Standing Senate Committee on Social Affairs, Science and Technology

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

Issue 34 - Evidence

VANCOUVER, Friday, October 19, 2001

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 9:00 a.m. to examine the state of the health care system in Canada.

Senator Michael Kirby (Chairman) in the Chair.


The Chairman: Senators, this is our last morning of hearings in Vancouver. We have with us today the Canadian Medical Association and the British Columbia Medical Association with Peter Barrett, who is the Past President of the CMA. We have Arun Garg, who is the Chair of the Council on Health Policy and Economics for the CMA - although when I first met you, you were with the BCMA so you have switched hats since we first met. We have Dr. Heidi Oetter, who is the President of the BCMA and Darrell Thomson, who is the Director of Economics and Policy Analysis for the BCMA.

Thank you all for coming. I assume that Dr. Barrett and Dr. Oetter both have opening statements and we will proceed from there. Dr. Barrett has come from the East.

Dr. Peter Barrett, Past President, Canadian Medical Association: Actually I am not quite from the East. I am from Saskatoon.

I am the past President of the CMA and I am still a practising physician. You have already introduced my colleagues.

I am a urologist and I am happy to be here representing more than 50,000 of Canada's physicians. We certainly appreciate the opportunity to offer our comments on the "Issues and Options" Report.

The Chairman: I knew all of your colleagues except Dr. Oetter.

Dr. Barrett: Dr. Oetter is President of the British Columbia Medical Association and she is also a family physician who is still practicing, combining two tough jobs here in Coquitlam, B.C.

I should mention that the information we will provide today is part of the Canadian Medical Association's ongoing work on sustainability and it will complement the work that we are doing for the Romanow Commission as well.

We will provide a detailed written submission, which will include a grid to assess and rank each and every one of your options in the "Issues and Options" Report according to "do-ability" and desirability. We are working on that now and that will be available to you at our next appearance, which I believe is October 30.

Let me say at the outset that we agree with your overall assessment that efficiency gains alone will not result in a sustainable health care system in this country, and we applaud your efforts to lay out a comprehensive array of options. We agree that we will not be able to manage our way out of this dilemma. We also appreciate your efforts to provoke new thinking, even if sometimes the options you present may fail our "do-ability" or desirability test. It is important to think "out of the box," and we congratulate you for doing that.

Today we will focus essentially on two areas. The first area will be what we feel are the Canadian Medical Association principles and parameters to help guide us through change. The second area will be an assessment of the options that you have talked about that we like and those that we think need more work.

With regard to the principles and parameters for change, there are five parameters that should guide us. The first is inclusivity. To truly achieve buy-in for all key stakeholders, they have to be involved. There has to be early and ongoing meaningful consultation with patients, with physicians and other health care providers. Too often in the past, meetings have been held behind closed doors and we, the physicians and the patients, have been left to implement and live with policies that, clearly, we knew were not workable. I do not want to get into that. That is old news. We must look to the future now.

That leads me to the second parameter, which is accountability. All stakeholders must assume some level of accountability for the health care system. Physicians have been under pressure for more accountability lately. We have always been accountable because we are the ones who actually have to sit down across the desk from the patients. The same accountability should apply to the rest of the health care system, to the policy-makers, and particularly to governments, federal and provincial.

Third, we, as physicians, have adopted the concept of evidence-based medicine. We stress that what we do should be based on solid evidence of what works and what does not. The health care system should rely on research to give solid evidence for the decisions that are made.

Fourth, we believe in evolution rather than revolution. Yes, we must change and modernize the health care system, but we should build on the best of what Canada has, being mindful that good can sometimes be the enemy of better. We can always do things better and we should consider that. We are always nervous about the big bang approach; we prefer an evolutionary process.

Finally, in terms of parameters, it is time in Canada that we begin to consider health care as an investment good. In the past, we have tended to think of it as a consumption good. In our view, health care is clearly an investment good, both in terms of the contribution it makes to enhancing the individual quality of life of our citizens and what it does to enhance Canadian socio-economic status as a whole and in our communities.

With regard to principles, we all know the five principles of the Canada Health Act and I will not go through those. As physicians, we believe there are a series of fundamental or first principles that truly underpin medicare. These must be taken into account explicitly when assessing new policy directions.

The first principle is universality. Health care must be available to all Canadians and health care resources must be allotted on the basis of need, not on ability to pay. Medicare truly is the best remaining universal program in Canada and this lies at the heart of the political sustainability of medicare.

The third principle is choice. One of the hallmarks of medicare is that patients can choose their physicians and they can switch physicians. The physician-patient relationship is very personal and sometimes you get along better with one than another. Patients should have the ability to choose their physician and the ability to seek a second opinion if they are not sure, or if they are concerned. The principle of choice of physicians is essential if the health care system is to sustain its integrity.

The physician must remain an agent of the patient. Medicare originally promoted the concept that the physician was an advocate for the patient. We feel that this must continue. There has been pressure on physicians of late to become advocates for the system, for the economics of the system. That puts us in a very awkward, in fact, a schizophrenic situation. We truly must be the patient's advocate in this system.

The fourth principle is quality. The health care system must continually strive to provide quality. By "quality care" we refer to services that are appropriate for the patient's needs, delivered in a manner that is timely, safe and effective.

These principles and parameters can serve as a guide to the modernization of the health care system I referred to. They will allow us to build on the best of the current system.

If we consider the proposed options and use these principles and parameters to provide a policy framework, or a screen for our approach - and I would acknowledge that it is not broad enough to necessarily cover all the recommendations in the "Issues and Options" paper - it can be a good place for us to analyze the various strengths and weaknesses in the five areas of federal responsibility that the committee has talked about.

Again, we will provide a more detailed analysis on October 30 where we have actually gone through each of these. We could call this a first-blush impression.

The Chairman: This is a work in progress.

Dr. Barrett: Exactly. It obviously needs a little more work.

There are a number of areas that we like and a number that we think require a little more work. There are a few areas where we have concerns that might not meet the parameters we have talked about, but I would emphasize we have an open mind and we would be willing to consider anything and everything. We commend the committee for taking that approach as well.

Areas where we agree and where we concur would be things like health technology. We have developed a detailed proposal that would help bring Canada up to par internationally in the acquisition of new technology and a further proposal that would lead to a national policy on technology. Our national health technology proposal reflects many of the observations that your committee has made.

On the spectrum of care, we like that. The CMA has developed "Scopes of Practice Policy." You may not have that, and if you do not, we will give it to you.

The Chairman: We do not, so that would help us.

Dr. Barrett: Okay, we will give that to you.

It clearly supports a collaborative and cooperative approach, the sort of thing that you have talked about and with which we agree.

We like what you have talked about on Aboriginal health. The Canadian Medical Association has long been calling for a national strategy to deal with what we view to be a national health care crisis in our Aboriginal population. As a physician from Saskatchewan, with our northern First Nations people and their problems, I am acutely aware of that.

We like the Health Care Report Card. As you may know, we issued our first CMA National Report Card on Health Care this summer. If you do not have copies of that, we will give them to you. That sort of assessment and accountability model is critical to assure a sustainable and equitable health care system in Canada.

An area where we think you could use a little more work is the rural and remote practice issue, which I know is a big one with you. The Society of Rural Physicians of Canada has developed a national rural strategy that should be examined in detail by the committee. If you do not have that, we will provide it. Its proposals certainly go well beyond the telehealth solutions that have been proposed by the committee.

In addition, the Canadian Medical Association has developed a rural and remote policy, which was released about a year ago today. There are 28 recommendations that deal with such issues as training, compensation, work, lifestyle support and that sort of thing. It is an excellent document that I would recommend to you as well. If you do not have it, we can provide that for you.

The health human resources issue is one of the biggest issues in Canada right now. There are increasing disparities across the country and that is likely to get worse as the population ages. Without the availability of physicians, talking about access to medical care is fairly meaningless.

We do applaud the HRDC/Health Canada study that was recently announced. The reality is we must have federal leadership in this area, a government that values not only the health care workforce but that is examining renewal of the health care workforce.

I would note that, in this country in the last 10 years, there have been three studies of the federal civil service, but we have not seen anything like that in terms of health human resources in Canada, which is the biggest issue there is today. We must commit to the principle of reasonable self-sufficiency in the production of physicians to meet Canada's needs. You have heard me talk about that before.

In the area of mental health, you should be aware that the Canadian Psychiatric Association has developed a detailed brief on future directions for mental health care in Canada. It is an excellent document and I would recommend that for your consideration. It is truly a very good document.

There are some areas, running through the screening principles and parameters that I talked about, that we would suggest need more work.

Before I get to that, there is one other area that we are working on right now at the Canadian Medical Association that we call tax policy in support of health policy. This is another key area, under the federal financing role, which could use further examination. It involves the use of the tax system to help individuals pay for a range of health care services and should be viewed as a serious option for the federal government. We have undertaken a fairly ambitious review of the available evidence and options and we are working to develop, with Statistics Canada and Health Canada, a detailed tax and benefits incentive analysis by income class and cost of analysis by various options. A thorough review of tax policy, with support of health policy as a goal, may yield alternative funding approaches and might be something you would be interested in. We will certainly provide information on that as it evolves, but it is fairly early in the works at this time.

Medical savings accounts are not necessarily an option for a global method of funding for what we would call "medically necessary" health care. That is open to interpretation, but that would certainly be a major shift in policy in Canada if we went that way. That is not to say that we would not support systems where you could go that way, in the RRSP sense, to support things like long term care or that sort of thing.

We have difficulty with user fees as that applies to acute hospital and medical services, which may not truly involve much choice for most patients. If you are comatose and going to a hospital, it is because you have to be there. When it comes to things outside immediate acute care, everything must be on the table and we are happy to consider anything.

We have difficulty with the tax point transfer. Further transfer of federal tax points in lieu of cash is neither desirable nor "do-able." It would weaken the federal government's already limited powers both morally and economically, particularly when it comes to enforcing the Canada Health Act. It might also result in a greater disparity between the have and have-not provinces.

