Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 6 - Evidence - November 3, 2011
OTTAWA, Thursday, November 3, 2011
The Standing Senate Committee on Social Affairs, Science and Technology
met this day at 10:28 a.m. to examine the progress in implementing the 2004
10-Year Plan to Strengthen Health Care.
Senator Kelvin Kenneth Ogilvie (Chair) in the chair.
The Chair: Honourable senators, I call the meeting to order.
I welcome you to the Senate Committee on Social Affairs, Science and
I am Kelvin Ogilvie, a senator from Nova Scotia and chair of the
committee. I will ask my colleagues to introduce themselves.
Senator Seidman: Senator Seidman from Montreal, Quebec.
Senator Verner: I am Senator Josée Verner from Quebec City.
Senator Demers: Senator Jacques Demers from Hudson, Quebec.
Senator Braley: Senator Braley from Ontario.
Senator Hubley: Senator Hubley from Prince Edward Island.
Senator Merchant: Senator Merchant from Saskatchewan.
Senator Dyck: Senator Dyck from Saskatchewan.
Senator Eggleton: Senator Eggleton, deputy chair of the committee,
The Chair: Thank you very much. I want to remind us all that we
are continuing our study, as directed by the Senate of Canada, to examine
progress in implementing the 2004 10-Year Plan to Strengthen Health Care in
Canada. This is our ninth meeting. The overall title of this meeting is
prevention, promotion and public health.
We have five presenters this morning. I will introduce them as I call
them to speak. We have an agreed order and I will call them in that order. I
would remind my colleagues that because of the number of witnesses, I would
implore you to be efficient with words in putting your questions so that we
can get all of your questions on the record.
With that, I will start with the Public Health Agency of Canada and ask
Dr. David Butler-Jones, the Chief Public Health Officer, to begin his
Dr. David Butler-Jones, Chief Public Health Officer, Public Health
Agency of Canada: Mr. Chair and members of the committee, thank you for
inviting me to speak today. It is a pleasure to be here this morning to
discuss progress on the public health aspects of the 2004 health accord.
I would like to start with a description of what is meant by public
Public health is the organized efforts of society to improve health and
well-being and to reduce inequalities of health. Put simply, it is about
promoting good health, preventing disease, protecting the population and
While care is about the individual and about treatment for disease and
injury, public health focuses on the whole population, preventing the need
for that treatment. While health care is primarily a provincial and
territorial responsibility, public health is the responsibility of all
levels of government and involves all sectors of society — health,
transportation, justice, education, environment and beyond. These are all
connected, and our health and prosperity rely on the interplay between them.
The level of success is dependent on all sectors acting together. Public
health is a team sport, with the shared goal of a healthy population, the
added benefit of which is a more sustainable health care system. Together,
public health and health care make for a complete health system.
Since the 2004 health accord, the public health landscape has changed for
the better in Canada.
The accord helped put public health on the agenda and made it part of the
conversation. Before the accord, public health was rarely if ever on the
agenda of federal, provincial, ministerial or deputy ministers' tables, let
alone a top-of-mind issue for Canadians. However, in the wake of the SARS
outbreak in 2003, the momentum was finally there for calls to action on a
more collective approach to addressing public health challenges in Canada —
among them, calls for a national immunization strategy and the Pan-Canadian
Public Health Network. While these initiatives predated the accord by a few
months, they were validated by this renewed focus on public health.
These are some of the areas I want to touch on today.
The context surrounding the timing of the accord is important here. SARS
occurring a year earlier was truly a national wake-up call, if not for the
world. The untimely deaths, illnesses and costs it created were the salt on
the wound of a badly fragmented system.
There was a recognition that during an emergency is not the time to be
exchanging business cards. We needed to build trusted relationships and
practised networks that transcend borders and jurisdictions before an
emergency. The network has since been one of our most important success
stories and has provided a means of facilitating effective coordination
between provincial, territorial and federal players.
This new level of collaboration became indispensible during coordinated
efforts in the 2009 H1N1 pandemic. In terms of collaboration, the way
jurisdictions, communities and individuals came together to address H1N1 was
unprecedented. It resulted in Canada having one of if not the best response
in the world.
Canada's management of H1N1 was not our only success.
We have used the Pan-Canadian Public Health Network to negotiate and sign
two memoranda of understanding on information sharing and provision of
mutual aid during health emergencies with provinces and territories. It was
also used to negotiate the declaration on prevention and promotion, which
was endorsed by ministers of health and healthy living last year, then
endorsed by ministers of sport and recreation and engaging ministers of
We are working together to address, for one, childhood obesity as a
particular concern. Otherwise, this may be the first generation of children
not to live as long as or as healthy as their parents. Mixing policy and
practice and different levels of government and experts keeps us all on the
same page, working toward the same aims. It is much more powerful when we
are all rowing in the same direction.
The PHN provided a mechanism that allowed us to get down to work on
helping Canadians avoid preventable infectious and chronic diseases. On the
former, we have the National Immunization Strategy, and on the latter, the
Pan-Canadian Healthy Living Strategy. I will begin with the NIS.
Through the National Immunization Strategy, the Government of Canada is
collaborating with all jurisdictions to prevent diseases by maximizing
equitable and timely access to vaccines for all Canadians. The government
has also supported immunization through trust funds, including through a
three-year, $300-million trust to introduce four new childhood and
adolescent vaccine programs to prevent meningitis, pneumonia, chicken pox
and whooping cough. All provinces and territories now have publicly funded
immunization programs for these diseases. Today, twice as many Canadian
children and youth in every province and territory are protected from the
dangers of these.
The federal government created a second three-year, $300-million trust
fund in 2007 to support the introduction of human papillomavirus vaccine. By
the time this funding ended in 2010, all jurisdictions had introduced this
Immunization works because it allows Canadian to entirely avoid certain
illnesses. This federal leadership has improved the immunization landscape
in Canada, which has resulted in the unprecedented introduction of
vaccination programs and higher vaccine uptake across the country.
While immunization rates in Canada are high and the occurrence of several
diseases has been reduced, the risk of exposure remains, and improving
immunization continues to be a priority. We are working closely with our
colleagues in the provinces and territories and stakeholders to renew the
National Immunization Strategy and ensure this important program remains
relevant and effective. The health care system does not incur costs to treat
diseases that people do not get.
This is a crucial point.
It has been said many times that it is far better to have a good fence at
the top of the cliff than a good ambulance service at the bottom. Canadians
suffering with chronic diseases like diabetes, cancer, heart and lung and
kidney disease, to name just a few, are being hospitalized across the
country and this carries a huge personal, social and economic burden. Much
of this disease burden is in fact preventable.
The prevention and promotion agendas have benefited from increased
attention in the years since the accord. The Pan-Canadian Healthy Living
Strategy was a commitment from all jurisdictions to take more coordinated
action in prevention and promotion. Governments have been able to fund
critical activities in these areas.
Our own federal contribution to this pan-Canadian approach is called the
Integrated Strategy on Healthy Living and Chronic Disease. The integrated
strategy commits $69.9 million every year to promoting healthy eating and
healthy weights, increasing physical activity and implementing
disease-specific prevention strategies.
Mr. Chair, from the Public Health Network to the National Immunization
Strategy and the pandemic plan, to new programs, surveillance, research and
partnerships, our collective public health efforts have grown from the
vision within the accord less than a decade ago. As a result, we have since
contributed to healthier Canadians in a healthier world, and to sustaining
our publicly funded health care system.
However, there is much more work to do.
As agreed to in the Declaration on Prevention and Promotion, a better
balance between prevention and treatment must be achieved. Surveillance,
research and knowledge sharing can always be improved and more attention can
be given to collaboration — quite simply, working together toward common
As I have indicated in my annual reports to Parliament on the state of
public health in Canada, the role of public health is to help find
collective solutions to ensure good health across the population, to improve
health overall and to minimize the gaps in health. I am pleased to say the
inclusion of public health in the 2004 accord has clearly benefited
Canadians, and we look forward to the future.
Thank you very much, Mr. Chair and honourable senators.
The Chair: Thank you very much. I will now turn to the Canadian
Task Force on Preventive Health Care and invite Dr. Birtwhistle,
Vice-President, to present.
Dr. Richard Birtwhistle, Vice-President, Canadian Task Force on
Preventive Health Care: I am pleased to be able to present the Canadian
Task Force on Preventive Health care to you. I think you have a PowerPoint
presentation in front of you that I will lead you through.
The task force was reconstituted by the Public Health Agency of Canada,
PHAC, in 2009. We have been working diligently on trying to produce our
first guideline, which will be coming out imminently.
The mandate of the Canadian Task Force on Preventive Health Care is to
develop and disseminate clinical practice guidelines for primary and
preventive care, based on a systematic analysis of the scientific evidence.
We are 14 members on the task force, 7 of whom are family doctors. All of
us have expertise in methods around guidelines and in epidemiology. As I
said before, we are established and funded through the PHAC.
The task force structure is the task force itself, but we also have a
number of people who are really helping us with our work. We have a task
force office at the PHAC that has scientific officers and directors that
help with the development of the guidelines, as well as thinking about
knowledge translation strategies for helping to make the guidelines useful
and getting them out.
We also have an evidence review and synthesis centre. This is the place
where a lot of the systematic market reviews of the particular subject are
done. It is currently at McMaster University and is funded through a
partnership between the Canadian Institutes of Health Research, CIHR, and
We also have a number of stakeholders who are really important in our
work in giving us advice about what the important topics are around
prevention from their perspective.
I will just take a moment and talk about how evidence-based guidelines
are developed. First, there is a group in the task force that creates the
topics, but we accept information from the public through our website
through various groups who may have topic suggestions for guidelines that we
want to develop.
We set certain criteria for whether we are going to select a topic or
not. Obviously, one of those would be how important it is for the public
health of our country and disease burden as to whether there is any new
evidence out there.
