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

Issue 3 - Evidence - September 29, 2011


OTTAWA, Thursday, September 29, 2011

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:29 a.m. to examine the progress in implementing the 2004 10-year plan to strengthen health care.

Senator Kelvin Kenneth Ogilvie (Chair) in the chair.

[Translation]

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

[English]

I am Kelvin Ogilvie from Nova Scotia, chair of the committee, and I will ask my colleagues to introduce themselves to you by starting on my right.

Senator Seidman: Judith Seidman from Montreal, Quebec.

Senator Martin: Yonah Martin from Vancouver, British Columbia.

Senator Demers: Jacques Demers from the beautiful province of Quebec.

Senator Merchant: Pana Merchant from sunny Saskatchewan, Regina.

[Translation]

Senator Verner: I am Josée Verner, and not only do I come from the beautiful province of Quebec, but I come from the beautiful city of Quebec.

[English]

Senator Callbeck: Catherine Callbeck, Prince Edward Island.

Senator Eggleton: Art Eggleton, Toronto, and deputy chair of the committee.

The Chair: Thank you, and welcome to our witnesses today and to the audience.

This committee is charged with examining under this current study the progress in implementing the 2004 10-year plan to strengthen health care. I will take just a minute to review, since this is our first meeting of the new session here. I remind everyone that this is an ongoing study, which we actually began with our first meeting on March 10. The theme of that particular meeting was accountability and reporting on progress, where we heard from the Health Council of Canada, the Canadian Institute for Health Information, Health Canada and Statistics Canada.

I should also inform everyone so they are aware that all documents received from our first meeting and the first act of this committee have been referred to us as continuing with regard to our study under our continued order of reference, under which we are operating today.

Today's meeting will deal largely with reduced wait times and improving access. We have four different groups presenting today. From the Association of Canadian Academic Healthcare Organizations, we have Christine Power and Glenn Brimacombe. I understand, Ms. Power, that you will be making the presentation.

Christine Power, Chair, Board of Directors, Association of Canadian Academic Healthcare Organizations: That is right.

The Chair: From the Wait Time Alliance, we have Dr. Chris Simpson, chair, and Stephen Vail. I understand, Dr. Simpson, you will be making the presentation.

Dr. Chris Simpson, Chair, Wait Time Alliance: That is correct.

The Chair: Welcome also to the Institute for Clinical Evaluative Sciences and Dr. Michael Schull. Appearing as an individual is Dr. Brian Postl. Welcome to all of you. With that, I will ask Ms. Power to begin her presentation.

Ms. Power: Good morning and thank you for the invitation to be here with you today.

I have the privilege to serve as the president and CEO of the Capital District Health Authority in Halifax, Nova Scotia, but today I am here as the board chair of the Association of Canadian Academic Healthcare Organizations. ACAHO is the national voice of the country's research hospitals, academic regional health authorities and their research institutes. Members of ACAHO are leaders of innovative and transformational organizations with overall responsibility for the provision of timely access to a range of services, from specialized care to prevention of disease, educating the next generation of health providers and leading in research discovery and the early adoption of innovation in the health system.

For purposes of my remarks, I will speak to three areas: our assessment on progress related to the wait times since the 2004 health accord, what factors are critical to build on our progress to date and what promise could 2014 hold for us.

ACAHO has been and remains a strong supporter of the 2004 health accord. At that time, the accord was an important step forward in terms of focusing attention, resources and an accountability framework on five priority areas related to access to care. The accord has not been an unqualified success or an unmitigated failure. Our brief notes a number of areas where progress is being achieved to improve patient flow and system performance across the continuum of care. However, there continues to be more work required to improve access to care, overall system performance and its measurement. Real-time innovations are occurring at the local level and are making a difference in the manner in which patients are prioritized, the speed at which they are moving through the system, and they underscore the need for different parts of the system to be integrated.

While ACAHO members have demonstrated progress in a number of areas related to access to care and wait times, we have identified eight policy challenges that can be grouped across the headers of community-based and primary health care, health system capacity building and research and applied health system innovation. Given that we are seven plus years into the 2004 health accord, we believe it is time to open a dialogue on what a 2014 health accord might look like. Noting the recent comments by the Prime Minister and Minister of Health, how can we improve accountability in overall system performance in terms of value for money? Are we making a difference? How do we know?

While the views of the association are still forming, we have identified a series of policy options where the federal government can play an integral leadership role in working collaboratively with the provinces and territories in facilitating health system renewal. When it comes to accountability and system performance, we believe that it is essential to continue to advance the ongoing dialogue when it comes to comparable national indicators for wait times and benchmarks across all jurisdictions, and that public reporting on all defined priority areas occur.

While the access agenda has been the central focal point of the 2004 health accord, it is time to have the 2014 health accord focus on quality, of which access is one important dimension, with the others being effectiveness, safety, efficiency, appropriateness, provider competence and acceptability.

Given the important work that has been advanced across the country by provincial quality health councils, is there an opportunity to consider how we can develop a set of national quality-based health indicators that are comparable across all jurisdictions? For example, the Canadian Collaborative for Excellence in Healthcare Quality, comprised of 11 academic health science centres, has agreed to 16 indicators across five domains, which will be released later this year. Furthermore, there are a number of federally funded agencies that focus on select dimensions of quality that can make an important contribution in this area.

In addition to the un-earmarked federal cash that will undoubtedly be part of the 2014 health accord, we also propose three specific funds that are strategically focused in areas that can contribute to improved access and wait time.

While we talk about reducing the impact of overcrowded emergency departments, this is only the symptom of a system under considerable stress due to an insatiable demand for services. The real issue is the lack of capacity to move people appropriately through the continuum of care because of insufficient post-hospital care resources and poor attention to preventive and supportive measures. Can the 2014 health accord act as a catalyst to ensure appropriate post-hospital supportive and preventive care strategies, facilitate integration of primary health care with the rest of the health care system and enable innovative approaches to health care delivery? Is there an opportunity to move forward with new models of primary health care that focus on personal accountability for health, encouraging citizens to work in partnership with their primary care providers and thereby alleviating some of the stress on emergency departments?

Given that one in five hospital beds are being occupied by those who do not require hospital care — these are known as alternative level of care patients, or ALC patients — we must find innovative solutions so that 20 per cent of hospital beds occupied by ALC patients can be used more effectively. In both instances, perhaps part of the solution lies with the creation of an issue-specific strategically targeted fund designed to move beyond pilot projects and accelerate the creation of primary health care teams — for example, team-based primary health care funds could be established — and the creation of an infrastructure fund, which we call a community-based health infrastructure fund to assist in the development of post-hospital care capacity, coupled with tax policies designed to defray expenses associated with home care.

Finally, a challenge that has been addressed earlier in our brief is the recognition that there are a significant number of pockets of excellence when it comes to innovative ways in which high-quality, cost-effective care is delivered to Canadians. That said, one of our ongoing challenges is to find more effective ways in which we can share these applied health system innovations from coast to coast to coast in real time. In other words, these innovations need to be driven horizontally across the country.

One way to do so is to consider establishing a national health innovation fund, of which one of its stated objectives would be to promote the sharing of applied health system innovations across the country with the goal of improving the delivery of quality health services. This concept would be closely aligned with the work of the Canadian Institutes of Health Research in developing a strategy on patient oriented research.

Combined, we believe our recommendations focus on strengthening the structure of the health system, the process by which we improve the cost-effectiveness of delivering care, and improving overall health outcomes by focusing on a system performance through the prism of quality.

These are our preliminary thoughts as we move closer to 2014. We hope that they will contribute to the policy thinking about what is the role of the federal government when it comes to health and health care and, more important, look to focus the discussion on what is needed to ensure that Canada is a high performing system with an unshakable focus on quality.

That concludes my remarks and I look forward to our discussion.

The Chair: Thank you very much. Now proceeding through the agenda, I will invite Dr. Simpson to present on behalf of the Wait Time Alliance.

Dr. Simpson: I am very pleased to be here today on behalf of the Wait Time Alliance in support of this committee's review of the 10-year plan to strengthen health care.

The Wait Time Alliance, or WTA, is comprised of 14 national medical organizations concerned about Canadians' access to necessary care. In addition to developing evidence-based wait time benchmarks and targets in the five priority areas identified in the 10-year plan, the WTA grades provinces' performances against both the pan-Canadian benchmarks adopted by provincial governments and the WTA's own medically determined benchmarks. It issues these grades in an annual report card, the most recent having been issued in June.

My remarks will focus on two areas. First, I will talk about the progress that has been achieved to date against the commitments set in 2004, and second, I will describe what we believe are the key areas requiring attention in any future health accord.

First, about the progress to date, I will say point-blank that the commitment of governments to improve timely access to care is far from being fulfilled. Canadians are still waiting too long to access necessary medical care.

