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

Issue 39 - Evidence

MONTREAL, Wednesday, October 31, 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, for those of us who have been across the country, so far this has been an extraordinary morning. We have with us today two Canadians who probably know more about the health care system than many of us, and certainly a lot more about the health care system than I do, so I am delighted to have a chance this morning to listen to two people whose opinions on the health care system I value so highly.

Our witnesses - and I think most of us know who they are - are the Honourable Claude Forget and the Honourable Claude Castonguay. Both men have an extraordinary background in the health care system, not only as ministers of health but also as people who have written extensively on the issue of health care reform. As usual, I will have each of them go through their opening statement, and then we can ask them questions as a panel. That seems to always work better.

Mr. Castonguay, I will begin with you, and then we will go to Mr. Forget, and then we will proceed with questions. Thank you both very much for coming. I know the busy schedules that you have, and having looked at your briefs I also know that you have taken this matter very seriously. As I say, I really appreciate your being here.


The Hon. Claude Castonguay: Thank you for your invitation. Given the time constraints we have, my comments will be quite brief and general.

First off, I think it is important to agree on our objective. We in fact have two systems here in Canada; hospitalization insurance and medical care insurance. These systems were set up during the 1960s when times were a bit different to today. The plan was to set up subsequent systems of the same type to cover other aspects of care. For all sorts of reasons, including an aging population, changes in the economy and a rapid rise in health spending, the systems were never put in place.

Today, we have a situation whereby hospital and medical care are insured but a whole range of often equally important care and services are not covered.

If we did not have the hospitalization and medical care insurance systems, we would look at the issue we are discussing in a significantly different way. It was with this in mind that I interpreted the report that you have drafted and distributed to us and attempted to reply to some of the issues raised in the report.

You asked whether the problem should be looked at only from the fiscal point of view or whether the issue should also be considered in terms of the efficiency of the system we have. I believe that both questions apply. It is not sufficient to simply consider the issue from a fiscal standpoint, especially if that standpoint consists only in increased public spending.

It is clear that for some years now, the federal and provincial governments have not been in a position to keep pace with the rapid increase in costs and also the practically infinite demand for health care of one sort or another.

We have to attempt to make the system as productive and efficient as possible, but we also have to look at the wider funding issue and not just limit ourselves to public funding. We have to think about other sources of possible funding.

As for productivity or efficiency in the system, well, I think if we were to look at what has been achieved in the private sector over the past 30 years, if we assessed how service delivery has evolved and how industry has succeeded in reaching levels of productivity which are significantly higher than they were 10, 20 or even 30 years ago, if we were to look at all that, we would find that we still have a long way to go in the health sector.

You mentioned this issue in your report. I do not want to get into specifics here, but it is clear that we could increase productivity in the health system by 10 per cent, 15 per cent or even 20 per cent. I really have no idea what a realistic percentage would be, but what is clear is that a significant improvement could be made.

As for funding, we must go further than simply looking at possible additional sources of funding, and also study how the funding system works currently.

In Quebec - I would imagine that to a certain extent, the same applies to the other provinces - the existing funding system does not encourage innovation, healthy competition between facilities of the same type, where competition is possible, and gives no incentive to increase efficiency. On the contrary, in many cases the system penalizes attempts to increase efficiency.

The financial contribution to be made by Canadians is another issue that you raise in your report. These user fees are equated? to a two-tier system.

Currently, Canadians have 100 per cent coverage for hospital care and complete coverage also for medical care. We know that even in the case of medical care, this coverage is far from comprehensive. When a person requires medical care outside a hospital, a large proportion of services are not covered. Very often the care they require is quite expensive. Take radiology for example.

Drugs are more or less covered depending on the province. Even if drugs are indeed covered, patients and those Canadians requiring medication are required to pay a large part of the price, which varies from one province to another.

As for care outside the hospital setting, home care or even other types of care such as dental and therapeutic care, these are not covered. Often, these types of care are just as important as medical care, especially for the elderly and for those who need certain types of care to allow them to go about their daily lives.

It seems to me that the issue of user fees should be looked at from a broader perspective than is the case currently. Resources should be more effectively targeted when costs are higher and this is all the more true when needs are greatest.

In your report, you refer to Canadians' right to health care. This right ushers in an interesting debate. The report refers to the Charter and to the fact that the courts will be the ones to hand down a definitive definition of the provisions of the Charter.

Obviously, this may be a lengthy process. Even if the right to health care is recognized, this right will always be conditional on available resources and treatment capacity. It seems to me that it would be much more appropriate to look at the issue of the freedom of Canadians to choose.

Many people - I am sure that you know some and I know some - are not necessarily rich, but, when it comes to quality of life and health care needs, they are prepared to pay for care outside the hospital setting. Currently, this is not possible in many cases, because the whole system is public-centric.

The freedom for Canadians to make choices about their own health care seems to me to be a very important issue. We do not judge someone who wants to buy a more expensive house or automobile. Why then would we deny that person the right - if he/ or she so desires - to have an active role in his or her own health care?

You have discussed the cost of medication. It seems to me that the real issue here is the use of medication, how this medication is prescribed, giving patients more information on medication, on health professional-issued prescriptions and the use of these prescriptions by patients.

Dr. Morin and I looked at this issue in committee a few years ago. We were struck by the amount of work that remains to be done here. The issue is not just one of the cost of medication but also one of the proper use of medication.

Quite rightly, you refer to the importance of developing primary care and home care. It is my view, particularly in terms of home care, that if we look at this issue from the perspective of developing home care within the well-established public format, we are likely to run into an enormous difficulty.

When I was Minister of Health 30 years ago, we were discussing the development of home care then. Despite all that has been said and done on this issue over the past 30 years, huge needs remain to be addressed. This type of care does not lend itself at all to the public system that exists for hospital care, for example.

It is very important to develop fiscal measures to allow Canadians to decide for themselves whether they want care in the existing well-established system or whether they prefer to get care somewhere else.

As for primary care in the clinic setting, I think that we still have a long way to go. In Montreal, there are some fairly well structured and efficiently organized clinics, but many clinics are not sufficiently organized to allow doctors to work as efficiently as possible. These clinics do not have the support staff they need to develop high levels of productivity.

These objectives will not necessarily be achieved through regulated and structured government programs, but possibly through tax incentives to encourage the development of well-or ganized and efficient clinics.

The Hon. Claude Forget: Mr. Chairman, I submitted a written text to your committee but I will not read it. Instead, I will highlight the main ideas and the reasons behind the suggestions made in this text.

First of all, I would like to congratulate you on your decision to launch a wide-open debate, one without restrictions. I think that it is high time that we set aside political correctness when it comes to matters of health. It has become a type of barrier that prevents us from doing what needs to be done. The Senate is in an excellent position to deal with this very difficult challenge. For some, our health services are a symbol of Canadian citizenship. At any rate, our health care services represent, for everyone, one of the most important aspects of life. Any attempt to change them results in a great deal of concern.

However, I want to assure you that for all the groups interested in health issues and with which I am associated, your work and the direction you appear to want to give it are generating a lot of expectations and hope. Everyone realizes how difficult it is to do what needs to be done in the absence of any clear political signal that changes are indeed possible. Right now, this feeling does not prevail. You have a big role to play. I am pleased that you are giving out signals that lead us to believe that you are in fact going to play this role.

The remarks contained in my text do not cover all of the proposals that you submitted to the public a few weeks ago. Not all of the aspects are equally important. Moreover, it would be unrealistic to believe that we could resolve all the problems in such a vast sector at the same time. I tried to identify two areas that are particularly frustrating. Rather than urge you to be guided by your principles, I tried to sketch out, in as concrete terms as possible, an idea of what the system, which would provide Canadians with all the benefits of the current system but in a radically different way, would be like.

I focused on two sectors which, in my opinion, are problematic: primary care and research and teaching hospital centres, the university hospital centres. That does not cover the full range of all the costs funded by the governments. Each sector represents more or less 25 or 30 per cent of the total costs. Together, these two sectors represent perhaps slightly more than half of the costs. However, the problems found in these sectors are much more difficult and troubling than those found elsewhere.

It would be difficult to be very concerned about health, compared to all the rest, without being concerned about, on the one hand, primary care, primary services, and on the other hand, specialized services. The nature of the concern is very different.

In the primary care area, I can assure you without a doubt, and this is something that you have probably already observed, that there is a very broad consensus in Canada about the need to completely rethink the way we provide primary care. Moreover, you refer to this fact in your consultation document. I think that this is quite true. The solution that is being formulated would be based on two main aspects: rostering, meaning that Canadians would register with organizations providing them with a specific range of services for which they would have a choice and aper capita funding system.

I described such a system in my remarks. I go a little bit further than what I described in the book that my wife and I published three years ago, where we recommended per capita funding.

It seems to me that the per capita funding system, as significant or attractive as it may be, does not go far enough to position primary care where it should be, namely, in a direct relationship with the user or consumer. I propose that we eliminate the government's role as an intermediary. Governments intervene between the public and primary care clients by collecting taxes and returning this tax money for service delivery.

But during this long detour, the user public is deprived of an essential lever, namely, the opportunity to use this economic power directly, which would enable it, by having choices, to exert the necessary pressure in order to obtain the quality and accessibility of services it demands.

Thirty years ago, Claude Castonguay and I initiated, in this province, a reform in which we had placed a great deal of hope: the CLSCs, the local community service centres. These centres were established in Quebec. Significant resources were given to them. According to significant testimony, it is obvious that where these centres succeed in providing services, their role and their contribution are greatly appreciated.

Despite that and despite the fact that these centres developed a type of very loyal client base that believed in them, we are compelled to observe that, 30 years down the line, these centres are not playing, either in reality or in the eye of the public, the role that had been given to them. This is due in large part to the fact that the structures were developed within the public sector, a point alluded earlier by Mr. Claude Castonguay, which put many limitations on their effectiveness and development.

I would suggest a refundable tax credit which would enable Canadians to be on the first line as service consumers. As for financial accessibility, they could benefit from all of the universality provided by the current system, but once again, the government would no longer play the role of intermediary.

My text contains certain details which I feel are essential in order to respond to anticipated objections. I will not delve into these arguments in my verbal presentation.

For many years I have experienced first-hand the problem associated with a second aspect; namely, the management dead end that is restricting the facilities, the institutions that provide high level services. Canada has about 30 or so major third- and fourth-level centres where teaching and research are done.

This is where Canadians expect to have the most difficult and acute problems attended to, but also where they lay their hopes for the scientific and technological advances of tomorrow.

However, it is there, as well as at various government levels, that costs are apparently spiralling out of control. To a large extent, this is where we find the most acute financial problems pertaining to technology, new drugs and intense management difficulties within the public sector.

It is desirable if not essential that we limit rising costs in the health sector. Taxpayers must come to terms with this reality. If promises are made to limit costs over the long term, they will be empty promises given the aging population and the tremendous development of new techniques, new procedures, new drugs and new equipment.

We must accept the fact that costs will rise. To contain costs within a reasonable limit, without doing damage, we must come to the realization that we need to put an end to the current system, where those who are responsible for managing these institutions are deprived of the means to do so. Let us give this matter some thought. We are dealing with a sector where we cannot do any financial planning whatsoever for any management program because, over the past 10 years, the budgets given toadministrators have been totally unpredictable. Not only have they been unpredictable, they have been subject to extremefluctuations, both upward and downward, and often in retroactive fashion. More financial stability is essential.

Furthermore, departments of health in all of the provinces have experienced instability, not only amongst the ministers but also amongst the officials. The number of years of experience of this very complex network within our health departments is constantly declining. We find ourselves dealing with people who must constantly reinvent the wheel, who are working without the required continuity, without any stability in direction. To resolve this problem, the criterion of public administration found in the national legislation should not be interpreted as narrowly as it has been in the past; we must, in fact, put some distance between governments and those responsible for managing this program.

In order to secure this relative independence, I would suggest - this is just one of many possibilities but I think that it may contain many advantages - the adoption of a tax system designed specifically for health.

A health tax system would be separate from income tax. It is, however, the tax best able to provide us with an acceptable financial base. It would become an earmarked tax. This allocation would be integrated into federal-provincial agreements. Given the inflexibility of these agreements, it would provide financial stability, foreseeable revenue and a transparent Canadian tax system as compared to the American tax system. It would become more visible. We would understand better that the high taxes that we pay are because of health, which the Americans do not have to pay for, at least not to the same extent.

We need to give the administrators in this key health sector all of the management instruments they require. Currently, all of the provinces are talking about comprehensive funding. This is, to some extent, a joke in poor taste because the funding provided by the governments is a refund for salaries and supplies.

It excludes capital spending, expenditures for equipment over which the administrators have no control, since such expenditures are left to the discretion of officials or ministers. As such, these expenditures are subject to all the vagaries of the political situation. Planning is, therefore, impossible and, as far as current expenses are concerned, medical fees are deemed to be a separate envelope.

An administrator's objective is to get his or her hands on all of the instruments that will allow an institution to progress. There is always a trade-off between rising operating costs and capital spending, for example, but these are choices that administrators are not entitled to make. They are subject to all kinds of arbitrary decisions. Then, everybody is surprised by uncontrollable costs. How are costs supposed to be controllable when those who incur the costs cannot do anything about them? Once again, this sector will continue experiencing rising costs. We must accept this reality. We need to give ourselves the means to manage this sector much more professionally by doing away with the inflexibilities and artificial barriers that, for historical reasons and without really wanting to do so, the governments created in this sector.

Mr. Chairman, this is a summary of the two sectors which I feel are most likely to be improved. We must bring the primary care services closer to the citizens, giving them the means to have some influence on the system so that it reflects their needs, while at the same time maintaining social equity. Furthermore, we need to give real instruments to the administrators of the 30 largest centres in the country so that these administrators can be responsible, accountable in the real sense of the word, for the resources that society has given to them.

If I may, Mr. Chairman, one final remark. In a presentation that was conceptually different, Mr. Hugh Segal, who is president of the Institute for Research on Public Policy - who unfortunate ly could not be here this morning - asked me, since I had an opportunity to cooperate with the Institute with respect to some initiatives in the health sector, to remember the Institute to you. He asked me to draw two Institute publications to your attention: one is - and this perhaps goes against my natural modesty - the book that my wife and I published in 1998, and the other is a document published in September 2000 which contains recommendations to federal and provincial first ministers who were meeting at that time to discuss health funding.

You will find in these documents - unfortunately, they are no longer available, but we did manage to find you a few copies - most of the ideas that were presented this morning by Claude Castonguay, myself and no doubt a number of other witnesses. There is a consensus about the need for change. Once again, I will close by inviting you to be as bold and daring as possible in your recommendations.


The Chairman: Thank you very much, both of you, for presentations that will certainly spark some questions.


Senator Morin: Mr. Chairman, I would first like to thank our two witnesses. For those who may not know, these two people spearheaded the creation of the health care distribution system that exists in Quebec. Major reforms that were implemented 30 years ago are still being used as models, not only for other provinces in Canada, but also abroad.

One example is the CLSCs, the local community service centres, which are working well in a special context, and a number of other initiatives that have been cited over the years and that are the fruits of the remarkable work done at that time by my two friends, Claude Castonguay and Claude Forget.

I would like to ask Claude Castonguay a question. I completely agree with the points that you have raised: productivity increases and competition. Private insurance would apply to certain private clinics for services that are not available in hospitals.

We also talk about coinsurance when we talk about individual contributions. We talk about the development of private clinics and their advantages, home care based on premiums and tax credits. Home care is used mainly for acute care and chronic care, especially by low-income elderly people. It is that segment of the population that uses home care most. How can we use tax credits for people who do not pay taxes? In those cases, perhaps there could be a government contribution.

In Quebec, we have a pharmacare system that is the best in Canada. It is not perfect. Our system of coinsurance, among other things, is criticized, but it is certainly the best system in Canada.

I would like to hear your opinion about the situation in some provinces where there is a complete lack of coverage, which leads to disastrous situations. This happens in the poorest provinces. In other provinces, the system is a partial one, et cetera. Given the current fiscal realities, how could we set up a pharmacare system that would provide at least some protection against catastrophe for all Canadians, keeping in mind that some provinces are poor and perhaps cannot create a system like the one in Quebec? Does it require funding from the federal government? In other words, do we need to provide a system for all of Canada to protect against high drug costs?

Mr. Castonguay: To begin with, I would like to thank you for your comment about how good the Quebec pharmacare system is. I know that your comment is very objective and not subjective.

I believe that drug insurance is very important. In fact, between 70 and 75 per cent of people come out of their doctor's office with a prescription. In many other cases, medication is the only treatment available for people who can stay in their homes as a result. These drugs give them a certain amount of control over their state of health.

In other words, prescription drugs have become an essential part of health care. So it seems to me that it is illogical to cover 100 per cent of medical care but not the cost of drugs, except in certain special cases. Drug costs have increased so much that they have now moved ahead of medical fees.

To get back to your question, if the federal government were to allocate a part of the funds spent on drugs, it could do so by letting to the provinces take the initiative and experiment or develop whatever systems seemed most appropriate to them. Provinces could learn from each other and develop some experience. Some practices would probably be adopted fewer than others.

In other words, if the federal government were to commit funds to this specific purpose, I do not think that we should at the same time try to develop an identical coverage model for all provinces. In Quebec, for instance, we knew that about four and a half million persons were covered by private plans. In some less industrialized provinces, are there more people covered by private plans?

But in Quebec, the number of persons covered was so high that it seemed reasonable to try to keep this coverage and to give it some kind of framework so that everyone could be treated and belong to a private plan or a public plan, in all possible fairness. That is what we did.

In another province, Saskatchewan, where the economy is quite different, this approach might be entirely inappropriate. The federal government should not try to impose one uniform plan on everyone.

Senator Morin: I read with great interest the book Qui est le maître à bord? [Who is in control?] It deals with internal markets, as well as the health issue as a whole. It has a very instructive set of statistical data.

I would like to raise the two points that you mentioned: primary care and university hospital centres. With regard to primary care, I would like to speak more about the internal markets. In Europe, Great Britain and Sweden, a number of countries are dealing with the issue of internal markets. The issue of internal markets has to do with the purchase of services by organizations which, according to the book, would be agencies. We could also consider teams of physicians.

The current reform of primary care includes organizing teams of physicians, multidisciplinary teams in charge of a given part of the population, who are remunerated on a per capita basis. They cover the entire range of services and they act as gatekeepers. These teams could even enter into contracts with clinics, hospitals or organizations.

Now, in the book Qui est le maître à bord?, these clinics are also indirectly responsible for financing the hospitals or clinics.

The issue I found puzzling while reading this book was the interim period, which could be quite long. We should not think that all the physicians and clinics will be ready to accept this process immediately. The interim period during which there would be funding from the internal markets would create a problem as compared to the traditional way of funding. Could we envisage, for instance, that the regional authorities would be in charge of contacting organizations and signing contracts with them?

I am very interested in this internal market issue, and the committee is also very interested. We discussed it several times. We met economists in Ontario with whom we discussed internal markets in depth. We met an economist from Toronto who was familiar with internal markets in New Zealand, and he discussed them with us at length.

This period where traditional and internal market financing both coexist was the stumbling block. I must say that we did not get any precise answers about this matter.

Regarding hospitals and university hospital centres, there is the issue of stable funding. In the book which I read, Qui est le maître à bord?, we see that wages make up a large part of the costs. Wages are rising more rapidly. The cost of wages for a hospital centre rises faster than for the rest of the population. More specifically, the wages of people not assigned to clinical tasks are increasing substantially. In other words, gardeners are getting raises much more quickly than in private industry.

This represents some 30 centres, a large contribution of 15 or 20 per cent. Is federal funding of the centres possible? One of the reasons why I am thinking of federal funding is that these centres have the main responsibility for research in Canada.

Mr. Forget: In my opinion, the issue of internal markets is central to our discussion. If markets are to work, first of all we must have entities in these markets that are ready to operate according to the laws of a certain market. Yet when it comes to primary or even secondary services, our networks in Canada do not currently have players that are organized and willing to play this role. That somewhat determines the answer to your question. Before allowing or considering the possibility of groups of physicians purchasing the services of community hospitals in a market that has been organized in this manner, groups of physicians must first exist for that purpose and must be willing to be entrepreneurial. That is where the whole problem lies. We must take one step at a time.

In my opinion, first we must have groups of physicians representing the clients as the main players, groups of physicians that are willing to play that role; at present, this is not the case. This is something I learned from the reactions to our book three years ago: for the past 30 years, the Canadian medical profession has operated within a public system.

The profession initially resisted the introduction of a public system. But the people who were born, so to speak, at least professionally in that public system really like the comfort of the public system and do not appear to be interested in taking on risk and becoming managers.

On an intellectual level, they certainly see that if they had the resources to do so, they would be able to play a far more active role advocating for their patients. Even so, this means taking on an additional responsibility. Some time will be needed to convert them to this new role. I am not saying that there is universal resistance to the notion, on the contrary. Despite everything, some habits have been lost, if ever they existed in the past, and they have certainly not been acquired.

First of all, we must have primary care groups and they have to be in the right context. I am slightly worried about the coalition in the public institution sector. As you said, we still have the concept that a group is to be created to serve a region.

So we create local monopolies. If the concept of internal markets leads to the creation of monopolies, obviously we are going down the wrong road. At the outset, we abandoned the concept of internal markets for an administrative, bureaucratic concept. And we know that this bureaucratic and administrative concept to manage the services has been a failure, not an absolute failure, but a relative failure in light of the legitimate expectations of the public.

The possibility of creating internal markets will eventually be the solution. But to get to that solution, we must create incentives. That is why the incentives can be within a system that provides resources to patients who benefit from a per capita approach or a refundable tax credit.

By the way, a refundable tax credit even benefits those who do not pay taxes since it is refundable. It is set at a certain level, which results in a payment if it is not used to reduce the amount of tax owing. I believe that is the initial phase.