A workgroup is established of a small member subcommittee of the task
force and key questions are developed to answer around each guideline. Those
questions clearly are often around what the benefit is of whatever screening
manoeuvre or preventive manoeuvre you are going to do versus the harms.
Increasingly, we are recognizing that there are both of those things.
The next step, once the key questions are developed, is that the evidence
census and review centre assembles the evidence. This takes a number of
months doing comprehensive literature reviews. The guidelines and the
evidence are assessed using a system called the grade system, which is
grading a recommendation's assessment, development and evaluation, and it is
used to rate both the quality of the evidence and the strength of the
The workgroups then work through the systematic reviews and the
literature searches and then draft recommendations that are based on the
evidence review. Those drafts are peer-reviewed and discussed within the
small group before going to the task force as a whole.
The final thing is debate at the task force about the recommendations
that happen before they are published.
We have a dissemination strategy that involves both knowledge translation
through publication and developing tools that can be used by practitioners
as well as the public to interpret and use the guideline.
We are also planning on doing research on the effectiveness of the
dissemination implementation and evaluation strategies as part of our
looking at the task force impact on preventive care in this country.
What does the task force bring to prevention? I think it brings credible,
appropriate, easily accessible guidelines that will improve preventive care
in Canada. It has evidence-based guidelines in the area of preventive health
care to help ensure efficiencies in the health care system. We have linkage
with PHAC for capacity building in the public health system and, finally,
some accountability around benchmarking the types of preventive tests and
programs that happen across the country.
Thank you for your attention.
The Chair: Thank you very much, Dr. Birtwhistle. I will now move
to the Canadian Public Health Association and invite Debra Lynkowski, Chief
Executive Officer, to present.
Debra Lynkowski, Chief Executive Officer, Canadian Public Health
Association: Thank you for the invitation to be here today. I represent
the Canadian Public Health Association. We are Canada's only
non-governmental organization that focuses exclusively on public health. Our
membership is nationwide and we represent over 25 different disciplines that
deal with quite a broad range of health and social issues.
I was going to speak to you about progress, what remains to be done and
our recommendations, but I heartily agree with all of the progress outlined
by Dr. Butler-Jones, so I will not repeat that. I want to flag for you that
he probably neglected to say that one of the other areas of progress is that
the creation of the Chief Public Health Officer's position has been a huge
benefit to this country. His work has been exemplary. We have only to look
at the response to H1N1 and the profile of the CPHO, of the Public Health
Agency of Canada and the local public health response to say we actually got
this one right.
We do have a few areas that we still are lagging behind in. Dr.
Butler-Jones talked about the National Immunization Strategy. I agree that
there has been significant progress there, but, as he said, it has to be a
priority to continue to improve that. The NIS lags behind in terms of
creation of a registry and in educational programs for the public, because
we know there is still an anti-vaccine movement in terms of a research plan
and in terms of harmonized schedules for immunization across the country.
The 2004 plan also talked about a pan-Canadian public health strategy
that looked at indicators and outcomes for health status for Canadians. That
is still something we need to develop. That was reiterated in the Senate's
own report that was led by Senators Keon and Pépin regarding the need for a
population health strategy. We need to move on that if we are to have an
You have a detailed brief in front of you and I do not want to repeat
everything in it. I want to highlight some of the recommendations for any
new health agreement. Dr. Butler-Jones alluded to some of them. In it, we
call for a shift in focus from health care to health equity as a guiding
principle of any new health agreement. We urge that any new agreement
include public health and figure that prominently so that we are focusing on
disease prevention, injury prevention and health promotion and surveillance.
We recommend better coordination between the Canada Health Transfer and the
Canada Social Transfer because a lot of how our health is determined
actually falls outside of the health sector. We need to look at those
We strongly urge that any new accord include meaningful commitments to
public health human resources infrastructure and surge capacity. Our
capacity to respond to H1N1, while exemplary, tested the limits of everyone
on the ground. It also delayed many other public health programs, some of
which will not be caught up.
In closing, I want to leave you with some overall observations and a
challenge. None of this is in the brief. When we were preparing this we took
out all of the briefs we have done to parliamentary committees for the last
10 years. Essentially, we cut and pasted the things we have been saying for
many years. What that says to me is, while we have made progress, we have
not made enough progress, and we have to move further and faster.
What stands out for me is that public health continues to be funded at 5
per cent of all health expenditures. When Dr. Naylor did his report, he said
it was 2 to 3 per cent. I told that to a reporter once, who said, "Then
there has been significant progress." Five per cent of all health
expenditures are targeted at preventing illness and keeping people healthy,
and we wonder why we spend 95 per cent on acute care and in curing the sick.
We need to change that balance because the math defies all logic.
We seem to respond to public health and there is a flurry of activity
when there is a crisis. We ably deal with those crises, whether it is SARS,
H1N1, Walkerton or listeriosis. Everyone in public health rises to that
challenge, but when the flurry of activity ends there is a silence again,
and as it relates to funding, public health is lumped in with all other
health funding. When we talk about initiatives that are cost-cutting or that
there is no new money, it does not make sense that in an area that has been
chronically underfunded for decades we do not look at new investment for
that area specifically.
The challenge to create a healthy, productive society takes decades. That
takes political commitment, commitment from organizations such as ours, that
spans decades. That is the challenge for Parliament, for the Senate and for
all of us who are working on this so diligently. That is where the real
change will come about.
We have all of the answers already. I know you have read it, but the
report done by the Senate in 2009 was brilliant. If all of the
recommendations in there were implemented, we would make huge progress. If
we implemented the recommendations in the CPHO's reports, we would make huge
progress. Our challenge as a nation is to finally implement that which we so
I leave you finally with this thought. The evidence says that the average
lifespan of Canadians has increased by more than 30 years since the 1900s
and 25 of those years are attributable to advances in public health such as
immunization, water safety, et cetera. If we want to maintain that legacy
and further those advances, we need to make sure that any new health
agreement prominently figures disease prevention and public health.
As a final thought, what you can do as an individual to protect yourself,
your family and those around you is to get your flu shot as soon as
Karen Cohen, Chief Executive Director, Canadian Psychological
Association: Thank you, senators, for this invitation to CPA to join you
today. As you may know, CPA is a national professional association of
psychologists. There are about 18,000 regulated practitioners of psychology
in Canada, making us the country's largest group of regulated, specialized
mental health care providers. I want to give you a bit of our perspective on
the implementation of the 2004 accord and then talk a bit about the role of
psychological factors in health.
The Chair: Slow your presentation. The translators are finding it
hard to keep up with you.
Ms. Cohen: In terms of health human resources, I think some of the
discussions we have been having since 2004 have evolved to talk about supply
in relation to need. It is really important that we look to the needs of
community when it comes to mental illness and health promotion and that we
respond to those in ways that are cost- and clinically effective. We would
like to mention that improving access is not only about reducing wait times
for publicly funded services, but also about enhancing access to services
that are not publicly funded, which is an acute issue in mental health. The
2004 accord talks about mental health in relation to home care, the
challenge being that home care is not the intervention that best addresses
the majority of problems experienced by Canadians when it comes to mental
health, namely anxiety and depression. For those kinds of problems, we are
looking at psychological and other kinds of community-based treatments and
Finally, investment in research is really an important need when it comes
to mental health, but in the full range of biological, psychological and
social inquiry. Any condition, be it mental health or not, is impacted by
this variety of factors.
It is clear, when we talk about health promotion and illness prevention,
that we need services and supports that support health. However, as I am
sure all of us know, building the recreation centre is easier than getting
people to it. There are a lot of factors that impact whether or not people
behave in healthy ways. A lot of those are psychological factors. Good
health correlates with self-worth, peer connectedness, school engagement and
parental nurturing, as well as healthy behaviour. Poor health is correlated
with poor mental health. Many chronic diseases, like heart disease, diabetes
and stroke, are risk factors for depression. Depression itself is a risk
factor for first and recurrent cardiac events. One in 20 Canadians will
experience a mental disorder in a given year. Seventy per cent of these, as
I am sure Dr. Manion will explain in more detail, begin before young
adulthood. Depression is the fastest growing category of disability costs.
In 2003, the economic burden was estimated at $51 billion.
The strongest evidence for return on investment in mental health and
mental health promotion are services and supports geared to children and
youth that reduce conduct disorders and depression, deliver parenting
skills, provide anti-bullying and anti-stigma, promote health in schools and
provide screening in primary care. Health-promotion and illness-prevention
efforts, however, also benefit people living with illness and at points in
between. Positive mental health and good health behaviour not only maintain
health but also help a person to manage chronic illness. Some of us will get
Treatment for mental disorders will be needed for some, and there are
barriers to getting it. Psychologists are not funded by provincial health
insurance plans, and their services are not sufficiently accessible to
Canadians with modest incomes or no insurance. Other countries have
recognized this. The U.K. has invested about 400 million pounds to make
psychological therapies more accessible, and Australia has also enhanced
access to psychologists through its publicly funded health insurance plans.
We have several recommendations that I will leave you with. The first is
targeted transfers for mental health proportionate to the burden of illness
in Canada. The second is health promotion and illness prevention upstream,
with a focus on children and youth. The third is that intervention for
mental health and illness, when necessary, needs to be collaborative and
integrated across public and private sectors to include funders,
organizations that deliver care, health professionals who provide it and
those of us who receive it. The fourth is that there needs to be research
into the full biological, psychological and social determinants and
treatments for mental health problems. Finally, we call on government and
other funders to help us improve access to effective psychological services
for people with mental health problems who need it.