Table 1 of our 2011 report card shows how provinces have performed in addressing wait times in the 10-year plan's five priority areas. Of note is the fact that we found no overall change in letter grades this year over last. Wait times for both cataract surgery and hip replacement increased over 2010, albeit not by enough to affect the letter grades. Those for knee replacement continue to receive the poorest grades. Diagnostic imaging wait times, however, improved over last year in several provinces, although some provinces still do not measure their performance at all in this area.

The progress that has been made varies by province and by region within provinces. Smaller provinces often experience longer wait times than the larger provinces do. Within a generally high performing province such as Ontario, the median wait time for a hip replacement in the Ottawa area is 125 days, almost double the Ontario provincial average of 65 days. The median wait time for cataract surgery in British Columbia's Fraser Health Authority is 12.1 weeks, more than 70 per cent longer than the provincial median of 7 weeks.

An appendix to our brief highlights several issues raised by the WTA during the 2008 review of the accord, many of which have yet to be addressed. One such issue is the lack of attention given to timely access to care beyond the initial five priority areas. The WTA has developed benchmarks and targets for an additional seven specialties and uses them to grade progress. These data can be found in Table 3 of the 2011 report card.

Notwithstanding a lack of data, all indications are that wait times for most specialty areas beyond the five priority areas are well beyond the WTA benchmarks. On the other hand, we are somewhat encouraged by the progress towards standardized measuring and public reporting on wait times. All provinces, for example, now have a wait time website, some of which report on a wider array of treatments and in greater detail, but this is something that simply did not exist back in 2004. Leading the way is Nova Scotia, which reports on a range of diagnostic services, including nuclear medicine and consultation wait times for some specialties.

I would now like to look ahead and discuss how the wait times agenda could be supported by a new health accord. With a better understanding of the causes of wait times and how to address them, we believe it is now time to raise the bar in our efforts to meet patient needs appropriately. This means there must be a commitment on the part of governments to continue the work that has been done so far. We have three recommendations for supporting such a commitment.

The first is that governments must improve timely access to care beyond the initial five priority areas, as a start, by adopting benchmarks for all areas of specialty care. Further, an approach that centres on patients requires us to look at the total wait time experience. The measurements we use now do not include the time it takes to see a family physician, which is a significant omission given that millions of Canadians do not have access to a family doctor.

Second, we believe stronger accountability measures must be a key element in any new health accord. These would allow patients and providers the means to assess progress on wait times and help them navigate the health care system more effectively. These should include appropriateness guidelines, comprehensive wait time websites and a patient charter with access commitments.

Third, while the WTA believes the targeted funding under the 10-year plan has helped improve timely access, we equally believe that money is only part of the solution. Efficiency strategies, such as the use of referral guidelines and computerized clinical support systems, can contribute significantly to improving access and a transformed health care system. In particular, we note the significant impact of alternate levels of care, or ALC stays, on wait times. ALC, of course, refers to hospital patients who no longer require acute care but who are waiting for more appropriate placement elsewhere. In Ontario, for example, ALC patients occupy one in six hospital beds, creating damaging backlogs in areas such as emergency departments and elective surgery.

We believe that addressing the gap in long-term care is the single more important action that could be taken to improve timely access to specialty care for Canadians.

Our biggest fear is government complacency in the mistaken belief that wait times in Canada largely have been addressed. It is time for our country to catch up to the other OECD countries with universal, publicly funded health care systems that have much timelier access to medical care than we do.

The next accord represents an important opportunity for positive and lasting change for Canadians. We therefore are following this committee's study with great interest and extend an offer to help you in any way that we can.

The Chair: Thank you very much. I will now invite Dr. Schull to present.

Dr. Michael Schull, Senior Scientist, Institute for Clinical Evaluative Sciences: It is a pleasure to be here. I appreciate the opportunity to represent the Institute for Clinical Evaluative Sciences in Toronto. ICES is an independent non- profit corporation that uses information derived from health administrative records to assess the performance of the Ontario health system. We receive funding from the Ontario Ministry of Health, but we are independent from the ministry and we have our own board. The board does not have a ministry of health representative on it.

ICES conducts extensive evaluation and research into the delivery and outcomes of health care in Ontario and elsewhere. Much of the work is done in collaboration with major health agencies, including Cancer Care Ontario, Health Quality Ontario and Public Health Ontario. The outputs include atlases, technical reports and scientific peer- reviewed papers. In the slides that are attached to my notes, most of that work is from ICES scientists — not all but most of it — and they are all attributed.

Since 1992, scientists at ICES have carried out extensive analysis and research into access and wait times. After pioneering work on access to cardiac surgery in the 1990s, this has extended to a range of surgical procedures, emergency department utilization and primary care.

Many provinces in Canada, and Ontario in particular, have made progress since the 2004 health accord following large investments in health system performance that targeted the following: linking more people with family doctors; organizational changes in primary care, such as the creation of inter-professional teams and important changes to remuneration models for physicians, for example, having a roster of patients; access to select key procedures like total hip replacement and better access to diagnostic tests like computer tomography. As well, we have seen progress in reducing waiting times in emergency departments in some jurisdictions in Canada and improving access to community- based alternatives like home care for seniors in place of long-term care. These have been achieved through new investments such as pay for performance incentives and policy change. They have had some important successes, but the work is incomplete.

Examples of the ongoing challenges that we face include substantial proportions of the population who do not have easy access to a family doctor when needed, even if they have a family doctor; little progress on improving rates of eligible patients receiving important preventive care measures such as pap smears and mammograms; continued high utilization of emergency departments and walk-in clinics compared to other countries; long waits, which remain a problem for many types of care. For example, in emergency departments, long waits have been shown to result in poor patient experience and increased risk of adverse outcomes, including deaths.

Another example is unclear accountability and antiquated mechanisms to ensure smooth transitions in care between providers and provider organizations. An example of a care transition problem is the frequent lack of adequate follow- up with a family doctor or a specialist after an emergency department visit because of exacerbation of a chronic disease. There is good evidence in Canada showing the prompt follow-up can save lives in some diseases, such as congestive heart failure.

A similar problem exists following discharge from hospital. Who is responsible for follow-up? How is information to be transferred? Who is accountable among community-based organizations to provide rapid access to home care? Poorly integrated and coordinated care leads to readmission to hospital, which is a revolving-door-phenomenon. This happens despite having tools to predict which patients are at higher risk and could benefit from more intensive follow- up.

Perverse incentives and disincentives exist, such as no adjustment in primary care remuneration to care for the sickest patients, thereby disincenting doctors to roster patients with chronic illnesses. Penalties when rostered primary care patients visit walk-in clinics but not emergency departments might incent doctors to direct patients to ERs when they cannot see them promptly.

Providing high-quality patient care requires that health care providers within one part of the system, for example, primary care, can effectively communicate and efficiently share information with providers in other parts, such as the hospital or community-based agencies. This is especially important at critical moments, such as when a change in health status results in an individual transitioning from one part of health care system to another. The examples I mentioned include after an exacerbation resulting in a visit to an emergency department or after discharge from hospital.

Making these changes requires integration across different parts of the health care system, which currently function in silos. So what is needed? Critical reforms needed to achieve health system integration include governance, information enablers and incentives. Achieving them will require political engagement at all levels.

We need reforms in governance and accountability. We need formal accountability and governance structures at population and local levels for patient care and outcomes that include providers and health care organizations. Such accountability and governance structures need to include primary care providers, regardless of practice or provider organization.

We need key information enablers. We need electronic information systems that provide meaningful real-time patient data to facilitate clinical decision making and measurement of local health system performance, including patient experience. Electronic information must be efficiently and securely shared between relevant providers and organizations across the local health care system. Data must also feed into administrative health datasets in a timely manner to allow for public reporting and a rigorous, independent evaluation of the health system at local, provincial and national levels.

We need appropriate incentive structures. We need reforms to incentive structures for providers and organizations in order to remove perverse incentives and disincentives and encourage coordination of care across sectors to achieve better patient outcomes.

Finally, we need an engaged federal government investing in the development and implementation of a national health system integration agenda in collaboration with provincial and territorial governments.

About eight months ago I attended an international health policy forum in Washington, D.C. It was sponsored by the Commonwealth Fund in the United States. The meeting focused on innovative reforms to health care delivery and financing that were occurring in OECD countries. Numerous health ministers and leading health system leaders were present. No Canadian health minister attended, despite invitations. The only official Canadian delegate was a Health Canada representative.

By the third day of the conference, what was most striking to me was the complete absence of any mention of Canada as a place where innovative health system reform was happening. The reforms happening in Canada in the last few years happened years ago in other countries. The only places I saw the word ``Canada'' was in graphs that generally showed us performing poorly compared with regard other OECD countries on many important indicators, including the United States.

At the break I asked Uwe Reinhardt, the renowned health economist from Stanford, who had just moderated a session, about this fact. I will never forget his comment. He said, ``Forty years ago, Canada had the best health care system in the world and was a model for the world. Since then, you have sat on your hands, and many other countries have passed you by.''

Perhaps the key question for this committee is whether the federal government will sit on its hands for the next four years. Thank you very much.