Without taking too much time, I would like to touch on the issue of wages. In nearly all countries, the inflation rate within the health care sector is higher than the inflation rate within the general economy. Some of the additional resources invested in health care are not used to improve services but rather to increase the compensation of people working in this sector. We have seen this at all times, and even recently when governments invested additional resources.

Should we be upset about this, or is this normal? To some extent, it is normal, for the following reason: We want to attract a greater proportion of the labour force to the health care sector over a given period of time. And we are trying to do this at a time when quality of life issues at work are important, because the health care sector gets very bad press nearly every day.

When you hear nurses or doctors on television every night or nearly every night at some times, saying that they are swamped, exhausted and on the edge of a nervous breakdown, obviously the young people who are considering these professions will think twice.

There are spots going empty in Quebec nursing schools because we cannot convince people that nursing is a good career. To make up for this problem, we need changes in the organizational culture. But we will have to accept that these very demanding professions offer compensation that will grow more rapidly than in other sectors.

This is part of the equation. It is normal. We will have to go beyond merely offering more money in some cases. For example, when the role of nurses is defined, the whole issue of gender in employment is extremely important, because often the doctors are men - although that is changing - and the nurses are women. We see some tension in these areas because these institutions have not changed with the times. This adds to our problems.

Yes, there will be financial pressure. It is a shame, obviously, mainly because of the principles of public administration. This sector is very unionized, very rigid, and there is an enormous upward pressure on costs in comparison with other sectors of the economy.


The Chairman: That was a perfect introduction to our next questioner, Senator Pépin, who, in her previous lives, has been both a nurse and the President of the Advisory Council on the Status of Women.


Senator Pépin: Senator Morin discussed some issues that are of interest to me. Mr. Forget, when I listened to you speak about nurses, wages and the work environment, I must say that after making several visits in the course of a few days to a hospital to help a friend of mine who is ill, I thought I was on a construction site, not in a hospital, if I think back to the days when I was a nurse. You say that women are invading medicine, but in gynecology and obstetrics, 38 per cent of the doctors are women.

Recently I read an article in which a doctor said that he had no idea where we were heading because there are more and more women in this field. They must stop working to have children and take care of their families. He said he was very worried about the direction the profession was taking. I would ask him another kind of question about this.

You mentioned the bureaucrats and administration of the health care system. I wonder. You touched upon several points: the bureaucratic administration of the health care system and the high number of doctors. I was wondering whether we could not organize the system differently. If you had people who work in the health system, not just public servants, bureaucrats but doctors, nurses, and other workers at various levels, things would be easier. If it was decided to reduce a particular program, a doctor, a nurse or a social worker could say, "yes, but if you cut that way, this is what the side effect will be." I wonder whether we should not be working with a multidisciplinary team. The public servants know all about administration, but they have not worked in a hospital with sick people; we are working with human beings here. Moreover, we know about all the problems caused by the aging population, so we will have to make a very serious decision. When we are composing an independent team that works with the health administrator - I will ask the question off both witnesses - I wonder if we should not have people from different disciplines. Both of you have far more experience than I do.

Mr. Forget: You are right, and the opposite problem also arises. Doctors and nurses hold management positions in our hospitals.

Senator Pépin: They are not part of the decision-making process.

Mr. Forget: They are involved in the decision-making process. These organizations are very difficult to manage because of their complexity. They bring together different groups of professionals who cooperate, but there are often professional rivalries, with unpredictable funding that is often arbitrarily cut. These are difficult management issues.

Are doctors, nurses or social workers in a position to take on management roles? It is often said that a multidisciplinary team is a good idea, but it just means bringing together people who do not know how to manage.

Senator Pépin: No, they must be with people who do know how to manage. I agree with the principle.

Mr. Forget: And it is not impossible to remedy. We must make sure that people who take on administrative functions receive some training. I think you are right. We must look at having these people participate. There is a lot of rigidity, many matters are decided, once and for all, without the consent or the participation of the people who will have to make decisions. In the hospital context in Quebec - perhaps the same is true elsewhere - many decisions on how these roles are defined are made in accordance with the act and the regulations. We are unable to adjust to the individual abilities of these people. No one in a facility has the authority to say: this individual has this responsibility. He is overwhelmed by certain events. We will redefine his tasks based on his abilities. That is not possible.

So it is a one-size-fits-all approach. Everyone is supposed to be interchangeable. Treating people like interchangeable pawns shows a complete inability to manage. Individual characteristics and talent no longer count.

Senator Pépin: I agree with you. Hospital administration requires good officials. Decisions must be made with people in the field.

Mr. Castonguay, I fully agree when you say that the system does not encourage innovation. We have begun to realize this more and more since we started our committee work. That is probably one of the reasons why we are exploring other avenues.

You talked, among other things, about the use of medication. Following Senator Morin's questions, you talked about using medication properly. What did you mean?

Mr. Castonguay: Dr. Morin and I were members of a committee and we dealt with this matter in detail in our report. Dr. Morin could at some point provide you with that part of the report. There are three or four components to the question. Often, people do not follow the directions regarding dosages on their prescriptions. They receive a prescription from a doctor who tells them to take the medication for 10 days. They stop taking it after five days.

Senator Pépin: That is true.

Mr. Castonguay: Quite often they go to see a doctor and get a prescription, and then they go to see another doctor and get another one. They have a friend who has one type of medication and they manage to get the same one. Some medication causes adverse effects when it is taken at the same time as another.

More often than not, when they go to see a doctor, they also expect to get a prescription. If the doctor does not give one, they feel the doctor has not done his or her job. People must be informed and educated. In many cases, medical problems can be resolved not by taking medication but by a change in lifestyle. People do not eat properly, they smoke too much or they drink too much alcohol. In all cases, for all kinds of causes, there is a clear problem with information.

Some doctors prescribe medication according to what is in. Systems are gradually being put in place to compare doctors' prescriptions to what could be considered standard practice. There are some rather significant variations. In some cases, doctors overprescribe medication. In others, they underprescribe. The variations in the way medication is prescribed can be quite worrisome.

There is a series of issues regarding the use of medication. In my opinion, they should be addressed in a more organized way than they are now.

Senator Pépin: You talked about individuals' freedom of choice, about citizens' contributions. For some time now, we have been hearing talk about insurance for seniors. We have heard about insurance where citizens, young people in their twenties, could start participating in a fund. They would invest money in the fund and when they reach their golden years, they would have enough for any treatment required.

Mr. Castonguay: Yes.

Senator Pépin: In fact it is a similar approach. We are studying various aspects. Most people have questions. Many years ago, 40 years ago, when I was in nursing, just before the introduction of medicare, people wondered if those who did not have money would be treated or what would happen to those people who could not participate. You propose taxes, tax cuts, on so on. How can we deal with people who do not have enough money to pay?

Mr. Castonguay: If I understand you correctly, your question revolves around the old age insurance project.

Senator Pépin: I do not want to play politics, but yes, it is one of the approaches that is being proposed.

Mr. Castonguay: This approach was dealt with for the first time in the Clair report in Quebec, then in Canada. The description is not very detailed. Moreover, if taxes were relatively low, in Canada and more specifically in Quebec, we could consider this approach for problems in the medium and long term. It will take some time to set up a fund that would work.

Senator Pépin: Several years.

Mr. Castonguay: I imagine that people with no income, in the minds of the people behind this idea, who do not have enough money to contribute, would be covered. With this type of universal system, those who have the means pay premiums, those who do not have the means do not. This idea, in the current context, is perceived to a large extent as a way of levying additional taxes. So it is not the type of system we are going to see in the short term. There is too much resistance to the idea in my opinion.

Senator Pépin: It should not apply only to certain groups of people, either.


Senator Robertson: Mr. Chairman, I have been listening rather intently here. I thank you, gentlemen, for coming here today. It gives us more confidence as we pursue this task that we have before us, shall we say. Let me continue where we left off with the previous senator, please.

You mentioned, Mr. Castonguay, that 4,500,000 Canadians were covered by private insurance. In a drug plan, do you see it that those of us who are covered by private insurance would continue with our private insurance? Are you suggesting that there would be those who would choose - and could afford - private insurance, with another type of insurance for those who could not afford it - and there are Canadians who cannot afford private insurance. In other words, there would be three categories, as I see it?

Mr. Castonguay: No, the way it was done, actually, was that we had about 4,500,000 people covered under group insurance plans, and their prescription drugs were covered to a certain extent. We decided that we would not touch that, and that we would rearrange a number of public programs to cover older people, to cover people with certain types of sickness; that we will integrate these public programs into one, and we will make sure that the private coverage is subject to certain constraints. For example, an employer with group insurance must cover prescrip tion drugs, and an employer cannot exclude from the coverage a person because of his or her state of health, or health condition. Thus we established a certain number of safeguards to make sure that the private coverage would attain the objective that was sought.

We then have two systems, actually, functioning in parallel: a public one, financed by contributions paid by people through their income tax, and a series of private programs paid jointly, as a rule, by employers and their employees, as is the case elsewhere.

The main problem with this approach, in my opinion, is that the public part of this overall scheme covers more aged people by definition, and the cost is increasing more rapidly because there is a concentration of older people who use much more prescription drugs than do younger people. Thus perhaps some adjustments will have to be made to transfer part of that extra burden to private plans, or some other approach.

Senator Robertson: You see, then, a public/private mix of insurance in that instance. Do you see, in our health care system, an opportunity, or do you think it would be feasible to have a blend of public and private financing in other parts of the system?

Mr. Castonguay: We have at the moment such a plan. Actually, about 30 per cent of the overall cost of health care services comes directly from the population. When we look at the situation overall, and we see that the public system is not capable of meeting the increasing demand, I believe that we must look at other ways, and this is why I was speaking of the freedom of choice of people to try to get, at a more opportune time, some health services through private channels, and by themselves paying for these services.

Senator Robertson: Perhaps I did not phrase my question properly: I understand about the 30 per cent, and I really am relating to the 70 per cent now. Is there more opportunity? What I am getting at is that a number of companies have public and private plans. Do you see the Canadian structure moving in that direction within the next few years, rather than staying just the way we are now?

Mr. Castonguay: Very well.

Senator Robertson: - so that there is more choice, and to perhaps get more availability of services. Do you see an opportunity for a continuing growth in that direction?

Mr. Castonguay: In the European countries there are all sorts of approaches. There is not a single one, I believe, that is predominant. Some of the approaches that have been taken are very interesting, but they were devised in accordance with their tradition, their culture, the way in which their institutions have developed. Therefore I do not think that we can copy what has been done over there in Europe.

However, we can definitely see for the future more of an involvement of methods of production, of services from the private sector being developed, and also people paying, not only through their taxes but voluntarily, more for the care that they need. I believe that this direction is inevitable when you look at the way in which the cost of health care is increasing, and the pressure on governments from other sources to maintain taxation at a certain level. We are an open economy, and the fact is that, even now, governments cannot meet the increasing demand and increasing cost of keeping the public systems in place, and they have not been able to do that for a number of years.

Senator Robertson: I have a question or two for Claude Forget. It is interesting that you mention your two major concerns: primary care and the university teaching hospitals, the centres of excellence, the centres of research, et cetera. I did not quite understand, but are you looking at those teaching units, those research centres, as perhaps being pulled out of the system and funded separately by the federal government? Is that what you are, perhaps, thinking about?

Mr. Forget: Senator, that is a very good question. In fact, to be totally honest, I have not considered whether that should be the case or not. My intent was to basically say that we have a limited number of these tertiary care centres that are the focus of this increasing cost of new technology, and so on, and we have just got to make them more manageable. Now, does that require pulling them away from the general system or not? Certainly, it requires pulling them away from primary care, because the other recommendation is to maintain not the public administration but the public financing only, so to speak, through a refundable tax credit. Certainly, then, primary care would be out of it.

Whether community hospital types and extended care facilities should be lumped together with teaching hospitals is a possibility, but it is not terribly important. If you look at extended care facilities, nursing homes and community hospitals, this is not where our problems are. The status quo, I believe, would be quite acceptable. Eventually, many of these institutions, if we do develop an internal market mechanism, could become providers of services to primary care units. However, I do not think that we can realistically envisage this in the short run because, again, there has to be an active ingredient in this internal market mechanism to make that work, and I do not think that could exist in the short term, or even in the medium term.

I would say that, for the rest, the status quo is fine. It does not seem to present many difficulties. This is not where big budget deficits emerge; this is not where there is this tremendous crush in emergency facilities, and so on. Things are working reasonably well, and I would say that "if it ain't broke, don't fix it" in a sense?

Senator Robertson: But with your tertiary care centres, your teaching hospitals, et cetera, there may just be an opportunity there to send some of those 30-some units, or whatever they are, out for federal funding. It might get the federal government...

Mr. Forget: Federal funding?

Senator Robertson: It might give the federal government an opportunity to say, "Hey, we fund that", because they are always looking for something to hang their hats on.

Mr. Forget: Yes.

Senator Robertson: And rightly so.

Mr. Forget: I realize that I did not answer the question from Dr. Morin, either. Also, I have tried to keep away from federal/provincial issues.

The Chairman: All of us around the table are sympathetic with that problem.

Mr. Forget: In my opinion, these federal/provincial issues are very contentious; they are very divisive, and it seems to me that they jumped the gun in the sense that we must know what it is we want to see our Canadian health system evolve into, and then try to apportion roles between the provinces and the federal government; not the other way around. If you start from an aspiring role for this or that level of government, the tool becomes the goal. In my opinion, that is inappropriate. I think that we have enough problems in the health system with trying to solve the health problems in the health system, and we should let these intergovernmental fights take their course. I have no presumption of even having wise thoughts on the subject.

The Chairman: May I say, sir, that you have not lost any of your political skills in answering questions.

Senator Keon: Let me first say how much I enjoyed listening to both of you again, and the wonderful contribution both of you have made to the health field over the years.

Let me start with Mr. Castonguay. I want to bring you back to the CLSC. The whole subject is very interesting. My brother, who was a family physician, was practising in western Quebec when the CLSC was introduced, and I recall sitting at dinner with him, and he had such enthusiasm for it. He said "You know, I was spending close to half my time doing social work, and now I've got a social worker who takes all that off my hands, and I can practice medicine, and it's a truly great idea." Unfortunately, he died prematurely of cancer, and I have not had the feedback that I would liked to have had about the system.

The thing I have never quite understood is why this concept did not grow and spread across the country, because to me it seemed like such a wonderful idea for the development of the primary care piece, with which the whole country has struggled, and which has never really developed in the way it should. It is true that there were things wrong with that system, for example with physician remuneration, and so forth. However, I am at a loss to understand why it did not grow and develop, and spread across the country. Can you tell me why you think that is so?

Mr. Castonguay: Senator, I can make some comments as to what has happened in Quebec, as far as I can tell. It is difficult for me to make any comment about the other provinces since I am not close enough to their situation. However, here in Quebec a number of factors have contributed to what the CLSCs are doing now, and how they are seen by the doctors and the population.

First of all, a good part of the medical profession reacted quite negatively to the concept. Initially, they did not want to go into the CLSCs, so they developed a number of clinics in reaction, actually, to the CLSC plan. I think that was not all negative. On the contrary, the creation of CLSCs put some pressure on the doctors to become a little better organized, actually. That, then, was one factor.

Another factor was funding. The CLSCs are financed strictly through public funds, and on account of the constraints on the financial resources available, quite often I would imagine that some CLSCs could have developed some services that were greatly needed, but they did not get the funds that they needed to do so. Thus it is understandable that some people would not find within that system a satisfactory range and level of service.

Another factor I think that contributed to their unpopularity was availability. The personnel within the CLSCs are all members of labour unions, so as a rule, CLSCs were open from 8 a.m. to 5 p.m., that sort of thing.In the evening or during the weekend when people were not at work, when they could have attended at an CLSC, they were closed. Accessability was definitely another factor.

In addition to that, at the beginning some of the people in the CLSCs saw the social services or social action as more important, actually, than the medical services, and they got involved in "des revendications," or social representations. Again, that kept some people, including a number of professionals, away, I would think.

Thus you have a combination of factors. Notwithstanding those factors, however, as Claude Forget has mentioned, some CLSCs have developed and provide obviously very efficient services, and I would say that they have concentrated on and have had much more success with respect to education, prevention, some social services at home for people, that sort of thing. However, the medical services component has not developed to the same extent.

Senator Keon: Mr. Forget, I want to take you down just a single path. You tossed out an idea which we hear about from time to time; an idea which gets tossed out and then does not go anywhere, and that is the tax plan for health.

In discussions with my American friends, if there is one component of the health system in Canada that they will say is so much better than theirs, it is the single payer. They would say, "We are paying a 30 per cent overhead for all these insurance companies, and all this paperwork, and all this other stuff, and you guys are saving 15, maybe 20 per cent just because you have a single payer."

If we had a tax plan for health, frankly, I think it would be a great idea. I can remember back when people paid their health premiums and this kind of thing in Ontario, for example, and it seemed to be all right; the premiums were going up, and so forth. I never quite understood why they stopped that system and just incorporated it into the one big sump of money.

If we had a tax plan for health, do you think this could be a comprehensive financial plan for health? If it were, it would introduce a very high measure of accountability that we do not have now; financial accountability. I believe the public would want to know where their various payments went, and what percentage goes for what, and so forth.

Would you expand on this idea a little bit?You just threw it out and you did not expand on it. Would you run the risk of being careless and expand on it a bit?

Mr. Forget: May I ask, when you say a "tax plan", you are referring to an earmarked tax that would go to health?

Senator Keon: A health tax.

Mr. Forget: And you are questioning whether that would lessen the public accountability?

Senator Keon: No. I think it would increase the public accountability, but I just do not know if we could introduce it across the country. You mentioned that it would have to be by way of federal/provincial agreements, and so forth, but if a portion of our tax simply went into a comprehensive budget for health across the country, we would have a measure of accountability because we would know what is coming in and what is going out.

Mr. Forget: Yes.

Senator Keon: How do you think that could work? How do you think it could be introduced? Where would research funding come from? Where would academic funding come from? Where would health care funding come from? Where would some of the social services that Mr. Castonguay was just talking about at the other end come from? This is the kind of stuff I want to know about.

Mr. Forget: Senator, to the extent that I may not fully understand the implications of your question, I would say that essentially you need to agree on an envelope for the cost represented, and that is strictly dependent on the definition of what you want to cover. I suppose, however, that that is a factual issue, and it can be established.

Then I suppose that you need federal/provincial agreement. Perhaps it would facilitate federal/provincial agreement if, instead of Ottawa saying, "We are giving this money to the provinces, but we don't know exactly where it's going," and so on, we announced that we are basically pulling back some of the federal income tax, and that there will be a pull-back also on the provincial side; that we know the proceeds of that pull-back will be used jointly to fund health care in each province, managed by an agency with a legislated mandate to cover what could correspond to the definition of coverage, with the need to account for what it does, and have medium term plans, and so on.

I would say that that would require a great deal of change in the way both provincial governments and federal governments address their responsibilities, but I think it would increase accountability, it would increase transparency, and would certain ly provide the managers of the health services a greater measure of predictability. In addition, it would be all-encompassing, in that they would have all the instruments they need to achieve their objectives, and they could be subjected to certainly report on performance, on a long variety of some objectives, if you will, and so on.

It would be a complicated thing, but the present system is very complicated. If we had to start from scratch today, we would be amazed at the complications we have gone through. Perhaps it is not more complicated, I do not know, but I would say it sounds to me like something that is feasible if the political will were there.

In addition, I see very little down-side except the cost of transition, of course. When you have to negotiate and re-think the way things are managed, the cost is not inconsequential. However, I think the prize is worth the candle if you have something like that, because it has a potential to serve not just the purposes of the governments involved but the purposes of a better management, a more comprehensive approach, more sustainabil ity.

Obviously, from time to time, people would say "With this definition of coverage, obviously the agencies are not in a position to do it all. Their performance is acceptable, and so on, but obviously they are running out of resources".Thus, from time to time, it would have to be readjusted. There would be a debate. It would be a debate that would have more formality to it than the present pre-budget, secret tug-of-war between the ministers of finance of various jurisdictions and the Minister of Health. It would need to be a federal/provincial agreement but it would also nened to cover a number of years so that it would be a sort of step-by-step progression.

We should not lose the single payer phenomenon, because I do not believe, frankly, that Canadians would accept from the public coverage, that we should move away from the public coverage, at least with respect to the upper tier, the high-risk, major catastrophic sort of coverage that you have to envisage with tertiary and secondary care. I would tend to agree with that view Any other formula with private insurance and so on is so complicated and beset with so many problems that I do not think that route offers any advantage.

Let us face it, there may well be abuse of the system at the primary care level. What I mean is that people may consult too much for colds and things, and they would just be better advised to sit at home and take an aspirin. That is possible. However, I do not know that we can document that. Certainly, people do not go in for major surgery just on a whim. Perhaps it is not appropriate all the time, but the best professional advice is that this is what they have to do, and they do it, and the personal cost in terms of trauma and anxiety is such that it is much more than the deterrent effect of co-insurance, or anything like that.

Therefore I do not believe that we should move away from the single payer, but maybe we should reorganize the single payer so that it is not also undermining the ability to manage the system efficiently, as it is now.


Senator Maheu: Mr. Forget, you mention tax credits often, and Mr. Castonguay mentioned CLSCs. As for me, I see dollar signs. Governments in the country are saying that they do not have enough money for health care. The federal government is saying that it does not have much money if it wants to pay down the debt.

I often hear middle-class Canadians say that they will no longer accept tax increases without revolutionary change in the various levels of government.

Have you thought about funding arrangements for all of these additional requirements, approaches that do not affect middle- class taxpayers? In your opinion, is it a question of the choices governments make? For example, I heard about the New Brunswick government that, at the time of Premier McKenna, did not have much trouble funding health care. It had fewer problems than others with health care. Did it make choices that were different from those of the other provinces? Is this something we should really look at?

