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

Issue 9 - Evidence - December 2, 2011

OTTAWA, Friday, December 2, 2011

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 8:04 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: Good morning everyone. Honourable senators, I call this meeting to order. This is the continuing study to examine progress in implementing the 2004, 10-Year Plan to Strengthen Health Care in Canada. This is our thirteenth and final meeting. It is a round table.

Before I get into some details, perhaps we can all introduce ourselves. I will start with the deputy chair, Senator Eggleton.

Senator Eggleton: Art Eggleton, Toronto.

Dr. John Haggie, President, Canadian Medical Association: John Haggie. I work in Newfoundland.

Kevin McNamara, Deputy Minister, Health & Wellness, Government of Nova Scotia: Kevin McNamara, Nova Scotia.

Senator Cordy: I am Jane Cordy and I am also from Nova Scotia.

Dr. Michael Schull, Senior Scientist, Institute for Clinical Evaluative Sciences: Michael Schull; I am a physician from Toronto.

Steve Morgan, Associate Director, Centre for Health Services and Policy Research, University of British Columbia, as an individual: Steve Morgan; I am an economist with the Centre for Health Services and Policy Research at UBC.

Abby Hoffman, Assistant Deputy Minister, Strategic Policy Branch, Health Canada: Abby Hoffman.

Dr. Gregory Taylor, Director General, Office of the Public Health Practice, Public Health Agency of Canada: Greg Taylor.


Senator Verner: Hello. My name is Josée Verner. I am a senator from Quebec.


Senator Braley: David Braley, Ontario.

Dr. Jack Kitts, Chair, Health Council of Canada: Jack Kitts.

Senator Martin: Yonah Martin, from Vancouver, British Columbia.

Ian Manion, Executive Director, Ontario Centre of Excellence for Child and Youth Mental Health: Ian Manion, from Ottawa. I am also from the National Infant, Child and Youth Mental Health Consortium.

Senator Merchant: Pana Merchant, from Saskatchewan.

Debbie Delancy, Deputy Minister, Health and Social Services, Government of the Northwest Territories: Debbie Delancy.

Nadine Henningsen, Executive Director, Canadian Home Care Association: Nadine Henningsen; I am also President of the Canadian Caregiver Coalition.

Senator Seidman: Judith Seidman, from Montreal, Quebec.

The Chair: I am Kelvin Ogilvie, from Nova Scotia.

I thank all of the witnesses for taking the time to be here with us. All but one of you have been with us before. We welcome Dr. Taylor to his first encounter with our committee. You have all been deliberately invited to participate in what we hope will be a most important final meeting of this committee.

I would like to go over a few ground rules before we start and indicate that this is a blue sky kind of meeting. We have heard from all but one of you before. This is not a meeting where we want to go over the groundwork again and have presentations. For my colleagues, this is not a meeting where we give speeches to introduce questions but rather use our time to help clarify and illustrate points that our witnesses are making.

The approach that we would like to use this morning is the following: We sent to all witnesses a list of the topics that have emerged multiple times throughout the course of our deliberations, and today we would like to go through these in order and invite you to comment with regard to innovative ideas in these areas.

As well, we have acquired a considerable volume of documents. Therefore, the issue of convincing us that certain areas of the accord need to be reviewed along with the many issues around them has already been well achieved. Today we would like to get at innovative ideas around each of the topics that have been put up for discussion.

I am sure, with the people we have assembled here, there will be no problem getting them to ultimately contribute to the discussion. However, to get things off the ground, we have identified certain people to initiate discussion in each area. You have not been alerted in advance, so we truly want to get your thoughts quickly with regard to the given issue.

We have 10 topics. We will end this meeting at 12 noon. That means roughly 20 minutes per topic., We will start with Item No. 1. My colleagues will help in getting you to clarify details that we find uncertain. Otherwise, the meeting will be largely in the hands of our witnesses today to comment on these issues. If an innovative idea is put forward and you have significant points to make around that idea, by all means that is where we want you to come in. We want this to be our witness meeting. We want to get your contribution to the innovative ideas.

This is a complex area. We all know that. In order to make progress, we will have to find those areas where something can actually be done — that is, examples of nuclei of ideas; an activity that can formulate an innovative concept. By "innovative," I mean something that can be broadly applied. An idea is not innovation until it is applied and more generally across the system. "Innovation" is something that is actually implemented across a reasonable part of a system.

I will start with the accountability and reporting mechanisms. I am going to pick on Dr. Kitts to start the discussion.

Dr. Kitts: Thank you very much, I think. It is a good idea not to forewarn us because then we would be really nervous.

To me, it is really the key cog in any system that is going to work. If I think about really successful organizations — and there are pockets of excellence across the country — it starts with really good governance. My question would be: Where is the governance in the health system? Governance provides vision, strategic direction, financial accountability and quality. In my organization the board is responsible for that initiative.

Being in the system as a physician for 15 years — and the last 10 as an administrator — I am not clear where the governance lies. That would be an important thing to establish and define, right from the federal level to the provincial, regional and front line levels. There is different governance there.

Second, then, is what is management and the role and responsibility of the management of the system? In that respect, there is not a good alignment throughout the entire key stakeholders in the system. Management, then, would be clearly defined, they would be aligned with the governance and strategic directions, and the accountability would lie right there at the different levels in the system — that is, accountabilities of governments, boards, management, physicians and so on.

Once you have that, clear action plans that focus on results are the recipe for success. Jumping right to an action plan without understanding the alignment and where we are going, I think, is problematic. I think in many cases we are out there, because the health system is made up of some mostly bright, very innovative individuals who will achieve a goal. That is a good thing. The bad thing is that we are all doing it in a different way, so the variability in the system becomes almost as variable as how many leaders you have.

Once you have that, then the key success factors would be to define the leadership and promote innovation. Because you are aligned, you know what the goal is. Probably the most important factor is to measure performance and then manage it.

The Chair: I will pick on a second person in each case. I will not alert them in advance, either. Kevin McNamara, I would like you to come in on this one. We will then open it up to discussion.

Mr. McNamara: Listening to Dr. Kitts, I agree with his comments. Regarding accountability, I think we have to set appropriate aims for the targets we are looking for based on evidence and measure against them. It is no good to have the wrong thing. For example, we can decide to build a number of widgets but we do not need the widgets. We can be accountable for them, but that does not really improve our health care system. Some the things we did in the last accord did not get us where we needed to go.

We also have to look at accountability as trying to find ways to improve health care for Canadians and becoming more patient focused rather than provider focused. The last accord led us too much on the provider side and the outcomes that we met. Those are a couple of key points that I would like to make.

The Chair: The floor is open.

Mr. Manion: When we talk about accountability, we often talk about wait times, how many people we are seeing and how long they wait to be seen. The problem is that is not necessarily measuring impact. If we are looking more at outcomes —that is, not the work we do but what are we accomplishing with the work that we are doing? We can have many people on the short list seeing the wrong person, which is particularly relevant for mental health and child and youth mental health, in particular.

When we are looking at accountability, we have to set the targets not just based on our productivity, but what we are able to accomplish. When deciding what those outcomes should be, it should be in dialogue with those who receive services — not just the providers that decide what a relevant outcome is, but those who are in need of services across the full continuum of can care that should be involved in that conversation.

We need to remind ourselves that accountability in the hospital is very different than a community-based service provider situation. Finding standards that are equitable across different levels and types of care can be a great challenge. Again, it cannot be a top-down approach; it must be an inclusive approach in terms of identifying those relevant outcomes.

Dr. Haggie: When you talk about accountability, the way it is done at the moment does not work. It may be useful just to reflect on that so that we do not perpetuate the errors that we have done in the past.

You have to be careful, when you make people accountable, that they have some ability to influence what they are accountable for because if they are not and there is no accountability, you are merely a scapegoat. There are times when the practising physician feels like that because you are at the pointy end of the system when it does not deliver for the patient.

In the past, with the previous accord, it was an attempt to hold levels of government accountable to each other, and that did not work at all. The system must be accountable as the insert to the end user, the patient. We need to have a patient-focused system so that the system, the providers, the administrators and government would be accountable for their actions in terms of better health for the population, better health care for the individual and good bang for your buck in terms of the money that gets spent.

I think that would be my take on accountability. You really have to be careful that you do not make people accountable for things they cannot control.

Dr. Schull: With respect to accountability — and I think a linked topic is governance, which Dr. Kitts raised — the question is how to get there. I think we would all agree that the governance is basically ministerial and that it is not being transmitted downward in an effective fashion. How do you get to a system that provides the outcomes, accountability and governance that you want?

If you are looking for innovative ideas, I will suggest one. I think we need to be moving toward a system of greater integration of care, toward integrated health systems so that we are not thinking of hospitals or community providers but a system of care. The only way to get there is to figure out the first steps. An integrated health system must have key attributes. One must be to define "patient population." We have to agree, at a regional or some kind of geographic level, or based on some practised utilization patterns, on a definition of a patient population that is part of a system. That system then must have providers, including hospitals and primary care and community providers, that agree that they are part of that system and that they are responsible for that population of patients — not just the ones who happen to come to their office or their emergency room that day, or even the ones that happen to be on the rosters. We have to think beyond a physician's own roster.

Second, we need information enablers. We need to have information systems that allow a system like that to work so that information can transfer smoothly in real time from one provider to the next. We do not have that yet, but we should. There has been too little progress on health information in Canada in the last decade. That needs to be accelerated.

We need to have clear outcome measures and metrics that relate to the patient-centred outcomes that we have talked about. We need to be able to measure those rapidly and in real time, and we need to be able to align our incentives with those outcomes. Currently, the incentives are not aligned whatsoever in most cases. There are exceptions and they are starting to be layered in, but we need an aggressive push towards incentives that align with the outcomes that we are trying to achieve and that also focus on the shared responsibility for these outcomes across providers. It is not just about what a family doctor does in their office, for example, does he or she order a mammogram. Rather, it is the shared responsibility between a primary care provider, community providers and specialists in the hospital on outcomes for diabetics, admission rates, hemoglobin management, and so on.

We need to start to build in these sorts of systems. I do not think it requires blowing up the current system. I think these are things that could be layered into the current system, but we have to start. We have to look at high performing systems elsewhere. There are examples in the U.S. and Europe that are doing this and doing it in a publicly funded environment and at no higher cost than our system. We need to define in very clear terms what we need to be moving toward or we will not get there.

Mr. Morgan: I have a couple of comments: one that sounds like it is from an economist; the other from a political scientist.

In regard to accountability and measurement, be careful about what we measure. If there are criticisms of what happened in 2004, it is that they set the goal posts once for 10 years and did not actually adjust those posts as things went along. Systems tend to adapt and perform according to what you say you will reward them for. However, the evidence from health system performance measurement suggests that you need to continually adapt your performance measures so that they are consistent with the evolution of the system itself. You need a framework and a system in effect not just setting benchmarks for 10 years but setting a framework for a process of benchmark setting, each of those 10 years.

The second thing I think about when pondering the accountability issue with the Canadian health care system is the double-edged sword that data represent for provinces and health delivery systems. Data regarding health system performance is a mixed blessing for managers and, importantly, for politicians. On one level it helps them manage their system, but on the other it lends to accountability in the context of newspaper reports suggesting, for instance, that one province is outperforming another.

In moving forward with a national framework, we have to be mindful of the fact that the provinces are, in effect, the data holders of a lot of the information today, and they must be brought on board. They have to be compelled to participate in accountability frameworks. That can be achieved by way of legislation or regulation that gives an organization like the health council something like auditors general powers. However, that is probably not sufficient. I think we need to find a system that would get the provinces to buy-in and feel that they are actually winning as part of the system.

In that regard, I would put two carrots on the table. First, I would invest in electronic health records, as Dr. Schull has suggested, and have the federal government put more money — and, I know you have discussed this issue at great length — on the table to help more provinces expedite the delivery or implementation of electronic information strategy in health care in Canada as a mechanism for buying access to the data that is generated through such a system.

The second thing I would do is assist provinces with their own struggles around accountability with the systems within their systems. I think that there would be mechanisms by way of information gathering and analysis that would help a province understand not only the provincial level performance, which I know the federal government is interested in, but also the performance of the systems within their province.

In this regard — and it has been asked before — there is a possibility that Canada might create something along the lines of a health observatory that would have the powers of the Health Council of Canada, but with the data available currently within the Canadian Institutes of Health Information and probably within some of the provincial health services research centres in this country, something where you could network expertise and data together for routine reporting, again with benchmarks that change and adapt over time, not just one of benchmarks for 10 years.

Ms. Henningsen: To build on the idea of the integration and the data, I would like to suggest a very concrete idea. You cannot be accountable if you cannot measure things. That was one of the challenges that we found in home and continuing care with the implementation of the recent 10-Year Plan. What I would like to possibly suggest is a suite of tools currently being used and implemented sporadically across the country called the interRAI assessment tools. I will not go into detail because I am sure you can find it, but interRAI is a beautifully eloquent system because it measures the client assessment and rolls back into a system assessment and then a policy assessment. You collect data at the front line so that you really are patient centred, but that data can roll right back and help you make policy decisions and be accountable.

In home care, we are a linkage. We work with acute care, primary care and long-term care, so we need to communicate to all those different sectors. The interRAI system allows us to have a common language. Although we all refer a service differently, when you use the interRAI you can have comparable data so that you compare a client's outcomes, whether they be in long-term care, acute care, primary care or home care. It is an interesting system, but the challenge is its implementation, the cost and getting provinces up to a point where they can actually get the data and use it. Data and integration is really important, but if we do not have the tools to collect the data, it is really challenged.

Ms. Delancy: It is important that we distinguish between accountability for results and for outcomes. As managers and administrators, we need to track and report on system sustainability. There is then accountability for outcomes.

Picking up on what Dr. Schull has said, we have a group of physicians in the Northwest Territories that is exploring the potential for electronic health records and electronic medical records to be able to track population health outcomes. We are in a unique situation because all our physicians in the jurisdiction are on salary. We will have one EMR for the whole jurisdiction. If you are looking for an example of innovation, there is huge functionality and huge potential in eHealth tools to be able to track health and patient outcomes at several levels. I will reiterate what we have heard from both Dr. Schull and Mr. Morgan, namely, it requires that investment. However, I think the investment will pay off in a number of ways.