Dr. Brian Postl, Dean of Medicine, University of Manitoba, as an individual: It is a pleasure to be here. I am presently the Dean of Medicine at the University of Manitoba. I spent the previous 11 years as the CEO of the Winnipeg Health Region. I had the honour of authoring a report on wait times for the Prime Minister in 2005 at the beginning of this process. I also serve as the chair of the Canadian Institute for Health Information and the chair of the Canadian Health Services Research Foundation.

I thought I would give you a little background. Clearly, the five key areas of interest were hips and knees, radiology, cancer care, cataracts and cardiac. They were of grave interest to ministers coming into the accord. It is fascinating that no one is quite sure where those five areas came from, in view of the many other options that were available. There was no evidence that these were the most in need, but clearly the public impression was these areas were key for intervention. That was, of course, transmitted into the political process.

As part of the accord, benchmarks were required. As we began the process it became clear there were no benchmarks available. There was no scientific base or evidence to support any of the benchmarks that were put in place. At best, they were a guess based on some consensus building, or a review of literature. The Canadian Institutes of Health Research came to the table with some research based on contracts with the collection of provinces. Once again they were not able to produce evidence in that short period of time to support the benchmarks that exist. I think there is much less than meets the eye when we talk about what appropriate benchmarks are.

Benchmarks were set once again without evidence. Perhaps the best evidence was in curative radiotherapy, where there was some evidence that if you waited beyond four weeks, both morbidity and mortality increased. The rest were based on consensus efforts of physician groups, administrative groups and whatever could be gleaned from the literature.

The one issue that was added was hip fractures in the process, not just hip and knee replacement. This was partly because there was evidence that prolonged waits for hip fracture repairs did lead to significant increases in morbidity. The evidence at that time was that there were long waits for hip fracture repairs, with long waits in emergency rooms and long waits prior to surgery. That was the second area where there was some evidence.

I think the other myth that we began with is that there were actually waiting list that existed. In most jurisdictions, the system was blissfully unaware of what the waiting lists were. Waiting lists historically resided in physician pockets. They may have been at a desk, in an office or in a file, but the health system did not have access in many ways in most jurisdictions to the actual waiting lists. It is of some interest that as this process moved forward, with variable effectiveness, in some areas, when wait-lists were centralized and grasped systematically, the list was reduced by 30 per cent by the act of going through it with any rigour.

I think the physician role in this was, and is, enormous. I think there has been considerable progress in role and attitude of physicians in the last five or six years. When we started, wait-lists were used by most physicians as evidence that they were best of breed, thinking, ``If I have the longest wait-list, it must mean I am the best physician.''

That was a widespread use of the information, which was then levered into more OR time or more patients being convinced that if you have the longest wait-list you must be the best, because everyone else was waiting. That phenomenon made it difficult to this day to move into a single wait-list phenomenon, where the next in order in line gets the next surgeon availability. That continues, not in all areas, but in many areas, to be a key issue.

The capacity of physicians to give up waiting lists into more of a pool was difficult because they saw it very much, understandably, as their future income. It was how they would make the mortgage and other payments for the next 10 years: ``If you erode my wait-list or if you share it with others, my income capacity would be more limited.'' This failed to recognize, of course, the phenomenon of which we are all aware — the wait-list keeps filling up. It is not as if it is static or that if your wait-list gets any shorter you will run out of patients.

There were almost no efforts in the country at the time to use basic queuing theory, which in simplest terms is what Disneyworld uses. When you stand in line it is a single line. You go to the next wicket when it is available, and you are always moving. These are very basic techniques in queuing that have not been part of the health system until very recently.

We made a series of recommendations, including much more work on the research about benchmarks. Can we actually define a legitimate benchmark where, if missed, the evidence would be that morbidity or mortality is increasing? There remains very little work done in that area, and that becomes a major problem in moving forward into other benchmarks.

We thought the whole process needed to be much more multidisciplinary in its focus and nature, much more team- based. Care had to be part of this because it is the only way of moving issues forward.

Lots of education of health care providers and the public is needed. Most importantly, the use of single lists is needed. This is still not in place in most jurisdictions. Each physician continues to keep, in most areas though not all, their own lists. Therefore, there is huge variability among surgeons in most areas about how long their lists are. If pooled, lists would be shorter. We have to be much more patient-focused. The system around wait-time management, historically and to this day to some extent, is much more professionally focused. How you serve the hospital and physicians and fit into their schedules is not as coordinated around the patient focus as it needs to be.

One word that was mentioned, but that we continue to pay far too little attention to, is the issue of appropriateness. How do we know all the surgeries being done are in fact needed? There is, once again, very little evidence that we know that material well. Some research suggests the number of cataracts being performed in some jurisdictions is way beyond what would be expected to be needed, but we need more research in that area to either confirm or refute that. That is clearly a disputable point, certainly if surgeons do not acknowledge that there are too many cataracts being performed in any jurisdiction.

The real issue was not what we do but how we do it. How do we rebuild systems to improve patient access, patient flows and appropriateness of care and to be more patient-centred? I think, ultimately, the accord did a very good job with what we do, but a much poorer job around how we do it.

In essence, the accord has bought a large amount of volume and a little bit of change. I think any future accords need to lever any purchase of volume or anything else with some capacity to purchase change.

The data would suggest that, for the most part, we have managed, in most provinces, to function reasonably within the wait-times that were set. We have seen volumes increase substantially across all provinces, without major detriment to other surgical or health care areas. I think it is a mediocre performance. Volume has increased, but we have not changed how we do business very much. I think that has to be the focus of any future change.

Senator Merchant: Thank you for your presentations. You presented us with a plethora of ideas and areas and problems to deal with, but we are here as federal government. Because the powers are split between the federal government and the provincial governments, if you are helping us to have a report for the federal government, what is the most important thing to do in sitting down with the provinces? Is money the main issue, or is that, in your mind, no longer the issue? Can someone start us off?

Ms. Power: Perhaps I could start. There are some resources that are required, but I think it is more about focus. You can pour lots of money into the provinces, and we could be going towards the wrong things. In our brief, we have been trying to get across what I think has been common to everything we have heard today: strengthening of the primary health care, the appropriateness of care, what we are doing and how we are doing it. I think if any dialogue were to happen, it should be along those lines. Any monies that are transferred to provinces around specific funds, for instance to make things happen, should have some metrics and accountabilities attached. We have seen that happen with the last accord. Monies have gone into provinces and there has not really been accountability. Has it made a difference? We have not always been able to tell that.

Areas of focus like appropriateness, the strengthening of primary health care, and transitions of care, about which I think we are seeing a lot of work being done around the country, are where we are focusing our attention for the future.

Dr. Postl: I think it is important that the federal government needs to continue to be a partner. I think, failing that, we will see enormous fragmentation of the many health systems we now have into more disparate health systems with less and less connection. I think the key issue in that partnership is to work with the provinces to decide what needs to change in the structure and systems, and then to reward the change, not just the activity. We have put lots of money into health care for many years and not bought any change in the process. In some ways, the sitting on our hands comment is exactly that issue. It has not been a lack of investment, but a lack of moving forward.

Dr. Schull: I would agree with my colleagues. The federal government needs to play a key role, a leadership role, alongside the provinces in recognizing the split jurisdictions. There is no doubt that the 2004-14 health accord has had a positive influence on health care delivery across the country. It has not been an unqualified success, but nonetheless a positive force. There is an opportunity for another health accord to have a similarly positive effect.

The point that Dr. Postl just made around buying change is critical. If you combine public and private expenditures, Canada already spends about the same amount as most OECD countries, with the exception of the U.S. and Switzerland, on its health care system. It is not a lack of money, in my view. I think just continuing to increase what we are paying without buying change, as Dr. Postl said, would be a mistake.

The question is what change we need to buy. In my view, that change needs to focus on the systemness of our system. We do not really have a system at the moment. We have a bunch of parties that are all part of delivering care and that all bill the provincial governments for that care and so on. However, they do not work together in an effective manner in many instances. It is that integration of care, and that comes down to governance and accountability. Who is responsible for the care being provided? We need to define that. What are the outcomes we need to achieve as a health care community? We need to define that.

We currently have a structure where physicians who work in primary care are increasingly isolated. Even though they are in family-health teams — multidisciplinary, which sounds great — they are very isolated from the rest of the health care system. There is no accountability shared across primary care providers and other providers elsewhere in the health system. That is a critical mistake, in my view.

Dr. Simpson: The key is exactly what everyone else has said, and that is changing the way we do business. The issue in the debate has matured beyond just a simple request for more money. We are all talking about accountability and targeted change.

From our perspective, it is the coordination piece that is missing. We call them the bottlenecks in the series of diagnostic and therapeutic events that is a care experience for a patient. It is at these transition points, between the emergency room and being admitted to hospital or back to the family physician, where the efficiencies are lost and where the expectations are not met. That is where medical errors are generated. The target for improvement is at these transitions of care.

