discouraging their children to go into medicine. I always like to tell people my wife threatened my daughter she would shoot her if she married a doctor.

We also have to look at who will be practising medicine. As we look at medical school enrolment, increasingly, we are seeing more women. Fifty per cent of our classes now are female. Women traditionally are more caring individuals and have tended to want a better balance in life. We are not seeing that only from the women, though. We are also seeing that from our younger graduates. We will have to deal with that.

We must do something about medical education. Here is where the federal government can truly demonstrate its leadership and commitment.

Tuition deregulation has meant that tuition for our students is becoming prohibitive. If we do not do something soon, it will only be the sons and daughters of wealthy Canadians who will be able to go to medical school and choose a career in medicine. That would not do good things for our demographics in terms of distribution of physicians, as well as some of the cultural needs of some of our disadvantaged communities in Canada.

Furthermore, even though Dr. Scully will be talking about some successes we have had in increasing medical school enrolments, the reality is our medical schools have been strapped. Their infrastructures are rusted. They do not have the capacity to deal with an increasing student load. We must do something to help them.

There is something the federal government could do for medical education. There is a precedent in the "Health Resources Fund Report of 1966." We must ensure that the opportunity to train as a physician remains available to all Canadians.

Finally, health care has long been a competitive advantage for Canada in attracting business and investment. Our publicly funded health care system and those who work in it have provided Canada with that competitive advantage.

We acknowledge the good work that the federal government has done in funding sector studies through Human Resources Canada and by the pending funding for the proposed study on physician needs to be forthcoming by my colleague Dr. Scully. He will talk more about that in his presentation.

However, we need to go further. We need, as a country and particularly as a government, to provide for and encourage flexibility so that we can do cross cutting multidisciplinary needs assessments with an application to the entire workforce.

We must realize that health care, like many other things, is now a global commodity. It is part of the knowledge global community now. Like other sectors of the economy, if we are going to compete and succeed, we must provide an attractive environment to not only retain but repatriate the physicians who have left. If we are serious about a world class health care system in Canada, we must provide an environment that will attract world-class people and retain the world class people that we train.

The deterioration of working conditions, inability to provide the patient care they were trained to provide, lack of access to health care technology and lack of other health care providers and, to a certain extent, lower fees and higher taxation have all led to that less competitive environment. In fact, when I met with the Consumers Association of Canada, they suggested to me that our health care system was no longer a competitive advantage.

Government must recognize that this issue is not just a workforce issue. This is an issue of competitiveness. We must look to other sectors of the economy and other countries to learn how they adjusted successfully to the complexities of attracting and retaining their workforce in today's global marketplace.

I would like to thank the committee for inviting us to appear today. We trust that we will have further opportunity to appear before you. You are doing good work and this is an important study. We would like to help in any way we can. Thank you very much.

Dr. Hugh Scully, Co-chair, Canadian Medical Forum Task Force I: I would like to touch on a few of the items that Dr. Barrett identified. Then I will focus on what it is that the profession as a whole has been doing working together and with others to try to address the issue of the workforce of physicians in Canada.

There is an organization known as the Canadian Medical Forum. The membership and the listing are in the text that you have. It was created to coordinate approaches and activities among the nine national medical organizations in terms of things that we have in common. One of those being education, one of those being access and quality, and another being the renewal of the workforce.

The membership is made up of the organizations, as I pointed out, but I would emphasize that it includes students, residents, deans, practising physicians, licensing authorities, the teaching institutions and the hospitals. It is a broad spectrum.

Being concerned about what was happening with workforce as we saw it, both in the workplace, as Dr. Barrett pointed out, and in the education enterprise, we came together in 1999 to form the first of two task forces. It was called "Task Force I", anticipating that we would be moving beyond that point. We were trying to address some of the short- and medium-term problems that we could identify.

Lorne Tyrrell, who was and is the Dean of Medicine at the University of Alberta and the president of the organization of deans, ACMC, and I as the president of the Canadian Medical Association had the opportunity of co-chairing Task Force I. Lorne Tyrrell and Dale Dauphinee wrote the report.

And as a matter of record, Mr. Chairman I think that you have the full report available and an executive summary in the material that you have. There is no point going through that in great detail.

We realized that we needed to identify a continuing mechanism to examine what was happening with the workforce in light of changing health and health needs, expectations on the part of the public, physicians, nurses and other health professionals and the environment in which we are working.

That is the basis upon which Task Force II, which is now up and running. Interestingly, it has some terms similar to those of your committee. We are looking forward to working with you in this connection.

Task Force II is looking at models of care, different ways of delivering care and the team approach to care. We are taking into account changes in information technology, technology and medicine, and the explosion of knowledge that is occurring in the medical arena.

Task force I was trying to address what was happening with physicians in training and physicians in practice. We came up with a number of recommendations that are outlined in the report to you.

There had been, by way of government policy decision, a cut back in the funding of undergraduate medical positions across the country of about 10 per cent as a consequence of a report commissioned by the deputy ministers in 1991. At that time, the ratio of physicians to the population was 1.9 physicians per 1,000, or in round terms, about one physician for every 540 Canadians. As has been pointed out by others, that ratio has been maintained until the present time. I will return to the issue of ratios because that is not how medicine is practised.

As a consequence of that recommendation, and due to several other factors, enrolment in medical schools was reduced by 17 per cent. One of the mitigating factors was that the post-graduate deans and program directors at medical schools did not have sufficient flexibility to identify areas of need and address them. There was also some resistance on the part of some of the medical societies and associations across the country, also with capped budgets, to having more physicians come on stream because of the dilution of the pool.

The causes were multi-faceted, but the result was a 17 per cent reduction in enrolment. By 1997, there was less opportunity for a Canadian to go to medical school than for any person in any other developed country in the world for its population. That is an important concept to have in mind.

Task Force I thought that Canada should be reasonably self-sufficient in the production of physicians as we moved into the future. That is not to say that we would exclude qualified international graduates in any way. As Dr. Barrett pointed out, we have a rich heritage across the country of international graduates who contribute significantly to the quality of health and health care in the country.

Our first recommendation was to increase the enrolment in the medical schools to the tune of 2,000 by the year 2000 without coercion. That is, there should not be unreasonable demands on return of service for enrolment in medical school that does not apply in any other area where there is graduate education.

We thought, also, that we should do what we could to enhance recruitment, retention and repatriation of Canadian physicians. Dr. Barrett mentioned the immigration that had taken place. We are talking about a net loss - not just certain people go away and come back. I know that I did that, and others did that. I know Senator Keon came back. We are talking about a net loss, which over the course of the decade of the 1990s, was more than 4,000 physicians - most of whom had departed within ten years of the time of their graduation. These were bright young physicians who left, in large part, because they could not practice what they were taught to do. The money issue was there but that was not the most important issue.

Forty per cent of the people who left have retained their licences in Canada. If we could create an environment that is attractive for those young Canadians to return with their families, we would be in a good position to address in the short- and intermediate-term some of the shortages that we see.

We need to do is to make it attractive for Canadians to stay here. With CIHR, the academic establishment has reversed the brain drain a significant amount. That has been a healthy move, and one that we strongly support. We continue to lose two medical class school equivalents a year as a net loss to the United States.

The next recommendation was that we increase the post-graduate training complement as well. The details are in the report. We noted three main issues in the report.

First, flexibility of career choice for medical graduates should be increased so that they could move into areas of need rather than being channelled, as they are at the present time, into areas where they may not wish to remain.

Second, the debt load of studying medicine should be better managed. About 50 per cent of specialists were general practitioners for two years or four years to pay off debts. Dr. Barrett made reference to the debt load - many of us had debt load when we came out. These specialists would enter a speciality practice after their debt load was lifted. That was true in obstetrics, paediatrics, psychiatry, and radiology, to name a few. Those positions were closed down.

Third, the graduate complement would need to be increased. We once had a much better capacity than we have at the present time to validate the international graduates who were qualified. Those men and women from other countries who have been well educated and pass the same kind of qualifying exams as Canadian medical students. That is important in order to ensure quality and delivery of care in the country for the Canadian public. If we increase the post-graduate complement, we could address those three issues.

We also need to set up an ongoing method of monitoring what is happening. Your efforts in this arena are certainly appreciated. CIHI is getting increasingly involved. Task Force II, which is not just the profession, is looking at that. I know that the deputy ministers and Dr. Ward will be addressing some of these issues. Things are moving in the right direction.

Finally, we need to be able to address distribution and mix of physicians. One of the issues in terms of quality of life that Dr. Barrett mentioned and the ratios that I raised, is that it is not just the number of physicians, it is what is happening. The body of knowledge is doubling every 12 months to 18 months.

There is not only a gender difference in terms of what is happening in the profession - about 50 per cent of the graduates being female. Most female physicians carry the greatest load in terms of family life and do not see as many patients during that period of time as their male counterparts. There is a clear generational difference, as well. The young male physicians graduating are not interested in working the same way that many of us around the room who are physicians did when we first started.

That, unhappily, is reflected in what happened this year in the match for medical graduates coming out of Canadian medical schools. In the surgical disciplines, in particular, we did not fill the slots. The message is clear. They are not prepared to work that hard. Dr. Barrett mentioned the 53 hours of work per week; the average workweek for an orthopaedic surgeon is 64 hours per week. For a thoracic surgeon it is 76 hours. In addition, there is call time. You begin to think about what that mean this is terms of what time you have left over for anything else.

We recognized that we needed a new paradigm, a new way of looking at it and a partnership modelling with others. This was the basis of the formation of the second task force. TaskForce II initially focussed on models of care and models of delivery. As we consulted with HRDC, we consulted more effectively with the deputies and the federal government than we had before. The federal government has been very helpful. We consulted with nursing, pharmacies, and lay representatives such as Louise Simard, a former health minister and now involved in regional care in Saskatchewan. We worked with Ray Hnatyshyn, former Governor General and a Member of Parliament.

With that kind of input, we could broaden the impact. We are now interested in working in a collaborative partnership with other health sectors as we look at what the needs are going to be, projecting into the future, so that each of us can draw down into the area with which we are particularly concerned. We want to work in an open and transparent way with others so that we develop the models and the teams that we will need.

We could talk about relative roles. We could talk about ours; and others could talk about theirs. We need to talk together.

How would these costs be paid? What are the best ways of delivering care? There is no particularly "best way" of paying for some things, but a blend is what we, as a profession would support.

There was a significant reduction in the funding of the medical education enterprise - undergraduate and post-graduate - as a consequence of the decisions taken in the 1990s when the deficit was being addressed. There needs to be infusion of money back into the system. Dr. Barrett made reference to the fact that there was significant participation by the federal government in the late 1960s, as new medical schools were opened and others were expanded. We are talking about expanding the existing schools; as you know, there is some discussion of another school in Ontario. However, that discussion is very much in the early stage.

If we are to have the teachers to do the work and the resources, both capital and physical, that we need, there needs to be some infusion. We think that the federal government can play a significant role in partnership with the provinces and the territories.

We need to examine the range of existing models and speculate about where we might go with new models. What are the long-term implications of this as far as physicians are concerned, because that is our area of expertise and particular interest? We must work with others and recognize that that may be modified, depending on how care is delivered, who delivers it where and under what circumstances and how we do referral, as technology improves and changes.

We also need to know what the options might be on the long-term basis of where we are going. We have proposed three phases. The first is to examine what we have and where we think that will take us. The second is to look at the different factors that affect physician supply. We have mentioned many of those between us as we come along: the environment, the working place, the resources, the technology, the information and so on. How will those factors affect us? For example, what will genomics do? The third is to develop strategies to promote a constructive, positive physician workforce, as we work with others to craft a future - the kinds of strategies that we can develop together.

The profession does not pretend for a moment that it can or should do it alone. This is not a patriarchal system; this is a partnership where we can have the input of our professional expertise, as well as input of the public's and the government's needs as well as input from other health professions.

There are no quick answers or quick fixes. Your committee has set an ambitious time frame for its work. We believe that this will take two or three years, but we can have a great deal of information within one year regarding the direction that we should take and how we can do that constructively together.

I emphasize a point that Dr. Barrett made, about which we have been gratified over the last few years. During the latter 1980s or 1990s, it was rare for leading physicians, nurses or other health care providers to be involved in discussions on policy in health care. That changed about one and one-half years ago. We are pleased about that, because the best way to plan for the future is to involve the people who are actively working in the field. We welcome discussions such as this, and we welcome the opportunity.

At the end of the day, good communication and strong alliances and partnerships will be the keys to our success. Thank you.

Dr. Thomas Ward, Chair, Federal/Provincial/Territorial Advisory Committee on Health Human Resources; Deputy Minister, Department of Health, Nova Scotia: Honourable senators, I am the Chairman of the Advisory Committee on Health Human Resources. I am unique as a Deputy Minister in that I have been a practising physician and health care administrator. I have also been in the hallowed halls of government for one and one-half years, which is pretty much the life expectancy for most Deputy Ministers of Health at this time. This may be my last visit.

Last year, I took over the ACHHR because I thought that one of the major challenges facing our system was in health human resources. We look out and see an aging workforce and increasing demands, but we do not see a plan in place to supply that workforce at the end of the day. It really will not matter how much money we have if we do not have the professionals at the bedsides or in the community clinics to care for people.

As Dr. Barrett and Dr. Scully have pointed out, there are issues related to physician recruitment training, retention and renewal in that workforce. Over the course of the day I am sure you will hear that the same is true for all members of the health care team. We are heading into a desperate time.

At the level of ACCHR, I have stepped back somewhat, and with the help of the committee and others, we have identified three strategic themes or thoughts that need to be dealt with now. The first is to have a discussion about an overarching approach to dealing with the health human resource problem in this country. Throughout jurisdictions, a number of studies are underway, either at provincial or national levels, including a physician component that is currently being done. In my own jurisdiction we have a group doing a home care sectoral study around home care workers. There is really no strategy or approach to these; somehow, we weave all of these pieces together into a comprehensive approach to the issue.

The second theme, as Dr. Scully has pointed out, is issues around models of care - different ways of delivering care and services. There are numerous publicly funded health care systems in the world that we should look at carefully to see how care or service is delivered in the various venues. Quite frankly, we should take the best from them if we think that they will work here, or we should at least pilot them in our system.

We need to have broader conversation with Canadians about other options for care. Certainly, if we look at both the report from the Claire Commission and the report from Ken Fyke in Saskatchewan, we see that they both promote new approaches to the provision of care at the community level.

The last theme is really to try to understand the impact of knowledge and technology on the population, particularly if it is well applied. The recent CIHI study was completed and spoke of the variability of care across Canada. In my own jurisdiction we have a cardiac care program called "ICONS," in which people are celebrating the success of getting up to 75 per cent of appropriate treatment for individuals with acute myocardial infarction.

For me, the challenge is about what happens to the other one-quarter of the population that are inappropriately treated. Is that the percentage of people who will end up with poor cardiac function, repeated episodes of cardiac failure and repeated hospitalizations? What will be the impact of appropriately applying care and technology to the 100 per cent level? What will that mean for the workforce of the future?

ACHHR is a committee that provides policy advice to all levels of government on not only the health care system but, ultimately, the education system. We are certainly pleased with the support in terms of the resources being place into CIHR, the Canadian Health Services Research Foundation and the Canadian Institute for Health Information. However, there needs to be more emphasis placed on the issue of health human resources - the research and the planning pieces. This is, from our viewpoint, an urgent problem.

We only need to realize that a student entering medical school this fall is probably about ten years away from practising. That is when the baby boomers will be retiring. The time frame of two or three years will pass very quickly, and I believe that we must act aggressively during this time period. We must continue the current dialogue. As both Dr. Scully and Dr. Barrett have pointed out, communication is absolutely the key to this. The view from ACCHR is that we will talk with anyone who can offer any help with this particular issue. Again, we welcome the opportunity to meet with you today and we would be pleased to answer any questions.

Senator LeBreton: My first question is directed to Dr. Barrett. When you talk about physicians having five-year plans to leave medicine, that is very revealing. One of the areas of concern is the entire issue of access to physicians, especially for the aging population. A week does not go by that we do not hear of someone's plight about a doctor retiring and how difficult it is to find a new physician. This is a serious issue. Has there been a plan worked out to address this problem? Where do we start? How do you deal with a situation like that?

Dr. Barrett: First and foremost, that is exactly what we do need. We need plan, we need a strategy as mentioned by Dr. Ward. We could start with a national strategy because it is a national problem. I realize a lot of health care is delivered provincially and territorially. First and foremost, we need a national plan.

This is an urgent problem. The numbers do not tell everything. As I have been around the country, I have seen situations where if one more person were to leave, the entire program would collapse because of the on-call and clinical loads. Those that would be left behind would have untenable loads, and they, too, would leave.

The problem is that is easy for them to leave. They can go everywhere. Everyone is looking for physicians. There is a big recruiting effort in the U.K. currently. The Americans are now recruiting off-shore.

Dr. Scully: I am representing Canada on the board of the World Medical Association. I am chairing the world working group on the mobility of physicians. You are not supposed to do that in your first meeting, but that is what has happened. There are 172 countries in that organization. The question of physician and nursing resources is critical to all countries. Canada traditionally would draw upon the U.K., South Africa, and some of the European countries for its medical graduates. That source has in large part stopped, not all together. Those countries are working earnestly to try to retain their own physicians and make it attractive for them to stay. The sources that we have had are not there. That is the short term.

We do need the national plan. The recommendations of the task forces about how we go about building up the undergraduate and post-graduate complement and focussing on attracting people to stay and return are critical. We need these actions because of the aging physician population and increasing number of retirements. That is an issue across the country. I am emphasizing what Dr. Barrett said.

Senator LeBreton: In your paper you spoke about the need for increased medical school enrolment. You said "2,000 by 2000" from 1577 currently. As Dr. Barrett said, we have a population armed with information and attitude.

If we were to have more people enrolling in medical school, who would teach them? With the new technologies, are teachers able to teach them? Are teachers able to keep up with the new technologies? Are doctors going to go back and start teaching?

Dr. Scully: I would like to be able to tell you, and it is true enough, that Canadian physicians are at the forefront in terms of advances taking place. It is a good country in which to get cared for when you get there. The quality overall is very good.

One of the points that we brought out is that the physical resources and the people needed as teachers will need to be supported also. If we are to increase it, we need more teachers. That is true in medicine, nursing and in other areas.

We cannot merely say that we will increase enrolment by 20 per cent do it if there are no resources to do it. This is where we think that the federal government, which had a partnership role before, could play a role.

We were somewhat disappointed that this was not mentioned in the first ministers' press release. I understand the dynamics much more between the federal government and the provinces and territories.

Senator LeBreton: How do they stay abreast of the changes in technology? Who teaches the teachers?

Dr. Scully: There are many post-graduate programs. We have by way of re-certification, assured the public that we are staying on top of the curve, or at least not getting behind it. Programs are exist in continuing medical education and teaching teachers how to teach and making sure that they are up-to-date with what is happening scientifically.

Dr. Ward: As a follow up, when I look at the health human resource, for me there are three pieces. One of them is renewal. How do you keep the workforce educated? Given that medical technology is changing at the rate of probably less than a year for doubling of knowledge, it is incumbent on us to design a system that actively encourages and supports every health care professional to be continually updating and upgrading.

The second piece is designing a system that keeps people comfortable. We need a system that allows people to enjoy their jobs. The last piece is recruiting people.

In my jurisdiction of Dalhousie, two-thirds of our faculty, the department of medicine, will retire in the next 10 years. One hundred and sixty-eight of 240-odd-faculty members will also be retiring. There is nobody coming up. The challenge for us is not only maintaining a physician workforce; it is trying to maintain a medical school.

As Dr. Scully has pointed out, these are very expensive propositions. Our current training cost guesstimate is about $50,000 to $70,000 per student, on top of that is post-graduate work.

We are talking about a significant public investment and public policy. We have that issue. On the other hand, we have the agreement on internal trade in this country that sees our medical school in the Maritimes primarily as net exporters of professionals to the rest of Canada, simply because of wage differences. Governments are caught betwixt and between.

Is it a good investment of dollars to train someone if they are not willing to stay or if the job makes them unhappy?

Dr. Barrett: I am passionately Canadian. I believe that we have a tremendous advantage in this country. The UN regularly tells us that this is the best country in which to live. I have recently become a grandfather. I can tell you that when young people leave this country with their children, they are leaving the grandparents behind as well. There are tremendous ties there.

If we could get it right, we would have a tremendous advantage. This should not be a problem in this country.

Dr. Scully: One of the things that I did not bring out in my comments is that there has been more movement on the part of the medical schools and the establishment in the last 18 months than in the last 20 years. There has been some increased enrolment, at the undergraduate in particular, the post-graduate and the re-entry and the validation of international graduates. It has not advanced more than it could have, relative to the recommendations made, because the resources are not there - the physical space or the people. We do need to focus on this in terms of what we do.

I will give you an example of how compartmentalized funding can be aimed properly, but does not have the desired effect completely. The cardiac care network in the Province of Ontario, on the basis of evidence, led the government to increase the funding for cardiac services for the hospitals, but not for the people. We did not get to the target. We made advances. We did not get to the targets desired because we did not have the people; this underscores the point that Dr. Ward made. We need to have the people if we are to get there.