Ian Manion, Executive Director, Ontario Centre of Excellence for Child
and Youth Mental Health: Thank you very much for recognizing the
importance, in any health dialogue, of child and youth mental health. I
think there has been a great deal of progress since the 2004 accord. We have
heard of a lot of the wonderful accomplishments. I think, though, that the
landscape has changed. We also recognize that the dialogue around mental
health in general, and child and youth mental health in particular, has been
more prominent and should be represented in the 2014 accord.
There are several recommendations we would like to make to the group. It
is all in the brief, but I will go over them briefly. The first
recommendation is to address the inequities in the Canadian health care
system by identifying child and youth mental health as an explicit priority
in the 2014 health accord, with dedicated funding for reform and innovation,
based on measurable outcomes. Fifty per cent of adults with mental illness
tell us that it first appeared before they were 14, and 70 per cent say it
appeared before they were 18. We know that, in our country, $51 billion a
year of economic burden can be attributed to mental health and that it all
starts with child and youth mental health. In many ways, child and youth
mental health is probably the best barometer of how we are doing as a nation
in health and well-being. Increasingly, in terms of children's mental
health, we cannot say we are doing well as a nation in health care or health
Our second recommendation is to increase investment in health research,
with immediate emphasis on applied research in child and youth mental
health. Through talking with families and service providers, we know that
they want effective tools, based on research, that can help them meet the
family's needs across the full continuum of care, from prevention to early
identification to intervention and, yes, to chronic care. Increasingly, we
are aware that young children with mental illness do become older children,
adolescents and adults with mental illness. We can decrease the burden of
that by identifying things quite early.
Our third recommendation is to establish a pan-Canadian child and youth
mental health surveillance system to obtain ongoing and reliable nationwide
incidence and prevalence data to support informed decision making at all
levels. Currently we are making decisions for child and youth mental health
based on data from the 1980s, and mostly from regional studies, not national
studies. We do not have good data to look at the scope of the problem. We
cannot make decisions around mental health human resource planning without
up-to-date data, and we cannot tell whether we are making a difference or
not without having integrated data, particularly as it relates to child and
youth mental health.
The fourth recommendation is to develop and implement a national suicide
prevention strategy that is supported by a full continuum of
evidence-informed mental health services. We know that roughly 25 per cent
of children and youth report to us having significant issues, ideas and
concerns around suicide. For 90 per cent of the young people who take their
lives, we can identify a mental illness that was part of the complex web of
factors that contributed to that suicide. In this community, it is part of
the dialogue on a daily basis. You open the paper, and you cannot help but
see another person who, without the effective tools to cope with their
mental illness or with the other stresses of their life, has decided to cope
by taking their life. It is time for us to do something significant in the
area of suicide prevention.
The final recommendation is to develop and implement a universal
parenting program. In many ways, the biggest yield we can have, both in
health and mental health for children and youth, is by effectively equipping
parents to deal with their children at all levels and with the transitions
that those children face into the school system, into high school, out of
high school and into adulthood. Parents are clamouring for assistance, not
just when things get so bad that they are beyond their means, but at the
front end of care, in their primary role as the effective teachers and
caregivers for their children. Thank you very much for your time, and good
luck with your very important work.
Senator Eggleton: Thank you for your presentations. I would like
to explore further the Pan-Canadian Healthy Living Strategy, initially with
Dr. David Butler-Jones, but certainly with anyone else who wants to come
into it. My understanding was that there were three targets to be achieved
by 2015, including increasing the proportion of Canadians who make healthy
food choices by 20 per cent, the proportion of Canadians who participate in
regular physical activity also by 20 per cent and the proportion of
Canadians of normal body weight, based on the body mass index or BMI, also
by a 20 per cent target. Can you tell me how we are proceeding on this? Are
we on track to meet these 2015 target dates? How far along the path are we
at this point?
Dr. Butler-Jones: The short answer is no, which is part of the
These are not our targets. These are shared targets across jurisdictions
in terms of recognizing the challenges. As I said before, it is a challenge
particularly for this generation of children if something does not
fundamentally change the situation they will be in as they grow into
adulthood. We are making progress but, also, it is reflected, I think, in
the declaration on prevention, the framework for tackling childhood obesity,
the emphasis of multiple ministerial groups, the focus on the after-school
period with education ministers and others and the realization that we need
to make much more effective progress.
It is not just about governments; it is about communities and industry.
We are starting to see some of the changes in industry. For example, we have
seen McCain reformulating all their products and other companies reducing
salt. They are not bragging about it because they do not want to scare
people, but they are actually reducing the salt and sugar content in their
foods, et cetera. We are making progress, but there is a lot more progress
to be made. I would be surprised if we were to hit those targets, but we
need to step up the efforts.
Senator Eggleton: How can we help do that? What kind of push can
we give? Is there something relevant to the upcoming 2014 accord that we
should be pushing on in this connection?
Dr. Butler-Jones: One of the things that, at least, I am hearing
and I think is reflected at the table here and elsewhere, whether it is from
professional associations, NGOs, ministers, deputy ministers and others, is
that whatever we do, and not specific to the accord but moving forward, if
we do not get primary care and public health right, we are in a pickle. It
is not just about money. It is also about how we work in concert and how we
Two things changed the tobacco challenge and made it actually a much more
positive thing. The first is the recognition of the effect of second-hand
smoke and the efforts around addressing exposure to smoke, and the second is
when all the organizations, governments, NGOs, and communities started
rowing in the same direction. In other words, you did not have a lung
tobacco strategy and a heart tobacco strategy. The NGOs worked together, and
governments worked with them and with other groups and communities to
actually change the face.
Similarly, whether or not on obesity or other issues, some of it is about
funding or some of it is about how we direct the funding or use the funding
that we have. Some of it is how we direct our resources, not just funding
but people and how we act. For example, when you look at something, the
clinical intervention, so back to whether it is preventive practices or
guidelines, just that five- or ten-minute intervention and two minutes of it
spent about not just how we diagnose and treat the current condition but how
it might be prevented in the future and what advice might we give to the
patient or the family so they can avoid it in the future.
Senator Eggleton: That is what this is. It is intended to be a
prevention kind of program.
Dr. Butler-Jones: Yes, but it is really about having that
inculcated throughout the system at all levels, not just doctors or nurses
and not just in the community, but that each reinforces the other.
For example, in the early days, I remember talking to patients with a kid
with asthma or an ear infection and saying, "If you want to quit, I can
help you, but if you do not smoke in the house, then your kid is half as
likely to have those problems." It is the teachable moment. What struck me
is how effective that couple minutes of intervention was because of the time
they were there with the kid, the kid is in pain, et cetera and the number
of people who then stopped smoking inside and then eventually quit because
it just felt stupid, et cetera. It is a mix of those things; specifically
governments and NGOs and individuals have a role. It is about creating
opportunities for healthier choices for everyone.
Senator Eggleton: There is still a long way to go, though.
Dr. Butler-Jones: A long way to go, yes.
Senator Eggleton: Mental health was not part of this strategy. I
am talking about this specific strategy. Dr. Manion has given us some
excellent recommendations regarding youth. How should we get mental health
either into this strategy or into the health accord?
Dr. Butler-Jones: That is more of a political question that I will
defer. I can say it really is about thinking about health comprehensively.
What are the interests of all jurisdictions moving forward that collectively
we can do better, whether it is mental health or prevention and promotion.
It is not a battle and it should not be a battle between prevention and
care. It should be if we want the best possible outcomes, what are the
investment strategies and approaches on the prevention and promotion end, on
the treatment end and on the care end that gives you the best outcomes.
The purpose of the health system is better health. It is not about how
many beds and hospitals. It is about do we actually achieve better health.
We have tended to block it as separate silos. If we think of it as a system,
we will invest in those areas that have been spoken of today.
Senator Eggleton: I do not. One of the areas I would like to talk
about is social determinants of health, because that keeps getting raised by
our witnesses. That is quite a broad area. It affects health, and it is
everything from housing to education to poverty, et cetera. How should we
get social determinants of health into the next accord? Anyone else can
respond on this as well.
Dr. Butler-Jones: The social determinants, health services,
including public health, is one element of the various determinants of
health, but it is not the exclusive element. On the prevention agenda, it is
not just Ministers of Health. It is ministers of sports and ministers of
education and ministers in other sectors that must be engaged. That is at
the political, governmental and bureaucratic level.
We just came back from the Rio summit on social determinants of health,
and the declaration there is worth reading because it does speak to the
various ways in which, at each level, we can better coordinate our
activities so we are not working at cross-purposes and are gaining the
synergies, because a healthy population is good for the economy, and a good
economy is good for health. It is a virtuous cycle. Making those
interventions, the health sector can deal with health, but it can also
engage other sectors, not in a health imperialist way, such as, "You must
do this because it is important to health," but, "What do we have to offer
collectively that makes for a functional, successful and healthy
community?" That is where it is crosses sectors, and breaking down some of
the sectoral barriers is absolutely essential to that.
Mr. Manion: In terms of how to integrate mental health, I am
consistent with Dr. Butler-Jones. Every time you have a preventive effort,
talking about family doctors asking specific questions, there is a question
about mental health that can be done every single time. Mental wellness
checks are as important as physical wellness checks. It can become part of
the training that we do fundamentally. It could be part of the discourse we
have every time. It can be part of what we check for in the workplace. It
can be that systematic in our approach. Prevention without mental health
does not make any sense, and health without mental health does not make any
sense. They are not two solitudes; they are two sides of the same coin.
Senator Hubley: Welcome to you, and thank you for your
presentations. My question is along the same line. According to the
Report on the State of Public Health in Canada, 2011, we learned that
Australia, Finland, Sweden and the United States have developed national
suicide prevention strategies. However, the report states that Canada can
address suicide prevention as part of a broader wellness strategy that
promotes mental health, prevents mental illness and also includes the
broader determinants of health. Do you feel that that is strong enough,
given the recommendations that we heard from Dr. Manion? What
recommendations would you have in order to address the issues of suicide a
bit stronger in our public health systems?