Coming up with national standards or national encouragement to develop IT solutions to help us have those tools to ease those transitions of care will introduce more transparency into the system. It will empower patients if we allow them to see where they are waiting and where the problems are. They will tell us what we are doing wrong and declare the issue much more starkly.

Senator Eggleton: I want to pick up on what Senator Merchant asked and the response from Dr. Schull. If I understand what you are saying, we do not need to spend more money but to spend it more efficiently and effectively; we need to shuffle it around how we do business. Do you agree with that?

Dr. Schull: I am not sure I agree with your characterization of what I said. I said that Canada currently spends about the same amount as OECD countries, with the exception of the U.S. and Switzerland, which are sort of off the map. All of those countries are increasing their spending annually above inflation, and Canada will have to continue to do that.

I am not saying to turn off the tap. I am saying to simply add more money without having that additional money, which will be required anyway, buying change in the system would be a mistake. Spending more money is not a mistake; rather, the way we spend it is critical.

Senator Eggleton: With respect to spending more money, the government has announced, for example, a 6 per cent increase over the next two or three years. Is that a sufficient financial framework to deal with?

Dr. Schull: I am not a health economist. I will not say 6 per cent is enough or not enough. To simply spend an additional 6 per cent in the same way we have been doing business for the last 10 years would be a mistake.

Senator Eggleton: I understand that.

Let me ask you about the five priority wait time areas. What can we do better? I guess we could say the cup is half full and perhaps better. We have a lot of compliance, but not entirely. What do we need to do to get better compliance on the five priorities that exist?

Second, have these five areas, the wait-list, affected other areas? Have the provinces tended to do other areas at the same time? Third, if not, what areas do we specifically need to focus on to add to the five areas?

Dr. Simpson: From my experience, I am a cardiologist, so cardiac was one of the five original areas. One thing that is not commonly understood is that about 99 per cent of patients who come to cardiac attention do not have bypass surgery. We are only measuring bypass surgery as a target, so right away we have excluded 99 per cent of the cardiac patients from any kind of wait time measurement in this context. You talked about shoring up the existing five. That is one glaring error.

There are also some problems with the so-called government benchmark of 26 weeks, whereas the medically determined benchmark, based on evidence — this is one area where there is hard evidence that people die while they are waiting — is six weeks. There has not been a bypass surgery patient wait time of 26 weeks in Canada for many years, but that is the government benchmark we are reporting against. These are easy things we can fix if we can focus attention on it.

What we need to do in terms of making this a more patient-centred experience and something patients can say, ``That looks like me,'' when we are talking about this issue is to focus on the entire patient journey from the start of the time they require medical attention — or even before the time they require medical attention, if we are talking about preventative strategy — all the way through to acute care, chronic disease management and end-of-life care, and start to build a wait time profile around that journey. That means coming up with sensible benchmarks that we can measure, count on and that patients can see. What does this centre look like? What are their wait times? Let us look at that one. If we can move to that, we can empower patients, and that is what will create the tipping point for change.

Senator Eggleton: Remember, I asked a three-part question.

The Chair: We have two minutes for the answer.

Ms. Power: In terms of compliance, your first question, on the ground what the issues are that face us is here there are five strategies put out amongst a myriad of other huge needs in the health care system. One of the issues for us in the real world is dealing with all of our other physicians and patients, most important, who require other services. Many of our physicians are saying these five are not the most important anymore. They are important, but not the most important.

Can we get more compliant in those five areas? It is a hard case to sell to say these are the most important with everything else that is happening.

In my world, where I have to look at the entire picture and the entire budget that is there and how we utilize that most appropriately, we are putting a certain amount of resources to these five areas, but they are not our top five priority areas anymore and frankly never were. That is an issue for us.

It has been a detriment to other services. If we think about, for example, bariatric surgery — we see obesity as an enormous issue in this country — bariatric surgery for people we know are using a lot of our resources and have a lot of co-morbidity is three years waiting time. That is one tiny example.

It is trying to look at the entire system and understanding where we have great evidence that waiting lists are problematic, we are moving towards trying to bring those down. Where there is not so great evidence, we are trying to look to the evidence to suggest where we need to put our time and limited resources.

Dr. Postl: The evidence is that not very much was missed, that there were things dropped because we were spending more time. Locally, there is evidence in the orthopaedic areas that it is tougher to get an arthroscopy as opposed to your upper knee done because the surgeons are busy. What is amusing to some extent when you are in the middle of it, this group of surgeons became wealthy in a short period of time because of the $5.5 billion being spent, and the envy that caused in every other surgical group escalated the costs of paying physicians because they all went back to the market saying, ``You have left us out,'' and that became the focus of negotiation and the next fee settlements across the country. It was an unintended consequence but a very real one.

Senator Martin: Thank you for your presentations this morning. They speak to the importance of what we are doing in evaluating and bringing together the key stakeholders to then recommend to the minister, as she prepares to examine the renewal of this health accord.

I hear all of you saying, from your experiences where you have the national and global perspective on this, some keywords and phrases like accountability and the need for integrated systems and a refocusing. In fact, you mentioned shared accountability. These are important words and phrases.

You have given us much to reflect on and for our analysts to look at in our report, but perhaps you could provide some sort of indication focusing on the accord itself because I think it is an important mechanism to try to integrate and coordinate as we are all saying how important that would be for each jurisdiction. The provinces have this jurisdiction, and yet we are best positioned federally and all of you as global and national experts to suggest what some of the enabling factors in the current accord are that have allowed certain jurisdictions to be more successful. For example, those are the things we must keep.

What are some of the gaps? What needs to be added to further the effectiveness of this accord? I would love to hear all of you, in the presence of each other, agree on identifying some of the gaps, as well as saying these are some of the enabling factors that have been very good so we must keep them. That is a question to all of you.

Dr. Schull: As to why some jurisdictions were more successful than others, I think the reasons vary from jurisdiction to jurisdiction. I would not claim expertise on this particular question. In general, I think that health system management is actually very complicated. The capacity of jurisdictions to do it effectively varies tremendously. Some of the larger provinces that have perhaps more administrative capacity have done better in some instances than some of the smaller jurisdictions, but there is tremendous variability even within provinces in terms of how successful those provinces have been.

What are some of the success features of the first accord? Focus, for one thing. There was a clear focus on wait times, for better or worse. Some said it is the wrong five targets. Some asked why we are just focusing on wait times. However, at least it was focusing on something. That is a key element of success. The amount of money that was on the table was substantial, and that is a key element of success. It buys activity, and certainly it did so in this past instance. Those are at least two elements that are critical going forward.

My personal view is that, if the focus were to shift more towards system integration and accountability, I believe we are not going to lose the focus on wait times. We have seen in some jurisdictions, like Ontario, that the attention to wait times has gone beyond those top five. There have been substantial efforts to reduce emergency department waiting times, as one example, and with some success. That has not been copied elsewhere.

I think you can get change outside the specific parts that are named in the accord but, if you were to ask me what would be the most critical area to be focusing on, it would be the ones I mentioned around integration of care and accountability.

Ms. Power: I would echo the comments of my colleague. We have tried in health care to boil the ocean and to be all things to all people for so long. A great part of the 2004 accord was to start to focus our attention. Rightly or wrongly, we needed to start somewhere. The dollars came with it, because there is that upfront investment that is required. We have had varying success across the provinces, but that is just life and that is the way it is.

As we go forward, we need to get more to the root of what the issues are in the health care system. Wait time, as we mentioned, is just one dimension. It is hugely important to our citizens, though. It truly is hugely important. We cannot take our eye off that. We all know that. We are trying to bring those down to whatever the national benchmarks are.

I think it is more trying to get to the root of what the issues are as we go forward and really starting to invest in the foundation of health care rather than pick off the one-ofs here and there.

Senator Callbeck: Good morning, everyone. Thank you for your presentations.

The first question I want to ask is about a problem that we have talked about for years. Ms. Power, you mentioned it, and I believe it was in one other brief. The question is about people in hospital beds who do not need to be there, because a hospital bed is so expensive compared to the alternatives.

I do not know whether we are making any progress in this regard or not. Ms. Power, you mentioned in your brief about having an infrastructure fund and maybe tax policies regarding home care and so on. Are we making any progress? Are there provinces that are doing things that are improving the situation? As I say, this makes common sense, and it seems that it has been a problem we have talked about for years. Are we making any progress? If not, why not? Why can we not do something about this?

Ms. Power: The answer to your question is yes, we are making some progress. There has been a huge infusion of funds and nursing home beds in Ontario, Nova Scotia and many places. However, the problem is that there is no silver bullet. There is no one thing. Ontario is leading the way here with their home first program and looking to how we can keep people safely in their homes. There was a period of time where we looked to nursing homes as the answer to everything. Just build more nursing homes, and everything will be fine. There is a need for some nursing home beds, but I think our attention needs to switch to the community resources that are out there. It is not so much always building more beds or nursing home places, but how do we keep people in their homes? How do we keep them well? What are the resources that need to be there? Sometimes it is as simple as having someone come and chop your wood so you can have firewood and stay safe, or someone to get your groceries. Sometimes it is much bigger than that and much more complex.