Mr. Forget: Yes, you are right. It is a problem of choice, but on two levels. First of all, there is the problem of choosing the funding arrangement. To speak in round numbers, let us say that Canada currently spends $90 billion on health care. Governments spend $90 billion on 30 million people. I am rounding the numbers off, so approximately $3,000 government dollars are spent annually for every man, woman and child in this country.

About 20 per cent of these expenditures are for primary health care. The government can continue to tax 20 per cent of $3,000, or $600 per person, and using a public administration mechanism, spend this $600 per person through regular channels to fund primary health care.

We know that there is a taxation dead weight. People who have studied the importance of taxation say that out of the$600 collected from taxpayers to fund primary health care, more or less 30 per cent is lost one way or another, either through administrative costs, or economic costs related to higher taxes than if the $600 were not collected.

There are significant costs associated with using a tax measure. The choice is to say: Instead of collecting the tax and subsequently spending, let us let people pay a premium and deduct it from their taxes. That would reduce, as it were, the fiscal levy. So you are giving to individuals, even the ones who do not pay taxes if it is a refundable tax credit, without spending another cent, I would even say by spending less, by reducing the size of government and the tax base.

The choice of funding arrangement does not change in terms of distributive justice, but makes it possible to channel resources in a different way. But by doing so, the expenditures that would be subject to a tax credit would have to be very clearly defined. It would seem that the discussion that is underway in Quebec on drug insurance, on insurance for a loss of autonomy or old age always runs into the same phenomenon: How do you add an additional tax on taxpayers who are already so taxed and who already have the impression, because of ambiguous definitions, that the services to be covered by the new tax are to some extent already covered?

It is as if no one ever wanted to clearly define it. A lot of ambiguity has been maintained around the issue. You could even say today that a senior's loss of independence is covered since the Quebec government has reception centres and claims to have enough comprehensive home care services, et cetera. Theoretical ly everything is covered.

The only new aspect would be the tax. The lack of definition that is maintained the current situation is such that new sources of revenue - in the form of a new tax or insurance premium - are impossible to consider politically. People say: Look, no, the only thing that appears new is the taxation aspect, not the coverage. It was never defined because we did not want to admit that it was insufficient.

It is clear that if a tax credit is used, the notion should be clearly defined, otherwise, managing the system will not be possible. It should be clearly defined. That is the difficulty in changing the funding. That is why your two questions are linked. There is a choice with respect to funding and coverage.

Since we have always hesitated to clarify the definition of coverage, for clear political reasons, as a country, politically, we have been forced into a situation where we are unable to move on funding. That is the vicious circle we must break.

Senator Léger: This is the first time I have participated in hearings. You said, Mr. Forget, that young people in school were less and less interested in being nurses or doctors because emphasis is being placed on entrepreneurship rather than on human beings.

I understand that we need short-term answers. Everyone is aging quickly. In the longer term, our discussions could focus on the fact that entrepreneurship exists because we need to take care of human beings. We need taxes. When you talk to ordinary people, the human factor needs to be the top priority.

It is as if the human factor used to be the priority and there was not enough entrepreneurship. Emphasis was put on entrepreneur ship, and now we no longer talk about the other aspect. Can we go back to focusing only on the human factor? No, that is clearly no longer possible.

Mr. Forget: Yes, it is a good starting point because the evidence is in the right place. You are quite right. I believe that our discussions on health reflect too defeatist an attitude regarding the human factor and instead place too much importance on financial aspects. This is an important problem.

The example of Germany and France, which certainly have high tax rates, is an interesting one. They are making a greater effort in the health field than Canada and a number of other countries. But there are no waiting lists in France and Germany. If there are, they are much shorter than they are here.

Are Canadians prepared to make much higher financial sacrifices in the future? You are quite right in saying that we need to deal with this question directly. Is it the financial considerations or the human and social considerations that should take priority?

There has been a little too much temptation to listen to the various ministers of finance over the last few years and to not listen closely enough to public concerns. I believe that if we need to keep taxes high, Canadians are prepared to tolerate that. However, they want it to be done properly, to see good management, et cetera, and that is clear.

Basically, I agree with you that this debate cannot be ignored. If Canadians want to keep everything and even make the system better, they are going to have to agree to pay more.


The Chairman: Thank you for that comment. It simply reminds me of the fact that all governments have talked about cutting heal however, however,th care expenditures for the last several years but they have never talked about rationing the supply of health care services. Of course, one is a direct consequence of the other, but it is not politically feasible to talk about rationing health care services, a move for which there would be no support. However, there would be considerable support for cutting taxes.

One of the things that we clearly must do in our subsequent reports is point out that one cannot avoid those two issues being integrally intertwined, for exactly the same reason that you mentioned. I suspect that if anyone did a public opinion poll and, instead of talking about cutting taxes, talked about rationing health care expenditures, you would get a totally different result in the public opinion poll than you would normally get.

May I say to the two of you, thank you very much for coming. We are truly honoured, frankly, to have had the two of you come this morning and share your views with us, and to take the time to prepare the material you did. Thank you very much.

I say this to our witnesses, I appreciate the fact that we are running over time. The problem is, as you can appreciate, when you get two witnesses with the experience of the previous two speakers, that inevitably happens.

Senators, we have received a brief from the next two witnesses. They have both been asked, obviously, not to read the brief into the record. We are quite capable of doing that for ourselves. Instead, we have asked them to hit the highlights, because, as you can see - and I noticed that both of you have been here during the last session - we really like to get into questions and answers as opposed to just following briefs.

Therefore I will ask Dr. Serge Boucher from Hôtel-Dieu in Quebec to begin, and then we will hear from Professor Contandriopoulos.


Dr. Serge Boucher, Hôtel-Dieu Hospital, Quebec: I would like to thank you for inviting me. I see that I am the only active clinical doctor representing a whole category of health workers. I am pleased to present here an overview of the document that I sent you. I will read it in French, if I may, and focus on the main points. After reading your document which, I must say, is very well done, very detailed, I would like to make a few points that I feel are particularly important.

Generally speaking, when we look at the health system in Quebec or in Canada - it is more difficult for me to talk about the other provinces, since I do not know them as well. I have worked in Ontario, but I live in Quebec, and so it is difficult to really know the other systems.

Basically, people want to have access to the system at the lowest possible cost. Over the past few years, this does not seem to be what has been happening. We have seen some deterioration. That is also no doubt why you have a committee working to find solutions to the problem.

Let us get right to the point. If we look at how resources are allocated, two approaches have been proposed to make the system more effective. On that point, I would echo to some extent what has already been said: Where would we be if all the generals had been effective?

One thing that we have to make sure to do is to continue to maintain an effective system. Right now, despite everything that the experts have tried to do to improve the system, it is not working as well as we would like.

I would definitely favour the second solution, that of additional funding coming not from the State but from individuals, since government funding obviously comes from individuals anyway. So I would favour the second approach.

Regarding the changes suggested in the first line, I have a lot of reservations and concerns about some aspects of that. There are basically two aspects. CLSCs were mentioned a little earlier; in the United States, these are called Neighbourhood Health Centers. In Quebec, they were hailed as something new when they were set up.

In the United States, 1,100 of these centres existed in 1930. It is not a new idea and these centres address a particular need. I will not come back to that unless I am asked specific questions on it. I would simply mention, with respect to the teams proposed to meet people's various consultation needs, that a team approach is not necessarily required.

If you have conjunctivitis, a cold, a respiratory infection, et cetera. you do not need a team complete with social worker, psychologist, on so on. That is what a structure like a CLSC has, in many cases. It is very difficult to get to see the doctor, as has already been mentioned.

Moreover, changes take place within these teams. Doctors and nurses are increasingly difficult to contact. As a result, some people have been placed outside the system. Practical nurses, orderlies and a lot of others offer excellent services but are now excluded. Once again, I refer to this in the document that I provided to you. If someone suffers from paralysis, paralytic sequela, and needs to eat, I do not believe that five years of training is needed to be able to help that person. We must make sure of one thing: all the various health professions are trying to improve the level of knowledge of their members. That is a worthy goal. That said, we need to focus on what the public wants and needs, and that is basic care in particular.

At present, there are severe gaps in this area. There is also the economic aspect which is very important. Once again, I am not saying that we should not strive for excellence, for there are costs involved.

For someone who has difficulty moving around or eating because of paralysis or because of age, receiving care from someone with a doctorate is a fine thing. But as long as the person gets help to be able to walk, that is what really matters. Often the people who are trained to do this work and enjoy it are much happier doing it.

Senator Léger was wondering about the human aspect. In general, I have noticed in the past and see every day, since I am a practising clinical doctor, that these are often the people who are closest to the patients. We can come back to that if you like.

With respect to where the funding should come from, there is the idea of user fees. I have reservations about that idea, since user fees entail administrative costs and can have an impact on a particular segment of the population. I would add that if the decision were ever made to apply user fees, they should be strictly limited to front-line care.

There could also be parallel resources, such as private hospitals or modern structures. I am talking about MRIs or other types of care. A democratic system embodies the concept of free choice.

The Americans, in their Constitution, affirmed that democracy meant protecting citizens against the State or vis-à-vis the State, if you prefer. That is perhaps less aggressive.

Do people have a free choice? Can they be treated within a reasonable amount of time? Do they have access to the system? I do not believe so. Things will not improve in the years to come unless we change the system. People must be given a free choice.

Thirdly, there is the HMO system as found in the United States. It is said that, in Canada, we have ten HMOs, since every province has its own system. This would be another way of viewing this approach.

There is a whole range of approaches. I hesitate to use the word insurance because as soon as you set foot in Canada, you are insured for everything. You have hospital insurance, health insurance, accident insurance, employment insurance. Now we are talking about old age insurance. It is very difficult to not be insured and to live in Canada. This is a fortunate situation, but there is a limit to this type of thing.

The other aspect would be to have, for instance, health insurance. In my document I referred instead to illness. This subject has perhaps been raised before or the witnesses that you will be hearing later on may mention it. We could set up a fund in which people could invest their money. They could then withdraw money from this fund, bearing in mind front-line care and maintaining a reserve for catastrophes. If you are hospitalized and have $2,000 in your fund, this money could be used, regardless of whether it comes from you or the State, for front-line care.

If I call my accountant or my lawyer, I am fully aware of the fact that I will be receiving an invoice on Monday morning, the following week or in a very short, usually too short, period of time.

If the person does not touch the reserve fund, he or she will be paid interest, an aspect that will be dealt with by someone who will be presenting this afternoon I believe, and this money could be reinvested in a retirement savings fund.

As we all know, in Canada we are lagging far behind certain countries such as Denmark, England or the United States in the area of registered retirement savings plans. This situation has resulted in significant concerns about what will happen in the future, when people retire at the same time.

To conclude, one of the major problems that we all appear to be dealing with, without really realizing it, is the fact that we talk about health insurance. I will instead be talking about sickness insurance. You may recall that we initially did talk about sickness insurance. Now we talk about health. I am responsible for my health. As a pneumologist and as someone who is sports-minded, it is not in my interest to smoke, I have never felt any desire to smoke. I can therefore claim no merit, if you like.

Health is up to the individual. It is the individual who decides to become obese. It is the individual who decides whether or not to smoke. It is also the individual who decides whether or not he or she should exercise. Should the State intervene? Should the State compel the individual to do something? It is very important that we pinpoint accurately what the State can or must do; namely, looking first of all after the illness. As for health, we can give information. We can really focus on the objective pursued by the State and by the system that we have implemented.


The Chairman: Thank you for that interesting and provocative opening statement. Let me also say that there is a huge similarity in some of your ideas with some of the ideas that Claude Forget put before us earlier.He was talking about refundable tax credits, and you are going a different route, but the goal is the same.

Professor Contandriopoulos?


Mr. André-Pierre Contandriopoulos, Professor, Université de Montréal, Faculty of Medicine, Health Administration: Mr. Chairman, I am a professor and researcher at the Université de Montréal University, I am an economist by training and for the past 30 years or so I have been working almost exclusively in research and training in the area of health. I have participated in various studies, and I was a member of the National Forum on Health.

I do not want to read my brief. I will let you, to some extent, try to determine, as you are doing, the reasons why our health care system must be changed. In Canada we are facing a difficult situation. We must decide whether, as a society, we want to take the necessary steps to ensure that our system once again becomes one that is admired throughout the world for its ability to take the human dimension under consideration, to react to the needs of people in a manner that is universal and adequate, or to allow our system to head off in the direction taken by our neighbours to the south, the so-called insurable system.

Canada is at a crossroads; if we let things go, in 10 years, the legislation protecting Canadians from the introduction of a private plan within the system will no longer exist. They will no longer have any support. If not, the system will be changed.

I find the issues of transformation interesting in our report. Our document contains ideas pertaining to this issue. The first idea, which I feel is quite fundamental, is that health is not an organization like any other. Health care systems in all of the developed countries of the western world were established in the 40s and 50s. These institutions reflect the values of the societies in which they were implemented.

In the western world, a type of accord was reached in order to, as Senator Léger was saying, deal with the aftermath of the Second World War in order to protect human beings in all of their dimensions. As a society, we invested in health, education and social protection. Our health care systems reflect the way we chose to organize this concern with respect to each and every one of us.

At the very start of your summary, you said that we need an objective approach. I can no longer agree with this. Moreover, when you talk about having the same ideology, I am no longer in agreement. When you talk about the health system, you have no choice but to be ideological. You cannot talk about the health system without referring to very basic values: equity, freedom, efficiency. We have jumped with both feet into the arena of values. Maintaining that we are not ideological is perhaps the most serious affirmation of our ideology. That means that we are ideological without saying so to others. Consequently, we can no longer be objective. Being objective in this field means revealing our ideologies so that we can talk about them.

It is important to mention that all of the technical decisions we will be making - conditions of payment, source of funding, et cetera - say something about the values we want to promote.

These things are part and parcel of values, ethics. There can be no reform without thinking about ethics. There is no resource allocation mechanism that does not have any consequences on values and respect for all of these values. This could generate some interesting discussions.

In my opinion, it is interesting to note that the health systems are extremely complex collective institutions based on only one rationale. There is a constant interplay of four rationales which justify the decisions made in the health system.

These four rationales include, naturally, the professional rationale. When a patient meets with Dr. Boucher, it is obvious that Dr. Boucher will react with his patient. According to his professional rationale, he will try to adjust, as best he can, his knowledge to meet the particular biological, social and psycho logical situation of his patient.

This attempt to adjust our knowledge and resources to meet the problems of each individual is not driven by market forces, by technocratic control, by ballots in our democratic process.

Moreover, another rationale comes into play in the health system. Mr. Forget and Mr. Castonguay talked at great length about the technocratic rationale. The health system is techno cratic. This tremendous bureaucracy will be horribly inflexible.Bureaucracy naturally tends to encroach upon sectors where it is not good. Consequently, bureaucracy will try to encroach upon clinics and interfere in areas under the purview of professional rationale.

The third tenet is extremely powerful. You hear about it all the time and you will hear about it a little later on: it is the power of the markets. We live in a world dominated by globalization. We get the impression that market forces will always improve productivity. Therefore, we are always pressured to include the markets in decision-making as a way of correcting a situation automatically, an approach which does not require much thought.

This belief in the power of the markets is extraordinary because it makes us feel that we do not have to think anymore. All that is needed is to let the invisible hand of the market do its thing and everything will work out for the best.

As you mentioned a littler earlier, the public is extremely concerned about health care. It is an issue which affects us all, as individuals, as members of families, as parents and as children. Health care is so essential that we cannot regulate it through a democratic system. This concerns us.

We all agree on the fact that democracy does not just mean voting. Democracy is first and foremost, as you said, the outcome of public debate. Democracy means that citizens have the right to participate, discuss, debate and vote whenever necessary. But voting itself is not the essential element of democracy.

These four tenets coexist within the health care system. What we need to define today, and it is something we see in every type of reform being carried out these days, is the relative weight to be given to each of these tenets. Clinics cannot be ruled by bureaucracy. Certain bureaucratic decisions must not be guided by the market. However, other decisions may be improved by relying on the markets. We need to reintroduce a democratic approach to debate, controversy and participation into the system.

There will be reforms if we manage to redefine the roles of each approach. But it will be an exceedingly complex, difficult and cumbersome process, as you said. I could have discussed that subject in detail. Why is it so hard to do? What have we learned about change in huge collective organizations?

Change does not happen when you snap your fingers; it is a complex social process. Change is an exceedingly complex process. When you want to change something, it is because you have to, not because you want to. Change is hard. We do things a certain way and we do not want to change.

But I think that in health care today, we have all realized that change is a must. Public opinion polls have indicated this. There was an interesting poll done about a year ago in which 5,000 people in Quebec participated. Each person had to answer five questions: Should some free services be subject to user fees? Seventy per cent of respondents answered no. Should taxes be increased to bolster the health care system? Eighty-one per cent replied no. Quebeckers do not want to pay more tax. Were people who have received health care over the previous six months satisfied with those services? Eighty-five per cent of respondents said yes, which is surprising, given what we hear from the media. Will health care improve in the future? Eighty per cent said no. People are afraid.

We are living in a very peculiar time in which the public is telling politicians what it expects: Listen, we are worried about the future. People insist that they are afraid for the future because the system is not going in the right direction. Together, we had constructed a vision of what a responsible and universal health care system in Canada should be. These days, we have the impression that the system is mutating into something which does not correspond to our expectations. We are now afraid of all these combinations, tax credits over here, user fees over there, a bit of insurance, unclear situations. It is better to have a transparent system. People are afraid.

If we are afraid, how do we bring about change? It is interesting to note that in your report you say that ambiguity represents change. You say:

We cannot trust those who believe you can reform the health system from the inside because it is too difficult to change.

But at the same time, people are saying that the market would bring about the changes which the bureaucracy cannot. There has to be more talk about change.

Senator Morin: Mr. Chairman, I have a few questions for Dr. Serge Boucher. Doctor, you have to deal with waiting lists and the reactions of your patients. Patients wait for the results of their biopsies, for medical imaging investigations, for an appointment with the right specialist, for the availability of an operating room and so on. This is what patients have to deal with. Beyond the figures and expectations, we cannot forget the anxiety patients feel when they wait for their biopsy report, not only because of what it will cost and because of its content, but also because of their health. It is something patients have to deal with. I would like to know what we can do to shorten waiting lists.

Dr. Boucher: You will understand that I do not have a silver bullet. In fact, that is one of the reasons you are here. You want to find solutions. Identifying the problem is already a step in the right direction. Professor Contandriopoulos mentioned that practitioners must be protected from an ever-increasingtechnocracy. If you ask a practitioner who believes in his work about how the system should work, he is usually in a position to provide you with reasonable answers.

But practitioners are not being consulted, they are not asked for their opinion. I would like to thank Dr. Morin for having invited me to appear before the committee. It does not happen often that we are invited to participate in an organization which has decision-making powers.

As regards the issue of accessibility, for instance, there is a lot of talk about the pet scan in Quebec these days. We know it is needed. What happens? Committee after committee is set up, reports are produced stating that it is appropriate and when and where it will be made available. Only then does construction begin.

As soon as it is ready and available, the technology has already become obsolete. From the moment a technology has been recognized - for instance, we were talking about medical imaging a little earlier - I could get the ball rolling in terms of the patient and all the steps leading to treatment.

That treatment is recognized everywhere today. We have to send people from Quebec to Sherbrooke for tests. They are put on a long waiting list. Our other alternative is to perform surgery, which is unnecessary in a certain number of cases, to make a diagnosis.

I do not want to dwell on solutions, because I do not want to stretch out the debate. There are clearly solutions at hand, but they do not lie in increased planning and a greater technocracy. I think we have to do the opposite. We have to give patients more choice.

There is an obvious problem when we have to refer patients to the United States.

I have a regular practice. Let me come back to this one issue; a friend was telling me that he was unable to live with a certain diagnosis. We told him that a pet scan was available at Mount Sinaï. So he went. He was told it would cost $650. An hour and a half later, he got the result; he was satisfied and returned home. The treatment did not cost the system a cent.

But what are we telling the public today? Listen, no, wait, we will put you on a waiting list and you will have to wait, not only for tests, but also for treatment. Canadians are told to get a tan south of the border and to spend their money there. But that is not what we tell them when it comes to the health care they have a right to and which is important to them.

I feel that that is a fundamental right in a democracy. Yes, I understand that health care is special, as the professor mentioned a little earlier. The public can choose. But if you told me today that a patient has choice within the health care system, I would reply that that is not true.

Senator Morin: You see, it was not without reason that I invited Dr. Boucher, whom I know. I knew that he had very specific ideas on what to do with our health care system.

As you know, Professor Contandriopoulos is probably the one who has contributed the most academically to the study of the health care distribution system in Quebec. He participated in every study, he attended health care forums and is very articulate. I would like to acknowledge the importance of his contribution and studies over the years; he has greatly contributed to bringing about change within Canada's health care system.

Mr. Contandriopoulos, I will read your report with great interest. I would like to discuss the issue of decentralizing the system as opposed to reforming front-line health care services. These are two distinct issues. As a hypothesis, I would simply like to compare what has generally been put forward and what you have proposed in terms of a decentralized system. Regionalization is not the same as decentralizing care.

I think that regionalization leads to the excessive bureaucratiz ation of the control over health care. It leads to mergers between institutions and services. There are places where this system works particularly well in Canada, such as Edmonton and Calgary. The people from Edmonton gave us a description which I found paradoxical: they said it was an advantage to have five or six people at a table, including the hospital director, the home care director, the director of this, the director of that and five or six bureaucrats, who all easily developed programs and distributed funds. They told us that this all happened in an atmosphere of complete harmony.

We were told it was a model of efficiency. I found it a little offensive because I was wondering where the real players were. Under decentralization, front-line teams would receive the power to spend and the power to establish programs. And that is more or less where the idea of the internal market came from. This has happened in England and in Sweden. The system provides for healthy competition and, instead of concentration, mergers and Marxist-Leninist central planning - a decentralization which involves the real players who are responsible. This is now happening in England and in Sweden, and I have been told that France is also considering this approach.