Mr. Manion: The irony is that Canadians helped develop most of
those international policies in other countries. We have a huge amount of
capacity here — knowledge, research, experts in the field — that have been
guiding others to develop their policies for years. I think having a strong
policy on suicide across the age span but with a focus on young people is
necessary but insufficient.
The best way to prevent suicide is to have strong systems of care that
look at providing support along the full continuum. When you prevent mental
illness, you are decreasing the rate of suicide. When you are educating
young people about health and wellness and equipping them with tools to cope
with difficult times, you are actually having a huge impact on suicide. When
you are looking at social determinants of health, decreasing abuse and
trauma through effective parenting, you are having an impact on suicide.
Above and beyond a specific strategy on suicide, we have to understand
how all the other aspects of health are contributors to a situation that
could lead someone to suicide. We cannot put all our efforts in one
direction. It must be a holistic approach and a loud signal that we will not
tolerate the levels of suicide we are seeing across the country, especially
in certain groups and communities. We must be able to do much better than
Dr. Butler-Jones: I think those might have been my words;
everything does occur in a context. If you look at the work, we know that on
many reserves, for example, adolescent suicide is a huge challenge.
However, when that was studied, looking at different communities that had
more control — in other words, they are actively involved in land claims and
have some control over health services, police, education, et cetera — the
suicide rates virtually disappear. When you look at the social determinants,
the basics in place — roof over your head, et cetera — I was struck by the
fact that there are poor communities that are very functional and more
affluent communities that are not.
Once you have the basics in place, the two things that actually make a
fundamental difference are, first, do you have some sense of control that
what you do influences your future, that you can make a better future, in
which case you do that? Second, do you have people that love you and that
you love? For adolescents and children, if those two things are not in place
— and for adults as well — then the chances of good health are poor.
Senator Champagne: I was reading an article this morning that
mentioned that there are many websites that young people look at to give
them ways to commit suicide successfully. Should there be a way for the
government to ban those sites or to do something about them? That worried me
this morning; and as you brought up the suicide problem again, I thought
that maybe this is something that we should recommend our government to do.
Dr. Butler-Jones: It is probably a question for Justice, but from
my understanding, it is counselling to suicide, which is what the sites are
doing. I thought that was illegal in Canada.
The challenge for websites, whether it is about how to produce a bomb or
how to commit suicide, is that they are all over the world. I know law
enforcement agencies are addressing that. Dr. Manion, do you have more
specific information on that?
Mr. Manion: I think you are absolutely right. There are people
that are watchdogs for these kinds of sites right now. They proliferate like
crazy; you cannot control them in a systematic way.
The better investment and strategy is where you provide young people with
different kinds of information at a fundamental time, before they reach the
point where they are looking for maladaptive ways of coping. Mental health
literacy in schools and in the workplace, equipping people with appropriate
skills to cope with or even tolerate distress will go a lot further.
Increasingly, we are looking to how young people turn to the Internet;
but they turn to something more than the Internet, and that is to their
peers. Where is the opportunity to engage the peers, young people
themselves, in finding solutions to this problem? I do not think anyone in
this room will find a solution to social media and the negative aspects of
it. However, if we engage young people creatively, they can tell us how to
use it more effectively to promote health and wellness and to prevent
illness and tragedies.
Senator Hubley: As a quick comment on that, on Prince Edward
Island, which is a pretty idyllic place to grow up, the suicide rate among
our young people is the leading cause of death after accidental deaths,
which is hard for me to believe.
Mr. Manion: We know right across Canada that suicide is the second
leading cause of mortality after accidents, but we also know that the risk
for death by suicide is higher in rural communities, for a variety of
different reasons. We know that young men die more often by suicide, but
young women think more about suicide and attempt it more often.
It is a very complex area. We need to understand not just some of the
variables — there is lots of research on the variables. We need to do
research on the solutions — effective programs to prevent suicide;
post-intervention in the communities, when the risks go up; and
understanding such subtleties about why certain communities are affected.
I know the studies Dr. Butler-Jones was referring to. It is not, by
definition, a certain type of community that will be at risk; but there are
things within a community that can be protective but also place that entire
community at risk. There are a number of rural factors that we know increase
the risk, even in idyllic situations.
Senator Merchant: If the objective of a health care system is
better health, to keep people as healthy as possible and provide the care
they need when they need it in a timely, quality and cost-effective manner,
then we have to think about new innovations.
We have heard from other people about multidisciplinary settings. Are
there any pilot projects that you are aware of that are in the works right
now that would help us to set up systems in the next accord that would
Dr. Butler-Jones: In Canada, ironically, my first specialty was
family medicine. The way I was trained in the 1970s was in multidisciplinary
care and clinics — social workers, psychologists, physicians, nurse
practitioners, et cetera working together, bringing each of their collective
skills to bear on the issues from a prevention standpoint. We were well
connected with public health locally to link our prevention activities
clinically and at the community level as well.
However, people came out into practice with fee for service, and you
could not bill for a nurse practitioner. Suddenly the schools for nurse
practitioners dried up.
There are a number of community health centres that do aspects of that.
Some are better than others, but there are lots of models in Canada where
people try different things to provide some success.
I think former Senator Keon and perhaps Senator Eggleton were looking a
bit at Cuba. Not to argue for the Cuban system, but one thing it does well
is link all the levels of care. It is not a series of isolated silos. You
have a physician and a nurse that look after your basic care. If you need
more complex care, you go to the polyclinic or to a hospital, as needed.
In your basic care, every patient is classified in terms of do you have a
chronic condition or risk factors, and there are protocols to ensure people
have access to that. If there is only so much penicillin, you have criteria
for this; you have some prevention programs. It is more of an integrated
system. That piece of it is worth learning from.
We see elements and examples of that across the country. There is a lot
written by the College of Family Physicians, the Canadian Nurses Association
and other professional associations. There is actually a lot of good
evidence there and work that we can draw on.
Again, it is not fractionated care. In Canada, we have moved to
specialized care; you need a specialist for everything. In my view, good
generalists can do most of the basic stuff, make the right links and see you
as a whole patient, as a whole individual, as part of a family and a
community, not as a body part. That is one of the big challenges in Canada.
We are starting to see in medical schools and elsewhere more training of
family physicians, better integration of multiple disciplines into teams, et
cetera. However, by and large, we are not trained in teams; we are trained
as isolated or individual professions.
There is a real desire to be more integrated. I think we are seeing a lot
of improvement in that. We are seeing more young women particularly going
into medicine and family medicine that are more willing to work in rural
However, nurse practitioners are not a substitute for lack of a
physician. Nurse practitioners have their own set of skills, which are
valuable in the city, the country and everywhere. It is about blending the
series of skills, providing appropriate levels of care to the individual and
then having a system of care so that if you need more complexity, it is
One last illustration: I used to teach family medicine. If I had a
patient I was worried about, I would call up the surgeon or the internist or
whatever it was, explain what I found and what I had done, and they would be
seen that day or the next one. There was no waiting list for people who
really needed to be seen.
For others, it could be three or six weeks or whatever — fine, if this
changes, come back. Again, it is thinking of it as a system of care, not
just my few minutes with a patient. It is about how that fits with the rest
of the system and what is happening in the community on the public health
and prevention side.
Senator Merchant: We have been told that it is not that the system
needs more money necessarily, but it is how we manage our services. I think
that should be kept in mind because we can throw a lot of money at things,
but it does not necessarily produce the results that we want.
Dr. Birtwhistle: I want to give a personal reflection because I am
a practising family doctor. I practise in a health care team that has nurse
practitioners, nurses, a pharmacist, a social worker and a dietician. This
team makes my life a lot easier. There is no question that I think we
provide better care. Taking smoking as an example, I can talk about smoking
to patients as they come in, and I do frequently, but our team has actually
organized a program in which there is support, phone calls and medication if
people need it. This team is highly functioning in terms of cross-over with
public health and others, and models of care in primary care are crucial in
terms of how you put this together. The evidence for this very expensive
team is not there yet because this has just started across the country.
However, I think it important to encourage thinking about this as a future
model of care.
Mr. Manion: I agree. It is not a matter of just pouring more money
into things. It is understanding how we are using the money. The family
health teams are an amazing model. There is some good research coming out of
that now. Do we know the various skill sets that we need within that team
across jurisdictions? Do we have enough of those skill sets? Are we training
enough social workers and psychiatrists and psychologists to be able to meet
the needs in different jurisdictions? We do not have that national health
human resource plan to tell us whether we are creating the right kinds of
skill sets to equip those teams to look at the health needs holistically of
the people across different communities.
Ms. Lynkowski: Briefly, beyond the health care team, the success
that is happening with regard to addressing the social determinants of
health and health inequities happens at the community level. There are some
communities that have exemplary programs with regard to this. I believe it
is because there are relationships there that go beyond a systems approach.
They really look at the level of education of a person and income, and
communities come together to actually address some of those root causes of
the problem well up front as opposed to dealing with it after the effect.
Senator Seidman: I would like to explore further the child and
youth mental health issues. You may know that Dr. Robert Boulay, President
of the College of Family Physicians of Canada, testified before this
committee just two weeks ago. During that meeting, I asked Dr. Boulay a
question about the collaborative position paper that was written by the
College of Family Physicians of Canada and the Canadian Psychiatric
Association in 2010. In that paper, a vision was presented for the
partnership between primary care and mental health providers, including the
integration of mental health services in primary care settings.
Specifically, I wanted to know the extent to which mental health services
could be integrated into the primary care system and what barriers we would
face. My particular interest was in child and youth mental health. I asked
witnesses to address this focus. You can understand, then, why I was rather
taken aback when Dr. Boulay candidly responded to my question with these
Child and youth mental health services in Canada are bordering on a
national embarrassment. We need to push forward in that realm.