Senator LeBreton: You talked about pilot project space and experience in other countries, Dr. Ward. Could you give us one specific example of one pilot project that you might have been thinking about?

Dr. Ward: In New Zealand, in particular, they use a system of specially trained nurses at the community level called Plunket nurses who are running community clinics.

The Chairman: What was that adjective?

Dr. Ward: Plunket.

The Chairman: Is that someone's name or an acronym?

Dr. Ward: They are called "Plunket nurses." That system has been reasonably successful in those jurisdictions. We certainly recognize that in other jurisdictions midwifery programs carry the bulk of obstetrics. There are other things at which we can look.

The urgency or the opportunity in this country is remarkable in the sense particularly of rural jurisdictions. In Nova Scotia, we have two islands in the southwest - Long Island and Bar Island - that have had neither physicians nor nurses for the past 18 months. We provide service with Emergency Medical Technicians, EMTs Is that the optimum? No, it is not, but we are just trying to figure out a better way.

Senator LeBreton: If we do a videoconference with New Zealand, perhaps we can ask them about Plunket nurses.

The Chairman: One supplementary on the basis of your last comment. The perception some of us would have, it seems to me, is that you spoke about the silos. It is extremely difficult to convince various parts of the health care professions to agree to hand over additional responsibility to other parts of the health care professions. Even if one were to decide that it would be wonderful to adopt the New Zealand model, I can imagine how difficult that would be to implement in Canada. I have some knowledge of the negotiations that have taken place at the provincial level, and I can imagine how difficult it would be precisely because of the silo mentality of the various professions. Is that an unfair comment?

Dr. Ward: It is fair to say that it is of concern in certain areas. Certainly, we have been relatively successful in trying to move to an integrated health care system and break down the walls of the hospital. However, we have run into, on occasion, the professional silo issue. That can be overcome.

If we sit down and begin dialogue about different models of care and about how teams might work, and if we gain focus on how individuals can support each other, we will be successful. All of us know that. We have worked in intensive care situations in which we have been parts of teams, and those teams work well. The challenge for all of us is to figure out is: if we can work at the bedside in a critical situation, whether intensive care or coronary care, effectively as a smoothly functioning team, then how do we move that out to the community level? How do we make people comfortable in that?

The Chairman: Do you mean to move it down to the primary care level?

Dr. Ward: Yes. There was a survey last fall in which, when Canadians were asked if they would rather receive their care from a family physician or from a primary care team that included a family physician, their response was 4 to 1 in favour of the team. They would much rather have a team of health care providers.

Dr. Barrett: Clearly, there will be an expanded role for other health care providers. They are better educated than they were in the past and the CMA recognizes that. We have put together a paper on this, which will be presented for consultation with the nurses and others. It should be ready shortly. The College of Family Physicians of Canada put out a paper in October 2000, in which they talked about the family practice networks. The silo mentality is coming down. Frankly, physicians, nurses and other health care providers work very well together on the frontline, it is just taken their organizations a little while to get together. However, that is currently happening.

Dr. Scully: We are working diligently on the silos within the medical profession itself, as we work more effectively together. We ask what young physicians would like to do, and I always return to that. They want to work in teams and in partnership, rather than in solo practice, by and large. In that way they are able to plan a more constructive life for themselves and their families, and they can then benefit from the cross-fertilization that takes place among other disciplines.

We have five nurse practitioners in our service, and we would not have the physicians otherwise. It is a very effective team. We are increasingly moving into the community with home care programs for continued cardiac care for people. There is plenty of work for everyone, so there is enough room to move.

Senator Robertson: I might suggest to the committee members, and perhaps to our witnesses, that rather than go to New Zealand to look at the Plunket system, we might just look at New Brunswick's extramural hospital system. There you would find that perhaps it is an even better system than the Plunket system. There is much happening around us, and so often we overlook what is in our own backyard. We think that someone else has something better, and that is not always true. Anytime any of you want to come to New Brunswick, please call me, and I will be glad to take you around to show you the system.

The Chairman: Some of you may not know that Senator Robertson was the Minister of Health in New Brunswick for some time.

Senator Robertson: When the extramural system was introduced, we went to New Zealand. When we returned, we did some copying of their system. Dr. Keon has heard me on this before.

Dr. Scully, you talked about 2,000 medical students by the year 2000 or so. Is there an ideal doctor-to-population ratio in the minds of your committee members?

Dr. Scully: First I will make an editorial comment. I had a good opportunity to look at the New Brunswick model and I agree with you that it works well for New Brunswick. However, one size does not fit all areas of the country; we need to be flexible. We can learn from other jurisdictions and what they have done, but we do not have a specific ratio.

Barer and Stoddart recommended in their report in 1991 - which contained many good recommendations that were not followed up - that Canada should try to maintain a ratio of 1:9, which is at the low end. In the material that you have before you, you can see the developed country ratio of physicians to populations.

The problem with ratios is that they do not tell you what people do. The 1:9 was okay 10 years ago, but look at what has happened in the field of technology, and to knowledge, attitudes and expectations, and the population since that time. People are living better and longer, and they are living better as they live longer, but it still costs more money for that group; and that is more labour intensive for physicians, nurses, volunteers, social workers and so on in the community. We need to adjust what is happening with the ratio and the numbers according to what is happening with the knowledge and the population as we move forward. There is no particular fixed ratio; we are below 1:9. With the recruitment that is happening in the United Kingdom, Canada is at the lowest end of the scale of all of the developed countries. We certainly know that we do not have enough.

Senator Robertson: We are at the lower end of the scale.

Dr. Scully: We are at the bottom of the scale.

Senator Morin: There is a good quote on page 8 that shows very well where we are situated.

Senator Robertson: We will have an opportunity to look at this documentation later. Those are disturbing figures.

Dr. Ward, you mentioned the percentage of medical school students in our two Maritime medical schools. How many doctors are remaining of those students?

Dr. Ward: In the last couple of years, the retention rate for Dalhousie graduates, even if they left the province and returned after post-graduate training, was 39 per cent.

Senator Robertson: In the work that you gentlemen do, you talk about the delivery system, but are you also making recommendations about teaching Canadians healthy lifestyles? Do you recommend the preventive approach? With the cuts that so many of the provinces have experienced, nurses were actually being removed from the schools. Instead of a teacher calling a mother and saying, "I think Johnny has the measles," mother would take Johnny to the out-patient clinic and tie up those services.

You have alluded to a strong body of thought that believes that hospitals of the future probably should deal with life-threatening circumstances or invasive circumstances. The rest, as much as possible, should be delivered in the workplace, the school or the home. Is that a general direction of which your profession is supportive?

Dr. Barrett: Yes, but you must understand that that has happened already. The intensity of illness of patients in hospital now is far greater than before the cuts in the mid-1990s. Much of health care was off-loaded to the community and to employers and spouses. That is not covered under the Canada Health Act.

Drugs were provided free under the Canada Health Act in hospital. The patient must now purchase them in the community. That is already happening. There has been that shift to the community. In some cases, however, the community certainly at the time, and to a certain extent still now, was not ready for that.

Senator Robertson: That is right. They were not ready for it. Merely because the patient is not being dealt with in the hotel/hospital is no reason for governments to withdraw their support for medications for prescriptions and other things. That is another area. The committee must review this entire area.

As long as we restrict certain benefits to the hospital, it would seem to me, many patients and doctors will be discouraged from placing the patient into the community, especially if that person is not able to afford the medication when they leave the hotel/hospital. The burden increases if they have to pay for nursing care and other things.

We are struggling along with an obsolete structure that must be rethought from top to bottom if we are to get the satisfaction for those of you who are working in that structure, whether it is at the medical level, the nursing level or the paramedical.

I appreciate what you say. Many people have left. If we were to walk through hospitals today, we would find many patients who do not need to be there. They are waiting for placement in a nursing home, or they are waiting for a service at home, or something else. I think that government - and you may disagree with me - has made regulations and rules so complex that it is difficult for staff, doctors, nurses, and discharged people to get through them.

Dr. Scully: You have identified a real concern that is out there. Dr. Barrett emphasized this.

As I look around to the other countries in terms of access, I am not sure that we need to rework the system from top to bottom. This system still provides better access to more people with fewer barriers than any of the systems that have I seen around the world. That said, we have some huge problems. There is no question, and that is what we are trying to address together. We can provide information; you can give leadership and direction. I think that we can work at it together.

The community base was not built up at the time that the hospital base was cut back. I would be interested to know how many people running hospitals think of them as hotels, but that is an interesting analogy. They do not have the amenities of hotels. But they got expert service when it can be put together.

The commitment to public education is strong. We have many committees that do work in those areas. What tends to happen is that focus on our acute problems is what gets the headlines. All of the medical organizations - the CMA, the Royal College, and the College of Family Physicians - have well-developed programs for public education. These programs, in partnerships with Health Canada and the provincial and territorial govern ments, create Web sites and information sources for patients and their families. The purpose is to better inform them so that they can do a better job of looking after themselves and, hopefully, stay out of those hotel/hospitals to which you referred.

Dr. Ward: When the hospital sector downsized, there was no funding put in place for the transition to the community and no investment in the community. In the absence of nursing homes, well-developed home care programs, hospital in the home programs, and the extramural hospital in many jurisdictions, there is no facility or service to which people might go when they are ready. At the end of the day, the patient's well-being comes first and foremost, therefore, they are kept in hospital.

Much more could be done in the area of public education and wellness. There needs to be significant investment particularly at the school level in terms of activity and lifestyle. The rate of obesity among young children in Canada has tripled in the last decade. That is astounding; it is absolutely staggering. We need to reverse that. We must somehow help individuals or communities to increase their capacity to care for themselves.

I see challenges for groups like the CIHR. There has been a wonderful investment in terms of building up the research arm and academic side, but it is all directed towards the biomedical basis of disease and diagnosis intervention. There should be matching investment in wellness and health promotion. There should be matching investment in dealing with the system and the health human resource problem before us. To me, that is important social research that needs to be funded. We need to get on with that.

The Chairman: Senator Callbeck is another former provincial Minister of Health and former Premier of Prince Edward Island.

Senator Callbeck: Dr. Ward, you mentioned three themes with which we must deal. One is issues around models of care. In answer to Senator LeBreton, you mentioned New Zealand as an example. Do you have any other examples? You said we should be looking at other countries. Could you be specific there?

Dr. Ward: As was pointed out, it is not only an issue of dealing with jurisdictions outside of Canada, it is really looking at pilot projects and specific opportunities in Canada.

It is interesting to most people that we immediately look at other jurisdictions without stopping to think about what is happening in this country. If we had a Web site on which people were putting on their best practices or their ideas, I think that we would astound ourselves at the innovation that is occurring in this country.

We have community health care centres in Nova Scotia that have unique programs fitted to their communities. They are providing care and are linked to other hospitals that have complements of physicians who come in and visit. They have special programs. They can convert long-term beds to observation beds to support people.

There are many things that are being done in this country, and we do not celebrate these things. We need to look at that.

One of the advantages of looking at other jurisdictions in a frank and honest way is that it would begin a national dialogue about what is good in our system, what is really effective, and what are obstacles in terms of care or what things we might do better.

It would present some options. It is much easier to have a discussion if someone says, "have you thought about doing it this way?", than simply "can you think of a better way?"

Dr. Scully: I would comment that that is phase I project for the expanded Task Force II. We will look at the experience and excellent models across the country, so that there is a range of options or a menu of things that could be chosen to fit different circumstances. We could learn from best practices and move forward from there.

Senator Callbeck: Could you comment on the telehealth applications? Do you think we should be more aggressive in this area? Where do you see this system ten years from now?

Dr. Barrett: That whole area of information technology and telehealth can enhance the health care system immensely. We have pilot projects in Saskatchewan that are run out of the University Hospital. Northern Saskatchewan saves enormous amounts of money because that system reduces the number of people who are required to travel to see a physician. In Canada, where distances are so great, there are tremendous opportunities for such a system. There is also a telehealth program at the University of Calgary, one at Sick Children's Hospital in Toronto and there is one in Nova Scotia. There are many programs out there and they are in the evaluation stage.

Canada has not, as a country, invested much in health-related technology and in conactivity. We had requested that prior to the first ministers meeting, and we were pleased to see that there was a modest investment there. If you look at what the industry spends in general, it is around the 6 per cent or 7 per cent range. With the total health bill of $95 million, we are considerably short of that. I have said repeatedly that we need innovation and ideas as well as money. However, many of those ideas will require up-front investment and we must consider that.

Dr. Ward: In many jurisdictions telehealth is the way of the future, particularly with web-based technology. We use it to support the emergency room physicians. We have also found it to be absolutely invaluable in using the services of our two dermatologists in the province, by having the images of individuals with skin lesions transmitted to Halifax. The doctors can see 60 patients per day without travelling across the province; and the patients do not have to travel to see the doctors. It has proven invaluable in supporting the children's hospital in their delivery of psychiatric services throughout the Maritimes. Providing such conferences for health care teams and families has been invaluable.

Certainly, in the United States, telehealth, or the management of kids with asthma using computer systems in schools, has shown a remarkable decrease in hospitalization and improvement in wellness.

We must understand that our society is becoming much more visually oriented in terms of knowing and knowledge. In the Maritimes we have a significant problem with literacy, particular ly in the adult population. Most people leave school at a young age to work on the fishing boats or in the mines. That population can be maintained at home through the opportunity for some sort of interactive link through television sets. The technology is there such that someone at the other end - a face - can answer a question, and it does not require someone to sit down and read through some technical document. It will be absolutely invalu able. It is a significant tool for the provision of service in the future.

Senator Callbeck: This would be one of the priority areas in the health care through investment.

Dr. Ward: In our own jurisdiction, we are moving to a province-wide information system. We have an advantage in that we have our own fibre-optic system that serves the entire province. It is not owned solely by government, so it is not a public network. We view that as being the backbone to our health care system in the future.

Senator Callbeck: On the subject of doctors from foreign countries, you mentioned, Dr. Barrett, that 24 per cent of doctors practising in Canada are international medical graduates. I believe that you said Canada issues 400 temporary licences to foreign- trained physicians. Do we aggressively go to those countries to recruit those people, or is it just that they are anxious to come to Canada and so they apply?

Dr. Barrett: Both. However, jurisdictions in Canada have aggressively recruited those individuals. I do not know where we would be without them, frankly. One could argue this on an ethical basis as this becomes a worldwide problem: Is this the direction we should be taking - robbing one country and then it robs another and so on down the chain, as it were? Ultimately, that is not the way we can deal with the problem. Dr. Scully may want to speak to this. It was an issue at a recent World Medical Association meeting.

Dr. Scully: One of the issues that arises is that of the ethics of poaching someone else's resource. Never mind what it costs in our tax dollars to educate our professionals - physicians, nurses or others, and what that represents, by way of loss in trade that occurs as people move south. Dr. Ward made reference to the costs of educating a medical student at Dalhousie, and those costs vary across the country, but it is an expensive venture.

Canada's "melting pot" has added to the richness of this country. That is true in many areas. We hope that we would continue to draw excellent physicians from elsewhere around the world, but we must come back to the point made earlier that we should be self-sufficient with all of the strategy that is constructed around that.

The issuing of temporary licences bypasses the academic validation of those individuals. That gives us concern in terms of the standard and quality that will be there at the end of the day for the populations being served. Many of them are good, but we would like to be sure that they are all good, just as we do for our own graduates.

If we find ourselves in a situation of shortfall, where more and more temporary licences are being issued just because there is a shortage, that quality issue becomes a paramount concern. We will look at that as a group and look at it with the licensing authorities across the country.

The Chairman: Senator Morin, please, and then Senator Cook on the Newfoundland experience.

Senator Morin: I thank Dr. Scully for his excellent contribution. I would also like to recognize Dr. Michel Brazeau of the Royal College of Physicians and Surgeons, which is an important player in this country as far as medical manpower is concerned.

My first question is for Dr. Barrett and Dr. Scully. Last week we heard that health care costs have increased by 7 per cent and have now reached $96 billion. We are just behind Germany and the U.S., but third around the world.

Are we spending enough? Are we spending in the right places? If not, where should we spend?

To Dr. Ward, as a representative of all provinces including Quebec, Ontario and Alberta, what do you think the federal role is in a workforce policy?

Dr. Barrett: We could spend more, but money alone will not solve the problem. Certainly, as we look around Canada we realize the percentage of the overall provincial budgets that are eaten up by health care - often at the expense of education and the environment.

We talked about physician workforce, but the reality is that this country is looking at a huge problem in terms of skilled workforce in the future. We cannot cut investment in education. We could spend more, but it is time to look for innovation and ideas. Some of that may require up-front investment. However, in the long run, perhaps we could do things better and cheaper with conactivity, with increased available evidence and some of the ideas that I have heard about today such as telehealth. There are ways of delivering quality care that may not require the tremendous expense. We have to hear the innovation and the ideas.

Dr. Scully: The simple answer is that nobody knows what is enough. The new definition of "universalism" at the World Health Organization is a level playing field for the people in a society in which they live. Everyone is assured of reasonable access to the services and the resources that are available in that country.

One of the reasons that we did not rank as well in the international rating of the WHO in terms of our health care system was the patchy nature of our system as it exists at the present time.

One of the points that ministers of Health and Finance ministers have made is that we could spend funds better than we are. There are efficiencies to be gained. We have much room to move in that area.

We would need to spend more in some areas. With telehealth and transfer of information, we could save billions of dollars with transmission of accurate diagnostic tests so that they do not have to be duplicated. We could do more together to spend what we have more wisely, without compromising other programs unfairly.

Dr. Ward: Recognizing each jurisdiction is responsible for the delivery of health services within its own provincial or territorial boundaries, I think that there remains a very strong role for the federal government. In particular, the federal government could continue to facilitate the national dialogue around health human resource issues and system issues. The federal government could certainly assist in helping to understand what is a reasonable approach to the system and opportunities to plan the system for the future.

The federal Government of Canada has a vested interest in that. It is the sixth largest provider of health care service in this country. It provides such services to the Armed Forces and others. Federal expenditures for direct services exceed that of many of the provinces and territories. As much as being a facilitator, it is also an important player.

As Dr. Scully and Dr. Barrett have suggested, there is a major opportunity for the federal government in terms of system renewal. There is a fundamental problem in terms of infrastructure. It is not only in equipment and physical plants across this country. More importantly, it is in the educational infrastructure. It is the opportunity to somehow begin to renew the professional training sites for all health care professionals.

The federal government has a role in the creation of health sciences centres, the renewal and training of the new professionals in nursing, pharmacy, and medical laboratory technology. It could begin to support those things.

As Dr. Scully pointed out, the establishment of the Canadian Institutes of Health Research was a major step forward in at least trying to retain and recruit academics. That has been a huge event in this country. Every jurisdiction is thrilled about being able to keep and attract our own quality people. More importantly, they now have the excitement of bringing in people.

There is a need to invest more in terms of system research. There should be a greater investment in coming to understand the system, how it works and what opportunity improves it. Expanding the activities of groups such as CIHI and the Health Services Foundation would assist. We should perhaps think more broadly in terms of the education piece of it.

Last, coming from one of those jurisdictions called a "have-not" province, there still remains an important federal role to try as best as possible to influence activities nationally to ensure that every Canadian has fair and equitable access to a system of health services that is reasonably comprehensive.

More important, like Dr. Barrett, I am passionately Canadian. My father worked for Tommy Douglas. I remember the advent of medicare; I remember the doctors' strike. I am here for a publicly funded health care system, and I will not accept any form of privatization. If the federal government must stand up and say, "No privatization," count me in. I will be there.

Senator Cook: With the amount of information that you have given me this afternoon, I am sure that when I get through it, most of my questions will have been answered.

I do come from Newfoundland. I served as a volunteer on a health board and have done so for nine years or ten years. I have a limited knowledge about the system, which could be a dangerous thing.

My first comment is about telehealth. I am sure you know that we have been participants practising telehealth since 1972. The practice was borne out of a necessity to have an x-ray read in the northern community of St. Anthony and from there taking it to the Third World countries of Africa. We have done some innovative things in the area of telehealth that very few people know about.

The words that haunt me, and I continue to hear it, are "money will not cut it," "there is a shortage of funding," "there is a shortage of human resources," "we are here to take care of people."

I hear that we need a national dialogue. I hear that there are all kinds of people and agencies doing all kinds of things to deliver a quality of service to Canadian people. I am sure that there are wonderful things happening.

We have new innovative equipment such as MRI and CAT scans. In my province, it is the public sector - the unions - who have supplied the equipment to help our nursing and medical people to deliver health care to our people.

I cannot buy into the money piece. I am convinced that we need more money that is directed at the source. How do we deliver if we do not have capital equipment, and it is not funded properly to deliver health care?

There are nurses who work the floor, go home after a shift and are called back immediately. There is much goodness happening. Our people are being given cared. However, to me, there is much looseness and untidiness in the system, as well as the good.