We believe that CMA, the committee and the federal government should clearly establish its first principles and parameters for change before deciding upon the options for restructuring the system, and we believe that our outline of first principles in management provides a useful tool for doing that.

To conclude my remarks, I re-emphasize that Canadian physicians foresee a need for change. We are ready for change. To reiterate, we agree with the committee's assessment that better management alone will not lead to a sustainable system. We cannot just manage our way out of this. In fact, we are concerned that without significant change, we will very soon lose the underpinning of social and political support for the publicly funded health care system we have in Canada.

However, the focus of change must be on restoring both public confidence and provider morale. We must concentrate on patient care and speak to individuals and their needs rather than just a systems level analysis. We must focus more on the "hows," the processes of change, and not so much on the "whats". We must focus on the health care workers in the system. Without an adequate and renewable health workforce, access to health and medical care will continue to be on the critical list.

We look forward to the next meeting in Ontario.

Dr. Heidi Oetter, President, British Columbia Medical Association: As Dr. Barrett mentioned, I am a family physician. I work in Coquitlam and I am currently the President of the British Columbia Medical Association.

I am pleased to share with you some of the opportunities physicians believe exist for restoring excellence to Canada's health care system.

The BCMA represents the interests of nearly 8,000 physicians across the province and is an advocate for excellence in patient care. The association supports health promotion, physician relations with the community, development of health care policy and negotiates compensation for physicians with the provincial government.

We are hopeful that your final report will deliver a workable blueprint for the needed change to our health care system. There are few who would dispute that our health care system is in crisis and that it cannot be sustained. Every day, as I see patients, it is clear that we are not meeting the needs of patients in the way that we should and I am increasingly concerned about health care's capacity to allow me and my physician colleagues to meet our obligation of providing the best possible care to those in need.

Some may argue that all that is needed is operational belt tightening. We applaud you for the acknowledgment that the changes are broader and require something more than just tinkering. In our view, what is needed is a reassessment of what medicare means to Canadians. It is time to fundamentally review our vision for publicly funded health care and the associated deliverables that flow from that vision. This goes to the heart of what Canadians want and will support in their medicare system, and this must be the starting point of any meaningful change that will deliver measurable results.

A natural outcome of this first step in re-establishing a vision for medicare must be a scope of coverage review. We must determine what services are and are not covered by the publicly funded system. We also have to determine how Canadians will pay for those services left out of the publicly funded envelope. Again, we agree with your assessment that this scope of service review is needed.

The doctors of B.C. reject any suggestion that additional first dollar coverage can be added within the current Canada Health Act parameters. This stems from our view that it is a fallacy to suggest that sufficient administrative savings can be found within the system to cover the growing costs. While we may all wish for such a very simple solution to the problem, we firmly believe that this is just not the case.

There are numerous ways in which the scope of service can be evaluated. Key to determining which core services should be fully funded by the medicare system is reaching broad public consensus about what the key priorities are. This question has been debated widely amongst health care professionals but is yet to be taken to Canadians in any meaningful way. As an editorial in Vancouver, in this past Sunday's The Province said so eloquently, "It's time for citizens and taxpayers to take ownership of this debate."

As you rightly point out in your initial report, the health care system is unduly hampered by the lack of predictable, sustainable funding. In our view, this need is imperative.

We have urged our provincial government to move to a long term planning and funding model that takes health care financing out of the electoral and political funding cycles. We agree that the federal government must provide clarity and certainty to the provinces as that relates to multi-year funding.

In keeping with the need to stabilize public sector funding of health care, we believe there is a need to evaluate the opportunities for Canadians for alternative funding sources. Canadians already pay for portions of their health care needs. Whether this be through co-payments for some allied health services, partial payment for prescription medicines or long term care costs, the reality is that individual Canadians are absorbing these costs and will continue to do so. What we believe is needed is an acknowledgment that these out-of-pocket costs are, and will continue to be, a reality and that tax related measures should be provided to offset these expenditures. We further support the study concerning the establishment of a health savings plan, similar to an RRSP, as part of the tax incentive package.

On the general issue of primary care reform, much good work has been done in this area. This is a subject that has attracted considerable interest and has been a focus of many studies and debates.

B.C. doctors support the pursuit of quality through more effective integration and coordination of care. In fact, we are already working on practical models that will deliver this goal where there is a clear leader who can be held accountable for the team's decisions.

However, we caution the committee that primary care reform is not well supported by the Canadian public, notwithstanding the fervour of policy advisors and provincial, territorial and federal governments on this subject. As Dr. Barrett already alluded to, and as a recent CMA poll has demonstrated, the vast majority of people report good primary care experience. That is certainly not where they report their increasing concerns with respect to acceptable access to care.

Furthermore, primary care reform is not a panacea for the sustainability problem. While the models that have been piloted to date may arguably provide better overall quality of care, there is no evidence that these models have reduced costs or are generally applicable to the entire health care system.

In my own region of Simon Fraser, pilot projects have been initiated and our experience shows that the quality of patient care can be improved, but this is done at an increased cost to the system.

Your report suggests that a change in physician compensation from fee-for-service to capitation would substantially reduce costs to the publicly funded system. We have no objection that there should be a plurality of compensation models to meet patient and physician needs. However, we contest the assertion that physicians over-service patients for financial gain under the current fee-for-service model. There is no evidence to support this.

It is true that under fee-for-service there is a financial incentive to provide service. Under capitation, the opposite is true. There the financial incentive is to reduce service. Financial incentives are, however, only a minor consideration in the decision to provide service.

Even in the remote case that financial incentives were a dominant consideration, one cannot argue that an incentive to over-service would not be replaced with one to under-service if capitation were introduced. From a patient's perspective, we believe that most people would prefer a system where doctors have the incentive to provide, not withhold patient care.

No payment modality has superiority over another. Different payment models appeal to different practitioners and primary care renewal can occur under any payment modality. As we face increasing physician shortages, let us concentrate on the end and less on the means of capitation.

In conclusion, the BCMA applauds the committee's efforts to promote systemic change. To be effective, these changes must be practical and designed to embrace patient confidence and improve provider morale. If the system is to be reformed, Canadians must be assured that decisions are made objectively and focus on patient care as the primary goal.

The fact is that we do not enjoy a health care system where patient needs dictate the allocation of resources and financial requirements. Instead, our health care system first sets financial constraints from which resource allocation and patient care decisions are expected to flow. We need a system that provides a better balance between these two extremes.

Thank you for the opportunity to make this presentation. My colleagues and I will be very pleased to answer any questions that you have.

The Chairman: In your section on physician as agent of the patient, your last sentence says:

Any option that puts physicians in the position of being an agent to the payer should be seen as "out of bounds."

Can you enlarge on what you mean as "agent to the payer?" I do not follow that.

Dr. Barrett: We feel that what we should be doing is what is right for the patient, and too often lately we have been told that we should be cutting costs. If that is to happen at the expense of the patient, that puts us in a very difficult position. That is not what we are trained to do and that is not what we are about. We are there for the patient.

The Chairman: Have the provincial governments told you that? That is not a policy issue.

Dr. Barrett: Provincial governments, hospitals - with the downsizing and financial cuts for the 1990s, physicians have been put under tremendous pressure. There are no beds. We cannot get patients into beds. We are told that we are the problem. One of the reasons physicians have been anxious about change in the past is we have frequently been the victims of change. We are the ones stuck with patients in our offices for whom there are no beds.We feel that our role in this system is, first and foremost, to advocate for the patient.

The Chairman: I now understand you.

Senator St. Germain: Yesterday your namesake was here, Dave Barrett, and he said there are no waiting lists.

Dr. Barrett: I could give him a list of names if confidentiality were not an issue. I do not know what he is talking about. People regularly wait a year or two years for hip replacements in this country. There is a waiting list. In fact, we have a fine cooperative effort in Western Canada called the Western Canada Waiting List Project, which is a cooperative effort between governments, physicians and others. It was created to deal with exactly that problem.

Senator St. Germain: Is there any way that there could be any credibility to his statements? He is representing the 10 -

The Chairman: Just in fairness, far be it for me to defend Dave Barrett, who is more than capable of defending himself in British Columbia, but he did not say that there was no waiting list. What he said was that, in effect - and we can get the exact quote here - that the waiting list issue was not nearly as big an issue as it is publicly perceived to be. I think that is what he said.

Senator St. Germain: I think he went further than that, but that is fine.

Dr. Barrett: Let me take you back to the old accountability issue then. I am the one who sits across the table from the patient - after the patient has poured out his or her heart to me - and explains how long it will take for him or her to receive treatment. Patients know there is a waiting list problem. I know there is a waiting list problem. The difficulty is that a lot of the policymakers and people higher up in the system never have to sit across the table from the patient. They do not receive the phone calls. I am on the phone every day, at least four or five times, explaining to people, "Yes, I understand the problem. I am afraid you are still not going to get in for another year." That is a terrible position for a physician to be in, because after a while, you start to think the patient believes we do not care, and that is just awful.

The Chairman: The reason is that there is a rationing in the system. The rationing is the consequence of budgetary allocations and you are the person left with delivering the message that the system is rationed.

Dr. Barrett: Exactly

The Chairman: Dr. Oetter.

Dr. Oetter: I will describe a very recent experience to demonstrate that we do not have the capacity at the front end to meet the needs. I had a patient who had the unfortunate experience of suffering not only appendicitis, but a ruptured appendix. After waiting an hour and a half for the ambulance to respond, he then waited for five hours in a chair outside the emergency department before he could even get triaged to be seen in the emergency department. Those are the very real experiences that Dr. Barrett and I experience every day.

The Chairman: Dr. Barrett, could I just ask you two other short questions and then turn to Senator Keon?

This is a factual thing. On your tax policy study, which, as I understand it from your description here, is really examining an issue that we had raised: Are there ways of designing incentives for patients that do not stop people who need the system from using the system, but nevertheless work as incentives to use the system responsibly?You are suggesting that the CMA is undertaking, or is about to launch a tax policy study?