Mr. Contandriopoulos: Your question is very interesting and lies at the heart of this debate. First, you must realize that in England, France and Sweden, the systems are not internal market systems. They are basically regionalized systems. In England, boards, district authorities, are responsible for providing care to the entire population in a given area, and so on, that gives you an idea.

It would be interesting to think about what we are trying to achieve, instead of comparing the systems in detail. On the one hand, you said that we are all in agreement, including Dr. Boucher, that health care is fragmented today. People do not know whom to turn to, they get some place, they do not get an answer, they go somewhere else. If a person has to go to the United States for a test which would relieve their anxiety, that person will do so privately if they can afford it. If that person gets an answer, very well. But if that person decides to stay in Canada, they will in fact cost our health care system much more because they will consult many practitioners and will only become more frustrated. It is not true that our health care is free. It is very expensive. We could save money by making services available faster rather than privatizing health care for those who can afford it. If we had a system which was more responsive, it would be an improvement.

At the heart of the solution, there is - it is something that is extremely hard to do - the dual responsibility of rebuilding trust in the clinic. Doctors must be made to feel sufficiently independent in their fields of practice to be able to work at their own convenience, and at the same time patients must have enough trust in a doctor or team to have confidence in the advice that is given to them.

The worst thing we have now is the lack of trust; different information is given by two or three doctors. At the heart of the discussion, the fashionable term is integration. How are we going to make sense of, or co-ordinate things?

It is important to understand that the concept of integration is not one-dimensional. Integration is not done because of adminis tration considerations, savings, failures that have never been established or for any old reason. Integration is done to increase the comprehensiveness and consistency of patient management.

We integrate to improve care. There are task forces. Obviously it would be important to have doctors and patients involved. There is clinical integration. In order for clinical integration to work, there can be no clinical integration without some form of integration. On these medical teams, these clinical teams, doctors play a role. If doctors are left out of integration, there can be no integration.

In England and Sweden, doctors are at the centre of these projects. Doctors are the conductors, the team leaders. In addition to the lead doctor, there are other doctors and so on. Doctors need support to play that role. We all know that you cannot spend all of your time doing clinical work, working with colleagues, managing activity, hiring managers and so on. Some bureaucracy must be set up, in order to delegate tasks to others who are better at doing them. You need support, which is sometimes called functional integration. You need authority, money and enough information to be able to manage things.

And it all goes together. When you have fundamental agreement on a definition of good care, on some kind of standard, you have to agree on what you want to do. If there is no agreement on that role, it does not work. You need a kind of clinic plan that everyone can buy into.

On the front lines, these groups of people should spring up in cities and in the countryside. I am not talking about regional administration, but regionally organized care, in whichprofessionals play a major role. This is done to improve care.

All of the studies are now telling us in the strongest possible way that this front-line organization must not be disconnected from the second or third line. Otherwise, the result is what happened in England. The front line, as soon as the case is a bit complicated, sends the patient to the hospital, the hospital gets backed up again, and another lineup forms at the hospital.

So there needs to be some connection, some financial and professional repercussions and so on, among the lines of care so that there is no spillover from one line to another.

And that brings us back to the point that there is a front line that is locally organized, like a CLSC, based on geographic space. There is a second line elsewhere and a third one based on other spaces. It all has to hold together consistently. That is the integration plan. That is what we call a decentralized system, with several levels of responsibility, based on the types of care needed.


Senator Robertson: I just want to follow up on Senator Morin's comments, Dr. Boucher. Thank you for being so direct and rather to the point, which is helpful.

Two things that you mentioned that I want to relate to the dreadful waiting times that the citizens have now, and that are causing so many problems. Of course, also in that box, I suppose, is the scarcity of physicians and nurses. There is a whole bunch of things that cause all this backup.

You mentioned improved efficiency, and you mentioned in your remarks also dollars from individuals. When you are looking at increased dollars from individuals, are you expecting the taxpayer, the user, to pay more taxes through the government, so that the government receives the extra money, or are you looking at the individual to pay more, so that that money comes directly from the individual into the system?

Dr. Boucher: No, I do not expect them to send the money to the government, because essentially, when we are talking about taxes, I would go back to the point that taxes are finally each citizen's money.

Senator Robertson: Yes.

Dr. Boucher: It could be coming from the federal government, the provincial government, I do not mind, but it is still coming from everybody's pocket. That is one point.

The second point that I would mention is that we are not putting to very good use the knowledge of all of those professionals. I would expect that, as is the practice at the Mayo Clinic, for instance, and it is still a lucrative business, they need to make sure that each person, each professional there is used at his maximum.Thus they make sure that a physician, such as myself, for instance, does not have to wait for an hour at the X-ray filmatech, as we call it, for an X-ray just because the clerk is not available.

Looking at the way things are going in the health field all across Canada, there is a scarcity of physicians, of nurses, and so on, so with less physicians and nurses, what we must do is make sure that each minute those professionals spend is spent in the best possible manner. That is one point that I see as being very useful. If you can do that, you would save a lot of money.

Senator Robertson: You are really looking at parallel structures?

Dr. Boucher: I would not say `parallel,' because parallels never meet, right?

Senator Robertson: You are right.

Dr. Boucher: What I mean is that I think it would be some sort of a helpful structure. I do not have the appropriate word, but when you talk about a parallel structure, as I mentioned, they never meet.

Senator Robertson: Never meet, yes.

Dr. Boucher: I just want to make sure that there is some sort of coordination about that sort of a structure.

Senator Robertson: Then I will ask you, sir, if I understand you correctly, if you were looking at the Canada Health Act's five principles, would you be changing some of those to allow more diversity?

Dr. Boucher: Yes, I think so. As I mentioned initially, I think a citizen should have a choice in a democracy, and right now we do not have a choice now. We can talk about equity, as the professor mentioned a moment ago, but still, equity means that you can be cured in a health system.

Senator Robertson: Yes. Thank you. Professor, do you have something to add to those concerns?


Mr. Contandriopoulos: To answer your question, it is worthwhile to give some clarification of what we call funding. It consists of three overlapping mechanisms, if you will. Funding is a system for raising money, a system for allocating money and a system for paying doctors, hospitals, nurses, et cetera.

There are three dimensions when we discuss funding. Each of these dimensions produces specific incentives. Money is so important because it literally dictates what to do, what we are not entitled to do or what we cannot do.

It is important to realize that modern democracies use funding through taxes to set up extraordinarily powerful systems to raise money from those who generally have some in their pockets. Democracies may do so for reasons other than simply to have money in their own pockets.

That is the function of tax systems. There is no other "insurance" or other system that manages to take money from the pockets of those who have some in order to distribute it based on certain needs, society's needs in particular. Therein lies an ideological position.

If we are convinced that a responsible society is a society that arranges to provide children an education, to provide lifelong care to people when they are sick, to enable people to live in healthy environments and to enjoy minimum social protection, and if we want education, health and the environment to be accessible to all, we have no choice but to fund them through a tax or public funding system.

Now, there are many conceivable ways to raise public monies. There is income tax. There are other taxes. There are special "health" premiums. There are all sorts of ways of doing it, with various advantages and disadvantages.

If we proceed thus, we can redistribute. If not, we will not have enough money to redistribute it to those who need it. We will wind up saying to those who have money in their pockets - unlike the government - to spend it as they see fit. They will not spend it in a collectively responsible way. That is fundamentally an ethics issue on which you have to take a stand.

You are either sensitive to the idea that everyone should have the chance to get ahead in society through education and health, or you believe that social and financial success are the rewards for certain qualities that come with certain privileges. It is really an ideological position.

There is no right or wrong answer. Everyone chooses his or her own position. The choice of position will determine the core policies. No private health care funding is consistent with an ideological position that everyone should have health, education and healthy environments.

Dr. Boucher: I would answer that I disagree with that.

Mr. Contandriopoulos: That does not surprise me.

Dr. Boucher: No, in fact, if you take the two basic economic systems, if you consider the basis of the market system, prices are what determine supply and demand.

In a "sovietized" system, there is limited supply and unlimited demand. The limit is the waiting list. That is what we are currently experiencing.

If you were to say to me that the fact that somebody can buy slightly more expensive clothing constitutes inequality because clothing, food and shelter may constitute basic needs, basic necessities, I would say to you: well, look, let us extend insurance then. As I said at the outset, we do not lack for insurance in Canada. We could have clothing insurance, car insurance and all those things.

Mr. Contandriopoulos: Well, that is what we have.

Dr. Boucher: Well, I do not believe I have clothing insurance. I am sorry.

Mr. Contandriopoulos: No, car insurance.

Dr. Boucher: I will continue, if you will let me. Some may say that simply because one person is able to obtain health care, another is not, but I would argue the opposite.

Currently, what is lengthening waiting lists is the fact that there is not just one limit, there is a bottleneck. Why not allow for parallel access, for example; this has been studied, and I could refer you to a study in my documents that would show that it is mostly the poor and those with financial difficulties who are asking for this kind of thing. They are the ones calling for access.

As you must remember, under the Soviet system, those with access to the system were not necessarily the richest, but rather Party members.

If you want direct access to the system, you had better know someone on the inside. I could go on about that, but you are aware of this and so is everyone.

If we raise taxes, by whatever means, the money always ends up coming out of the same pocket, yours and mine. We have to give people a choice, once again, and they have to be able to make that choice outside the system, to shorten the waiting lists. That is the system we have chosen.


The Chairman: Thank you. I must say, as a former academic myself, I have never heard of a situation in which the economist is arguing for not using market forces and the doctor is arguing for using market forces. This is sort of a disconnect in my mind.


Mr. Contandriopoulos: Hence the importance of ideology.

Senator Pépin: My question, in part, had to do with the integration of the medical system. My impression is that the current system is a pyramid. Doctors are at the top of the pyramid. Health care workers, like nurses, pharmacists, social workers and laboratory technicians are on another level.

I was wondering, given that we are exploring other avenues, if you think doctors will agree to share certain responsibilities or to work in teams with health care workers. Will they agree to give up or share some of their powers?

Mr. Contandriopoulos gave us his answer. Doctor Boucher, what is your approach?

Dr. Boucher: I would give you the same answer to that. I would say yes, they will agree. If nurses agree to hand powers over to nursing assistants, then I would say I see no reason why doctors would not agree.

You see, there is a whole pyramid within the system. When you say that doctors are at the top of the pyramid, I would say it depends where you are. If you are in a hospital, it is the administrator, the deputy administrator and the coordinators. Doctors come somewhere in the system on the same level as nurses. There is no real pyramid, I must say. People are used to team work.

I wanted to point out earlier that we have to make the best use of what costs us the most. If we can reduce what I would call the clerical workload of nurses or doctors, then I would say, do it, please. That is the way to save money and improve efficiency.

For the time being, there is the bottleneck. When I have to wait an hour for an X-ray, that clearly does not cost much. Similarly, when you talk about teams, I would say to you that you do not need a team when someone is seeking medical advice for a run of the mill respiratory tract infection. The power can be shared. We can work in teams. There is clear and readily available evidence to that effect.

I am very concerned about the way the system is going, particularly with respect to not doctors, but nurses. The problem is that nurses with bachelors and master's degrees are being glorified. As a professor with a doctorate at the university near where I live said: Look, you have nothing but bachelor's degrees and do not have access to me, you have no business speaking to me. When you have your doctorate, I will be pleased to talk to you.

This anecdote is an extreme example of what I have heard. I note that people made sure there would be no assistants, no one to replace them. Nurses feel uncomfortable, neglected. I have not observed this phenomenon among doctors, oddly enough. Doctors are quite happy and have no problems working in teams.

Some doctors may have problems. Some well-knownspecializations like neurosurgery and heart surgery have a certain aura of glory.

Senator Morin: The challenge!

Dr. Boucher: It so happens that those are the only two specializations in Quebec without an income ceiling. So from the doctors' side of things, there is no problem. The problem that I see looming and that we are going through, if people continue at this pace, is that there will no one left to take care of the ill.

Senator Pépin: There will be no bedside nurses.

Dr. Boucher: No. Nursing assistants are being brushed aside. Nurses are less valued in hospitals without a bachelor's degree. It is nurses with bachelor's degrees that are being recruited.

Senator Pépin: As a bedside nurse, I agree with you. It is all well and good to hire a nurse with a bachelor's degree, but we need bedside nurses to be there for the ill, and that is very important.

When you are working in a team, and someone comes along, that person does not necessarily need to see a doctor, perhaps a nurse will do, or someone who could point that person in the direction of the right person. That would save time for doctors and patients. I am actually glad to hear that doctors will have no problem. But we have suspected for some time that there will be problems among nursing assistants, nurses with bachelor's degrees, et cetera.


The Chairman: Last question, Senator Keon?

Senator Keon: Dr. Boucher, coming back to market forces and looking specifically at the imaging situation and the waiting lists, you have private MRI clinics in Quebec, and you do not have private PET clinics in Quebec. Has the fact that there are private MRI clinics in Montreal and Hull eliminated the waits for MRIs in the province, do you think?

Dr. Boucher: I would not say that it has eliminated the waits, because there are so many people who are waiting, but still it helps. I am thinking here of the people who do not need any surgery, who do not need any specific treatment. Once that examination has been done, that investigation has been done, they feel more at ease, and they do not have to be on a waiting list. Thus, while it does not eliminate the list because the number of patients is ever increasing, it still helps. While I would feel that I would not open all the way for that kind of structure, but still I think it helps.

Senator Keon: Have you noticed a difference since the private MRI clinics opened up?

Dr. Boucher:The way it works now is that, for people who are not familiar with the system, if you want to have access to some sort of investigations, you have to be hospitalized, you have to stay in the ICU for a while, and there is then a priority for you coming from the hospital where you had the investigation done. Otherwise, if you are at home, they will not take care of you; you have to be hospitalized. Thus it is obvious that the person who stays in the hospital for that investigation, in the ICU, even though they do not have any kind of specific treatment, has better access. It does not cost a lot, but still, it is not very effective, over all.

Senator Keon: What has been your experience in sending a patient to Hamilton, for example, for a PET scan, as opposed to sending him to Syracuse?

Dr. Boucher: I did not work with Hamilton, but I tried with Sherbrooke, and it has been an awful experience; awful because I have sent three patients, and no patient has been investigated up till now. They have been waiting for about six or nine months, now

Senator Keon: Yes.


Dr. Boucher: He asked what my experience was with patients.

Senator Pépin: Why?

Dr. Boucher: Why? Well, because there is no access.


Dr. Boucher: The other thing, too, is that, looking at the expenses related to those big devices, I do not know why they stop using them at 3:00 in the afternoon. I am very surprised to see that. I do not know why they do not use those devices 24 hours a day. How would Bombardier work if they had to stop working at 4:00 in the afternoon? I think they should be operating 24 hours. I would say the same thing for the operating rooms, because a patient who is waiting for a bed would be pleased to be operated on at midnight, and leave the hospital at 8:00 in the morning, instead of having to wait for nine months.

I think it is obvious, looking at the expenses related to those large devices, we should be using them 24 hours a day, and seven days a week.

Senator Keon: I must say, since both of us are MDs, that the barrier to that is the medical profession. All of the other people are quite prepared to work around the clock.

Dr. Boucher: I think that we can work on that part, I would not say it will be easy, but we can do it.

Senator Keon: Professor Contandriopoulos, you mentioned that patients have nowhere to turn. I asked one of our previous witnesses, Mr. Castonguay, why the CLSC has not worked out in the way it should have, since it looked like such a great idea. As I analyzed his answer, he gave fundamentally two reasons: First, was they got derailed into an over-concentration on social services rather than on medicine, and second, that the medical profession would no cooperate with them.

I know personally of least one CLSC that was embraced with open arms when it came about by the general practitioners in the area. They thought it was the greatest idea they had ever heard of because now they would not have to do social work, which they did not know how to do in the first place, but which was consuming large amounts of their time.

In any event, perhaps I could hear from you why this system has not worked out. Quite frankly, going back 25 years or so now, most of us thought this was the solution to the primary care piece, and it has not happened. Why has it not happened?


Mr. Contandriopoulos: The history of CLSCs is a good example, in that it started with a good idea, a promising innovation, but it was never fully carried out, never fully implemented. So CLSCs became a partially implementedinnovation.

We could go back over the reasons for their partial implementa tion. They are basically the same as the reasons we just discussed for the conflicts among various groups of doctors, between doctors and nurses, and so on.

When Mr. Castonguay was Minister of Health and introduced CLSCs, do not forget that in his report, there was a very explicit recommendation that the way doctors were paid needed to be changed. Otherwise, it would be impossible to arrange adequate front-line care. These recommendations were made in 1970 in the Castonguay report, Volume IV, chapter 4. Nothing was done. Thirty years later, in Quebec, the Clair commission said the same thing: adequate front-line care cannot be arranged without a change in the way doctors are paid. A change is needed, or there will be no change.

Today, with the groups of family doctors or health centres in Ontario, there are the same problems. If there is no change in the way doctors are paid, there is no real hope of properly implementing the concept of front-line care as discussed.

The idea behind the Castonguay report was clear; its implementation was flawed. It was so flawed, mainly because of the way doctors were paid, that it was felt that the CLSCs were becoming essentially social organizations. The medical profession had in fact kept its distance from CLSCs. They were thus discredited over the years and remained on the fringe of the health care system.

Indeed, this proposal was never implemented. Today, we find the same proposal before us. The proposal Mr. Clair made in Quebec, and that of the other provinces, is more or less the same thing. But it will never become real unless, as you say in your report, the issue of how doctors are paid is squarely addressed.

If it goes through, physicians will be in a better position to participate in more interprofessional activities; it will be easier for them to find the time if they do not have to do the simple things which can be done by others. They will be able to apply their know-how to problems which are truly complex. We have to get other people to do much of the work still done by doctors. These other people can do this better, and at a lesser cost.

Dr. Boucher: Local community service centres (CLSCs) have a basic problem. There is much talk of innovation in Quebec. Let me repeat what I said a few minutes ago: in 1930, there were 1,100 local community service centres in the United States. You are aware of the reasons why these centres were successful south of the border. May I also remind you that in the Hochelaga- Maisonneuve area of Montreal, there was a local community service centre which went by a different name and which existed long before the centres were officially created.

It is easy to understand how they came about. It is easy for me to deal with a patient suffering from pneumonia. I do not need an entire team. If I realize that this patient also suffers from malnutrition and lives in an abusive family, and is an alcoholic, I know that a whole team is needed and that a local community service centre can play a role. Take the Roxbury neighbourhood in Boston, for instance. They have local community service centres because physicians cannot work on their own, they need a team.

The success of certain community centres in certain areas depends on the type of problems that are treated. If a centre, however, is not successful, it is simply because the patients who are referred to it do not need to be treated by that type of facility.

I just want to mention one thing regarding the way physicians are paid. I have just finished a week of being on call for 24 hours a day. Twenty-four hours a day! But I am only paid for the treatment I provide. I am not paid to be on call.

If you want to change the way doctors are paid, this is one area which must be addressed. Doctors will want to be paid for being on call. The same principle applies to the tax lawyer you have asked to be available on the weekend while you fill out your income tax form. On Monday, the tax lawyer will bill you for being on call.

The existence of local community service centres also explains to a certain degree the different type of doctors who work there. When residents finish their residency, they make a choice. Some of them want to work for community centres, knowing that the work hours are not as long, they do not have to be on call as much nor do they have to work in emergency. So, from the outset, they choose to work in a local community service centre.

There was a study which was published about 5 or 7 years ago which revealed that a regular appointment in a local community service centre - which does not include treatment formalnutrition or violence, for instance - cost about $65, whereas an appointment in a general clinic cost $12. The service provided was the same in both places for a patient suffering from pneumonia - I am tempted to say this is a routine appointment - but in any case, treating a regular case of pneumonia does not necessitate an entire infrastructure.

Local community service centres which are used well and in the right place for patients who need them will work. The way physicians are paid will not be an issue. Doctors working in these centres will know what to expect. That is how I see it.

As for the increase in the number of polyclinics allegedly generated by the creation of CLSCs that Mr. Castonguay referred to earlier, I will point out that polyclinics were not built because CLSCs were created. It is because hospitals have become places where specialists work. Hospitals have become places where it is difficult for doctors to practice. Doctors spontaneously started opening clinics at their own expense. That is what happened in a number of cases.

Mr. Contandriopoulos: The Quebec Federation of General Practitioners nevertheless issued an official directive to set up polyclinics opposite CLSCs in 1970. Mr. Castonguay exper ienced that while he was minister.


The Chairman: May I thank both of you for coming? We really appreciate your taking the time to be with us. Thank you.

Senators, just so you know the schedule, we have one more panel before lunch. We will then take our full hour and the final witness this afternoon has been cancelled so we still will finish at 5 p.m., in any event.

Senators, our next panel is Nancy Hughes Anthony, the President and CEO of the Canadian Chamber of Commerce, and Gilles Taillon, the President of the Conseil du Patronat.

Dr. Boucher, thank you for coming, I understand now exactly why Senator Morin recommended you.

First, let me apologize to the witnesses for our being late. As you may have heard, we started off with Claude Castonguay and Claude Forget, and it was very difficult to deal, in any reasonable amount of time, with two former ministers of Health who have written as much on the subject as they have.

Thank you both for being here. Mrs. Anthony, can I ask you to begin, and then I'll turn to Mr. Taillon?

Ms Nancy Hughes Anthony, President and CEO, Canadian Chamber of Commerce: I would like to mention to the committee that I am also accompanied here today by my colleague Michael Murphy, who is the Senior Vice-President of Policy for the Canadian Chamber of Commerce. We are very pleased to come before the Senate committee today to present the views of the Canadian Chamber of Commerce on the health care system.

As I am sure many of you know, the Canadian Chamber of Commerce is Canada's largest, most representative business association. We represent more than 170,000 members from every industry and from every region across the country, and I would say I am sure that each one of them is a health care consumer. Many of them obviously work in a volunteer capacity, perhaps, with the health care system in their communities.


