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

Issue 22 - Evidence - March 10, 2011

OTTAWA, Thursday, March 10, 2011

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:28 a.m. to examine the progress in implementing the 2004 10-Year Plan to Strengthen Health Care.

Senator Art Eggleton (Chair) in the chair.


The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.


Today we begin our examination of the 2004 health accord, or the 10-year plan to strengthen health care in Canada. This is the second review that has been conducted, which is a requirement every three years. The last review was done by the House of Commons Standing Committee on Health, and we are doing this one. This committee has a long history of dealing with health issues, going back to 2002, perhaps even before, when my predecessor Michael Kirby was chair of this committee. It produced a significant report that came out at the same time as the Romanow committee report. We have before us what are referred to as the Romanow report and the Kirby report. The Kirby report, of course, is a product of this very committee.

We will go through numerous meetings between now and the middle of June, before the summer recess. We have a dozen planned at this point. That is all conditional on there not being another kind of recess that might be imposed upon us at any time, called an election. In the fall, we will then complete our report and submit it. This requires, obviously, an extension in time from what was originally envisioned in order to complete the study. We just got the request from the Minister of Health to conduct this report at the end of January.

Today we will start with four key entities to bring us up to date. Two of them were created out of the previous health accord; there was one in 2003 as well. We have with us, from the Health Council of Canada, Dr. Jack Kitts, Chair, and John Abbott, Chief Executive Officer. The Health Council of Canada was established in the 2003 Accord on Health Care Renewal and their role was enhanced further in the 2004 10-year plan. They report on the progress of health care renewal, on the health status of Canadians, and on health outcomes of our system. Their goal is to provide a system-wide perspective on health care reform for the Canadian public, with particular attention to accountability and transparency.

The Canadian Institute for Health Information — and, I remember the former deputy chair of this committee, Dr. Keon, referred to it as CIHI, so I will as well — is an independent, not-for-profit corporation that provides essential information on Canada's health system and the health of Canadians. Their goal is to help improve Canada's health system and well-being of Canadians by being leading a source of unbiased, credible and comparable information to enable health leaders to make better informed decisions.

Health Canada is responsible for the Canada Health Act. Abby Hoffman, Associate Assistant Deputy Minister; and Gigi Mandy, Director, Canada Health Act Division, are with us today.

Statistics Canada is always here. They give us lots of charts, every time. Gary Catlin is Director General, Health, Justice and Special Surveys Branch; and Claudia Sanmartin is Senior Analyst, Health Analysis Division.

Welcome to all of you.

I might add that James Gauthier and Karin Phillips are here as analysts from the Library of Parliament.

Dr. Jack Kitts, Chair, Health Council of Canada: Thank you for the opportunity to comment on the progress made on the 10-year plan to strengthen health care. The more voices that weigh in on this review, particularly as we get closer to 2013-14, the better equipped we will be to make proper decisions in the future.

Reporting on progress is what the Health Council of Canada does and what we have been doing since we were formed seven years ago. Our voice is unique because we provide an independent pan-Canadian assessment and insight on health reform. More and more, our focus is on identifying best practices and innovations so that planners, providers, administrators and the public can know who is doing it right and how.

Though we often call it the Canadian health care system, it is really a collection of 14 individual systems that are well served by learning best practices from one another. Our health care system has come a long way since 2004, but there is still a lot of work to do to achieve the first minister's vision — indeed, the vision of all Canadians: a more accessible, higher quality and sustainable health care system.

In 2008, we released a progress report on all the commitments in the 2003 Accord on Health Care Renewal, and the 10-year plan to strengthen health care. We found much to celebrate and much that fell short of what could and should have been achieved. This spring, three years later, we will be releasing a follow-up report on five of the health accord commitments.

Where do we stand now? The answer is not a simple one. Over the next five minutes, I will try to give you a brief overview of some of the highlights as the Health Council of Canada sees it. We have made progress on wait times because governments set targets and provided the funding to tackle them. Buoyed by success in the initial five priority areas, governments have moved to address other wait times now. For example, in response to the Patients First review, the Saskatchewan government has promised that by 2014, no patient will wait longer than three months for any surgery. Wait times are a good example that progress can be made and sustained when health care leaders develop an action plan and stick with it. This approach also serves to gain the confidence of the public.

Primary health care is critical to the sustainability of our health care system. Despite that, we are not measuring for results nearly as much as we should be. More Canadians have chronic health conditions than ever, and they need a strong primary health care system to support them. Recent surveys show that Canada has catching up to do compared to other OECD countries. Canadians have difficulty accessing primary care, particularly after hours and on weekends, and are more likely to use emergency rooms.

The 10-year plan called for half of Canadians to have access to a primary health care team by 2011. In 2009, we reported that only 32 per cent of Canadians had access to more than one primary health care provider. The benefits of teams are well known. They improve access, quality of care, and reduce pressures and costs on the acute care system. In Peterborough, Ontario, for example, a region-wide shift to team-based care dropped emergency department visits by 15,000 patients annually and gave 17,000 more access to primary health care.

We believe that jurisdictions are now turning the corner on primary health care and are reinvesting in finding pathways to improve the service delivery. With the support of our provider organizations, we believe we can expect much more progress in the coming years.

By the end of 2010, an electronic health record was available for nearly half of all Canadians. Many physicians still rely on paper records and until they go digital, electronic health records cannot reach their full potential. Sustained federal funding and strong jurisdictional direction will be critical to ensuring that we can accelerate the update of electronic health records across the country.

The creation of a national pharmaceutical strategy was a critical part of the 10-year plan. In 2011, today, unfortunately, progress is slow. That being said, individual jurisdictions across Canada are taking steps to expand coverage and address the growing costs of publicly funded drug programs by controlling the costs of generic drugs. At the same time, pharmacists' scopes of practice are expanding, although through different approaches across Canada. Another promising strategy is joint tendering. The premiers have called for a national alliance to consolidate public sector procurement of common drugs and medical supplies and equipment.

While addressed in the 10-year plan, health prevention and promotion, and their role in improving the health of Canadians, are only now gaining momentum across the country. For example, we are encouraged that several governments such as Yukon, Ontario, Newfoundland and Labrador, have developed poverty reduction strategies that will go a long way in addressing the underlying health needs of their vulnerable citizens.

Your committee has produced landmark reports on the importance of determinants of health and whole-of- government approaches. Likewise, the Health Council of Canada recently issued a report on taking a whole-of- government approach to health promotion. We cannot and should not expect health ministries alone to be able to solve all of Canada's health issues, including the state of Aboriginal health.

On top of the progress I have mentioned so far, there have also been improvements on our capacity to collect, interpret and use health information, and I expect the CIHI people will expand on that. This work is absolutely essential to allow us to address the issues of providing appropriate care, patient engagement and improving the quality of care overall.

Leading up to the next review, governments need to focus on health human resources planning, expanding and integrating home care, improved public reporting, and a continued focus on quality across the entire system.

Finally, we need continued leadership from governments. While much of the progress since the 10-year plan has been generated by individual jurisdictions, real progress lies in having all governments work together in the interest of all Canadians. We are optimistic that these Senate committee hearings will inspire our leaders to re-engage on the heralded commitments made in 2004.

John Wright, President and CEO, Canadian Institute for Health Information: CIHI is a pan-Canadian, independent and not-for-profit entity. We focus on providing data for sound health policy, health management and public awareness of the issues surrounding health and health care.

As part of the 10-year plan, CIHI's role was to reduce wait times in priority areas and improve access. The five priority areas are cancer, heart, diagnostic imaging, joint replacement and sight restoration. Since 2006, we have been publishing annual reports. Later this month, we will come out with our sixth annual report on wait times. This forthcoming report is much clearer as there are more data and information available.

The question is: Is care provided within the benchmark time frames? As shown on slide 4, with respect to bypass surgery and radiation therapy, they are within benchmark time frames that were established.

Slide 5 shows how each of the provinces are doing relative to the benchmarks. The check mark means that it is meeting target. Ninety per cent is a practical target. One hundred would be perfection; however, 90 per cent recognizes the realities of surgery. From time to time, the patient maybe ill and not be able to attend the surgery. Alternatively, the patient may want a change or be on vacation when surgery is scheduled.

Across the country, the wait time benchmark for bypass surgery and radiation therapy has been met at the 90 per cent level. Certain provinces, such as Quebec, show a dash in the bypass surgery category. That is because the data are still collected in a different manner than the other provinces. In the case of P.E.I., there is a dash in bypass surgery because they do not do it there.