The Chair: I will now go to Senator Eggleton and then back to Dr. Kitts to give him an opportunity to wind it up. I keep thinking about all of these things and I want to leave time at the end for people to come back with brilliant insights that have occurred to them over the course of this exchange as we put it together. Of course, I will be ruthless in pulling each of the 10 items to a conclusion.

Senator Eggleton: I appreciate the many ideas that you are putting on the table. I need to understand them, and I think the committee needs to understand them, in the context of how we get there from where we are now and in the further context of the work of this committee. This committee was established to do the statutory review of the 2004 plan. I am far more interested in the 2014 plan. I am far more interested in where we are going to go next. We need concrete ideas. I am afraid we will not be able to do all the things like defining "governance" or "management" in the context of the work of this committee — God knows how that will ever be done, but it is something at the federal- provincial-territorial table. We need some concrete ideas that we could then put in our report that we send to the federal government. Remember that we are reporting to the federal government that will be at the table and to the Minister of Health more specifically.

If you can couch your thoughts in those terms or as close to those terms, so we can pick up on ideas to move them forward, so much the better.

I personally feel, in terms of the 6 per cent that will be put on the table by the federal government for two years anyway, that we should use all of that money to buy a reform of the systems. Thoughts along those lines would also be helpful.

Because you will be wrapping this up soon, this seems to be the only section wherein we can deal with the question of wait times, which was the biggest single item in the 2004 accord. What should this committee be saying to the federal government about wait times? Should we be saying, "You did some good"? It is this whole story about whether the glass is half empty or half full. Then I see reports indicating that when you look at us in an international context, we are not stacking up all that well on wait times.

Do we need to further advance that in the five areas that we identified in the 2004 accord? Do we need additional areas?

Dr. Kitts: I would suggest again that accountability is an often used term in health care. Everyone has a different idea of what it means. For the most part, it is a service agreement, this much money for this much volume. That is not accountability.

I would again say start with the basics, get the governance right, get the management right and understand your roles and responsibilities vis-à-vis the results. Be accountable for the results.

I will go back. It has been said at different times here, but I want to be clear. You cannot have accountability if you cannot measure performance. We have a lot of aggregates and proxies that are a year or two years old for performance of the system. As Dr. Schull said, we need real-time performance that is meaningful to the people on the front line.

I would say put the money into measuring performance, set the targets and then hold people accountable, as long as they have the authority to make the change.

The Chair: Moving to Item 2, Quality of Health Care and Patient Safety, Mr. Manion will start on this item.

Mr. Manion: In child and youth mental health, we have asked young people to help us understand what quality should be. They have been involved in developing the standards for quality of their mental health care, which has been incorporated in accreditation standards, wherein young people themselves have become part of accreditation teams to see whether those standards are being met.

When we talk about the quality of care, we have to talk about the experience of care. The best people to understand the experience of care are those receiving care, whether it is mental health care or physical health care. There is also prevention or promotion in terms of whether we are achieving what we think we are achieving across the full continuum of care.

Ms. Henningsen: We also have to look at not only the experience of the client and the experience of care but at the experience of care across the continuum. We talk about integrated systems, but we measure quality within silos. We need to look at a quality system that breaks down those silos and measures not only the experience of that one moment when I saw my family physician, but the whole experience of me as a patient using the health system. Patients do not see silos; we put them there. Therefore, in order to have a quality system, we need to brainstorm as a country, and certainly as provinces, as to what an integrated quality system would look like. How do we measure quality across an integrated system?

Dr. Schull: To pick up on Ms. Henningsen's point, we are talking about transitions of care. We have a real problem in our system where as soon as you move from one silo to another and then to primary care, such as being referred to a specialist, from a community service trying to get access to primary care or vice versa, in the Emergency Department being sent home or an in-patient being sent home, as soon as you cross the transition, the system begins to fall apart rapidly.

When we are talking about quality of care and patient safety, we tend to focus on measures that are within silos, as has been stated, and we need to focus on measures that actually cross silos. These are not just time-based measures but outcome-based measures that include parts of both silos.

That is a key challenge, and it is something that could be built into a future health accord, which is to say the next phase of measures should focus on transitions of care.

In addition, I do not think any of this will work unless we engage primary care effectively in governance. Currently, primary care in virtually every jurisdiction, except perhaps in the Northwest Territories, is not effectively engaged in governance systems at the local or even the provincial level. It is all based on service contracts, which is not effective.

Until we solve that riddle — and it is very solvable; we just have to take it on — we will not get very far forward. Primary care is too key in this debate.

Dr. Haggie: I would offer another lens you could use as a tool rather than simply just a set of principles. The document you waved with my picture on the front earlier in fact speaks to the Institute for Healthcare Improvement's Triple Aim.

The ultimate goal of health care is a healthier population. Then, with a better patient experience, a better health care experience and better health for the population, tie in the third leg of that stool, which is value for money or value for investment. You can then use those three aims with the little subgroups about patient-centred and quality as being the patient experience, health promotion and wellness and equity as being the health of the population experience. Then, finally, the bang for your buck would be sustainability and accountability. If you actually use those as a barometer against which any recommendation comes out for the next accord or indeed in any silo from policy all the way down to clinical management, you could determine how it stacks up against those six criteria.

Do you get a red light? Do you get a green light? What metrics can you put in there that would show this initiative or innovation is going to fill a need? Is it patient-centred? Is it focused there? Much of the innovation has honestly been based around institutions and structures rather than patients themselves. Rather than using those as abstract principles, you can use them as a litmus test to assess what your next step might be and where it fits.

Mr. McNamara: When looking at quality, the primary care aspect is extremely important. One of the things we need to think about is how to get patient access as quickly as possible, because delay also creates many of the problems we are dealing with.

Even when a patient gets access, because of our current fee schedule, often they come in and we will see one or two complaints when dealing with chronic diseases in many cases, particularly in the elderly. They have to make two or three appointments to get seen, and that takes numerous attempts. Therefore, we really have to change how we are doing. If we are going to deal with quality, we have to change the fee system of how we pay physicians.

We also have to look at the principle of closer to home versus practice makes perfect. There is sometimes a sense that we should do everything in every place and, in fact, when doing so infrequently, we are hurting patients. We have to change that so the skill is used appropriately and be able to explain to citizens why we do things differently, why some people have to go to central areas of expertise and why certain other things can be done in the local community.

The Chair: I will go back to Ms. Henningsen for a final comment, and then I will go to Item 3.

Ms. Henningsen: I will build on Dr. Haggie's comments about the Triple Aim. It is an excellent framework to work within. As a matter of fact, to measure quality, we have actually seen a model at the Fraser Health Authority in B.C. where they have approached the Triple Aim with a particular population group. They use it as a barometer for the services and engagement with primary health care. They have very clear metrics, so I would reinforce the value of looking at that approach to quality and measuring an integrated system. It is really easy, and it is easy for Canadians to understand it as well because it is just three broad strokes, and then it becomes personalized, depending on what patient population you are in.

The Chair: I would like to have time at the end for a free discussion on the thoughts that emerge as we go forward, so I am going to be ruthless on moving us through these items.

We will go to Item 3 now, which is Integration of Health Care Service Delivery. I will have Dr. Schull begin.

Dr. Schull: We have covered this a little already, but I think it is critical. In response to Senator Eggleton's question about what we can recommend, I think the issues around integration can again be focused, at least initially, around transitions of care and looking at how patients move between our systems, get access into the system and then move around within it or move around themselves within it.

The problems of integration currently are manifest across the country, whether it is getting access to primary care in the first instance, when one needs it, which is a first measure, whether it is in the transition to specialty care, from hospital back to home, et cetera. If for the new health accord this committee could recommend to the federal government that it should be focused on transitions of care, you would achieve a number of things. If you are buying change with the 6 per cent theme that I completely agree with, that change could be focused on transitions of care. You will not get there unless you improve governance and accountability at the local level. You will not get there unless you have measures that focus on transitions of care, which are not just about how many hips and knees you are doing this month. It is about actual movement across the system and patient-focused outcomes.

You will not get there unless you build and improve electronic health information systems that work in real time.

In my view, integration can be the theme of the next health accord. It is critical that we do focus on it going forward, not necessarily to the exclusion of other issues, but it is a major driver and enabler and opportunity to leverage all sorts of other change in the system.

Ms. Henningsen: To build on the transitions of care and to go back to the triple aim concept, when you look at transitions of care, you are looking at improving the health of a patient population, enhancing the client experience, and then, ultimately, your goal is to maintain or decrease the cost of the care. It is in the transitions of that you find the cost, and that is where the dissatisfaction with the system is, whether it be from a patient's point of view or from a service provider's point of view.

I do not know if it would be in the recommendations of this committee, but we have seen that a clear philosophy change can be very powerful in making integration happen. We have seen this happen in Ontario, Nova Scotia and B.C., where the philosophy is, in this case, home first. Home is best. We want to provide the best care where the individual lives. That is a philosophy that goes right across the province. Then your governance and management and all your other integration elements happen based on that philosophy. If you do not have that clear philosophy, people forget why they are integrating because integration is hard and continuous. We have to look at transitions of care but also at a real philosophy change.

Mr. Manion: In terms of transitions of care, I agree. I think that is a real opportunity. We cannot forget the transitions across age. Whether it is from pediatric care to adult care, mental health or transition to chronic care, we know that is where a lot of our patients fall off the face of the earth. In elderly care, there has been a shift of who is making decisions about the nature of care. Age has to be a critical factor if that will be of primary focus.

In terms of integration, we have an opportunity to reintegrate the mind and body. If you have within health teams the opportunity for mental health care to be an integral part of physical health care — holistic care — you are already decreasing stigma because it is not a second kind of practitioner. It is not being sent to a different line. It is integrated as part the health care, period. When looking at the models of effective health care teams or family health teams, they have mental health professionals integrated in those teams, and I think that is something that we have not done in the past systematically, but, clearly, there are models that demonstrate this is quite effective, and if we are looking at integration, that should be key.

Senator Eggleton: I was trying to figure out how we can upgrade the mental health component in our recommendations in our report. You have said integration with the primary care system is the thing to do. Is there anything else anyone would add to that?

Dr. Haggie: I was going to start with a slightly different topic, but as we have that thread about mental health and integration, I would speak very strongly in favour of that.

For example, in my institution mental health records are kept completely separate. They are not even electronic. They are paper, and that has led to some real clinical disasters because of the separation of mental health from physical health, which is totally artificial. It stems from the stigmas of the 1940s and 1950s, I think. Just on a very practical level, that is an easy fix or an easy step on the way to fixing it.

There was an allusion to wait times and what to do to fix them. The problem with wait times is they are a symptom of a problem that happens in another silo. All the discretionary beds in my institution, the ones I would use for elective surgery, the ones that my orthopedic colleagues would have access to for the hip and knee replacements, are occupied by people who would be cared for better, cheaper and more happily elsewhere. However, because of the transitions that have been alluded to and because of the problem with not having a system but having many little systems that do not speak to each other, the effort that went into the wait times issue was appropriate, whether you picked the right five areas and whether you ought to use that paradigm and expand it. I personally think you should because it shows if you have timeliness, timelines and measurables, you can make a difference with the money.

If you want to make a real difference, you could clear 25 per cent of your hospital beds by fixing the problems that Ms. Henningsen's groups deal with daily. They simply do not have the infrastructure or the investment to manage the problems they face. It is not blaming them; it is just that is the way it was set up. I cannot do my job because these patients are inappropriately and unfortunately placed.

Mr. Manion: One of the challenges Dr. Haggie was referring to is that in given institutions we do not have the same systems. We also do not have a proper understanding of the other person's role. If we talk about stigma in mental health, probably the ones that propagate the stigma the most are mental health care providers and physical health care providers because they lack understanding and respect for each other's roles. That is definitely an area in which we can have a very marked improvement in the quality of care, through better integration. That is an educational piece, whether in the fundamental training of our professionals across disciplines and across sectors, or how we continuously train our professionals in their professional development over time.

Ms. Delancy: We have heard a lot about transitions of care and integrating mental health expertise into the primary care model. If we are using a true primary care model, we will tackle many of those issues of transitions of care and continuity of care.

However, the point I would make is there are many communities in Canada, including 32 of the 33 in my jurisdiction, where the population is simply not big enough to provide a full complement of primary care. We need to be innovative in terms of how we can provide that continuity of care and how we can give that quality patient outcome. An innovative approach that we are starting to roll out in the Northwest Territories is using the functionality of tele- health to create virtual teams. We are trying to use virtual primary care teams where you might have a psychiatrist or physician in Yellowknife working with a mental health worker and an individual in a small community. Many of these concepts are difficult enough to achieve in a large centre, and then when you add remote isolated communities, they become even more challenging.

Dr. Haggie: I have a practical example of how you can use that. In Northern Labrador, there is a thing called "Rosie the Robot." I do not know if you have heard of it, but it was a partnership with Dr. Jong, the VP of medical services there. It is a very high tech way of doing something very low tech, which is putting a doctor at a patient's bedside, and in partnership with health care, they did this. It is basically a set of wheels can be steered around with a TV camera and screen. Rosie has been in Nain, a community you can only get to by day by aircraft, and if the weather is bad, forget it. She has been in action for 15 months. She has actually saved the life of a guy who was shot in the chest, because it was possible for a physician in Goose Bay to take the team through the procedures necessary to resuscitate this guy, literally, within five minutes of death.

In addition to that, they turned 28 out-of-hours medevacs into scheduled evacuations, or not even needed to be evacuated. These people out of hours would have had to be picked up by a Cormorant, and according to an article I read recently, that is $32,000 an hour in the air.

It is a two-and-a-half-hour round trip, 28 patients who did not need to leave the community in 15 months. Rosie could have two babies for that amount of money. She was $150,000 dollars. That is a very high-tech way of delivering what is essentially a very low-tech concept, which is a doctor at a patient's bedside when needed. I offer that suggestion building on telehealth.

The Chair: That is an excellent intervention. Thank you.

Mr. McNamara: I am thinking about integration. To me, integration is a no-brainer if we are going to have an impact, because we have to get the health promotion. We have to move more things into the community. We have to start doing things at the lower end.

I will give you a quick example from Nova Scotia. Some of our small ERs do not receive patients at night. We move patients to collaborative emergency centres where at night we have a paramedic and a nurse who see the patients. If a patient comes in with the idea that they should see a doctor, they suggest they come see them tomorrow.