This statement was frank, and it was very poignant. I am hoping that you,
with your expertise, can help us understand the barriers that we face and
explain how a future health accord could work to address some of these
Mr. Manion: Thank you for your question. I think you have put it
quite well in terms of an embarrassment. There are a number of barriers. One
of the barriers we face too often is that the Canadian population does not
believe that children and youth can suffer from a mental illness. They do
not think it is a reality. They do not understand that the majority of those
who will have lifelong mental illnesses actually experience them during
childhood and adolescence.
The other issue we have talking about children and youth is that it is
not just one sector. We cannot just talk about health and primary care. We
cannot look at those needs without talking about education and child welfare
and youth justice and recreation. Unfortunately, each one of those sectors
has a different language, different culture, different barriers and
different policies that guide them. All of those differences create barriers
to integration, to holistic care and to preventive efforts. We need to
develop a common language and a national understanding of how relevant
mental health is to our children and youth and how we have an opportunity to
actually do some significant prevention during primary school, high school
and key transition periods. We need to start to understand that and train
that across all disciplines, for anyone that works with a child, thinking
about police officers and dentists and teachers. They all have a role to
play. That is when we will have the right kind of impact and a better
appreciation of a system of care that looks at things in a holistic manner.
Dr. Butler-Jones: It was a previous Senate committee and review
that gave rise to the mental health commission looking at a number of these
issues. I think that is really important.
To reiterate on the issue of the integration, our mind is not separate
from our body, nor is it separate from our culture. We need to have an
integrated view so that we are thinking about mental health issues along
with physical health issues in other areas.
One area is children, and we just assume kids will be fine. Another area
is people with chronic disease or chronic pain and the mental health
implications of that. We tend to focus on the physical ailment and not even
acknowledge sometimes the mental components of it. There is huge opportunity
as professionals and as communities to come together in a different way,
which I think will benefit everyone at the end of the day.
Ms. Cohen: In terms of early identification of problems for
children and youth, as Dr. Manion said, it is not just through primary care.
We need to have resources in schools and in the communities in which they
live where those kinds of problems are likely to be most early identified.
The challenges are infrastructure in terms of how health care is delivered.
The bulk of providers of specialized mental health care are social workers
and psychologists, and those services are not funded. If we have an
infrastructure that is funded fee for service, it makes it more difficult to
access that care in a timely way, in addition to the stigma.
Senator Seidman: You are getting at some interesting issues. If we
specifically look at improving access to services, for example, and wait
times and improving the knowledge and training of health care workers — and
I think you were already starting to touch on that — as well as the other
settings and professionals who can deliver the kind of programs that you
might be talking about, do you have something specific to offer in those
Mr. Manion: A significant amount of work has been done on access
and wait times in general health procedures. Increasingly, we are looking at
how that has to be applied now to the mental health questions.
Unfortunately, when a population does not understand mental health or mental
health care, often they will go to the most specialized provider as quickly
as possible, creating bottlenecks in the system. We do not have a lot of
pediatric child and youth psychiatrists in Canada, but not everyone with a
mental health concern should be going to see a psychiatrist necessarily.
That is for a certain kind of problem. There are community-based providers,
psychologists and social workers that have tremendous skill sets that can
meets the need across the continuum and decrease some of the bottlenecks
that are created in our system, but there must be a mutual understanding and
respect for the various roles in that system that I think we are lacking,
for all the reasons that have been mentioned, including the lack of cross-
training. We do not train our professionals to understand other professions.
We train our professionals to work in silos, and then magically we expect
them to work as teams when they get out. That has to change.
Senator Martin: I have so many questions. I will try to focus to
the 2004 health accord. In terms of mental health and the growing need and
concerns that we have as Canadians, would you say that the 2004 health
accord made a difference in how we have done? Although we say we are not
doing a good job, did it assist in ensuring that we do a better job with
mental health? If not, what should we be looking at in the next accord? I am
asking specifically about the language of the text that needs to be there so
that we can focus. I think this is an area that we must focus on. We all
agree around this table. My first question is with regard to the 2004 health
accord and what it did or did not do and what we need to ensure we have in
the next one.
Mr. Manion: When you talk about the 2004 accord in terms of
explicit mention of mental health in the accord, it was incredibly limited.
It was subsumed in small pieces under other things, which did not give it
the chance to be highlighted for some cohesive and focused action.
As has been mentioned, other Senate committees have looked at the issue
of mental health, such as the Out of the Shadows at Last report that
spawned the Mental Health Commission of Canada, which I think has gone a
long way to changing the dialogue nationally. They were awaiting
recommendations and a plan from the commission, but the 2014 accord cannot
wait. We must acknowledge that this is something that has to be part of
I will be honest with you in that I was a little disappointed when I
looked at all the different themes and testimony of how we are trying to get
mental health in the back door as opposed to being the primary focus.
Leadership goes a long way in this respect. If it is an add-on, it will
always be the poor cousin, and it must be a focus.
Ms. Cohen: One of things that has happened since 2004, whether a
direct result of the accord or not, is the Primary Health Care Transition
Fund that was funded by Health Canada. There were two aspects. One was
enhancing interdisciplinary care in general across health care providers,
and the other one was the Canadian Collaborative Mental Health Initiative,
which looked specifically at collaborative care in mental health.
There has been a lot more discussion and recognition about the importance
of collaborative care in terms of providing accountable and effective
service. As Dr. David Butler-Jones mentioned, there is a lot more
recognition that working collaboratively makes people's jobs easier rather
than harder because there is a team upon whose expertise you can rely. Where
we have stopped a bit is at the barriers. We know how to do it better, but
there are further infrastructure barriers in the way of doing so.
Dr. Butler-Jones: I would not attribute it to the accord, but I
think with the Mental Health Commission, with the investments in research
and the kinds of conversations taking place, there is a greater visibility
now. At the time the accord was written, it did not have the same kind of
visibility. Maybe the fact that it did not have that visibility contributed
to having new kinds of important conversations moving forward.
Senator Martin: My question is about these barriers. How do we
begin to dismantle or attack them? Can the accord facilitate that?
Dr. David Butler-Jones and Dr. Birtwhistle, you described this integrated
or comprehensive centre to provide the kind of health care services that we
need and that it should be a trans-disciplinary system. We know that it
exists in different places. We know it is the way we must go. I, for one,
had to be the quarterback to help navigate my father through the system with
many specialists. Not understanding the system myself, I have seen firsthand
the importance of doing this for patients who use the medical system. How do
we transition towards that? Can the accord in some way facilitate that? We
know what we need to do.
Dr. Butler-Jones: I think that is a fair question, and you will
provide your advice as to how it could be done through the accord, per se. I
think it is essential.
One of the challenges is that we have structural problems. For example, I
was responsible for setting up primary care reform in Saskatchewan when I
was there a number of years ago. One of the biggest barriers was not finding
physicians and others who were interested in working in teams and using a
different model of payment, et cetera. There was a rule in Saskatchewan that
if you wanted to do that as a new graduate or coming into the province, you
first had to build up a fee-for-service practice and then convert it to the
new model of payment. That is a very fundamental structural barrier.
We have systems where the incentives are identifying the one issue for
today because I only have time for one issue. How does the patient know what
that one issue is of the 4 or 5 present? You have to do as Dr. Birtwhistle
and his colleagues do, actually work through and then figure it out. You may
have to come back and deal with them later, but how does the patient know
that? If you just have a regular prescription, why would a patient have to
come in for an appointment, take time off work and try to find a parking
space just for a renewal of a prescription when their blood pressure is
well-controlled and they are managing it at home?
Again, these are structural problems that we have created by the systems
we have created, and those are just a few examples.
This is a chance to step back. In the conversations around the accord,
independent of what the future looks like in terms of accords or not, there
is a real appetite for the conversations and the planning around how we can
address these things more effectively.
Senator Martin: It would be great to see what the structural
barriers are and if we could dismantle 40 per cent or else. I know that is
not possible, but try to attack those barriers. It would be great to get a
list of those key structural barriers from you, Dr. Butler-Jones, for
consideration in our report. I am sure we have a running list as it is, but
are there specific ones?
Dr. Butler-Jones: Another running list or something in addition.
For example, the College of Family Physicians, the Canadian Nurses
Association and others have focused on the challenges in primary care and
the way forward. It is really about what we need to do now as opposed to
what some of the problems were in the past. What kind of system do we think
would serve us well into the future?
When the Hall commission was established in the 1960s, they went around
the world and looked at what the best match and the best system would be for
us, and then we could look at how to get there. If there were barriers to
getting there, they looked at how to identify them. I am not sure we have
had that kind of conversation, but there is a huge appetite for it today.
Dr. Birtwhistle: To put one of the barriers on the table, and
hopefully it has been improving, it is a political barrier in terms of a
physician giving up turf. This is an issue that physicians have had
difficulty with over the years. It is changing, but it is still there.
Senator Dyck: I want to return to the topic of suicide amongst
youth. The statistics you provided to the committee are quite shocking. I
knew that the rates were high within the Aboriginal population, particularly
up North in Nunavut, and other groups are also at risk. Given that the
Aboriginal population is relatively young — half of the population is under
the age of 25 — and because it is growing rapidly, they are particularly at
With regard to the Canadian Task Force on Preventive Health Care and the
model that you presented, Dr. Birtwhistle, how would various groups interact
in terms of designing preventive structures? Is there a mechanism whereby
people from the school, parents or organizations that youth might be
involved with after school, can have input? It seems to me that, relatively
speaking, a young person probably does not see their family doctor very
often, I would guess maybe once or twice a year, unless there are other
health problems. With something like suicide, because often those thoughts
are kept to the person themselves, they may not interact with the family
Within a model of health care, how do we reach people like that? Is that
covered by the kind of structures that we have in order to cast as wide a
net as possible in order to pick up those first signals? Those signals may
not come through the typical medical care system.