On slide 6 are more check marks across the piece. These checkmarks represent a target of 75 per cent being met. Due to the size in population of B.C., Ontario and Quebec, these provinces carry the pan-Canadian statistics. In Ontario and B.C., there are check marks across the piece. This means that patients are being taken care of at 75 per cent of the benchmark. Other provinces are not doing quite as well.

We will turn to slide 7. In summary of the wait time initiative, the three largest provinces generally drive the national data. There is significant variation among the provinces and within each of the priority areas as well.

The provinces and territories were charged to look at the area of diagnostic imaging. There is no evidence-based benchmark for diagnostic imaging as yet. As a consequence, we do not report it. In 2009, there were two provinces reporting on diagnostic imaging. In 2010, there were five provinces reporting on diagnostic imaging and their wait times. We continue to work with other provinces to bring them on board.

The numbers are extremely good in terms of bypass surgery. There is a number of urgency rating scores within that category. Not everyone is perfectly aligned; therefore, we have gone to the easiest priority, meaning that patients within the easiest priority are all being seen. We still have work to do with the provinces on fine tuning the data to ensure comparability across the piece.

Slide 8 shows the distribution of funds. From 2004 to 2010, the total health expenditures in Canada increased by 45.6 per cent. From that, we have isolated the provincial and territorial numbers. In 2010, the provinces and territories spent $125 billion. The overall increase is almost 48 per cent over that time period.

What did Canadians buy with the infusion of the federal funds? Slide 9 shows the significant increase in the number of surgeries, let alone the improvements in wait times that I spoke to earlier. For hip, knee and cataract surgery, the increases from 2004 through to 2010 are quite substantive. The category of revascularization does not include Quebec. We still have some data issues. However, year by year, we are making improvements with the territories and provinces. It is a cooperative exercise with them.

Slide 10 shows that the money bought an awful lot more diagnostic imaging scans and services. From 2003 to 2004, CAT scans increased by almost 50 per cent. More MRI and CAT scan machines have been purchased. The provinces are becoming more efficient in the utilization of these machines. Canada runs them harder and longer compared to other countries.

Slide 11 shows the number of physicians that have been added. From 2008 to 2009, there was 4.1 per cent increase in the number of physicians. A record number of medical degrees were granted in 2009: a little over 2,300. There has been a 47 per cent increase of medical graduates since 1999.

The overall outlay on physicians has increased dramatically. While drugs were one of the fastest growing areas and expenditures, physicians now are. As well, the number of regulated nurses has gone up shortly since 2004. These numbers, per capita, are not what they were in 1992. In 1992, there were 824 nurses per 100,000 patients and in 2009, there were 789. There has been a decrease. I speak of registered nurses, registered psychiatric nurses in the Western provinces, licensed practical nurses and nurse practitioners.

Slide 12 shows that the total expenditure for drugs has increased dramatically. The public sector has increased substantially in terms of the billions of dollars. This is tending to flatten out more. Drugs are the second fastest growing category next to physicians.

Many patent drugs, such as Lipitor and Crestor, will be coming off patent, about $8.3 billion worth. There should be savings into the future as the generics step in from there.

What about performance measures? With Statistics Canada, we produce an annual report with over 40 different health indicators. This year, we will develop some new indicators in the area of mental health. We have developed a Canadian Hospital Reporting Project. It is not public as yet. We are still trying to clarify and ensure comparability. There are 33 indicators. A substantive number of them are quality, financial and patient satisfaction indicators.

The "big dot" indicator was developed in 2007: the hospital standardized mortality ratio or HSMR. That is a big dot indicator of equality. We are pleased to report that, since 2007, 80 per cent of hospitals have reduced their mortality rates.

Abby Hoffman, Associate Assistant Deputy Minister, Health Canada: My remarks are directed to the Canada Health Act. I will note at the outset that the Canada Health Act, as you may know, is referred to in two places in the 2004 accord, once implicitly and once quite explicitly.

Near the beginning, at page 2 of the 10-page accord document, first ministers indicated that they had agreed on an action plan based on a number of principles. The first set of principles cited is the five principles of the Canada Health Act: universality, accessibility, portability, comprehensiveness and public administration principles embedded in the CHA.

The second instance is at the end of the accord document, on page 10. The final commitment that first ministers made under the accord also concerns the Canada Health Act, and that section effectively states:

By inclusion in this communiqué, governments formalize the agreement reached on dispute avoidance and resolution with regard to the Canada Health Act in an exchange of letters in April 2002.

This was a kind of formalization of that process that had been codified earlier in an exchange of letters.

Our understanding is that you have asked for some information specifically about the Canada Health Act dispute avoidance and resolution process. That is the commitment in the accord, and I will speak to that subject.

The Canada Health Act dispute avoidance and resolution mechanism in place today was developed initially as a follow-up to a commitment made in the Social Union Framework Agreement in February 1999. All governments, except Quebec, signed that agreement, which included a set of principles for social policy and collaborative approaches to the use of the federal spending power. It set out broadly ground rules for intergovernmental cooperation, including mechanisms for resolving disputes between governments.

Quite specifically, the agreement committed federal, provincial, territorial jurisdictions to a dispute avoidance and resolution process specifically for the interpretation of the Canada Health Act principles. Work among officials on the design of a dispute avoidance and resolution mechanism ensued. Health Canada and Alberta co-chaired this work that ultimately culminated in an exchange of letters initially between the federal and Alberta health ministers, and then between the Premier of Alberta and Prime Minister Chrétien in April 2002.

Premier Klein's letter, which basically pulled that process to conclusion on behalf of all premiers except Quebec, expressed support for the dispute avoidance and resolution process, as written. The acceptance of that process was formalized in the 2004 accord.

To speak to the process itself, there are three sections: dispute avoidance, dispute resolution and public reporting. Each year in an annex to the Canada Health Act annual report tabled in Parliament, the details of the dispute avoidance and resolution process are written up at some length. The 2009-10 report was recently tabled in Parliament.

I will speak to the three elements quickly. In practical terms, dispute avoidance is the most frequently used, because the aspiration is to avoid disputes and not have to move on to a formal resolution process. Basically, the dispute avoidance process formalizes how federal, provincial and territorial governments will work together to avoid disputes concerning the administration and interpretation of the act.

There are three elements to that. The first is the active participation of governments in ad hoc committees on Canada Health Act issues. Those are issues that would be of interest to all governments. The second is government-to- government information exchange, discussion and clarification of specific issues as they arise with the government in question, where the issue is in play. Finally, if requested by a province or territory, we would provide an advance assessment of a proposal or initiative in order to advise the province or territory whether a plan they have would fall into compliance with the act. This governs most of the normal business we do as related to the Canada Health Act.

Then there is the dispute resolution mechanism itself. If the dispute avoidance activities have been unsuccessful, either the federal or the particular provincial or territorial minister of health directly involved in the issue, may initiate or trigger a dispute resolution process. This needs to be done in writing by the minister of the respective jurisdiction to his or her counterpart, clearly articulating the issue in dispute.

It is important to understand that, if this process is initiated, the dispute resolution process will precede any action that might otherwise be taken related to the non-compliance provisions of the act. In other words, neither mandatory nor discretionary penalties under the act would be imposed while the dispute resolution process is under way.

The initial stage of dispute resolution begins with a government-to-government process. Within 60 days from the date of the letter that I mentioned a moment ago that initiates the process, governments involved will jointly collect and share all of the relevant facts regarding the issue, they will prepare a fact-finding report and they will enter into negotiations to attempt to resolve the issue in dispute. If the issue is resolved, they will prepare a report on how the matter at hand was resolved.

However, if there is no agreement on the facts or if the negotiations were to fail to resolve the issue, then either of the ministers of health involved in the dispute may initiate the next step, which is a referral to a third-party panel. This, too, must be done in writing.

The panel must be struck within 30 days of the formal letters being received. A panel comprises one appointee from the province or territory and one federal appointee. Those two appointees together select a chairperson. The panel's role is to assess the issue under dispute in accordance with the provisions of the act, undertake fact finding and provide advice. At the end of its work, the panel must provide a report to the governments involved within 60 days of their appointment.

The federal minister would take the panel's report into consideration when deciding whether to invoke non- compliance provisions under the act. However, the federal minister retains the final authority to interpret and enforce the act.

Finally, the third piece of this dispute avoidance and resolution process is public reporting. When a dispute resolution process has been completed, governments will publicly report on the Canada Health Act dispute resolution process, including any panel report.

This concludes my formal remarks.