How can do we make it move smoothly? I feel like I am in a gale wind, gentlemen. You may comment on that in any way you wish.

Dr. Barrett: I would like to emphasize that the quality of health care in Canada is very good. The problem is not the quality of the care; it is timely access to that care. It is the wait for theCT scanner; it is the wait for treatment or radiation, or having to go out of the country to get it. Once you do get the attention, it is quite good. In any surveys that have been done, the public says that they are quite satisfied with their care. Their concern is getting that care in the first place.

The Chairman: I have heard CMA and others make that statement before. Let me ask you a question. How can you separate out quality from the waiting time? It is hard to tell people to wait for four months for a particular procedure and then they are treated well, but by that time they are so sick that they die. Are we to claim that they were treated well while they were alive? You cannot make the distinction that you are trying to make. If so, I do not understand what you mean by quality.

Dr. Barrett: I mean the quality of care that health care providers are providing. We are working very hard, in spite of the stress and long hours, to provide first-class care. That goes for physicians, nurses, technicians, everyone. The problem is getting the patient there to get that care. That is the problem.

Senator Morin: Your point is well taken. We know that quality of care varies from one part of the country to another.

The Chairman: Geographically variable.

Senator Morin: Access is part of quality.

Dr. Scully: Apropos the comment that "money does not cut it," we are not saying that money is not necessary. We are saying that money alone will not do it.

There is a need to address the looseness, the untidiness, and the variability that are there. In the past, we have been operating independently to try to do that.

The proposition here in the workforce project, is to work in partnership with others - including governments - to address those issues so that there is a much more level playing field. As a by-product, access would be improved in terms of its timeliness, never mind the quality once you get there. Those are real issues that you identify.

Certainly in a province like Newfoundland with the distances, geography and the demographics, there is a microcosm of the problem that exists in the entire country.

We need to invest the money wisely and to spend more in some areas, such as technology and human resources, than we are at present. Let us try to work together to make the playing field more level than it has been.

Senator Cook: How do you see that happening from a national perspective? In my province, the quality of delivery of health care is second to none. I would be quite comfortable being ill in my province - I know I would get first-class care.

That is not what I am talking about. I am talking about the things that are needed: the processes to ensure that I receive care. It means that there must be an adequate number of doctors, nurses, support staff, and equipment. How do we get all those things into place to ensure that the consumer is serviced?

Dr. Scully: That is why we are here. We are here talking about the workforce. The Canadian Medical Association has made a very detailed presentation about technology and what can be done in that connection. Dr. Barrett may wish to comment on that.

We are here today to talk about how we can work together to address the workforce issues.

Dr. Ward: The issue of quality really implies some set of standards. Over the next few years we will see a growing demand for national standards. Certainly the Western Canada waiting list study will be coming out. It will contain some remarkable information that will be of surprise to many Canadians.

One of the challenges in all of this is to move to that integrated health care system. Dr. Barrett was talking about the fact that we still have, in many circumstances, physicians practising solo. How can they have a conversation with someone else about standards when they do that? Where is it written down? Where is that common approach? Where are those clinical guidelines?

With information technology and the knowledge we have and decision support systems, there should be, over time, fairly standardized approaches to diagnosis, to treatment, to acceptable waiting times.

In my province, we have an interesting scenario in which everyone thinks that if their doctor is concerned about their health, they will be sent to Halifax. An individual in Truro would never be sent up the road to New Glasgow even though the staff are excellent. They have a brand new CAT scanner. However, the patient would go to Halifax and wait more than five months for an elective CAT scan when they could drive up the road and get the CAT scan the same day.

There are some process problems with which we must deal. You are talking about that seamless flow; the fairness, standards and targets for people to meet. We must begin to have a dialogue about the process.

Senator Cook: Who would assume the role of leadership for that dialogue?

Dr. Ward: That would be all of us. I think that clearly it is for all the people in the system, including myself as a deputy minister, people working in the hospital system, administrators; for representatives of the medical associations, registered nurses associations, and nurses unions. All these people need to be involved in identifying the problem and the methods of managing it. They need to identify who will take charge of leading the process.

Senator Cook: Do you see it being done province by province rather than from a national perspective?

Dr. Ward: I think that you must begin at the provincial level. However, at the same time, as the deputy minister, I have an expectation that we should be part of a national process.

Senator Keon: I have enjoyed your presentations. You said that that "money alone will not fix the problem." I also believe strongly that numbers alone will not fix it when it comes to manpower.

We are all aware of what happened in France. They turned out all these medical graduates that were driving taxis because there was no place to fit them in. The same thing happened in Italy. It is happening in Eastern Europe now.

We must sing from Dr. Ward's hymnbook and look at an integrated system across the country so that the health professionals fit in the system when we turn them out. This is not difficult to do.

Our industrial friends in the high-tech community and engineering sectors, told the colleges and universities, about seven or eight years ago, that their graduates were useless to the industry. They said that the colleges were turning out "generic" engineers that were of no value. They wanted the educational programs changed so the graduates could be hired. Bang, what happened? It happened very quickly.

We have a tremendous amount of information behind us, as all of you know. We have all served on task forces during the past 20 years that have looked at manpower and so forth. There is a tremendous amount of good information there. It must be integrated with the other health professionals, including the nurses from whom we will hear. We must look at systems that will do something.

I believe that we made a tragic mistake in hospital downsizing in that we fundamentally brought in bulldozers and pushed all the hospitals into one place instead of looking at integrated health systems in the communities. We created these big monsters that are dysfunctional without community resources plugged into them. We will have to review the situation again.

I want all three of you to come out with your profound wisdom now about how you would turn out the next generation of medical graduates to fit the requirements.

Dr. Scully: Let me take a first crack at that. I agree that numbers alone will not do it. It is fair, however, to say that the countries that you cited do not have the same kind of entry or exit qualifications for medical students that Canada and other countries like Canada have. There may be many physicians, but they would not be hired anyway because they do have the qualifications or the quality that we have.

The figure we recommended in Task Force I is a conservative projection. Initially, it was going to take a lot more than 2,000 by 2000 to restore the balance to where it is. We said that "things are changing; physicians are working differently together and with others. As a projection into the future, we will sit down with others and work out where we are going with this conservative number, which is not a replacement number." We are trying to keep even with where things are going.

We do not think it is an overshoot. The recommendation would have been closer to 3,000 by 2000 if we were to do a replacement equation.

I am cognizant of the point that you make. It is not only the number but it is what people do. That is why the ratio issue is not the right approach either. It is a combination of how we will work together as physicians with nurses and others, hospitals, communities, governments and community leaders as we move forward.

I take your point, but we are trying to bring a balance to this in an integrated way, as you look at the information, so that we get it more right more often than we have.

Dr. Barrett: We need that national planner strategy. That should include a needs assessment. Part of the problem is that the numbers do not tell you what people are doing, as you have suggested. A family physician who retires in a northern community may be only their only anaesthetist. Upon his retirement, no more surgery could be done in that community. An entire program would collapse.

From the federal point of view, in addition to the national planner strategy, we need to look seriously at post-graduate secondary education, not only in medical schools but education in general, regarding a skilled workforce for the future. That is particularly important when you look at the debt that our students have when they leave school. Some of those debts are in excess of $100,000. If the graduate has young children and a mortgage, moving south holds appeal because it is easier to pay off that debt reasonably quickly, as opposed to paying it off here.

Dr. Ward: Academic flexibility is absolutely an important key in all of this. At the current time, changing a program at the university level takes approximately two years. In an environment in which the level of knowledge is doubling every year, that is, quite frankly, unacceptable. That is absolutely unacceptable. Somewhere in the midst of this, we must get universities attuned to working in this new environment.

With respect to the medical graduates of the future, I see a life-long commitment and partnership between that individual and the system. I believe that, if we value those workers, the system would offer the opportunity - two weeks each year, or three months every other year - for them to upgrade their skills.

We would have a system such that if they were to work in a group practice in a small community, we would guarantee a locum to them. That locum would be someone from an academic centre who would use that opportunity to upgrade the skills of everyone on the health care team. They would be there not only to give service, but they would be there to give education. This would become a continuing lifelong learning experience for everyone. That is what the system must support and nurture.

You cannot do it by turning someone out at the end of a 10-year educational program and simply wish them good luck, God bless. "Look after your own continuing education; worry about finding your own locums; and worry about your kids and your family, if you have time, if we are not asking you to work 100 hours per week."

We must think about how we value people and what we are interested in. Money is not the important thing for graduates today. It is their lives, their lifestyles and job satisfaction; it is the opportunity to do good; and it is the opportunity to learn and continue to be good. Money is not at the top of the list. We have a system that drives them to want money.

We must step back and look now at that in a serious way.

Dr. Barrett: We can look to the private sector where competition has occurred and they have done it successfully. There are basically three things. One is competitive remuneration, and there is no question that you must pay them enough. I agree, if you can offer people the opportunity to be part of something that is good and where good things are happening in a stress-free environment, they will be willing to work for less. If we can provide that environment with the third thing - opportunities for professional development - that is what we will have to do if we are to compete. The private sector has done that successfully.

The Chairman: You raised the private sector analogy. If the private sector found that there was a shortage of a particular set of skilled manpower, they would juggle the pay scales so that, effectively, the skill set that you were seeking would receive more and others would receive less. Again, based on my own understanding of the difficulty that exists within the medical association and medical societies of shifting the relative importance as noted by the remuneration among the various categories of specialists, it is extremely difficult to do. I raise this because you used a private sector analogy and that is one step that is critical, but you did not comment on that.

Dr. Scully: One of my past hats was Chief Negotiator for the Province of Ontario.

The Chairman: I am well aware of that. That is part of my experience in terms of understanding the difficulty.

Dr. Scully: As Senator Keon and I can attest, there are few people more resented than cardiac surgeons, who do, in fact, generate larger incomes than many others. We happen to think that we earn it, but you can only do so much. Beyond a certain point, you can only work so many hours.

It is not just what is happening with physicians, it is also what is happening with others around us. Again, we come back to the issue of people and the balance that exists. With regard to simply paying people more to do the work, you can only do so much beyond a certain point. Then it does not matter any more, because you cannot spend it, you cannot spend time with your family, and there are not enough people to fill that need.

The real problem is that, even if you were to increase the fees across the board as they have in Alberta by a tremendous amount of money relative to the rest of the country, there are not enough people to do the work. It is not just a matter of paying more for the work; we must address the issue of people wanting to move into the area for reasons other than the money. One of those reasons could be because they want to make a difference and they want to look after people. That is why most of us went into medicine in the first place.

The Chairman: That is an interesting answer, but it does not address my question. However, that is fine.

Dr. Barrett: There is no question in my mind that if people can come and be part of something good, then you can recruit them. For instance, in Saskatchewan, the weather is not that good for much of the year, and the pay scale is not that high compared with other provinces. However, the reality is that they have had no difficulty recruiting people to areas because they have the opportunity to be part of a system that is world class - that is delivering exciting health care, and they want to be part of it. If we can create those centres of excellence in the communities and other places, people will come.

Dr. Ward: The excitement issue is a fundamental thing for me. Canadians are challenged by their system as it exists, and they are concerned. More importantly, we are hearing a chorus of voices from the professions saying that it is not much fun to be a professional. Unless we work constructively to change that in the next year or two, we will have serious problems with enrolment in our programs. Enrolment in nursing programs at Dalhousie has been dropping by 50 per cent per year for the past four years.

The Chairman: Did you say 50 per cent or 15 per cent?

Dr. Ward: I said 50 per cent. Nursing is not a career that people are choosing, and it is becoming a problem. The issue about the costs of education is also becoming a problem. We have seen a dramatic swing in the past four years, in our province, in the distribution of people coming into the medical school. As university tuition has gradually risen, university medical schools are a cash cow for most universities, quite frankly. We have seen that the percentage of students coming from rural Nova Scotia is dropping steadily. As Dr. Scully pointed out, only wealthy families will be able to send their kids to medical school. Yet, the single most important determinant as to whether an individual will work in a small community is if they are from a small community. If we close the door to that group, we have done the system a disservice.

The Chairman: On the fee question, I do not need the numbers. I am sure that you have a time series that shows the increases in fees over the last decade or so. That would be useful for us to have. Could you please send it to the committee? Thank you.

Senator Roche: I have two questions for Dr. Scully. The first deals with quantity and the second deals with quality. I am receiving mixed messages today about whether money is the problem or money is not the problem. On the quantity issue of that mixed message, why is it that in a country that is growing in population and aging at the same time, there is a reduced number of students entering medical schools? Senator LeBreton spoke to this problem. What is the real problem? Is it that the costs are too high? I was shocked a moment ago, when I heard that medical schools are a cash cow for universities. As an innocent layman on this subject, I was shocked to hear that.

What is the real cause of the diminishing number of entries to medical school at a time when we need more doctors?

You could trace it down the line. It would take ten years of full training to have them graduate. What is the real problem? Are there not enough places receiving funds from governments? Is it too expensive for young people to take on? They do not want to face the burden of $100,000 down the line? Are the standards too high?

Help me to understand. This is described as a desperate time. Why is this happening in our country?

Dr. Scully: I will try to give several brief responses.

First, there does need to be constructive money in some areas. The United States spends far more money than we do. They have far more problems in many areas than we do. It is not just money alone. Money must be channelled to where it will be effective in terms of what we get. Yes, we need to spend more in the education enterprise.

The answer to your question with regard to enrolment is that it was a policy decision to decrease enrolment at both the undergraduate and the post-graduate levels in 1991. We are living with the consequences of that now. It resulted in a 17 per cent decrease in enrolment, not a 10 per cent decrease. It further resulted in a 30 per cent reduction in the opportunity for Canadians to go to medical school because the population is getting bigger at the same time.

The post-graduate areas were cut back; the re-entry programs were cut back; the validation of international graduates were cut back. Dramatic cuts took place in four or five areas at a time the population was getting bigger and older. The opportunity to go to school was diminished. The opportunities for training and flexibility were diminished.

The report that we have put to you as the first phase is trying address turning the trend around and at least track what is happening with the population as we move forward. We put forward the requirement at a conservative level.

The next phase in which we are involved, as are you, is how we work together to ensure that we continue to do that so that we have sufficient trained personnel for the future.

Senator Roche: Must we encourage provincial governments to change those policies?

Dr. Scully: It is both provincial and federal. It is a dual role. In the late 1960s when the schools were expanded, the federal government played a strong role in supporting the education enterprise in partnership with the provinces. We think that could happen again.

Some of the provinces are responding and some are not, depending on how much it would cost. There needs to be money put into the education enterprise to allow that to happen.

Senator Roche: Maybe this committee could help to push this along.

My second concern is regarding quality. I am not speaking of the competence of physicians. I certainly have no doubt about the competence of the ones with whom I deal. I am speaking about the conditions in which they operate.

I am troubled by this "brain drain" to the United States. I would like to get your frank assessment as to the true motive. Is it really money?

I come from Alberta. My physician, an experienced man, was the head of a family medical clinic. He went to the United States at the peak of his life. I said to him, "John, why are you going? You are making a good living here. Why are you going to the United States?"

He said, "Doug, this government will not let me practice medicine the way I want to practice it." Was he speaking for many physicians or is this his own particular rebellion against the changes that had been foisted on him by the Government of Alberta.

Is it money for many physicians? You say that they may have $100,000 education debt, and they are attracted by higher pay scales in the U.S. Do we need to pay our doctors more? What do we need to do to retain their motivation so that they will stay in Canada, the country that trained them?

Dr. Barrett: There are two issues. The first is in regards to the $100,000 debt. Physicians as a group seem to be aging faster than the general population because we have tended to lose our young people. Tuition deregulation has done that. When you graduate with $100,000 in debt with little kids and mortgages, you will be tempted to go where you can pay that off quickly. Someone of my stature, as a surgeon with my years of training, would have difficulty paying that off quickly even at my current income level.

Second, those students and the more mature people that you have talked about - and it is discouraging when they leave - told us that they were leaving out of frustration that they cannot provide what they think they should be providing in this service industry right now.

I spoke earlier about us getting tired of apologizing all the time. That is what we do. We say, "I am sorry, Mrs. So and so. I know we think that you might have cancer, but you must wait a month for your CT scan because everyone else in the line thinks they have cancer, too." That is how long it takes because we do not have enough of them or the one we have is rusted out.

Senator Roche: Are these complaints peculiar to Alberta or are they across the country?

Dr. Barrett: It is across the country.

Senator Roche: I do not understand how governments are telling physicians how they can practice or restricting the ways in which they feel they need to practice to maintain certain professional standards.

Dr. Barrett: It is not the governments telling us that, it is the resources that are provided and our ability to have our patients access it. We are apologizing all the time. There is no satisfaction in that after a while.

Dr. Scully: Senator Roche, you answered your own question in part when your physician reflected accurately that he cannot practice what he was taught to do. An orthopaedic surgeon in Calgary is told he could have a day and a half to operate. In North Dakota, he can have three and a half days with an MRI down the hall.

The money is no different in Alberta than North Dakota. It is not a question of money. It is the facility to take care of your patients' welfare. If we want to attract and retain physicians, we need to work together to ensure that the facilities are there so that physicians, nurses and others can work to provide the services that are needed by people. That is where we can do it together.

The reason that we are here, and very pleased today, is that too often groups who were not involved in the delivery of care were making the decisions on the basis of the bottom line. We need to do it together.

Dr. Ward: The availability of equipment and staff will always be an issue for most jurisdictions. In Nova Scotia, when we pay off our annual interest charges, the Department of Health - for which I am responsible - uses 48 per cent of the money that is left over. Health and the Department of Education and Community Services use 87 per cent of the province's budget. The remaining 13 per cent is meant to support industry, tourism, natural resources, fisheries, agriculture, correctional services, highways, public works, et cetera. Every government is challenged. Last year, our jurisdiction counted up $150 million worth of x-ray equipment that needed to be replaced. We have a portable machine from 1971 that is being used in one of our hospitals. It is a museum piece. We must go outside the country to get the parts to keep it going. That is the situation we are in.

The infrastructure piece that we talked about earlier and the opportunity for cash infusions to deal with the fundamental infrastructure problem remains. It is difficult in those provinces that are struggling financially.

Senator Cordy: I have two questions. First, Dr. Scully, I want to ask you about measuring physician services in terms of ratio to the population. It seems that it is being done just according to head count. There are so many doctors in the population. In fact, if you were to look back 25 years ago, 150 doctors in a community would be far different than it would be in the year 2001 because of the types of things that you have explained earlier today - lifestyle, a higher percentage of women who would be more likely to job share and those types of things.

How can we more accurately depict that for purposes of building community health systems in an area? That is my first question.

Second, Dr. Barrett, you said the shortage of physicians is not only in rural areas, it is all over. I have no doubt that that is true.

In Nova Scotia, there certainly appear to be more under-serviced or under-staffed areas, which seem to be the rural areas. You also mentioned, Dr. Ward, that at Dalhousie there are fewer students coming from rural areas.

I wonder whether, at Dalhousie or other university medical schools in the country, there should be reserve spaces for students who are willing to stay and work in under-serviced areas, or, for that matter, students from rural areas who would come to the medical school and would be more likely to return to their home community to practice.

Dr. Scully: With regard to measuring physician services, you are quite correct. I did make the note that doing just the head count does not indicate what physicians are doing or that society is getting the best value for the physicians who are there. That is why we think it is important to look at the models of care and the teams that are out there and developing. We must determine what the public needs in terms of the best projection as an overarching study that Dr. Ward referred to. In that way, nursing, home care and physicians can draw down on it. Then, we can work in conjunction to put together the team that will deliver those services or education or prevention as the case may be.

When the numbers and the ratios were developed, it was usually solo practice and free for service; and it was a head count in terms of those services being delivered. The practice and the models are changing, and we need to change or we will not be able to correct it as we look forward. There is a number involved and that is why we are staying away from the straight ratio. We are looking to work cooperatively with others - physicians with physicians and physicians with nurses and others. That is the direction that we are taking. Together, we have a chance of success.

Dr. Barrett: With regard to your second question, I agree with you completely. The problem that I alluded to earlier is that as tuition deregulation has occurred, tuition costs have escalated. We have essentially cut off people from smaller communities, where parents do not have the income.

You talked about rural Nova Scotia. I will give you an example from my province of Saskatchewan, where we have a huge Aboriginal population. The best way to deliver health care to them would be, especially in consideration of their culture, to have First Nation's health care providers. However, right now our system has barriers that hinder their receiving the necessary education. That is why we need to look at the whole area of post-secondary education. In particular in consideration of tuition deregulation, we must examine who we are educating today.

Dr. Ward: On the student side, I could not agree with you more. Certainly, in Nova Scotia we are currently looking at other options to deal with the rural student through district health authorities.

There is a history in this country of the Armed Forces entering into long-term relationships with students in or entering medical school. I believe that opportunity should be in place for young people in rural communities. If they meet the entrancerequirements, good on them, and that could be an opportunity.

Senator Morin: Many provinces have a plan like that: P.E.I., Quebec and Ontario.

Senator Cook: Newfoundland also has such a plan.