Thirty years ago, Canada set up a universal and comprehensive public medical insurance plan. This health care system was, and I reiterate "was", in the past, a source of pride for many Canadians.

The Canadian Chamber of Commerce feels that the time has come to reform the health care system by recognizing its main challenge. The health care system in Canada is facing a crisis. As members of this committee, you must be well aware of that fact.

In our opinion, the situation can only get worse if difficult decisions are not made immediately. Therefore, the Canadian Chamber of Commerce is presenting a number of recommenda tions designed to ensure that the health care system in Canada is better prepared to rise to the challenges of the future.


I believe, Mr. Chair, that you do have our brief. That has been distributed to the members of your Committee in English and French, and I will not repeat that brief, I will hit just some of the highlights of that brief.

Before getting into some of the specific recommendations, it is important to understand two fundamental issues, and I think that is the reason why we are here before you today as a national business organization.The first is the importance of the health care sector to the Canadian business community. To put it simply, a world class health care system matters very much to Canadian business. I think this is true from the point of view of the financial investment of the private sector in Canadian health care, as evidenced by the growing percentage of health care funding, now estimated at around 30 per cent, coming from private and not public sources.

The second issue is the importance of the health care sector to Canadian competitiveness, and I do not think we need to go into the large body of work regarding the key elements required to ensure that Canada is a competitive country. However, there is a need to stress the importance of that sector for a high level of quality of life and for maintaining our standard of living. An investment in health care can, and does, increase quality of life, and ultimately economic growth.

Much has been written about the most important piece of national legislation in the health care debate, the Canada Health Act. The core values expressed in the act through its five major principles, which you know very well, have been cornerstones in the development of our health care system. The Canadian Chamber of Commerce believes that meaningful progress on reforming health care will only take place if the debate needed to arrive at the best possible solutions includes a review of the five principles and, in particular, the principle of public administration.

We applaud the committee; we commend you for your openness and for your willingness to take on what some people consider to be rather difficult topics, including a discussion of these five principles. There are, indeed, some who do not even want to discuss these five principles, and we find this completely unacceptable. It flies in the face of the reality that 30 per cent, as I mentioned, of our expenditures on health care is funded by sources other than the public purse. This fact alone demands a serious review of the public administration principle.

Equally important, however, is the necessity to place the restrictions caused by this principle - some say the handcuffs - before the decision makers so that a full assessment of its impact can be made. We cannot shy away from dealing with these tough questions.

In the Canadian Chamber's view the real issue at the heart of this debate is not just money; the real issues include a need for creativity in our thinking. Regardless of the need to find a source of additional funding, whether it be provincial governments, or health care institutions, or practitioners, the reality is that we spend a great deal of money already on the health care system. It is not acceptable at this stage, in our view, to continually argue for more spending without a thorough analysis of the value received for the expenditures made.

The Canadian Chamber is not in a position to question the merits of specific requests for more funding, and I am sure this committee is hearing a lot of requests for more money, more funding. What we are in a position to do is to propose two fundamental notions to guide your discussion: The first is the requirement to ensure that efficiency considerations are given a high place in the determination of funding decisions; the second is to instill accountability into the system. Efficiency andaccountability for funds spent with a clear focus on patient outcomes must be on the table.

The Canadian Chamber of Commerce believes that any decisions regarding an increased level of spending on health care can only be made after a comprehensive and thorough review of the health care system, including its structure and its funding. More specifically, you will see that our brief calls for the principle of efficiency to be instilled into the Canada Health Care Act with the objective being to attain excellence in health care.


Moreover, the Canadian Chamber of Commerce is calling for a renewed partnership between governments at the federal, provincial and territorial levels, to make the system accountable and to equip the Canada Health Act with an "accountability" principle.


The Canadian Chamber is concerned about the lack of accountability in the current health care system. In fact, if there are no financial consequences to poor performance as far as federal funding is concerned, how are we, collectively, to improve the system for the betterment of all of the users? The Canadian Chamber argues that the development of consistent national measures to guide decision makers is very critical. They must be implemented. We also feel that business representatives should be added to the list of those to be consulted by governments. Currently, as you know, that list includes health care subject experts, health care professionals, and individual Canadians. We think that the business community has some good suggestions to bring to the table. While there is a need for public governance, for public policy direction and for public standards for health care, that should not preclude private sector involvement, and the key there, Mr. Chair, is accountability.

I will conclude on that note, Mr. Chair. We feel that the key challenges are efficiency, accountability, and a serious look at the public administration principle of the Canada Health Care Act. The health care system is in crisis; it is broken, as you have indicated in your reports, and in our view we can no longer just muddle along with Band-aid solutions.

We are happy to answer any questions the committee may have.

Mr. Gilles Taillon, President, Conseil du Patronat du Québec: It is a pleasure for the CPQ to be heard by your committee.


I want to provide some clarification, you will see this in our brief, on certain points of view raised in your report, and then I want to cover some of the reforms that we have already submitted to the Clair Commission that sat in Quebec. These proposals are still current, even though the Commission's recommendations were not implemented.

I will not go back over what Ms Anthony said regarding businesses in Quebec, regarding business people. Theperformance of the health care system is a priority. We must have an impeccable health care system in terms of efficiency and effectiveness, with reasonable costs, in an economic context that increasingly relies on human resources. It is important for workers in this field to be in good health.

First of all, we pointed out that with respect to the Canada Health Act, and you address this in your report, the notion of public administration, the fifth most important criterion in enforcing the act, must be clarified. It is our opinion that some people often misinterpret the act which bans privately-managed health care systems. We feel that this is not what the act is advocating. We urge you, in your final report, to clarify for both levels of government how the Canada Health Act is to be interpreted.

The Conseil du patronat strongly believes that it is not advisable to call into question public financing of the health care system. Moreover, with a publicly funded system, it should not be ruled out, it should even be desirable for the private sector or the public sector, depending on each one's ability to provide the best possible service, to manage the health care system to ensure that it is as effective as possible.

We want a publicly funded system, without user fees, and without any new taxes, necessarily. Recent newspaper reports have been talking about a tax on the elderly. We will come back to that later. We want to see a complete overhaul of the management system, without any new taxes.

As for federal government funding, contrary to what the provincial premiers made known during the Victoria conference, we do not think we should come back to the funding situation that existed in 1994-95. The reason is simple. The Canada social transfer, at the time, was funded in good part with borrowed money. We do not wish to come back to a situation that would increase the public debt.

We think there are probably possibilities in the next federal budget to review present agreements. We must absolutely not go back to the prior situation, which, in our opinion, would be irresponsible.

Fundamentally, we would hope to see both orders of government agreeing on a formula that would allow the provinces, who are responsible for managing the health system, to be able to count on annual growth of the federal health transfer that would be known to them in advance.

We think, at this stage, and this is the third element we are looking at, that the health system can only benefit from shared management. We think, because of the complexity of the problems in the system, that two governments are better than one in this area at the present time.

We also think that if there is no agreement possible, if there is not enough maturity to allow for a concertation between the two orders of government, federal and provincial, that we would doubtless have to think about a clear separation of responsibilities and powers. At that point, we would probably have to think of transferring tax points as an alternative.

I do not want to get into this discussion, but we gave you an excerpt of our proposals to the Séguin Commission on fiscal imbalance. We analyzed what the tax point transfer might be for Quebec. We are telling you that that is not our first recommendation. We would prefer agreement between both levels. If ever this did not happen, if they could not agree, then we would have to think about defined responsibilities for both orders of government. At that point, of course, the provincial govern ments will take on full responsibility for managing the health care system.

Concretely, here are our main suggestions to review and ensure that the health care system is really an efficient system. These are the recommendations we made to the Clair Commission. They are still fully valid. In our opinion, of course, they concern the provincial governments first and foremost because they are the ones responsible for the system. They also concern the analysis of the total reform of the Canadian health system.

We think that each patient - and you will find these proposals on page 6 of our brief - should have a centralized computerized clinical file. Each patient should be able to show up with a health insurance card containing all the essential information on the patient's health.

We suggest setting up multidisciplinary teams practising in private or public clinics, and that that choice be left to the professionals and human resources working in those clinics. This would be an open, base organization accessible to patients 24 hours a day.

The family doctor is at the heart of the system and is the team co-ordinator. In our recommendations to the Clair Commission, we went further than that simple statement. We said that the team should have more responsibilities, that the nurses should be entrusted with more of the major tasks. To have a system of clinician nurses, you could emphasize the job of auxiliary nurse which is a profession that is disappearing in Quebec. The doctor would have to work with a team with broader responsibilities in that clinic he is coordinating.

The essential and most important recommendation, if we want this system to see the light of day, has to do with changing the funding of establishments and the funding of human resources working in those establishments. We propose financing on a per capita basis. Our objective is for the money to follow the patient. It is in the best interest of the basic medical team to ensure the best quality of service and see to it that the health services are in the best position to manage the health of our fellow citizens at the lowest cost.

The clinics and the institutions, the major hospitals, absolutely have to have a free hand with managing human, financial and material resources. We favour radical change in the organization of services in each one of the institutions; put an end to wall-to-wall collective agreements, iron-clad agreements, policies that mean you lose all kinds of time managing rather than dispensing care. This is what that recommendation implies.

The basic clinics are the ones who buy the services from the specialized institutions. All the funding goes to the basic clinics and those clinics are the ones buying the specialized services. The system is still publicly funded. The system is funded by the government. The management and the production activities needed to deliver the medical services remain possible. Contract ing out is favoured. With per capita funding, the internal market system should develop. That should be the basic criterion to determine what is private and what is public in the organization and management of the service. Of course, we are in favour of efficiency and economy. Those are our main recommendations and I am ready to answer your questions.


The Chairman: May I say thank you to both of you. Before turning to questions from the members of the committee, may I just ask both of you a question that would be sort of putting your two ideas together?

Ms Hughes Anthony, in your paper you talked about the difficulty, or maybe even the impossibility, of reforming the behaviour of health care recipients. Mr. Taillon talks about having money follow the patient. It seems to me that what you are proposing, if I put all of it together, is essentially separating the payer function from the provider function; that there would be a single payer, which is the government, and that the money would follow the patient, not just as Mr. Taillon suggested for primary care but for everything.

In other words, if some doctor did a hip replacement and the hospital got paid for that hip replacement, they would be paid by the government. However, they would get paid for the hip replacement, as opposed to the current structure where hospitals are given a global budget, and, frankly, cannot even tell you what it costs to do a hip replacement. Is that a fair conclusion, that you would favour that separation?

Ms Hughes Anthony: Yes, I would say, obviously. When we are looking at this at a national level -

The Chairman: Of course.

Ms Hughes Anthony: - there are many ideas emerging all across the country. We touched on some of those in the latter part of our paper here. Certainly, the idea of medical savings accounts, some kind of capitation, these sorts of ideas have been debated and have been suggested by some of the members of our chambers, but I do think the one that you raised is an important distinction.

Mr. Murphy, did you have any more feedback on that?

Mr. Michael N. Murphy, Senior Vice-President, Policy, Canadian Chamber of Commerce: No. I would simply add that I would agree with your fundamental premise, but also, it is important from the business perspective, which is the one that we have tried to bring here to your attention - and I will use the term "behaviour modification" very carefully, but if you look at both sides, we clearly have come out on the side of focusing on the delivery of services as the way to start this process in terms of looking for efficiencies there. That is very much the bias that we have on the table at this time.


Mr. Taillon: I think your conclusion is the proper one; I would say that we would like to change the behaviour of those offering the services. The objective, of course, is still to have people in good health. Exchanges will take place between the medical team and the patient and these exchanges mean that everyone's interest is that the patient's health be the best possible. The objective is to change behaviour and we think that the change in behaviour will flow from a change in the funding system.


The Chairman: Your goal is, as you put it between the two of you, to focus on changing the behaviour of providers rather than patients?

Mr. Taillon: Yes.

Ms Hughes Anthony: Yes.

Senator Robertson: You have given us a lot to think about, and I look forward to taking time to read your documents, because we have just received them and it is somewhat difficult to relate to the issues there.

I just have a simple question: I see, Ms Anthony, that you are looking at a review of the act and the principles. However, I would point out to both of you, if the recommendations that you make regarding efficiency and accountability and all of these nice things, if they do not provide the funds required to run the system, which seems to be the case now with the long waiting lines and the scarcity of professionals, and so forth, then there is a crisis. You ask the people in the street, and they recognize a crisis. If you get into the system then you are not so crisis-prone, shall we say, because you have got there, and when you get there the treatment is not bad. However, the problem is getting into the system, which creates all sorts of other problems.

If, for instance, all of these efficiencies, accountabilities, et cetera, that you have all mentioned, do not provide sufficient funding to resolve some of the problems, because I really think you have to have funds; god knows what the level of funding is at this point, because the system seems to be breaking down; but if there is not enough money, and you need to get some more money, where will you get it from? Will you get it through taxation? Will you tax the individual? Through the system that we have now, will the government collect more taxes and designate, or will you ask the patient to provide something or other?

If that happens, then what about choices for the patient who provides more money? I understand where you are coming from, but I do not know what happens when the system breaks down.We have heard from so many witnesses, and there is a real debate going on as to whether we can secure sufficient funding through tightening up the administration and delivering more effectively. There is a real question mark over that particular point of view. I would like to know where we go from there if it does not work.

Ms Hughes Anthony: How do we know whether we have sufficient funding? I think this is a dilemma, and I am sure there are points of crisis that people are pointing out to you. However, as a country, we do spend a lot of money on health care, and I guess the question I would hope your committee could focus on is that the base amount of money currently being spent cannot go unquestioned. What I mean is that we all have anecdotes of inefficiencies that we, or our families, have experienced in the system. We can go chapter and verse about the sort of problems we have all experienced. As Mr. Taillon suggested, why do we not have a Smart Card so that we can get into the hospital environment and, zoom, we are through; we do not have to go via 17 people with clipboards. There is all kinds of information that our system is not set up with the right incentives to make it efficient.

I would hope that your committee would be very much trying to ascertain that, and not necessarily focusing on the fact that, at the moment, everybody needs a whole lot more money. I know our members would agree that surely we can make the system more efficient and find some more sort of funding within the system as a starting point, and then we might have some basis upon which we can ascertain what the right amount of money is. At the moment, we have absolutely none.

Senator Robertson: I do not disagree with you. Some of us do feel that there is sufficient money in the system if it were used properly, and some of these efficiencies took place. However, the other point of view, always is, "What do we do if that does not happen?"

Ms Hughes Anthony: Yes.


Mr. Taillon: Senator Robertson, I would say, first of all, that we think there is enough money in the system. We favour reorganization rather than adding any, putting more in. We have to fundamentally review the organization of services and their funding.

If ever that failed, we could think of doing something else like having a user fee or an old age health fund or home care. Before doing that, we would absolutely have to review the foundations of the system, its organization. But if we do not do that, we will add money in and we will have settled nothing, we will still have waiting lists, we will still have overflowing hospitals and emergency services. That work has to be done. It takes political courage to do it, but we think it has to be done.


Senator Robertson: Actually, then, it is a two step process -

Mr. Taillon: Absolutely.

Senator Robertson: - that we are looking at. Thank you for that.


Senator Morin: A year ago, the President of the Royal Bank made a speech that made quite an impact. He explained how privileged Canadian employers were to have the Canadian health system as compared to American employers, who have to support the health insurance system for their employees.

For instance, to any car built in the USA, you have to add $800 in health insurance costs whereas that is not the case in Canada. A major factor in our large volume of exports to the USA is the weakness of the Canadian dollar and our public health care system.

Employers are really privileged. All Canadian taxpayers subsidize employers to a certain point if you compare them to American employers.

Now, whether we like it or not, health care costs are increasing by 5 per cent a year and that is true just about anywhere in the world, whatever the system may be. It goes from 3 to 7 per cent; in the USA, it increases even faster. We have to look at the cost of technology, our aging population, the cost of drugs. Any time you introduce a new drug for a new disease, the cost goes up and it has nothing to do with the drug's effectiveness. You have to pay for the drugs and that is the factor that is increasing the most in our health care distribution system. Either we do not pay for them or we pay later.

I do not think it is terribly clear that by changing a bit of history you can reduce costs.

There were some witnesses, Mr. Mazankowsky out West, for one, who suggested, based on a study on health care costs for employers in the USA, considering a special tax for health care distribution that would be supported by employers. I would like your opinion on that.

Mr. Taillon: First, we share Mr. Cleighorn's analysis which is that we have a system in Canada that we must preserve. We do not want a system based on the American model. That is why our recommendation is to maintain public funding.

We think that if the dynamics of the services offered were changed, drugs, for example, could become a cheaper way of treatment that costs less - despite the increase in cost - than certain hospital stays or surgical procedures. So optimization of the best medical tool can be found but the present system does not allow this.

That is our reaction to your question, Senator Morin.

Ms Anthony: If I may, I would like to add a few comments. There was a sort of myth, that might have been true, according to which our health care system represented an extraordinary advantage for the business sector. I would say that this argument is becoming less and less convincing as the years go by.

As I pointed out, there is an increasing percentage contributed by the private sector to global health care in the sense that employers are paying contributions for their employees' health care programs.


Ms Hughes Anthony: The private sector is taking an increasingly larger piece of the pie. In addition, because of the current difficult situation with the health care system, experienced particularly in some areas of the country in finding a family physician, difficulties in communities where there just isn't a specialist in X, or Y, or Z, lineups for surgical procedures, what we are finding is, in terms of recruitment, particularly at the higher executive level in Canada, the people are having to go that extra mile and add on bells and whistles in order to get a professional to come into Canada, let is say from the United States. People are looking for some assurance that they can go and get health care treatment in private clinics, or go south of the border, or something, if they need it, and they expect their employers to pay.

This is, I think, a further indication of the fact that there is a crisis in this health care system. It is not recognized any more as the pearl and the advantage, in a business sense, that it once was.

The Chairman: Monsieur Taillon?


Mr. Taillon: Something else perhaps, Senator Morin, is that we should not think that corporations do not pay taxes to fund part of the health care system. The health care system is funded, of course, through personal income taxes, but also through corporate income tax, business taxes, and in Quebec we have a specific payroll tax for health care. If you set aside personal income taxes, you could say that we fund, at least in part, the health care system and that is why we are interested in its optimum performance.

Ms Anthony: I would like to emphasize that the idea raised by Mr. Mazankowsky, of paying even more taxes for a health care system where you do not have an exact idea of its value, the investment of all the costs, in my opinion, would not be very well received.

Senator Morin: I did not expect you to support it.


The Chairman: I think you struck a chord.


Mr. Taillon: Mr. Chairman, could we put the question, what do the senators think of all this?


Senator Keon: First of all, I agree with virtually everything both of you have had to say, but I intend to play the devil's advocate and see what I can learn from you.

My socialist friends in America say that the fundamental difference lies in the fact that they are spending 14 per cent of GDP and we are spending 8.5 per cent, and the 5 per cent spread can be virtually all explained in overhead; that 30 per cent that it costs them to send all of their bills from all of the payers, and the profits. To illustrate this, they point to some of the health management organizations that have gone from a $90-million company to a $25-billion company in five years. And the list goes on.

The bottom line is that probably, in balance, our systems are about the same. There is no question that you can get deluxe care in America that you cannot get in Canada; on the other hand, the life expectancy of a black man born in the Bronx is no better than that of a citizen born in the third world. Thus neither system is perfect, and I am loathe to compare the Canadian and American systems. I just feel that it is always a superficial comparison, and we must look at the global picture rather than just those two.

What I am doing is to focus on what some people say that, that businessmen are not that smart after all; that they will not pull a lot of profit; that they will not pull a lot of efficiencies out of what we are doing in the health care system in Canada. How would you like to handle that ugly question?

Mr. Murphy: Senator, you have asked a lot there. I am not sure I disagree with the fundamental premise of your remarks, and I do not think you will see in any of our references any kind of indication that we have a preference for someone else's system versus taking a good hard look at our own.

I just wanted to raise the subject of how business people approach a problem such as this. That is how we come at a lot of these issues. When you are forced to look for efficiencies all the time in running your business - and our members are faced with this reality constantly - you look at the tools that are available to you. One of those tools that we have taken advantage of more and more is bench-marking. I think it has increased productivity and efficiency within the firm, which also leads to more wealth creation in the economy and a higher standard of living, and that creates benefits and choices for all of us within the economy.

Thus when you start looking at how you will undertake a challenge such as this, one of the concepts is bench-marking. In other words, we take a hard look at how we do what we do, what it is essential to do, and then we try to decide what are the best practices done elsewhere. `Elsewhere' could be firms with which you are competing. In our case, we could apply this direct scenario to others who engage in the provision of these kinds of services, and those others could be domestic, they could be across our border in the U.S., or they could be in Europe, or elsewhere. Lots of people have good ideas on how to do things and there are best practices, and there are acknowledged best practices in this sector as there are in others. I think there is an opportunity here to take a good hard look at the whole situation and take advantage of what might come out of that process. That is kind of where I come out of that.

Ms Hughes Anthony: Just to add to Mr. Murphy's remarks, and I am sure this point has been raised, the maximizing of technology is one of the issues that seems to come up fairly frequently in our members' minds. I am sure there are issues that have been raised by some witnesses before you about how much technology you can use, how much you can knit together our very fractious system through the use of technology, and I would just wonder if that has been a theme with your witnesses here around this table.

The Chairman: Just to comment - yes, it has been, and you saw a very good example of it in the exchange between Dr. Boucher and I guess it was Senator Pépin, when Dr. Boucher said "They shut the machine down at 15:00 in the afternoon, so I have patients waiting for nine months". It does not take a genius to say that, since you have made the capital investment, there is something wrong with that system. By the way, it is not unique to Quebec.

What we have heard is a lot of comments about capital investment being made in equipment, and then equipment not being operated full-time. By "full-time" I mean if not 24/7, then at least 18 hours a day, or something like that.

Monsieur Taillon, go ahead.