Dr. Birtwhistle: I think you have expressed the point very well. I
do not necessarily think that the primary health care or medical care system
is the way we will move this forward. I think it can be part of the solution
once things are identified but often, you are right, young and healthy
individuals do not see their doctors often or even visit the health team
often. I think it is in other places that the antenna must be put up in
terms of trying to move this forward with regard o the identification.
Mr. Manion: I think we have to be careful. Often when people are
beginning to have mental health concerns, it shows as physical symptoms. We
have done research where we have asked young people about risk and suicide,
and roughly a third of them who had suicidal thoughts told us they never
told anyone before. Half of the young men told us they have never told
anyone before, yet they just told us. Therefore, sometimes asking the
question explicitly should be part of the examination.
If a young person is presenting with some physical symptoms because of a
problem with anxiety or is self-medicating through using substances, that is
the opportunity to find out how that young person copes with things,
including going as far as thinking of ending his or her life. If that is the
case, what steps has that person they already taken?
We also know that in many communities there has been a huge impact on
suicide by never discussing suicide, focusing instead on wellness. Some of
the isolated communities we have worked were having suicides every month
with people as young as age 10, which, on a monthly basis, is a huge
proportion of the population. Going in, working with the natural caregivers
and having the community own the prevention and wellness efforts has
resulted in no suicides over the last three years.
There are different ways of getting at this question. Part of it is
through primary care, part is asking the hard questions at times, even with
the family, and that is where parenting comes in, but part is also looking
at the holistic approach we have all been talking about today.
Dr. Butler-Jones: I have a story to reinforce the point of asking
the questions, actually listening and the importance of that contact. I was
working in the tropical disease clinic and a patient came in, a recent
immigrant from the Philippines, who had problems. They assumed it must be a
tropical disease; they had had myriad tests, multiple specialities, et
cetera. I listened to her for a while and we chatted. Basically, she was
being abused in the family, and it was a physical manifestation of abuse in
that case. Taking the time and having the time to listen is essential,
whether it is a physician, nurse, social worker or psychologist.
The other point is to reinforce the issue of the role in communities and
having alternatives for kids. One of the worst things we did in the 1990s to
save money in the education system was cut back on after-school programs,
bands, orchestras, art and all the things that kept some of us in school.
The irony is when you have daily physical activity, orchestras and so forth,
kids actually do better in their academic subjects, but those were the first
things we cut. That is a simple, practical way, along with having adult
mentors such as good teachers, Scout leaders and so forth. It is a huge
impact in terms of that positive avoidance of the alternative.
Mr. Manion: We have data that shows that when young people are
meaningfully engaged in things like after-school and community activities,
they are physically healthier, engage in less risk-taking behaviour, are
less likely to become depressed and are less likely to become suicidal.
Dr. Butler-Jones: One good example is the Ranger program in the
North. I do not know whether you are familiar with it, but it is one
Senator Dyck: You are describing the kind of mental health or
well-being aspects of having after-school activities. Has anyone ever done a
study that shows the economic benefit in terms of maintaining a healthy
community with those kinds of supports? Many times, unfortunately, it seems
to fall down to how many dollars we will save if we bring these programs
back by making people healthier. People would rather cut the programs out to
save money instead of investing in well-being. Has there been that kind of
Mr. Manion: There have been some studies. Some of the work of a
giant in child and youth mental health, Dr. Dan Offord, was about looking at
community response, the determinants of health, the role of recreation in
terms of improving health and mental health outcomes. Sadly, sometimes for
financial reasons, when we try to replicate this work, we cut the guts out
of these programs so that they are no longer effective. We are not
implementing them with fidelity. I think that we are lacking information in
terms of mental health economics. That is an area of research that we should
be connected to. There are very few, I think, talented researchers that look
at mental health economics, especially from a child and youth perspective,
and that is an area in which we can have some increased capacity.
Dr. Butler-Jones: Ministers of sport and recreation, ministers of
health and ministers of education are working together and focusing on the
after-school period for a whole range of reasons. One is adult mentorship.
Another reason is when you think of adolescent or youth crime, most of it
occurs in that after-school period. It goes on and on. The evidence is clear
that small investments in this area — they do not need to be large — have a
tremendous impact not just in terms of day-to-day issues but also with
respect to those kids' future, their sense of purpose, mentoring and desire
to become something.
Ms. Cohen: It is certainly true we know more about what is
clinically effective than cost effective. When it comes to programs and
issues that have an impact on mental health, the impact is over a great
period of time and across sectors. Therefore, you may invest in schools and
see the outcome years later in the workplace. That is a challenge because
the value of that program is not immediately obvious as it is with cardiac
surgery for someone who has a heart problem.
Senator Braley: Many of my questions have been dealt with by
Senator Dyck. She did an excellent job.
We have to keep people healthy from birth through the teenage years
through adulthood and into older age. My children are in their 40s, and my
grandchildren are youngsters, from age 6 months to 22.
I see the education system has not been adjusted so that things like
eating good food and ensuring you have exercise all occur as part of the
curriculum. I can teach mathematics or history, but there is also just
living. I do not know the facts that are needed, and I am sure my children
do not know the facts for the grandchildren. There must be a correlation of
education and health at the provincial level, but to what extent? Do we
tackle that by starting to educate the children as they enter the school
system? The parents may not have had the opportunity to do it properly. Then
we have to have the social system tie into it so that when a person shows a
physical problem, it is immediately identified and can be partially or fully
dealt with. I do not know if I have tackled the thing right, but we have to
look at how we keep healthy and then reduce the health costs in a major way.
Mr. Manion: There is more work being done in school health than
ever before. For example, the Canadian Association for School Health, or
CASH, is looking at the best knowledge available to answer the questions you
With respect to mental health, a national project is looking everywhere
in the world at the best programs that are school-based that can help us in
terms of the mental health literacy not just of students but also of staff
so that we can answer some of those questions.
One of the problems is it cannot be on the backs of teachers. Teachers
are very busy already. They have a skill set that can be enhanced around
identification. However, it will be through partnerships across sectors, for
example, education working with service providers in health, mental health,
child welfare and youth justice to understand the holistic needs of their
students. The school can be a place where much of this can happen, but we
must think about whose role is to do what piece. Part of it will be in the
curriculum and part of it will be having the right skill sets within the
school system. However, a greater part will be breaking down some of the
silos between education and the other sectors, so it can be a community
response, maybe based in the school, but using the best tools from all the
different players at the community level.
Dr. Butler-Jones: I would certainly agree with that. CASH is one
forum nationally. There are other fora. As I said, ministers and deputy
ministers across the sectors are starting to recognize the importance of
getting there and thinking coherently about how we approach it. We often say
we should do it in school while realizing the tremendous competition and
pressures, but we can assist that, whether it is a public health nurse or
whatever to help facilitate that. There are different ways to encourage
At the same time, it is not to take away from the parents'
responsibility. It is not a substitute for it; it has to be complementary to
that, and there is also the issue of supporting parents and communities to
As for the tools and resources, for example, the options in the
cafeteria, there is a lot of good evidence that if you put the salad bar
before the checkout, people pick up salads. If the better foods are well lit
and the chips and gravy are stuck in a corner, people pick the brighter
foods. There are many simple things, ironically, that can encourage that.
Mexico has banned pop from all its schools. Hydration is an issue in
Mexico and many schools did not have clean water. First, they made sure
every school had clean water, and then they removed the soda pop. Is that
the answer? It depends on the community, and each school board is so
different. However, to the extent we can help cross- jurisdictions identify
the best practices and find easy ways to implement them, we are more likely
to be successful. It is complementary, however, and it is important that we
support parents as well as the kids in school.
Ms. Lynkowski: The other thing is that for decades we have talked
about literacy and promoting it, but it is only in the past little while
that we have talked about the concept of health literacy for young people
and adults. As we have growing expectations on all of us to take more
responsibility in managing our own health and our care for our health, you
do need strategies and tools to make that happen. There are several recent
excellent reports in regard to how to do that at a community and a national
Senator Braley: Is it being done? How do we educate the parents?
Is it only when they have a baby and they are going for their first baby
training? It has to be a whole thing right across the system, like let us
reduce smoking or eliminate it. It cannot be done any other way.
Dr. Butler-Jones: I totally agree. It is not just education or
advertising, per se. For example, when you go through the grocery store,
there should be clearer labelling so you know what is in the product; and
you need to have health literacy so you know what actually matters. What we
do in terms of school policies does make a difference. For example, what do
you sell for the fundraiser at the school?
There are a number of things. It is not just when parents are first
considering it. There are other supports throughout life that they can
access, particularly as people become more net savvy. There is the downside
because there is a lot of junk on the net, but there is also a lot of good
information; people need to understand where to find the good and valid
Senator Braley: It is the one place where you have their attention
because people want a better way of life for their children. You have their
attention and you can combine a number of those things, so it is sort of a
Mr. Manion: I am glad you are talking about the parenting issue.
That is why it is one of our recommendations in terms of universal
parenting. Sadly, a lot of parents only get parenting classes before they
become a parent. Even then, we can argue whether the right parents are going
for those classes. Where are the incentives to do that?
We also know that the parenting role changes over time. If you treat your
16-year-old like a 4-year-old, you will be in big trouble. Parents are
clamouring for easy answers and guidebooks to how to raise their
increasingly young adults with various issues.
There is also a knowledge base. We know more about parenting than any
other intervention in the world. We have great evidence in terms of what
works; we just do not use it. We do not have incentives to encourage parents
to use the information. We do not have systems that make it accessible to
the general public at all stages of development.