I think this is something that is coming at us. We have known it for a longer time with the baby boomers. We know that in the next 20 years the impact on the health care system will be very intense with the increased needs, because we are getting older and we are not a healthy population, generally speaking.

In our minds, we really need to start to focus and invest in that infrastructure, whatever that looks like — from just supporting you in your home right on through to end-of-life care. It is not that we are not making progress; it is that the demand is insatiable. We have been doing a lot of things. If we had not done anything, we would be in bigger trouble than we are today, but this is an ongoing issue for us. We need to address it in a major, systemic way.

Dr. Simpson: To tie the wait time aspect to the ALC issue, I think it is perhaps not appreciated fully that we actually create ALC patients by making them wait. I see this every day in my hospital. Many Canadians are waiting for their hip or knee replacement or waiting for a cardiac procedure, sometimes even for a test. Since some jurisdictions do not have a robust outpatient infrastructure, they wind up coming to the emergency room for lack of anywhere else to go. We then admit them to hospital to get the test faster. The weekend goes by, and they are in bed. No one is getting them up because the physiotherapists are not working on the weekend. Before you know it, this person who is just functioning on the edge is now institutionalized. We have done this to them. Then they get C. difficile and, before you know, it is a one-way trip and they become ALC.

The whole thing is interconnected. We cannot just solve the ALC problem by saying we need more long-term care beds and better supports. All of those are important, but waiting for care generates these unintended consequences of admitting people to hospital simply so they can get care that could be easily delivered and better delivered in an outpatient setting.

Dr. Schull: I would echo the comments earlier that we are making some progress. The home first program is an example in Ontario. The idea there is that a patient who is designated as ALC, needing alternate level care, actually goes home to wait for the long-term care bed. In a large proportion of cases, they no longer need the long-term care bed once they get home and the support services are put in place in the home. That has been a success story.

If you think about the problem, you have a patient in a hospital bed who does not need to be there. They need to be somewhere else, whether it is long-term care or home care. Who is accountable for providing that? We have a system now where the hospital wants to get the patient out because they need that bed, so they are incented to get that patient out. However, there is no accountability in terms of the long-term care home to take those patients in with any sort of performance metric. There is no accountability on the part to the community-based home care services to provide home care more rapidly. There are efforts to do so, and I am not suggesting people are not trying to do so, but there is not any sense of shared accountability across our system even at the local level. This is just one example of one of the critical problems we face. We are not all working on the same team, effectively.

I believe that many of the building blocks to create a system where there is shared accountability are already there. We have regional health authorities with defined geography and populations. We have health organizations that have a history of working together, but they do not have that shared accountability. I believe that is a key reason we are not making more progress than we could be.

Senator Cordy: I spent Monday morning in Nova Scotia at the signing of the palliative care coalition. I congratulate all of these organizations for coming together for a stronger voice. They asked me to use my voice in Parliament to talk about palliative care.

We have talked about long-term beds being used, and we know that 80 per cent of Canadians want to die in their homes. It is not a question of if we die; it is when we die. Eighty per cent say they want to die in their homes, yet 70 per cent are dying in hospitals. This is an area where we really can do what Canadians want and save money at the same time, which is a crass way of phrasing it, but at least we would be doing what Canadians want.

A number of you have mentioned reforms with incentives, and you have talked about stronger accountability. How do we get the incentives in place to make changes that Canadians want? Someone mentioned it earlier; I was on the Kirby committee when we studied the health care system, and Canadians were not nearly as open to changes at that time as I think they are in 2011. How do we get the incentives?

Ms. Power, you talked about a national health innovation fund where we share best practices and innovation that is happening across the country. This was sort of a double or triple question, dealing with the incentives, the accountability and the innovation fund, which was one thing that you mentioned, if you could expand on that.

I truly believe Canadians are more ready for change, and there are a lot of things that Canadians want. I do not think Canadians want to be in hospital beds for months and months on end. They would like to be in more of a home setting or in their own homes. One thing I heard on the Aging Committee was that we should really have in place something like the Veterans Independence Program, where people can stay in their homes longer. I think we are always looking at the hospital-doctor model, where some people just need someone to make a meal or, as someone mentioned earlier, shovel the driveway or mow the lawn, housekeeping types of things.

We have to get away from it being just hospital-doctor-medical and use other agencies in our communities. Could you comment on that?

Dr. Postl: I think palliative care is not an innovation any longer, frankly. To kind of categorize these issues as innovations is counterproductive. It is just a program that makes sense and needs to be implemented which therefore needs funding and some action.

I think the risks of trying to tie every change into innovation, if we know the change needs to happen — and there is lots of evidence to support it — it stops being an innovation at that point and it really is a change. The more we pretend everything is an innovation, the more we start pilot projects we test in one or two places and they stay as pilot projects. Things like palliative care and the proportion of people able to die at home is not a news flash. That is something that should have been in place many years ago and it is something that should happen.

Ms. Power: Thank you for the question. It was a great question. I agree with Dr. Postl for sure.

Our reference to the innovation fund was to look at other areas where those pockets of excellence are happening across Canada; we know they are happening. We do not have a good clearing house or a good place where we can start to share what those innovations are to really make the change. I agree that palliative care is not an innovation.

I want to share with you, as an example, a palliative care program in terms of where we could be headed. It is something that comes out of Halifax, but we are trying to share this across the country. We call it the PATH program. It is meant to be palliative and therapeutic harmonization. It is focused on the frail elderly, particularly people with dementia. We use, for example, a case study of a man with dementia in his seventies who is on the waiting list for cardiac surgery. The cardiac surgeon will go ahead and do it because he is looking at the heart and his ability to make that better. However, when you look at it in the context of the person, you recognize that going through surgery will be hugely detrimental to that patient; it will increase their dementia and there will be lots of co-morbidities that could happen. In the conversation with the patient and family, we must recognize that this is not the most appropriate way to go. How do you help the patient and family live with the condition? A whole program was put in place around that, which has been wildly successful and has cut down incredibly on lengths of stay and inappropriate care, et cetera.

I think there are wonderful examples of innovation around palliative care and all kinds of other things that as Canadians we need to share and be able to tap into to really make a difference in what we are doing.

Senator Seidman: I think we all recognize that undoubtedly we are at a serious crossroads here. I too have tried to listen very carefully to what you have all been saying. It is very evident to me and probably to everyone sitting around this table that you have all been emphasizing the same things.

Ms. Power, you were very focused on accountability; Mr. Vail on efficiency; Dr. Schull, you were very patient- centred; and Dr. Postl raised very serious issues about accountability and scientific evidence.

In that spirit, I would like to ask about reporting, comparability of data and electronic records. Very specifically, the kind of impact that a coherent plan could have on these three themes you have put forward today: accountability, patient-centred and efficient systems.

Dr. Schull: I am a clinician wherein I see patients in the emergency department, and I am also a health services researcher, so I use data every day in my work.

One of the four things I mentioned in my brief was a critical reform. We need to make progress on electronic data systems in Canada. We have made far too little over the last 10 years. There are jurisdictions and hospitals that have made more progress than others, but as a country and when you look at individual private practitioners and the use of electronic data systems, we are far behind most other comparable countries in the OECD. Actually, that distance I think is getting worse, not better. We need to make more progress. I will not claim expertise in understanding why we have not made as much progress as we could, but I would say that is absolutely critical.

Where we may have gotten off track a little bit is that at the outset, there was the idea that it would have been ideal to have some kind of national electronic health record, wherein if I came from Toronto to Ottawa today but suddenly had chest pain, I could go to the Ottawa General and someone could pull up my record from Toronto. Would that not be wonderful?

All I want as a practising clinician, when someone comes into my emergency room at Sunnybrook, I would like to at least be able to pull up the records from the clinics in Sunnybrook Hospital. I cannot do that right now, let alone the records of their primary care physician or outpatient records.

A few weeks ago, I had a woman come into the emergency department with her husband who had a number of chronic issues, and when I asked for results from the battery of previous tests he had had, she asked, ``Can you not pull it up on the computer?'' It made perfect sense for her to say that. I said, ``I wish I could but I cannot.''

The point is, we need those data systems at the coal face, when we are seeing patients. We also need that data to feed into electronic data systems in a timely manner in order to judge how well our system is performing, and we can report that to Canadians. Right now, we have that in places, but it is spotty, there is not good national public reporting, on top of which it really is not timely enough. The typical report at the Institute for Clinical Evaluative Sciences is probably at least 18 months old by the time we report the data. By then, most people say, ``That is old data.''

Dr. Postl: I would agree with that entirely, that it is almost a no-brainer that you need to be able to access information about patients while you are caring for them from wherever that data may exist.

One of the fascinating features that we have to deal with is the issue of privacy, because for these records to be effective, they must be part of a public system. They cannot just sit in a doctor's office or a clinic or a hospital. They have to be widely shareable, and we have to make sure we manage the issues of privacy to make that possible. Without that, they will also be seen as mediocre in their performance 10 years from now, when it is better implemented because we will not be able to share the data effectively.