Mr. Taillon: I think it is important, and I share Senator Kirby's opinion, to see what is done better elsewhere and find the most interesting ways of adapting that to our own reality. I do not think we can copy existing models as such. We absolutely need a combination that blends the best of private contribution and public contribution. Each one of those sectors could go ahead and give its best performance and use complementary means. I think that is the objective. If there are any profits after that, all the better, we prefer businesses that make profits. We prefer them to businesses who generate losses and fire people.

Senator Pépin: You partially answered the first question. The second question, Mr. Taillon, pertains to the recommendations you made and with which a lot of us agree, I think. You are saying, in fact, that service should be accessible 24 hours a day. I think we have to look at that very seriously. In making your recommendation, you say that the institutions have a great deal of independence in the management of human, material and financial resources under present funding arrangements. That means restructuring staff through the unions.

Mr. Taillon: We are quite aware that this recommendation is daring. Our colleagues on the other side, as we usually call them, are not always in agreement with that. But we think that if we want a service that offers quality care, we must not maintain rigid work organization. So human resources management must be decentralized and referred to the lowest level, where the service is actually dispensed, and that is essential.

Negotiations can be possible between systems X and Y. We have to have the courage to set up those systems. Otherwise, just the same as if we do not set up capitation as the preferred funding system, we will not be able to reform our health care system. You will probably get another mandate in a few years to come back and see us to discuss how to settle the problem of lack of funds.

Senator Pépin: So I have understood you clearly; thank you.


The Chairman: May I thank all of you for coming here today. We appreciate your taking the time to be with us.

Senators, we will adjourn until 1:45.

The committee suspended its proceedings.


The meeting resumed.

The Chairman: First, I apologize to our witnesses for being late. We ran about 45 minutes late this morning because we started with Claude Castonguay and Claude Forget, and it was difficult to wind up the discussion in the length of time we had, so I appreciate your tolerance.

Senators, our two witnesses this afternoon are, first, Jean-Luc Migué, who is chairman of the scientific council at the Montreal Economic Institute, but also a senior fellow with the Fraser Institute in Vancouver; and second, Dr. Lee Soderstrom from the Department of Economics at McGill.

Can I ask each of you to take a few minutes, not to read your brief, but to hit the highlights of it, and then we will turn to questions. Again, please accept my apologies for the fact that we did not run the ship on time this morning.


Mr. Jean-Luc Migué: Mr. Chairman, I have entitled my presentation "Returning to Basic Principles in Health Care Services" because, for some time now, the public debate seems to be surrounded by some kind of mythology which has led to the current regrettable - if not appalling - situation in health care services. I want to return to the basic principles to dispel these myths surrounding the public debate.

To begin with, I take it for an established fact that the current health care conditions are disastrous. This can be measured by the long waiting lines, unequal access to services, lack of access to modern technologies, or the shortage of professionals. Conditions are appalling. Illusions have created a certain number of myths. The first one that comes to my mind is the belief that, under our free system, it is the patient who is sovereign, who makes his own decisions, and that the system adapts to the needs and preferences of the population. Nothing could be more removed from reality than this myth. It is rather the political and bureaucratic system that determines the allocation of resources, the system's capacity, the number of hospitals, the number of hospital rooms, and the number of doctors. Ten years ago, we judged it excessive; for the past few years, we have been judging it insufficient.

This is a system in which it is forbidden for an individual like you and I to contract, for a diagnosis, with private providers to get a diagnosis, to get quality services, and even to add insurance that would guarantee the quality of these services.

The second myth that characterizes our system and the debate around it is that equal access, consistent access to services is an ideal. Consequently, the advent of a dual private/public system such as the parallel system has become a kind of threat, while in reality, economic theory and experience show that the coexistence of two systems increases the capacity of the system and enables everyone, whether they stay in the public system or access private services, to better meet their preferences and needs.

This way of depicting the dual system as a two-tier system, this perception - by the opponents to the dual system - is based on a concern to maximizethe the public budget rather than the health budget. Ideally, the system should have 31 million tiers in Canada since there are 31 million people. This is the ideal to look for.

This is not the unique system. It is not two-tier; it is 31 million tiers. The opposite vision which dominates the debate is the most widespread. The World Health Organization promoted this so-called "fairness," that is, egalitarianism, as being the first principle of the quality of a system.

As a result of this, Canada ranks thirtieth in this hierarchy, behind African countries and clearly underdeveloped countries. Of course, these people enjoy egalitarianism, i.e. everybody has nothing in terms of health services, but they are equal.

Yet this is the ideal that is often proposed to us. In addition, this vision contradicts, as it were, the basic principles of moral in economy, because egalitarianism implies that the most careful, conscientious, and disciplined people in terms of health services receive the same services as careless people, those who mistreat themselves and have no concern for their health. Yet they have access to the same public services and at the same price, i.e. zero dollars.

I would also like to add another very important dimension according to which the state of our system only requires administrative, or managerial, reforms - better planning as it were.

Actually, our system is condemned in its very nature, in its very essence. In our system, all agents, including consumers, pro ducers, doctors, hospitals, politicians, and bureaucrats, have the wrong incentives, i.e. they all have an interest to adopt inefficient and anti-social behaviours, as it were.

As we know, and literature is convincing about this: consumers abuse the system. The Rand Corporation has demonstrated this. Its demonstration was later confirmed by works I could quote, i.e., for example, under the American system, people who acquire Medicap, i.e. who get more insurance than required by Medicare, consume between 25 per cent and 30 per cent more than those who do not have this insurance.

What is the greatest institutional innovation in health care? It is managed care; not only the American version, but the institutional formula by which production was combined with insurance. This is the essential characteristic of managed care.

This resulted in savings of 10 per cent to 40 per cent. Why? Because in managed care, as opposed to conventional insurance, there is someone who is concerned with saving. Under traditional private insurance, however, consumers abused the system. Doctors are given the wrong incentives, but so are hospitals.

Our system suffers from what Mr. Hayek, Nobel Economy Prize a few years ago, characterized as a "fatal conceit," a kind of fatal pretence that we can collect all the information required to plan an entire system like the health system.

This fatal pretence according to which, through central directions to administrators, we can get all the quality, innovation, and savings we want from producers like hospitals, is an unlikely pretence.

Hospital administrator are administrators, period. We removed the innovators from our system. These are people who have an interest in innovating, developing new ways to produce and save. However, we have criminalized private capital. We have criminalized profit to the point that there is a lack of funds, investment, and innovation in today's system.

The other myth is the perception of no-charge service and public production, of public monopoly as a symbol of social justice; as the expression of compassion that we, Canadians, would have and that the current system would inspire.

In fact, when people call, for example, for more taxes to save the system, they are calling for more taxes for their neighbour. Economic theory and analysis demonstrate beyond any doubt that all political choices are dominated by the fact that a majority of people want to unload the cost of their services onto their neighbours. This is what we observe in health care.

The majority of people or households in Canada with an income of $46,000 unload the $1,500 per year cost of their health services onto a minority with an income of $62,000 per year, i.e. the average income in Canada. Consequently, the first rule in our system is to unload the cost of services onto their neighbour.

The second principle is the domination of interest groups in public decisions: of course, people are rationally apathetic; there is such a thing as the silent majority, and this gives free rein to interest groups, to producer groups. For example, 80 per cent of our hospital costs are made up of labour. Therefore, union policy dominates our hospital management and production, while next door in the United States, this percentage is 55 per cent.

I will now turn to my political corollary, if I may. To free ourselves from these illusions, and at the same time guarantee access and resource savings, it seems to me that there is a privileged way which would consist in putting consumers, patients, back in the centre of the system, i.e. to restore choice.

However, choice is incompatible with public assistance, and even with public funding. It is simply the accumulation by families, by individuals, of what I would call health saving funds, similar to retirement funds, which would be funded by individuals as well as public budgets, through which individuals would recover full sovereignty in terms of public choice.

For example, if public allocation were established at $1,500 or $1,800 per year, this would mean that these $1,500 would be affected, according to the wish of individuals, to this budget beyond this allocation, which corresponds with the $1,800 budget. This is the average cost in Quebec, and $2,200 on average for Canada as a whole.

The advantage of this system is that, beyond the proposed allocation, individuals would be responsible for their decisions, i.e. they would carry the burden of their decisions. Incentives would be for providers. Individuals would request services beyond this minimum from the providers, doctors, and hospitals, with all ensuing incentives. According to the Canadian ActuarialAssociation and the Consumer Protection Institute, this could represent about $6 billion per year in savings, which is quite significant considering an overall public budget of approximately $60 billion.

The advantage of this system would be that the funds belong to the individual, who would therefore benefit from sparingly using his resources. This would also introduce a greatly desirable competition in a system that is characterized by public monopoly. We would achieve the fairness objectives, i.e. equal and universal access to health services, but in a system that would conserve resources.


Dr. Lee Soderstrom, Professor, Department of Economics, McGill University: I presume everyone has a copy of my text, and you will notice on the fourth page what is essentially a table that I will address in the second hour of my presentation this afternoon.

Thank you very much for the opportunity to discuss with you your fourth volume; my remarks this afternoon are based on a reading of that volume. After reading it, I would like to make two fairly general points. The first is that I would urge the committee to give more attention to the economic efficiency of the various reform proposals being considered in the report.

As I read through Volume 4, I was struck by the fact that there was almost no discussion of economic efficiency in that document. There were a number of references throughout the document to the general idea of social equity, but very little was said about efficiency. This was a great surprise to me, because having worked in the health care system now for almost 30 years, I realize that most health planners, when thinking about reform of the health system, are concerned about two basic issues: What are the impacts of the reform on, first of all, equity, and secondly, what is the impact on economic efficiency more generally?

When I started to read the report, I got as far as page 5 before I realized that something was amiss. I read:

Canadians have opted for universal public health care insurance on the grounds of compassion, equity and fairness.

Surprisingly, absolutely nothing was said there about the efficiency gains of public insurance.

Now, I teach, and have long taught undergraduate and graduate students in health economics. When I talk about insurance arrangements, I tend to focus on the effects that those arrangements have on efficiency, not on equity. There are major equity gains to be made with public insurance schemes, and there seems to be no recognition of that in this report. I'll come back to that point in a little while.

As I continued to read the report, I noted that the authors suggested on page 34 that:

It is important to balance public and private involvement in the health care field.

When I read that, I asked myself why should such a balancing act be socially appropriate? The role of the public and private sectors, it seems to me, and, I think, to most health planners, should be dictated by their impact on the twin goals of equity and efficiency. There is nothing socially desirable about a balancing act, per se.

Now, after reading that phrase, I began to ask myself what was going on with the report, what sort of vocabulary was being used. It occurred to me that the authors of the report were using "public involvement" and "private involvement" as code words. Public involvement was seen as indicating a concern about equity. The idea is that public involvement will promote equity, but, alas, will have adverse effects on efficiency. The phrase "private involvement" was being used as a code word to indicate improved efficiency. The thinking there is that private involvement would promote efficiency, even if it did have some adverse effects on equity.

If this were the belief of the authors, the notion would be that by balancing the public and private sectors, you would in fact have some sort of a balancing of concerns about equity and efficiency.

That seemed to be a plausible interpretation of what the authors were doing. However, there is one major problem, and that is that the view that apparently rests with the authors, as well as many in Canada, that the private sector promotes efficiency, is not correct. The available research indicates that the private sector is not always more efficient than the public sector in the health care field. This essentially brings me to my second point. I think the committee should pay more attention to the extensive research indicating that various forms of privatization would not improve the efficiency of Canada's health care system.

In Volume 4, the authors list many different proposals for increasing the involvement of the private sector in health care. They talk about expanding the role of the private sector in finance and in the provision of services.

How do we evaluate those ideas? My point is that we evaluate them by thinking about what impact they will have on equity and efficiency. One does not want to simply speculate as to what their likely effects would be, one wants - and this is what research exists for - to know what their likely effects are going to be. To get a feel for what those likely effects will be, we turn to the research evidence. We are very fortunate that there is a very large and rich research literature in which people have evaluated many of the proposals being considered by this committee. Unfortunate ly, little use is made of this rich literature in Volume 4. Almost no reference is made to that literature, which I find very surprising.

Throughout the volume, one finds various references to experiences in other lands - reforms in Sweden, in England, in other parts of Europe, and things going on in the United States. That is just descriptive information; just because the Swedes are doing it, the Germans are doing it, or the Americans are doing it does not necessarily mean that it promotes equity or efficiency. The only way we can get a feel for what those effects are is by looking to see what sort of evidence there is where people have actually tried to evaluate it. My point is that the committee is faced with a situation where there is a rich body of evidence. Unfortunately, the committee does not seem to be making use of it, judging from the text of Volume 4.

The committee talks, in the report, about wanting to have a non-ideological debate. I agree with that view. However, it would seem to me that the best way to promote that non-ideological debate is by providing a good summary of the research evidence that is out there, and some analysis of what those research findings imply. That is not in the present report.

Now, what does one find if one goes through this literature? I have tried to give you, in the text, some feel for what you will find if you go through the literature, but I've summarized it there in Table 1. Let me just quickly go through Table 1 to conclude my remarks.

First of all, under private financing of health services, two possibilities are extensively discussed in the report. First, we know from extensive research that private insurance is more costly because it involves higher administrative costs.

With user charges, the second frequently mentioned scheme, we find that they do not seem to be able to reduce health care costs. The best study of that is from Saskatchewan and its experience with user charges in the late 1960s.

Two other examples, if I move down in the table, relate to the private provision of services. One is for-profit hospitals. There is an enormous amount of literature here, particularly American, relating to the effect of for-profit hospitals on hospitalperformance. This literature extends over 20 years, with a bibliography of probably 30 to 50 articles. What is so striking, and it was certainly striking to me when I first encountered it, is that this literature tends to suggest that for-profit hospitals are no more efficient than non-profit hospitals. The for-profits make their money through charging higher prices, not through greater efficiency. There are a lot of studies to indicate that.

That is an important result for two reasons. One, it suggests that we have little to gain by thinking about privatizing hospitals. Secondly, because there is so little work in other areas, it warns us that we should not think that turning to the private sector would prove to be an effective way to improve efficiency. The literature here is very extensive.

There is one last example. If I go down to the bottom of the table, to for-profit nursing homes, there is an exception. We have no Canadian literature on this point, but the American literature does in fact tend to suggest that for-profit nursing homes are more efficient. They tend to have lower costs, and the quality of care seems to be about the same as with non-profit homes. Here is an area where looking at privatization might in fact improve the performance of the Canadian health care system. It is striking, I think, that there is no reference to this literature in Volume 4 of the report.

Having stated my two points, I will stop there.

The Chairman: Thank you. I agree that it would be really useful if we had a summary of the basic research results, and you have put them in point form on your Table 1. Is there a document or something that synthesizes the available research? I understand what the conclusions will be, but is there such a synthesis?

Dr. Soderstrom: I am not aware of an up-to-date document that covers all of those fields. I have been sort of collating the evidence now for the last two or three years. However, your research staff surely would be familiar with that literature.

The Chairman: Yes. People have done comparative studies, so that is okay.


Senator Morin: I would have a certain number of comments to make, Mr. Migué. I think you agree that multiple insurers for the same service increases the complexity of the system. In fact, this is why you propose a single payer.

The problem with the reduction of health costs by the patients is that it opposes two values. Is it under-consumption? For example, the people who do not benefit from Medicare in the United States are often poor patients who under-consume health care.

Obviously, if we do not have insurance, and if we do not have personal funds to consult or pay drugs, there is often under-con sumption. With under-consumption, it is always very difficult to evaluate the effects of health care.

Health care is essentially quality-of-life care, and there is no point in simply evaluating mortality cases.

The greater part of health costs of industrial health saving funds, that is, 40 per cent, are really affected, as they are only spent on the health care required for the three last months of our lives. Almost 30 per cent of health care goes to people with chronic diseases, such as multiple sclerosis, rheumatoid arthritis, or to people who are generally handicapped. And for these two groups of people, industrial health saving funds are more difficult to obtain. Of course, the relationship between healthy lifestyles and health costs is not always as obvious. The more we age, the less the lifestyle we had when we were younger has an effect on our health.

Mr. Migué: As regards under-consumption, nobody would think of depriving the less fortunate people of the assistance required to access services.

Data show that, in terms of consumption, when responsibility is imposed by consumers, they tend to adopt wiser behaviours, that is, to consume less without jeopardizing their health. Imposing some form of responsibility on consumers is generally followed by a reduction in consumption without any deterioration of people's health. These are the results of the Rand Institute and several other studies. The principle I am stating is that a system is not established to meet the specific needs of 5 per cent to 10 per cent of the population.

As for the very accurate observation you made for certain individuals and consumption, the needs are so huge that this may ruin them. Proposals relating to building a health savings fund always involve the hypothesis of a disaster insurance, beyond a certain number.

I did not attempt to operationalize the system because, I have no illusions, I doubt that we ever adopt it. In any event, it is not for me to operationalize the system. However, for the kind of problem you raise, there is a limit to pay beyond which public or private insurance would take over.

If I may, I would like to make an observation about what was said by my colleague, with whom I differ fundamentally, although we are both economists. The principle is to say that my colleague uses the term "efficiency" in a generous way. However, efficiency to him, if I get it right, is to minimize costs as if this were an objective.

However, there is only one principle of efficiency in economy, not eighteen, not two, and it is first and foremost based on the individual's supremacy. Economists have a moral and philosophical principle - the only one ever in economy - and it is the principle of the individual's sovereignty, of the individual's supremacy.

Do you understand? Of course savings can be made by depriving people of what they want. This is exactly the system that brought us to the current circumstances. So I want to disagree with my neighbour, who proposes efficiency as having the only goal of minimizing costs. Do you understand?


Dr. Soderstrom: Excuse me; let me clear the record. I never said that.

Mr. Migué: You did. Implicitly, that is what you were saying. Hospitals got less here, and more there.

The Chairman: Senator Morin?

Senator Morin: Well first of all, Mr. Chair, I'd like to take exception to the finger pointing. Professor Soderstrom is stating that we did not consider the evidence. This was an options paper in which we just posed questions. Why should we consider evidence when we pose questions? I do not agree with this finger pointing at us. We cannot be that wrong in posing these questions for two reasons. If things were that clear, why would every OECD country, without exception, have private insurance and a flourishing private sector, and even be considering using it more? Prime Minister Blair said recently that he wants greater use of the private sector; Sweden is going into the private sector more than in the past and so is Australia.

Why should we be blamed for considering this as an option? Why should somebody tell us that we are not considering the evidence?

There is another good reason why we should propose this as an option. As you have just heard, Professor Migué on your left, who is a renowned economist and has published books on the health care system, takes the opposite position to yours. He believes that we should make greater use of the private system.

Therefore, I do not agree at all, and I take exception to this. It is perfectly correct for you to state your point of view. However, we are not in the position of having to be subjected to this finger pointing and these accusations.

Concerning the efficiency, I do not think we should have a single payer, so on that point I think we agree.

Concerning what you call "for-profit production of health services," witnesses have appeared before us stating that, on the contrary, there was considerable recent evidence demonstrating that the for-profit providers were more efficient and produced better outcomes. I realize that you point to evidence, but we do not have any references in your document. What does "American and Canadian research" mean to me? At least we should have had the references.

Having said that, I know the material you are quoting, but many witnesses have appeared before us to say there is recent evidence that for-profit providers have better outcomes at lower costs than public providers. I am not saying that we should go private all the way, or public all the way, but I think we should consider the possibility of moving towards private providers to some degree.

Dr. Soderstrom: It seems to me that if the committee wants its report to generate debate and discussion that is educated and not ideological, it should be trying to inform the readers of its reports as to what is known about various proposals. I have no problem with the committee listing all kinds of proposed reforms, whether they involve a greater role for the private sector or the public sector. There are some things to be gained from expanding in the direction of the private sector, but there may also be things to be gained from expanding in the direction of the public sector.

My point is that it is important to ask the right question. The right question is not how do we balance the public and private sector, it is what can we surmise will be the likely effects on equity and efficiency. With due respect to the other testimony, I go through the scientific literature where people have made serious evaluations of various proposals, and what you have in front of you is very up-to-date.

I will give you one example, the interest in private clinics. Eighteen months ago, in the New England Journal of Medicine, one of the two leading medical journals, a study was reported on the adverse health effects of private renal dialysis clinics. That is up-to-date research, and that is what you have in Table 1.

Senator Robertson: Just turning to your table here again, I am sure that you would be able to give us information on the why's of these things. For instance, in your for-profit nursing homes, where there are lower costs of care, lower costs for quality of care, and...

Dr. Soderstrom: Oh, that is a typo. That should be, "No effect on quality of care" for the nursing homes.

Senator Robertson: So it is the same, whether it is for profit or not?

Dr. Soderstrom: Yes.

Senator Robertson: Therefore, in this literature that you are referring to, there must have been some indicator or indicators of why a for-profit nursing home could have lower costs and still have a balance of quality of care and access. Could you advise what the commentary was that gave this result?

Dr. Soderstrom: Off the top of my head, no. I am not a specialist in that area. I have just gone through the literature and made a summary of what the findings were.

Senator Robertson: We would have to search that out and see why, because it stands out. I do not challenge your integrity on this at all, but I am always just a little concerned about a table without proper references to back it up.

The Chairman: Just to help to emphasize Senator Robertson's point, it is indeed puzzling that for one part of the health care sector, which involves institutions and their provision of service and so on, you say that the quality is basically the same and costs are lower. Then you have to say to yourself, is it not odd that that does not, apparently, according to the table, extend to any other institutions that deliver services? There is one of two conclusions; either there is something totally unique about long-term care - and I do not know what it is, but that is a question - or one has to say that the research is probably not correct, because there has to be a rationale. You cannot just say that one segment works, and I am not being critical. I am asking about the literature here. You understand that the literature creates in your mind the idea that either part of the research is not correct, or there is something unique about long-term care, in which case, what is it?