Several benefits come from this. First, because the doctor was not there overnight or having to be on call, more physician hours are added during the day. We have now gone to same day, next day access for those patients because of having more physicians seven days a week, 8 a.m. to 8 p.m.

Second, it was not a direction from the government to have those patients referred to the doctor the next day. I have to give the staff of the clinic the credit. If someone did not show up, the staff followed up at home the next day by phone.

These are some of the ways to start changing the model of care to be able to move things. That is an example of how you can be innovative, similar to what is being done in the North. We have to do that to get this access.

Dr. Kitts: I agree with all the others. Integration is a huge key success factor. The way to do it is to take down the silos, not just between the organizations but between the different levels of care. At the Ottawa Hospital we have the problem of ALC — alternate level of care. It dawned on me and the team that the question we in acute care should be asking is: Does this patient need an acute care bed? Unfortunately, the question the team asks is: Can this patient go home? In the acute care sector you have no idea, because you have no idea what is out there. Recently we brought the director of CCAC — Community Care Access Centre — into the hospital, gave him an office and said, "When we decide the patient no longer needs an acute care bed, it is over to you." We cannot spend inordinate amounts of time trying to figure out if it should be long-term care, home care, continuing complex care or all the different levels of care. That is a step in the right direction. It is not easy, but if it is directed properly, the teamwork is really essential for integration.

The Chair: Item 4 is remuneration of health care providers. I will go to Mr. Morgan to start.

Mr. Morgan: This is certainly a topical issue for 2014, in part because the data are now showing that payment for health services — in particular, remuneration of health care providers — is one of the big cost drivers in our system. I believe the provinces might willingly go to a negotiation if they could find their hands bound to the mast, so to speak, on remuneration of health care providers.

There is no question that the fee-for-service system of payment that dominates primary health care in Canada is a model that needs to be changed. Provinces are making progress on changing it in terms of getting doctors on to alternative forms of remuneration. Some data that is emerging suggests that what is happening involves supplementary forms of remuneration, not substitution from fee-for-service to alternative payment, but actually the addition of alternative payment on top of fee for service.

The literature suggests there is no magic bullet; there is no one form of paying a provider that will result in optimum outcomes, but that the best systems are ones where the money follows the patient, and where the incentives are to produce outcomes, not churn volume of services through.

This is an area where the 2014 accord might have impact in trying to get commitments in terms of getting patient-based funding for primary care in the provinces, certain percentages perhaps of the population that are served on a capitation or some model of that sort in their primary health care provision. Again, in terms of the politics for the provinces, this may be helpful to them in a sense, having some binding commitment that they have to go down a certain path because when they negotiate with their individual provincial medical associations, this is a real challenge for them. Having federal guidance might help them in those negotiations.

Dr. Schull: I would agree with Mr. Morgan. In terms of the new health accord and concrete suggestions around incentives, one key problem we face is misalignment of incentives and sometimes complete opposite alignment of incentives. The example Dr. Kitts pointed out of the CCAC coming in to the hospital, that situation would be rendered even more successful if the CCAC's budget depended on getting those patients out of your hospital more rapidly.

Right now we have two completely separate budget envelopes so the incentives are not aligned. The incentives for CCAC are not aligned with those of the acute care sector. I can come up with a thousand examples like that.

We need to do a better job of aligning incentives. I hate to say it again, but it goes back to governance. If you have one body responsible for all those envelopes, suddenly the incentive is there. If we get patients out of the acute care sector more rapidly into CCAC we all save money, as opposed to you saving money costs me money.

Second, if we are going to move away from the fee-for-service system, and I agree that that is essential, we can layer in new incentives as opposed to trying to explode the fee-for-service system, which will not happen overnight. Any new incentives need to be focused not on individual provider activity but around bundling of payments to reflect an entire episode of care. That works very well in elective procedures where you pay a hospital the in-patient costs, the outpatient costs, the rehab costs, all as one payment. For chronic disease you can look at shared outcome models where payments are based on patient level outcomes, and those payments do not go to just one provider. For example, if a diabetic patient has better hemoglobin A1C and there is an agreed-upon population of diabetics that are managed by an agreed-up population of primary care doctors and specialists, those providers together share in the incentives that result from better outcomes for those patients.

Again, you then have an incentive whereby rather than me having to refer a patient to an endocrinologist so that he or she can get paid for their service, I can just pick up the phone and ask, "I have a problem. Should I just adjust the dose of this drug or add that drug?" You are all getting paid. At the end the day, the outcomes are what is being measured and paid for, not the act of seeing the patient.

It goes back to the issue of tele-medicine. There are huge opportunities there. How do you pay for it? We do not have good structures to pay for that, to pay the physicians at the end of the TV screen. It works in some instances and not in others. These are not complicated things to solve, but it requires a willingness and the kind of courage to take these issues on that are sometimes difficult given the vested interests.

Mr. Manion: When we think about remuneration, we think about how we are paying to get people well again, but there have to be incentives for maintaining wellness. Where are we remunerating our professionals to look at the long- term care of an individual to keep them well? They do not have to get into our systems of care that are more expensive, involving more technology-dependent solutions to help issues that upstream we could have prevented in the first place. It is a very big cultural shift, where family physicians are responsible for keeping people well and there are incentives to do so. The amount of effort that is required is less than when they become ill, with all the extra resources required to try to get them well again.

Dr. Haggie: In fact, many of the points that I was going to make have been made. In particular, if you carry the funding issue to its logical conclusion you would be far better off with the small fixes upfront because at the end of the day you are after a healthy population. Health care probably accounts for about 25 per cent of health itself.

The statement that there is not a magic bullet in terms of health care provider compensation is true. It is very easy to demonize one form or another. The way to get around that is to ask, what are the outcomes you want and how do you get those? For chronic care and chronic disease management, fee for service is useless. It does not incent the right thing.

On an elective basis, for hips or knees, where you have standards of quality and competence and this kind of thing, there is a volume that will come from fee for service that you might not get from a different compensation model.

Have a tool kit. Pick the right compensation on the right day for the right provider. That may be an approach to take, depending on the local geography and circumstances.

Telehealth raises some interesting things as well from a regulatory point of view. If you are a physician sitting at the other end of a TV screen that happens to be in a different jurisdiction, where is that physician practising? The colleges have not always been terribly cooperative about answering that question. That comes up with packs and radiology, for example, where you have films taken in one jurisdiction and electronically read in another. That has caused some issues with licensing. The minute you do that, that is kind of a third rail for most physicians. They do not want to go near anything that would upset the licence. There is a bigger halo around that.

Ms. Henningsen: When looking at health care providers, we are getting certainly a feel that care needs to be shifted to the community and be very patient centred. We need to look at a health care provider called a home support worker, and 80 per cent of care in the community is provided by this individual. When we look at human resource strategies and integrated strategy, we always talk about doctors and nurses. With this level of home support worker, we will actually run into a big crisis because we are not recruiting them. They are not choosing health care and certainly not home and community care as a sector they want to work in, and our demand will keep going up. We will run into a big crisis in the next couple of years.

Two other really important, valuable human resources that you need when you talk about patient-centred care are the family and the family caregiver and the volunteer. When we look at any sort of incentives or we look at the health human resource team, we really need to look at a very expanded team as opposed to just looking at those practising professionals and how we compensate them.

Ms. Delancy: I want to pick up on Dr. Haggie and Dr. Schull's point about outcomes. By way of example, when I was in the health system in the Northwest Territories 10 years ago, we worked very hard to move all the physicians to a salaried model. Part of the reason for doing that was we thought we would get better quality care because, with the fee for service model, they were just seeing as many patients in one day as possible. When I came back to that system nine years later, I hear complaints that now that our physicians are salaried, they are not seeing as many patients as they used to. That was the whole point. If you are going to move to a new remuneration model, you need to have outcomes and be tracking them so you can demonstrate there is a linkage of quality of care to improve patient outcomes. I want to echo the point Dr. Haggie raised about the importance of understanding remuneration and tele-health, EMR, EHR environment, because that is a challenge we are facing in remote locations as well.

Dr. Schull: I want to follow up on a point Dr. Haggie raised around fee for service versus other forms of remuneration. This is not an either-or debate. With regard to the example you raised around elective surgery being a particularly good model for fee for service, I would agree that that is true, but I would suggest we bundle that payment to the orthopedic surgeon along the payment to the hospital for the operative care with the payment to the rehab facility for the rehab. Again, you align incentives. There is no reason that you need to move away from fee for service, but you can certainly bundle that with other payments, and it works particularly well for elective procedures.

I also want to come back to the issue of teamwork, which is critical, but I think we should make one thing clear. We have been moving across Canada much more towards team-based care, family health teams in Ontario, multiple models, similarly in Quebec and elsewhere. One of the problems is that people are being brought administratively together in teams and being remunerated, but not necessarily working together as teams. We have heard anecdotally of stories especially on mental health where the physician says, "Ah, there is a mental health problem; go see the mental health worker," and that is going to be in four or five days, but there is not really any teamwork going on there. That I think is a real issue. We need to try to address that.

Let me give you one example of a very interesting team-based model in Toronto. It is called the Impact Plus Clinic. It is bringing together primary care doctors, social workers, CCACs, pharmacists and general internists to not just assess the patient as a team but to do it simultaneously. There is one extended two to three hour evaluation of that patient. One person on the team leads it, but everybody sits in and listens to the patient's issues, and then they jointly come up with a care plan which is then handed back, essentially, to the primary care doctor. It is that notion of doing these things together. The internists I have spoken to in one of these teams says frequently what he does is he basically cancels orders from other specialists that have been involved and says, "No, he does not need a CT. They do not need more of this or more of that, because if you do that, it will interfere with this other disease over here that Specialist A has not thought of." That is the kind of teamwork that we need to be moving towards and we need to be driving for. We need to have accountability around to say it is not enough just to create a team where you have listed 12 people on your team but they happen to work in 12 different buildings across the city and never see each other. Tell us about your real teamwork, and let us incent that kind of real teamwork in a meaningful fashion.

Senator Eggleton: What I am hearing is that a mixed system is probably what will work best here. Does a mixed system automatically mean a lot more money? Is it on top of what is there now, or does it mean a reorganization of how we pay the money?

Mr. Manion: It does not have to be more money, but a means to figure out what kinds of skill sets we need within teams across the country. What is our health human resource plan for the country? We do not have one. We do not know how many we need of any type of profession, whether or not it is community based. We do not know. When we do not know, we invest sometimes in the wrong places, and sometimes our investments are in the high end. Sometimes different skill sets are remunerated at a different level and could have just as good outcomes if you get them at the right time. I would suggest that if we had a comprehensive health human resource plan for the country, we would be in a much better position to figure out, within the envelope we have, how to make a better investment.

Senator Martin: All of these ideas are excellent, and we know that is the direction we have to take. Certain jurisdictions are doing it. There are examples. To ensure that we move towards it, does it have to start earlier with universities and the training? Are these professionals coming out ready to work as a team? We could put the teams together and incent them, but does it have to start earlier? Has that piece been addressed?

Mr. Manion: You are right. We train people in silos, and magically we expect them to work as teams when they come out. As part of the fundamental training, we have to get people to start working together and understand the different roles. There are some good examples of that across the country that we can learn from in terms of scaling things up, but the fundamental role of colleges and universities in terms of training I think it critical.

I was at the University of Western Ontario last week because of a very large legacy gift to the Faculty of Education. They are now going to be training educators in the role of mental health for children and youth, as a fundamental part of their training. It is cheaper to train them there, if they get the right lens. It does mean, though, that you have to change the curriculum, and now they are talking about perhaps it needs two years of training to become an educator, which is a significant increase.

In the long run, it will probably be much more effective with a person understanding their role, working with other professionals so that, when they get into the situation where they are working with people in the community, they know what their role is, what someone else's role is, where to hand off and where to hand back. This has huge implications for promotion and prevention, but across the full continuum of care. There are models we can learn from.

Dr. Kitts: The universities are doing a lot of work on interdisciplinary education, training and teamwork. I think even in the last two years, there is a lot of that really going on. It takes about six months to take that all away, once they get into the hospital where the teamwork does not work.

The Chair: This issue is clearly important. We have heard throughout the course of our hearings that it underlies a great deal of the issues of bringing about innovation.

Item No. 5 is the role of the health care sector in addressing the social determinants of health. You can interpret that backwards and forwards. I will start with Dr. Taylor.

Dr. Taylor: Thank you for the opportunity. It seems to me that addressing this issue depends on what you mean by "addressing." From a public health perspective, the role in the social determinants is trying to mitigate the effects of the social determinants because we do not have the levers to actually address the underlying social determinants. If it is addressing them in the larger perspective in terms of approaching and addressing the causes of the causes, I think we have probably got the wrong players at the table. Most of those are well outside the health care system.

From public health, we have been challenged for many years to influence the policy decisions that are made by other sectors.

We are doing our best, working with folks in sport, education, et cetera, but the actual levers to change those determinants are well outside our system. We have been challenged in the way we can effectively influence the policy decisions that other departments and other sectors are making.

Ms. Delancy: I am not sure I would agree that the wrong folks are at the table. We need to shift the focus, and certainly we have heard that prevention and promotion is critical to bending the curve, to turning the tide of chronic disease and some of the other lifestyle related diseases that we deal with in acute care.

The federal-provincial-territorial ministers of health have made healthy living with healthy choices a priority. Maybe it is time the next accord focused on that as well. Our system is really geared to acute care and funded for acute care. The Canada Health Transfer is focused on an acute care system, but we need to invest at the front end in prevention and promotion.

Coming from a jurisdiction where we have more than 50 per cent of Aboriginal population with poorer population health status and outcomes than the rest of the population, we are very much aware that our acute care dollar does not go as far. Those lifestyle related diseases and those choices translate into bigger acute care costs down the road. That would be something we would strongly recommend be considered as a priority in a new accord.

Mr. Manion: I am a great believer in the importance of mitigating the effects of social determinants of health, but we have to face the fact that we are also facing the tsunami of the elderly. We start talking about promotion, prevention and getting at this very early downstream. We need to talk about children and youth and I do not hear much of that at this table. I do not think many representatives look at those constituents.

I also represent child and youth mental health, where it is even more important in some respects because we know the human and system costs if we do not deal with it early. If we are going to be looking at this, whether it is changing some of the influence in terms of the social determinants of health, whether it is mitigating some of the effects, we have to look at infants, children and youth. We have to look at where our opportunities lie and the other sectors that need to be involved in this. It is not just the health care sector.