Gary Catlin, Director General, Health, Justice and Special Surveys Branch, Statistics Canada: Statistics Canada was not specifically mandated in the accord to monitor any aspects of the accord; however, we do have data to present to you that we hope will be relevant to your deliberations today and into the future.

The second slide provides two areas on which we will try to present some information today. The first is around the primary care reform area and the second is around the aspects of prevention and promotion.

We move on to the next side. For many Canadians, the first point of contact for medical care is their doctor. Being without a regular medical doctor is associated with fewer visits to general practitioners or specialists who can play a role in early screening and treating of medical conditions.

The slide presents the percentage of Canadians across all the provinces and territories who report not having a regular family physician. In 2009 about 84 per cent of Canadians aged 12 and over reported having a regular medical doctor. In 2009, the most common reason respondents gave for not having a regular doctor was that they had not looked for one, and that was mostly among young Canadians. Another 44 per cent, however, or nearly 1.9 million people, reported they could not find a doctor. The reasons they gave were "no doctors available in their area," "doctors in their area not taking new patients," or their "doctor had left or retired."

Of the 4.3 million Canadians without a regular doctor in 2009, about 82 per cent reported having a place they usually went when they needed health care or advice. When they needed medical care, most went to a walk-in clinic. Another 13 per cent went to emergency rooms, and about 10 per cent went to community health centres or, in Quebec, CLSCs.

The next slide is based on a Canadian survey of experiences with primary health care. Actually, it is a good collaboration between the groups we have at the table here today. It was funded through both the Health Council of Canada and CIHI, and was conducted by Statistics Canada in 2007 and 2008. One of the things we tried to look at with that survey is the objective that was mentioned earlier on, that 50 per cent of Canadians have access to 24/7 multidisciplinary care.

We are not able to measure this directly with the survey, but we have tried to pull together a composite from the various questions in the survey to look at this. As you can see, over 30 per cent of the population has some access to additional health professionals in the office, in addition to the physician who would be the primary care provider.

The next slide looks at difficulties accessing health services. The detailed analysis we have on these data was based on an early survey. However, as you can see, not much change in this particular aspect has occurred over the time period we collected information.

The study focused on two types of first contact services: first, in the blue bar, immediate care for minor non-life- threatening problems such as a fever, cuts or burns; and second, routine care provided by a family or general practitioner, such as annual examinations or prevention or ongoing care of an illness.

The study showed the respondents with a regular family doctor were just as likely to face some of these difficulties for minor health problems as those without a family doctor. Canadians who did not have a regular family physician were more than twice as likely to report difficulties accessing routine health care compared with those who had a regular family doctor.

One of the good findings out of that report was that income was not associated with difficulties accessing care. The chief reason cited for difficulties in accessing routine care was the availability of physician services; and in terms of immediate care for minor health problems, the primary barrier was longer wait times.

On the next slide, we show the percentage not getting colorectal cancer screening in the time period that is recommended. The differences among the provinces and territories in the percentage of people who were up to date with colorectal cancer testing were substantial. In general, the likelihood of testing was lower in provinces east of Ontario and in the territories than elsewhere, and markedly higher in two provinces — Manitoba and Ontario.

In 2007, Ontario initiated a province-wide, organized colorectal cancer screening program. Manitoba launched a similar pilot program in Winnipeg in the Assiniboine Regional Health Authority that same year.

For colorectal cancer, the likelihood of up-to-date testing was greater among people who lived in high-income households, had a regular family doctor, did not smoke and were active in their leisure time. Higher percentages of seniors aged 65 and older had been tested compared with individuals 50 to 64.

Up-to-date testing for colorectal cancer was related to the presence of other health risk factors. About 30 per cent of daily smokers had been tested, compared with 42 per cent of non-smokers. Physically active people were more likely to get tested than those who were inactive.

The next slide looks at screening mammography. Again, it is the percentage of women not achieving the guidelines in the age group where it is recommended. In 2008, 72 per cent of women aged 50 to 69 reported having a mammogram in the previous two years, which is up from 40 per cent in 1990. The increase occurred in the decade between 1990 and 2000-2001, when use peaked. Rates subsequently stabilized. Since then, provincial rates have become much more similar.

The next slide looks at perceived health. According to the results of the Canadian Community Health Survey on Healthy Aging, 76 per cent of Canadians in midlife, those 45 to 64, and 56 per cent of seniors reported good health in 2009. This was based on a definition of "good health" that comprised self-perceived health, both general and mental, functional ability and independence in activities of daily living. Good health existed even in the presence of chronic conditions such as high blood pressure, arthritis and back problems, all of which were common among those people 45 years of age and over.

The eight modifiable factors that were associated with good health were smoking status, body mass index, physical activity, diet, sleep, oral health, stress and social participation. Eighty-four per cent of the younger age group and 91 per cent of seniors reported positive tendencies on four or more of these factors. The factors were definitely associated with the likelihood of reporting good health.

The final slide gives an indication of other indicators that are available that might be relevant to of your deliberations as you move forward.

The Chair: Let me start with the Health Council, Dr. Kitts or Mr. Abbott. You were mandated in the accord to report yearly, but you have not reported since 2008. Why is that?

Second, when you read the report from the House of Commons standing committee on health from 2008, they are quite critical of the attempts to analyze what is going on here. Because of the different benchmarks being different in different provinces, there is very uneven reporting. They are critical of both the federal government and the provincial governments in this regard. They say one of the organizations or committees that was set up — a federal-provincial committee — ended up being disbanded. That has to create some problems in terms of getting the information that you need.

In addition to saying why have you not produced a report since 2008, which priorities have made the most progress since that last report from the health committee and which priorities have made the least and need attention?

John Abbott, Chief Executive Officer, Health Council of Canada: Since 2008, rather than repeat annual reporting on the whole, the Health Council has delved into specific topic areas under the 2003 accord and the 10-year plan to provide a more thorough analysis and reporting.

At the same time — as we are at the present time — every three years, we would look at overall progress. On a go- forward basis, we are now working with the provinces on doing annual reporting on different components of the accords.

One thing we found is the issue of where the data is and how best to access and use it. As you have heard in the other presentation, we are improving quite markedly in terms of having better data on which to report.

One of the observations that the council made back in 2008-09 is that on an annual basis, it does not have a lot of new data to report on and therefore would end up saying much the same as other sources. It was in that context that we went into specific elements. We have looked at issues around pharmaceuticals, primary health care and wait times. Currently, we are looking at the issues around home care. We feel that will provide better information to the public and to governments as they are dealing with the issues.

With regard to the House of Commons standing committee report in 2008, we were at the table then saying that there is an issue around data, that it is difficult to report on some of the things we would like to. That was true for each of the jurisdictions.

With the advent of the quality councils at the provincial level and in Quebec, they have built their capacity. Having built their capacity to report, we are then able to take their data and do further analysis at the national level. We needed that series of building blocks. We are finally coming to the stage where we can do much better reporting, though we are not there yet.

The Chair: Dr. Kitts, is that because what was set down in the accord was not realistic at the time, to be able to achieve and make all these progress reports every year? Are you having to adjust to really get at what is happening? There are 14 different entities among the provinces and the federal government. Are they just not living up to their obligations?

Dr. Kitts: That is an excellent question. What is in the accord is 100 per cent the right direction. The items listed are things we must accomplish in order to improve health, sustainability, access for Canadians and quality.

In 2004, we had very little knowledge in terms of performance measures with respect to how we were doing and, therefore, it was difficult to measure progress.

I have been a practicing physician for 23 years and a CEO for 10 years, and I would say, probably since 2005, people have been starting to get their heads around the fact that this is not sustainable and it is not good quality. The number one thing we have to do is be able to measure how we are doing.

Today, I run one of the biggest academic health science centres in the country, and I can tell you that we provide high-quality care. If you are wondering how I know that, I do not have the data yet.

Since 2005 — I am sure Stats Canada and CIHI can confirm this — there has been tremendous work and focus on trying to gain the ability to measure performance — get the data, make sure it is right, make sure it is timely, accurate and comparable and make sure we can benchmark across the country — but we are not there yet. We are on the cusp of getting closer, but we are not there yet.

Much of the data you hear today is probably 18 months to two years old. It is aggregate data and it is looking at high levels. We need to get down to the health service provider level. I feel strongly that we are setting the building blocks to get there, but I think the Health Council of Canada's job to report accurately annually, reflective of the reality that is going on, is a difficult job. In 2004, we anticipated it would be easier by now.

The Chair: You had a federal-provincial-territorial advisory committee on guidance and accountability that has been disbanded. Why was it disbanded? How much of a problem did that create? It must be a setback if you do not have an advisory committee for the very people you are trying to get information from.