Part of it is finding effective ways of engaging families. The solution
to that is to ask families how to engage families, not to sit back and try
to guess how they want to be engaged. Not every family will be engaged in
the same way because not all families are the same. We need to have a
Then it has to be accessible and meaningful to them in terms of the kinds
of information we are giving them so they can see it has an impact on their
family situation. Then they can feel more competent and attached to their
child, no matter what age they are, and continue their parenting role
without being intrusive either.
Senator Verner: I am still a little stunned to see that, in 2011,
we have to teach parents how to be parents. This is nonsensical to me.
My colleagues' questions are very interesting and so are the answers. I
would like to address a different aspect with respect to the sharing of
information between provinces, the territories and the government in crisis
situations like H1N1 and SARS, which happened in 2003.
The analysts have told me that memoranda of understanding were concluded
between the provinces, the territories and the federal government to make it
easier to share information and to clarify the role and responsibilities of
each level of government in public health emergencies. I am told that, in
December 2010, the committee made recommendations that would make the
sharing of information mandatory and the memoranda of understanding
Does the agency still intend to make this issue a priority? Will steps be
taken in the near future to make information sharing mandatory?
Dr. Butler-Jones: Access to information is very important. Our
agreement with the provinces and territories is in place to receive
information in public health emergencies and crisis situations. Cooperation
is very important and so is respecting the entity that has jurisdiction in
the provinces and territories. That is our arrangement. We have good
cooperation with all the jurisdictions when it comes to access to public
health information. During the pandemic, it was shown that cooperation was
essential, and everyone cooperated.
Senator Verner: I simply wanted to mention a recommendation made
by this committee last December.
Dr. Butler-Jones: We now have a formal approach with a
jurisdiction in Ontario and we are working with the others for a formal
agreement, in addition to a memorandum of understanding.
Senator Champagne: Dr. Butler-Jones, you were such a big part of
that report that we made last fall.
Listening to all of you ladies and gentlemen today, I am alarmed. Dr.
Birtwhistle, you were talking about how physicians of different disciplines
work together; and Dr. Butler-Jones, you mentioned the fact that ministers
of health and ministers of education sometimes do work together. What is
alarming me is the fact that in most of our schools, we will have a nurse
that can look after a scrape or a sprained ankle or wrist, but those who are
supposed to be counsellors are not necessarily psychologists.
Are they really trained to recognize the seriousness of some of the
problems that may arise from abuse, from bullying, from discovering a
different sexual orientation? Maybe having someone trained to recognize the
symptoms of the problems before it is too late would be something very
important that we might recommend to our ministers so that they could get
together and find a solution to that?
Mr. Manion: Currently in the province of Ontario, the ministries
of education, health, child and youth services, and colleges and
universities are looking at joint efforts so that in schools, teachers have
screening tools that they are trained in; but that they are also being
trained at the same time as community partners, who are service providers
and health providers as well. They have a common language and understanding
about how to use the tool.
Then once they identify someone at risk, they realize the limits of their
role, and how they now have to partner with the other person from the
community to hand off for their next part to be done. That person, whether
it is a physician, a psychologist or a social worker, can work effectively
with the family and the school and hand back. The goal is to have people
reintegrated and be functioning within their systems in their communities.
There are good examples where that is currently happening. What we found
in some of the work we are doing across the country is that it is very
scattered. There are some school boards that have nailed this. They know
exactly how to do this; they have wonderful partnerships, sometimes
developed out of need.
Sometimes the poorest of communities have got this right because they
have had no choice but to partner together and do it effectively. It is too
much happenstance. It is not a cohesive approach to things across the
country. You might be in a community where a school has it right or another
community where they completely have it wrong and where the person who has
the most responsibility for identification intervention at that early period
is the least skilled person to do it. Some of the efforts that are required
across the country relate to how we gather the best learnings from those who
are doing it right and how we facilitate uptake and implementation of those
same strategies right across the board with some clear markers for what we
can track as success across the systems — not one system but the "systems"
Senator Champagne: All over Canada we have read and heard about
this young man in the Ottawa area. We are not talking about some place far
away, lost in the great North, where no one could realize in time what this
young plan was going through. It happens in our cities and in our small
municipalities. It happens all over. There must be a way for all those
people to get together and make sure that this does not happen again.
Mr. Manion: That is a good example of how complex the issues are
because I know the situation quite well; I have been involved. I think that
we have read in the media about the role of bullying. There was a piece
related to bullying. We have heard the issue of sexual orientation; there
was a piece of that. What we have heard less, however, is that this young
man was suffering from depression and struggling with depression and was
receiving some support. There are lots of players that could potentially be
involved in this.
We talk about recreation. Sometimes the greatest bullying of individuals
happens in recreation centres. This young man was a figure skater. We have
some people that have experience with hockey players and the mindsets and
the cultures that are developed and how tolerant and accepting we are of
differences. There are a lot of different issues here and there is no simple
answer to it. Some of that education and helping people become more
accepting of differences, to be more aware of different ways of coping; can
happen in schools and in families.
There was another tragic loss in our community where a young woman died
by suicide. Her father was an assistant coach for one of the national hockey
teams. He was quite frank and open about how in his house they talked about
everything. They talked about sex, drugs and school. They never talked about
mental health. They never talked about suicide. There are places beyond
schools where these dialogues can take place. Increasingly, people are
standing up and saying we have to do it better, but it is complex. We have
to appreciate that the solutions will also be just as complex.
Senator Champagne: Let us hope that our people who make decisions
will find a way to get together and help us avoid such sad stories.
Mr. Manion: That is where you have an opportunity to ensure that
we have it incorporated in the accord as a frank target for action and not
just a side conversation.
The Chair: Final comment, Dr. Butler-Jones?
Dr. Butler-Jones: I would like to just say how important this is.
At the one level, there are many solutions and complexities to it. The
reality is that sometimes there will be nothing we can do. Someone may be
standing on the side of the subway tracks, in an adolescent hormonal
whatever, wondering what it would feel like to jump in front of the train.
They can act on it or not act on it. They are much less likely to act on it
if they think, "Well, what would happen in terms of my family and friends
and their view of what I have done? I have something to live for. I want to
be a doctor." If no one cares, they might think, "Why do I bother? Life is
Senator Champagne: Or, "I have inoperable cancer."
Dr. Butler-Jones: Our job is to continue to make the healthiest
and the easier choices, to create environments that are supportive to good
health and good choices, respect that people will make choices different
that ourselves but that we can create environments that will increase the
likelihood that those choices will be positive and that, at the end of the
day, we all benefit from that.
At the same time, sometimes we will do something really stupid and we
will agonize about that. Maybe there was nothing to do about that, but this
is an area where we can significantly reduce the numbers, the impact and the
consequences in a range of areas. That is why I think this panel is focusing
on the upstream, the factors — not just the individual choices but the
context in which those choices are made that will allow for a healthier
society, the end point being a better economy, better management and an
ability to deal with those times when we do get sick in spite of everything
and we need appropriate treatment.
Senator Demers: Thank you for being here this morning. I learned a
heck of a lot more than I did when I first got to this room today.
With regard to Mr. Manion talking about the hockey player who,
unfortunately, lost a child, they were both very good parents, too.
I certainly will never blame teachers because I do not want to lose the
friendship of my good friend Senator Martin, a good teacher. In the past few
months, I have gone to five different schools across Canada talking about
literacy — something that I struggled with when I was younger and,
fortunately, overcame it. How do we start? We have to start from the bottom.
All the questions were great today from both sides. How do we start when,
first, kids go to school without breakfast? How do we start when 57 per cent
— statistics are different everywhere — of parents are divorced, where some
kids do not know where their father is and other kids live with their mother
but she never comes home until two o'clock in the morning? That is not just
1 out of 20; it can be almost 50 per cent in some cases.
When I go into a school, I usually talk to principals and teachers. We
have teachers right now that are getting beaten up after school or during
We then talk about mental health. We do not have enough people like you,
which is the problem, because you are very competent. Where do we start all
When I speak to students, I always try to talk to two kids: one young
girl and one young boy, 14 or 16. I remember a young girl who said, "I have
no hope." It happened to be the case that she was a beautiful young lady. I
said, "What do you mean?" She said, "Coach, I was listening to what you
were saying. I have no hope. I live with my grandmother. My grandmother is X
number of years old. She hardly knows what is going on in the house." For a
14-year-old not to have any hope, where do we start from a mental health
perspective? We talked about smoking in the house; I never smoked. It is a
worse problem than that in our society. I do not know where we start. Your
help, or whatever you might say, would add to what I am trying to learn
Mr. Manion: Senator Demers, you are actually talking about the
determinants of health. You are saying it in a passionate way, but you are
speaking to the determinants of health.
It is sad that this generation of young people will probably have less
earning power than their parents. The sense of hopelessness and commitment
to a future and to a nation is not necessarily there.
You talked about the importance of parenting. We have to be careful, too,
because some single parents are doing a magnificent job in raising their
children — strong, capable and resilient. There are a lot of circumstances
of a lot of intact families that are struggling with their parenting as
well. We have to be careful in how we discuss that.
Clearly, there are areas of support well before young kids ever get to
school in terms of what we are doing in preschool to prepare them. How are
we allowing young kids to experience challenges so they can become more
resilient in the face of those challenges?
We talked about determinants of health and Dr. Butler-Jones talked about
countries that have healthy economies have healthy people in them because
they have a sense of being able to work and a sense of purpose and a sense
of self- esteem that allows them to feel well physically and mentally. That
trickles down to their kids and their families. There are a lot of things
that we can do from an early age, but it goes back it determinants of
When we talk about education, it is not formal education. Sometimes it is
how we interact as human beings and how parents interact with their children
and how that is transmitted to other relationships, including relationships
between students and teachers and respectful relationships between students
One of the best predictors of a healthy mental health outcome is having
one significant person in your life that you feel a secure attachment to. It
does not have to be a parent. It can be a mentor or a coach or a number of
different things but that one single person. Where are we creating those
opportunities for that one person to engage with that young person, whether
they are 2 or 22?