Senator Fairbairn: I am left almost speechless today by the presentations of our witnesses, particularly by Dr. Ward. Thank you for raising the issue of literacy and the difficulties that people who are troubled by that issue have in accessing the complexity of our health system, even at the most basic levels.

There is a frightening problem in rural Canada. I am from Lethbridge in Southwestern Alberta, and we are surrounded by rural towns. It seems to be impossible to bring services to those areas. In addition to what Senator Cordy suggested, I wonder if it would be helpful for medical schools in parts of this country to have a special "indoctrinational" training? For some people who are attracted to these rural areas, there is an excitement issue of working in a surrounding different from a major urban centre. Is there any move at all to bring those differences to light for the students? Is anything being taught that would make the differences have a special appeal to young students?

The disincentives - money and lack of services - are more readily known than the incentives. Smaller communities have their own terrific culture. How can we fire up young Canadians who are entering medical schools to realize that this could be a huge learning opportunity for them? At the same time, they could give an enormous service to parts of our country that desperately need them.

Dr. Ward: That is happening in several jurisdictions. At Dalhousie medical school, our family-practice residency programs are located in Cape Breton and in Sidney. We are finding that the majority of students who go there are staying in the industrial Cape Breton area. We have a program in St. John's. We also have programs in Fredericton and Moncton. Medical schools are beginning to understand that opportunity.

It will remain a challenge in the smaller communities, simply because of finding the groups that have the interest and the expertise to be educators, mentors and to carry on a clinical practice at the same time. Unfortunately, currently, most clinical trainers are not well remunerated for that function. That is a major issue. We are actually trying to increase our fee for people who are taking students to $500 a month, recognizing that they will lose five times that much by the inefficiencies in their practices.

Dr. Scully: The College of Family Physicians is responsible for the output of family physicians in terms of the academic development once they have graduated from medical school. The Royal College of Physicians and Surgeons of Canada, is responsible for certifying all of the specialists. Both of these institutions have developed accreditation programs that are much broader than the teaching hospitals of the past. These programs require that students spend significant time - and that time is increasing in the future - in communities other than the immediate area of the urban teaching hospital. That should address some of the issues that you mentioned.

We have talked about that and I know that you are meeting with the rural and remote group. They are very much part of Task Force II, by the way. We have actively involved them in these discussions, and they are right at the table with us all of the time. There needs to be, again, investment - this is where the money part comes in - in that education enterprise so that the teachers are recognized financially for the time and the effort that they make, and for the practice that they give up in order to do that.

Again, as we work together, I think we can begin to address that distribution issue, which is very real.

The Chairman: We appreciate the quality of your presentations and the tolerance you showed during the question period.

The Chairman: Senators, we now have four witnesses from various parts of the nursing profession. We will begin with a presentation from Ms Linda Jones of the Nurse Practitioners Association of Ontario.

Ms Linda Jones, Nurse Practitioners Association of Ontario: I begin by thanking you for the invitation to the Nurse Practitioners Association of Ontario. The NPAO has represented nurse practitioners since 1972. In 1990, we made a presentation similar to this one to a Senate committee regarding the role of the nurse practitioner and our vision of where we hoped to be. It is good to be here again to be able to discuss our future vision.

I have been asked to speak as a past-chair of the Nurse Practitioners Association, and probably because I am located in Ottawa. I have been a nurse practitioner since 1984. I have been a registered nurse much longer than that. I have been involved in the Ontario initiative since its inception. My current hat is as co-investigator with my physician colleague in the Nurse Practitioner Family Physician Collaborative Research Project, which has been sponsored through the Health Canada Transition Fund.

Nurse practitioners are not a new idea. The first initiative for nurse practitioners in Canada began in the late 1960s and early 1970s - primarily related to expanding the role of the registered nurse in rural and remote areas. For many reasons, that particular initiative did not fulfil its potential. As I speak about barriers today, many will ring true to what happened in the sixties and seventies as well.

Following the first initiative, there were about 250 of us who continued to practise. We continued to be politically active. Beginning in the 1990s, new initiatives started. Those initiatives were primarily related to increasing access to primary health care services.

I will begin again by who we are, and I hope that you are able to see the power point presentation. I have asked to be able to present in this manner because I need the laptop to be able to see it with my senior eyes and bifocals. I was also told that you like to write things down so I presented you with both a brief and the slides from the overheads. It is not two different briefs.

The Chairman: I only ask you to focus on the time because we want the opportunity to ask questions.

Ms Jones: I will speak to the Ontario situation because that is what I know well. In Ontario, we are called "registered nurses in the extended class." That is our protected title. The nurse practitioner title is not protected in Ontario.

We are autonomous health care providers working with our own scope of practice. We are experienced registered nurses and have advanced nursing education that allows us to take on an expanded role in which we share knowledge and skills that were primarily restricted to medicine. We provide care to individuals, families, communities and groups, because of our community-based care structure.

Within the expanded role, we provide comprehensive health care. We are authorized, in the Province of Ontario, to communicate a diagnosis of disease and disorders as part of our expanded role; to order laboratory tests, X-rays and ultrasounds; and to prescribe from a limited range of drugs.

In our own history in Ontario, we had educational programs up until 1983. Then, in 1993 through the NDP government, the new initiative began. Throughout that time, when there were no programs, we continued to advocate for the role.

With the initiative in 1995, the College of Nurses developed a new class of registration called the RNEC, or extended class. In 1998, our legislation was proclaimed, which allowed us to diagnose, and to prescribe and order laboratory tests, X-rays and ultra sound.

The college initiated an extended class proceedings for the first recipients in 1998. There are now a total of 401 RNECs in the Province of Ontario, with approximately another 25 waiting to be registered this fall.

The educational program for nurse practitioners involves the consortium of all universities that grant nursing degrees in the provinces. This is the first time that nursing has come together to offer one program, and it is based on distance education. Therefore, it is based on supporting nurses in rural and remote areas so that they can take the programs at their nearest university. Much of it is done through the Internet.

There are two streams of education. RNs who already have experience in the extended role are able to enter the program, and receive the certificate with two years' study. The program also offers a baccalaureate entry for a 12-month study. There is now a master's option being indicated at the University of Ottawa and the University of Windsor.

Under the College of Nurses, our registration in extended class is quite extensive involves quite an extensive procedure, so we are well tested to ensure that we have the knowledge and skills to perform our work.

We have competent standards for practice within ourcertification: the expected level at which we will consult physicians; and the standards for prescribing for the ordering of laboratory tests, X-rays and ultra sounds. Our role is defined and restricted under our standards.

The role of the nurse practitioner, in its 30-year history, has been what I would say, researched to death. The research has always indicated that the nurse practitioner is able to deliver safe, high quality care with high patient satisfaction.

We have seen that our caseloads have increased by 25 per cent to 50 per cent through the delivery of collaborative models in the Ontario pilot projects. We have also seen the decreased use of hospital emergency rooms. With the focus on health promotion and prevention, there have been increased rates related to primary prevention, immunization and secondary prevention, mammography, Pap smear, risk factors, screening, lifestyle and counselling, with the focus being healthy patients, less utilization and lower costs.

In Ontario, we have worked primarily in community health centres and nursing stations. There are 401 registered RNECs, most of whom continue to work in community health centres. In 2000, there was some government funding that allowed us to work in family practices, clinics, public health units, long-term care, emergency departments and community programming.

So far, within the province, there has been funding for 125 positions, which was a top-up of positions that were already formed in community health centres. In addition, there was funding for 31 new positions for Aboriginal health access and nursing stations. Then, there was the funding that came out in 2000 to expand our role.

The last point is that of our 401 graduates, 200 of them are under- or poorly employed as nurse practitioners.

Our vision for the future is full integration wherever primary health care is provided through practising within interdisciplinary teams. I have given you an assortment of areas where we feel that our role could best be utilized, and that is explained in the brief.

I use the Ontario examples for lessons learned, and then we will focus on the national situations. One of our first barriers is funding. There is lack of permanent funding with the flexibility to support us in a variety of service models and settings. Initially that funding went to agencies, because there was no mechanism to support us in, for example, fee-for-service practices.

It was incredibly difficult to obtain that funding. Ontario made the process very complicated. Therefore, many rural and remote areas that wished to have nurse practitioner positions, gave up because of the process. There was insufficient consideration of the cost to bring in a new primary provider and for the incentives to move and relocate the provider to remote and rural situations.

When working with fee-for-service physicians, the whole remuneration system discourages the use of NPs. It does not allow for their payment; it means that family physicians need to do most of assessment again, and to bill for that. Plus, it means that if the nurse practitioner comes into the practice, and there is no increase in the number of patient visits, much of the money is being taken from the nurse practitioner in salary.

The existing legislation, although we are incredibly excited about the fact that we now have our own autonomy to do our role, leaves us with barriers. For example, the public hospitals act does not allow us to perform our role in hospitals. We cannot order; we cannot do our work if, for example, we are in the emergency department or ambulatory care. We face a restricted drug list, which does not allow us to fulfil our role in monitoring chronic illnesses because we cannot renew medication. Even though we are very excited about the legislation, there are still limits.

Medico-legal responsibilities related to shared decision making is extremely important, in terms of both nursing and medicine needing to look at what it means to work in the interdisciplinary teams and what it means to share liability. This is a major barrier to us. Our family physicians are anxious about consulting with nurse practitioners if they do not have clear understanding of liability.

We have systemic barriers within our own systems. For example, although we have skills and knowledge to refer to medical specialists, the current payment system under OHIP does not give a specialist the full consulting fee if the referral comes from nurse practitioners. Therefore, they decline our referrals.

Nurse practitioners and nursing have not been equal partici pants in the planning and delivery of primary health care services. Our nurse practitioner initiative in Ontario, although we have made great strides, was never part of an overall plan for health human utilization, which we clearly need. These are barriers that have been local to Ontario, but you can see that the issues can be applied to the rest of Canada.

We are fighting for permanent funding for our educational programs. That still has not been achieved. Education of health providers does not prepare our graduates for interdisciplinary work. Working in collaboration with interdisciplinary teams is not innate. We need educational programs and preparation for that kind of work.

Lack of understanding by employers results in the inappropriate use of our role. For many people who applied for funding - many employers who were under-resourced - it sounded just wonderful, the idea of bringing a primary health care NP into a role that was not at all designed to take advantage or the full scope of practice for nurse practitioners.

A very important last point is the lack of public understanding of the role, impacts and utilization of nurse practitioners. If we are seen as physician replacements - you cannot see your family doctor, you must see your nurse practitioner instead - that will not enhance or increase public acceptance of us.

Nurse practitioners are strongly committed to the Canada Health Act and its five principles. We are, basically, primary health care nurse practitioners who support the principles of primary health care. Under the Canada Health Act, in 1984, a window of opportunity was opened when it mentioned "funding to health care providers," rather than restricting funding only to physicians. That door needs to stay open to allow the functioning of interdisciplinary teams.

We need legislative and policy changes at the national level to remove barriers that impede utilization. Again, another solution would be, joint nursing and medical directives related to liability with shared decision making. Both of our protective societies must put their heads together to develop guidelines and directives that clearly speak to interdisciplinary work.

In terms of long-term funding, a good strategy is part of well thought out health human resource planning. That is what this commission is all about. It allows for a flexible and supportive way for a wide variety of settings in which we will be able to do our work. It will be comprehensive, equitable and separate from MD funding - certainly not tied to it.

We would also be best supported by changes in physician funding such as alternate plans, compensation for consultation and changes in the specialist referral funding.

Currently, the nurse practitioner initiatives are being incorporated in seven provinces and three territories, at various stages of implementation. The good news is that nurse practitioners are generalists, so we can be used to solve local problems. The bad news is that we now need national standards. There needs to be a national way to identify nurse practitioners, a national certification exam and the protection of the title.

We need, as with family physicians, to come up with retention and recruitment strategies to encourage nurse practitioners to work in remote and rural areas. There needs to be interdisciplinary collaborative education and education on collaboration. We need a broad-based public education program to increase understanding and acceptance of the role.

I have talked about the past, present and the future possibilities of the role of NPs. I have focussed on Ontario in my discussion of the barriers. I have offered some possible national solutions. The goal of primary health care nursing - be they primary health care nurse practitioners or our other colleagues in public health - is to assist Canadian families, groups and communities to attain and maintain optimum health. To do this well, we wish for full integration into the primary health care system, so that our role is fully utilized. Thank you.

The Chairman: Thank you for your presentation and for verifying my earlier comments about the silo nature of the various parts of the health care profession.

Our next witness is Mr. Régis Paradis, President of the Ordre des infirmières et infirmiers auxiliaires du Québec.

[Translation]

Mr. Régis Paradis, President, Ordre des infirmières et infirmiers auxiliaires du Québec: On behalf of the Ordre des infirmières et infirmiers auxiliaires du Québec, I would like to thank you for this opportunity to express our position in relation to the study you are currently conducting.

First, the profession of auxiliary nurse was created in Quebec in 1973 and recognised as a professional body or corporationby the Quebec code of professions. Our order currently has over 16,000 members. However, only one third of those16,000 members hold permanent positions.

The majority of our members are women, with an average age of 43.3. Auxiliary nurses work in all areas of health care, particularly in short-term and long-term services. However, they are almost completely absent from homecare services as provided by local health community centres.

We consider, however, that our training fully prepares us to assume a larger role in that area, and we shall come back to that thorny issue a little later in our presentation. As you pointed out in your first report, health is a national priority reflecting the concerns of Canadians. The universality of health care is considered a fundamental value by about 85 per cent of the population.

In Quebec 88 per cent of the population consider that our health care system should remain public, free-of-charge and universal. The population of Canada is aging and increasingly requires health care services, thus placing enormous pressure on sources of public funding. Health care costs are rising at a significantly faster rate than economic growth.

For a number of years the provinces have consistently expressed concerns about their ability to meet the expectations of the public with respect to health care. We see that Canadians are increasingly dissatisfied with the availability of health care, given the level of taxes they pay.

In our view, the federal government has also contributed to the worsening of this problem, particularly through its decision in the 1990s to reduce its commitments by significantly lowering transfer payments to the provinces.

The effect of these measures was to increase the provincial contribution to public health spending. The Quebec Minister of Finance estimates that the cumulative shortfall resulting from federal transfer cuts to Quebec amounted to $16 billion between 1982 and 1999. Under the Established Programs Financing formula, initially in 1976 the federal share was 50 cents for every dollar contributed, but it has been gradually reduced, and by 2005 will account for only 12 per cent of total public health spending in Quebec.

Even if the federal government had to take various steps to put its fiscal house in order, we believe that the cuts have been too drastic, carried out without meaningful consultation and also without taking into account the real needs of the public.

While we cannot assess the real will of the federal government, we consider that if it wishes to propose and fund a national homecare program, it must be more respectful of the constitutional jurisdiction of the provinces in the area of health care.

In addition to these constitutional considerations and the organisation of service delivery, we believe that Canada must invest more money in the health care system.

We consider that the experience of Canadians and particularly Quebeckers over the past ten years has been quite different from that of people living in other OECD countries. The changes in the Canadian health care system confirm the feeling people have that the services offered to them are deteriorating, particularly when we see, as has been the case in Quebec, that Canadians have to go to the United States for health care.

It is to be expected that we will compare our situation with that of other countries. We must remember that in 1977 Americans spent, as a proportion of their GDP, 56 per cent more than Canadians, notwithstanding the fact that in the year in question their GDP per capita was 25 per cent higher than Canada's.

This could be one of the factors explaining the exodus of doctors and nurses, attracted by the quality of the medical infrastructure and the financial and tax benefits offered by the U.S.

We believe that in its basic principles, the health care system meets the expectations of Canadians, even though there are some irritants which lead us to make comparisons with our neighbours to the south, but these do not necessarily give the whole picture.

However, a recent World Health Organisation report indicates that the U.S. system is inefficient despite the financial resources invested in it.

The United States is ranked first in the world as regards health spending per capita but 37th in terms of the overall performance of its health care system, and 72nd in relation to established standards for measuring the general level of health of the population.

We agree that there is a shortage of nurses. However, we consider that the extent to which this is due to inadequate organisation of nursing care has not been studied in detail. Last year the Conference of Ministers of Health decided to address the issue.

As result of this initiative, by the fall of 2000 a national study should have been underway funded by the Human Resources Development Canada focussing on the employment market for auxiliary and psychiatric nurses. We are concerned about the delays in the initial timeframe, as we believe it essential that such a study be conducted at the national level.

We also consider that the skills of Quebec auxiliary nurses are not being fully used. The number of registered nurses in relation to the number of auxiliary nurses has consistently increased over the past twenty years. Various reasons have been given to explain this trend: more people needing care, more sophisticated technology, changes in health care delivery methods, greater independence, versatility, et cetera.

There are few studies which have seriously documented the impact of registered nurses replacing auxiliary nurses. However, hospital administrators are acting as if it had been clearly proven that there are greater benefits to using registered nurses, regardless of the type of care to be provided.

Registered nurses, with whom we work in our professional capacity, provide the care patients require. We consider it reasonable to expect that auxiliary nurses be used with respect and as effectively as possible by hospital managers and those in charge of nursing care.

In March 2000 the Quebec Department of Health and Social Services undertook an in-depth planning study on auxiliary nurses. The mandate of the committee is to analyse future needs for auxiliary nurses as well as the projected supply of new graduates in this area over the next fifteen years.

The task force found that 1,555 new auxiliary nurses must qualify each year in order to meet new demands and replace those who decide to leave. Currently the average annual number of auxiliary nursing graduates is 476. It is projected therefore that there will be an annual shortfall of 679 auxiliary nurses in the Quebec health system between the years 2000 and 2015. The Department of Education will therefore have to increase by 900 to 1000 the number of people registered in the basic program for auxiliary nurses.

The organisation of nursing care is the responsibility of the institutions concerned. However, the Department of Health and Social Services projects a change in the past twenty-year trend which has seen auxiliary nurses being replaced by registered nurses. In coming years, instead of observing an increase in the proportion of registered nurses to auxiliary nurses, we expect to see a reduction. This means significant changes in the management of nursing care and in the way institutions operate. Such changes have yet to be implemented.

Our professional body considers that auxiliary nurses should be given the responsibility to provide the care for which they have been trained. They are legally qualified to do so and even to increase their areas of involvement. Such an approach would make it possible to make more effective use of all health professionals, particularly registered nurses who would be better able to assume management responsibilities and care services requiring more advanced training.

The training, which is provided by school boards under vocational training programs, is devoted exclusively to nursing care. It takes 1,800 hours over two years, and requires a secondary school diploma for admission. There is a theoretical component covering 885 hours, and a practical component of 915 hours.

It can be seen that the professional training of auxiliary nurses in Quebec compares very favourably with that of other provinces, which generally require a one-year program following secondary school.

In view of this, it is difficult to understand why the proportion of registered nurses to auxiliary nurses is far higher in Quebec than in Ontario and the United States. The most recent data indicate that in Quebec in 1999 the proportion was four to two, compared to three to three in Ontario, and three to zero in the United States for the year 1998.

If Quebec had the same proportion as Ontario, it would now have almost 4,500 more auxiliary nurses, which would lead to savings of approximately $50 million annually.

Home support services are underdeveloped and underfunded in Quebec compared to Ontario and the rest of Canada. In 1997 Quebec allocated 2.4 per cent of spending to that area, whereas the figures for Ontario and the rest of Canada were 5.3 per cent and 4.0 per cent respectively. In terms of spending per capita, Quebec is below the Canadian average even though in 1997 the number of people using the service per 1,000 inhabitants was twice as high as in the rest of Canada.

There remains a lot of work to be done in Quebec in this area. With a proportion of 49 to one in favour of registered nurses to auxiliary nurses, the latter are almost absent from health care. However, in Ontario and the United States, where the proportion of registered nurses to auxiliary nurses is three to one, auxiliary nurses are heavily involved in home support services.

In view of the high standards of professional training given to our members, we believe that the use of auxiliary nurses in the provision of home support services would be a logical and financially advisable option.

We consider that auxiliary nurses could provide nursing care which might be less complicated but equally necessary to the health of the patient, whereas registered nurses could make more use of their professional skills helping patients with more complex problems.

In conclusion, training is clearly a provincial responsibility and must remain so. However, policy and administrative decision makers, as well as Canadians in general, must be able to assess the consequences of the choices made.

However, we need reliable and well-documented interprovincial data on the performance and effectiveness of the health care system, particularly as regards home support services.

The Canadian Institute on Health information is an example of what can be done. The work done by Human Resources Development Canada is also important as it provides an overall assessment of the problem of human resources in a given area. Of course, planning for human resource requirements in the area of health care and careful management of public funds are essential.

However, there is no doubt that the federal and provincial governments must agree to reinvest significantly in the health care system so as to better meet the current needs of Canadians and address those new challenges facing the delivery of quality health care in this country.

[English]

The Chairman: Thank you Mr. Paradis. Next we will hear from Ms Kathleen Connors, President of the Canadian Federation of Nurses Unions.

Ms Kathleen Connors, President, Canadian Federation of Nurses Unions: The Canadian Federation of Nurses Unions is the largest organization representing nurses in Canada. We were founded in 1981 and today our membership comprises every provincially based nurses' union, except Quebec.