Dr. Kitts: I have taken over the chair in the last six weeks, so I can claim innocence for the next few months, but I will defer to Mr. Abbott.

Mr. Abbott: From the Health Council perspective, there is no control over that piece. The strength of our ability to report is on the data that CIHI and Stats Canada has available, what the research community has completed and what the provinces, territories and Health Canada can provide to us. We are reliant on all of those players to help us do our work. We take that and put context around it to report.

We have a very good working relationship with the jurisdictions, and that has improved over time. As Dr. Kitts said, there is an acceptance and willingness now to get to better measurement and better reporting. One of the strengths in the country is that at the provincial level we are seeing these quality councils taking on significant roles in their jurisdictions. We are able to work with them to pull this up to a national level.

The Chair: The accord talks about the wait time priority areas being cancer, heart diagnosis, imaging, joint replacements and site restoration. You have those factors listed here.

Is radiation therapy the only cancer-related measurement you have?

Mr. Wright: Yes. Subsequent to the signing of the accord, the provinces, territories and the federal government were charged with the duty to come forward with evidence-based benchmarks. There are very few evidence-based benchmarks out there. This was one that by December 2005, the provinces and territories could report on, on an evidence basis.

The Chair: The only one on heart is bypass?

Mr. Wright: That is correct.

The Chair: What others are you working on in those two areas?

Senator Martin: CIHR, the Canadian Institutes for Health Research, were charged with the task of looking at alternative benchmark indicators. They looked and looked. It must be based on evidence, not on consensus or how you feel on a particular day, and other evidence-based benchmarks have not been developed.

The Chair: Ms. Hoffman, you have given details on how the avoidance structure and the dispute resolution would work. Has it ever been invoked? Do you have any examples? Did you ever use the third party panel?

Ms. Hoffman: As I indicated in my remarks, dispute avoidance activity occurs all the time. That is the daily activity of the Canada Health Act division. We are constantly in communication with provinces and territories on issues that come to our attention. They may be raised by the province or territory, they may be raised in the form of a letter to the minister and they may be raised through the media. There are all kinds of occasions where issues come to our attention. As per our normal practice, that leads to a quite extensive interaction with the province or territory concerned. The dispute avoidance part is basically our daily work.

There has never actually been a formal panel convened that has led to a report. You could regard that to a degree as a success, not to pass judgment here necessarily. If the dispute avoidance approach works, then the idea was to have that safety valve of a formal panel process if necessary, with a view to employing that mechanism on as few occasions as possible, and that has been the case to date.

The Chair: I have one final question, and it is about whether or not the provinces and territories have lived up to their obligations. If they have not, what is the penalty? What is done about that? Has the federal government ever said, "You are not doing this, so we will freeze the funds until you live up to this obligation?"

Ms. Hoffman: Absolutely. In fact, each year in the Canada Health Act annual report, is a report on deductions that have been made from the Canada Health Transfer payments to provinces in respect of the conditions, particularly those conditions related to extra billing and user fees set out in the act. That is an ongoing activity.

As far as the compliance of jurisdictions is concerned with their reporting obligations, the fact that they have that obligation to report is what allows us to actually prepare and deliver a Canada Health Act annual report. We would say we are in the ongoing business of compliance and enforcement. We try to do that in conjunction and collaboration with the provinces and territories.

Senator Demers: We talk about the review of the accord in 2004 and in 2008. How many government programs have been created as a result of the accord?

Mr. Abbott: I cannot answer that question. It is within the context of each of the elements, and each province and territory has then taken those and developed programs and services around them.

Senator Demers: Would you say there has been progress?

Mr. Abbott: As we say in our written submission, throughout the whole process there has been progress. In some cases, there has been much more than in others.

Senator Eaton: Mr. Wright, the wait for bypass surgery is 26 weeks or 6 months. That is a long time.

Mr. Wright: Yes.

Senator Eaton: Should we not be striving for fewer, different and higher benchmarks in the next accord?

Mr. Wright: There are actually three benchmarks for bypass surgery; we only show one here. The three benchmarks range from 2 weeks through to 26 weeks. Unfortunately, the provinces do not collect all the data consistently, so for presentation purposes, we are showing you only one benchmark, the 26 weeks.

Senator Eaton: In other words, you cannot say whether 10 per cent or 50 per cent of people who need bypass surgery are seen in two weeks. Because of the inconsistency of the reporting, you cannot give us any kind of indication?

Mr. Wright: That is correct. The only indication we can give you is to roll everyone up into the 26 weeks.

Senator Eaton: Would I not be dead after 26 weeks if I needed bypass surgery?

Mr. Wright: You would be in the lowest priority ranking of the three. Hopefully you would not be dead.

Senator Eaton: Dr. Kitts, I do not know whether you read the health report by this committee published last year. In your presentation you said that Canadians have difficulty accessing primary care after hours and on weekends and that emergency rooms are clogged.

I am a director of the foundation of St. Michael's Hospital in Toronto, and I know something of what a big tertiary hospital has to go through.

What about encouraging more community-based clinics; in other words, taking care out of hospitals? Is that within your bailiwick? Could that be pushed in the next accord?

Dr. Kitts: I think it is starting now. The introduction of family health teams is a huge step in the right direction. Not everyone needs to have a family doctor; they need access to a family health team. We need to fundamentally change the service delivery model and, as you all know, change in health care is almost impossible without sound performance measures and data to ensure that we are doing the right thing.

With all the family doctors we have now after a 47-per-cent-increase in medical school enrolment, we just need to change the way we do it. We need leadership in all sectors and we need to reform primary care. We must not focus only on the primary care physician but on the team you are talking about. It would be immensely important, not only for getting hospitalized patients out, but also for preventing hospitalization.

As I said in the report, more and more Canadians have chronic diseases. Chronic diseases should not end up in hospital if we are doing the right thing. If they do end up in hospital, they should move back out after the acute phase is over. That is our primary care system — full stop. We can do much better.

The good news is that in the Ottawa Hospital we are now recruiting family physicians jointly with the rural areas. Medical residents and family doctors are now on call once a week. They have the protection of the whole big environment; they have access to CT scans and other things. When they get into rural Canada, they feel completely isolated and lost.

It is the responsibility of the big ivory tower academic centres to do joint recruitment and to ensure that the doctors get the support and connections they need. I suspect that if we can do that, many young physicians will want to work in rural Canada because they will be part of a team.

Senator Eaton: Is there a possibility of changing the status of a so-called family care physician? Young people seem to want to be specialists, and we do need specialists. Is it a matter of money or status? Could someone who provides complete care as a family physician not be given the same status as a heart surgeon, for instance?

Dr. Kitts: You read it right. The family doctors in our hospital feel like second-class citizens, and they should not. Unfortunately, although 25 years ago the family doctor was everything to everybody, today family doctors are being pushed into more of a triage role, and they are losing their ability.

The family health care team should have strong family physicians who are focused on diagnosing, treating and controlling chronic disease. They should not have to deal with promotion, prevention and diet. Other health providers should provide all of that care and family doctors should get back to focus.

The problem is that the family doctor is doing everything for everybody, and probably most of their work is on the social end as opposed to diagnostics. There needs to be a fundamental change in the team and in who is responsible for what.

Senator Eaton: Are there countries we can learn from?

Dr. Kitts: I have visited a few countries. People come here because they say Canada is doing something really well. I suspect that there are now pockets of excellence in every country. Peterborough is a good example of that. At a time when all our emergency departments are facing 15,000 increases annually, Peterborough has gone down 15,000, so people can learn from that experience.

I do not think any country has it all right, but there are pockets of excellence, even in our own country. I think that is why the mandate of the Health Council of Canada has been adjusted to focus more on best practices and innovation and getting that word across. What has happened in Peterborough is profound.


Senator Champagne: I can personally attest to the quality of care that we receive in Quebec and to the availability and quality of home care offered to us by the CLSCs. However, where there has not really been any improvement is in the availability of family physicians.

In January, I tried to make an appointment. The earliest date I could get was in mid-June. It should not come as a surprise that emergency hospital departments are full. Since people are unable to see their doctors, they go to hospital emergency departments.

There is a family physicians group, but until all records have been digitized, we will always have to start over again by providing our life history, medical history, and that takes an enormous amount of time for the physician and for the people waiting.

Could we make the digitization of records one of the priorities? I know the Government of Quebec wanted to do its share by admitting larger numbers of students to the faculties of medicine. We should therefore have more doctors, but, as Senator Eaton said, an incredible number of those students go in for specialties. It is very hard to get a family doctor, and if you are lucky enough to have one, you have to wait four and a half months for an appointment, which is hardly any better.

