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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
The Chair: There is the problem of the 14 jurisdictions.
Senator Braley: There are federal dollars, too, if you put them in the
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
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
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
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
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
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
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
Mr. Abbott: Yes.
The Chair: Thank you for getting us off on this good start. We have
much to think about.