Dr. Barrett: Yes.

The Chairman: The study reveals how the tax system could be used to provide those incentives. Is that correct?

Dr. Barrett: Right. The tax policy in this country, with regard to health care, has not been reviewed in many years.

The Chairman: Right.

Dr. Barrett: This is the time to do that, now that we are examining how to modernize the system.

The Chairman: That is totally consistent with our view that we must consider ways of providing incentives.

Let me ask you a question, which is probably a little more difficult. I agree wholeheartedly with your notion that patients should always have the right to choose their doctor. Would you extend that concept to the institutions in which treatment will be provided? In other words, let us suppose that you had separated the payer - there is still a single payer, which is government - from the providers or the institutions as is happening increasingly in social democracies in Europe, where, in countries that have universal plans, there is nevertheless an element of choice or, if you like, competition among institutions. Would you have difficulty with that concept?

Dr. Barrett: The problem now with competition among institutions is the problem that we have with the health human resources issue. We do not have enough people to consider that. We do not have enough people for the hospitals or institutions that we have. Maybe I am misinterpreting. Are you talking about a parallel system?

The Chairman: I am not talking a parallel system as in public/private. Let me give you a concrete example. In Sweden, essentially there is a completely government funded program, but instead of a global budget going to the hospital, the budget goes to the patient. If Hospital A or Hospital B performs a hip replacement, the hospital is paid by the government so that the patient does not suffer, but the patient has a choice of which hospital he or she goes to. Sweden's experience has been that has led to a significant decline in waiting lines as hospitals become more efficient to ensure that they continue to get a reasonable number of patients. The inefficient hospitals drop by the boards.

So, my question is have you guys examined that? Dr. Oetter will help you out for a moment. Dr. Oetter, why do you not go first? That is the concept. I point out that it has absolutely nothing to do with public/private.

Dr. Barrett: We have no problem with choice.

The Chairman: In the European examples, the hospitals to which I refer are all owned by the public sector, but these public sector institutions compete.

Dr. Oetter: The only experience I can bring to you from British Columbia is the regionalization process that has gone on here. We just do not have the capacity to meet the needs of what people require today, and when the regions start to compete with each other around the human resource issue, communities are, in a sense, stealing pediatricians from one another.

The Chairman: That is as you steal them from other provinces.

Dr. Oetter: There is that, too, but we have a very real problem.

The Chairman: Sorry, as a Maritimer, I could not resist that, Dr. Oetter.

Dr. Oetter: Yes, yes. It has not worked out particularly well because the regions compete with each other to the detriment of the system, not to the betterment of the system. We do not have enough excess capacity to really foresee that sort of competition providing a tangible result.

Dr. Arun Garg, Chair, Council on Health Policy and Economics, Canadian Medical Association: In terms of internal competition, in most of the work we have done, clearly, we support further studies and we also support that should be done to determine where you can bring better access with internal competition within a single payer model.

The Chairman: Right. To do so within a single payer model, to the extent there is more competition, is a good thing. I share your view. I just put that forward as a concept, not as something we have any details on. Given the work you have done, have you, in your BCMA hat, done work on that issue that you can, at some point, share with us? I will leave that with you as a thought and, Darrell, you can let us know later.

Senator Keon: Thank you very much for coming back, Dr. Barrett, and thank you, Dr. Oetter. Both your presentations were concise, thoughtful and far reaching. You have obviously put a great deal of time into the preparation of your ideas and I would encourage you to continue.

Dr. Barrett, on your role, as an individual in the CMA and as a patient advocate, one of the huge problems, I believe, that that has existed in Canada for the last 20 or 25 years is a lack of involvement of the medical profession in health care policy and planning. Consequently, there are times when we have to try to straddle our responsibilities to both camps. In my whole professional career I functioned as a CEO and as a practitioner. Sometimes there is conflict in decisions, but without being involved in both areas, we cannot make the contribution we must make. Society is very dependent on the intellectual wealth of the medical profession for that contribution. I would like you to comment on that first, and maybe, Dr. Oetter, you would follow.

Dr. Barrett: I agree. I truly believe that one of the problems that we have had lately is that we have not had grassroots involvement, in terms of the people on the front - the doctors and nurses who are actually there and have to make this system work. They have not been involved in the decision making and, in fact, we have been deliberately excluded.

Everybody goes nuts when you talk about a doctor becoming a health minister. We hear all kinds of things about conflict of interest, et cetera. The justice minister is, invariably, a lawyer. The education minister usually comes from an education background, and yet, through the history of the health care system, there have been very few physicians, particularly over the last 10, 20 years, involved at that level. I truly believe that is why we have some of our problems. I do not want to go over the spilled milk of the past, but where is the accountability for a number of the decisions that have been made, which, in a way, have created the mess we have? If physicians or patients, key stakeholders, as Dr. Oetter mentioned, had been involved we would not have taken some of the directions we have taken.

Senator Keon: Do you see a conflict, for example, with yourself being heavily involved in policy?

Dr. Barrett: No.

Senator Keon: Do you feel that you can still be an advocate for the individual patient who sits opposite you?

Dr. Barrett: The reason I am here - and I am sure Heidi will tell you the same thing - is that I am an advocate for the patient and an advocate for what has been one of the best health care systems in the world. It is having trouble now and it is time to fix it. This is not easy. Dr. Oetter will you tell you how late she was up last night looking after patients. This morning she is here doing her second job. I want to emphasize that we are both practicing physicians. This is not a full-time job that we take on in physician leadership. We do this because we both believe that things can be better and we want to make them better for our patients and our families and our communities, for people who will need the system at some point. Canadians have concern that the system will be there for them when they need it.

Dr. Oetter: I would echo Peter's comments that there has certainly been a disconnect between the policy planners and physicians. Certainly our previous experience with the NDP government's two terms was one of very deliberate exclusion of physicians in any kind of policy decision making, whether that was at the provincial level or at the regional health board level. Where there was physician involvement, rather than seeking people who were elected by their peers to represent physicians' interests, the government hand-picked certain physicians who often were not really part of that medical community. We have instances where hospitals have been built to meet political needs and in no way reflect manpower requirements or what the true access-to-care pressures are.

It is time to bring the front line workers to the table. They do represent the interests of their patients, they are advocates for the system change that we need. At the end of the day, if we do not have solutions that improve access to care for our patients, reform of the health care system will be a non-starter.

Senator Keon: This is a fascinating subject. Over the years, I have frequently sat in a crowded room where I was the only doctor talking about health policy and the other people in the room were firm believers that you could not contain costs without getting doctors out of the policy making forum. They always tagged that to fee-for-service medicine and that this was an endless, bottomless pit that kept putting more and more demands on the system.

There is a lot of anecdotal evidence in the U.S. now with the HMOs that the reverse is true when you move to rostering or another remuneration system that encourages doctors not to see patients and not to order any extra tests unless they really have to. Some of the HMOs are losing clientele because patients are unhappy that they are not getting the same care as patients down the street who are going to doctors on a fee-for-service system of remuneration.

Would both of you talk about that?

Dr. Oetter: I would love to start. Certainly, the health care cultures of Canada and the United States are such that they are not necessarily applicable one to the other. The United States is the only place in the world at the primary care level - and I will let Peter speak about specialty care level in terms of capitation or global funding - that pays primary care physicians capitation at 100 per cent. Anywhere else in the world capitation is anywhere between 35 and 65 per cent of doctors' remuneration. They also do fee-for-service. They do salary. It is always mixed funding. Why? In the United States, on capitation, where you have an insurance program that signs up a type of person - and it does not take all comers, which is quite different from the Canadian context - they have the flexibility to do that.

Because people are walking away from those systems is not evidence that doctors being paid differently has anything to do with it. People are voting with their feet. They are choosing to go where they perceive the quality of care and access to be better. At the end of the day, as I said, we are welcoming to a plurality of models of paying doctors. That is not the issue. The end has to be improving access to quality care for those most in need. The myths around paying physicians 100 per cent capitation are not applicable, nor do they have the same level of evidence that we can observe in the United States for a whole variety of reasons. You really must examine the U.K. and other European nations around on what they do with capitation, which is not the predominant payment model.

Mr. Darrell Thomson, Director, Economics and Policy Analysis, British Columbia Medical Association: I firmly believe that we really must set this issue about physician payment modalities to rest. We have been caught up in a delayed ability to make improvements to the health care system over the past decade because we have been focusing on how to pay physicians instead of focusing on what really should be the issue, which is how to improve the integration and coordination of care. The focus has been wrong, in our view.

You can deliver good, integrated, coordinated, high-quality care under any payment system imaginable. That is not dependent on one particular payment model. What you must have is a group "within the team," working in conjunction with the governance body, whoever that may be, in terms of identifying what the core objectives are, what you want to achieve through this mechanism, and put proper governance models into place. As Dr. Oetter mentioned, we have been working on that at the BCMA and we will be delivering options on that over the course of the next few months.

On primary care demonstration projects under the Health Transition Fund that the federal government has introduced, we have seven practices in this province that are operating under what is effectively a capitated model scheme as part of the demonstration projects. We have encouraged the provincial government, to its credit, to enter into another model where fee-for-service is the dominant practice. We have put all of the same support information, both in terms of technology and human resource support, into those two and we are trying to evaluate those to see whether there is any real difference.

In our submission, we were delighted to see the folks at McMaster, Brian Hutchison and Julia Abelson, have done a really good job in an article that appeared in Health Affairs in May/June, in terms of identifying what the real evidence is around these issues. The fact is that there is either no evidence at all, or it is minimal, or it is very inconclusive in terms of many of these issues about which of these payment modalities makes more sense.

We really have to get off this notion of focusing so much on the payment modality. Let us concentrate on developing practical models, particularly in the situation we are in now of very short supply of health professionals. Let us develop practical models in which people are willing to work rather than feeling that they are somehow being coerced.