If any funding were available in our new agreement for the digitization of records, that would facilitate matters and then, if there were five or six other physicians that I could consult at the clinic where my doctor normally is, and they had access to my file on their computers, that would vastly facilitate matters and we would waste less time.


Dr. Kitts: I agree entirely with your comments and concerns. You have hit on two essential things that need significant improvement going forward. One is the primary care availability and the electronic health record. It comes back to the same thing: Why can you not get an appointment with a family doctor? If you come to the hospital, you get to see the doctor. It should be the same for primary health care. If we are to prevent you from coming to emergency departments or being admitted to hospital, you have to be able to phone up your doctor when you have an earache and be seen that day.

Senator Champagne: I have to be able to reach my doctor by phone.

Dr. Kitts: That is right. Therefore, what are they busy doing? They are busy doing all of the other things that, in my mind, can be done well by a team. If we truly are to change primary care reform, we cannot have a family doctor lining up 12 healthy physicals and having no room for a patient who needs to see him or her. We need to change fundamentally, and there will be changes in incentives and changes in the way they work. Change is difficult in health care, but I believe strongly that we have the family doctors; they are just not doing the right thing.

That is up to us to change. It takes alignment at the federal, provincial and rock face health service providers level, the CMA and so forth. Everyone needs to agree. We have many family doctors; they are not doing the right thing. They need to be able to see patients when patients need to see them.

The electronic health record is another issue. Today, as we speak, we are finalizing the liabilities around privacy, confidentiality and so forth. I expect that in the next six weeks all the family doctors in Ottawa will have access to the electronic health record at the Ottawa Hospital so they can see their patients' information as it is happening. A lot is happening there, but if we are to move the yardsticks on improvement, sustainability and quality, we need that alignment right from the federal government to the provincial government to the front line providers and to the health service providers to say, "We will do this." I think we can.


Senator Champagne: I hope that digitization of records is an important point when we redo this agreement because, otherwise, if you are very sick and go to our hospital emergency departments, triage will move you up much more quickly than a person suffering from an ear infection.

It is not that an ear infection is painless, but meningococcal disease will make you sicker. I hope we can digitize records and that, within a year or two, we will be able to get appointments without having to wait three or four months.


Senator Seidman: It is such an excellent beginning because you have given us a series of presentations so rich in information. Being someone who is always very excited by data, I will begin with Dr. Kitts.

Dr. Kitts, you said that your focus is on identifying best practices in innovations. Is there a willingness to share best practices across this country? Is there a depository as such or will there be?

Dr. Kitts: That is an excellent question. If you talk to any senior executive, chief of medical staff or chief nursing officer, 100 per cent of them will say there is absolute willingness. We want to share best practices.

You could also ask them whether there should be an atlas of best practices, and they will say absolutely. It never happens because it has never risen to the top of the priority list at any of those areas. It is a 100 per cent good idea that is 100 per cent possible, but it is not likely to happen without strong direction from above.

I will give you the example that is happening now in Ontario, namely, the Excellent Care for All Act. Some of the hospitals have had quality plans for some time. Those are plans with actual strategies, investments, tactics, targets and outcomes around a number of things. Most of the hospitals have no quality plan. There is a best practice. On April 1 of this year, 150 hospitals in Ontario will have a quality plan posted on the website with performance measures, targets and how they are doing. That is because an act of legislation made it happen. Everyone agreed that it should and could happen, but it did not.

CIHI, Statistics Canada and the Health Council of Canada can only report on what we have. More and more at the rock face and the frontlines, I am seeing individual health care providers creating national collaboratives, saying, "We know we can do better and are wondering if you are," and pushing that forward.

Your idea and suggestion is 100 per cent right, but it does not happen until someone elevates it to an important priority. An act of legislation may be as far as you can go, but it does work.

Senator Seidman: Your response leads me naturally to CIHI.

Your mandate is so critical. Stated objectives must be measurable, have hard data and be comparable if we are to understand how our health system gives us value for money, which is the bottom line.

Do we have hospital-specific and physician-specific data being collected? Dr. Kitts has already begun to answer that question. Specifically, I am interested in outcome-based data to measure objectives and quality of care. If we do not have it, will we have it? Are we moving in that direction?

Mr. Wright: With respect to acute care institutions, namely, hospitals, I mentioned the "Canadian Hospital Reporting Project." That is 547 hospitals from across the country in 10 jurisdictions. It started out as a pilot project. We hoped to get two or three provinces onside, and they have flocked to this project. We had discussions with the jurisdictions that are not involved, and they are looking forward to coming on board.

As part of that project, there are 33 indicators in three basic categories. One focuses on clinical indicators, which are measures of outcomes in many circumstances, for example, 30-day in-hospital mortality rates, readmissions after asthma and so on. We also have patient safety indicators, which are also an outcome of sorts, and we have some financial data.

We will be adding other indicators. It is not public at this time because we are still working on it, and, as I mentioned, by March of next year we hope to make it public. It provides an opportunity for someone to compare his or her hospital in that mythical town in Saskatchewan, Podunk, with that mythical town in Nova Scotia, Oddsock, on the basis of performance, outcomes, quality and financials.

With respect to physicians, it is a different story, and that ties into the electronic medical record. From CIHI's perspective, we collect simple data on physicians: age, place of graduation, how long they have been in the field, retirement practices, or when they will retire. It is just a simple database of the number, specialty, family physicians, how much they are paid, whether they are fee for service or alternative. We do not collect data on outcomes associated with treatments.

Dr. Kitts: To follow up on the physician data, today, the outcome measures are an aggregate at a hospital level. Members of the public want to know how he or she will do with that doctor. That is the ultimate goal we need to get to. Substantive change in how we deliver health care will only be realized to its full extent when we are able to measure the cost and outcome at the individual patient and the individual physician levels.

In the absence of that, medicine remains very much an art. You do what you were taught to do in the best interests of your patient. In the absence of any objective real time data that shows another way is better, we will still be practicing the art of medicine, which may not always be the most cost effective and have the better outcome.

Senator Seidman: I appreciate that, and if we are trying to look at best practices and establish norms, can we then look at, for example, surgeons and their specific outcomes in their surgical interventions?

Dr. Kitts: Yes, if we have those outcomes.

Mr. Wright: We simply do not have that data. With the introduction of the electronic health record and the electronic medical record, it is hoped that data will flow off that for clinical purposes, but data for health system use to assist in the overall management, though very important, is privacy sensitive.

I will add one more quick point on quality. Dr. Kitts and I worked together on a project dealing with the academic health science centres across this country. We are looking at developing quality indicators that are not old data so that we can turn the results around within a month. This is a major project for both Dr. Kitts, who heads up this collaboration, and CIHI. There is good stuff in the mix.

Senator Seidman: It is important if we are trying to measure value for money to have this kind of data. You talked about comparable data and said that there was no comparable data for Quebec on several things. What are the issues around that situation?

Mr. Wright: The data not available in a comparable way is hip fracture surgery repairs. That being said, they collect data slightly differently. We have a publication coming out in April that we worked closely on with Quebec, Alberta and Ontario to enable the comparisons on an apples-to-apples basis. We are working with them to do that.

The other data set is on bypass surgery that is collected differently in Quebec. We have made great strides collectively, including Quebec, in developing the databases, but it takes longer because of the nature and the way in which they administer their systems.

Senator Cordy: I will go back to Senator Eaton's comments about benchmarks. In reading about the benchmarks, I learned that provincial and territorial benchmarks were longer than the benchmarks established by the medical community. Is that true?

Mr. Wright: There are different types of benchmarks. For example, there is an evidence-based benchmark, which is a research of the academic literature where evidence prevails and a benchmark is established. The provinces and territories reported on that in December 2005. They could not find one for MRIs or CT scans. Another type of benchmark coming from the medical community might be a consensus-based benchmark. For example, the medical community might establish that no one should wait longer than a specified time for an MRI. Within the medical community there are many different views that are not evidence-based on how long someone should wait for various surgeries.

Dr. Kitts: Perhaps I could provide a concrete example that might typify our struggle. Mr. Wright is absolutely right in saying that we truly need evidence-based benchmarks. We need to know that if we set a benchmark of a four-week wait for prostate cancer, the patient will not have a bad outcome. The argument can be for two weeks, four weeks or six weeks. Certainly, if I needed the surgery, I would want it done tomorrow. For the vast majority of quality benchmarks, we do not have the evidence. A group of experts get together and say it should be done in four weeks or six weeks, but we cannot measure the outcome for the vast majority.