The Chair: Who should make it happen?

Dr. Schull: I do not think there is any one player. The federal government, again, has a leadership role to play. The Canadian government invested billions of dollars in Infoway and needs to continue to take that leadership role.

My view is that where there has been most progress is where local systems have taken this by the horns and developed a system that works locally. I do not really care if I cannot get records from when my patient lived in Edmonton four years ago. What I want to have access to routinely is the local health care information in my system of care. There are examples where systems locally, including different organizations and so forth, have come together. Alberta has made huge progress in terms of developing population-based data records.

Jurisdictions or organizations such as the veterans administration in the U.S. have proven, and there is terrific evidence, that having a coherent and smoothly functioning electronic health data system, overcoming these issues of security — which are important, but I fear are sometimes red herrings and are used to delay progress in this area — demonstrated substantial improvements in quality and reduction in cost. This is absolutely a no-brainer, and the federal government has to be at the table leading the way in collaboration with the provinces and territories.

Dr. Simpson: We have talked a lot about personal health information and how important it is for practitioners to have that and to be able to share back and forth. The other part of this, of course, and I think you were alluding to this, is the system data and how we can use it to make the system better. The key role for the federal government is clearly assisting in the development of national standards and national data definitions. We have 13 different political jurisdictions that measure wait times in different ways and report them in different ways, so comparisons across jurisdictions become difficult to interpret. That creates a lot of noise and distracts from the mission of trying to all move forward together. From a very macro-level, that kind of leadership at the top would be a big step forward.

Ms. Power: I think there was gross underestimation going into this of the level of sophistication in the IT world in health care. We were starting with Rolodex, in some instances. We were going back a long way.

You asked who should do this. I do believe that the federal government needs to take a leadership role around a vision for a national IT infrastructure. Yes, today, we are so far behind that all we want to care for the patients in front of us is what is local, but we have to be thinking bigger than that. We have to be thinking that, as a country, we can start to share information and use it to compare ourselves and to be able to care for the people who come through our doors.

Senator Demers: I found your answers to be extremely honest with no sugar coating, and I like that. I do not like BS, and you did not do that. Last year, at this time, I was not able to attend the Senate because I was recovering from a medical mistake. We started with a minor operation. It ended up being between life and death in 48 hours. It was a tough situation. It became publicized because I happen to be a former NHL coach, and it came to be known around North America. I am not bragging here.

I have a friend who is a doctor, and we have discussed this over the years. The system is broken. It is not just the Jacques Demers. In the United States, 180,000 people died last year because of medical mistakes, and there are a lot of people in Canada. Where do we start? By the way, the two doctors who operated on me were great doctors, so no accusation. They are overworked and fatigued. The younger doctors, but not all of them, are not willing to put the time in that they used to. The nurses are overworked. There are people today fighting for their lives because of medical mistakes, or they are sent home and they never recover. Where does it start? Is the system broken? I feel for those doctors and nurses. They have made a change at the hospital where I was so the doctor does not come in for two minutes, ``Hi, coach, how are you? Did the Montreal Canadians win last night?'' It is nothing personal. They look at my stomach and walk out. Three days later, I am between life and death. That happens a lot. Where do we start from there? It is not money. Where do we start? Thank you for your answer.

Ms. Power: Is our system broken? I would say that the system is not broken. By and large, as a health system, we do great work and save lives every day. Are mistakes made? Absolutely. We talk in our brief around quality and focusing on quality. How are we doing? How are we measuring up? Where are we making mistakes? How can we stop them? If you look around this country, there are a number of organizations dedicated to looking at quality. In fact, there are a lot of them. Maybe something to think about is how we streamline that whole look. There has to be a push on quality. We have, through Accreditation Canada and the Canadian Patient Safety Institute, recognized that these things are happening all the time.

I would bet my life that there is not one health care organization that is not spending a tonne of time and money on quality and being sure that we are doing everything we can to prevent those errors. However, it still requires a much greater focus and a convergence of all of the work that many organizations are doing around quality to ensure that, the next time you come into hospital, we have learned from those mistakes and have processes in place to prevent it from happening again.

Dr. Simpson: Senator Demers, I grew up in New Brunswick when you were coaching the Fredericton Express, so I came to know you then as someone who does not sugar-coat things.

Senator Demers: Especially when I lose.

Dr. Simpson: Listening to my radio at night, I heard you in those post-game interviews.

Medical mistakes are huge. There has been a culture change. There is a culture of patient safety that has penetrated every corner of the country and every medical environment in the country. Part of that is the commitment to disclose the error in an honest, forthcoming and timely way so that patients and their families can understand exactly what happened. They can prepare and deal with it, take charge again and become in control again. They also need to know that the system in the hospital and the providers and everyone who has been involved in the adverse event are committed to learning from it so that things like that do not happen again. Your comment is bang on.

It could potentially be part of a patient charter. One of the things that patients are entitled to is having a safe hospital stay or a safe medical experience but, when there is an adverse event, they have a right to timely disclosure of that event.

Dr. Postl: The first thing about safety patient issues is that they have always been here. This is not a new phenomenon. It will never be zero. The environment is too complex. Where you see patient safety issues come to bear is often in transition points, in patient movement between ORs and ICUs, between emergency rooms and ICUs or between hospitals and personal care homes. We have not done as well, and people are working hard on, on how to systematize our processes so that you consider patient safety in every step in the progression of care. That is part of being more patient focused. When you are not patient focused, you are moving patients as entities, not as patients, between units, between activities or between functions. If we focus on the patient in that movement, in that journey they have through the health system, patient safety starts improving very dramatically.

Dr. Schull: I would argue that patient safety is probably one of the bright spots over the last ten years in terms of a general culture change. There has been real progress certainly in terms of measurement, identification of indicators, measuring those indicators and trying to address change. The problem is that most of that attention has been within hospitals or within organizations or within one part of the system. If a surgeon walks in and amputates the wrong leg, it is pretty obvious who made the mistake. Where we are having ongoing challenges, as Dr. Postl just said, is in diffuse responsibilities or in transitions of care. When a patient leaves the emergency department and goes home, there is no report that gets to the family doctor, and a blood test never gets followed up properly. Who is responsible? When a patient is discharged from hospital to a long-term care facility and there is never any good interaction between the primary care physician and the specialist, who is responsible? That is unclear in our system, and that is where there are a lot of errors and safety problems occurring. While they can be measured, at this point it is not that clear how we resolve them because the accountability is unclear.

[Translation]

Senator Champagne: According to most of the charts we see in the media and the ones for Quebec's health care system, the situation seems to be worse in Canada. I do not agree with that. Over the past five years, I have seen the best in our health care system. I had meningococcemia and I was in a deep coma for 42 days.

After being in the hospital for 65 days, I wanted to go home. Yes, I needed a walker, but I wanted to go home. I was finally allowed to go home instead of going to a convalescent home. For two months, a CLSC nurse came to my house every day to change the dressings on my legs, do the blood tests and send the results to the doctor so that he would adjust the Coumadin dosage, and so on.

That is a great way to free up hospital beds. They ended up letting me go home five or six days earlier than they had hoped. After meningococcemia, the last thing I needed was depression. Do the other provinces have this type of service? If not, should the government not push to make a service like that available? The fact that they were able to come to my house to change the dressing on my legs every day, since I was not able to walk to a clinic, made it possible to free up a hospital room at the time. What do you think about that?

[English]

Ms. Power: This is what we are talking about for home care and there is home care in all of the provinces that is working very well. The area where we need to strengthen that somewhat is the degree of home care that is made available. If you are having your dressing changed once a day, or a couple of times a day, that is pretty standard in home care across the country and that is supported by most provincial governments. If you require a lot of home care that is where the gap is, and people are staying a long time in hospital because those kinds of resources are not in the community.

We are talking about that when we talk about enhancing primary health care and some kind of structural fund for the community, and how we put additional resources there so we can let people go home. They will recover far better than they will in hospital, surrounded by the things that are important to them. That is a good point.

[Translation]

Senator Champagne: I was lucky to have a husband who ran errands and took care of the rest at home. At the same time, I thought it was great that I did not have to go to a clinic every day; they were the ones coming to my house. That also helped my husband, since he did not have to drive me and bring my wheelchair so that I could get around.

I have also seen the worst. I recently had to go to the emergency room because I could not see a doctor. I was not dying, but I was in a lot of pain. I got there at 11 a.m. and went to triage at 12:30 p.m. At 6 p.m., I was still in the room when I was finally called to a second triage. This is what they told me, ``Wait, you are not a priority.'' I asked what process they used to determine who was a priority and they said, ``Accidents, people in cardiac distress, children, old people and others. You are with others, so just manage!''

So I asked: ``How old do you have to be to be considered old?'' I said that I was 72. ``How long do I have to wait before I am considered old?''