We are governed by an unpaid, elected board of top officers of member unions, and the president and secretary-treasurer of the Canadian Federation of Nurses Unions must stand for election every two years.

We currently represent 118,000 nurses, including registered nurses, licensed practical nurses and registered psychiatric nurses. Our members work in hospitals, in long-term care, in our communities and in our homes. One of our missions is to give voice to nurses and patients concerned, when they are discussed here on Parliament Hill and in the national media.

We also take very seriously the protection and improvement of medical system, which was built by our parents and grandparents, and which has served my generation of Canadians and our children so well. I must also say that we are distinguished here from my other colleagues through the fact that we are the umbrella organization that delivers the wages and benefits to nurses across the country.

A great deal has been said lately about the issue of sustainability. We have heard the word used often when politicians talk about our public health care system. I know we will hear much more. Curiously, we do not hear it used when we talk about the people who make up the system. No one is asking, "Can we sustain doctors and the administrative staff?" No one is asking, "How can we sustain the nurses who provide 80 per cent of the actual health care in this country?"

We talk about these systems as if they were things instead of real people who are doing their best to take care of people who are recovering, injured, sick or dying. My colleagues in the Canadian Federation of Nurses Unions have asked me to emphasize the point that sustainability must begin with the people who provide the care.

Today, Canada is suffering a nursing shortage that regularly closes emergency rooms and shuts operating rooms. The shortage has cut services in nursing homes and community health care settings, as well. The shortage has wreaked havoc on our positive human resource practices. While the best-run government agencies and businesses have become more flexible with their employees and flatter in their hierarchies, health care employers have become regular coerces of nurses. It saddens me to have to say this to you.

They regularly require nurses to work overtime, even when the nurses have small children of their own at home. Shifts piling on top of each other take their toll on nurses who might be taking care of your mom or your child. In some cases, we are doing so having worked more than 60 hours in the week.

Administrators have forced us, as nurses, to cancel our vacations. Flight attendants have mandatory time off, but nurses do not. In the end, that is not good for nurses and it definitely is not good for those for whom we care.

The whole issue in all of this is sustainability. It is a sad fact that nurses are sicker than any other worker in the country, In fact, 8.4 per cent of nurses are absent from work due to illness each week. That is twice the national average. Nurses are quitting their jobs at a remarkable rate. A five-country study of 43,000 nurses found that one in six Canadian nurses working in hospitals plan to quit in the next year. Even worse, among nurses under the age of 30, that figure rises to almost one in three. High rates of illness and turnover leaves a 10 per cent vacancy rate in nursing. You find that nearly 20 per cent of nursing care is being provided on overtime by tired - frequently exhausted - nurses.

Sickness and resignation are two powerful indicators of just how unsustainable the situation is for nurses. There are sources of this problem, with budget and staff cuts that were made in the last decade, and I will not speak to them today. The facts are there; we laid them out for you in the material provided.

I will spend some time talking about the impact of that context in which these cutbacks occurred and the impact on nursing. We need to recognize that.

The Canadian Nurses Association projects that there will be a shortage of 113,000 registered nurses by the year 2011. Our international body, ICN, recognizes that the shortage of nurses is an international one, with only Hong Kong indicating a surplus of nurses.

The reality of headhunters at every nursing opportunity in Canada attests to the fact that there is an international shortage, because the Americans have seen us as a rich target group. There are issues such as mandatory overtime, denial or cancellation of vacation, calls from staffing personnel to work or volunteer an extra shift on scheduled days off, stay on duty until the crunch is over - up to 16, 18 or 24 hours. These are the testimonies that I have heard across this country.

Only 21 per cent of us are under the age of 35. The situation facing those younger nurses is that of casual or part-time employment opportunities - working for several employers, instead working full-time for one employer. In 1998, 48 per cent of all nurses in Canada were working part-time. It just should not be.

Over an entire career a nurse's income will grow by36 per cent, as compared to an accountant's, which increases by up to 193 per cent. That statistic was made available to me through one of your members, Senator Pépin. I think it is a sad testimony about the reality facing nurses' work and the perceived value of that work.

There is real evidence that demonstrates the contribution of nurses in the provision of effective and efficient health. Based on these realities, we must ask ourselves how to solve the shortage and restore the health of nurses who are working in the system - long-term care, the communities and the home.

Do we focus on recruitment, or do we focus on retention? It is our position that you have to focus on the retention immediately. It will take a while to educate and to put the numbers back into the system. In the interim, if we do not keep the nurses we have currently, the system will be in jeopardy.

There are solutions. Restore funding for nurses and nursing and, in the process, require accountability from the provinces. It is not enough to turn money from the federal government over to the provinces without some conditions or strings attached in relation to nurses. The deal between the provinces and the federal government had strings attached for health information technology; it had strings attached for equipment; but it did not have strings attached for health human resources. I think that that is a prime solution.

Provide respect for the work that nurses do and recognize the contributions that they make. Establish a healthy workenvironment that addresses the occupational health and safety issues facing nurses. We have a high incidence of musculoskeletal injuries in Canada. It is higher than in the construction industry, the forest industry, or on the assembly lines. Those people have lifting limits; nurses have none. We need to look seriously at that issue.

Issues of needle stick injuries, incidents of burnout and violence in the workplace, all take their toll and they have to be addressed. Establish a work environment that provides autonomy, control over practice, positive working relationships with physicians and job satisfaction. These are the characteristics of magnate hospitals and the characteristics are listed there.

Recognize the high level of trust consistently afforded us by the public. On the public index trust, nurses are consistently at the top. Nurses are able to provide emotional and empathetic care, psychological support and patient education. These are job satisfactions, which all improve patient outcomes. Quite often, there is not value for that kind of work.

Provide pay and benefits that clearly say to us, "You are worth it." That means competitive salaries, decent evening, night and weekend shift premiums, and pay when we are in charge. It means recognition of the education that we obtain.

Provide also paid educational leave and professional development. I consistently marvel at the fact that the Canadian Auto Workers have a paid educational leave for each auto worker in Canada. Only in the last round of bargaining did the United Nurses of Alberta achieve paid education leave of three days for continuing education purposes and five days of paid leave if we want to work towards additional educational preparation. They are the first group of nurses in the country to achieve that.

Health and supplementary benefits have to be included. We would like to have medicare cover everything, so that we would not need to spend our money negotiating supplementary benefit programs. All Canadians could have access to prescription drugs, dental and vision care benefits, and short-term and long-term disability.

I listened with interest to the presentation by the physicians. Again, it was Alberta nurses who negotiated in their March contract a premium pay for mentoring our young and new people in the profession. There should be a penalty for cancelling our vacations. We should have enhanced pensions. Nurses have terrible pensions, and we face retiring in poverty.

Improve early retirement options. In their last contract the New Brunswick nurses negotiated the ability for nurses, as they approach retirement, to move to part-time employment while both the employer and the employee continue to make full-time pension contributions. That was a commitment, and it needs to be replicated elsewhere.

We need zero tolerance of staff abuse. We want to see the use of EI monies for educating nurses and other individuals who go into nursing so that they can practise. Then, during their working career, they can use EI funds to upgrade their education.

The Republic of Ireland waived tuition fees for schools of nursing, because the shortage of nurses was so severe. They have seen some positive results of that action.

We want some recognition of our on-the-job learning - prior learning assessment recognition so that we do not have to spend as much time in the education system to obtain that.

Finally, nurses want recognition of their right to bring their consciences to work. The words of Justice Murray Sinclair in respect of the 12 pediatric deaths at the Cardiac Care Centre of the Winnipeg Health Sciences Centre were incredibly powerful. He wrote:

...the experiences and observations of the nursing staff involved in this program led them to voice serious and legitimate concerns. The nurses, however, were never treated as full and equal members of the surgical program, despite the fact that this was the stated intent $ the attempted silencing of members of the nursing profession, and the failure to accept the legitimacy of their concerns, meant that serious problems in the pediatric cardiac surgery program were not recognized or addressed in the timely manner.

The justice went on to recommend that:

The Province of Manitoba should consider passing "Whistle Blowing" legislation to protect nurses and other professionals from reprisals stemming from their disclosure of information arising from a legitimately and reasonably held concern over the medical treatment of patients.

For the sake of the children who, through accidents or genetics, will wind up in our hospitals; for the sake of our parents who may find themselves in nursing homes - for all their sakes, let Canada recognize the right of nurses to bring their consciences to work.

We have seen the establishment of a Canadian Nursing Advisory Committee of some 16 members that will do one year's work to look at improving the quality and work-life environments. We have the commitment of Federal/Provincial/Territorial ministers of health to implement a national nursing strategy for Canada. We have a home care sector study proceeding and a national nursing sector study currently seeking budget approval. Those are positive steps, but we know that some substantial changes have to happen now.

I will close by saying that I marvel at your ability to sustain yourselves through a month of hearings and still have the ability to retain more information.

I will leave you with the three most important points. The situation for nurses is unsustainable. Nurses must be paid what they are worth and our system must have many more - at least 100,000 - by the decade's end. We want to see full restoration of funding that was cut from our health care system in the 1990s. With the possible exception of spending to meet the rapidly rising costs of pharmaceuticals, we do not believe there is a spending crisis.

Restoring funding is not enough. To improve medicare, restored funds must be accompanied by a large dose of accountability. Strings must be attached to ensure that funds are spent to sustain health care providers, the system within which we work and the ways that are necessary to truly improve patient care.

Canadians fought to achieve medicare and now we must fight to restore and improve it. Our patients and our children deserve nothing less.

We hope that you will invite us back. I have talked about the issue of health human resources. However as someone who represents nurses who work 24/seven, in the system on the front lines, we have strong feelings about the issues - from privatization to primary health; from hospital cuts to home care; and the costs of pharmaceuticals.

Today, I focussed on the sustainability of our nursing workforce, but I would be pleased to come back with additional nurses' perspectives on these other important issues for our cherished health care system.

The Chairman: Thank you Ms Connors. Our next witness is Ms MacDonald-Rencz, Director of Policy, Regulation and Research at the Canadian Nurses Association.

Ms Sandra MacDonald-Rencz, Director of Policy, Regulation and Research, Canadian Nurses Association: I will talk about the issues that face nursing in the health care system. Specifically, I will look at recruitment, integration and retention of nurses. I am sure that you will note some points similar to the previous group who presented. The issues that we face are similar within the whole health human resource. Although, for nursing it is a more significant issue.

Our board has been watching, with interest, a number of initiatives that have taken place across the country. At a recent meeting, our board identified two areas of priority for work that support much of the work that has been taking place at the national. The first priority is the promotion and implementation of principles around primary health care and the fact that it is an extremely important part of the health care system and one that is often neglected in the discussions. The second priority is advocating and speaking out on behalf of strong "quality practice environments."

These priorities will come up when I talk about the successful recruitment integration and retention of nurses. Unless you have the kind of practice environments where nurses feel that they can be providing quality care, you will not retain them.

CNA welcomes the attention that provincial governments are focussing at the moment in studying the health care system and making recommendations for improving its effectiveness and efficiency.

We applaud the announcement in September - the framework for the health system renewal. We were pleased to note that while not identified as a significant separate focus, the whole issue of health human resources was a crosscutting issue threaded throughout all of what they identified for themselves.

This framework provides a workable structure for looking at moving the health care system forward. However, an important part of that is to recognize that you need the kinds of knowledgeable, competent, qualified workers to make that happen.

As well, we recognize that there are a number of initiatives taking place at the national level, which will support a number of the strategies that I will talk about. One of those is, as mentioned by both Ms Connors and Mr. Paradis, the national study taking place with the guidance of HRDC and Health Canada to look at some long-term planning for the nursing profession. It looks at not only RNs, but at the licensed practical nurse and the registered psychiatric nurse. It addresses many of the long-term issues that need to be looked at with those three groups.

We also applaud the nursing strategy document that was released by the Federal/Provincial/Territorial Ministers of Health. It is an excellent move forward. The 11 recommendations contained therein outline some of the immediate strategies that could be implemented. We look forward to working and seeing those actually roll out.

However, they do not address the fact that nurses are faced with increased workloads. They are dealing with patients who are sicker; longer waiting lists; the whole issue of access; mandatory overtime; and increased incidents of verbal and physical abuse. Nurses face these issues because of the stresses that are created by such work environments. These are all issues that we are concerned about. The strategies that I will talk about are meant to address some of those.

Next we will look at some specific recommendations, or bundling some strategies together that could address the crisis in our health care system. We have organized those under "Recruitment" - bringing knowledgeable, bright, young minds into the profession; getting graduates successfully integrated into the workplace; and keeping them.

We have seen a 50 per cent reduction in the number of graduates in nursing over the last 10 years. Again, you heard one of our previous presenters identify how the enrolment has decreased at one of our colleges. Another interesting point about that more than one-half of those graduates went to the United States. In essence, we were educating for another country and that is a major issue for us.

Once you have them in the workplace there is the need to keep them in a work environment in which they can provide the quality care that they have been trained to provide.

The CNA believes that action needs to take place in the short term to repair the profession. We believe that to enhance recruitment opportunities, we need to act in seven areas that could be classified in three main categories. One is to attract the students in high school. How can we attract them, when the programs are not flexible? As has been mentioned, tuition is a significant barrier. We need to look at either grants, tax incentives or a number of innovative strategies to take that disincentive out of the way. We also need to link academia and education so that we are indeed preparing the individual in a way that the integration takes place better.

Another is that we will not attract people to the profession if they continue to hear about workplace conditions not being favourable and if they continue to have the sense that their salary will not be competitive. Of course, someone who has a high academic standing will choose another profession, where they feel they will have more incentives.

Create permanent positions. The period that we have gone through saw a significant move to part-time and casual status. Signing bonuses are another incentive - which, in a field like health care it sounds almost heretical to be taking on that kind of orientation. However, it is something that many organizations are realizing that they may need to do. In other words, we need to be more aggressive and recognize that people will not just naturally come into the profession.

The next area is the transition, or the successful integration, of those new graduates into the Canadian health care system, so that we do keep them. We believe that mentorship is extremely important. Experienced, seasoned nurses can be invaluable in helping to integrate that new graduate. However, such as task cannot just be added to that experienced nurse's workload, especially when they are already facing extremely demanding workloads. We must adjust the workload, remunerate and recognize mentoring as a responsibility within the experienced nurse.

We also believe that, right from the time that they graduate, we need to have an orientation to continuous learning. When we look at why the Americans are so successful in recruiting our new graduates, we see that it is because they promise continuing education opportunities right from the time they sign on.

We also need to be more creative with our scheduling. The new nurse needs a sense that she will have some kind of control over her practice and how she will practise. Many countries have been very successful at instilling that.

The last area that I have identified is the retention of our current workforce. We have identified seven areas for action. We need to improve the design of how work takes place. The current structure was designed during the industrial age. We now recognize that we have knowledge workers - they come with a great deal of knowledge and learning. We must look at the kind of practice environment that allows them to take this learning and have stronger accountability within the practice setting. We need to facilitate full use of scope of practice. When you educate, often the system is not prepared to have those nurses practice to their full scope.

We need to provide support for professional development and instill in all nurses a sense of continuous learning. If they feel that they are not provided with those opportunities, then they will perceive that perhaps it is time to move on.

There is a need to identify career opportunities. Career laddering has not been done well within the profession. There must be support for flexible scheduling. Access to professional supports, such as clinical leaders, must be established so that practitioners are encouraged to integrate research findings.

What you based your practice on when you graduated should not be the basis of your practice 10 years later. We need to ensure that the practice environment creates the opportunity for the integration of continuous learning within the clinical setting.

The CNA acknowledges that the actions that we have identified to improve recruitment, integration and retention within the nursing profession will require financial investment. We believe that we will receive that return on investment. It will be measured in improved health of Canada and better efficiency of the health system.

The CNA knows that government is concerned about productivity levels in Canada. We believe that improvements in productivity in the health sector, means innovation. You only get innovation if you have the kind of quality knowledge worker working within the system. It means better population health; it means a dynamic, knowledgeable, professional workforce; and it means positive improvements to the Canadian economy.

If I were to leave with you any message, it is that I believe that investing is extremely important. We need to invest so that we can have the kind of qualified, competent worker within our health system. If you do not have that competent, qualified person, you do not have a health system.

The Chairman: I have a question for Ms Jones. In your presentation, you observed that there are over 200 nurse practitioners in Ontario who are not employed as nurse practitioners. Why is that? Is it because of the barriers that you talked about? It would be useful for us to have a list of those barriers in greater detail. Your organization may well have them, particularly because some of them are systemic, and some are related to the legal liability questions.

Ms Jones: The initiative in Ontario and those in the other provinces have been political initiatives. We needed these initiatives to move politically when the opportunity rose to bring about the role and bring the initiative back. It meant that it was not always well thought through. In the Province of Ontario, we were able to make great strides in having legislation passed and in re-establishing the educational programs. However, there was not a clear vision of where the nurse practitioner would be integrated into the province. As well, there was no clear thinking of the funding mechanism at a time when there was all downsizing. We are suffering from the fact that two funding pools came to us - one in 1999 and one in 2000 - with no other earmarked funding. Therefore, 200 of our new graduates are not involved.

The Chairman: Could you expand on some of your barrier issues? Do you have more details about them? I do not need them now, but if you have them, could you please send them to us?

Ms Jones: The Nurse Practitioner Association is a volunteer association and is an interest group of RNAO. I would be able to obtain that document relevant to the Ontario situation. With new provincial initiatives arising, and without a national organization, it is a little more difficult to do for the other areas. I will do my best.

The Chairman: Thank you. Ms MacDonald-Rencz and Ms Connors, you both talked about the problems and possible solutions. Basically, if I can group the potential solutions to the shortage problem, they could be placed into three main categories. One category is more money in a variety of forms. The second category is to hire more nurses because that is the only way you will deal with the workload problem. The third would be the non-monetary, soft side of the job as listed on page 5 where Ms MacDonald-Rencz talked about career planning, flexible scheduling and other things.

I understand that you would like to have all three of those solutions. Realistically, you will not have all three, so my question is: If the federal government was to put more money into nursing, which of those three categories should it consider and in what order of priority?

Ms MacDonald-Rencz: That is a difficult question to answer, because one feeds the other. If you do not invest in strengthening the practice environment and making it the kind of environment where nurses can practice at a level that is appropriate to their levels, then you will not draw anybody into the profession. High school students will hear from their friends' mothers that it is not the kind of place you will want work.

However, if invest in the workplace and you do not do something about retaining the number of seats so that new recruits are in constant supply, then it does not matter how great it is, you will not have the base.

The other problem we are facing in nursing is that over the past decade, the number of seats in nursing has been cut. As well, people have not been attracted to the profession. It is a double-edged sword and so we are at a base than it has been in decades. We are facing an issue that goes beyond just keeping people entering the programs. We have to get ourselves back up to a base level of people so that we are regularly refreshing the workforce. It is a compounded issue we have.

Our current population curve is fascinating to watch as it dips to the below 30 group and then suddenly goes way up to the older ages. We have to do some building. You cannot consider just one, because one affects the other.

Ms Connors: As nurses prepare for bargaining, they frequently fill out questionnaires. The union will ask the members about their priorities - what their needs are to have the collective agreement reflect their basic needs. As Ms MacDonald-Rencz said, all of those issues are priorities.

Nurses want to be paid for what they are worth, and if they are required to work short-staffed with tremendous workloads, they want to be compensated. They want to be properly rewarded for staying overtime. They say, "Pay me double time instead of time and a half. If I work hard, the system will have to acknowledge that I work hard."

They also want to nurse in the way that they were educated to nurse. Not only do they want to perform the physical parts of the care, they also want to teach and take the time to sit on the side of the bed of someone who needs to be supported and comforted. They want to counsel, nurture and do all those things on which it is difficult to place a monetary value. They want a work environment that encompasses occupational health and safety issues and in which they can make decisions.

If I, as a nurse, feel that we cannot take one more admission to a ward, then the system should allow me the latitude to make that decision on evening or night shift. I know that one more admission can compromise the patients in my care if I am forced to it without additional staff to assist.

It is not a matter of giving us one or two of the priorities, because they are so interconnected. It is a complex question. We are in a bit of a pickle as a country over nursing health human resources. Let us be honest, 96 per cent of nurses are women. It is the non-valuing of "women's work." Let us put that fair and square on the table. I maintain that if there was a shortage such as this in the private sector, the solutions would be found just like that.

Because this is happening in the public sector and deals with a predominantly female workforce, the attention has not been occurred. That is why there are nurses who refuse to work overtime in B.C., which is crippling the system.

[Translation]

Mr. Paradis: The solution to the problem of work overload, in addition to putting more money into the system, lies partly in making more use of auxiliary nurses.

In Quebec, for example, an auxiliary nurse could easily perform up to 15 professional services, such as checking vital signs, administering certain injections or changing dressings.

In hospitals, six out of 15 professional services are carried out by auxiliary nurses. Of course this creates extra work for the registered nurses, who in the past were helped in this regard by auxiliary nurses.