I will provide an example of an internationally renowned best practice. A few years ago, an emergency physician at The Ottawa Hospital asked the question: Does every patient who twists their ankle and arrives at emergency with a swollen ankle need to have it X-rayed? To find the answer he applied to CIHR and received a grant. He developed an algorithm to diagnose the ankle by touching here, here, here and here. If the patient answers, yes, yes, yes, no, the patient does not need an X-ray; the ankle is not broken; and you can send them on their way. It was scientifically studied and 100 per cent proven that you do not need the X-ray, and you are not sending someone home with a broken ankle. It was published in the New England Journal of Medicine, disseminated across Canada and found in every emergency department around the world. It has saved billions of dollars in health care and has saved people from long waits in emergency for an X-ray for a swollen ankle. That evidence-based benchmark is in the New England Journal of Medicine. Everyone who applies it knows that they are not sending someone home with a broken ankle.

A couple of years ago, my infection control people said that MRSA, the superbug, is a big problem. They were no longer able to identify who is at risk of bringing it into the hospital based on where they came from and who they are. It is in the community, so we have to do universal screening. Everyone has to have a universal screen that comes into the hospital. All the infection control experts — my great doctors who are among best in the country, if not North America — said that it was a good idea — best practice, leading edge. The University Health Network in Toronto said the same thing.

A year and a half later, we did an evaluation based on the data. Increased costs were $400 per patient — $1 million in my hospital. There was no reduction in outbreaks and no measurable effect. It was not cost effective so we stopped doing it. Good thing it was not adopted as best practice across the country at $1 million per hospital simply based on consensus. We have to be careful when we start implementing best practices because if they are not based on evidence and outcomes, we might do more harm than good. That is the struggle we face all the time. The absolute key to a better system is the data coming out of CIHI that reflects the reality of what is happening at the individual patient level.

Senator Cordy: Are we looking at evidence-based benchmarks for diagnostic imaging? That was part of the accord in 2004 seven years ago. How far have we come in seven years?

Mr. Wright: In 2005 Canadian Institutes for Health Research was charged by the provinces with the task of finding suitable evidence. A thorough research of the literature simply found that there are no evidence-based benchmarks for CT scans, MRIs or PET scans. I do not believe that anyone is looking at that currently. Some general guidelines have been developed, though not adopted by all.

Dr. Kitts: The good news with these types of benchmarks is that everyone knows when you need an MRI within five minutes: after you have an acute stroke or are hit by a car. There is no issue, even with an urgent MRI that must be done in less than a week. We have no idea how long you can wait on an MRI wait list without sustaining harm. The sequence is: Your acuity jumps, and you jump the queue based on acuity. We had long MRI wait lists, so I asked the question to all our best health service researchers: What is the harm being done to people who wait eight months for a CT scan? The answer is: They move to the front of the line as the acuity changes, which is not a good system. In the end, I do not know what the right wait time is for an MRI.

Senator Cordy: Private diagnostic imaging clinics are springing up across all provinces; and public reaction is favourable. The public in Nova Scotia have accepted that if you want an MRI the next day, they will have to pay $500 at a private clinic. It was part of the accord, but it seems to be the area where we are veering into two-tiered health care.

Dr. Kitts: Like in most wait times for surgery, MRIs or cardiac bypass, priority one means you cannot wait; you have to go to the front of the line immediately. Priority two means that you can wait two weeks, and priority three means that you can wait six weeks. I hate to say it, but priority four waits so long that it eventually becomes a priority three.

When we talk about benchmarks, we have to talk about acuity levels of patients. The evidence is pretty clear for the high acuity; however, for the lower acuity, I do not think we know what a reasonable wait time is for someone with chronic low back pain.

Senator Cordy: It depends on whether or not you are the patient.

Dr. Kitts: Exactly. If you are told by an orthopaedic surgeon that there is a 99.5 per cent chance that that lump is not cancer, and the only way you will know for sure is through an MRI, how long will you wait for that?

Senator Ogilvie: What we are looking at, as you know, because you deal with it more often, is the accord, which is the agreement between a body that gives out a great deal of money and a group of bodies that receive the money to deliver; and the success of the accord is ultimately determined by how people benefit from that transfer of money.

We spent some time talking about benchmarks, which are absolutely essential. However, as you have, in my opinion, so correctly outlined, what we choose as benchmarks is perhaps as critical. We know that there are certain areas where delay, such as for hip or knee replacement, is a much more obvious and direct measure, as opposed to access to other kinds of issues.

For example, if we take colorectal screening, and to use the sprained ankle example of Dr. Kitts, my understanding is that there are four principal indicators that the family physician will look at in terms of whether the patient is high risk when first coming in. One of those indicators is family history. However, it will take two or three generations before there is enough history, in other words, for people to live long enough for that to be a real indicator. Yet, here is a situation where early screening completely eliminates a life-threatening situation. I would say that the results we have across the country with regard to that illness are disappointing.

I assume that the numbers are beginning to get better in the last three to five years. They remained really very poor in Canada up until about three to five years ago. Can either you or Mr. Catlin indicate whether you see an improvement in the percentage of people over 50 getting colorectal screening?

Dr. Kitts: I can comment. I believe the next time they do the statistics, there will be a tremendous improvement, because there is a federal-provincial cancer care and front-line provider, as well as public alignment that it is the thing to do and it should be done. When you get that, you can hit 100 per cent and there is no question. Up until the last few years, for the most part everyone was paying lip service. I think everyone gets it now, and I expect the statistics will be much better.

Senator Ogilvie: That was my assumption. I looked at the results from the review in 2008, and I felt that it did not show tremendous cooperation among the provinces in terms of developing indicators and reporting appropriately. In the end, I am hopeful that in the areas we have touched on this morning, such as cancer reporting — whether it is radiography, chemotherapy, doses, et cetera — the real indicator will be the percentage of people with the issue of certain cancers. In my view, the job of Health Canada is to identify the performance of the deliverers of health care to ensure that the real indicators are changing through an overall effort.

I do have one question for you, and it is not really a fair question to the group of you. I will direct it to Dr. Kitts and Mr. Wright. My question deals with the issue of pharmaceuticals. I realize that you are largely reporting figures, but some of you have medical and scientific training, so I want to ask the question.

When I look at the data, what I see in a number of different reports is that adverse drug effects are either the fourth or fifth leading cause of death. We know, as well, that there is enormous over-prescribing of pharmaceuticals. This is an enormously costly area, simply in terms of dollars; and when there are adverse impacts, this has an enormous adverse health impact, from something that is supposed to be bringing treatment, not the reverse.

By the way, I want to make it clear that I believe that the electronic record issue is critical to making progress in most of the areas we have talked about so far today, and in this area I think it is absolutely essential.

As you survey the potential impacts of genetic screening and the individual health record identity, using measures as advanced as genetic screening, do you see an opportunity to, first, improve the health of Canadians through such directions; and second, do you see a significant reduction in the overall cost to the health care system? I will direct my question to the two of you first, but anyone who wishes to answer may.

Dr. Kitts: The answer is yes, absolutely, 100 per cent. I think we are a long way from there. I think the theory of personalized medicine is very sound. Every one of us has an entirely different genetic make-up. Therefore, if I give you a drug, you could have a 400 per cent different response from that of the chair, for example, and we do not know. There is no drug without an adverse effect.

In the future, I think drugs can be made to deal with the genetic makeup of the individual by way of personalized medicine. However, I think we are a long way from that. In the meantime, every time someone gets a drug, the risk- benefit analysis goes on in the physician's head, and maybe in the team's head, if it is a particularly toxic drug. In the end, it is a judgment by your health professionals as to whether the benefit outweighs the risk. If it does, you may get the benefits, but you also get some of the adverse effects. It is a Catch-22. There are no drugs without a risk, but the benefits far outweigh the risks in most cases.

Mr. Wright: I do not have much to add. In some cases, expensive drugs for rare diseases are manifested in the identification of a particular disease and a particular molecule that can be used. These drugs can be very expensive, and I suspect the provinces are extremely concerned about this going into the future. That is about all I can add.

Claudia Sanmartin, Senior Analyst, Health Analysis Division, Statistics Canada: I want to touch on one important point, which is the role of multiple medications. We came up with a finding in the primary health care survey when we questioned individuals, particularly those with chronic conditions and multi-co-morbidity, which is the key. It is not just people with hypertension, diabetes or arthritis, but having three or more of those conditions catapults you into an area of risk in terms of disability.