She finally looked at my file, which she had obviously not done before, and moved me from the 12th spot to the fourth, which meant that a doctor saw me at midnight. I had been there since 11 a.m. I really want to believe that I was not dying, but it was very painful.

Something is not right with that picture. If the triage staff person does not look at the patient's age, perhaps that is one thing we could work on.

In short, there should be ads to help people be better patients for their doctors, encouraging them to always bring the list of drugs and allergies along with their health cards. I think that would be a great thing to put in TV ads, for example. I think we would avoid additional problems.

Dr. Schull: As an emergency room physician, I have to say that I find your experience horrific. I apologize on behalf of all the emergency room doctors. Is Quebec the worst? I do not think so, but I must say that, in terms of emergency room wait times, Quebec is certainly among the worst. We do not have the information for all the provinces, so we cannot really tell. If I understand correctly, the wait time target set by the Quebec ministry of health is 12 hours on average. So you waited for 12 hours, which means that you reached the target if that is the average.

As a doctor and as a patient, I find that unacceptable. This partly has to do with the target that is set to begin with.

Ontario has been quite successful over the past few years in terms of emergency wait times. Ontario's target is that, on average, 90 per cent of patients with serious problems spend a maximum of eight hours in the emergency room. That means that the total amount of time from the moment you arrive to the moment you leave is a maximum of eight hours. It would be four hours in minor cases.

We have seen wait times go down because of a policy that included major investments. I can tell you that, as an emergency physician, I have seen a major change in emergency rooms over the past ten years. I hope this will be the case everywhere, but that takes a government willing to focus on the problem and ready to invest.

Senator Champagne: I wanted to tell you, since you are an emergency physician, that an emergency doctor from my small regional hospital was actually the one able to diagnose my meningococcemia in 36 hours. And all the specialists who saw me afterwards gave him credit for saving my life, and I thank him for that.

[English]

Senator Braley: I am going to tackle the question a little bit differently. You are all experts and you are all doctors, or at least you have the background in the medical profession. Does the medical school, for example, teach from birth to palliative care? Do they have a course for the general practitioner on palliative care?

In my business I would go and get the people, such as the tool and die maker and other various people, to solve a problem. You are the people most aware of the problem. Are you doing research on what the doctor should do versus what the nurse practitioner should do, versus what the next person in the line should do, so that you can have clinics where you can handle double the number of people so they all have a GP? Is the research being done on how to administer and prioritize?

You are a dean at a university. I would think that those areas of applying how to make a business better would be perfect research for some of the doctors, or some in the business schools or some of the people working together to do, and the problems can be resolved between the governments and the profession to better service the people. Customer service is the only thing that matters here.

I am really asking whether the solution should come from within. It is a crazy question, but when we solve problems in a company that is exactly what we do. We tackle that as the priority. Then I assign the best people who are part of a group. They could be from any department. They work together and draw the people in that they need. Then they go back to their own jobs after.

I would like a comment on that.

Dr. Postl: I believe the answer is yes, the medical schools across the country are trying to focus much more than they traditionally have on issues of accountability and how you teach social responsibility to medical students. Universities generally are trying to get a grip on multidisciplinary care, how to expand scopes of practices for nurses, for example, or introduce new workers such as physician assistants and clinical assistants. Certainly our province has done a lot of that. The answer is yes, it is moving. However, health professions, historically — and I do not think this is changing dramatically, despite the movement — are vested and have strong interests. They have trouble sharing and playing in the same sandbox, so that takes a lot more practice than we have had yet. I think it is coming, but it has to be a growing and major emphasis.

Around the research, I think that is a key question. We are not doing enough health services research as a country to allow us to ask the questions. One of the real opportunities, building up to the accord, are for governments to define the six or ten or twelve questions they want answered, and then ensure that research is done so that when we head into an accord, there is evidence to support potential change, that we actually have some ideas of what will work in moving forward future changes.

We tend to do the research after the fact. The barn door has been opened, the money has spent, and then we try to figure out whether we had any impact. I think we can do a much better job of that.

Senator Braley: We have such great professionals.

Ms. Power: Thank you for raising that, because it is a great question and an area that we have fallen down on over the years. I am the only non-physician of my colleagues sitting up here, but a nurse by background. We have traditionally been focused on our own profession and what unique contribution we make to patient care. It has just been in the last few years that we have really started to look at interdisciplinary care. As Dr. Postl says, there is huge push-back from many of the disciplines themselves about sharing that accountability and responsibility for patient care. We need a lot more work in that area, lots of work and research going on around different models of care.

Where we see it in action, it is beautiful to behold, that, based on what the patient's needs are, we bring the right practitioner to them. We have a long way to go, but it will be one of the things that will change the face of health care. Whether we like it or not, as professionals, our public are demanding it of us.

Senator Braley: The customer will be the person.

Dr. Simpson: I completely support everything that has been said. Dr. Postl's comments are bang on, particularly the comments about the need for more health services research and the opportunity to perhaps define in a focused way what those might be.

I hasten to add, however, that there is a whole lot of stuff we already know how to do and we are not doing it. Chronic disease management is the perfect example of how multi-professional teams can work together to get proven good outcomes, but we have not been able to overcome these political and other barriers in order to make it happen. Better care, and care that is cheaper, should be an easy sell to everyone, but for some reason we are not doing it as much as we should be.

Senator Braley: Is that management? Is that getting the research done properly so it is out there and they have to defend it?

Dr. Simpson: Part of it is just overcoming those political barriers. We are all trained in silos and then expected to work together after we are done training. We are now starting to train them together too.

Senator Braley: The best teams are not in silos.

Dr. Simpson: Exactly.

Dr. Schull: Thank you for the question. Your analogy of a company CEO is apt. There is no CEO in charge of the health system. There is no one in charge. There is a real governance vacuum in terms of trying to determine who should be responsible. It cannot be a minister of health. It cannot possibly be at that level. There needs to be local governance that is established with responsibility and accountability.

Second, you mentioned that if there is a problem, you go out and hire the tool and die makers. Let us assume that analogy, that the tool and die maker is the physician. The physician does not work for you. The physician does not work for the health system. The physician is a private practitioner who bills directly to the health care system. He does not work for the CEO of the hospital or for the local health region. Therefore, your control and the levers you have with that individual are limited.

The truth of the matter is that the structure of our system needs some fundamental reform. It does not require blowing it up and starting all over, but it does require a layering in of new incentives and new governance models, I am convinced.

Senator Braley: How to manage it, basically, will become the research that has to be done, and the customer will demand the service. In the final analysis, the customer is always right, the person who is getting the health care. That is one of the most important things to everyone in this country.

I think there are huge possibilities for the medical schools to lead the charge on this for the country. They may be a little different here and there, but when you put them together, you will get something that is really special, and that is basically doing it without having the doctors who have the silos, coming out of the medical schools themselves. It is just a thought that has crossed my mind over the last little while.

Dr. Postl: I point out that what we are talking about — and something that we tend to forget — is that from the start of intake to the point of finishing your specialty training, you may be in a 15-year cycle.

Senator Braley: The demographics change, so you have to keep moving that.

[Translation]

Senator Verner: First, thank you and welcome to our committee this morning. It is refreshing to hear something other than the usual ``we need more money, we absolutely need more money for that.'' Without denying the fact that, since the population and the demographics are going to require it, we have to continue making significant investments in health, I think we have to be realistic and come up with new ways of doing things. That is a very refreshing speech.

My question has to do with another topic. Given that we have some doctors and a nurse here with us, could you tell me how this affects the provision of care? How many times have we heard, at one time or another, that there was an outbreak of C. difficile or bacteria in a hospital or in a seniors residence? I am not a microbiologist but, quite frankly, we have been losing elderly people because of that. The numbers are not high, but a loss is a loss. Anyway, as a result, my old mother keeps telling me to wait for her to be really sick before bringing her to a hospital. Have the bacteria outbreaks that we hear so much about always been like this? Do we just hear more about them now because of media coverage or are they connected to other factors beyond your control, such as the aging hospital infrastructure?

The Chair: Who wants to start?

Dr. Schull: I am not a microbiologist and I cannot say that I studied epidemiology and outbreaks, but based on my clinical observations and the data I have seen, I think that, for one thing, the patient population in hospitals has changed; the population is not just aging, patients are much sicker today than they were when I started my career. I am not very old, but I can say that the average patient on a hospital floor — I am not talking about ICU — is sicker than patients used to be 15 years ago. The shortage of hospital beds forces us to use them more wisely. We also have better solutions in many cases. So the patients are older and sicker, which means that they are more susceptible to diseases, such as C. difficile.

The aging of the infrastructure can also play a major role in some hospitals.

The cuts in the 1990s certainly had something to do with the decision to cut support staff because they were not a priority and cuts had to be made. I think we now know it was a mistake and we are starting to reinvest in those basic services.

We cannot point to just one factor; there are a number of factors. I also agree that we are better equipped to monitor what is happening in hospitals and that perhaps we were not aware of outbreaks as much in the past.