There really is a major problem as regards the organisation of work and use of resources. When we are told that in Quebec80 per cent of an institution's budget goes to salaries, a decision should be made to make the best and most rational use of auxiliary nurses.

In Quebec there are barely 150 auxiliary nurses in home support services, as compared with 8,000 registered nurses. Of those 8,000 registered nurses, 3,034 have Bachelor's degrees. The congestion of emergency services, where highly skilled staff are needed, could be relieved by making more use of auxiliary nurses in the local community service centres rather than registered and university graduate nurses. Such an approach would not be any more expensive and would increase access without reducing the quality of the health care available.

[English]

Senator Fairbairn: Mr. Paradis, that was a very courageous presentation, which I think many of us in this room can identify with, in certain ways. I am also aware of the strength of the arguments and the movement from my own province of Alberta, where great advances have been made, but at great cost.

To an extent you have already answered some of my questions. I wanted to raise the issue of the value or your work. It seems that the people value nurses and the patients value nurses; evidently, the system does not value nurses to a large degree. We all know that they have been leaving Canada in droves. Is value a strong enough word? In the application of your work, do you suffer discrimination in the degree to which your work is treated by colleagues - to say nothing of the governing system?

Ms Connors: I will provide an example. When you talk about value, I will talk about economic value.

A nurse working in Prince George, British Columbia is paid $1.25 per hour to be on call. A physician is paid $40 per hour to be on call. That speaks volumes about value, because the on call physician will frequently return to an operating room that requires the presence of nurses. That is a message to us about the value, or the lack thereof, of the work that is absolutely essential for the system to function.

Yes, we feel valued by our patients. That is the greater part of what keeps us going - when someone says "thank you for taking the time." At Children's Hospital in Winnipeg, the parents thanked the nurses for having the courage to speak publicly about the untenable situations. We feel that value by those for whom we care, whether we are home care nurses, hospital nurses or community nurses - it keeps the "boomers" in the system. It will not be enough to keep the Generation Xs in the system, because their set of values is different.

The issues relate to economic value and systemic value. Lack of nurses' participation in some cases around the table when substantial health policy decisions are made, speaks to us about value and the importance - or the lack of importance - of our input on the issues.

When we provide 75 per cent to 80 per cent of the care, is it not a given that we should be present when substantive decisions are made about the system in which we work and the policies that are implemented? Those are some of our points about our analysis of "value of nurses" in the system in which they work.

Ms MacDonald-Rencz: Studies and polls have shown that we are one of the most respected professions. Why does that not translate into power within the organization? In looking at it, by and large, nursing service is invisible. It is permeated throughout the organization. Our services are, if you will, institutionalized. When you try to extract the evidence - the result of nursing services - we have not been as effective at demonstrating that these nursing services activities are being done, you end up with this result.

In a time of evidence-based decision-making and data research, we realize that that has been a void. We are working with other groups such as the Canadian Institutes for Health Information and others, to make it more evident. When it came to the time of restructuring, and what Dr. Keon talked about - the "smushing" together of many buildings in the name of collaboration and called it "integration" - many of the nursing positions, as a cost saving, were eliminated.

The administrators did not have a clear sense of what the impact of that would be. To the nurses, the impact was obvious. It would make an impact if you eliminate one-quarter of the workforce, but there was not the evidence or the data to substantiate that logic.

That is another thing that we need to look at. That is why we speak so strongly to the issues of research, evidence and ensuring that information is shared so that decisions can be made and an idea of the impact can be known.

Senator Fairbairn: Ms MacDonald-Rencz, you used the word "pickle." You are in a situation that could make it dangerous for the country. It seems totally incongruous for me to see a group of people - largely women - who are trained and committed to helping other people, having to take to the streets for lengthy periods, withdrawing their services so that they can make small acceptable gains that will get them back to work. There is something terribly wrong with that. I do not know whether this committee will ever be in a position to come up with any answers, but certainly it is terribly wrong. It is not the Canadian way.

Senator Morin: Thank you for your interesting presentations. To me the issues relating to nursing human resources are by far the most serious facing our health care delivery system. In a way it is symptomatic of the problems that our health care system is facing.

I have two questions, one for Ms MacDonald-Rencz and one for Mr. Paradis.

You told us that the U.S. attracts and retains Canadian nurses, while we are unable to do so. What is so good about the American health care system?

[Translation]

You indicated that more use is made of auxiliary nurses in the United States. What is so good about the American system that we cannot do in Canada? I would ask Ms. Macdonald to respond first.

[English]

Ms MacDonald-Rencz: What is so good about the American system? I am not certain it is so much the American system as it is the way in which they treat their human resources.

Senator Morin: It is part of the system.

Ms MacDonald-Rencz: In the Canadian health care system, traditionally, the employers treat the health care graduates as though they are privileged to be hired. They say: "Complete an application form and we will call you if we need you."

When you see how high-tech companies recruit people - job fares, signing bonuses, et cetera - they search for employees; they offer employment, as opposed to the potential employee hunting down human resources somewhere.

The orientation is also not as strong as it could be. The Americans have a long tradition of aggressive recruitment. They like our Canadian graduates and we are seen as a source of workforce that they could employ to meet their cyclical shortages. They provide moving allowances for relocation; they look after spouses, who may need jobs; they help people with immigration; and they will help with any of the associated costs. When the employee arrives, there is an extensive orientation program and they offer mentoring programs. Many of the suggestions today have been taken from the American system.

Senator Morin: They also retain their nurses.

Ms MacDonald-Rencz: As soon as the probation period is over, they sit down and plan their career with the nurses. Would you like to go on and get certification? Would you like to get your masters? They offer funding and flexible hours so that they can pursue post-graduate training and education while they are employed. Having made this investment, they will then offer more employment opportunities. They are groomed for future positions.

None of that is reflected in our treatment of health care. Similarly, there has been a development of a "magnet" kind of environment - a strong practice environment - where they involve and engage the nursing community within that organization to make decisions. That is a powerful incentive to stay, because you feel like you are a valued employee.

[Translation]

Mr. Paradis: I would like to add that what my colleagues said about registered nurses is completely correct. The working conditions of auxiliary nurses are quite similar to those of registered nurses, since they do the same work as their colleagues. As regards the value of one's work being appreciated, I would say that when two-thirds of nurses have to work part time for over ten years before obtaining a full-time position, such a situation is not very attractive or good for one's feeling of being appreciated.

In answer to your question, Senator Morin, it was decided ten years ago in Quebec that they would have a health system comprising, in addition to doctors, only registered nurses. They thought they could do without auxiliary nurses, although there were about 20,000 auxiliary nurses in Quebec at the time. It was a growth period. The number of registered nurses is now over 65,000.

In 1997 something important occurred: the Quebec government decided to offer attractive severance packages to all health professionals wishing to retire. Over 5,000 registered nurses and 2,000 auxiliary nurses took retirement. That created a problem which has never been resolved and has worsened the shortage we are experiencing today.

We now need more auxiliary nurses. However, the decision to make the optimal use of auxiliary nurses, in accordance with the training they have received and with a view to providing a broader range of services so as to free up registered nurses, has not been implemented in the institutions concerned. There is a will to do so, but it has yet to be acted upon. The situation remains difficult. I would reiterate that the problem could be resolved in part by using auxiliary nurses. They are more available and could work far more hours each week that they are currently doing.

[English]

Senator Keon: I think that anyone who has been active in health care realizes that you have probably understated your case. I do not know that we could say the same about any other witnesses that we have ever had.

There is simply no question, from my own experience in the past 30 years, that there is a horrible problem coming down the road - a truly horrible problem coming. Part of the solution would be the churning out of large numbers of nurses. There is no question about that. You can see it happening when the nurses are overworked. When the nurses have enough resources, are happy in their environment and have the right resources, they are reasonably satisfied. However, when they are overextended, as you have pointed out, they begin to come apart; they become sick; and they move into other areas.

I will oversimplify a suggested solution to you, just for the purpose of discussion. You need big numbers and you need them now. There is no question about it. You need a much more flexible system than you have had for the last while. I think the rigidity of the system is killing you.

The Chairman: Do you mean the "system of education?"

Senator Keon: No. I mean the health system in which they work. Nurses have been swallowed by the big hospitals. I am a hospital administrator myself, as you know. In the early years, our nurses had many options. They could be nurse clinicians, ward nurses, ICU nurses, OR nurses, clinical educators, or any of many other choices. They had options for direction and higher education. Now the resources are snuffed out to the point where those options are non-existent.

I will throw something else at you. Earlier today a deputy minister stated that he would be totally opposed to any kind of private health care. In fact, 30 per cent of our health care is private now. The home care programs are largely private; the reimbursement of the nurse, if you can find one, is largely private. There is room in that for a little enterprise.

In addition to the numbers that you have to bring into the system - and adequate remuneration would come with that - what do you think of a look at the whole system? We have to develop an integrated health system that integrates everything from A to Z. The role of all health professionals must be defined in there. Nurses would largely run the primary and community care levels. What do you think of the private sector?

Ms Connors: I will respond to that, Dr. Keon, because you made a reference, specifically to the "home care" sector of health care. One of the realities of the 1990s was that we substantially reduced the capacity within the acute care hospital sector - the illness care sector. We created shorter periods of hospitalization, increased acuity of those in the sector and job intensification as a result of that, and then we sent people home to the community without the subsequent investment in the home care side of the provision of health care services.

I come from the Province of Manitoba, where the home care system is publicly funded and delivered. There is no private-for- profit service. In fact, the Manitoba government's experiment with private-for-profit home care proved a dismal failure. They could not obtain bids that were more cost effective in the delivery of quality home care services in Manitoba, and so they reverted to the publicly funded and delivered system.

Nurses in Ontario have gone through the experience of the requests for proposals and the competitive bidding process in home care. They can tell you that the result of that process, and the incursion of the private sector and the emphasis on providing levels of profit margin for their stockholders, has led to a direct downward pressure on those very nurses that work in the system. That is because the private-for-profit providers have to find a way to take the bid away from organizations such as St. Elizabeth's and the Victorian Order of Nurses, which has a 100-year history of providing private but not for-profit home care.

We have heard good testimony and decisions could be made on such evidence-based testimony. Our organization is supportive of publicly funded and delivered service that includes the education of the health care providers in Canada, and we are adamantly opposed to increasing the level of private sector involvement in our system, currently.

Senator Keon: To pursue that, I have also had the great privilege of spending my whole career in the system as it is, and I will retire before it changes. However, there are a few members of your organization who are currently working as private home care nurses. Do you think that is a reasonable option or do think that is a failure?

Ms Connors: Some nurses want to work in the home care area of the work environment. They find, frankly, that hospital nursing and long-term care nursing are not desirable work environments. Many nurses find reward in the independence of their clinical decision-making; they are able to work in an area where they can set the priorities, et cetera, in the provision of home care. That is part of the reward that keeps them there, despite the fact that they are subsidizing the system with inferior wages and benefits. Some of them do not even have pensions.

There is the whole issue of the motivator, or the "satisfier," for each individual practitioner. That "satisfier" must be recognized. Discrepancies of $5 per hour between the earnings of a nurse in the home care sector and a nurse working in a hospital, is having a huge impact in Ontario with the bleeding back into the acute care sector. Nurses recognize that, economically, their financial requirements are available more readily to them in the hospital sector than they are in the private for profit home care sector, because of the introduction of the bidding process.

[Translation]

Mr. Paradis: During the summer and the fall of 2000, the Quebec Minister of Health Ms. Pauline Marois set up a commission of inquiry on health services. The commission focussed on two issues: organisation of funding and organisation of services. Surveys indicated that 88 per cent of Quebeckers reiterated their wish to maintain a public, free-of-charge and universal health care system.

Quebeckers consider that the $16 billion they are currently allocating to the health care system should be adequate to provide quality health care to everyone in the province. For our part, we are firmly and strongly opposed to privatisation, because it has not been demonstrated at all that the private sector would perform better than the public sector in this regard.

[English]

Senator Morin: On the same subject, Ms Macdonald-Rencz, a few minutes ago you described the superiority of the American health care system in its ability to attract and retain nurses. You did so very convincingly, and I am with you on that. Is their system not a private health care system? Why not? There have documentaries about that recently. Some of the featured hospitals that have job fairs, et cetera, were for-profit private hospitals. I refer only to the U.S. where the hospitals are not all public facilities.

Ms MacDonald-Rencz: You are making comparisons within the American system and that could be the subject of a another discussion. My examples included the activities of some American recruiting firms that is done equally between private and public.

Senator Morin: For example, is the State of Illinois the recruiter?

Ms MacDonald-Rencz: No, the hospitals are the recruiters.

Senator Morin: They do not have the same relation. Their hospitals do not have the same relation to the state government as we have to the provincial governments. In Canada, they are private only up to a point.

[Translation]

Mr. Paradis: On a per capita basis the United States spends more than any other country on health care. However, as regards performance, it is ranked 37th, far behind Italy which is close to the top.

In the United States the private health care system must not only break even but must also make a profit. In terms of quality, the public are forgotten about and have very little access to health care.

Senator Morin: Why are Quebeckers being sent to the United States for health care?

Mr. Paradis: As I mentioned earlier, in 1997 too many professionals were encouraged to retire. As a result, many women with breast cancer had to go for treatment to the United States. It is true that there is a problem of money, but there is also a problem of manpower planning. The situation should improve with time.

[English]

The Chairman: To clarify a point, when you consider the issue of the private sector, it is important to separate the issues of funding from service delivery. Often, when we think about a publicly funded service, we assume that it has to be delivered by the public sector, or the not-for-profit sector. The point that my colleagues made was that if you separate those two notions, it is not impossible have for part of, or all of, the population, a publicly funded program that could be delivered by the private sector.

I noticed in some of your answers that there was a tendency to assume that "public funding" automatically meant "public delivery," and they are two quite different issues.

Senator Cordy: First, I will comment on your report, Ms Jones. We have had many witnesses before us who have spoken about community health care teams, partnerships in health, et cetera. It is troubling to hear that, in Ontario, there are 200 trained nurse practitioners that are not working in their chosen field. I understood that the role of the nurse practitioner was an integral part of any community health care team. After hearing about what is happening, I wonder how seriously this profession is being taken by those who are in charge?

Ms Jones: When our illness system is in crisis, our health system, once again, is put on the back burner. Talking from the perspective of a community-based nurse, steeped in the principles of primary health care, there is a devaluation of the importance of the nurse practitioners' roles.

There was a thrust and a move forward, because there was an appreciation that we truly needed to look at and to open up community-based care. Now, as we again become more con cerned about illness care, the potential of the nurse practitioners' roles has been put on the back burner.

We have fought long and hard, as primary health care nurse practitioners, for recognition of the skills that we share with medicine and for the understanding that that is the only gateway open to us - through our medical skills under the current health care system. You must be ill to enter into the system and that illness care usually came from another provider.

As primary health care nurse practitioners, we now have the skills to allow that gateway to come to us, from an illness care perspective. However, once we have an individual, or a family, within our practice, then we are able to put the focus on health promotion, disease prevention and supportive care, which encompass the nursing approach.

Opening our health care system to allow that focus on the importance of primary health care, and to be able to organize primary health care is really the key. As we get caught up in what is happening to illness care and the funding of illness care, the tendency is to say that our community system can fall under private funding. That will, again, devalue the community system and not place the same emphasis on the importance of community-based care.

Senator Cordy: We are all aware of the shortages of nurses, certainly in Nova Scotia, where we hear about it all the time. Yet, the material we have mentioned the increase in numbers of casual and part-time workers in the nursing profession. Part-time work certainly affects benefits and pensions. In the teaching profession, many teachers choose to work part-time while their children are young. Are nurses voluntarily working part-time, or is it because our society is increasingly directed toward the part-time or casual status?

Ms MacDonald-Rencz: Probably, yes, to both of your questions. The movement to that began in the early 1990s, when restructuring was taking place; there was significant downsizing. Nursing services are one of the largest budget items, and if you need to make significant cuts in your budget, reviewing and reducing those services is automatic for an immediate and significant cost saving.

Yet, they knew that the administrators - whether home care or community hospital - still needed people to work at certain peak hours, and so they decided that casual or casual part-time status could provide the requisite staff and still maintain the cost savings - no benefits to pay out.

As a result of that, many of our new graduates who entered this working climate were forced to hold three or four part-time jobs. They have come to like it, though, because they do not have to work all of the weekends - they do not have to take their turn - and they can choose which unit to work in.

Many of the organizations are reporting difficulties with that system. They have converted many positions and now realize that it was a mistake. They were not saving money; by the time they reviewed the costs of the overtime, et cetera, they were paying, they decided to converted the positions to full-time status. However, they are having difficulty filling those positions because not all of the nurses want to revert.

Our concern relates to professional practice. For example, let us say that more than half the nurses in a renal transplant unit are casual. They are in this unit now and next time they'll be in home care or another unit. Will they understand the blood results that come back? The optimum situation is to have a core group of nurses working within that renal unit who know renal transplants and the signs that need to be looked at. This is true in any practice area, and I use that as an extreme example because most of us can relate to it.

We have a concern with what has been created. Yes, because it is a predominantly female profession, there has been a tendency to see the times in the life of the nurses when they will choose more part-time and casual because they have very young children. However, normally that reverts to full-time when the children are school age. We are now seeing something different.

Ms Connors: In the early 1990s, there was a proliferation of the casual employee. Frequently, it was the new graduates who held those positions. For a new practitioner, how do you solidify a skill set - your knowledge skills and abilities - if you are working in four different places, with four different sets of policies and procedures?

The stories that nurses told about those times in their work lives were horrendous. That was one of the reasons that the option of full-time employment, which led many of our new graduates - the cream of the crop - to work in the United States. There was full-time employment to be had, as well as some of the other incentives that we talked about.

There are, certainly, individuals who will opt for casual employment. Let us be honest, we do not have a national child care program. We do not have on-site child care available for nurses, who may be breast-feeding moms. The incentives to return to work are not in place. Those options are available in the U.S.

I hate to talk about the depressing reality of the workplace, but things are pretty bad. Casual workers can too easily refuse a shift that promises to be difficult, whereas the nurse with full-time status will go in because she has a commitment to work, even if she knows it will be a terrible shift.

Again, it is the issue of addressing the quality of the workplace - the work environment. I firmly believe that, if there were improvements to the work environment many of those who previously refused full-time employment positions would have a willingness to return.

There are still huge numbers of casual employment positions that need to be converted to full-time positions.

Senator Cook: Relative to the nurse practitioner surplus in Ontario, I understand you have about a 200 nurses who are not employed as nurse practitioners. Are they employed as registered nurses, or are they waiting for work?

Ms Jones: If we look at those 200 it breaks down to50 per cent of each. Our graduates have returned to their previous employment in acute care or in community-based care, or they may be employed in locums or half-time capacities as nurse practitioners. We see that 50 per cent are working in their capacity and 50 per cent are not employed.

Senator LeBreton: Are they lost to the system forever? It is a tremendous tragedy. If they have gone elsewhere, will we ever get them back? When there are such shortages, especially in the rural areas, it is shocking that 200 nurse practitioners are not employed. Where are they and will we get them back?

Ms Jones: There is a lack of identified funding for advanced practice nurses or nurse practitioners. There was not a clear appreciation of how they would be integrated into the system, so that it was a knee-jerk reaction. In the Province of Ontario, removing those funding, legislative and medical liability issues will bring them into the practice. While nurse practitioners who entered into those programs, were required two years' experience as RNs, most of them had an average nursing experience of 15 years.

We had an incredible strength of nurses who were attracted to the programs because we could use our full autonomy. We were able to make the decisions that nurses in other sectors would love to be able to make. For a nurse to have the right to say, "I have a practice" is incredible. I do not think that our 200 are lost to us. If they had a chance to hold NP positions, they would do so immediately.

Senator Callbeck: You have certainly given us much to think about.

My first question has been answered, concerning the graduate nurses moving to States to work, and we talked about the reasons for that. I wonder if the shift from permanent status to casual and part-time status played a part in our nurses making that decision. A Library of Parliament document of a recent comparative survey states that 41 per cent of American nurses expressed satisfaction with their jobs compared to 32.9 per cent in Canada. I found that statistic surprising.

From what you have said, I understand that, initially, it did play a part. Those graduates went to the states because they could not get permanent work here. Now, however, I understand that there are many permanent positions available and nurses cannot be found to fill the vacancies. Is that correct?

Ms MacDonald-Rencz: As our studies have shown that once you have lost them to another country, they are gone for good. They connect with the new community and set down roots; they develop relationships, settle and raise families. In actually looking at repatriating - and that is the phrase that is being used by recruiters - a number of the Canadian nurses are simply not interested. They would be interested if they could be guaranteed some security and the same kind of continuing education and career path opportunities that they have had.

To address the high incidence of dissatisfaction, I believe that shows up when you compare one study with another. A report was just released on May 7 that received a fair amount of media attention. It is an international study that looks at the quality of care and working conditions in five countries. It examines those issues in the United States, England, Germany, Canada and one other country. The report compared the satisfaction levels in the different countries and correlated the satisfaction and the workload to actual patient outcomes. There is not a great variation between Canada and the United States, which is interesting. I could certainly share a copy of this report if you care to look at it.