Dr. Soderstrom: I would think that it is probably the latter. One of the things that is striking about this literature, particularly if we look at hospitals and the nursing home literature, is that there are a large number of studies out there, using different methods and different variables, that are all coming to basically the same kind of conclusion, and that is the kind of thing that researchers look for. It is the pattern of the results. The basic pattern is that in both the non-profit hospitals and the nursing homes, quality of care does not seem to be adversely affected.

I apologize for not providing you with references. I made a deliberate decision not to do that, because when I have done so in the past, people have looked at my documents, seen long lists of references, and gone to sleep. However, if the committee would like references to support those claims, I would be more than willing to provide them. That is not a problem here.

Senator Robertson: Coming down to very basic issues that the public is well aware of - and we relate to the public because most of us have been around for a long time dealing with the population in one capacity or another - one of the two factors that we hear about all the time is the long waiting times to obtain care. Most people are reasonably happy once they get into the system, but they worry about waiting to get into the system for very critical assessments of problems. Of course, the other factor is the professional shortage.

I am listening very carefully; how would your beliefs affect both of those issues?


Mr. Migué: Mr. Chairman, if I may intervene. I have taken for granted that the two dimensions you raised outlined the fundamental deficiencies of our system. These deficiencies were due to the fact that the incentives offered to all parties in the health system, i.e. consumers, service providers, doctors, hospitals, clinics, politicians, and bureaucrats, were wrong. Everyone had an interest in adopting inefficient behaviours. So much so that, to correct this, consumer sovereignty must be restored, and at the same time, consumers must be able to express their true preferences. Consumer choice and competition must therefore be reintroduced in the system, and the system's capacity must be increased, in terms of providers. By reintroducing consumer sovereignty and individual funding with savings, there will be additional calls for services.

As a result, there will be more doctors, more services, diagnoses and equipment, treatments and diagnoses, and the capacity of the system will increase. Waiting lines will also be reduced, as observed in Europe and elsewhere.


Senator Robertson: Are you then looking at a public and private payer in your model?

Mr. Migué: For sure, but in my model, individuals express their wish, using their purchasing power, to public and private suppliers.

Senator Robertson: You find there is no contradiction there?

Mr. Migué: Not at all. As a matter of fact, it is common practice almost across the world.

Senator Robertson: I understand that, except for here.

Mr. Migué: Except for here, and I think Cuba and North Korea are also exceptions.

Senator Robertson: Yes, the exceptions. I just wanted to be very clear where you were coming from, sir.

The Chairman: I do not think we will pursue that line of questioning.

Dr. Soderstrom: Can I just respond briefly to that question? I do not think there is any magic solution to waiting lists by going the route of user charges or private insurance. Perhaps we have a lot to learn, though, from some experiences in Ontario. I think somewhere in Volume 4, you make reference to the very positive experience in Ontario with better-managed waiting lists for cardiac patients, and I am surprised that the report did not make more use of that experience. There you are getting a sense that if you have a better-managed system, you can in fact deal with some of these waiting list problems fairly effectively. These waiting lists often exist in situations where things are not being well managed.

Senator Robertson: Therefore, we have to have better management to balance the system.

Senator Keon: I cannot resist. That Cardiac Care Network was designed by a very brilliant person; that is why it worked.

The Chairman: Who happens to be asking the question.

Senator Keon: Mr. Migué, you began to extol the virtues of managed care, but because of the lack of time, you did not go on. Would you expand a little on managed care and the contribution you think it has made, because I have also heard it severely criticized, by the medical profession in particular.

Mr. Migué: What I have read on this topic states that managed care is the greatest institutional innovation in health care in the last 50 years, and its first most important contribution has been to combine production of services with insurance. People in the system have an interest in economizing; that is, not wasting resources, not over-consuming and not allowing physicians to over-produce. Often, but not always, the doctors' remuneration is generated differently. Also, competition is maintained to the extent possible in health care.

Theoretically, we have the best of both worlds.


Mr. Migué: The obligation of having agents in the system who are concerned with saving cannot be avoided. Under the current system, there are none. In our system, we are faced with the wrong incentives, and consumers feel the need to over-consume, and producers to overproduce. Capacity has been blocked; capacity is static. The number of hospitals, rooms, doctors, et cetera, is predetermined, and of course, consumers line up, which results in a reduction of quality.

This is very harmful in terms of individual sovereignty and supremacy. The managed care system, on the other hand, introduces awareness of costs while maintaining competition and, hypothetically, consumer sovereignty. At any rate, savings were real.


Senator Keon: It is interesting that the American Medical Association managed to get that right up front on the agenda of the last presidential election. President Bush referred to it several times.

Mr. Migué: That is it.

Senator Keon: He said that he would like to see the system go back to the point where decisions were made between the patients and their doctor. Nothing has happened, to the best of my knowledge, on that, but certainly there was tremendous resistance to that in America.

Mr. Soderstrom, will you comment on it from a health economics point of view?

Dr. Soderstrom: There are some interesting features in managed care, but let me approach the question from a little larger context.

One of the things that I think the American experience teaches us is the importance of good management in a health care system. Prior to the managed care plans, as you probably well know, there was extensive experience with HMOs, which were controversial, but they were very attractive to many health planners. To my way of thinking, the key feature of the HMOs, and the reason for their success and why they were copied by the managed care operations, was that they had good management, with good responsibilities, good incentives and good information. Managed care has tried, to some extent, to replicate that. I think we could learn a lot in Canada about the importance of good management.

In various things that I have written, for example, for the commissions here in Quebec, I have suggested various ways in which we could capitalize on those ideas. The idea here is the importance of having good health system management, if we are going to have a system. It deals with the waiting list problem, as well as a lot of others. My fundamental concern with the Canadian health care system today is on the management level.

The Chairman: I have a question for the two of you, but perhaps most importantly, for Professor Soderstrom. It has to do with research that is comparable and relevant in Canada. I do not know the answer to this, so it is a genuine question. Given that the Canadian system and value structure are much more similar to that in most European countries, or even in Australia, to what extent can U.S. research results on, for example, the pros and cons of for-profit institutions, be extrapolated to Canada?

I ask the question because it seems to me that in the U.S., which does not have a universal system except for medicare patients - so ignoring people over 65 for a second - the attitude of the profession is quite different from the Canadian attitude. The set of values of the Canadian profession is somewhere between the European set of values and the American set of values. Therefore, I have always been a little hesitant about just taking U.S. results and extrapolating them to Canada.

Am I right to be leery, or can I just assume that if something is true in U.S. literature, it is automatically true in Canada?

Dr. Soderstrom: No. The key thing here is to decide what you are trying to extrapolate. I would be concerned about trying to extrapolate the experience with managed care in the United States to the Canadian context, for exactly the kinds of reasons that you listed. I have no problem there. However, when we are talking about private versus public insurance and the potential for high administrative costs with private insurance, I think one can extrapolate those results without great difficulty.

I think you have to be a little more careful when talking about the cost differences between for-profit and non-profit hospitals. That is a kind of middle ground.

The Chairman: That is partly why I asked the question.

Dr. Soderstrom: Yes, and the reason I say that is that the studies are comparing American for-profits with American non-profits. The Canadian non-profits are different from their American counterparts, in part because they have already been squeezed financially now for 20 to 25 years, depending upon where you want to start the clock. Arguably, they might be functioning better than their American counterparts, which would suggest that the Canadian non-profits might be more efficient, which in turn would underscore my earlier point about nothing being gained by going the for-profit route.

The Chairman: Then let me just ask you one last question, because I think certainly Dr. Migué would argue that - and I use a different terminology here - the money should follow the patient, not go to the institution. Professor Soderstrom, you made the argument that the single-payer system is more efficient, and I do not think that anybody argues with that.

What are your views on separating the payer from the producer of the services, which essentially combines both ideas? In other words, a hospital would not get a global budget, but it would be paid for the services it performed. The patient would still be covered by public funds because it is a universal, publicly funded system. Do either of you have any comment on that structure?

Dr. Soderstrom: I would have no problem with that. In principle, I see no problem with that sort of a scheme. I would ask, is there some evidence that would lead us to think that that would actually improve the performance of the system?

The Chairman: Well, it would certainly improve patient choice.

Dr. Soderstrom: Yes, it would.

The Chairman: That is worth something.

Dr. Soderstrom: I agree, but one has to remember here that you have to be careful on patient choice. Patients currently have a choice. I can go to the Royal Victoria or I can go to the Montreal General. The thing that really determines what hospital I go to is not so much my preference, as where my physician has admitting privileges. That is what tends to operate, and I think that is true of most of the American schemes. Going back to your basic idea, there is nothing wrong with that. I think hospital care is probably a very good example of where perhaps there should be a greater tendency towards having dollars follow the patients.

The Chairman: Okay, but then it would follow, I presume, that you would not care who owned those institutions?

Dr. Soderstrom: Oh, absolutely not. That is not an issue. The issue here is not who owns it; it is a question of what are the results.

The Chairman: All I am saying is, in the model I suggested, where the price for a hip replacement was paid to whatever institution the patient went to, the public-versus-private issue does not arise because you do not care whether the institution is public or private?

Dr. Soderstrom: Not on the level of principle, no.

The Chairman: I always worry when people say "the level of principle, but..."

Dr. Soderstrom: No, no, no. I want to be consistent here. Our decisions about what kind of institutions we have ought to be dictated by what we know about the effects of different kinds of institutions on equity and efficiency. That is my point.

The Chairman: I thank the two of you for coming. That was very helpful.

Senators, our next panel, from the Montreal Economic Institute, consists of Dr. Edwin Coffey, who is the former president of the Quebec Medical Association, and Michel Kelly-Gagnon, the executive director of the institute.

Thank you very much for coming.


Mr. Michel Kelly-Gagnon, Executive Director, Montreal Economic Institute: Thank you for accepting to hear us; this is an honour for us. I am the Executive Director of the Montreal Economic Institute. The Montreal Economic Institute is a private and independent think tank which is the Quebec counterpart of the C.D. Howe Institute, or other similar organizations.

Our operations began on June 1, 1999, and we operate on an annual budget of approximately $500,000. For those who are interested in knowing more about the Montreal Economic Institute, please refer to the blue corporate brochure that was probably distributed to you.

Before presenting Dr. Coffey and leaving him the floor, I would like to share with you a brief observation, which is very simple but, I believe, nonetheless crucial. I am sure you are aware of this observation of people as distinguished and knowledgeable as you are. However, it is sometimes useful to outline certain key elements, with a yellow marker or red pencil, to allow the Canadian population to be exposed to this distinction when your report is made public.

If we want to have a rational and constructive debate on an eventual reform of the health system, a distinction must absolutely be made between two very distinct things: first, a state monopoly on health care insurance and production in Canada, and second, the universality of health care. I use this term not in a technical or legal sense, but to refer to the principle according to which all Canadians, regardless of their income level, have access to a reasonable basket of quality health care services within a reasonable time.

I make this remark because, since I have been observing the debate on this issue, I have observed that there are different groups, different people, and different political parties who constantly maintain the confusion between the two concepts. Both ideas may have merits. These are two distinct principles: state monopoly is one thing, and universality in health care is another.

The experience of the vast majority of OECD countries proves the point I am making, i.e. countries like France or Germany have universality in health care without the monopoly as we know it. If the report outlined very clearly this aspect so that everybody could make the distinction in the future, you would have accomplished something great.

Without further delay, I am pleased to introduce Dr. Edwin Coffey.


Dr. Coffey is a research associate at the Montreal Economic Institute, a retired associate professor at the Faculty of Medicine of McGill University, and also the co-author of "Universal Private Choice," a publication of ours that inspired our brief, of which I think we sent some copies to your committee. If that is not the case, we can make sure to provide you with both French and English versions of that publication.

Dr. Edwin Coffey, Retired Associate Professor, Faculty of Medicine, McGill University, and Former President of the Quebec Medical Association: First, I would like to thank you for inviting us to share our comments and suggestions concerning the state of Canada's health care system and the roles and objectives of the federal government in health care reform as proposed by your committee.

Rather than reporting a litany of well-known problems and shortages in the system, we will concentrate on policy options and suggestions for improving the legislative and economicenvironment in which Canada's health care system is situated. Such improvements and modernization will permit and encourage pluralistic and alternative methods of public and private financing, insuring and delivery of medical and hospital services. We consider this to be the best overall approach to achieving the goals and objectives of the first five federal roles in health care described in your interim report on issues and options.

We are generally in agreement with these roles and objectives, but there are some minor exceptions. For instance, in the financing role, under the transfer of funds for provision of health services, we have suggested a rewording, a bundling together, and a reduction of the objectives to three from four. This would better motivate legislators to rescind the provisions in their health and hospital insurance legislation that now prohibit private, alternative health insurance and private contracting of medical services in hospitals.

In the same section, we suggest the promotion of sustainable reform and renewal in the public, private, and mixedpublic-private systems of health care and health insurance. This will better ensure quality, access and free choice in health services than simply providing stable funding of the status quo, which does not necessarily ensure sustainability nor foster reform and renewal.

Under the infrastructure role, we have suggested a rewording of the final objective concerning the planning of human resources. This would motivate the provinces and territories to remove unreasonable restrictions on the free movement and location of physicians and allied personnel, and encourage the provinces to rely less on outmoded practices of central planning and social engineering.

Finally, we would direct your attention to the Montreal Economic Institute's recently published proposal for health system reform in Canada, entitled "Universal Private Choice: Medicare Plus," a concept of health care with quality, access and choice for all Canadians. This approach to universal access through parallel public and private health care and health insurance systems is somewhat like the European approach. I had originally said "surprisingly," but I scratched that out. It is compatible with most of your committee's objectives. It awaits a rigorous field trial, however, and an evaluation along the lines suggested for pilot projects under the federal role in research and evaluation.

That concludes my introductory remarks, and we would entertain any questions.

The Chairman: I have a question on your latter point. Would not the kind of pilot project you want violate the principles of the Canada Health Act as they now stand? The pilot projects for primary care reform that the federal and provincial governments agreed to a little over a year ago were all to be consistent with the Canada Health Act.

Dr. Coffey: Yes.

The Chairman: The kind of pilot project you are talking about requires a change because it would be outside the Canada Health Act.

Dr. Coffey: Yes.

The Chairman: Unfortunately, the Canada Health Act does not give the minister the right to allow certain things to be done outside the act on an experimental basis, in other words, not to change the act, but to say, "Here is a new way of looking at the delivery. Let's try it, even though it violates the Canada Health Act. We will allow it to happen purely as a pilot project." The minister does not have the flexibility to do that. I am not arguing that he should not have that flexibility; I am just telling you that he does not. In order to do the kind of thing you are talking about, there would have to have that flexibility, right?

Dr. Coffey: That is right. We would have to do what all the other countries in the world have essentially been doing for 40 years, that is, experimenting with health systems financing.

The Chairman: Right.

Dr. Coffey: Unfortunately, since the Medical Care Act, we have not had any health system experimentation in Canada.

The Chairman: Health system financing experimentation?

Dr. Coffey: In financing, yes.

The Chairman: Now you could not do that. Prior to '84, you actually could. You could have experimented.

Dr. Coffey: Well, you could not in Quebec.

The Chairman: No, you could not. In any event, you cannot because of the Canada Health Act.

Dr. Coffey: Yes.

The Chairman: All I am saying is, people did start experimenting in the late 70s and early 80s.

Dr. Coffey: Yes. I suppose we might consider that they are approaching an experimental model in Alberta, if they are able to move it forward.

The Chairman: On that, by the way - and I look at Senator Morin and Senator Keon when I say this - when we made our western circuit, we heard from people running private clinics in Manitoba, Alberta and British Columbia. The people from Manitoba and British Columbia both said that the last place they would go to start a private clinic would be Alberta, because of the famous Bill 11. It so constrains their options.

Dr. Coffey: That is right.

The Chairman: In fact, they said it was much worse than if Bill 11 had never been introduced in the first place.

Dr. Coffey: Yes. Newfoundland would be the ideal place.

The Chairman: Why?

Dr. Coffey: They have no prohibition against private health insurance, for one thing.

The Chairman: Is that the only province?

Dr. Coffey: No, there are six provinces that forbid private health insurance. In Newfoundland, I understand that even physicians who opted into the provincial plan can still opt out on an individual basis, if they and their patients are agreeable. Unfortunately, with the state of the economy, there is very little demand for private services.

The Chairman: You can always offer a choice, but there is no chance that anyone will take it, right?

Dr. Coffey: More or less, yes.

Senator Morin: I would like to come back to the single-payer concept that was referred to earlier. Do you not think that having multiple payers will increase the complexity and the cost of the system? One of the major problems for U.S. providers, where they have multiple insurance companies, is that dealing with all the various plans does increase the complexity and the administra tive costs. What is your opinion on that?

Dr. Coffey: This is, of course, the reason for experimenting with multiple providers and multiple payers. We do not have a Canadian base of knowledge to answer that question properly. Looking at Europe, where there are multiple providers, multiple payers and public-private parallel systems, it seems to work. Competition is a great leveler of administrative costs and so on. If you had health plans, health insurance, and even hospitals competing, if you had a completely open system with competition among hospitals, the management would certainly be efficient. That would be particularly true if the funding, both public and private, came with the patient rather than from the health authorities.

Senator Morin: It has been said that 75 per cent of any health care delivery system in a country is historical, and the reason that all these countries have private insurance and a private delivery system is historical. For example, in Britain, when the system was brought in there, there was so much opposition from the MDs and the "upper class" - Britain is far more class conscious than we are - to alleviate their fears, they brought in private health insurance. That was an historical compromise.

Dr. Coffey: Yes.

Senator Morin: Apparently, that was true in most European countries when these systems were brought in. In Canada, we do not have an upper class, I suppose - in any case, it was not brought in. Apparently, the main reason is historical, and our national health care system is also based on history. We really have the Saskatchewan system in Canada.

Therefore, I am not too sure we can follow what is being done in Europe as closely as that, as it was not a matter of logical, rational choice. It was more a matter of compromise when these national health schemes were brought into existence.

Dr. Coffey: Yes.

Senator Morin: Could we have your comments on that?

Dr. Coffey: One of the interesting things that I have observed over the last year or so is the stuff coming out of Sweden - and I assume you have looked at that - and particularly out of Stockholm. We had a conference here in Montreal last fall, and the data coming out of the Stockholm experiment were very revealing. When I came across these data, which is the first time I have really seen anything on paper, I was very surprised.

For instance, all the nurses' unions in Stockholm are forming private companies now and contracting with governments as private providers, and the nurses are happy. Their morale is up, their productivity is up, and they are not so hung up on seniority. If you are a really good worker with a lot of skills, you move up a level in salary, and so on.

The other interesting thing is that of the seven - I think there are seven - large hospitals in Stockholm, one was sold to a private hospital company, and in the first two years, they were able to reduce their costs by 30 per cent.

The Chairman: I think that was St. George's Hospital

Dr. Coffey: Yes. That is right, St. Goran's. I guess that is "George" in English. That is one of the first impressive figures that I have seen. This is all with public money, this is an internal market concept, so that it is publicly funded, but the hospital is privately owned and managed, and their services are all contracted out to private operators. The ambulance service is contracted out, and the nurses, the lab techs, diagnostics, and even many of the physicians, are now forming small groups and contracting for services.

One of your senior members in the corner there will be interested to know that the average wait for heart surgery in the private hospitals is now two weeks, compared to 15 to 25 weeks in Sweden's public hospitals. These are in the outlying regions, where they are very conservative and still very much into the status quo of the social democratic model.

Senator Morin: My final question is, how is this hospital funded? How is St. George's Hospital funded?

Dr. Coffey: It is funded through patients who bring their funding with them.

Senator Morin: So the money follows the patients.

Dr. Coffey: Yes, it is public money, but it follows the patients.

Senator Morin: They are not necessarily coming from group primary care or a private care system? They do not have to be referred, necessarily?

Dr. Coffey: That is my understanding.

Mr. Kelly-Gagnon: I do recall we spoke with a gentleman who referred to Mr. Johan Hjertqvist, the gentleman who was working on the design and study of this so-called "Stockholm experiment," and he was explaining to me that their equivalent of our "communauté urbaine," their greater metropolitan areas, have the flexibility to deliver services in different ways, so they can make comparisons. The federal government in Sweden will impose and monitor certain norms, but the delivery will be at the so-called "municipal level" - a greater municipal level. He mentioned that this hospital, St. George's, does not allow extra billing, so there is no way that somebody could jump the queue by paying extra.

Therefore, it is still a fairly social democratic scheme, but with different kinds of features. They have been around now for a couple of years, and I can say that in 2002, our institute aims to conduct an extensive joint study with the Swedish institute to try to collect trial data, and really detailed data, about how they are proceeding with this. We may even do some fieldwork and so forth, because I think that the Canadian public is rightfully sceptical of any major reform. We need the literature and textbooks, but maybe we need to do some fieldwork to really monitor things.

I believe there are three criteria under which we should look at the reform. There is the outcome in terms of cost, the outcome in terms of what I would call "patient empowerment" or patient choice, and the health outcome. Sometimes, costs can go down and the patients can be relatively happy, but they do not know that the choices they have made will have negative or adverse consequences for their health over the years.

If we were able to monitor a reform based on these three criteria, be it the Stockholm plan or any other, then we would really know if that is the path that Canada should take.

Senator Keon: Dr. Coffey, I want to pursue with you this very interesting tangent, that is, when you compare the European experience with multiple private companies with the American experience, the Europeans, as you said, have been able to "deliver the mail" at a much lower proportion of GDP than America. I am told that they fundamentally achieved that by taking a shot at the medical profession, whereas America's free enterprise system had, and continues to have, many medical high rollers. In Europe, they found a way to just wipe them out. Can you confirm that they are all capped?

Dr. Coffey: Yes. Going back to the Swedish study, they reported on three specialties. These were 40 private physicians working outside the hospital and 20 public physicians working within the hospital. Ophthalmology costs in the public hospital were 28 per cent higher; similarly, for ear, nose and throat specialists, the costs were 17 per cent higher in the public hospitals than in the private; and in general surgery, internal medicine and dermatology, the costs were 13 per cent higher. There is no question that, through competition, they were able to lower the costs of the specialists.