We have talked about the role of health care in promoting wellness. It is significant. That will be in partnership with recreation. That will be in partnership with education. That will be in partnership with child welfare and youth justice and all the other sectors. The integration of health care from this lens must be across sectors, with an emphasis on the young.

Ms. Henningsen: From the community point of view, there are two areas in which we see the social determinants of health. Obviously, when you provide health in the community, it is very important that someone has a house, they have a meal, they have transportation and they are not socially isolated. However, it really is, in some of the provincial initiatives, looking at aging at home or aging in place. That aging-at-home mentality or strategy, particularly, for example, in Manitoba, really caused the health people, the policy people and the administrators to look more broadly. They found they could not just provide a nursing visit to someone and expect them to thrive and live independently and safely at home. Those social determinants of health are really wrapped around the aging at home or aging in place philosophy.

Two concrete suggestions to consider in the new health accord are aging at home or aging in place strategies. That would go beyond just fixing and discharging the acute case. One that was disappointing in the last health accord is that First Nations, Inuit and Aboriginal were not even included. That certainly is something that the social determinants of health really impact. From a First Nations and Inuit home and community care point of view, they are struggling with being able to provide appropriate services with their limited budgets.

Senator Art Eggleton (Deputy Chair) in the chair.

Mr. McNamara: In talking about the determinants of health, I will give an example of what is happening in our province. We have a ministerial committee comprised of ministers of health and wellness, community services, including housing, justice, labour and workforce development, and education. We are trying to deal with a number of issues across the continuum from complex cases, which include individuals who are brain injured, and how to deal with that in many of our different institutions. We are dealing with mental health, addiction, children and youth, better health care sooner, housing strategy, transportation, abuse and bullying. We are trying to bring a number of departments together.

As we work together, we are finding we would be able to work and different departments can take different roles in trying to deal with the preventive side, as well as the others, with the determinants of health.

The health accord has become the topic of the day and we have some concerns that it cannot be at the expense of other transfers. If that happens the housing will go, education will go and community services will go. We have to make sure we keep that part in play at the same time. If we do not start breaking down the silos, even within government, we will not achieve anything.

The Deputy Chair: Silos, no doubt, are an additional problem when talking about social determinants.

Mr. Morgan: I wanted to tie this one back to a couple of the other items on our agenda, including the remuneration and accountability frameworks. This is an area where there are some demonstrated benefits of bundling payments, particularly around primary health care for team-based care and for services that go beyond health care but include a variety of social services.

I would look, for instance, to some of the examples of CLSCs in Quebec, where health and social services are reasonably well-integrated. Admittedly, that model is marginalized within Quebec because of the dominance of fee-for- service primary health care provision; nevertheless, the provinces and the federal government could possibly come together in agreement around moving some percentage of the populations in the provinces toward that kind of model of primary health care and that level of breadth of funding.

I have to agree with Minister McNamara around the notion that this cannot be seen as health care dollars doing what social services and housing dollars also need to do. If you are going to expand the scope, you still require those multiple envelopes of funding, and probably in those silos, otherwise the acute care sector of health would suck up what would be valuable and important social service in housing dollars.

Senator Kelvin Kenneth Ogilvie (Chair) in the chair.

Dr. Haggie: The word "mitigation" was used earlier. That has certainly been the physician's traditional role in coping with the social determinants of health.

If you look at a healthy population as your ultimate goal, then really the profession as a group has a role to inform, educate and perhaps even then start to advocate. I do not know that you would necessarily roll that specifically into an accord on health care, but from a social responsibility point of view the medical profession probably has a task to speak up there.

It is probably not a terribly practical thing in terms of writing the next accord, but by raising the profile of social determinants of health as a profession — and this is our goal over the next six or eight months — we have a role to play in bringing it to the fore. It is a huge issue for a lot of people.

Childhood obesity is an epidemic, but is it a health care issue or a societal issue? On my trip to Labrador, everywhere I went further away from the Trans-Labrador Highway the cost of a head of lettuce went up and up and up, and hit seven bucks by the time I reached the coast. However, at each of those stores a can of pop and a bag of chips was exactly the same price as in downtown Toronto. If you are on a fixed income and hungry, where will you go?

Senator Merchant: I come from Saskatchewan and we have a large First Nations population. I know this is a problem across Canada. There is such a dire need in our First Nations communities. I am wondering, looking around the table this morning, if we have someone here who will speak to the very particular attention that we must pay in recommendations that we can perhaps make in dealing with the health of our First Nations.

We know, from all the reports on the mortality rates, the infant mortality rates, the special health rates they have as a group, and we really need to pay some special attention to them. I know we need to deal with every part of our society.

I am happy that Mr. Manion is here to speak on behalf of mental health. I know you are all involved in this, but I am wondering if someone could speak particularly to that issue at some point.

Mr. Manion: I have made a note.

The Chair: I will return to that question at the end. Perhaps you can all give that some thought, and we will have intervention later in that regard.

Let us move to Item 6, Research and Innovation. We have asked you to approach every one of these items from the innovation point of view, but we wanted to put up the topic in its own right. I will ask Dr. Kitts to begin.

Dr. Kitts: I know research and innovation is a key success factor to a better future in health care. It is an incredibly important part of investment in health. It is future-oriented but very important.

There is a lot of innovation happening in pockets across the country. What drives innovation is necessity. The most meaningful innovations are happening at the rock face, right at the front lines, when stressed by shortages of health professionals, money or capacity. There is a huge opportunity for us as a country to tap into that and identify it, evaluate it and communicate it across the country.

I want to issue a word of caution because most innovation is a number of bright, knowledgeable people in the field getting together and agreeing on a good idea. It does not always pan out. If you are going to identify it as a best practice, I think that term is a bit overused.

Currently at the Health Council of Canada, we are working to identify what would be an emerging practice or innovation, a promising practice, a leading practice and where there is scientific evidence based on results, outcomes and costs, a best practice. It is a huge, untapped part of Canadian health care, and there are some pockets of world-class innovations that could be propagated out. We need to be able to identify, support and communicate them.

Dr. Schull: I would agree with Dr. Kitts. I think that as a society, we need to be willing to make greater investments in research and innovation. You have asked us for innovative ideas, and that is great to bring us around the table, but at the end of day, this reflects our opinion, some based on research out there. Ultimately, are we willing as a society to invest in the production of this kind of knowledge?

For example, in the Obama health reform legislation, a centre for innovation has been established in the form of the Centers for Medicare & Medicaid Services. It is well funded. I think one of the mistakes Canada makes again and again is we pay lip service to these issues but underfund small agencies and expect they will somehow produce miracles.

When you look at the quality councils across Canada, for example, and you see the variation in their funding, including the Health Quality Council of Canada, we are not investing in a serious way in the production of innovative knowledge. If we want innovation and research, we will actually have to invest in that. The payoffs are not a one-to- one ratio; not every project results in success.

In addition, the production of new knowledge and innovation in the health care system requires better information systems. We could gain tremendous insight into better ways of delivering care that would be able to measure the triple aim of satisfaction and outcomes in value if we actually had information, if we had data systems that were responsive and shared across the country. We have a tremendous problem of a lack of access to information in this country. We are very secretive, even within jurisdictions, about health data. It is seen as a political risk for this data to be available for research. That is completely crazy. Reports done by ministries of health to evaluate X, Y or Z are treated like government secrets, yet we should be out there learning from each other, but we are not.

Again, when talking about research and innovation, it is occurring at multiple levels. We need to be willing to invest in it. That requires infrastructure, information systems and, frankly, leadership from the federal government on this point. The federal government should seriously be investing in the production of this kind of knowledge and innovation. We need to move away from the pilot project society, where everything is a pilot project that lives for a year or two, produces some nice results and then dies a silent and quick death when the funding runs out. That requires sustained funding.

Senator Martin: Innovation has come up again and again and we know it is important. Did the 2004 accord incent or encourage innovation better than before the accord? If so, how? What needs to be built into the next accord to improve that?

Dr. Schull: It incented innovation in the narrow areas that it targeted. Therefore, we are now delivering hip and knee replacements more rapidly than before, but it is very narrow.

If we identify, for example, integration and transitions of care as kind of the next generation of targets that we need to try to achieve, then that needs to be incented and the innovation will follow in producing a change in that area. The 2004 accord produced some innovation, but it was very narrow.

I want to make another point. This word "innovation" is way overused. We hear it all the time; everything is innovative these days. There are two types of innovation in my mind. One is doing things that are truly new and innovative and that have not been done before. The second thing, which is probably more important for our system, is to adopt ideas that work elsewhere, modify and implement them to suit our system. It does not sound as fantastic or innovative, but at end of the day it will deliver better care, and that is what counts.

The Chair: I want to remind us all that at the outset we said that we consider innovation not the original idea but something that is actually implementable and implemented.

Ms. Hoffman: I wanted to pick up on some of the points that have been made in these last couple of interventions around research and innovation. I will start by noting that in the 2004 accord, three of what we call pan-Canadian health organizations were mentioned: The Canadian Institute for Health Information was referenced apropos of reporting on wait times; Canada Health Infoway was referred to in the context of moving forward and making further progress on development and uptake of electronic health records; and the Health Council of Canada was referenced in the context of reporting on best practices and progress against various of the elements of the accord.

I note those three were referenced because there are, in addition to those organizations, a number of other what we would regard as quite important pan-Canadian health organizations that have roles to play in and around not only the area of knowledge translation, but the development of new knowledge about best practices, appropriate use and so on, which I am not sure have come up in any great detail or depth in the work of the committee so far.

I will refer specifically to ones that are part of the intergovernmental apparatus in health care in Canada. They are principally funded by the federal government, but in some cases they are supported by the provinces and territories, either in their core funding or in the actual activities that they pursue. I am referring to organizations like the Canadian Agency for Drugs and Technologies in Health. I think you have received a written submission from that organization. There is also the Canadian Health Services Research Foundation, the Canadian Patient Safety Institute, the Mental Health Commission of Canada and the Canadian Partnership Against Cancer.

There are many others. These are ones, as I say, that we refer to as this kind of bundle of eight pan-Canadian organizations, but there are many other organizations representing provider communities or regulatory bodies at the national level.

These organizations, with the exception of Infoway and the cancer partnership, have very small budgets, as Dr. Schull mentioned. They range from $25 million per year down to $8 million or $9 million per year. However, they do a lot of work and they produce a lot of information.

With respect to your specific question around knowledge translation, whether and how their findings are disseminated and whether and how they are taken up is an entirely different matter. This is a theme that came up earlier this morning. This issue of aligning incentives to ensure that best practices are adopted is a pretty key issue. I would want to commend to the committee as you think about research and innovation that there is dissemination and knowledge translation but also the issues of what is it about how providers are remunerated, institutions are financed and so on that help ensure that many of these findings are taken up.

If I recall correctly, in the session that the committee held on the National Pharmaceuticals Strategy, it was either Mr. Morgan, or Dr. Bob Peterson who gave the example of work that had been done by the Canadian Agency for Drugs and Technologies in Health related to the use of diabetes test strips, which produced some findings. I will not belabour the example, but they represented that had that practice been adopted within the remuneration systems of public drug plans across the country, there would have been literally hundreds of millions of dollars in savings. However, it is to the point that reinforcement through the remuneration systems, in this case, remuneration through provincial drug plans, has not occurred, and there are all kinds of reasons for that. I want to make that point.

Second, with respect the networking among these organizations, I do not want to say they operate in silos, but they could work better together and they could work better with some of their counterparts across the country, like ICES, Dr. Schull's organization and many others. We have quality councils and health technology assessment capacity distributed broadly across the country, but I think we are in the early days of having these organizations work well together.

Finally, on this topic, often when we talk about innovation, we may tend to focus on shiny new super high-tech technologies. A great deal can be accomplished in the kind of less sexy environment of appropriate use of available technology, just to use that as an example. This may have been referred to in passing in earlier testimony; I am not sure, but I will give the example of what has happened and what has emerged in the aftermath of some of the supply disruptions related to medical isotopes in Canada. When there were problems at the Chalk River reactor with respect to producing medical isotopes, the initial reaction was that it would have catastrophic consequences for care and treatment, particularly around diagnostics and treatments where medical isotopes are used. As time went on and the disruptions in available supply persisted over a period of time, it became clear that both administrators and clinicians found better ways to make use of the available supply and, ultimately, realized that there had been considerable misuse, wastage and unnecessary procedures that had been prescribed, and, in fact, the system could make do with considerably less.

We then decided that in order to follow up on that in a more rigorous way, we provided the Canadian Agency for Drugs and Technologies in Health with some funding over a couple of years to bring together providers and policymakers pertaining to the imaging area to take a look at the appropriate use of medical isotopes in the health care system. Our expectation, based on the work done so far, is that the innovations they will produce will be more guidance about how best to use that scarce and expensive resource. The isotopes are not expensive, but the procedures in which they are used are expensive.

A lot needs to be done, and a number of the other organizations I mentioned are in that world of making sure that the resources that we have are appropriately used. Getting that information out and getting that adopted as practice and policy is where the further innovation is required.

Senator Eggleton: Dr. Schull started off by talking about innovation in two senses. The second sense was the sharing of best practices or innovations that are emerging or promising in one part of the country or the other. I understand that a best practices network was set up but then fell apart.

What can we learn from that in terms of how we move forward on this issue? Why did it fall apart, and what do we need to replace it? I thought that was the idea behind that. No one knows?

Maybe Dr. Kitts knows about this because it was reported by the health council and then subsequently we were told it was dissolved.

Dr. Kitts: Do you mean the health innovation fund?

Senator Eggleton: It was called the "best practices network," I understand.

Dr. Kitts: I am not sure what best practices network was, but this follows on your question to Dr. Schull, Senator Martin.

What Dr. Schull was getting at when he used wait times was if someone sets the targets, what is important for us to look at innovation? That focuses it better than everyone scattered doing everything to meet their own needs at the local level. What are the three most important things we would like to hear from across the country that would improve innovation? Something like where are teams actually functioning and working, maybe impact. There may be others across the province where there are teams, if that becomes an important thread.

I will give a concrete example. Everybody jumps on the need for an innovation fund. There is a lot of innovation happening across the country without any innovation fund, but I believe we need something like a network to bring it together and focus on what is really important.