Ms Connors: We have wonderful international working relationships with many nurses and groups who do the bargaining for nurses in the United States. Certainly, dissatisfaction levels among nurses, with respect to their work environments, are quite similar to ours. Again, the questions are raised. What does the workplace look like? What kind of support system does it have? Does it have a magnet-type of work environment, where people are valued for their work in the system? Those are very much issues.

Many American nurses have never known anything but the American way. They hear about the Canadian health care system but they have not experienced it. I have asked nurses in the States, "How can you stay and work in a system where you have to check your cheque book before you can access care, in many ways?" They say, "We are not the ones checking the cheque books, but rather, we provide the care. Checking the cheque book happens elsewhere in the building."

Nurses do not have to confront those issues. I have spoken with some nurses who said that that is one reason why they returned to Canada - the whole philosophy of the American system is just not compatible with their set of values, and so they returned home.

There is also the issue of job security. Canadian nurses who work anywhere in the U.S. say that they could come back to Canada, but when the next round of budget cuts occurs, they would be the first ones let go, because they were the last ones hired. Thus they say, "Will we leave the security that we have? "

The issues surrounding continuing education, support for education and what kind of career, rather than what kind of job, are very important. They do not see those kinds of provisions in the work environment that is being offered to them by the recruiters, who are now going across the border and trying to bring Canadian nurses home.

[Translation]

Mr. Paradis: I would like to add that if more full-time positions were created - and there is talk of doing so - that would lead to a better quality of life, better work schedules and in all likelihood less overtime.

At present in Quebec registered nurses and auxiliary nurses have to work overtime because they are practically obliged to do so. People become burned out because they are overworked and so move elsewhere, like the United States which offers better working conditions, higher salaries and tax benefits. If we were to improve the organisation of work in Quebec, we could certainly create a better atmosphere which would help us keep our nurses.

[English]

Senator Callbeck: We talked tonight about the number of young people entering nursing, the decreasing numbers and the importance of a track record. Have some provinces been more successful than others in enticing young people to enter the field of nursing?

Ms MacDonald-Rencz: I cannot speak to specific numbers. Anecdotally, there are some provinces that are more successful. Alberta is one with the recent agreement that they have. There is no doubt about it. Their programs are drawing nurses from other provinces and are being oversubscribed. However, this is anecdotal information, because the trend to have some incentives to do this is relatively new in Canada. It would be interesting to follow up on what you have identified in a document.

Ms Connors: In the two weeks following the ratification of the United Nurses of Alberta agreement, there were 500 calls from nurses, who were currently not working in Alberta's health care system, about job opportunities within the Calgary Regional Health Authority. Again, if you pay people what they are worth, they will be enticed into returning.

That is why one of the issues that we continue to promote and hope that there will be support for, is the use of employment insurance dollars. There is a surplus. If skilled trades can access EI dollars to continue to advance their education, why can nurses not do the same thing? We need to look at that. Why does EI prevent access of dollars for post-secondary education?

The reality is that, for many nurses or people who entered nursing, it was a job that was seen as open to all, not necessarily the richer families. I came from a rural farm background and nursing was something that our family could afford for me. If I were now that same young woman in that community, I have to tell you, I would really seriously question whether I could choose to go into nursing, because our family could not afford the burden of the tuition and relocation for the post-secondary education.

Ireland got it right - free tuition. The nurses organization there talks about the increasing numbers of people looking at nursing. We have not always traditionally relied only on the young people. Many people have chosen nursing as a second career. Those kind of things need to be valued as well.

Senator LeBreton: We have been doing this health care study for quite some time now. I have found this testimony the most distressing and depressing because we are talking about the most fundamental basics of our health care system. We have been talking about technology and new pharmaceuticals. However, if we do not fix this then I think that we are in a canoe heading to Niagara Falls in a quick hurry.

Ms Connors, I am prompted to ask you this question because of a statement made by Dr. Keon which makes me realize how right you are. He said something to the effect that we are soon into a big disaster if something is not done.

You talked about the rate of nurses quilting their jobs. You said that one in six Canadian nurses working in hospitals plan to quit within the next year. Even worse, you said that among nurses under the age of 30 years, that figure rises to almost one nurse in three nurses plan to quit. You noted that the young people will not put up with this.

I was raised on a farm. I thought I would be a nurse when I was young.

Where is the point of no return? Has there been a study done? If this condition continues, when will it get to point where we will not be able to function if this is not fixed?

Ms Connors: The 1997 study by the Canadian Nurses Association forecasts that if nothing is done to address this topic, by the year 2011 there would be 113,000 too few registered nurses in the system. That is not that distant in time.

The average retirement age of a nurse in Canada is not 65 years of age. It is 56 years of age. The average age of nurses currently is 47 years of age. The bulk of us are heading for retirement over the next several years, in less than 10 years. We are getting into a real crunch.

The importance and focus of addressing the nursing health human resource issue is imperative. We ignore it at the peril of our health care system. That is the message that we cannot state any more passionately to you as a committee looking at the future of our health care system.

I return to the issue of sustainability. If you do not sustain the nursing workforce, you will not sustain Canada's health care system.

The Chairman: On that note, I thank all of you for having taken the time to be with us.

Senators, we are going to do our last panel during this meeting tonight because they are from out of town. I would ask you to be a patient.

We have Kurt Davis of the Canadian Society for Medical Laboratory Science, Dr. Tim St. Denis of the Canadian Chiropractic Association, and Dr. Paul Johns, the past chair of the Canadian Radiation and Imaging Societies in Medicine.

Mr. Davis, if you would begin please.

Mr. Kurt Davis, Executive Director, Canadian Society for Medical Laboratory Science: Mr. Chairman, I would like to start by mentioning that we are privileged to have tonight with us Mr. David Ball from Newfoundland. He is the elected President of our national society. He is laboratory manager at the Western Memorial Hospital in Corner Brook, Newfoundland.

I will tell you a little about who we are because while medical laboratory technologists represent the third-largest health care profession, they are probably the least understood and least known.

Our organization is the national professional society and certifying body for medical laboratory technologists in Canada. We were founded in Hamilton, Ontario in 1937 as the Canadian Society of Laboratory Technologists. We changed our name in 1997 to the Canadian Society for Medical Laboratory Science. Our head offices are located in Hamilton, Ontario.

We are the third-largest health care profession. Eighty-five per cent of practitioners are female. We have approximately 21,000 members practising across Canada.

Our members work in the hospital, medical and diagnostic laboratories. If you have had a blood test, a throat swab, or some other body fluid sent to the lab for analysis, then one of our people have taken care of you.

I must point out that the laboratory generates 85 per cent of the diagnostic information in the health care system. Please remember that fact. It will be important when we come back to it later.

Health reform has had a significant impact on the medical laboratory. The downsizing of the 1990s eliminated 29 per cent of the medical laboratory technologist workforce. In Alberta in 1995, we had a reduction of 1500 medical technologists overnight.

I will update you on information that was completed yesterday and is not in your papers. We now have 10 programs in Canada operating with a September 2001 enrolment of 295.

Our profession is not unlike many of the other health professions in that we are facing a shortage in the future. We have identified this through data on certification information from our organization. We have lobbied the Advisory Committee on Health Human Resources - ACHHR - to examine our profession. We started those discussions in 1996. Finally in 1998, they started a study. In 1999, their recommendations came down.

Unfortunately, nothing has been done with those recommendations. Our problem continues to grow. We are a profession comprising baby boomers. Nearly 45 per cent of our profession will be eligible to retire by the year 2015.

The accumulated knowledge and the resources that will be leaving our industry are immense. The number of training programs across Canada was significantly reduced during the excesses of the 1990s when we had a surplus of medical technologists. We faced considerable concerns on what our future supply would be. We looked at the numbers as presented in this slide. You can see that over the next five years we will be short by about 120 technologists. Each technologist does between 10,000 to 20,000 diagnostic tests. That is an enormous number of tests that will not be done each year if the system continues in the current direction.

In five years, that shortage almost doubles. There is an extreme concern about the ability of the sustainability of the future programs.

Training positions in Quebec were not reduced during the 1990s. The Quebec government policy is to offer education to the students in the community of their choice. Therefore, we have a significant surplus of francophone graduates in our profession.

Some of the concerns that was not addressed in this report but are looming in the background are the increased demands for medical testing. Throughout all the health cutbacks of the1990s, the amount of diagnostic testing was not reduced. In fact, it increased. Patients were sicker; they needed faster test results because they needed to get them out of the hospital quicker.

There is also the evolution of new tests. You have all read about the impact of the genome project and molecular biology. Genetic testing is in the domain of the medical laboratory and will have a huge impact in the future for our profession.

I must reiterate the concerns that you have heard already today about burnout and fatigue resulting from staff shortages and overloads. There is already evidence of an impact on the quality of work. A study produced last year in Ontario clearly evidenced the declining quality of laboratory testing in the province of Ontario.

This is not a made-in-Canada problem. As you have also heard with other professions, there is a global shortage of medical laboratory technologists. We are not immune to the brain drain to the United States. During the 1990s, we had a surplus of technologists. A number of our members moved to the United States. They are staying there, and it is unlikely they will return. The United States is in about twice as much trouble as Canada in this regard.

We cannot rely immigration to solve our human resources problems. In the late 1960s when medical laboratory technology grew rapidly as a profession, we relied on immigration from the U.K. for a large number of practitioners. Those practitioners have retired out of the system in large part. Replacements are not available from the U.K. today to replace them. The U.K. has a shortage about twice as bad as what we are facing.

In your paper there is a list of our recommendations to the provinces. Our recent human resources study was released to ministers of health and education across Canada. In that paper, we identified the problem areas. We are extremely concerned about the provinces of Nova Scotia and Manitoba where no training program currently exists for medical laboratory technologists. Ontario, B.C. and Saskatchewan also have concerning situations, and the other provinces need to monitor carefully.

There will be a large amount of corporate pilferage. It is already happening in our profession. We have an employer from the Fraser Valley Health Group in B.C. coming to Newfoundland to recruit technologists at our annual Congress this June.

We would like to see the ACHHR report given more priority. Some of the key recommendations are listed in your handout. The lack of a national database on human health resources is severely hampering any activity towards doing something about the current issues.

We also endorse the Canadian Health Care Association's recent recommendation to establish resources and funds for the education, training and recruitment of health care professionals. You heard the concerns of the other groups today. We will be competing for the same limited group of health graduates who are interested in health careers. The health professions will be fighting amongst themselves for the same limited group. There needs to be cooperation and consolidation of the programs and the planning to ensure that we do not run over each other in this regard.

We have presented our human resources study to the Advisory Committee on Health and Human Resources. They have agreed to look at the report. We discussed it in length on April 26, 2001. They will study it further.

The report has also been sent to ministers of health and education across Canada. I have been in contact with five provincial governments in the past week. The report was made public on May 10, 2001 through a general media release. We have made it available on our Internet site. We will also be publishing in it the June issue of our national publication to inform all members who are suffering under the stresses of the current system.

Dr. Tim St. Denis, President, The Canadian Chiropractic Association: Mr. Chairman, as President of the Canadian Chiropractic Association, it is my pleasure to address the committee this evening. The Canadian Chiropractic Association - the CCA - is a federal association representing its members in cooperation with the provincial associations and our affiliates. We represent 10 provinces and the Yukon Territory. Through them, we have approximately 4500 members that comprise80 per cent of the total profession in Canada. Over the next five years, we hope we will grow to about 6000 members.

We are now, and have been for years, the third largest primary care profession, after medicine and dentistry.

The mission statement of the CCA is:

To help Canadians live healthier lives by informing the public about the benefits of chiropractic care; promoting the integration of chiropractic into the health care system; and by facilitating chiropractic research.

We have been around for 106 years. We are regulated and recognized by statutes in all Canadian provinces. Our graduates must successfully pass both national and provincial board exams before being licensed.

There are two colleges in Canada. The Canadian Memorial Chiropractic College is in Toronto, and the University of Québec at Trois-Rivières. The program requires three years' university education, but 90 per cent have obtained four-year undergraduate degrees prior to the extensive four-year program in the college itself.

Chiropractors are primary health care practitioners, meaning that the public could contact us direct, without referral. We address primarily problems of the spine, nervous system, joints and extremities. We provide diagnosis, treatment and advise on how to prevent these problems from recurring.

The primary focus is to restore movement of fixated joints, primarily in the spine, and let the body's natural healing abilities relieve the inflammation surrounding the joints. Those tissues are the ligaments, muscles and nerves. Approximately 90 per cent of all visits to chiropractors are conditions related to headaches, neck pain, and back pain.

We have a number of issues that we would like to address. The first one is the trends impacting the costs and methods of health delivery in public funding implications. We have heard about the nurse's dilemma. We have one that is quite the opposite. We feel that we offer the capabilities of giving relief to the health care system, as we know it today.

We believe that there is a significant shift being taken in public funding away from the focus on patient care and well-being to one of cost-containment based on the continuity of existing methods of health care. We feel that Canadians are entitled to safe and effective health care options that are accessible, affordable and appropriate.

Chiropractors have not been utilized by Canada's health care system in a most effective way. Many studies have proven unequivocally that we are both medically effective and cost-effective in what we will do.

Legislative barriers, policy barriers and sometimes funding decisions often result in unfair resource allocations, irrespective of the patient's choice.

Canada's health care system needs to introduce efficiency and cost-effective measures. We have several here that we would like to put forward.

We suggest minimizing or eliminating duplication of services. We would ask that there be an increase in cost-effectiveness of diagnosis by ensuring that the patient is referred to the most appropriate practitioner in the first instance and reducing delays in instituting that proper care.

We would ask for a shifting of an institutional-based care to community-based care, thereby reducing the stresses on hospitals.

We would ask for the implementation of an interest system shift in which utilization of providers is available irrespective of specific health conditions.

We would also ask for investing in health promotion, maintenance and disease prevention.

We see a need to generate a system-wide plan for effectiveness and accountability.

We are dealing with the issue of the aging population and a strong growth within the Aboriginal and special needs populations. CIHI has noted that 30 per cent of the Canadian population utilize 60 per cent of the health care system. That 30 per cent - the aging population - is on a growing curve for which the health care system is not suitable. Canada's Aboriginal population, which has long embraced chiropractic care, is growing at faster pace than non-Aboriginals are.

Increasing demands from Aboriginal growth is being put on facilities in locations where population densities have traditionally been considered insufficient to support the infrastructure. Canadians are becoming concerned about the future of health care. Traditional delivery methods are no longer effective or efficient at responding to total health care requirements. While traditional medicine has enjoyed success in treating acute illness, it has yet to show the same for many chronic conditions. There are significant quality of life challenges to chronic disabilities that may affect longevity.

Allowing other regulated health care professionals to address chronic conditions would relieve pressures on the current health care delivery system. In other words, better service would be provided at lower cost.

Chiropractors are mostly neuromusculoskeletal physicians. They are currently unable to utilize all the tools of the profession and are hampered clinically. We are denied hospital access, sometimes unable to treat lifelong patients who become institutionalized. We are denied x-ray access and access to blood and urine analysis.

Canadians are seriously disadvantaged by the impracticable restraint of essential chiropractic services available to the medical profession. Chiropractors are required by law to refer patients outside their expertise yet there is no law requiring reciprocation. Canadians are becoming increasingly aware that the management of this system is little more than the management of one profession's economic interest.

The CCA recommends a focus that emphasizes health promotion and disease-prevention on the aging population that will have an immediate impact on reducing pressure on the current system. We recommend health care of the chronic population to be undertaken by those most qualified. For example, chiropractors are well trained in pain reduction and should no longer be marginalized due to a lack of system integration.

We also recommend removal of restrictions that stop Aboriginal populations from seeking the less costly mode of health care that is more in line with their traditional cultural values.

To better address the emerging needs of these populations, a shift in financial resource allocation should be undertaken rather than commit more funds to go the current system.

We have also been asked to speak on increasing the public expectations about health care in terms of a variety of services available. It is well known that Canadians want choices in their lives. However, when it comes to freedom of choice of health care, they are limited to drugs and surgery. Canadians do not want exclusive management of the health care of choice. They want to be able to mix and match the professional services to the best suit their personal circumstances. Canadians are increasingly knowledgeable about their health conditions and the benefits and/or risks of the therapies available.

You are probably aware of the research in the area of choice of Canadians. Canadians are now voting with their feet. Four and one-half million Canadians visited chiropractors last year - an increase of 25 per cent over the last five years. Those same Canadians overcame barriers of cost, non-referral and regulation to seek the treatment of choice.

Our research shows that new chiropractic patients have often been in the public system for six months and has not obtained relief. This represents six months of ineffective treatment and discomfort. Six months for the problem to progress from an acute to a chronic condition, requiring longer recovery time. There has also been six months of additional expense to the system, as well as six months of disrupted lifestyle resulting in time off work.

The CCA recommends promoting the evolution and the roles played by each individual profession to provide flexibility of patient choice thus reducing stress on the current system. We also recommend realigning resources to recognize and support existing but under-funded regulated health professions.

We recommend ensuring that the most appropriate, cost-effective care is provided to the patients based on quality outcomes and patient satisfaction as supported by search.

We also recommend broadening the definition to incorporate chiropractic as medically necessary.

Upon the topic of research, we live in a world supported by paper qualifications. Canadians have a right to expect that extensive high quality research has been conducted to the highest international standards. They have a right to know that they can be provided with objective third-party information upon which they can base their health care decisions. They have a right to be informed based on clinical trials of the efficacy, cost-effectiveness and patient satisfaction.

The majority of health care research in Canada is not health care research, but research on drug therapy supported by the pharmaceutical industry through hospitals and universities. The chiropractic profession, without the deep pockets of third parties and comparatively small base of practitioners, has before it over 30 randomized clinical trials showing that adjustments and manipulation are superior to other therapies for low back pain. We have 14 studies proving costs effectiveness and 16 studies showing reduction in work time loss. We have seven government-funded studies supporting chiropractic protocols.

A University of Ottawa research, Professor Pran Manga, estimates that the Ontario government would save $1.25 billion annually with a greater incorporation of chiropractic service into the health care system of Ontario. He suggests that if we were to spend $200 million to save $1.25 billion, we would spend $1 to save $6. Similar studies have been conducted in Saskatchewan and Manitoba, with similar results.

The CCA recommends undertaking econometric to examine the cost-effectiveness of health care services based upon the elimination of duplication of services. Health care services should be provided by those practitioners who have the best education and demonstrated competence in their areas of expertise. Treatments and therapies should be funded on the basis of demonstrated positive outcomes.

We also recommend publicly funded research into the benefits of preventive health care. Finally, we recommend that health care interventions that have been identified as producing positive outcomes in patient and condition management be incorporated into the publicly funded health system.

The Chairman: Dr. Johns, we had a presentation about three weeks ago from the Canadian Association of Radiologists, I believe it was. You could almost go directly to your recommendations. You may want to make a couple of other points, but we have already received much of the data that you have in your brief.

Dr. Paul C. Johns, Past-chair, Canadian Radiation and Imaging Societies in Medicine: I am a medical physicist. I am employed at Carleton University in physics. I represent the Canadian Radiation and Imaging Societies in Medicine, which is an umbrella organization. I think that you have two sets of handouts from me. One is speaking notes, and one is a report dated last week May 7, 2001.

The Chairman: It is the report that I read.

Dr. Johns: I would like to acknowledge Dr. Richard Lauzon, Executive Director of the Canadian Association of Medical Radiation Technologists, who is with me here tonight.

I would like to briefly describe the Canadian Radiation and Imaging Societies in Medicine, the CRISM. We are an umbrella organization founded in 1998 and consists of five societies that are involved in medical imaging or use of ionizing radiation in medicine. The list includes nuclear medicine, medical radiation technology, radiology, medical physics, and diagnostic medical sonography.

We have three main concerns: the shortage of professionals in each area; insufficiently installed equipment base for imaging, image-guided treatment and cancer therapy; and lagging pure and applied research in Canada. These concerns are interrelated.

Due to the focus of today's session, most of my presentation is in regards to personnel. However, I will also talk about the other two items.

With regard to personnel, there are some items common to each profession. There is a long lead time required between enrolling in a university or training facility and completing training to provide that service. There is an approaching bumper crop of retirements.

Our field of imaging technology and therapy procedures are becoming more complicated and often require more time per staff member. Thereby, it is more personnel intensive.

Listed there are the times to educate. Physicians typically will have a bachelor's degree, followed by the four-year medical degree, followed by a residency in their specialization, such as radiology or nuclear medicine, followed by a fellowship. That is 10 years of specialized education.

Medical physicists follow a route that is dependent on research training in the universities. They will do a bachelor's degree, a master's and doctorate in research, and then a clinical residency.

Technologists typically do a two-year or three-year diploma. In the case of medical radiation technology, that is changing to a four-year bachelor degree. There is quite a bit of time required to effect a change in staffing levels.

We have some numbers for the different professions in terms of personnel. I am sure that you have these numbers already. With more than 1800 radiologists, there are another 200 vacant positions in Canada. Only about 58 residents graduate in Canada per year and remain in this country.