Senator Keon: As you go forth in the preparation of your documents on this, though I fundamentally agree with everything you said, I want to draw one thing to your attention: The fee-for-service structure makes it impossible, on many occasions, for a medical team to engage in leading-edge clinical care because the fee structure does not catch up with scientific progress for four or five years. I have lived through this with many of the programs we have introduced at the Ottawa Heart Institute where there is no fee in the system to pay the doctor to do what you want done. You must have a salaried system to be able to do that, or you must have some kind of system that keeps bread on the table for the guy or lady while the system catches up. Perhaps you would give that a little thought as you go forth.

I have a number of questions for all of you but I am being unfair to the other senators and I will back off for a while, but I will be back if there is time.

The Chairman: For members of our audience who may not know, Senator Keon in his other life is Chief Executive Officer of the Ottawa Heart Institute.

Senator LeBreton: I found both of your presentations very compelling. You certainly have hit the nail on the head.

Yesterday we had a family practitioner, Dr. Wilson from Prince George, B.C. I found him to be an incredibly good witness. As I listened to his description of problems that are faced in smaller centres, I got the sense that quality of life issues were very important. I also got the feeling that there is burnout, and there seems to be an age gap.

I think our education system discouraged people from entering medical school. There is a whole new group, often women, coming into the medical profession as doctors, but there is a gap. In his presentation, Dr. Wilson said a result of this is "orphan patients." I have seen quite a few examples of that, personally and on television, where people are not chronically ill, particularly those I call the healthy elderly. Doctors move out of the system or to other occupations within the medical system, but these people are still there. I wonder whether the Canadian Medical Association or the British Columbia Medical Association have tried to ascertain the extent of the seriousness, not only for the healthy elderly but also for other people, of being able to replace these doctors who are no longer in the family practice business?

Dr. Oetter: I will start with that. I work as a family physician. I have admitting privileges at three hospitals. I am in a call group of six. We provide 24/7 coverage. Certainly, colleagues in my community are all the same. At the front end, we hear the federal and provincial governments telling us they need primary care reform, and they often comment that this is because GPs are not doing a good job. We are often hurt by those comments. I think valuing family physicians is really important. What message do students get? They do not want to go into family practice. We are seeing an unprecedented decline in the number of people choosing family medicine as a career. I love family medicine and I would love to do it for the rest of my life, but unless I am valued - and I mean that truly in the broadest sense, part of which is the messaging that we get from the people who run the system - you will find people like me being discouraged.

One of my associates last year left. He is 50, which hardly could be considered retirement age. He chose to work at a salaried position at a hospital where he had more control of his private time. He had been working 60 to 80 hours a week, not as a specialist, but as a GP, and he found the requirements of 24/7 a bit onerous.

Two of my other colleagues have left to go into the computer software writing business. Information technology is important, along with family medicine. I had two other colleagues who left. They are doing something else. We cannot even keep the physicians that we have interested in family medicine because of the conditions of work, the valuing, and really the sense of insecurity because of what is happening at the primary care level. The message gets out to the students. They do not enter family medicine. The end result is there are "orphaned patients," and that is very unfortunate.

Senator LeBreton: That is not to mention the psychological effect, especially on seniors. Dr. Barrett, you talked about provider morale and that it falls right within this category.

Dr. Barrett: I have a couple of comments. Dr. Oetter did not mention this, but it is well known that the group of physicians that American recruiters are most interested in is Canada's family physicians. They are extremely valuable and that is what Americans have been seeking. We have to value them. Dr. Oetter has explained why.

Morale and burnout problems are not unique to family physicians. They exist throughout the whole spectrum. We released a specialty document a few months ago, which I would recommend to you on this topic. This is not just a family practice issue. This is a system-wide issue. Physicians and nurses are all working harder.

I would argue, Dr. Keon, that doctors and nurses actually do extra things even though they are not paid for that. For those who work 12 hours a day, Canada's tax system is not an incentive to work those extra four or five hours but we do it because it has to be done. Clearly, all of us know now that working harder will not be enough anymore, and working harder is taking us to the point where it is not just young people who do not want to be part of this, but the people who have matured and have experience to go along with the knowledge, are leaving. That is a bad situation to be in. We have to do something about this. This is the number one issue.

Dr. Garg: I am a specialist, but I must say that if we lose our family practitioners we will never have quality medical care. Familiar practitioners are the backbone to providing comprehensive continuity of care. We must consider the patient as a whole. The family practitioner does that. If we could leave one message, it would concern the value of family practitioners and the ongoing things we must do to make sure that we have family practitioners. I cannot overemphasize that, even though I am a specialist. There is clearly that need, with what has happened to our system.

Senator LeBreton: You mentioned the nursing profession. How does the Canadian Medical Association or the British Columbia Medical Association interact with nurses? In the testimony we have had as we go across the country, we get the sense there is a crisis in the nursing profession. What do you think has to be done now to address that? It will not be a quick fix. What has happened? Why is there such a crisis in the nursing profession, and is it the same as what you are facing as doctors?

Dr. Barrett: I am not sure that I am competent to speak for the nursing profession but, frankly, the issues are the same. We want skilled people, but there is a North American, in fact, a worldwide shortage of skilled people in general and in particular with health human resources. It has become much worse. We will only now lose people to the United States, the United Kingdom is now recruiting tremendous numbers because it has fallen far behind.

The issues are simple. If you value your work force, you provide them with a competitive salary or income, you provide them with working conditions where they can enjoy what they do and get pleasure from it, and provide opportunities for professional enhancement so that people can better themselves doing what they are doing. It is not rocket science. There are three simple factors. This applies to physicians, nurses and to other health care workers.

We often focus on nurses and physicians, but there are also technicians. We have situations in this country where we have been able to buy equipment that sits idle because we have nobody to operate it. This applies to the secretaries who work in my office. Everybody forgets that they take the phone calls and get the abuse for the system that does not work. People do not call the doctor and bawl him out because they are not getting in. They do not call the hospital. They call that lady on the line who is their connection to the system and that is who often takes the abuse for a system that is not working. Secretaries have not had much input, I assure you.

Dr. Oetter: Dr. Barrett covered this very eloquently. It is not for the doctors to make comment, but my personal experience - with the nurses with whom I work and who are also patients in my practice - is that conditions of work really matter, and they are not valued. We cannot run a health care system without the nurses. We need them. There are not enough nurses. There is a global shortage. Until such time that we resolve the nursing shortage, we will continue to have access problems.

Senator LeBreton: Is there not enough incentive for them to get into the education stream at the very beginning, or is that improving?

Dr. Oetter: My sense is that, certainly in the British Columbia context, there is starting to be more positions, although often people wait two or three years to get a position at a nursing school, whether they are going through the diploma or baccalaureate programs.

Senator LeBreton: This is all cyclical.

Dr. Oetter: Their problems are really mirrored in the medical profession.

Senator Keon: There is a very important area here that is not being highlighted enough. Dr. Barrett raised the issue of the need for a health human resource commission or study, a truly focused endeavour to examine the whole situation of health human resources. Mr. Chairman, the following statement may not be quite accurate, but I suggest we should research this: Nurses have the highest absentee rate for sick leave of anybody in the Canadian workforce.

The Chairman: We have certainly seen that.

Dr. Barrett: Yes, definitely.

The Chairman: That statement has been made. The rate is highest particularly for sick leave due to stress.

Dr. Barrett: That has been confirmed by outside agencies.

Senator Keon: Many of the problems that family physicians are encountering lie the fact that they are working as members of a team where the nurses are depressed and upset and overworked and so forth, and that rubs off on everybody, including the patients. Those of us who have spent our lives in this business, certainly all of us who are doctors who have spent our lives in this business, have to admit we would not have got through a single day without nurses. I recall being an intern in Cleveland on my first night on call. I had never been taught how to pronounce a patient dead. Excuse me for this anecdote but it is important. I was called to the ward at 3 a.m. The nurses at the station were killing themselves laughing because the intern they had called over to pronounce the patient dead came over and stood at the foot of the bed and said, "He is dead," and went back to bed, and the nurses were so gracious that they would not call him back and embarrass him. They called me over to pronounce the patient dead and I had to admit I did not know how to do it either. So they taught me, and from there on in they have taught me a lot.

There is a terrible problem in the nursing profession now, and it is affecting the medical profession in a very adverse way. The medical profession cannot address its problems in isolation. They have to be addressed in concert with the nursing and other health professions. I certainly think you should keep harping on the need for a special health human resources study.

I wanted to question you on some ideas this morning but time is running out. I have talked too much, but I will be back to some of you on the telephone.

We sort of have decided where we would like to go with our next report in general terms. Maybe one of our next endeavours should be this one.

Senator LeBreton: This might be a loaded question, but I agree with you concerning the lack of medical professionals at the decision making level of government. You are right. We never question having a lawyer as Minister of Justice, although many of us would think that would be probably more questionable.

What would you think of the idea of Canada having a Surgeon General as in the United States - or something like that to represent the medical profession at the highest level, perhaps an ombudsman. Maybe Canadians, being Canadian, would have a problem with the term. What do you think about a person or an office like that?

Dr. Barrett: I could be supportive. We have to get politics out of health care. That is part of our problem. We talk about the lack of medical and health provider input, and on the other side of the equation, what is the length of office of the average Deputy Minister of Health in this country? It is about nine months. For ministers of health, it is not much more.

We need some other body, individual, or whatever, that will let us put politics aside. If I were a politician, I suppose health care is an area I might not want to be involved in right now because there are so many problems. Politicians burn out too and they move on and we do not have stability. We do not have a plan or a vision in this country right now that we can all work toward. Hopefully your committee will come up with one that we can all support. That is what we will need. Somehow we have to get politics out of health care and that is a possibility.

Senator LeBreton: Would anybody else like to comment on that?

Dr. Oetter: That should be something at arm's length that allowed the "operationalization" of the vision of medicare and removed politics from this.We should get back to first things first. We have to improve access for the sickest people in the country. If "operationalizing" that vision is best done by something that is arm's length from the government, this would be a great idea.