In Ontario, I belong to a council of academic hospitals, Council of Academic Hospitals of Ontario, and we recently agreed as a group to use innovations in our own organizations to solve problems that we identify as significant problems.

Everyone will then submit what they are doing in terms of trying to solve the problem, like med reconciliation, antibiotic stewardship in the ICU, hygiene — all simple problems we are struggling with. It would be reviewed by a group of vice-presidents of research, knowing it is not a scientific decision but a reasonableness decision; it is an emerging practice, a leading practice. We see who has the leading practice, and then we all sign on to follow along or work together to make sure it happens. In that way, innovation in our 24 organizations does get identified and disseminated, and we have agreed to follow along to bring everyone up.

That could be done at a national level through the provinces, regions and front-line organizations, but you have to identify what you are trying to solve and bring the innovation forward.

Mr. Morgan: I want to make a couple of points on this one. First, in regard to health innovation and health technology innovation, whether medicines or devices, Canada's strategy on that file is important, and there have been a number of criticisms of our heavy reliance on indirect incentives for research and development in this country. With respect to health technology innovation strategy, I think Canada needs to look at international examples and evidence around direct investment in strategic types of technology platforms that Canada would become a global leader in. I think there is consensus across the political spectrum that there is merit in terms of the international record on that kind of investment.

As it relates to health system innovation, which I think is the primary focus here, I would remind this committee and Canadians that although our investment in terms of R & D dollars represents just about 2 per cent or less of the world research and development dollars for health technologies, whatever we spend in this country, 100 per cent of the research is on the Canadian health care system.

There is a concern among researchers on health systems and health policy in Canada that there is a gradual decline in the support for that kind of research in Canada. We have heard about organizations like the Canadian Health Services Research Foundation and others. There is the Canadian Institutes of Health Research. There is evidence, for instance, that the CHSRF is on a spend-down of its endowment. It has a finite life course unless there is a reinjection of funding and maybe a rethinking of its position and mission. In the CIHR, our primary federal source of funding for health research in this country, health systems research does not receive a proportionate representation in the research dollars. There is right now a considerable interest in demonstrating the commercialization value of CIHR expenditure. The message needs to be sent to our federal health minister that as it relates to health systems research, the value proposition is not commercialization, it is the improvement in the health care system in Canada.

We might recommend to CIHR that a certain proportion of its budget be dedicated and protected for research that is about health systems for research on knowledge translation in health systems that will not have that broader commercialization mandate.

Mr. McNamara: I just remind folks that the pharmaceutical companies when they had the patent protection were to put a percentage of their income into R & D. Over the last number of years, that has been reducing every year since that agreement was made. We have to go back to reinforcing the original agreement.

Second, much of the information that people look at on the Internet is incorrect. One way to help Canadians is to look at the Cochrane Reviews, which for about $500,000 a year would give Canadians good information. At the present time only three provinces plus the territories that have purchased licences. This is a credible source that uses all the research, all the good information that comes out, and is a way to get good information not just to individual Canadians but also to clinicians.

The Chair: A number of times interveners have brought us back to what is innovation. People in general have to understand that innovation is not invention.

When I was president of Acadia University, I introduced the President's Award for Innovation. I defined innovation as the successful implementation of new ideas. Now, new ideas — that could be taking an old broom handle and using it in a new way to solve an immediate problem. Innovation is only innovation when an idea is successfully implemented. It is not invention. There could be a discovery that leads to a new innovation, obviously, but it does not become an innovation until it is implemented. A number of you have made very important points here. That is really important for us to keep in mind as we move forward in this area.

Number 7 is the adoption of electronic health records among health care providers. I will start with Ms. Hoffman.

Ms. Hoffman: There have been a number of references this morning to electronic health records. You have heard also in earlier testimony from representatives of Canada Health Infoway.

We know that progress is clearly being made. I think almost everyone, and we would certainly say the same, would make the statement that we need to keep working and accelerate the work on uptake on EMRs and EHRs, as well as other health information technology applications in the system.

When one talks to patients or people who have interactions with the system, often individuals will say, "Yes, it is great. I have been to see my family doctor or to a clinic or a specialist and certain of my records or test results are digitized." Just to hark back to the topic of integration of care and continuity of care that the round table representatives were discussing earlier, the fact of having a digitized record of X-rays, ultrasounds, other test results or a record of prescriptions, but absent ready access to what various providers said or did with a patient at various points along the way when these various results were examined or drugs were prescribed, leaves huge gaps still when it comes to continuity of care.

First, there is much more work to do to realize the dividends and leverage the value associated with EMRs and EHRs. Second, more incentives are needed in the system, some combinations of carrots and sticks to ensure that providers in fact are using EHRs fully. As you know and will have heard from representatives of Canada Health Infoway, the initial target was to have 50 per cent of Canadians in a situation where an electronic health record would be available to them. That does not mean that actually the electronic health record and all that goes along with it is being implemented and progress on that front is being made, but some of us would argue that the imperatives around uptake need to be pursued quite vigorously.

Ms. Delancy: We spoke about this when the territorial DMs appeared before you. The success that we have had using the EHR and EMR in the early stages of rollout has been tremendous. We see potential again with remote, isolated communities to transform how we deliver services.

In terms of EHR, we have initial deployment to the first tranche of clinicians in the NWT. We have had feedback from, for example, dialysis coordinators in remote communities, saying that it has cut down their prep time. We have visiting specialists who say they can provide a better quality of care. We again have a team of physicians working on a concept of a virtual call centre in Yellowknife who are using the functionality of EMRs. They think we can transform how we deliver care by using the EMR to connect with community health nurses in those communities where we do not have physicians, to use the communications capability of the EMR, which can include an e-consult and not only give our residents quicker service and better access to services but also reduce medical travel, as Dr. Haggie noted, with the equipment that is being used in Labrador.

It is a tool that increasingly is becoming absolutely critical in providing residents of Canada who do not live in urban centres with the level of care that other residents have enjoyed.

Dr. Haggie: An electronic health record has been shown in this discussion to be a fundamental building block for a lot of the items that you have had here today. The problem is that the process of implementing EHR has stalled. The early uptake is finished and the long tail of everyone else has not been dragged in with it.

For 63 per cent or thereabouts of Canadians, the technological paradigm for their health record is no different from the paper scrolls and clay jars that Hippocrates and the ancient Egyptians used. It is exactly the same. We have just changed the paper and the ink. The reason is, honestly, that it is not relevant to the bulk of practitioners in the medical field. If you want a quick, potentially fairly straightforward way of getting the EHR taken up, I would suggest, based on what we have heard from our physicians, that you push the idea of electronic prescribing. If you can get a virtual prescription with a record that shows you what was wrong with the patient before, a bit for their current complaint, and a dynamic real-time pharmacy network access, and the elements are all there, you can write a virtual prescription and authenticate it on the spot, and the one record that the patient has is instantly updated, that will make a difference to the point-of-care delivery.

That is the hook. That is the carrot to get an electronic health record in point-of-care providers' offices because, at the moment, changing from paper to electronic is greeted with the same enthusiasm as sticking your finger in a power socket and turning the switch on. No one wants to do it. It is just a huge hill to climb.

There is a good example of best practice out there, and that is the Canadian Forces. You can pull up a soldier's medical record in Kandahar from the time he was in Petawawa or Gagetown or Comox. It is updated real time. If he happens to be in Petawawa in three weeks time, that is all there. It is one record. There is not, "Well, I have a computer with some on." Unlike in my testimony before, the computers down the road bought by another health authority will not speak to each other.

With the data collection, you could have real time, point-of-care data collection. You could have that feed into a regional system where the decision makers there would know how many diabetics had turned up that week and know how many of them have had their HPA1C, or even low tech, how many have seen a foot care specialist at home and had some appropriate foot care as a nice preventive measure, a little fix up. That would feed into a provincial or even a national database, so you would have the public health information there that you need to look at some of the more social elements of the system that we alluded to. That is my little rant.

Dr. Morgan: This is a critical issue, and it ties back to the accountability, our first topic. It ties back to quality. It probably connects all the dots here.

It is important for the federal government to figure out how it buys change and how it can buy particular improvements in electronic health records and the data that are developed through them. One key thing is to ensure that the systems are being developed in a way that allows for secondary use, for health system management, evaluation and ultimately health system innovation. The federal government can use a carrot in this way to make sure that systems at the provincial level are designed with secondary uses in mind and the processes are structured so that data can be accessed both by ministries but also by other organizations for health systems evaluation and research.

I want to tie on to Dr. Haggie's point with respect to electronic prescribing. It is critical both for quality and safety of patient care. That is an important asset also to physicians. They will benefit in their practice.

Second, in terms of expediting uptake of electronic medical records and the population of them, tie remuneration to this. We talked about bundling payments particularly around primary health care or incentive payments for outcomes. The way to get these systems used widely is to say, "No new money without using these systems. If you want these incentives, this extra income, you have to do it through an appropriately populated electronic medical record." The examples internationally are, in effect, remuneration tied to electronic information system use results in rapid uptake.

Mr. Manion: We have to remind ourselves that this is a tool and, to use a tool effectively, we need a good instruction manual. It is not just a question of everyone having a bright, shiny new thing to use, but how are we supposed to use it? What is supposed to go into the health record and what is not supposed to go in the health record? How much is good information? What sensitivity are we showing in terms of what is going into this record? Think about the mental health data that we would be putting into the record and who has access to that and to what end? Who owns the record? Is this something that will be a driver of some of the integration we talked about before so we are not duplicating services? What happens if, in a record, it is clear that an evaluation has been done, but the next person along the chain or in a related sector wants to do their own evaluation because they do not trust the other sector that has done it? Where are the sticks to prevent duplication now that we have one record that allows us to identify when the work has already been done?

In and of itself, it is a potentially fantastic tool. We have heard about where it has been used quite well and where it might provide answers to some to our data questions that we want systemically, but it could also be abused if we do not teach people how to use it effectively.

Dr. Schull: I want to come back to a point that that Mr. Morgan just raised around incentives. This is critical. This does not necessary mean paying people to use an EMR but rather that someone has the incentive and an EMR actually makes their job easier. It is important that when we talk about incentives, we talk about the concept of meaningful use. It should not be good enough just to have a monitor on your desk top with a couple of patient records in it, and then you get the incentive, whatever it is. We need to demonstrate meaningful use. It has been defined in the U.S., and that would be an important role for the federal government to take leadership on: What is meaningful use of electronic records.

The other big issue that I am concerned about is that we end up with systems that really do not talk to each other effectively. There are many isolated EMRs throughout the province, but you cannot actually collect the data in a simple fashion. That is an area where Infoway could play a real leadership role. At the end of the day, we need to ensure that the systems that are being paid for are actually ones that can talk to each other in a simple fashion.

I can give you an example. One of my colleagues is doing research on EMRs. She has gathered electronic records from about 100 different practices but has had to hire people to manually read the free text in the EMR in order to extract information on chronic disease because it is not clear from the EMR who has hypertension or COPD and so on. It is strikes me as completely ridiculous that we need to hire someone to read free text when you have an EMR. What is the advantage of that over pulling a chart?

Finally, I think where we will get a lot of bang for our buck in electronic health records is where we allow for local innovation. Some of the best systems I have seen are ones designed by a couple of guys down the hallway at my hospital because it actually responds directly to the need that I have as a clinician to provide better care. It is probably not going to be a one size fits all solution from on high, so we need to have room for local innovation, but we also need to ensure that those systems at the end of the day talk to each other.

There are models that can go beyond also electronic prescribing. In the U.S., there are things called health information exchanges, which are actually companies or businesses that gather information from practices, including patient data, including prescribing data, including referrals, and they manage that data in real time. It is used as a clinical tool, and it aids in the clinical practice, but it also can be used for secondary purposes, research purposes and so on. It does not need to be a private model, and I am not supporting that and I am not against it either, but the point is that I think we can try to bring together information from disparate sources and put it together in a way that can suit clinical needs in real time and also administrative and performance measurement and quality needs.

Ms. Henningsen: When it comes to EMRs, when it was first rolling out, it targeted acute care, which individuals hopefully just go visit, they get discharged and do not stay very long. We need to look at the Northwest Territories model where an EHR is built around the client who lives in the community. Electronic prescribing is great, but only if it reaches out, and an EHR is for home and community care too. Otherwise, we are just EHRing our old silos. I loved when Ms. Delancy explained how her EHR was working, because sometimes we learn so much from isolated communities, because they just do it. They do it because they have to. They do not build around big hospitals because they do not have them. I would challenge, because I know we worked with Canada Health Infoway to determine is the home and community care sector ready for an EHR? We are ready and waiting. It feels like it is never going to come to us. I think that a big oversight.

Dr. Kitts: This is one where your definition of innovation would go really well, if we were to drill down on this, because there are pockets of superb excellence across the country in terms of electronic health record.

Can I take a second to read a note I got from a surgeon yesterday morning at the hospital? He is one of my crusty surgeons. I will not say they all are, but he is the first one to point out when there is something glaring. He says, "My name is Dr. So-and-so. I have been working as a general surgeon in this hospital for 22 years. I have owned every generation of PC, Palm Pilot, et cetera. In an effort to make patient and practice management more efficient, I have had one of the hospital iPads now for about two weeks. I want to say that this tablet, and especially the clinical mobile software, is the first piece of technology that has had a real impact on patient and practice management from the perspective of a working surgeon. I am especially impressed by the clinical mobile software. It is so practical, no useless layers, and very fast so it can be used at the bedside in clinics. I also love that it syncs with my email and my calendar beautifully, and I browse journal articles during down times. Now, if we could write all our orders and could see real- time patient vital signs, it would be even more perfect."

This is not the leading edge, even in this country.

There are others who are further. There are those who can do the orders. Therefore I would go back to Dr. Haggie and others, when OHIP told physicians that they would no longer get paid unless they did electronic billing, boom.

When the wait time strategy was mandated, electronic wait time information systems were implemented in record time. If someone were to say "if you can do it in parts of the country, you can do it in the rest of the country, find the best practice, hook it up," we could be a heck of a lot more innovative and better off.

Mr. McNamara: I agree with the e-prescribing. I also think we might want to add e-referral, which would also be beneficial. I agree that money drives change if we are going to make it happen.