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The Chair: I would like to put a couple of questions. One is with regard to the benchmarks using wait times. Clearly, this is an obvious benchmark that can be measured. I want to know if, as a broad stroke, it is a good one. You mentioned the issue of knee replacement being one of the ones that had not progressed very much, I think, in an earlier comment, or perhaps it was Dr. Simpson who said that.

Let us take the case of someone who is obese, perhaps diabetic, who comes in and needs a knee replacement. My understanding is one of the first things that may be required is the loss of significant weight. However, that may take up to 12 months. That, I assume, is included in the wait time for that particular patient to get to surgery. Obviously, it would not be appropriate to carry out the surgery before the surgery will be effective.

Are there aspects of these direct benchmarks that need to be taken into consideration in using them to report to our citizens on the delivery of health care?

Dr. Postl: We went through that while we were discussing the system, such as when do you start the count? When does the time begin? An important comment was made early in that should it really begin when the primary care physician decides on a referral because they suspect a knee replacement is required? Or is it at the point that the specialist sees you and agrees that the knee needs replacement? Or is it at the point that they actually book the OR because there may be other issues intervening, such as getting blood sugars or blood pressure or obesity into a better condition before actually being slated for surgery? When you look at some of the anxieties that come out of the public with these long wait times and you actually slice into them, you discover many of those things, that the actual wait time was not out of sync based on how it was being counted; it was all the other times that the patient was experiencing, so to them it is still a wait time, but the count had never started until two months before the surgery. That is part of the debate and discussion that has to go into each wait time.

We began with the booking of ORs, in effect, as the start time. When the decision was made that surgery was required, that was the start point and the OR was requested. There is a good argument that can be made in measuring at least two different times. One is the time of the primary care decision to move into specialty care. You may want to measure them as two different times, otherwise it becomes very complex. For example, the primary care physician may think they need a specialty referral. When the specialist does a review, they decide that surgery is not required, so it would be a bit nonsensical to count that as a wait time for surgery. We have to get better at agreeing on what we are measuring and then measure it more routinely and systematically across the country so it can be compared.

Dr. Simpson: Dr. Postl said it well. The central issue is how to define these, and more precisely, how will we define the components of the patient's journey? In your example, a patient should not be on a knee surgery wait list if the decision has been taken to try this other strategy first, such as losing weight, and once that strategy has failed, then they will go on the list.

You can see the potential for creating circumstances where it becomes difficult to measure across jurisdictions as to who is doing better than others. Precise definitions of each component is key.

The Chair: The other question deals with issues you have all touched on, which are the efficiency of delivery, the coordination of specialists and so on. For example, a diabetic comes in for a serious issue who may need access to several different specialists. When I casually look at the scheduling of those specialists at a given hospital, I see this one comes in on a given day, another on a given morning. The possibility of the patient who requires input from several specialists seeing them on a given visit strikes me as vanishingly small in certain circumstances. Is that an issue in terms of the effectiveness and the success in the delivery of significant health care?

Dr. Postl: Absolutely. It is clearly one of the key issues about a patient's journey. How do you help patients navigate a system that is so complex? How do you coordinate appointments, ensure the appointments are necessary and make sure that the consultants are communicating with each other so one is not taking care of the renal problem and the other the cardiac problem, but they are not communicating about the patient? That is frankly a frequent issue in the health system.

Dr. Simpson: That is a great point. There are some typical patient pathways that require multiple components. There may be a patient who requires Test Y, X, and Z, and most patients require that package. It is possible to create a one- stop shop kind of model for patient convenience and to shorten overall wait times for a lot of patients that we do not see. There are some who are very complicated and who have to be navigated through the system. This is where patient navigators can perhaps assist.

The Chair: Since I have some senators on a second round, I wanted to get that on the record. If you have additional points to make, I would like to ask, with regard to what I will say next, I have three possibly four senators on a second round. We do not have time for the kinds of answers and the detailed preambles that we have had to this point.

If a senator has a significant question that will not be able to be handled in just a quick couple of minutes, I would ask them to direct the question specifically and ask if the witness could respond in writing within a couple of weeks of this meeting.

To my colleagues on the second round, if that is agreeable to you, I will start with Senator Callbeck.

Senator Callbeck: Senator Ogilvie addressed the wait time issue, but I want to be sure of the definition. When we talk about wait times, my understanding is that is the time from when the specialist says, ``I will replace your hip.'' You go to a general practitioner, and probably two months later you get in to see a specialist. However, those two months are not factored into the wait time at all. Is that right?

Dr. Schull: That is right.

Senator Callbeck: Do you agree with that?

Dr. Schull: No.

Senator Callbeck: Two people are shaking their heads.

Dr. Postl: The patient does not know the difference between what they are waiting for. They just know they are waiting, whether for the specialist or for the surgery. In their mind, it will be part of the wait time. We only count the point the decision is made that surgery is required; that is the starting point of the wait time.

Dr. Schull: Part of the problem is we do not have good data on when the referral took place. We do not know. As far as I am aware, there are not any good data systems currently, with the exception of the family health team, electronic medical records and so on, that would allow you to measure the first wait. I think that is why the second wait was chosen because it is actually measured. However, I think we all agree that both of those are important, both need to be measured but also separated so we understand where the delays are occurring.

Senator Eggleton: Following up on this, when does the clock starting ticking in the different provinces? Does it vary from province to province, or do they all have similar wait time calculations?

Dr. Postl: They are all similar. They are not precisely the same. If you dig into it, you will find minor variations, but the wait time clock was agreed to as part of the negotiations between the provinces and federal government as part of the health care accord. It was engineered or participated in with the Canadian Institute for Health Information to build the definitions.

Senator Eggleton: The wait time clock is more like Senator Callbeck described it; it is from the time you see the specialist as opposed to the wait. You think it should be right from the beginning of when you see the GP?

Dr. Postl: Yes.

Senator Eggleton: Can I clarify one other thing? Ms. Power, with respect to the national health innovation fund, you are saying this should be an opportunity to share pockets of excellence or best practices kind of thing. How would that relate to the work of the Canadian Institutes of Health Research? Would they administer this kind of thing? How do you see that so it does not duplicate what they are doing or what someone else is doing? Who would administer it? You would not set up a whole bureaucracy to accomplish this, would you?

Ms. Power: No, we would not. That may be an opportunity for that. We have not looked at how to make that happen. It is more a concept for us as we start to work through what needs to happen.

Senator Seidman: I would like to know whether there is available evidence on the appropriateness and overuse of certain procedures and technologies. I am mindful of diagnostic imaging. It has not come up here at all today, I do not think, and I know that there are no benchmarks currently for it. If you could make quick comments about that.

Dr. Schull: There have been some good studies that have looked at CT and MRI utilization in Ontario and have found there are substantial portions where at least the decision to initiate the test was questionable, if not inappropriate, by virtue of the fact that the results are normal, it was a repeat of prior tests that have already been done or the clinical indication was not there.

The appropriateness of many of these diagnostic tests is difficult to establish, but I think it is possible to do so. There has not been a lot of effort to do that yet. Designing a system to implement gates, so to speak, so that you only perform tests when appropriate, is a challenge. We know that in some instances those sorts of systems, where you are dealing with limited access to, say, CT, and so someone has to review the requisition and decide on its appropriateness, actually acts as a further obstacle and can delay what are important tests.

The simple answer is that we do not have a good approach to determining the appropriateness of the tests that are done. This is a critical issue with respect to not just diagnostic tests but even operative procedures.

Senator Martin: I go back to asking about the enabling factors, what we need to include in the accord to recommend to the minister, and insertion of specific content language. You mentioned in your presentation accountability matrices. I wanted to ask for your input, in writing, of what those specific enabling factors should be. I have my own list, but I would love to hear from each of you.

The Chair: We will look forward to that.

Senator Merchant: Perhaps you can let us know as well if you think there should be conditions placed on money in return for performance. I do not know how that would work exactly. Does the federal government right now have any control over how the provinces spend the money? Do they know how the provinces spend the money?

The Chair: Who would like to take that on?

Dr. Postl: The answer is that the federal government has very little information about how the provinces spend money, other than what the provinces report.

Senator Merchant: Should they?

Dr. Postl: To me, if I were using my spending power, I would want it in exchange for something else. If that is on the list of what the ``something else'' is, I think that should be a key part of the discussion.

Dr. Schull: Does the federal government know? I would say the answer is no. Should the federal government know, and should the money be conditional? I would say absolutely yes.

The Chair: Thank you all for the precision and frankness of your responses. Areas were explored today that got to a number of very important aspects. As was indicated a moment ago, we would certainly welcome further input from you in writing on matters like the list of 16 items that should be on a checklist or a benchmark or whatever, and other aspects where you can provide us with additional information and suggestions in response to the issues discussed here today, based on your experience, that you believe can help us in our deliberations.

I want to thank my colleagues for adhering reasonably closely to their times and focusing their questions. With that, I will thank you all and declare this session ended.

(The committee adjourned.)