We found that even though there is a low risk of having an adverse event due to drug reactions, when you are in the world of having five or six more drugs, this places you at higher risk. The ability to track that information for the individual doctor who is describing that at that time, to know what else that person is taking, is critical. Having coordinated care for those people, those with chronic conditions and co-morbidity, is essential.

Senator Ogilvie: I do not disagree with your observation that this is on the horizon. I think it is closer than we think. My final observation is that I believe the electronic health record is absolutely critical in dealing with these multiple dose issues. The evidence is beginning to show that roughly 30 to 40 per cent of prescriptions have no positive impact, so there is enormous opportunity for health benefit as we move forward.

Senator Dyck: In the media we have seen examples, and one in particular comes to my mind of patients with rare diseases. I cannot remember whether it was a baby or a young child who had some rare metabolic disease, but there was a specific drug that would treat it. This would be catastrophic drug coverage.

Has there been any progress achieved in developing some kind of coverage for catastrophic drug coverage? Have there been reports on what sort of plans are coming? What sort of progress has been made to help the families in situations like that, when they are in a unique and terrible situation faced with bills not covered by medical care, which can be enormously high?

Dr. Kitts: I will defer to Mr. Abbott.

Mr. Abbott: In terms of catastrophic drug coverage across the country, it varies by province. Most of the provinces now have some kind of coverage in place for the situations you describe. The National Pharmaceutical Strategy talked about having a plan or an approach in place across the country. In terms of these high-cost situations, certain provinces have put in place some policies to ensure they can address those issues, particularly for rare diseases. There has been a lot of discussion at the federal-provincial level around that issue as well and also working with the drug manufacturers, because they are a critical part as well as the research community.

We have a bit of a patchwork across the country. It is not consistent. Depending on which province you are in, the coverage will and does change. That tends to get played out from time to time.

Senator Dyck: I am from Saskatchewan. When I was looking at the data that Mr. Wright presented with respect to wait times, I thought, "Oh, I am in the wrong province. I should move to B.C. or to Ontario." I think I will choose B.C. because the weather is better.

Within the data that is collected, is there any indication of why it is worse in Saskatchewan? Having lived there most of my life, I suspect that a big part of it might just be due to shortage of doctors. We are continually facing a shortage in northern communities and rural areas. Rural hospitals are being closed and there is a lot of competition for doctors. Would that be part of it?

Can the provinces use this accord in some way? Does it help them overcome these types of situations? Is there a mechanism whereby we can take advantage of the accord to solve a provincial problem?

Mr. Wright: I, too, am from Saskatchewan originally. I was also the deputy minister of health there for a while.

The interesting thing about Saskatchewan is that, on a three-year trending basis, it is showing positive improvement in each of the areas. It would be fair to say that Saskatchewan was a bit behind some of the other jurisdictions around 2004, but the trending data — and this will come out later this month — shows Saskatchewan making strides in all the areas.

There are a whole series of reasons that can relate to population health characteristics, the First Nations community in Saskatchewan. A whole series of factors are behind that characterization, all of which are quite legitimate.

In terms of the accord itself, the additional funds that were part of the accord for wait-times reduction were welcomed by all jurisdictions and resulted in improvements in wait times, certainly within the five areas that were identified as well as in other surgical areas.

Senator Dyck: You answered one other small question that I had, namely, whether or not the data included Aboriginal people. It sounds like it does.

Mr. Wright: Yes, it does include Aboriginal people. Unfortunately, we cannot identify them as Aboriginal people because there are no clear identifiers across the country. We are working with the First Nations, Statistics Canada, and others to see what we can do in the future about identifiers.

Senator Dyck: Mr. Catlin, regarding your graph on page 8 on perceived health, has this type of information been transmitted to the general public? As an individual, I might look at this and say, "Well, there are eight factors that help me improve my health, but it looks like I only need to do five or six." What are those five or six? When you have grouped them together, if you have six of them, can they be any six or can you predict from this which is the factor that helps you the most? My guess might be physical activity.

Mr. Catlin: I do not have that before me, but I think the evidence was that as soon as people got to four or more attributes, that was very predictive as being in good health, both perceived health and functional health.

I will go out on a limb and say that smoking is probably the most important of those, but physical activity and the body mass index were also critical.

Senator Dyck: Do you think it is possible to look at these items and come up with a general edict for health promotion ideas? Although this is perceived health, it is not actually a measure of health that these are the things we should concentrate on.

Mr. Catlin: Yes. This was published in a report that Statistics Canada put out last year, based on the survey of healthy aging. There will be more reports coming out in the next few months.

Senator Martin: I am having a struggle trying to wrap my head around all of this information. I can only imagine being you for a day — or for a year, for that matter. This is something that I feel personally committed to because health is something that touches every single one of us. I have had to care for aging parents and a father who went through the system, so the e-records between health jurisdictions really could have saved a lot of trouble for my father.

I go back to the question about the accord itself. Senator Demers asked: "Have we made progress? What programs have been created?" You answered yes in general terms, but not in specifics. I can imagine how every jurisdiction would have different kinds of programs that have been created and the roll-out would be different, depending on the provinces and territories. However, who has that information? Who would collect it? Whose responsibility is it?

We talk about the stats and the data, but for this accord to be more effective now than it was eight years ago, or when it was established, we must know what that progress has been. Is the data in existence out there? If so, who has collected it?

Dr. Kitts: I do not think we have the data to accurately answer the question. We can talk about proxies for data and proxies for outcome: Is it high on the government's agenda? Is it a directive? Is there alignment between the provincial government and the local health service providers? Is it a priority? Is it an act of legislation?

The best way to answer, in my opinion, is that because of the accord, a lot of attention and focus has been put on trying to achieve it, or at least understanding that we need to achieve it. A lot of building blocks are being put in place. I cannot tell you exactly, but I can give you snippets of where it is happening. The Excellent Care For All Act in Ontario is the ultimate building block.

The notion is that everyone, from the federal, to the provincial government, to the health service providers and to the CMA has rallied around a better health system. We are not far from giving you hard data which will show that we have moved yardsticks and that the quality is improving.

For the most part, hundreds of thousands more Canadians have had at least one of the big five procedures since the accord. I cannot tell you if the outcomes were all good. However, volumes are up.

Over the last six years, everybody has rallied around a focal point. It will continue to move from here on.

Senator Martin: CIHI is one of the best positioned entities to do that kind of coordination. Speaking as a former teacher, curriculums have learning outcomes.

There are provinces that have fallen behind for various reasons that we may not fully understand. If a province has fallen behind, how do we bring them up to the other provinces? How do we identify the need and how best to bring them up?

The coordination piece is the biggest challenge for all of us involved because we live in a vast country where every jurisdiction has its specific needs. The transfer money is a huge sum. The provinces and territories are using the funds to roll out their programs and as they best see fit. To what extent are the provinces and territories accountable to not just the federal government but also Canadians in terms of how effectively they are using that money?

In the accord, is there an opportunity to strengthen the accountability piece so that we can ensure that the progress is clear? I can appreciate the complexity of this task.

Dr. Kitts: The more we provide measures that accurately reflect the reality of what is happening; the more individual jurisdictions will focus and move their yardsticks. It is an incredibly complex question. The whole health system is complex. It could be that one area is lagging in the wait times for hips but is accelerating in cardiac surgery. There is that push and pull in the whole thing.

In health care, the good news is that you do not have to incent people to do anything. I do not know of any professionals more competitive than doctors or executives more competitive than executives of hospitals. Give us the data on how we are performing; make sure it is accurate, reliable, and reflective, and we will move mountains to jump over the next guy.

We do not have that data yet. We have some volumes. The Saskatchewan government has promised that, by 2014, it will be a three month wait for everybody.

That is an example of what data and transparency can do.

Mr. Wright: There have been tremendous developments in data collection. The accord played a key role in that, around wait times and other forms of data such as historic, home care, long term care and drug data that are comparable across the country. Without question, there are gaps. It is CIHI's job to fill in those gaps as resources permit. Across the system, people are asking for data, indicators and comparable reports. We are working with some cardiovascular surgeons around some quality outcome indicators. There is a lot to be done.

Senator Martin: As we are doing this review, do we need to do anything to ensure we are collecting that data?

Dr. Kitts: The Health Council of Canada will give you the data as we get it from the service providers. There are many building blocks right now and not a lot of substance.

Senator Martin: In terms of the accord as it stands, is there anything we need to tighten up?