In nuclear medicine, the numbers are smaller because the society is smaller, which is one reason for this umbrella organization. Each year about 11 people in nuclear medicine retire and one leaves the country, for a total of 12 departing. However, only less than 10 people are graduating from residency programs each year.

In medical physics, we do not have good numbers for all the different areas in which medical physicists work, but we have reasonable numbers for radiation therapy, cancer therapy.

There are 217 physicists in this country working clinically in that area. There are 41 positions vacant at regional cancer centres across Canada for physicists - about 20 per cent of positions. In Ontario, one cancer centre is currently under construction and three more are planned soon. These four will require at least another 30, probably 40 positions to staff. We are now in the hole by 80 positions.

On the supply side, there are something like 60 graduate students currently in training programs at Canadian universities in the area of radiation therapy. These are supported by research funding of their supervisors or by scholarships. Many of these do not carry on to residencies. They leave the country.

Currently, we have 28 students in residency programs in clinical facilities. Half that number complete per year and 20 per cent to 30 per cent of these leave the country. Therefore, it will take a long time, if ever, to fill those 40 vacant positions.

These numbers are only for radiation oncology physics. Medical physicists also work in diagnostic imaging, radiation protection, industry and government, et cetera.

We have anecdotal data for sonographers. There is a shortage in every province. Services are shut down intermittently due to a lack of sonographers. Their workload is increasing. Ultrasound is being used for more and varied examinations, including musculoskeletal studies and bowel studies. There is an epidemic of musculoskeletal injury to the sonographers including carpal tunnel syndrome, spinal injuries - basically repetitive strain injuries. Many sonographers leave the profession or drop down to part-time.

In common with radiation technologists, sonographers are primarily female. After going on maternity leave, many choose to return only part-time or not at all.

Medical radiation technologists by far is our largest group. There are approximately 10,000 in this country. One-quarter of these are eligible for retirement in five years. There are approximately 500 graduating per year. There is quite a shortage of technologists in specialized therapies, for example radiation therapy, nuclear medicine and magnetic resonance.

There are 964 technologists working in radiation therapy across the country with 244 vacancies. The training programs only graduate about 55 students per year.

We are recommending that Canada comes up to the OECD average on the installed equipment base for imaging and therapy. If this is done, then that equipment must be staffed, which represents an estimated 1900 new positions for technologists.

With regard to equipment, we rank very low compared with the OECD average in medical imaging installations. For therapy installations, we are about average. This may be due to the fact that in every province except Quebec, radiation treatment for cancer is run by a provincial agency as opposed to the individual hospital.

Much of our equipment is aging. I refer to page 14 of our submission; the numbers are there. Notice that the worst number is for fluoroscopy. That is run-of-the-mill equipment that is used in every hospital. It is harder to get that replaced. A hospital can run a community program to raise funds to buy a new CT scanner or MR unit, but it is not as sexy to buy a fluoroscopy unit, and they tend to be neglected. The culmination of equipment and personnel shortages is long waits by the patient.

In the lengthy document I have referenced an article in The Globe and Mail, which reported that a facility in Plattsburgh, New York was able to install a new treatment unit as a result of fees paid by the Quebec government on behalf of its referrals. Quebec patients are frequently sent to New York for treatment at $10,000 per patient.

Finally, I would like to say something about research because personnel, equipment and research are tied together. This country has been a leader in developing medical technology.

Cobalt-60 for cancer treatment was developed in this country. It was invented here in the 1950s. The international marketplace for this product is still dominated by a Canadian company, M.D.S. Nordion. Cobalt-60 was commercialized by AECL medical. It has now been privatized.

These medical advances form an important area in the economy. This country has quite a poor balance of payments on medical technology.

An important development for us was that last year the Canadian Institutes of Health Research was inaugurated, replacing the Medical Research Council. These comprise 13 virtual institutes, which are listed in my document.

I would like to comment that these institutes are organized along disease and public health lines. It is excellent that they are there. However, from our point of view, none of these institutes have the mandate to develop something new in technology unless it is specific for cancer, or specific for heart and lung, or specific for brain. If you want to develop a new imaging modality that cuts across everything, it does not in anywhere.

Senator Morin: Health Systems Research Institute.

Dr. Johns: Maybe.

Senator Morin: It is a fact.

Dr. Johns: It does not appear that way when you read the documentation on that institute.

Senator Morin: Read the mandate of that institute. You will see that that is where it is.

Dr. Johns: I have spoken to Dr. Bernstein about this. He has agreed that there is no natural home for imaging or biomolecular development.

South of the border, the National Institute of Biomedical Imaging and Bioengineering has been signed into law. It will be running in 2002 and have a mandate for technology development.

I will now move to our recommendations for personnel. First of all, we will need more personnel. Some of the programs are quota controlled; residency positions are quota controlled in the various provinces. Radiology feels it needs 25 per cent more nuclear medicine and 50 per cent more residency positions.

Medical physics is different. It is open. Anyone could decide that they want to become a medical physicist. However, they must find a university where a supervisor would offer a research project in that area. Medical physics education is tied to CIHR and NSERC funding to that area. It is connected to the research side.

We are pleased that the federal government has transferred money for equipment to the provinces for capital equipment in health care. We understand that it is a one-time process and it would be good if that were made into a permanent program. If the fund runs for a small number of years and ceases, there will be a big influx of equipment and then back to a dessert situation again. That does not make for orderly planning.

Of course, the provinces must be accountable to the federal government on how these funds are spent. As well, the province is ultimately accountable to the public.

With regard to research, we recommend that CIHR look at some cross-cutting technological institute, such as an institute of biomedical devices. The mandate would be to foster research and development technology applied to health care, including imaging, monitoring, and therapeutic and image guided treatment technologies, and to aid in the education of scientists in this area.

The Chairman: Thank you, gentlemen.

Senator LeBreton: Not only do we face an aging population generally but we will have a human resources problem in the areas in which you are each dealing. What can be done? Are we missing the boat on the recruiting side? How will we get people to undertake to embark on careers in these fields, and then keep them here? Are we not doing enough to make these positions attractive to young people in our learning institutions?

Mr. Davis: In our profession we are competing for people who are technically oriented. Many of these people are going into the high-tech industry. We have a technology-focussed industry. It is predominantly a female industry competing with many of the other health professions. Today across Canada we have empty training seats. There are positions that were not filled this year in the existing training programs. We are already short wellover 100 seats to meet the true need of the industry.

A cyto-technology program in Regina had no applicants. They normally take six to eight students each year. They had no applicants for the September entrance.

Senator LeBreton: Is it our education system? When I went to school, the guidance counsellors tried to direct people into emerging occupations. Something is falling through the cracks.

Mr. Davis: Today's student is not going to the guidance counsellor to figure out what they will do for the rest of their life. They are sitting down to the World Wide Web.

At a recent meeting of the HEAL Alliance, of which our organization is a part, we were discussing amongst a number of the partner organizations the need for the health professions to make a cooperative effort to establish a mega-health recruiting Web site. Students could possibly fill out some sort of mini-questionnaire that would direct them to the best area that they might consider for pursuing a health career.

Not everybody will be a doctor or nurse. There are many other opportunities within the health industry. We may be losing people to other industries simply because they do not have the information up front. Many of the people coming into the medical laboratory come into it in an indirect fashion. This past year at the Michener Institute in Toronto - a three-year training program - almost 90 per cent of the entrants into the program already had a four-year science degree from a university. They will spend another three years in a college program.

We are in a transition process within our profession of currently moving to degree entry. However, when facing a human resource crunch, you cannot bring up those topics and be well received. Students are already spending seven years to arrive at their destination. If they had good career information up front, they might shorten that time, save the taxpayer money and lessen student loan debt.

I heard recently that many students do not know what they want to do when they enter year one, which is an unfortunate circumstance. There are others who have always dreamed about being whatever, and unfortunately did not know the right path. We have identified the need to do a concerted effort in career awareness for entrance into our profession.

Senator LeBreton: Having identified the need, is there now a plan on which to embark?

Mr. Davis: We are working on something within our professional group. We are also working with a subgroup of the HEAL Alliance. We had a teleconference this past week to discuss some initial initiatives. We expect to launch something within the next year. To be honest, with empty seats already in these programs, the problem is yesterday.

The Chairman: The shortage problem is not unique to Canada. Have you looked to see what is being done elsewhere in the industrialized world to deal with exactly the same problem?

Mr. Davis, why in heaven's name would you move from a three-year technology program to a university-based program? I understand that the optics are better. Some of us around the table were formerly university professors. It would be hard to convince us that students would be that much more knowledgeable for the jobs that they would do if they have an undergraduate degree than if they have a three-year technical degree? Why complicate it?

Nursing has done that now. Is in fashion but it seems counter to a situation in which you have a manpower shortage in the first place. You may want to comment on that.

What is going on elsewhere in the world? We must be able to learn from somebody.

Mr. Davis: We hosted the World Congress of Medical Technology last year in Vancouver, B.C., which drew representatives from 36 countries. Canada was about five miles ahead of everybody else in even addressing this issue.

Our colleagues in the United States are asleep at the wheel on this issue. They have seen about half their programs close.

To counter your previous question, Canada is the only country in the world that does not have a degree associated with professional medical lab technology.

The Chairman: That does not make it right.

Mr. Davis: That does not make it wrong either.

The Chairman: My point is that following the leader is not necessarily the correct approach.

Mr. Davis: We are not following the leader. The leader is pulling us along. A number of our medical technology programs develop partnerships with universities. Dr. Stuart Smith raised this at our congress in 1987. He spoke about the partnerships that could and should evolve amongst community colleges and universities.

A majority of our programs today that have university degree as part of them also include a community college component. The articulated programs typically have a first year of university, followed by two years of college and then a completion year in university with an option to step out after the third year and go directly into the workforce. That is a typical university-based program today.

The Chairman: You are allowing them to take extra if they want, but they do not have to take the extra?

Mr. Davis: The entrance into the national certification exam is after the third year of the program. They can achieve their national certification after the third year. That is the credential that is required for licensing.

Dr. Johns: It is a question of both recruitment and retention. You must bring people into the system, and then you must keep them there. In the case of technologists, in the last few years the competition from the software industry, which has been so healthy, has caught the attention of high school graduates. You must compete for those people and offer them attractive opportunities.

Why go to a degree program from a diploma program? Things are becoming more complicated. The technologists are being asked to do more complicated things - they don't just push the button.

Is the educational system behind? It takes time to change the system so that the shortage of magnetic resonance technologists is partly because it is only now that specific training programs are being set up for that. It is a program that you must enter secondarily, after the basic training in radiation technology. Eventually, that will become a primary access.

For the physicians and physicists, it is partly competition to enter the profession, but it is also the environment once they are in. Cancer Care Ontario, within the last two years, raised its salaries of medical physicists significantly because New York State was poaching. This was the only way to stop it. The assumption is that Ontario will poach now from the other provinces to staff its new centres.

The Chairman: That leaves Nova Scotia and other places in deep trouble.

Dr. Johns: Yes, it may. There are not enough physicists there to start with because of the population.

What do other countries do? In the case of physicists and possibly any group that is movable under NAFTA, the United States hires from us. It is well known that the Canadian educational system is good; the Canadian medical physics graduate students win a disproportionate amount of prizes and competitions for research presentations at conferences. This is gratifying.

Do they all stay in the country? It is not a matter of whether they are paid the same here as in the United States. Salary is one factor. A more significant factor is the opportunity to be at the forefront of research of new technology and new procedures, et cetera. It is the entire environment that is a factor. I think that the same is true for the physician groups.

Senator Keon: Dr. Johns, I would like to focus on a Canadian problem that I raised repeatedly at the Royal College in the years I was on council there. About 50 per cent of what we are teaching our students is obsolete by the time that we are finished educating them. Radiologists in a subspecialty coming out of the system normally have about 12 years of training by the time that they start their M.D. Is that not correct?

Dr. Johns: Correct.

Senator Keon: It is not an exaggeration to say that 50 per cent of what they are taught is totally useless. The average Ph.D. does a B.Sc., an M.Sc., a four-year Ph.D., a two-year post-doctorate, and then finds a job. The same thing has happened to him.

We must change our entire focus in education programs. We must shorten them at the front end and intensify the continuing education components of them. We cannot afford many of these programs in the first place, and it makes no sense to be teaching people a lot of material that they would never use. I would like your comments.

Dr. Johns: Basically, I agree with your observation of the facts. I am not sure that I agree with your recommendations. In an education program, the first thing you are learning is how to learn; then you learn some facts. It is presumed that when you leave you will continue to learn and update your knowledge. You could focus programs, teach fewer and more up-to-date courses, and teach them faster. However, would graduates then be able to adapt 15 years out as a professional in the field, or will they use that knowledge until it is obsolete and then become stale? That is the hazard that you run.

Another hazard is that if you teach a narrow base of knowledge, and three years later graduates decide that they do not like that field because they are limited. What is their opportunity to change? Their options will be much more limited than if they had a broader base of medicine or science on which to build.

Not all radiology residents or nuclear medicine residents go on and only do that for the rest of their career. Not all medical physicists end up in a diagnostic or therapeutic facility. Some go on and work in the semi-conductor industry or vice versa.

I think that most people would prefer that flexibility.

Mr. Davis: A major focus in our educational system recent years has been to stop teaching the "ologies" and start teaching the science. If you understand the science behind the "ologies," you can keep pace with the changes.

This has demanded a completely different approach to education and training within our profession. It relates to the relationship of focussing towards the degree process as we build that approach.

The "ologies" have been obsolete many times over since I was a student. Glucose alone has changed six times since I was learning how to do it in a boiling water bath.

Senator LeBreton: I have a question for Dr. St. Denis. I can only speak from the Ontario experience, but the Ontario Health Insurance Plan now covers chiropractic care?

Dr. St. Denis: Partially.

Senator LeBreton: Is this the case in all of the provinces?

Dr. St. Denis: No, it would be safe to say that there is some provincial health coverage in provinces west of Ontario. The Maritimes and Quebec have no coverage.

Senator LeBreton: Without getting into the details, could you tell me the percentage of the patients that you look after in Ontario that would be covered by the OHIP?

Dr. St. Denis: Do you mean what portion of my office fee is reimbursed by OHIP? I would say about 30 per cent to40 per cent.

Senator LeBreton: You say that you do not have hospital privileges. If you have a patient that is in a hospital and OHIP is paying you to look after that patient, how could they say that you could not use the facilities of the hospital? How do they justify that? Has your association attempted to change that?

Dr. St. Denis: We have gone on television with it. We have done just about everything we could do, but it is a closed door. It really is. I could visit a patient pretending to be a cousin. We are not allowed to go to the hospital as a treating chiropractor and treat lower back pain caused by a patient being in bed for a lengthy time.

Senator LeBreton: We are talking about an integrated health system. If you have a patient in Dr. Keon's heart institute with a bad back, it makes sense to me that the person who has been treating him or her would be able to treat the individual for the same condition.

Dr. St. Denis: I agree with you.

Senator LeBreton: It does not seem to make sense.

Senator Fairbairn: A number of my questions have been asked and answered. I am looking at the brief for radiation technologists. Are these jobs well paid?

Why, when there is a tremendous need for these people, are there so many training spaces and job vacancies? Given the nature of the jobs, I would think that this work would be quite attractive to young people coming into university. What keeps the flood gates from opening? Is it the length of commitment that they must make? Have you any thoughts on that?

Dr. Johns: I do not believe it to be a high-paying profession. In general, technologist's positions are not high paying in any sector of society.

Also, the work environment can be stressful; it might involve a lot of shift work. For various reasons, a substantial number of medical radiation technologists are part-time workers. That may be a discouraging factor. A high school student talking to someone in the field might hear about enough negative aspects of the environment to be compelled to choose to learn JAVA in community college instead. However, it could be a very attractive position. It involves working with people and science. Imaging is naturally interesting to many people.

Senator Fairbairn: And critical.

Dr. Johns: Yes, it is an important profession. It could be attractive to entrants. It would be the way that it is presented and the way the work environment is known in society. The nursing profession has certainly received much public sympathy for their work environment. There are concerns about the medical radiation technology area as well.

Some of the environment problems are due to the manner in which hospitals administer. There are actually a decreasing number of full-time opportunities.

Senator Fairbairn: Why is that the situation in a hospital? Could they pay less salary that way?

Dr. Johns: There may be savings on benefits for those who work part-time. That practice has been in place for some number of years; it takes time to change things.

The hospitals now - at least in this province - are trying to sort out the ramifications of the various amalgamations. This topic is way down toward the lower half of the priority list.

Mr. Davis: Employers have taken advantage of the surplus of technologists and the downsizing that occurred in the 1990s to "casualize" our workforce. As has been done in nursing, they have reduced the number of full-time positions and split up full-time jobs into part-time positions because it provides better flexibility in their organization and planning.

However, that is coming to an end now because that part-time pool of people is being absorbed into full-time jobs. The surplus of people has disappeared out of the industry. Now, they are in trouble; they are in big trouble. British Columbia, in particular, is in big trouble today because that is the approach they took during the 1990s. It is coming back to haunt them.

Senator Fairbairn: I noticed in the brief the need to bring us up to OECD standards on some important pieces of equipment such as MR scanners. In my community, we did not wait for somebody else to hand us an MRI. We raised the money through the local hospital and telethons to purchase it. This is happening elsewhere, too. People want those things in their communities so they do not have to travel a great distance. Do you suspect that at some point you will be finding it difficult to staff that equipment?

Dr. Johns: Yes.

Senator Fairbairn: A community could obtain the equipment and not be able to hire the expertise to operate it?

Dr. Johns: The way in which these things are funded is complicated. The community may raise the money for the capital purchase, but the province must be convinced to paythe 10 to 30 per cent of the capital cost of the operation per year. Funds are needed for a service contract to maintain the equipment and for the staff and the professional fees for reading examinations on it, et cetera.

You may have the equipment, but you do not have a budget to run it. You may have to take that budget from another part of the hospital.

The Chairman: There was a specific example of that in Ottawa this past year. The Ottawa Hospital had a sophisticated machine but the province would not pay the operating expenses. Ottawa patients were travelling to Montreal to use such a machine. The absurdity of the situation became a political issue, and money was granted by the province to operate the machine.

Senator Morin: You must see the government point of view though. They are not expecting this equipment to be purchased from donations, and therefore, have not the budget for the operating costs. There are two sides to that.

Mr. Davis: Without the proper trained technologist to operate that equipment - whether it be the medical laboratory or in the radiation area - the entire diagnostic engine of this health care system will stop cold in its tracks.

Senator Fairbairn: This is a strange way to run a modern-day scientific business, which we are all supposed to be doing.

I have one question for Dr. St. Denis. The concerns that you very well expressed in your brief are not new. The benefits of chiropractic medicine have been difficult to sell to the system for some time. What do you need to do to gain positive awareness so that you might finally open those hospital doors?

I have deteriorating disks in my lower back; nobody has ever told me to go see a chiropractor. You could probably fix me up in a few minutes.

The Chairman: This is called a private consult.

Senator Fairbairn: I would not have to take anti-inflammatories when I am lugging my luggage all over the country.

I am wondering how your association can integrate within a system that we keep being told should be an integrated system?

Dr. St. Denis: That is one of the reasons why we are here. Unlike others, we do not want to ask for more money. We want to ask for better use of what is there.

In answer to your question, there are ways in which we can integrate. University education of the physicians is a good first step. Dalhousie University did a study two years ago and found that six out of 10 medical schools now have integrated a short compulsory course on chiropractic in their schools. There needs to be more of that cross-meshing. That would help. We advertise as well and use word of mouth. That is going on all the time.

We are here to discuss integration. We can provide you with the information and tell you that people are choosing chiropractic treatments and that chiropractic medicine is indeed a necessary and valued discipline. What can we do to work together? How do we make the system work?

Senator Callbeck: I would like to follow up on that. Chiropractic services are covered under medicare, to a certain amount, by six provinces, correct?

Dr. St. Denis: Yes, to a certain amount.

Senator Callbeck: Do most private insurance plans cover chiropractic services?

Dr. St. Denis: Many of them do, up to say $300 to $500, with a $25 deductible.

Senator Callbeck: I have a question on medical laboratory technologists. Do the advances in technology have an effect on the number of technologists that are needed? In other words, do we need fewer technologists because of the advances in technology?

Mr. Davis: It would be nice to think that because of robotics and technology, we might need fewer trained people. However, the technology has become more complex, and we are doing many more tests. Where previously there were one or two diagnostic tests ordered, there now may be a dozen or more ordered and they are much more complex. A typical example is the troponin T test now being used for cardiac assessment in emergency departments. Five years ago, this test would not have been thought of as "routine." It was the in the research environment. No one knew when it would be put into use. It is now a routine test in most major medical centres.

As we automate and improve the technology, we come up with many new things to do. The male equivalent of a Pap test, not covered by most health plans, is being rapidly introduced in the health care system across Canada.

The Chairman: Thank you, gentlemen, very much for coming.

The committee adjourned.