One of the issues we also have to consider is privacy rules, which are different in each province, This creates problems in trying to look at this. There are federal privacy rules and each province has their own.

One other consideration about patient files is the fact that if I have a lawyer the legal file is mine, but with my physician the file is the physician's and the information is mine. We have to work our way through that as well.

I would really love to be like the Armed Forces because I would have 100 per cent compliance in my province as well. However, the situation now is that we are going that way but we also have the CMA policy, which says physicians have choice. We have reached that block of choice versus the one system that Nova Scotia has tried to implement. I like the idea of mandating, however it is done, to get us all there.

The other suggestion of combining the long-term care community has to be built in if we are going to move this forward. The only way we will break away from the isolation, even for physicians, is to have access to records in order to talk to each other's systems. We can use different systems, but it is the expensive cost of interoperability that creates the havoc. It means we have to take away from other programs.

Senator Champagne: Having electronic health records would be fantastic but, whether the patient's file is on paper or on a computer screen, if the file is not read it does not help a lot.

I will give the example of someone who has been in ICU for six weeks and is finally transferred to an ordinary setting. An hour or so after, a new group of nurses and doctors come into that unit. They have not read the health record. They do not know about the allergies. They may be giving a painkiller to which the patient is really allergic and that will cause the patient to be sent back to ICU.

The discussion earlier was about governance. Someone must ensure that the person who is there in charge has read the file; otherwise, whether it is on a screen or on paper it is not doing anything. I know that for a fact.

The Chair: The point Senator Champagne has made emphasizes points that have been made throughout the morning. The idea to move things forward is only useful if there is some way of ensuring they have been implemented and measured in terms of impact. That is a very precise example of that kind of issue.

I will move to next steps for catastrophic drug coverage and/or pharmaceutical programs.

Mr. Morgan: This issue is an area of considerable interest for me. I will not repeat all of what I said when I came last time, other than to remark that Canada needs to have a conversation about what model of pharmacare meets the needs of Canadians and the health care system.

We have put forward catastrophic coverage partly as an accident of history. It was put together as a model that the provinces should follow. We need to revisit that. Catastrophic coverage has some advantages in terms of the politics of the policy, but it has disadvantages in terms of achieving certain goals with respect to equity, access and, also notably, cost control.

I believe we probably now need to work with the provinces and determine a plan of action around the types of models. There may be multiple because I am not sure there will be a single national model of pharmacare. We need to determine which models will ensure Canadians are covered for medicines in a comprehensive fashion, not just for extraordinary high-cost medicines.

We need to think about a strategy that might evolve incrementally. It may involve the federal government taking responsibility for what is referred to as expensive drugs for rare diseases. When I was speaking a few weeks ago, I mentioned that if the federal government put in some real money, some skin in the game so to speak, the provinces might view the federal government as a more meaningful partner in pharmacare or in drug coverage in Canada. That would go a long way to reconciling some of the jurisdictional tensions around pharmaceutical regulation versus pharmaceutical funding, which is federal versus provincial responsibilities.

If the federal government took responsibility over a file, such as expensive drugs for rare diseases, that would achieve certain outcomes. It could then work with the provinces to ensure meaningful coverage, beginning with the very first prescription. I do not mean last dollar or catastrophic coverage, but something like first dollar or first prescription coverage.

I would refer in part to a recent paper that was published in the New England Journal of Medicine by a Dr. Chaudhary, a Canadian working at Harvard University who ran a well-designed randomized trial in the U.S. on access to free drugs following myocardial infarction amongst a network of insurance companies in the United States. That trial resulted in improved adherence to medicines, better cardiovascular outcomes, and no overall increase to the health system because the improvement in outcomes compensated for giving away the medicines following the cardiovascular events. That is an important lesson.

There is work that my colleague Michael Law and I have done with Abby Hoffman's unit on pharmaceutical policy at Health Canada, demonstrating that Canadians with insurance, one form or another, public or private, are far more likely to fill the prescriptions they are prescribed than Canadians without. My recommendation is to try to find the model that would be sustainable and equitable for all Canadians to access medicines with insurance, starting with their very first prescription each year.

Mr. McNamara: In terms of catastrophic drug coverage, we have to look at what we can do to work together in a national system. One of the difficulties we have, even as provinces, is knowing what drug to fund and when. That becomes a real challenge for us because the pharmaceutical companies spend more money in lobbying than we can in being able to get at the true facts.

One of the things that I would say is Health Canada can help us. They approve the safety of drugs and I am really glad they do. They could also look at the efficacy of some of the drugs, particularly when something new comes on. What is the difference? Does it really make a great impact to a patient or is it minimal? That will help us make the decisions.

I also think we have to watch how we outbid one another, province to province, because a drug company will get a drug into one province and then move it through the system. They also use vulnerable patients to be their spokespeople. When we talk about cost containment I will get into that.

Our province is one that does cover a number of catastrophic drugs and I know it is not national. There are a few provinces that do not. However, I think we owe it to those who particularly need coverage to figure out a system to do it.

Senator Eggleton: I do not know how interested the federal government will be in getting involved in catastrophic drugs because it seems that most of the provinces already have a plan. I am not sure they will want to go to the table at this point in time.

I would hope that they would still pursue purchasing strategies. I would welcome any comments about that because that is a way of helping deal with the pricing, but that discussion might come out under number nine.

One of the pieces of evidence we have before us is a report that was done by Marc André Gagnon at Carleton University. He is an assistant professor there. He did it for the Canadian Centre for Policy Alternatives and the Institut de recherche et d'informations socio-économiques. He says that those entities claim we could actually save money by having a national drug plan. I suppose that is not totally in the government context, but in the population context we could save.

He puts a number of scenarios here; they all say we can save money if we have a national pharmacare plan. Why would not we go for a national pharmacare plan, or do you not think this case is strong enough?

The Chair: I will go back to the list. You can think about that, in this instance, as it relates to catastrophic drug coverage. Perhaps it will come back again under "Pharmaceutical Cost Containment."

Ms. Delancy: I want to support those speakers who have encouraged the federal government to take a role in catastrophic drug coverage and expensive drugs for rare disease. Speaking as someone from a very small jurisdiction with a limited budget, one or two patients who require catastrophic drug coverage can have a huge impact on our budget. The unfortunate fact is, then, that jurisdictions may start to take that into consideration in deciding whether or not to approve certain drugs. There needs to be a level playing field and some assurance to Canadians that these decisions are being made not on quality of care and not on cost basis.

Dr. Haggie: Regarding the lack of a national approach to catastrophic drug coverage, the principles that we espoused at beginning were better health, better health care and better value for money. One of the principles under the "better patient experience" side of it is the issue of equity. If you look at the cost to individuals in different provinces, where you have roughly comparable median incomes for example, the amount of out-of-pocket expenditure varies from one side of the country to the other. Covering catastrophic in one province, you might pay $1,500 of the family income; in Newfoundland you are up to $5,000. Really and honestly, that does not speak to the principles that we would like to see.

Under cost containment strategies, you can talk about the issue of a national pharmacare plan. One of the optimistic lights on the 2004 accord was a national pharmaceutical strategy. That may have addressed a lot of this, but, within two years of the accord being signed, it kind of died the death and no one has heard of it since. I would encourage people to look at that again and also to use those principles to see what recommendations they may want to put in place to replace it or augment it and see if they match up with those principles.

The Chair: I will go to Mr. Morgan next on this and I was going to go to him again on number nine, "Pharmaceutical Cost Containment."

I think, Mr. Morgan, I will get you to make whatever comment about catastrophic drugs you wanted to make and then we will move to item number nine. Some of the things are starting to overlap here, and I think it might be efficient to move to number nine after you have had your comment on catastrophic dugs. When you signal that is over, then go right into your next comment.

Mr. Morgan: I will repeat, for the benefit of some people here, my diagnosis of the failure of the national pharmaceutical strategy. It was partly a result of provincial expectations that the federal government was going to put in the multiples of billions of dollars per year on the table for partnership on catastrophic coverage. However, when it became clear, over the subsequent months/years after the NPS was launched, that, in fact, the federal government had not promised that that was going to happen, the provinces, I think, backed off.

One of my representations thinking about 2014 and beyond is that if the federal government is not in a position to take over a specific component of pharmacare or put billions per year on the table, they should signal clearly, take that off the table and work on the other issues related to pharmaceutical strategy that are still critically important.

I want to remark on the out-of-pocket costs in catastrophic coverage. A study that Jamie Daw and I did from our centre at UBC recently assessed the progress of these programs in Canada over the last 10 years and the variety of out- of-pocket expenses by Canadians in different provinces. Even within this single model, there a significant amount of disparity across provinces.

I want to highlight another finding from an earlier study that I had done with Gillian Hanley, also at UBC, to evaluate the catastrophic UBC's program, which is an income-based program. We followed patients in B.C. for a four- year period to look at out who were high users of medicines and what their trajectory of expenditures on prescription drugs looked like over time. We found that approximately 5 per cent of the population account for about 50 per cent of drug expenditures in B.C. That is probably true in other provinces as well.

When thinking about the equity of these catastrophic drug benefits programs, it is important to note that patients who face the highest drug costs face those costs year after year after year, quite often until they die. As a consequence, that means that those patients faced those very high deductibles every single year that they were dealing with whatever serious, chronic illness they were facing that required those expensive medicines. In thinking about equity around catastrophic drug benefits, we have to think not just as though this was insurance against the house burning down. Usually, a house only burns down once. In health care, for people with chronic needs, the house burns down year after year. That will be my end of those comments on catastrophic coverage.

To shift over to pharmaceutical cost containment strategies, I think that the provinces and the federal government, working together on things like the common drug review, has been a benefit to Canadians in all provinces. I know that there has been a lot of debate and controversy at times over the impact of the common drug review, its timeliness and, in particular, the timeliness of decisions that follow a recommendation from that body. I think that levelling the evidence made in a critically appraised, transparent and rigorous fashion in Canada is actually helpful to all of the provinces in managing their own listing decisions.

That said, as mentioned in the national pharmaceutical strategy in 2004, there may be benefits from joint purchasing strategies. This is politically challenging because it would require each province participating in a joint purchasing initiative with other provinces. In effect, the province seeds its autonomy over the decisions of what to purchase or what not to some joint decision making process. That is a challenge, but I do believe that times will come to the point where Canadians would recognize that their province making such a decision might be to their benefit.

I will now focus on a couple of strategies in particular. I think there is value in considering purchasing strategies around generic drugs for primary health care conditions, the garden variety cardiovascular diseases, mental health, gastrointestinal diseases — things that are relatively routine and things that large numbers of Canadians purchase. Most of those blockbuster drugs from primary health care categories that were developed in the 1980s and 1990s have come off patent or are soon to come off patent. We have research from British Columbia that indicates that a purchasing strategy that did buy medicines in bulk, generic medicines in particular, could cost governments no more than they are already paying, for instance, on hypertension medicines. However, being able to purchase in bulk for the entire country, or any given province or set of provinces that wished to do that together, requires running tendering processes. You take bids for contracts to supply a province or provinces for those drugs. Tendering processes have come under some criticism in recent months, but it is still worthwhile to look into.

Canada needs to be looking down the path a little bit toward the expiry of patents on many of the new and the early biological drugs that have come to market, some of which have done so at extremely high cost. Those drugs will lose patent protection; some already have. We probably need a national strategy on bio-similar products. It would be important for Canada, Health Canada and the provinces to have conversations around how we can effect reasonable and rapid competition in this segment of newly competitive biologic products. Bio-similars is, in effect, a similar version to a biological product.

I also think that, given that the pharmaceutical research and development pipeline is stacked right now with cancer drugs in a way that is unprecedented in the history of pharmaceutical innovation at least over the last 60 to 70 years, approximately 30 per cent of drugs in the R & D pipeline are for cancer.

Many of the drugs that have come to market in recent years have been oncology drugs. They have come at extraordinarily high costs and sometimes with less than optimal amount of evidence about the value for money that they pose, both for patients and, importantly, for health systems as well.

I believe that we might consider a pan-Canadian strategy on cancer care and cancer drug purchasing. The Canadian provinces run some excellent cancer agencies, and I know that they communicate and coordinate. I think that some of their information sharing might be ramped up into a more meaningful cooperation and collaboration.

Dr. Taylor: I want to give a good example. During the pandemic we negotiated on behalf of the provinces and did bulk purchasing not only for the vaccine but for antivirals as well. There were substantial savings. In my understanding, we were amongst the lowest in the world in the cost of the vaccine because we did bulk purchasing for the country.

Obviously, the negotiations were not difficult because people saw the value-added, but we had to ensure everybody was at the table and agreed. It could still be done under the current auspices of the accord with no changes whatsoever.

Mr. Manion: I wanted to speak more specifically about the use of psychotropic drugs, which are increasing dramatically and may actually be a symptom of a dysfunctional mental health care system, where we are not looking at the full array of tools that we have. A primary care physician who does not necessarily have the skills, tools or training to deal with the early stages of a mental health concern will over-rely on the use of psychotropic drugs as opposed to some of the things we know might be available.

I think there is a role federally to have a conversation with insurers who will insure the use of psychotropic drugs without end but will have very limited support for the use of psychotherapies, where there is a strong evidence base when referring to the long-term benefits of different kinds of care.

If you look at children and youth, for example, I think it is no more apparent that we are talking about mental health concerns, where we now have teachers prescribing through family physicians by pressuring parents on the use of Ritalin for ADHD in the absence of other more appropriate methods for dealing with mental health concerns in schools. If you look at the data about use of psychotropic drugs and at insurance data from employers, for example, it is going through the roof. I do not think we have any clear leadership being shown federally on supporting alternatives to an overreliance on psychotropic drugs.

Mr. McNamara: I have a number of points that may be in random order.

There are deals being made currently with provinces and pharmaceutical companies with certain drugs. There is a privacy agreement, and the inference is each province gets the best deal. I suspect, as Gordie Howe found out in his contract, he was one of the lower paid and not the highest.

The practice in the U.S., and I am sure it takes place in Canada, is "pay-for-delay," where the large pharmaceutical companies are paying the generic companies to delay bringing new generics to the market and then splitting the difference. That is an issue I think we must address.

The funding of health advocacy groups by pharmaceuticals is costing us a lot of money, as I mentioned, even using vulnerable individuals as the public face in order to get the drug they want approved in each province. This happens on a regular basis.