Senator St. Germain: Thank you, doctors, for appearing this morning. The man to my left is much more qualified in this area than I will ever hope to be. However, there is the political side of this whole thing. You say "Get the politics out of it." During the last political election, every leader was jumping up and down saying "Maintain the status quo." You cannot get the politics out of it. A Surgeon General at arm's length is a joke under the parliamentary system, regardless of who is in power. I am not being partisan here. It does not matter whether it is the Conservatives, the NDP, the Liberals, or whoever is in power. There is no such thing as an arm's-length appointment, because everything is done by the Prime Minister. Everything comes out of the Prime Minister's Office. As long as we have that, we will never have "arm's length."

There are individuals who take a lead role, but this is scary. In the last election leaders were jumping up and down and saying, "No change," and the system is going down the tube.

We had the same thing with free trade. Brian Mulroney wrote in his little book that he was against free trade. Then he saw the need for it and he got the business community behind him.

Unless somebody has the intestinal fortitude to take the lead on something like this and take a political risk, I think you people cannot get out of the politics of it. You have to stand up and say, "Hey, listen, these four, five leaders are crazy, they are destroying our medical system, they are mitigating the possibility of people getting good health coverage and they are driving doctors out of the country." Apparently, of 1,500 doctors, we lose 400 to the United States every year.

Doctor, you have said that we have 8,000 doctors in B.C. and we have 10 per cent of the population. You said there are 50,000 doctors in the country, so we have a good percentage in this province, and still, they are burning out.

I am not a doctor, nor am I a lawyer. I was a commercial pilot and businessperson, but if I ran my businesses like this I would be bankrupt. I am not bankrupt. I have been very successful in a lot of things I have done, but it is because I have applied logic to the formula. I have met with doctors. I was an MP in your riding. I was the MP for Richmond - Port Moody.

Dr. Marco Terwiel, was head of the CMA at one time I believe. I met with him. I like Marco, but if you talked to him and it was as if "We are sort of above this political level, we can not get down into the fray. You do not get down there." I used to be a cop in the 100 block East Hastings. Many a time I got beat up in the back lane. If I had not gone to the back lane, my street would not have been safe.

Why do you take this position? You must take a position of leadership. The business community got behind Brian Mulroney and he got his legislation through. Some people disagree with it, but fundamentally it has worked and Ontario's economy has boomed for the last 10 years. That is the only way I think you will have change.

Dr. Oetter: First of all, I will tell you that Dr. Barrett and I have excellent digestive systems so we do have the intestinal fortitude to do this and that is why we are here.

Senator St. Germain: Good.

Dr. Oetter: I would encourage you to read the BCMA policy document, "Turning the Tide - Saving Medicare for Canadians." We have made 29 recommendations. We are making recommendations that are tough, and, undoubtedly, they will tread on people's values. But until we have a redefined vision of what medicare will be and get away from the tinkering, we will never have a sustainable, accountable health care system. So, we are out there. We are being political. I am sure we can give you your own hard-bound copy before you leave today, and I would be happy to sign it.

Senator Lawson: Dr. Barrett, I am going to start with you because I am delighted that you are from Saskatoon, Saskatchewan. Senator Buckwold served with us with great distinction. His proudest moment was when he was the mayor of Saskatoon. He was so proud of that. I remember his favourite story. He said that a group of English ladies took a VIA Rail tour across Canada and they stopped in Saskatoon. One of the ladies went out on the step and asked the station agent, "What place is this?" He said, "Saskatoon, Saskatchewan."She said, "Oh, thank you." She went back into the train and she said to the ladies, "How quaint. They do not speak English here." That was his favourite story about his city.

You were talking about waiting lists, in response to Senator St. Germain's question, and some system you have for putting it all together and so on, but is there any way to measure the costs of lengthy delays on the waiting list? We have had evidence, and I have read some of the reports, where, as a result of waiting lists, people waiting for heart surgeries and so on suffer strokes, heart attacks and various effects which increases the cost by great multiples for their care as a result of lengthy delays. Has any attempt been made to measure the costs of waiting lists?

Dr. Barrett: That is one of the things that the Western Canada Waiting List Project will hopefully examine. One of the problems is that we always talk about costs in terms of the cost of the health care system and ignore that costs are borne elsewhere. In the 1990s we have seen a lot of that in the off-loading of the health care system to the community without much community support. Those costs have been borne by employers, spouses and parents. Nobody acknowledges that.

At that level it is hard to measure, particularly strictly in the health care system. You have to go beyond that. I could not agree with you more.

Senator Lawson: My friend, Senator St. Germain, spoke about the politics of the situation. Those from B.C. know that Premier Campbell said that, "You tear down the walls. We have to do things differently. We have to take a look at private medicare. We have to talk about anything that is going to make it more efficient and get better value for our tax dollars."

You may have heard an announcement this morning that the government has made. We have a problem in Abbotsford, which is about an hour away, where, for the last decade, the hospital has been funded to go ahead, it has been stopped and it just has not gone anywhere and people are a little bit upset about that. This morning it was announced that the Abbotsford Hospital will go ahead. Will it be financed by public funds? No, it will be financed by private funds, following a model in Great Britain.

Does your association have a response to the private funding of hospitals?

Dr. Barrett: I will discuss that nationally, and then Heidi will give you the B.C. perspective.

In this country, I think people are often confused about public/private. We have always had private delivery of health care in this country.

Senator Lawson: Right.

Dr. Barrett: I am an example of that. Health care has been publicly administered but privately delivered. People confuse "privately delivered" with a totally private system. We do not have a problem with that.

The Chairman: That is why, earlier, when I was explaining an element of competition between hospitals, I was very careful to say that was not an issue of competition between a privately owned hospital and a publicly owned one. It is the single government payer model that Canadians truly care about.

Dr. Barrett: Yes, exactly.

Senator Lawson: Just following on that, does the association have a position on private clinics? We had evidence yesterday from the Cambie clinic and what is done there. Do you have a policy position for or against those kinds of things?

Dr. Barrett: We have private clinics all over the country. I am in a private clinic.

Senator Lawson: Some of the governments talk about -

Dr. Oetter: I think what you mean is private clinics that provide privately funded services.

Senator Lawson: Yes.

The Chairman: They take non-medicare patients.

Senator Lawson: Yes.

Dr. Oetter: Right, and to the extent that Canadians want that, they already get it by driving just about an hour south of here. Our associations want to make the public system work so well that the number of people who seek that private option is minimal. Unfortunately, the increased number of privately delivered, privately funded services is a testament to the access problem for urgent and emergency health care. To the extent that the private community can step up to the plate to provide capacity for publicly funded services where that is efficient, of the same quality and in a regulated environment that is based on need - look after the sickest first and foremost - it is a good thing.

Senator Lawson: Yesterday Dr. Day said that in the work his clinic does with the Workers' Compensation Board, the WCB saved $90 million last year.

Dr. Oetter: Those costs may reflect that there are costs to the employer in having people off work for an extended period of time, which may not necessarily be reflected in the care of that individual. You are quite right that for WCB it is very efficient.

Senator Lawson: However, a savings of that kind that goes back to a public agency like the Workers' Compensation Board is really either to the employer or to the employees or to the taxpayer.

Dr. Oetter, in your submission you talked about the fallacy in suggesting that sufficient administrative savings can be found within the system to cover growing costs. I can understand the general application of that, but we have had relevant examples. Yesterday a witness talked about a particular medical institution or a hospital, which over a 20-year period, went from one president and one assistant to manage the hospital to the present situation of two presidents, one CEO and 11 vice-presidents, which seems to be a large amount of administrative staff. That is one example of what seems to be a little administratively heavy.

Another example is the care facility for seniors at White Rock. People are complaining vigorously because on the night shift, for over two dozen patients, there is one nurse or nurse assistant. People are very upset about that, and when they asked for a meeting to complain about it, an army of people arrived: a nutritionist, a dietician, a director of nutrition. One thing on which the patients agreed unanimously was that the institution served the worst food anywhere, but they had a series of other administrators - large numbers of them. Something seems to be out of whack and there should be an examination. Are we talking about an overload of administrators and not enough nurses or assistants? Could not some serious savings be made through an examination of that?

Dr. Oetter: I think there would be savings. The myth is that those savings alone will be enough to create a sustainable system, and that is where we depart a little bit. Are there efficiencies that we can still pull out of the system? Yes, there are, but that will not be to the magnitude that will cover the kind of increase in pressure that we are experiencing with an aging population, the technology, advances that we have, and certainly the evolution of new and heroic ways of saving people's lives or reducing their disabilities. There are efficiencies, but they will not sustain the system.

Dr. Garg: In the last 10 or 15 years people have kept saying, "Let us just manage the system better," and the outcome of that is better management means less role for practicing physicians and nurses and more role for management. That is what we are really talking about and that is really the key. Practicing physicians and nurses should be given a greater role so that they have ownership of the system and less of the management part.

Senator St. Germain: You discourage the use of user fees, yet, with chiropractors - and I know that may be a dangerous word to use in this company, but they are great people and have kept me going for 64 years - I pay a user fee. If I want to go to a physiotherapist, I pay a user fee. Dave Barrett yesterday basically said those types of services were not flourishing the way they should as a result of user fees. I believe in user fees, and I believe as well in competition in the private clinics. Competition drives everything in our system. That is proven. The USSR tried a system without competition and that did not work. Our system is based on competition, so why not in the private hospital side?

I have basically two questions. I just cannot believe user fees would not work. If there are poor people, we will give them $20 or $30 or whatever they need. This system would discourage a lot of abuse. I am sure people visit you because they are lonesome and they like you as a person more than they are sick. Would you answer those questions please?

Dr. Barrett: The key word in that document is "acute." We can consider user fees or any form of full payment as long as we consider that through the parameters that I outlined. The difficulty with user fees for acute, emergency, necessary care is that those patients have no choice. User fees will work to discourage people from accessing the system unnecessarily in a situation where they have choice. You do not have choice when you are in an acute situation. Our comment on user fees relates to that. Certainly when you discuss other areas where -

Senator St. Germain: What about the administrative costs you have here?