Dr. Butler-Jones: I have two quick stories and then a specific
reply to what you are asking. There are a number of reasons I got into
public health, but here is one example.
A young single mom attempted suicide. I worked with her for six weeks in
the mental ward of the hospital, to the point where she was able to go home.
It was easy to realize why she did it. She was unemployed and had no family
or friends who really cared about her. She was trying to raise these kids;
she was in a terrible situation. She had every right to be depressed. I can
help her to not be suicidal, but she is in an impossible situation. The only
way to address that is by creating environments and by giving her
significant people in her life. All of us have mentors, throughout our life,
who have made that difference.
I worked with a child psychiatrist who was very wise. He said, "It is not
about your parenting style or technique; most of the kids who are truly
loved will turn out okay. It is the kids who are not that you really have to
If I have not mentioned this before, one of the best things we did for
health in Saskatchewan in the 1990s was to provide dental and pharmacy
benefits to low income families. You could come off welfare and not lose
these benefits for your kids. Suddenly, there were thousands of people
working. When we studied them, we found out that they were healthier,
happier, contributing and feeling like they were contributing. The funny
thing is that they were actually making more appropriate use of the system.
This was more than a decade ago. Has any other jurisdiction in Canada done
that? No, in spite of the evidence. This is not a health policy, but a
social policy that contributes directly to health.
Specifically related to your question, Senator Demers, I would say start
somewhere. You are looking at the big picture as a Senate committee. You are
looking at the broad systemic issues. However, at the end of the day, it is
about being practical. Do something. For example recognizing that kids came
to school hungry, parent groups in a small health unit said that they would
bake muffins and do a voluntary program. The health unit came along and said
that they needed three sinks and this and that. The fire marshal said, "You
cannot do this and that," et cetera. We had all of the groups sit down and
ask how this could be made easy, so that when parents and teachers wanted to
do this they did not run out of energy trying to navigate the various
bureaucracies. Again, we create these barriers for good reasons, but they
are totally inappropriate to, and a disincentive to, a community's ability
to organization and address the issue.
I think doing something is important. As levels of government and
professionals, part of our job is to make it easier for people to do the
Senator Eggleton: This has been a terrific panel and meeting.
Dr. Birtwhistle, you have described what your task force on preventive
health care does, how it does it and who is involved with it. Does your task
force have any recommendations with respect to the next health accord and
things that, from your studies, you think should be in it?
The only other general question I have, and it does not have to be
answered at this time, involves best practices, which were mentioned a
couple of times. In particular, Dr. Manion mentioned that some schools have
it right, while some do not. Do you have any information about where we can
find best practices, either domestic or international? That is always good
information for us to have because we can look at those further.
Dr. Birtwhistle: From a task force perspective, I think that we
want to use our resources in the best possible place. If there are
preventive activities going on out there that are not very effective, which
I know there are, we should be labelling that and stopping the behaviour,
and then using that money for many other things, including mental health,
which I think has been highlighted here and is extremely important.
Senator Eggleton: Maybe you could put something in writing to us
because you did say you had some recommendations. It would be good to see
what some of them were.
Dr. Birtwhistle: I will summarize this aspect at the end.
Senator Merchant: I am not sure if there is a quick answer to
this, but I was thinking that the Canada Health Act pertains to services
delivered by physicians and in hospitals. We are now moving to a completely
different model. We are moving the services to these integrated units. Does
that present some difficulty in setting up these units? Do you have trouble
dealing with the provinces or with the federal government about your funding
models? How do you pay for some of these people who are not in those
Dr. Butler-Jones: It is a mix. First, public health is local. It
is essential that you have capacity locally, and then we can complement that
provincially and nationally, do value-added, et cetera.
To come back to Senator Eggleton's question, our key activities include
partly sponsoring this to fill a gap in terms of clinical guidance, and
gathering best practices around the world and what I have in my reports, et
cetera, through the best practices portal and the chronic disease portal on
The provinces have primary responsibility. Public health is kind of
shared. The Canada Health Act and the CHT were originally set up for the
insurance system and have been modified a bit since the 1960s. We also have
transfers to the provinces and to community groups. About one third of our
budget is grants and contributions, for instance. There are different ways
that we do it. Going forward, I think there is an appetite for a different
kind of conversation. Part of what I am hearing — and I will not presume
anyone's view — is that people want a different kind of conversation, not
just to do with fiscal transfers, but with how we collectively can actually
make this system work better. You then decide who and how and everything
else that follows.
Senator Merchant: When people hear that, they start to worry about
user fees. You open a different kind of spectrum there.
The Chair: If you could forbear, I will go to Senator Martin to
get her question on the record.
Senator Martin: As an educator for 21 years in the B.C. school
system, I have seen that there is one school psychologist for the district,
sometimes two, and that it takes a year before a child that I refer is even
tested. That is the reality.
When education and health overlap, like in the school system, and there
is money that gets targeted for action for mental health, or for whatever
other health services, within the school system, how do we ensure that that
money is spent in that way? How is that accountability built in? I agree
that we need to target funds for specific action on mental health and to
ensure that schools have the kinds of health practitioners that can address
the kinds of needs there face to face.
How do we follow that money? Can we ensure that the money that is
targeted is actually spent in that way by the districts? I am not sure how
that works at the provincial level when health and education overlap. What
can be in this accord? Has it been in the accord in the past but not been
fully accountable? I feel that accountability has come up again and again.
How do we follow that money to ensure that the money that is targeted goes
where it needs to go?
The Chair: I will go to Dr. Cohen, and then, if others of you have
input, you can follow up after the meeting.
Senator Martin: They do their best, let me assure you. I have
great respect for them, but a one-year wait, minimum, was the reality.
Ms. Cohen: I think you highlight what is really a critical
problem. It has been identified to us in many ways. One of the promising
things you hear family health teams doing is responding to community needs
and staffing accordingly. If a school is in a community where certain needs
are identified and where there is a certain incidence or prevalence of kids
with learning problems or with other types of behavioural or hearing
problems or whatever it is, that information is used to determine staffing
I think the erosion of other support services is similar to the erosion
of other after-school programming and social supports. We are not listening
to what communities need and providing those services.
The Chair: As all my colleagues have indicated, today has been
another remarkable session in our study. We deeply appreciate the expertise
you represent, the knowledge base and your ability to articulate significant
aspects of the issues that we are dealing with.
It better be obvious to us that we do not live in a perfect world, as a
couple of you alluded to in responding to questions. However, we clearly
need to identify areas where we can actually make success and move forward.
I hope that on reflecting on today you will think about that perhaps in ways
other than you have up to this point. If you could provide us with some
thoughts in those areas of specific examples, it could make a big difference
to help move through a number of these issues, because what we clearly heard
today, and have heard in other sessions, is that our problem is the silo
This occurs in several aspects of the delivery. It is in the different —
if I can use the term — bureaucracies of society that need to work together
to provide a solution. It is not just the school system and it is just not
this or not just that. In many issues we have to have large parts of our
society working together to bring about solution, but within individual
sectors such as health care we are hearing the silo issue a great deal. Yet
we are hearing today and in previous sessions about clear examples of how
groups can work together.
Dr. Birtwhistle outlined a family practice unit with real success and we
have seen a number of these examples in the popular press. What we do not
seem to be seeing is the identification of situations that work in a
particular area and then their promulgation across the system. To use a
simpler example, discovery is of no value to society until it is implemented
and becomes an innovation that is spread across some sector of society.
Is it possible that one of the issues the new accord should deal with is
clearly identifying a way to take innovative practices that develop
somewhere and find a way to apply them more broadly? Then as we dig down
further into the individual areas — in this case I will stick with health
care — I will come back to Dr. Birtwhistle.
In one of your slides you outlined the need for credible appropriate,
easily accessible guidelines that will improve preventive care in Canada. We
have some of those. If we take the anti-smoking campaign, for example, it
has had a profound effect. A number of issues have gone into that, as you
have outlined. We have heard at this table in the study that there are a
number of areas that could have a profound impact on health, such as simply
brushing your teeth, children and dental care, impacts at that level.
We have heard in the case of those with diabetes, which are not an
insignificant portion of the population, the simple situation of clipping
your toenails could avoid a later amputation. We have heard today here, in
terms of health, about the school breakfast issue which a number of us have
heard in other sectors. I mention these things and I am coming back now to
one that crosses into different areas of social responsibility.
I would appeal to you to look at these after you leave here in order to
see if you have some recommendations for us of specific examples that you
think we could reflect on as we make recommendations forward.
The method-of-payment issue comes up kind of carefully in a lot of our
meetings. It seems to me that that may be almost a catalyst in keeping silos
as silos or, to put it differently, could be a powerful catalyst in moving
away from silos if we could find ways of dealing with method of payment. The
example of patients going to their family physician and being limited to one
or two questions that day, that occurs widely and that is a payment issue we
hear. Then there is the issue of how do groups of expertise come together in
a situation like yours, Dr. Birtwhistle. Again, it is sometimes implied that
method of payment is a barrier to developing those kinds of situations.
Finally, we have deliberately attempted to deal with the issue of mental
health in this round, even though specific aspects of health are not our
mandate as such. It is incorporated into the larger issue of preventive
health and the development of health for Canadians.
In winding this up, if you could reflect on the questions that my
colleagues have put to you today in these areas and try to identify the
specific best practices, or even examples that you know have worked in given
areas, to illustrate the kinds of recommendations you have made to us to
move forward in the next accord, it would be extremely helpful to us.
Lastly, I would repeat that we would like you to bring to us, following
this meeting, any issue that occurs to you that on reflection you think we
should be aware of.
With that, I want to thank my colleagues and you very much for a
(The committee adjourned.)