However, you cannot have your cake and eat it, and if you really want competition, you have to be prepared to learn how to provide the best skills that are going to satisfy both sides.

It is interesting to just read the conclusion of that Stockholm experiment.

The Chairman: Who did the evaluation? Was it the hospital itself?

Dr. Coffey: No, no.

The Chairman: I wanted to be sure that this is an objective piece of analysis.

Dr. Coffey: Most of this work has come from the gentleman that Michel referred to, Johan Hjertqvist, who is an economist working on this project with the Stockholm Council.

They say in conclusion:

While opponents of the privatization reforms hadpredicted that the private sector, by seeking to make a profit for shareholders, would drive costs up and efficiency standards down, the opposite has in fact been true. Across the board, private contractors in Stockholm are operating with less staff and on smaller budgets, while providing the same treatments to more patients than their public counter parts. As a pilot program for testing the potential effects of competitive market mechanisms on public health care systems,Stockholm's internal market has proven the ability of the private sector to dramatically out-perform state-administered facilities by reducing costs, improving care, and saving lives.

The Chairman: You were here when the professor from McGill was speaking?

Dr. Coffey: I heard the tail end of it.

Senator Morin: You did not hear the argument going back and forth?

Dr. Coffey: Yes. That is why I read it.

The Chairman: This is a question you may not know the answer to, but it would really help me if you would think about this. Let's suppose we wanted to try three experiments in which you would continue with a single payer model, but the structure could be quite different. There would be some element of competition between the institutions, et cetera. You would want to run an experiment that was replicable, in the sense that whether it turned out to be good or bad, you would be able to draw reasonable conclusions that were sustainable. Similarly, you conduct a drug experiment in the hope that it is replicable, and people will not shoot it down by saying you picked the wrong bunch of patients, or whatever.

I do not know if you would do it with a general hospital or a specialized clinic that does joint replacements or whatever.

Have you given any thought to what those experiments or trials would look like? Assuming we had the ability to ignore the Canada Health Act and to get a province or a community to do it, what would you do?

Dr. Coffey: I am a great believer in gradualism, and I think one of the prudent courses would be to use a specialty group, maybe a group of cardiac surgeons, or a multi-specialty clinic. You could think of places like the Mayo and the Cleveland Clinic and so on, long-established, multi-specialty clinics of high quality. We do not have too many of those institutions in Canada. They are mostly in university hospitals. However, those could be encouraged, and already, people are starting to think about the possibility of a really first class, good quality specialty clinic that would offer services in the areas where the waiting lists are the longest, which are orthopedics, cataracts, heart, and maybe diagnostic. For instance, the McGill Imaging people have opened a new, private diagnostic centre in Montreal.

The Chairman: Owned by the university?

Dr. Coffey: Well, most of them are university people.

Senator Morin: Owned by the physicians.

The Chairman: Owned by the physicians, though, not owned by the university?

Dr. Coffey: No, it is a privately owned diagnostic clinic in Westmount Square. They have the latest in modern imaging equipment and top-notch physicians to interpret the results. A lot of people, many of my acquaintances, who have gone there are extremely happy. The results are handed back to the referring doctors very quickly. They are electronically linked with the hospitals, so they can get the image transmitted immediately to the Royal Victoria or the General, if they wish.

Senator Morin: However, that is not an experiment.

Dr. Coffey: True, but if you wanted to run an experiment on private diagnostics or imaging, this is the sort of group that, augmented, could say, "Sure, we will make a contract with the regional health board and come to a financial agreement to do diagnostics on 1,000 patients this year at a certain set price."

The Chairman: I believe that that is how the clinics in Alberta work. I will give you an interesting example. I think all of us found the witness from a private radiation clinic in Ontario very interesting. They do exactly what I talked about. They actually rent the radiation facilities from Sunnybrook Hospital from 6 o'clock to ten o'clock at night, when they are never used. They are only paid by OHIP, by medicare, and they do not take any private patients, so there is no element of private pay. What they are basically doing is extending the use of that facility by four hours a day, five days a week.

Dr. Coffey: Yes.

The Chairman: They focus primarily on breast cancer, and they are now expanding it into prostate cancer. They caused the waiting list for breast cancer radiation in Toronto to plummet.

There are these isolated examples, but if we are going to really change the system, I think we need a little better scientific proof. I started life as an academic too, so I am trying to get my mind around how do you actually do that.

Dr. Coffey: Yes, well, as I said, we have not really been legally allowed to do any experimentation.

The Chairman: No, right.

Dr. Coffey: So we are babes in the woods, and when we travel to other countries, they say, "What is happening in health system reform or financing in Canada?" I say, "This."

Mr. Kelly-Gagnon: You can experiment on a geographical base, where a particular province or a particular community could try some of these things we have been talking about. You can also have experimentation with a segment of the population, and I am referring here to the nursing homes, or other segments of populations where they are already used to having a certain range of services available to them.

It might be just a small step, because I am looking at it not only from the perspective of what is intellectually interesting, but of what I would call "real politics." We have a certain political context in Canada with which we might agree or not, but that is not the issue. It is there. I think that nursing homes and similar facilities might be more willing to, say, allow an old lady of 85, who is almost blind because of cataracts, but who has managed to acquire a small pension, to have quicker access to certain services within the nursing home.

Listening to the professor from McGill, it seems that even he acknowledged that something could be done in that area.

Senator Keon: We are into some really interesting stuff here with this whole question of capital for new endeavours. The public hospitals in Canada now really cannot raise capital, the banks will not lend them money, and they are not allowed to go into debt. Therefore, the idea of forming a corporate structure that will build a new hospital, or whatever you want, and rent it back is really coming to the fore. I am not raising it to debate it with you, but I just wanted to put it on the table so you can keep it in mind when you move forward with some of your interesting ideas. Thanks.

Dr. Coffey: Is this applicable to the private sector, or just the public hospitals?

Senator Keon: No, it is a hybrid of some kind. I know, for example, that one major public hospital in Ontario is currently flirting with the private sector to build a new hospital that they will rent back, because they cannot raise the capital to build it themselves.

The interesting thing is, these fellows who are starting their private clinics have no problem going to the bank and raising the money.

Dr. Coffey: That is right, yes.

Senator Keon: However, a public hospital cannot raise the money because the banks will only lend a very small amount.

Dr. Coffey: We have not tried to raise money for a private hospital, although there is a group in Montreal that is really rooting for that. They think we badly need one.

The Chairman: To follow up on Senator Keon's point, we were in Vancouver last week and heard about a new hospital in Abbotsford that will be built just the way Senator Keon has described it. It will be built by a private contractor, and just like an office building, the province is going to lease it back. The province simply found it easier to deal with the capital cost by leasing.

Dr. Coffey: Sure.

The Chairman: Unfortunately, the way governments keep their books, capital expenditures have to be recorded in the year that they are made, so if you spend $100 million on a hospital, you record it in year 1. If you spend $10 million a year on lease payments for 10 years, you record it as $10 million a year, and therefore, given the need to keep the deficit down, they are moving to a system in which hospital construction will essentially be a lease buy-back proposition.

By the way, interestingly enough, there was considerable opposition from unions, Friends of Medicare, and groups like that. That is not surprising.

Senator Léger: This may be quite naive, but if I understand correctly, private equals profit, for which you need to reduce costs, which equals, from what I heard here, happier. That means the patients are happier, plus you have more workers, more nurses on staff, and we suddenly have a lot of doctors in the private sector, where it was not possible in the public system. Is this, under the private system, available to everybody? I understood the machines that were being rented from six o'clock to ten o'clock at night were. Is that available to everybody?

Dr. Coffey: Yes. If you look at this Universal Private Choice proposal, the "raison d'être" of that study is to make private choices available to all Canadians, rich or poor. That is unique, and that is why I am very enthusiastic about this, because not only does it fit the political spectrum, it fits the economic spectrum as well. You can find a place in there, I feel, that will answer any of those needs. Low-income persons can still have, for instance, a government-issued health voucher with which to buy a basic private health service if they want more choices. Of course, we do not really worry about the rich, because they can pretty well do what they want - they can leave or whatever. It is the poor people whom we are trying to empower, so they can go to hospitals, doctors and clinics with the purchasing power to make those people shape up. If they do not give good service, if the doctor does not give them enough time, they have the power in their pocket to go elsewhere. It is the same with the hospital.

It does bring in a competitive environment, but not a mean-spirited environment, because everybody has a choice. It seems to provide the kind of balance that I think Canadians are looking for. They do not want big differences in the choices that are not available to all.


Mr. Kelly-Gagnon: I would also like to clearly point out the fact that one must avoid having - I am not saying you had it; I am just making a general comment - a statistical conception of resources, i.e. to think that there is a pie and that it must be shared.

The power of innovation and research at the technological level must never be underestimated, i.e. if people have an incentive, there will be an incentive at the technological level to improve the machinery.

The example I always use is that of a VHS VCR to watch movies at home: we bought one in the early 80's, and it cost $1,200 at the time. I bought one last week of a better quality than the one my parents had at the time, and I paid $129. Why the price reduction? Because companies had an incentive to improve the technology.

Similarly, the importance of improving managerial techniques must never be underestimated. Companies like General Electric, for example, have completely reengineered their practices. In addition, we sometimes take certain things for granted: We build them this way because we always did.

However, there needs to be a motivation or incentive to change these managerial practices, as did nurses in Sweden, who were given a better role in cases where doctors had traditionally been called for. It was not only about the number of nurses or dollars, but about the way these nurses worked. A better role can even be given to nursing aides where regular nurses were called for.

This is possible. Let's be honest. It is possible to do so within a public system, but the incentives are much less powerful. One must therefore really think in terms of doing more with less. It is never just a buzz word; it is the reality of the entire market economy of the twentieth century, and even the previous century, that showed that production practices were consistently improved, if I may say so.


The Chairman: I thank the two of you for coming. That was a very fascinating discussion, as you can tell.

Senators, our last panel this afternoon is from the Frosst Health Care Foundation: Dr. Monique Camerlain, the president of the board of directors; and Janet Dunbrack, the executive director.

Thank you for coming. I believe one of your board members, Dr. Camerlain, was before us in Winnipeg, although not on behalf of the Frosst Foundation.

Ms Janet Dunbrack, Executive Director, Frosst Health Care Foundation: It was probably Deborah Vivian from the Manitoba nurses' association.

The Chairman: Right, and she commented that you people would be coming to see us.


Dr. Monique Camerlain, President of the Board ofDirectors, Frosst Health Care Foundation: First, allow me to introduce the Frosst Foundation. Our vision is that of a health system focused on the patient, and we see it through bringing the patient's voice in the reform process, in the policies, and in the planning of health policies.

In fact, we are focused on getting the patient to become involved in and concerned with determining health policies. We are different from charity groups in that we operate across Canada and have a global perspective; we are not focused on one disease. We want to reinforce the patient's voice, and especially unify it, as we currently perceive it as broken through different silos.

Our objectives are to inform, connect, and enable the patient, and these objectives were drawn from a strategic planning meeting we held in Montreal with 81 representatives from all groups involved in health services, including government, businesses, professionals, and patients.

In fact, our foundation is still in its infancy, as it was only established in 1998. We are an independent foundation, not a for-profit organization, and we have a specific niche in that we do not compete with charity organizations for the same dollar.

The members of our Board of Directors represent all the regions of Canada. They have very diversified experiences, ranging from professional groups to communications and the industry, and they represent all groups, not interests, but all who are involved in the health system.

What we have done to this day is to listen a lot. I referred earlier to our first national "Speaking for Ourselves" event, where 81 participants from different systems were gathered in Montreal for two days to look at the priorities that were common to each of these groups.

We now hold such meetings at the regional level. Our next meeting will be held in Toronto very soon. You have received, I believe, the small brochure, the text of the first meeting, "Speaking for Ourselves," held in Montreal.

This year we participated as one of seven partners in the "Health In Canada Survey," which is a survey on the health system conducted across Canada. We award grants based on criteria which correspond with the objectives of our foundation. For the future, we are considering a "deliberative pooling," which is a collection of data, after informing the patients. We will also publish a magazine.

Ms Dunbrack will now present the new paradigm we are considering.


Ms Dunbrack: I had actually sent a package of materials to Madame Thérien last week with enough copies in English and French for all members of the committee, so I am hoping that you will have the materials when you get back to Ottawa, perhaps.

What distinguishes the Frosst Foundation from certainly disease-specific health charities is that our mission is to bring the voice of the patient to the health policy table, rather than to focus specifically on health care and health services directly. Based on the consultations we have had, patient groups and consumer and citizen groups have told us that that voice must be active, responsible and informed.

We have been trying, in our activities so far, to bring together, as Dr. Camerlain said, diverse groups of health charities, seniors' groups and so on, to find out what common elements unite them and would allow them to participate in health policy deliberations, rather than just speaking to the needs of their own particular constituencies.

Patient groups have told us that they would like us to helpthem develop collaborative and accountable mechanisms for participation. They have also talked about the need to improve their skills so that they can participate in health policy decision-making. It is very easy for people to talk about their own parochial interests, it is a little harder to get people to the skill level where they can take a global perspective and sit at the policy table. It all boiled down to, "Help us inform, connect and enable the patient."

We would argue that the benefit of including the patient's voice at the health policy level is that tough choices then become a shared responsibility. I think the benefits of that are self-evident, and we may discuss that afterwards, depending on your questions.

Policy decisions would therefore have greater legitimacy, the public would buy into them, and the services flowing from health policy would then be more appropriate and responsive to need.

I was very interested to see that in your Volume 4 report, you stated firmly a couple of times that the health care system in this country needs to become a 21st century service industry, which obviously would reflect the voice of the patient, the ultimate consumer of the services.

This is a new way of thinking in some ways, bringing together many special interest groups to inform, enable and connect, but I think it also opens up new possibilities for health policymakers and health care providers. At meetings which we have attended with medical associations, hospital associations, provincialgovernments and so on, they are all looking for ways to involve the citizens, so it is something of which people are currently becoming very conscious.

We would like to work to create opportunities to bring everybody together at the health policy level, and as I said, we have noticed a rising interest in developing models of patient and citizen involvement in health policies such as deliberative polling, citizen juries, focus groups and so on.

The mandate of this committee is to study the federal role in health care, although obviously you are looking at the constituent parts. Therefore, we gave some thought to what that role might be from the patients' perspective. The federal government can certainly create opportunities to move towards a new paradigm, a new model, which would involve patients in health policy determination - in other words, sponsoring forums for dialogue and funding or supporting the creation of demonstration models to show how it can be done effectively. Obviously, that would include research and dissemination of results in this area and skills building

I would say not only skills building for patients, but also for those who sit around the policy table who may not be used to sharing power, which is another point that you raised in your Volume 4. We need skills development for all the participants in health policy determination.

Finally, we want to say that the Frosst Health Care Foundation would like to be a partner with the Senate committee and the federal government, in whatever way we can, to help bring the voice of the patient to the health policy table and the health reform debate. Through our foundation, we can tap into expertise networks and resources to make a contribution.

The Chairman: Thank you for that. Senator Morin and I met with Roy Romano two weeks ago, or whenever we were in Saskatoon. That commission is planning some quite innovative "deliberative models" is what I think you would call it. Have you been in touch with them?

Ms Dunbrack: Yes, in fact, we are in active discussions with them about potential partnering.

The Chairman: You absolutely you should do that because they have some unique things in mind.

When you talk about "demonstration models" and "forums for dialogue," could you flesh out the details on those two points? Many of the participants in the health care system, even the providers, for example, or the nurses, often feel that the policymakers are over there, they are over here, and there is really no forum in the country for a discussion between policymakers on the one hand, and the people who provide the service on the other.

Ms Dunbrack: Exactly. There is certainly potential.

The Chairman: Yes, and one of the questions that we have been kicking around informally is how would you actually do that? You people have had more experience of that. We are experienced at hearing from people as opposed to "dialoguing" with them, if I can make the distinction. It would be helpful if you had any detailed thoughts on what that process would look like.

Ms Dunbrack: We would be happy to follow that up with a letter, but I will tell you about one small-scale experiment, a research project in Nova Scotia at Mount St. Vincent on aging. They brought together a group of female informal caregivers, I believe.

The Chairman: By "informal," you mean unpaid?

Ms Dunbrack: Family caregivers, yes.

The Chairman: Care giving is actually quite formal, but it is unpaid.

Ms Dunbrack: Right, it is unpaid.

The Chairman: All women?

Ms Dunbrack: Largely older women. They were very dissatisfied with the way the health system was servicing their needs and the needs of the people for whom they were caring. They were brought together as a group because they said they realized that they needed to participate at the health policy level, and not just at the direct service-delivery level.

The researchers developed a demonstration model whereby these women had to role play health policymakers. They suddenly started to see that it is not so easy to make health policy; you have to make difficult decisions. Then in stage 2 of the project, they brought them together with actual health policymakers from the provincial government, and they found that some of the old attitudes had been broken down. That is a small example, but I think there are opportunities for fairly exciting bridge-building experiences.

The Chairman: Okay, and the federal government is not in that business, so that does not encroach on anybody's territory.

Ms Dunbrack: Exactly.

Dr. Camerlain: We experienced that when we had our first "Speaking for Ourselves" event. There were all thesedisease-specific patient groups competing with each other for the same dollar, and all of a sudden, after being in the same room together, they realized that they had much more in common than was keeping them apart. We want to simply get people together in a room to realize their common issues and work on those together. Everyone keeps reinventing the rule. We want to connect, enable and get as many people as possible working on the same effort.

The Chairman: In your view, whether someone got into that room because they had cancer, arthritis or heart disease is not the issue, the problems are inherently the same?

Dr. Camerlain: Some of the problems are the same, and if they could work together towards those common goals, so much time and effort and resources would be saved and so many new ideas could come out of it. This is part of our mission to connect, inform and enable.

Ms Dunbrack: The Health Charities Council of Canada has brought the health charities together to help them start working together. The other part is to connect the professional associations and the policymakers, and also the provincial and federal governments, because they are very important parts of health policy determination too.

Senator Robertson: Ladies, I do not know much about your foundation except from what I am reading and listening to here, but I must tell you that two very good friends of mine are on your board, one from the East Coast and one from the West Coast, so I shall learn a lot more about this in the months ahead.

I just want to ask you one particular question. You are a new, young association just starting out, and although my question applies to all associations, whether it is the Kidney Foundation or whatever, in particular, have you determined your "yardsticks," in the street language, to measure the success of your project, so you can better identify with the public and the other stakeholders? If you can measure your success through identifiable factors, your growth will be faster and you will have a bigger impact on all the other stakeholders with which you work, including the govern ment.

Ms Dunbrack: I think that is a good comment. I would say we would probably judge our success in five years from now on whether people automatically think, when making health policy, of including a patient or a citizen representative at the table and we can see that reflected in changed policy.

Our mission is not content focused, it is process focused, and so what the patients or the citizens say when they get to that health policy table is really up to them. Our goal is just to get them there.

Senator Robertson: However, I would suggest that the process of getting them there also needs to be monitored and measured.

Ms Dunbrack: Exactly.

Senator Robertson: Anyway, good luck.

Ms Dunbrack: Yes, thank you.

Senator Robertson: I shall read all about you.

Dr. Camerlain: Thank you.

The Chairman: I just want to come back to the demonstration project. It would help us to know specifically what kinds of demonstration projects you think would be useful. We need to be able to take the concept and ultimately make a very specific proposal. I am not being critical of what you said, but we have to go beyond saying "We think demonstration projects are a good idea," to saying "Here are one or two that really do make sense."

Ms Dunbrack: I can give you an example from a world I know very well, the world of HIV-AIDS. The federal government funded two very large demonstration projects, one in Edmonton, Alberta, and one in Montreal, in which they brought together everybody involved in AIDS care, from the provincialgovernment at a fairly high level, to the regional health boards, the consumer, the community-based groups and professionalsinvolved in all aspects of care. They created "dialogue tables" at which all these people came together. They began by having all the professionals and all the community groups meeting at separate tables, and then they started mixing them up. As a result, three years into the project, Montreal and Edmonton have developed a much more integrated care delivery system for HIV-AIDS, but also a much more integrated policy development process.

I will give you another example from the world of palliative care, which I also know very well, and again from Edmonton, Alberta. The provincial government and the care deliverers were looking at the coming aging population and the potential costs for end-of-life care and decided to do something about it. They decided to integrate service delivery so that it would be seamless, but that also tends to affect the policy determination level, where one party in the system can no longer make an autonomous decision without consulting all the others.

The Chairman: It is interesting that you name Montreal and Edmonton, because if I had to pick the four best regional health authorities in the country, they would be Montreal, Edmonton, Calgary and Victoria. Everybody I have talked to across the country raves about those two, which, by the way, are run by women, which is an interesting aside.

To what extent does it really require progressive leadership at the regional health authority level to make this kind of thing possible?

Ms Dunbrack: I think that is crucial, because if they will not play, then nothing can happen.

The Chairman: It cannot be forced?

Ms Dunbrack: No, it cannot be forced. However, I think we can talk about advantages. For example, if I take your argument that our health care system should be a 21st century service delivery system, then the client or the consumer - the ultimate buyer - is the patient. Increasingly, I think demographics are going to produce a feistier bunch of baby boomers who will say, "We are not going to take this lying down; what do you mean you are making decisions for us?"

The Chairman: We heard from Dave Barrett, who is now close to 75, when we were in British Columbia, and I tell you, he has not lost one ounce of the feistiness he had when he was premier 25 years ago, so your point is well taken.

Ms Dunbrack: If I were trying to convince the regional health board to become involved, I would say, "You are going to get a much better political ride if you have had a solid process in which you brought the consumer to the table, than if you are trying to impose something and going against the current.

The Chairman: May I thank both of you for coming; that was very interesting, and please try to think out some details for us and let us know about them.

Dr. Camerlain: Absolutely. Thank you.

The committee adjourned.