Dr. Barrett: The key study is the "Beck and Horne" study from Saskatchewan from the mid-1970s, which shows that user fees essentially discourage the poor and the elderly and the administrative costs were not worth the savings, in terms of utilization.

For us, the issue with user fees is the acute. If you are having a heart attack that is not the time to ask whether you have enough money or to do an assessment of your income. You should in be in the hospital and you should be looked after.

Senator St. Germain: That makes sense.

Dr. Barrett: In areas where there is more choice, sure.

Dr. Oetter: I think it depends on what you want from the user fees. Is the user fee to encourage more appropriate use of the medical system, or it to contribute a significant portion of funding to the medical system? You must consider those two issues.

User fees must be considered, but I agree with Dr. Barrett, there is a difference between a user fee that is associated with chiropractic treatment for back pain versus a user fee in the emergency department for treatment of a broken back. Those two analogies might help set the context of where the Canadian Medical Association is coming from. Certainly at the BCMA, we believe that user fees must be considered, but in light of those kinds of things. We want to make sure that there is not a barrier to access to necessary care, especially for people with low or no income. We have to protect them.

The Chairman: Dr. Garg, just by way of follow-up for further issues, not for comment now, I assume you are now heading the policy committee nationally. Is that right?

Dr. Garg: Yes.

The Chairman: Can we, in the next 10 days or so, have a brief discussion about where your tax study, the health human resources national study that we have mentioned and that you talked about, and the issue that has also been discussed that was raised by Senator Keon earlier, which is the need for a forum that allows all stakeholders together, not simply one in which policy makers in governments operate and the stakeholders operate outside that. We should talk about where those three issues.

Dr. Garg: Yes.

The Chairman: Thank you very much for coming. We appreciate it.

Dr. Barrett: Thank you for having us. We have great expectations of you.

The Chairman: Senators, our last witnesses are Dr. Peter McLean, who is a professor and Director of the Anxiety Disorders Unit in the Department of Psychiatry at UBC and Dr. Mark Godley, who runs a private medical clinic, which we heard about when we were in Manitoba. He was not in Manitoba, but he also has a clinic in B.C., as I have just discovered, and he is here on that subject. Thank you very much for coming.

I will begin with Dr. McLean on a very important issue that, unfortunately, we have not heard as much about as we would have liked to. That is the issue of mental health. Dr. McLean, thank you for coming. We had a number of your colleagues here yesterday from UBC, including the dean and a variety of others. We are delighted to have another member of the faculty. Let us start with your opening statement and then senators will ask questions.

Dr. Peter D. McLean, Professor, Director, Anxiety Disorders Unit, Department of Psychiatry, University of British Columbia: Thank you very much for this opportunity to talk to you. I realize the brass was here from UBC yesterday and I am a bit of -

The Chairman: Now we get the people who do the work, right?

Dr. McLean: I am a bit of a lone rabbit in that I was a late applicant to this process.

The perspective I bring is my 30 years in the mental health delivery system and in the training organization of a prominent university, and also, as founder and board member of the Anxiety Disorders Association of British Columbia, which is a non-profit, voluntary organization. I should point out that anxiety disorders represent the single largest type of mental disorder in Canada.

I was quite relieved and delighted to read your report. There are many things that are positive about this, particularly challenging the icon status of our health plan as it was stated, thinking broadly, "out of the box" and reviewing system options that are obvious in other countries.

I agree with the previous speakers that we can neither spend nor manage our way to sustainability, and I think two-tier or blended sector solutions are encouraging. I also like the idea of using technology, as in telehealth, for example, to overcome geographical problems in our country, vast as it is, which is an obvious solution. We just completed a major study in training family physicians, with over 50 rural physicians, in the recognition and treatment of mental disorders via the Web and telehealth and found it to be very successful and that it demonstrated hard learning.

I believe that there are unique issues in mental health apart from the rest of medicine or health care in Canada that require your very special attention. First of all, it is totally underestimated. There is a highly prevalent set of conditions. Conservative estimates are that one quarter of all Canadians will meet criteria for mental illness at some point in their lives. Right now, approximately 400,000 Canadians suffer from debilitating, serious mental illness.

The economic burden has been even more underestimated. Traditionally, I think we have examined direct costs, acute care costs and so on. What are much larger are the indirect costs, which would be unemployment, absenteeism, disability and so on. For just two sets of disorder symptoms, depression and anxiety, current economic modelling data show that the cost to Canada is over $20 billion a year. That is for these two disorders.

I bring to your attention that, despite these lines of rather compelling evidence, there are significant barriers to care throughout Canada. The public does not understand mental illness and is frightened by it. Family physicians are not particularly well trained in this area. Heaven knows, they are pressed in learning to acquire much information and mental health suffers because it is not seen as acute. It is well known that 50 per cent of patients presenting to family physicians with clinical depressions are missed.

The average period of time, from onset to the treatment of obsessive compulsive disorder, which is a particularly serious anxiety disorder, is well over 10 years. The patients are often schoolchildren.

One of the problems is that mental health care is strongly biased towards acute care. In effect, we have to "grow" the problem. There are prevention programs that have established efficacy for some, but not all, mental disorders. Certainly there is a strong case for early intervention, but the difficulty is that they are not picked up at that time. We, in effect, have to grow the problem and then treat patients expensively once the disorder is well established and the person is relatively dysfunctional.

Inadvertently, we have created a system that permits this to occur in terms of a self-serving and self-perpetuating system. We must move toward more community-based care rather than hospital bed care in this area. We must train providers in evidence-based treatments, which, I can confirm, we simply do not. We must focus on early intervention. We have to broaden the concept of providers. We have almost exclusively, at the top end, medical providers that bring medical treatments to a disorder for which there is no known physical pathology. We expect that there will be, as genetic studies continue, but at the moment, there is no evidence for organic pathology in any mental disorder, which is compelling enough to complete for the entire disorder. We are left with psychosocial determinants. I would suggest to the committee that must have ecumenical solutions to this to be effective.

I offer five suggestions for your consideration. We must have system incentives for prevention and early intervention. We have to foster competition for breadth of knowledge and for economic and available treatments in a variety of ways. One model may very well be, as you mentioned regarding Sweden, Senator Kirby, in effect individualized payments where sufferers can seek their own provider as long as that provider is on a registrar of competent individuals. At the moment in Canada, we deny, I would suggest, free choice of a doctor. What we have is free choice of a medical doctor, not free choice of all doctors.

The Chairman: In the second context, are you using a Ph.D. as a doctor?

Dr. McLean: Correct.

We must make, as your report considers, the contrast between the cottage industry organization and modern, specialized, hierarchically-fed forms of expertise. That should be done through the model of shared care, wherein we have regionally-distributed primary care physicians and mental health workers who are at the coal face dealing with their patients, who often have need for expertise. With the technology available to us today, through the Web or telehealth, we can access that cheaply, without physically transporting either doctor or patient to that source. That has been demonstrated. The difficulty is that we do not have that set up through a centre of excellence by disorder arrangement, and more particularly, we do not have any facility yet to pay for it, so it does not happen.

I would also suggest that all publicly supported mental health training institutions, primarily universities, should be required to train their respective practitioners in evidence-based treatments in order to gain or retain accreditation. I work in an institution that trains people in techniques that have not changed in 80 years.

The Chairman: Was that eighty years?

Dr. McLean: That was eighty years.

There is no system incentive. If you have a mental health problem and you go to a mental health community centre and see whoever you see, a case manager who is whatever, or if you go to see a psychiatrist - I am excluding family physicians simply because they are too busy - with these folks, there is no way of knowing what goes on in there. You could undergo age regression, have seashell therapy or whatever, paid for by the public account. It is not supervised. There is no accountability, and what is worse, we are still training people in a variety of these sorts of historical treatments.

The UBC educational counselling does this, and many of those people filter into the mental health delivery system. Psychiatry does it. Primary care physicians are taught a little bit. It is a time crunch problem for them. Some universities and clinical psychology departments do it and others do not. The point is that there is no need and no incentive. That must be addressed and integrated so that institutions that are producing people who will be at the delivery phase are tethered somehow to a currently acceptable and accountable system.

Finally, an obvious offshoot of that is that once they are out they will revert to whatever behaviour the payment structure provides, so, naturally, we must ensure that there is some form of supervision and accountability on an ongoing basis.

In conclusion, we have the health care delivery system in mental health that we have paid for, and it could be improved dramatically with some moderate level of modifications.

The Chairman: Thank you for that. I have a lot of questions, but I will turn now to Dr. Mark Godley.

We actually heard a fair bit about Dr. Godley's clinic because he operates one in Manitoba as well as here. I will say, Dr. Godley, as you can imagine if you looked over our witness list, not everything we heard about your Manitoba clinic was positive in the sense that there are a number of people for whom the whole notion of a private clinic is an emotional issue. We had emotional testimony on your behalf, both for you and against you, when we were in Winnipeg - not you personally, but on the clinic idea. We are delighted to have you here to tell us about the clinic.

Since we want to make sure we have time for questions, can you focus on two things: Who are your patients and what do you see as the advantages and/or disadvantages of the clinic you operate, and is the structure different here from that in Manitoba?

Dr. Mark Godley, Maples Surgical Centre: Thank you for allowing me the opportunity to be here.

I will leave documentation that outlines our evidence and our experience over the last three to four years in British Columbia. You can examine that evidence and we can also talk about how what we have done in British Columbia has resulted in contributions to the overall health of Canadians in British Columbia and so on. We can also consider the recommendations.

Just as background, I am an anaesthesiologist and in British Columbia in 1995, when I graduated, the policy-makers in health care delivery were examining reducing costs of health care and one of the recommendations was to reduce operating room time. Subsequently, I found myself lacking the opportunity to find a permanent position as an anaesthesiologist in British Columbia, so I had to consider an alternative delivery system in which I could practice my vocation, which is anaesthesiology. We opened the False Creek Surgical Centre, which is a multi-disciplinary, free-standing surgical facility in downtown Vancouver.