Mr. Abbott: I do not think so. We need to stay focused on and improve public reporting. We need to be committed to it at the political and delivery end.

Senator Braley: I seek clarification on a couple of points. Dr. Kitts, you talked about how primary care can be improved by including nurses, nurse practitioners, physiotherapists, and social workers in a team. That might free up the time to 50 per cent on the family practitioners. Am I right in hearing that? Is the scope of their practice what we are talking about?

Dr. Kitts: Yes, it is.

Senator Braley: The 2008 report mentions concerns about provinces going in different directions. Has that been fixed or does it still need fixing? Please do not point out a province; just say "yes" or "no."

Dr. Kitts: It is more complex because, again, we do not have one system. We have 14 systems each designed to work for that province or territory. We are not sharing best practices. Therefore, we need to ensure that whatever is being done is based on the best evidence outcomes and practices. I would not try to fit it all into one system; however, I would certainly use the 14 to improve everybody.

Senator Braley: Suppose one of my employees needed an MRI tomorrow. Knowing that the wait would be three or four months, we would cancel the appointment and send him or her to the States. Are you including in the data the percentage of people who are getting their work done elsewhere and paying for it? I imagine not.

Ms. Sanmartin: When we started to collect wait time data years back, we looked at the possibility of getting that number. It is difficult to do that in a survey sampling the population. It is, in fact, quite rare that that happens.

Senator Braley: In Hamilton and southern Ontario, if employees are told they have to have an MRI, we as a company would send them and pay for it. We want them to know they can be well or be fixed fast. We work on making sure that the diagnostics are done so we can get proper medical care to our employees. This happens far more often than you think. It is done by most of the companies and people in southern Ontario.

That is something for you to look at. Suppose that I am trying to run my company and saying, "He is doing this and he is doing that." Do we have a leader in charge of this health accord? Do we have a business plan that is reviewed quarterly and weekly so that we are sure that the things we want worked on are being worked on? Is somebody in charge of the coordination of it in a proper fashion? Perhaps there are ten different items that are being managed and monitored to the extent that adjustments are made. When you reach blocks in the wall, corrective action must be taken. I do not see most of these things. I see pieces of information here and there which are not consistent. Have I missed something?

Dr. Kitts: No, you have not.

Senator Braley: Maybe we need a business plan.

Dr. Kitts: We are without a leader.

The Chair: Does anybody want to respond to that?

Dr. Kitts: He articulated it very well.

Senator Braley: We end up with this recommendation. I am sorry to be so direct.

The Chair: There is the problem of the 14 jurisdictions.

Senator Braley: There are federal dollars, too, if you put them in the business plan.

Mr. Abbott: Governments came together and laid out a plan. That was good. Then they identified having a pharmaceutical strategy or a series of commitments to move forward. The system was working together. When the ministers and governments are joined, progress is made. When that starts to dissipate for whatever reason, then we are 14 individual organization systems, moving at our own pace.

Senator Braley: Put somebody or something in charge of the whole works and reorient the priorities as per what needs to be done.

I will give you an example. McMaster was tenth in research. I took over chairing all the research with Dr. John Kelton. We are now second in Canada. We will be first, and then we will be in the top five in the world. It is just something we decided we will do. The reputation of the school is built up in that way.

You need a business plan to get there. I do not know how you do it any other way. You can have ideas, visions and things in place but how do you get there? You need somebody to manage it.

Dr. Kitts: I think you have hit the nail on the head.

The Chair: If we had one company, we would not have needed an accord. However, we have 14 companies.

Mr. Wright, you said at the beginning that there was some information you were not giving us today. I cannot remember in what context you said that. Can you provide that information to us?

Mr. Wright: It is under embargo and it will be out on March 21. It is good stuff.

The Chair: There was an objective of ensuring that 50 per cent of Canadians have 24/7 access to multidisciplinary teams by 2010. Dr. Kitts, in your submission in 2009, you talked about it being at 32 per cent. You were about to report further.

One issue raised previously was the definition of "multidisciplinary team," and the term "primary health care team" has also crept into this. I do not think they are necessarily the same thing.

Is the definition continuing to be a problem? Will we reach that 50 per cent?

Dr. Kitts: I know there has been a tremendous focus for Ontario on creating family health teams, which are multidisciplinary primary health care teams. I believe that is the case in the other jurisdictions. I will let Mr. Abbott respond regarding what we know so far for the upcoming report.

Mr. Abbott: We have identified Peterborough as an example. We know it works. There are quite a number of examples, both in Ontario and across the country, where this is working in practice. The challenge seems to be for the community next door to embrace and learn how to develop and use these teams. The primary health care teams, family health care teams, and inter-professional practice are all essentially talking about the same thing.

We are seeing a lot of progress. Canadian Health Services Research Foundation is doing a lot of work in this area to help the various systems to embrace it and move forward.

In our report in April 2009, we looked at this in more detail and went across the country to see what was in place and how things were working to find out what was working best. The question then came up about whether 50 per cent of the population is the appropriate target, or whether it is the population itself to be served. That gets us back to those with chronic diseases. They will benefit most by having teams working for their care. Supplementing that are the telemedicine, tele-triage and other clinic services. If you see, for instance, what the Ontario government promotes in terms of needing access, they give quite a comprehensive list of points of entry for service. Therefore, in terms of actual service, we are seeing that points of service have increased. Teams and professionals working together have increased.

We are working to see whether we have hit that 50 per cent magical number.

The Chair: I have one final question, for the Health Council and to CIHI.

This is our first meeting and our first encounter with the Health Council and CIHI. Hopefully, we will have more. What do you think are the two or three of most useful things this committee could do in its examination of this issue to move the yardsticks and the agenda forward?

I am sorry to hit with you. It is a big question. It would be helpful to know as we go through the future meetings on those ten areas.

What is the most useful thing you think we can do?

Dr. Kitts: No one can argue the ten areas. You will not get pushed back by people saying that they are not important. The key thing is how to get alignment from this accord in the jurisdictions, the agencies, the frontline health service providers and the docs. If you get that alignment, amazing things will happen.

Right now, every one of those key stakeholders can opt out. They should not be allowed to opt out. You need to move the yardsticks in those ten areas.

The Chair: Mr. Wright?

Mr. Wright: Mr. Chair, it is not in my nature to duck and run on questions, but with your indulgence may I duck and run on this one, please?

The Chair: You can send me a note on it, if you have one.

Mr. Wright: Perhaps.

Senator Cordy: I would like to come back to the national pharmaceutical strategy. It was a key part of the accord in 2004. The Romanow Commission had catastrophic drug coverage as a major part of its report. It was a major part of this committee's report under Senator Kirby. I was a part of that committee. Our committee said you would pay a percentage on pharmaceuticals, but no more than $1,500. Yet, in your presentation to us today, Dr. Kitts, you said it has stalled. I have read that costing was done and a few minor things have been achieved, but really nothing is coming forward.

The coverage on pharmaceuticals Canada is about 90 per cent. It might be a little more or a little less. However, when you break it down by provinces, the Atlantic provinces' numbers are different: Over 20 per cent of people have no coverage for whatever reason. When you look more closely at my province of Nova Scotia, or Prince Edward Island, a higher percentage of people have little or no coverage. Has the issue fallen off the table?

Very little has been done, from what I have read. Is that the case?

Dr. Kitts: I do not know if I can accurately reflect what is being done because I do not think we know. Things described in the report are being done but getting to where I think the intent of the accord was will take a lot more effort on behalf of the jurisdictions.

Back to the chair's question: What can we do? Perhaps we can put a spotlight on that.

Senator Cordy: It was your report that I read, and it said things like costing was done.

Dr. Kitts: Yes.

Senator Cordy: They were superficial kinds of things.

Dr. Kitts: The pharmacists' role in health care was good. Procurement and tendering are all good. However, I am not sure if it will positively impact the person on the front line who is paying for their drugs.

Mr. Abbott: There is a good example of what happened around generic drug pricing. The national pharmaceutical strategy had identified costing around drugs and generics as an issue they wanted to tackle. Subsequently, Ontario tackled it and then other provinces followed suit.

The question to ask is: Knowing that was an issue up front, why would not they, could not they, should not they have acted together sooner? That was the promise of the national pharmaceutical strategy, or NPS.

I would say it was an opportunity lost, but I do not think it is lost forever. Governments are working on the issues. Ideally, from working together, we would be that much further ahead.

Senator Cordy: It is one area we have to consider in our report, I would think.

Mr. Abbott: Yes.

The Chair: Thank you for getting us off on this good start. We have much to think about.

(The committee adjourned.)