At the present time, when a drug is coming out, the company has to bring it to Health Canada for safety testing. My understanding is no one else can bring that drug forward. I use as examples Lucentis and Avastin. Lucentis is a very expensive drug. Avastin is in the same family but is much cheaper. It could be used for wet macular disease just as effectively in most cases, but we are using it as an off-label, as has B.C. As I understand it, a province cannot bring a drug forward to Health Canada and ask, "Is this a safe drug that can be used by everyone?"

Ms. Hoffman mentioned test strips. We were one of the provinces that tried to go the route of changing test strips based on the information that was provided. We were inundated by the companies, individuals and the Canadian Diabetes Association, who is funded by the drug companies, and it became such a hot potato, the government backed off. This is one of those things we have to figure out, maybe even ensure that if a lobby group or health charity is funded heavily by a pharmaceutical company, that that information on their website so we all know up front there is funding going into that. That is something to think about.

In terms of provincial negotiations, we are trying to do that. Currently, with respect to one drug, the Province of B.C. is leading the negotiations for all provinces. The company broke off negotiations just prior to the Ministers of Health meeting and tried to get to individual provinces by using the back door approach. The Ministers of Health said, "No, we are sticking together and we will go through that process." It will be interesting to see what the outcome is in terms of trying to look at bulk purchasing.

As was mentioned by Dr. Taylor, the process that was used in terms of pandemic was very successful. One thing we did miss with respect to that, which was not his fault, is the drug company sold the same drug to pediatric hospitals and told them they needed it but at the much higher company price, not the government price. We are going back to that issue.

Another thing we have to be aware of is that the bio-logics are coming along, and they will be more expensive for all of us as boutique drugs.

Finally, we have to spend more time on the appropriate use of drugs. There is a lot of poor utilization. Something that happens with many of our seniors, for example, is they get a prescription, go to the drug store and the pharmacist takes a lot of time telling them about all the different contraventions. When they go home, they are afraid to use it. We have to do a better job of explaining the benefits versus the contraventions.

Dr. Schull: I will pick up on a couple of comments, the first by Mr. Morgan regarding the 5 per cent of patients responsible for 50 per cent of costs for pharmaceuticals. The same is true for total health care costs; about 5 per cent of patients equal more than 50 percent, I think it is 80 per cent of total health care costs.

Therefore, when we talk about cost containment of pharmaceuticals, we need to be careful not to silo these issues. They are all interlinked. If a patient is spending a lot on medication, chances are they are costing the system a lot in terms of hospitalization and ER and family physician utilization.

The point is that we are talking about 5 per cent of patients; should we not be designing a system that focuses more heavily on that 5 per cent? It is a small number in our system, and if we can assure we are providing better and more integrated care for that 5 per cent, we can get at the issue of appropriateness. Are these patients on too many drugs? The wrong ones? Is a combination of drugs leading to inappropriate admissions to hospital? Perhaps they are not on the right drug, which again leads to re-hospitalization and potentially death.

This is an issue that is linked with where we started, which is integration of care and thinking in a holistic fashion about the patient's experience in our health care system. I think we again need to think about how our care system and incentives are aligned because that will address cost containment of pharmaceuticals as well as better health care overall.

Dr. Haggie: I am coming around in a circle with what Dr. Schull said. We at CMA produced an optimal prescribing initiative a few years ago with the hope that we would have electronic prescribing to support this.

However, the idea of an electronic prescribing module with decision support at the point of care is crucial to this. The average physician has no clue about the cost of the drug they are prescribing. The only information they get, if they ask, comes through the drug company.

One of the other issues was where physicians would get information on new drugs and best practices. The bulk of new non-cancer drugs that come out are actually "me-too's." In other words, they are twists on an old drug already out there, yet there is a significant incremental price to be paid for it. If you put real-time decision support in front of the physician writing the prescription, that would be a factor. No physician wants to unnecessarily spend money.

The facts of the case are that drug interactions are a significant issue. Again, with a real-time record, there is some evidence that 15 per cent of hospital admissions are attributable to drug-drug interactions. If you could cut those down by a single real-time record with a prescribing module, that is $1,200 per patient per day and 15 per cent of hospital admissions across the country. It would have an immediate effect.

The Chair: I am going to move on to Item 10, but before I do, ADHD came up. I can tell you that I am awfully thankful that Ritalin was not around when I was a kid. I cannot help but think that this has more to do with the effort to stifle any kind of energy expression in the school system than it does with any basic health need. That is just a personal observation.

We will move now into the role of the private sector in health care. Mr. Morgan will start this off.

Mr. Morgan: I teach health policy at UBC, and this is often one of the most interesting segments of the course. Most Canadians are under the false impression that there is not a significant role for the private sector in Canadian health care, but, in fact, virtually all Canadian health care is provided by the private sector. It is important to remind ourselves and to remind Canadians that our hospitals, for the most part, are private organizations that have contracts and financial relationships with governments, but they are run independently. Medical offices of physicians across the country are independent businesses that are, in effect, in the private not-for-profit sector. Virtually every prescription drug we consume as Canadians and every piece of medical equipment we use is provided by a for-profit private sector entity.

There is a critically important role of the private sector in providing health care in Canada, unquestionably.

The great debate and the one that divides us in policy debates in this country is the question of the role of private financing of that care, and there are fault lines in the Canadian health care system defined by the Canada Health Act, where, if it is medically necessary physician services or medically necessary hospital care, in effect, legislation says there shall be no role for private financing. Private delivery will be fine, but private financing would not be.

In the rest of the health care system, we have a considerable amount of private financing, whether for prescription drugs, home care or complementary services provided by a range of health care providers.

It is important to recognize that trying to open up the system to private financing for hospital or physician services is not likely to solve critical problems that we have been discussing today. It will not likely solve issues around wait times and access, and it certainly will not promote equity, in part, because, as a physician once told me, a dollar has never treated a patient. Bringing new money into the system does not necessarily bring new health care providers into the system, so the same providers need to allocate their time and energies perhaps in different ways when new forms of financing come in.

I would caution against bringing new private financing for services that are currently protected from private financing in Canada, that is, the services under the Canada Health Act. As we have just discussed, as it relates to things such as home care, or pharmacare, there is merit in considering an increased role of public financing because of the benefits of the purchasing power that comes with it.

I would be on the record here and in every course that I teach that there certainly is nothing wrong with private delivery of health care. In fact, a vast majority of care in Canada is privately delivered.

Dr. Schull: I am not sure I have much to add to what Mr. Morgan said. I agree completely. In fact, when looking at the per cent of total health expenditures in Canada that are private versus public and compare that internationally, we are right where everyone else is, except, perhaps, the U.S. and Switzerland, who are outliers.

I think that there may be value and opportunity for looking at new ways of delivering services, such as the health information exchanges that I mentioned earlier, and ways of organizing health information to provide, perhaps, a more responsive system for clinicians and administrators. There may be a role for private companies to get engaged in that work. I do not see a problem with that. I think the key principle is that for what we consider to be the core essential services, they should be free at the point of care, and we need to look at redefining those core services if we enter into that debate. However, I would agree that the role of the private system is already large in Canada, and there may be more opportunities.


Senator Verner: As a senator from Quebec, I feel I must intervene. I hear your positions on the role of the private sector in health care. As you know, the Quebec government, while complying with the Canada Health Act, has negotiated contracts with certain specialized private clinics for certain surgeries that had an overly long wait time in the public sector.

In your opinion, do contracts such as these lead to greater efficiencies?

Also, are their any figures indicating that because certain patients were treated in a public-private mix, there has been a positive impact on wait times in public clinics?

Dr. Schull: I do not know if there are figures available to show whether there has been an impact as a result of more procedures being carried out in the private sector.

But I would like to come back to a comment made by Mr. Morgan to the effect that the number of orthopedic surgeons in Quebec has not changed. The contract has not meant that there are more surgeons than there were before. If a surgeon is operating in the private sector, it means he is not operating in the public sector. Conceptually, I do not see how that could help the public system. Also, it is not enough to consider wait times alone. Consider also that because the remuneration for these surgeons is probably better in the private sector, might not they be inclined to quit or curtail their public sector activities? I have worded this comment as a question, because not knowing whether figures are available in this regard I do not think I can answer your question.


Dr. Kitts: It comes back to what you are trying to achieve by introducing more private sector involvement in the health system. I would argue that if you step back to the first conversation, does introducing the private sector to reduce wait times, if that is what it does, allow us to obviate the need for better governance, better management, more accountability and focusing on results? I guess I would have to understand how introducing the private sector would introduce better governance, better management and more value for money in the public sector. I do not know see how that connects. I would start with that and see if we need more help from the private sector.


Mr. Manion: At this time, we know the opposite situation exists. If, for example, the specialized systems cannot meet the population's mental health needs, we have seen that they move on, or some patients in that community move on, to private practices. Other countries have noted the lack of experience in our specialized centres for things like cognitive behavioural therapy, and they have trained a good number of public practitioners to better meet this need so as to have greater control over the product.

Are they now dispensing treatment based on what the studies say and on substantive data? That could be something that points to a shortcoming where we can have a provincial or national community response bringing its influence to bear on training, as well as a cover-up of practices that are based on substantive data.


Mr. Morgan: It is an excellent question, and I think that the answers we have heard so far to the question illuminate one of the fundamental problems with experiments, if you will, with private sector operating facilities and surgical facilities in Canada, and that is the lack of data about both the experiences of provinces that have purchased services from them, and, importantly, about the services provided by the centres when they are paid for privately.

These centres exist and they do charge for services that they would argue are outside the auspices or the mandate of the Canada Health Act. When they engage in those practices, we do not see the data. Unfortunately, the public system occasionally sees the patients when things go wrong, and there is a problem with this in terms of the possibility for cream skimming and then offloading the unfortunate consequences of medical events gone wrong.

This is the big question. I appreciate Dr. Kitts' intervention on whether this is the right form of governance, having these parallel systems, particularly when there is a lack of information. I would certainly argue that we need better data and better information. To ask that fundamental question, if you were to design this system de novo, would you have this level of redundancy on purpose or would you just involve these people more meaningfully in the public system, in our public hospitals, the infrastructure for which exists? Again, these same personnel work in both of those arenas.

Ms. Henningsen: Coming from home and community care where we are not under the Canada Health Act, we think about this issue often. We deal a lot with the role of the private sector in delivery. It is quite an eclectic mix. Depending on the province, you can have public delivery or a mix of public-private. When you look at private, you can have profit and not-for-profit. Interestingly enough, as it has evolved over the years, this mix has worked quite well, coming up from the grassroots, as long as all providers are held to accountability, a cost standard and a quality standard. What happens is that their tax status, whether they are private or public or charitable, becomes null and void, as long as you hold companies to a certain quality standard.

Around financing, we have given this a lot of thought, once again because we are not under the Canada Health Act. We consider two things. Home and community care can be a very broad range of services. We do agonize with provinces on what you should and should not cover because it could be a very long laundry list.

We have been kicking around or investigating some different ideas on where the federal government could come in in two areas. One is a registered chronic care savings plan or some sort of plan that encourages Canadians to save for their long-term care, but goes beyond the Tax Free Savings Plan, because I may be using that to go on Hawaii. A registered chronic care savings plan would build awareness with the average Canadian that as you get old you will get frail and you may require additional supports and long-term care. It builds awareness. That is an idea we have been thinking about.

Another one, which is interesting because you do not think about it when you think of financing, is the role of family caregiver. The role of the family caregiver, as soon as you take care outside a hospital, is absolutely critical. What sort of financing or mechanisms could we look at to support this role? Whether they be refundable tax credits to help offset additional financial burden or whether it be provision of respite, when we look at financing a system outside the hospital we need to look at people's real lives, and their real lives involve their family caregivers.

Dr. Taylor: From a slightly different perspective, if we are talking health as opposed to disease and specifically promotion and prevention, the private sector has a critical role, be it through workplace wellness, building constructions, the built environment, pollution — grocery store design was alluded to earlier — the pricing structure of our foods and even things like the salt content of the food.

We must work with the private sector, in a variety of ways. It can be through influencing — there is much debate around the salt content of food now — versus regulation, et cetera. From a promotion and prevention perspective, it is a critical role for our health.

Mr. Manion: Dr. Taylor took the comment I was going to make about looking at it from a different lens, in terms of employers promoting health and wellness, especially mental health and wellness. If you look specifically at the role of the federal government as one the largest employers in the country, there is a role model role to be played here in terms of whether the federal government is an employer of choice when it comes to health promotion, mental health promotion and family mental health promotion in the workplace.

Senator Merchant: It is an interesting dichotomy when we talk about private health care. It is not politically saleable sometimes, but is it not a fact that sometimes provinces are the biggest purchasers of private health care? As an example, when provinces want to get people off Workers' Compensation, sometimes they see to it that these people get in and get whatever needs to be done through a private purchase. How common is that? Maybe people do not realize there exists this layering, depending on where your pocketbook lies.

Mr. McNamara: WCB is perceived by most provinces as not being part of the health care system. It is seen as an insurance company. It works similar to other insurance companies. They do purchase services, some within hospitals and some in the private sector, but we do work with them. For example, in Nova Scotia we have a number of larger regional hospitals that on Saturdays do orthopedic surgery for WCB, and WCB pays for it as a private clinic. There are opportunities for that.

It is also fair to say that we do purchase from private companies long-term care. There are also things that we fund outside the Canada Health Act that we pay for through home care.

Obviously, our biggest client is doctors, who are individual businesses. One thing they often joke about is that doctors are the only profession where you can graduate from university, set up a practice, see as many patients as you want and as often as you want, and send the bill to someone else. It is not quite that simple, but that does happen in many cases.

Yes, we do spend a lot of money with the private sector, but from Nova Scotia's point of view we believe in the principal tenet that it should remain out of private hands and providing the major services of health care.

The Chair: Thank you all very much for this phase of our discussions today. I would like to breakdown the rest of our time into three sections. For the first one, I would like to put out two items, one that is the Aboriginal health issue that Senator Merchant raised earlier. The second is that there should be 10 separate accords because that way the federal government could perhaps find ways of incenting innovation and development by having the provinces essentially compete with one another. We will take a few minutes on each of those two subjects.

In the second phase I want to reward my colleagues, who have been remarkably patient and cooperative today, and I would like to go around the table and give them each a chance to raise the one item they think still remains to them, something they would really like to get a reaction to. We will not be debating. We will ask the question, it will be answered and we will move on.