It is important to get an understanding of what ambulatory surgical centres are and what private ambulatory surgical centres are before we go any further. There are many office-based practitioners who perform plastic surgery and maybe other smaller procedures such as cataract surgery and so on, but what we are talking about here is a truly multidisciplinary, functional, free-standing, away from the hospital, private, ambulatory surgical centre. There are not a whole lot of those in Canada today.

It is important to examine the experience of the United States. The first ambulatory surgical centre opened in the United States in 1970. Today there are over 2,700 of these centres, providing an alternative route for the delivery of surgical services. This gives people choice. Today, in Canada, people do not have choice over their delivery system. They have only one choice, and that is a monopoly, medicare, that is government funded and universally accessible, supposedly. We must understand that. That is the first thing.

In the system in the United States, let us take, for instance, two of the big third party payers, Medicare and Medicaid. Seventy-eight million Americans can access over 2,000 different types of procedures within these ambulatory, free-standing, privately owned and operated facilities. This brings competition into the picture. Competition - what we have heard about over the last two hours that I have been listening to the other speakers - gives Canadians, and will afford Canadians, the luxury of at least being able to choose where they receive their care, which is something they do not have today.

I will address Senator Kirby's question about what patients we treat and where they come from.

We believe in the Canada Health Act, in the five principles, except that we add another principle, which is quality of care. That is something that we do not find too much in the principles of the Canada Health Act. Quality is very important and part of quality is access to care. We are talking about giving people choice to access services, not rationing their services.

What we are accomplishing is being able to provide services to peoples who fall outside the Canada Health Act. We have been able to take advantage of moving our centre from primarily providing uninsured, non-medically necessary services to providing necessary medical services because we are able to perform these services for people who fall outside the Canada Health Act. WCB is an example. RCMP is another example. There are over 36 groups of Canadians, in British Columbia alone, who fall outside the Canada Health Act and can receive services in of our surgical facility. In a sense, this has been a good thing because it has meant that these people have come off the waiting lists and that has allowed space for other people to move up on the waiting lists. At the same time, it has introduced unfairness.

Everybody in Canada talks about the fact that all should have access to health care on an equal basis. What about people not having access at all? What about people who do have money to pay for surgical services? Is it right to deny them the choice to use a facility if they have the means?That is part of what I have to say.

I will now discuss the Maples Surgical Centre in Manitoba. We went to Manitoba with the expressed interest from the Workers' Compensation Board to enter into an expedited surgical program similar to that in British Columbia, where, as we have heard, there have been massive savings in expediting surgical services for the clients and the patients of the WCB. Brian Day yesterday told you that there was a savings of over $92 million last year just in lost wages alone. That savings is not in all aspects of delivering timely surgical services. That is just in lost wages because that could be measured. As Senator Lawson mentioned earlier, how do we measure the cost of a person being on a waiting list? This is an example of a measurement of a cost of being taken off the waiting list and of the savings.

WCB, across the country, as a Crown corporation that has different governance in different provinces, has been examining this. We have been approached by the Workers' Safety Insurance Board of Ontario to consider setting up a similar project.

Yes, we work within the realm of the Canada Health Act. That is to answer your question.

The Chairman: Can I just be clear that your patients are either WCB patients or the patients of some other group that is excluded under the Canada Health Act?

Dr. Godley: That is correct.

The Chairman: Can they be non-Canadians who, therefore, pay privately? You do not have Canadian residents, who are normally covered by medicare, coming to your clinic as patients.

Dr. Godley: Yes, we do.

The Chairman: Are you paid by medicare for those procedures?

Dr. Godley: No, we are not. We are paid by a third party.

The Chairman: Are you paid by a third party such as an insurance company?

Dr. Godley: Great-West Life is an example.

The Chairman: Okay, I understand the structure then.

Dr. McLean, just as a comment on what I think was an outstanding brief, it is a fact that a number of members of our committee and our various extended families have had dealings - extensive dealings in my own case, as part of my extended family - with the mental health system in the country. Your recommendations resonate very strongly with me, although I will be honest, I am stunned to hear them coming from a psychiatrist.

Dr. McLean: I am a psychologist.

The Chairman: You are a psychologist, but you are in the department of psychiatry. I assumed you were a psychiatrist.

Your views are so heretical, as you said, on much of the way mental health is practised. Are you a lone wolf or is there a group of people like you with whom we could have a more extensive conversation? Your comments about the focus in mental health being on drugs and not necessarily going to the most appropriate person, and so on, is not what one would normally get, I suspect, if we talked to the Canadian college of psychiatrists, or whatever the association is called.

Dr. McLean: Let me clarify that. I do not want to leave you with the impression that there is an exclusive emphasis on pharmacological approaches. Rather, I would like to point out that if you have people who are virtually exclusively trained in that area, on the somatic side, it is no surprise that people do what they are familiar with. Furthermore, there is a very important role for pharmaco-therapy in mental illness - flat out. I am not against medications.

The Chairman: I did not take it that way.

Dr. McLean: Okay, good. Very often a blended treatment is highly appropriate.

In answer to your question, yes, there are a number of spokespeople who would tell you the same thing. For example, four years ago Health Canada published a report commissioned by several people from Ontario. Dr. Richard Swinson, current head of the Department of Psychiatry at McMaster University, was co-author on a document dealing with evidence-based treatments for anxiety disorders.

Earlier this year, the University of Toronto's Department of Family and Community Medicine published a very important document on guidelines for the treatment of anxiety disorders in primary care. If one examines that, as I encourage you to do, one will find that the treatment of choice is very often, or equally often anyway, cognitive behaviour therapy, which is a psychological treatment that is evidence-based.

The other treatment of choice is pharmaco-therapy, for which exact medication and indications, of course, vary. This group and Swinson's group years prior have taken advantage of an awful lot of expertise, nationally and internationally, primarily with physicians, but of all sorts of people knowledgeable on this, and have come up with these two as in the top tier of treatments for at least this set of disorders. You could do the same for schizophrenia, depression and so on.

So, if you move to evidence-based treatments, there is a finite number that are paying the rent in terms of demonstrating results.

The Chairman: Is there an organization that includes a lot of people like you? I am surprised we found a psychologist in the Department of Psychiatry to begin with, but if we wanted to talk to a national organization, or a collection of people like you, where would we find them?

Dr. McLean: Many of my colleagues in the Canadian Psychiatric Association would support what I am saying. In a way, this is motherhood. How could you not argue for evidence-based treatments? The opposite is to say that we will use taxpayers' money to treat people with something that we do not know works. In many ways, it is motherhood. I would think that Dr. Richard Swinson would be glad to give you suggestions as well.

Senator LeBreton: That is interesting. I know Dr. Swinson very well because he just completed a term on the board of directors of Mothers Against Drunk Driving, where I worked with him very closely. We should try, when we are in Toronto, to have him as a witness.

Dr. McLean, you talked about the issue of mental health, and you said one-quarter of all Canadians meet the diagnostic criteria. You went on to say 50 per cent are missed. Is there another 50 per cent over and above that are missed in the system? When you talk about 400,000 Canadians, is there a possibility that there is another 50 per cent more than those 400,000 that have been missed?

Dr. McLean: Absolutely. What I meant to communicate was that not everybody presents to the family physician. People may not even be aware that they have a mental disorder. For example, if I could just briefly illustrate with the sets of disorders I work with most, anxiety disorders, these people are cognitively intact. They are not psychotic. They are not kicking up a fuss at midnight at the 7-Eleven or pushing people into trains. Consequently, they are ignored. This is helped by the fact that they are highly avoidant and embarrassed, and they frequently hang out in their parents' basements, forever, on disability. They often present to their family physicians for other problems but may not volunteer information that they have one or the other of these disorders. I think that the solution is public education.

Senator LeBreton: My next question is a public education question. One of the problems with mental illness is that people, who may recognize they need help, fear negative social stigma could affect their jobs or their ability to participate in the community. How do you help people who require treatment for mental illness to overcome the fear of social stigma and seek help?

Dr. McLean: Frankly, and with due respect to the various and sundry organizations such as Canadian Mental Health Association, various schizophrenia societies, mood disorder groups and so on that have been trying to do this for a long time, I think they have it wrong. I think what they are trying to do is usher people into medical treatment. That has been their modus operandi in terms of telling people what to do. What that does is frighten people.

People do not understand the differences between mental illnesses. Somebody comes to me with a panic disorder, which is drop-dead easy to treat, relatively, and says, "I am worried that I will by psychotic. Will I end up in Riverview Hospital?Will I lose my job and my marriage? Will my kids visit me simply on my birthday and Christmas and say, Hi, Dad?" That is a typical question. They have no idea.

What we must do, in the way of public education, is differentiate among the mental health disorders and point out that, for some, not all - schizophrenia tends to be dichotomous, like pregnancy - but most disorders tend to be continuous. You can be a little anxious or a little bit depressed as opposed to clinically so. It is a continuum.

It would help to point out, for example, how many model Canadians have successfully dealt with these kinds of issues or are dealing with them currently and functioning just fine. I think that the schizophrenia societies, for example, should get successful Canadians who have a diagnosis of schizophrenia, are well- managed on medications and are captains of industry or whatever their jobs are, to come forward. That would be radical for them to do so, but I think it is necessary if we are to win the battle of public education.

Senator LeBreton: I have one question for Dr. Godley. I was just looking at your statistics at the False Creek Surgical Centre and the breakdown of your cases. You note 80 colonoscopies here and you have noted three as being positive for colon cancer. How do those people get to the clinic? Were they referred by someone? Was this preventative surgery that most of them were getting? I am just curious as to why you would have 80 cases. One almost gets the sense that people have had this operation against the event that down the road they may develop colon cancer.

Dr. Godley: Today in British Columbia, there is no insured service fee for patients requesting screening colonoscopy. In the United States this has been endorsed so that for everybody over the age of 50, where it is felt that part of a full physical exam would entail having a colonoscopy, it is recommended. In this country it is not a recommendation because one of the problems is that if everybody over the age of 50 wished to have this procedure done, it would result in skyrocketing health care costs in this field of medicine, so the recommendation not has not pushed in Canada. Certainly, in British Columbia, the surgeons and hospitals shy away from this progression in innovation because it will result in health care costs being driven up. We have introduced this as a procedure that is performed at the expense of the patient, and, if we happen to pick up disease or a disorder, the patient can have the treatment. This is an example of 80 private colonoscopies, where we, by complete coincidence, have picked up three positive colon cancer patients. This is an example of how we are able to contribute to the community by bringing in new programs and informing the public through a forum where doctors have presentations to the public to give people the power to make decisions about their own health care.

Senator Lawson: Dr. McLean, I do not profess to understand much about mental health, but I found your presentation very refreshing. If I had someone with a problem, I would want to have a consultation with you.

Dr. Godley, I am sure you are aware that we are embarrassed, here in British Columbia, because we have a hospital building that has been built, on which we have spent millions and millions of dollars and we have 10 or 12 empty floors up there.

Dr. Godley: That is correct.

Senator Lawson: We wonder what is happening with our medicare system.

If a proposal came from the government to your clinic for a joint venture, that you would take one of those floors and operate a clinic and do these kinds of things, would you agree to that? Would you consider it?

Dr. Godley: It sounds like a great idea but I do not think it would be practical. Part of the problem is the fact that hospital is unionized and unionized labour introduces a number of issues. The first issue is rigidity in job subscription.

Senator Lawson: Yes.

Dr. Godley: Rigidity means that we lose efficiency and we lose the ability to behave as a team.

The other thing is that I believe we must move more towards allowing health care to become dispersed and more horizontal than it is with these large vertical towers of health care delivery, where we have small, focused delivery health care systems, where you would go to a centre that specifically deals with surgical needs, where you would go to a centre that specifically deals with psychological needs, and so on. All of these facilities would become integrated and would talk to each other and work together.

The benefits of small, integrated facilities, such as the False Creek Surgical Centre or the Cambie Surgical Centre, or having a surgical hospital, for instance, would be that you can cross-train your staff and you can become efficient. You can focus on your patient as sovereign. Patients are sovereign in this type of delivery system, and they have a bill of rights and they have more information at their disposal. Allow these small, focused facilities to compete in a healthy way.

What we would like to have is the government coming to us and saying, "We want you to abide by the Canada Health Act and how are you going to do that? We are going to publicly fund you, even though you are privately delivering services or care." In so doing, we would allow all Canadians to gain access to care in a timely, efficient way.

That is where my recommendations come in. I introduced the subject of triple bottom line. Triple bottom line accountability says that basically, to be fiscally accountable, be it a private provider or government provider, that provider should profit from the delivery of care, also, the payer must profit from that delivery and the patient must profit. That is the importance of profit. Not just one of the three providers must profit. That is the first part of the equation in triple bottom line.

The second part is access, and a good example of access is what we do with the Workers' Compensation Board. The Workers' Compensation Board of British Columbia specifically states in our contract that we will provide a service within a time frame of 21 days. That is part of the accountability equation.

Senator Lawson: Yes.

Dr. Godley: That is part of needed access. Another side of the coin is that the government, in its willingness to contract out to private facilities, will bring in that level of accountability through access.

On meeting health status indicators, we believe we meet at least seven of the 12 health status indicators that were publicly announced by the health ministers' conference of last year. That involves continual self-evaluation to have the ability, in a centre like ours, to be able to publicly broadcast and publicly state what our infection rates are, what our patient satisfaction surveys are like, what are the chances of morbidity in such a centre and, if you see such and such a doctor, what are the chances of your needing admission to hospital or referral to hospital.

There are community aspects that can be attached to this. What do you contribute to the community? We went through an interesting exercise. The False Creek Surgical Centre is the only private surgical centre in Canada that is accredited by the Canadian Council on Health Services Accreditation. This is a body that accredits every single hospital in this country. There are 1,800 hospitals. Its focus is very much on how you contribute to the community. It gave us some very important avenues and information on how we could do that.

The colonoscopy program is an example of that. Another example is training nurses and sending them to conferences and upgrading their skills. Another example is allowing residents to train in your facility. We do that as well. Another example is an expedited back surgery program like we have with WCB where we provide, exclusively, an expedited service to treat patients who need back operations and so on. There are ways that we can contribute to the community.

In the evidence that I present to you today, I want to address some of the vehement opposers to privatization of health care. There are a few coined phrases that you have probably heard from time to time. The first is "cherry picking." "We do not want to see private health care flourishing in this country because it will result in our best staff being picked out of the hospital system and moved to the private sector." That is not true. This is the evidence of False Creek Surgical Centre: We have only three or four full-time nursing staff, we have 57 part-time nurses who work in the local hospitals and gain added employment and added benefits from working out of an alternative health care delivery system when it comes to surgery. We provide them with an alternative place to deliver the services in which they have been so well trained. It keeps them in their vocation. It stops them from becoming pharmacists or pharmaceutical represemtatives or going to the United States.

That brings me to the point of taxes, at-source deductions that our nurses and our staff have contributed. False Creek Surgical Centre this year alone has contributed over $100,000 in taxes, federal and provincial, just through having a facility like ours in the country. Would this money have gone to the United States? If people cannot gain access to care, where would they go if they cannot receive services in their own country? We have to really examine ways that these centres can contribute.

Senator St. Germain: Dr. McLean, I too am impressed by your delivery. In my family, about 80 years ago, we had challenges with some of my relatives.

Having been a policeman on the street in Vancouver, I still talk to the guys down there despite it is about 30-some years since I left. I find that everybody raises this hue and outcry about the added problem, basically in the skid row areas or the areas that are generally challenged in any community. Is this a result of, as you explained, our being 80 years behind in our methods of treatment, or the fact that we just hope this is something that will go away instead of dealing with it? Has this contributed to the fact that there are so many people in these skid row areas who are challenged and often end up with drug and alcohol-related problems? Has this been exacerbated by the fact that, as we become economically stronger as a society, we have tended to try to sweep this problem under the rug instead of dealing with it in the manner that we should, as a community?

Dr. McLean: That is a good question. The kinds of problems that you talk about have pretty much always been there. That it is a good example of the requirement to have specialized treatments, outreach treatments, which may include a variety of other services, in terms of housing support and so on, for this at-risk population. I think it is true that mental illness and criminal activities are intermingled by default. Many of these people end up in forensic psychiatric institutes or in our jails when they predominantly have mental problems that could be treated through a more specialized form of intervention that is community based and has nothing to do with the hospital bed.

Senator St. Germain: I will not pursue that.

The Chairman: We will close with a comment and/or question from Senator Keon.

Senator Keon: I have a comment for you, Dr. McLean. I am truly sorry I missed your presentation. I had to take an urgent phone call from my own institution. The finance committee is meeting this morning.

Senator LeBreton: That would be urgent.

Senator Keon: Yes.

Dr. Godley, I am really very interested in your clinic. Time does not permit us to learn much about it today. Sometime when I am in Winnipeg I would like to visit.

It is a very interesting concept. I have served my life in academia. My friends in America in academics have had great difficulties with the HMOs, which have opened up private clinics. You talked about "cherry picking." They cherry pick the cases and they cherry pick the patients. They get the high-revenue, low-cost stuff and they deplete the revenues dedicated to educational centres that are necessary to prop up the educational programs for nurses, doctors, technicians and so on. America has never known quite how to cope with that because it makes financial sense to have efficient clinics that run at probably about 60 per cent of the cost of the health sciences complex.

However, there is a paradox arising now in America with the HMOs. People do not want to go to these clinics anymore because they feel that they are not getting top-level treatment and that they are being pushed into clinics for cheap medical-surgical care where, indeed, the facilities are not available to diagnose and treat them properly. I would like to hear your thoughts on the impact of this.

Dr. Godley: We have a tremendous opportunity to learn from the United States and to learn from their misgivings with HMOs and so on. It is very important that we labour on introducing a community contribution that these centres can play.

To get to that though, we must set up national standards. We must define what a hospital is in Canada. Across this country, different provinces have different views about what hospitals are, and that is very political. I came to Manitoba, for instance and we opened up an ambulatory surgical centre, the Minister of Health introduced a bill to ban it and call it a hospital. The minister said, "We have just decided that a hospital is a facility that has one overnight-stay bed." We deny access to the very people who need it. There are already, in Manitoba, publicly-funded private facilities to provide services. Why would they not do that with our centre? What is the problem?

I believe the problem stems from the fact that we have to consider the very stakeholders in health care today. Who are the stakeholders in health care? One of the biggest problems is that the unions would lose their ability to negotiate.

Senator Keon: Yes, you are right.

Dr. Godley: If they lose the ability to negotiate through the delivery of health care in an alternative delivery system, or allow Canadians the choice to go to an alternative delivery system, they lose out big time. But the individual who is part of the union gains hugely. That is what our nurses are starting to discover.

The Chairman: May I thank both of you for coming.

By the way, Dr. Godley, I will leave you with a question. I do not need an answer. Yesterday Dr. Day, from the Cambie Surgical Clinic, made the observation that if he were setting up a private clinic in another province, Alberta is the last place he would go because of Bill C-11. We did not have time to get into a discussion with him as to why that is the case, but I would like to understand that. Just quickly, would you basically agree with that?

Dr. Godley: I would absolutely, 100 per cent, agree with that.

The Chairman: Then would you provide us with the reasons, in point form, you have reached that conclusion? I would like to understand. I just do not understand that.

Dr. Godley: Yes, I will do that.

Senator St. Germain: Could those of us from British Columbia tour your facility and get an explanation?

The Chairman: That is a good idea.

Dr. Godley: We would love to have you.

The Chairman: We thank both of you for coming.

The committee adjourned.