Finally, I would like to go around to our panellists again to give them an opportunity for another single intervention. Should there be any time remaining, and something has emerged, we will get at that.

Who has thought about Aboriginal health?

Ms. Henningsen: We have had the opportunity to work with the First Nations and Inuit and Health Canada and the communities to develop two different reports on home and community care promising practices and Aboriginal health. Recently we released a report on promising practices in mental health in First Nations communities.

It is really interesting what you can learn. It is like what our colleague from the Northwest Territories said, when you have to do it what can happen. Out of all those promising practices, we saw some leading practices in governance that we talked about this morning, some leading practices in leadership and integration, and a real client-centred approach. It is the approach that happens in all communities no matter what province or territory they are in.

We can learn a lot from what is happening in the First Nations and Inuit communities. From a home and community care point of view, it is really quite challenging because the actual funding for home and community care services limits the range so badly. The funding has not been increased from the federal government for many years. They have been doing amazing things with what they have but, really, with a focused injection of more resources? Provinces and territories could learn a lot from the way they organize their health services in First Nations communities.

Mr. Manion: This is a complex issue. We must first and foremost be careful not to have a paternalistic approach to trying to solve problems for our First Nations, Inuit and Metis communities. It is a long-term partnership. Dialogue has to take place. There are historical things that are clearly at play when involving those conversations. There is a lot to learn from what has been done well but also from those communities themselves. Many communities are role models for wellness. It is not all about money. Sometimes it is about approach or about culture. They have approaches that would solve some of problems we have been discussing today in terms of our health care systems that are not necessarily technologically dependent but looking at people in their communities from a holistic perspective. There is a richness there that we have to be aware of.

We speak often of the mental health needs in these communities. When we have gone to these communities and have been able to go into some of these communities, we realize we are not necessarily talking about mental illness. We are talking about the psycho-social indicators of all kinds of social conditions and determinants of health. We have to be careful how we label these problems, and we cannot over-generalize across communities because many of these communities are in a position to help other communities by what they have been able to accomplish for their citizens.

Mr. McNamara: I agree we have to do more on Aboriginal health. Jurisdiction is an issue. One thing on which I would like clarity is what is the role of Health Canada and what is the role of the province. Sometimes we are not really sure. We get caught in the payer of last resort, which may not help in how we deal with it. When I was here with Milton Sussman from Manitoba the other day, he talked about the number of Aboriginal individuals who end up in the ERs. We find, in some ways, except for the Cape Breton District Health Authority, which has a partnership with the Membertou First Nation, that people stay away because they do not feel welcome. We have to figure out how to invite them more into our system and make sure the home programs that we provide to other citizens are still there for the Aboriginal community. That is our biggest challenge. They are part of our community, and we have to make sure that they feel that they are citizens.

Ms. Delancy: Mr. Manion touched on a key point, which is some of the psycho-social trauma, the legacy of trauma of residential schools, of social change, and this is an area where the social determinants of health are really critical. Obviously the health system cannot tackle it alone, because we have issues like low employment and poor housing and lack of clean water, but there certainly is a need to be mindful of but also to invest more in supporting Aboriginal communities to come up with culturally appropriate, community-based responses. Some of the mental health issues are extremely challenging, as are the addictions issues. It is the communities that have the solutions, but I think when we are funded for universal programs, it is difficult to find the flexibility to provide communities with the support to tap into the answers and the strength that exists there in the community.

The other point that I would like to make is, having worked and lived in many First Nations communities, being the former spouse of a First Nations person, and being an anthropologist by training, we need to invest resources in ensuring that the providers that we have within our system have some training, awareness and understanding when they go to work in First Nations communities of what some the challenges are and not just cross-cultural orientation but providing people with tools to deal with some of those very difficult social situations and some of the very difficult challenges they are going to encounter.

Dr. Schull: I want to make a point of not losing site of Aboriginal individuals living in urban areas as well. The events in Attawapiskat recently have focused attention, quite rightly, on reserves, but clearly many Aboriginal individuals live in urban areas and suffer similar problems in terms of problems of poverty, mental health, addiction and many social and cultural problems. I do not have a solution. I do not think we can give you the bullet point or concrete recommendations that will solve this, but it is something we need to not lose sight of.

Ms. Hoffman: Members of the committee will have heard from Valerie Gideon at Health Canada earlier on in this process, but I would remind you, apropos the committee's mandate to look at the results out of the 2004 accord and progress on the commitments there, that sizeable funding commitments were made for Aboriginal health human resource development and Aboriginal health transition fund. There were related commitments around Aboriginal Headstart, eHealth and so on. The committee was advised at that time, I think, that there were significant financial commitments made in 2005. They were then renewed by the government in 2010. I trust some of the commentary from the committee in your report will focus on the results from those particular program initiatives.

The Chair: Can we have a quick reaction to the idea of ten accords versus one.

Mr. McNamara: I was thinking about this, because I had heard of this idea before. I started going back to my background as a human resource labour negotiator. When I deal with a union and get an agreement, then it becomes an extra agreement to become equal and better. Then I started to think this is what really would happen if we had that much differentiation.

We need to see an accord across the country that deals with equality and at the same time has the flexibility to recognize some of the differences. In my presentation the other day, I mentioned the fact that B.C. has one the youngest populations, Nova Scotia has one of the oldest, but we both need those programs. I need programs for youth, as do they, but how do we build in flexibility.

Dr. Haggie: When we went across Canada with our dialogue earlier this year, Canadians we spoke to wanted one pan-Canadian standard. They regarded it as a matter of equity that you should be able, in broadly similar communities, to have access to broadly similar standards of care, and they were very clear about that. Mr. McNamara is right that a solution that you want to put in place for Nain or Goose Bay or up in the Northwest Territories will not work in downtown Toronto, so you have to have some flexibility across jurisdictions. I would suggest that by adopting a principled approach and by crafting an accord that is based on, for example, those principles, both as a statement of intent and as a barometer, you could actually get that done. You could build in enough structure so that people felt there was a pan-Canadian standard, yet enough flexibility so that B.C. could do things differently than Newfoundland.

Dr. Schull: The question is, should we have ten separate accords instead of one? My answer would be no, not 10 separate accords. What is the purpose of the accord? As I understand it, the purpose of the accord is to buy change. If we are going to be investing in the system, we are buying change. I have said this before at the previous committee meeting. If the feds will invest 6 per cent more pour annum for the next few years and do not get anything for that additional money, then it is a real missed opportunity, to say the least. If the purpose is to buy change, I do not think there is real value in having 10 separate processes. It will just become a political circus.

The innovation and improvements that we all want to see happen will not happen because the federal government and provinces agree on doing 47 innovations as part of a health accord. It will be because the health accord sets out a broad agenda and then brings money to the table so the provinces will agree to that agenda and work to implement it. That is what the first health accord did. It focused on wait times in a number of key areas and has had success.

Where did we not do enough in that first accord, and what should we not repeat this next round? First, we did not actually provide the tools to measure the benefits of that health accord, so we have some spotty information across the country about wait times and a few procedures. The measures are different. The comparability of the data is not perfect, and there are black holes of inadequate information. We want to be sure that the change that we are trying to buy in this next accord will provide the tools to measure whether or not it is happening.

For all its faults, the last health accord was smart in that it targeted specific issues. If you go back to what we have been discussing all morning, we have been focusing on a few key issues that we have all agreed are necessary to buy the kind of change we want to see in the next accord. I think that should be the focus, not the number of accords.

The Chair: I will move to phase 3 and give each one around the table an opportunity to raise an issue, starting with the deputy chair, Senator Eggleton.

Senator Eggleton: I would like to get some feedback on the area of prevention and promotion of public health. We operated, together with the provinces, very successful anti-smoking measures in past. Flowing out of the accord an integrated, pan-Canadian healthy living strategy that focused on three targets that were to be achieved by 2013 was developed. This included increasing the proportion of Canadians who make healthy food choices by 20 per cent, increasing the proportion of Canadians who participate in regular physical activity by 20 per cent and increasing the proportion of Canadians with normal body weight, based on body mass index, by 20 per cent. This all seems to relate to the issue of obesity, which I keep hearing is one major area that we should be tackling, and/or diabetes.

In that same vein, the Royal College of Physicians and Surgeons says we should do something on injury prevention, and that could save a lot of money. Dr. Taylor talked about salt. Are we doing enough on salt? These are areas on which we could get into the subject of prevention and promotion of public health. I would like to hear more about those subjects.

Mr. Manion: When you mention those two topics, they are two of the three mentioned by Dr. Kellie Leitch, in the Reaching for the Top report, in terms of pediatric health. The third one is mental health. We are talking about prevention and promotion. We actually know where the biggest bang for our buck should be. We know where the greatest morbidity is coming from in terms of looking down the road at the major health concerns around the world. Mental health is sadly becoming one of the top ones.

There are opportunities. Efforts are being made, sometimes in pockets rather than in concert. There is a rallying point perhaps around the three topics that Dr. Leitch recommended. I know there has been limited systematic effort across all three.

The Mental Health Commission of Canada is doing some significant work on the mental health piece, but not specifically in child and youth mental health. In some respects they might be lagging behind in some significant work in that area.

I would recommend that we dust off that report, look at the recommendations and implement some of the very good ones that were made after systematic consultation across the country.

Mr. McNamara: At the recent health ministers' meeting prevention and promotion was one of the primary issues. The ministers, including the federal minister, are trying to move that issue forward as we try to address the issues. Obesity was recognized as a real issue and we know we have to deal with that. There was agreement on moving the subject of healthy weight forward.

In relation to salt, there was an agreement on targets but there is a disagreement on how we get there. However, that is something we can work out over time.

The ministers of health, education and sport are meeting early in the spring to talk about after-school programs and how to do more with youth to get them involved in activities. The issue is moving through all our systems, particularly as to how we can do a better job.

Senator Cordy: This has been an amazing morning. I would like to go back to mental health, which we have discussed. You discussed it earlier today and talked about the health care providers working together and recognizing that mental health is equal to physical health and we have to deal with it in that way. We talked about the integration of services.

I was part of the Kirby committee that studied mental health. We kept hearing, over and over again, that when dollars get tight the mental health aspect falls off the table. A lot of the care for those with mental health does not follow strictly under the hospital, and we are hoping that in fact there is very little hospitalization. We are hoping there will be community care and many other things that follow within the closed realm of the health care model.

I agree with the integration. I agree with all the things said this morning relating to care for those with poor mental health, but how do we put a red flag on the issue in the accord so it does not get lost?

Mr. Manion: I will disagree with one thing the senator said in terms of fighting to make them equal. That almost suggests that we have two different solitudes here. The reality is health outcomes are better when you pay attention to mental health. I doubt you can give me a single health concern where there is not a mental health perspective that will play a significant role in the uptake of care, the engagement in care, the practice of the practitioner and what they are doing. It is critical. Until we start looking at that as part and parcel, we are not going to get very far. Until we stop saying that it should be as important as physical health care, and start saying it is integral to physical health care, we will not get far. That is how you get into the accord. You cannot have health without mental health. None of our systems will work unless we pay attention to mental health.

Even the conversations we have had about changing how the system works are based on how individuals interact, which is based on their mental health as well. That is the change in the conversation that needs to take place.


Senator Champagne: As Senator Verner mentioned earlier, by virtue of asymmetrical federalism, Quebec has a distinctive health accord. Quebec has some positives and negatives, but we only ever hear about the negatives. Surgeries postponed because an operating room is not available so people turn to private clinics, or if a room is available, there is no anesthesiologist on hand or the head surgical nurse called in sick that morning and patients are sent home. There is also a lot of focus on ambulatory patients, meaning they're sent home very early.

I agree with Ms. Henningsen, who spoke about caring for a recuperating or long-term patient at home. Obviously, this requires a family member who is devoted, attentive and very helpful, and that the CLSC sends a competent, qualified, experienced nurse to see the patient — if not every day then every two days — who can take blood samples and do whatever else is necessary, and then the results are forwarded to the doctor. That is very important. There is also a 24/7 hotline that people can call to have a nurse sent to see a patient in an emergency; a blocked catheter, for example.

Yes, there are good things in Quebec. I hope the 2014 accord will lead to improvements and that the provinces and territories will be able to share in all the successes and innovations and will put them into practice in an effort to improve the situation in Quebec and everywhere else in Canada.


The Chair: Are there any interventions?

Senator Verner, would you like to raise an issue?


Senator Verner: On the individual accords.

The Chair: Do you have a question pending?

Senator Verner: No. I would like to add a comment in connection with what Senator Champagne was saying. Yes, I am a senator from Quebec. I am a senator in the Parliament of Canada, of course, and I hope that in the public interest and for the common good of all Canadians and of Quebecers, we will be able to find innovative solutions to ensure that patients, who should be the pivot of a health accord, reap the benefits of the best practices, regardless of their province of origin or their care providers, be they physicians, nurses or anyone else in the spectrum of health professionals who work in the system.

We are now in a society where our issues are becoming global issues and we should not work in silos; we should make every effort, again in the interests of providing patients with the best possible care, to share our information and best practices.


Senator Braley: I would like to come back to the theme, and then I will just make a statement that I have made in the 12 or 13 meetings that we have had. After we have our vision, which we do because we want quality health care for all Canadians, we have to train starting basically at grade 1 so that young children eat right. My wife only allows me one steak a week and that is tonight. There is also fish and various other things to eat. This requires leadership. This whole thing boils down to management. Dr. Kitts expressed it clearly as the big picture, the big overview. That will take the silos and the various elements to move back and forth. I think it needs a board of directors or something, because the minister would not be capable of handling it on a day-to-day basis. Maybe a board and either five or seven people are needed to manage it, which would include all of the items that are involved, namely, to prioritize and to be able to put into effect innovation, research and development.

We call that "applications engineering" in the businesses that I run, where we look at ways of applying cost effectiveness to all the various pieces of the puzzle. I believe there is enough money in the system now to pay all the bills if all the things were tackled properly — whether it be doctors' wages, or whatever. I am not trying to pick on anyone. However, a little competition never hurt.

To give you an example, in our company we cut the insurance company out and self-insured. We saved several million dollars. We use that money now. If a person is sick today and he has to wait four months for a CAT scan, he goes to Buffalo and has it done tomorrow. The private sector can serve certain needs so that the next piece is handled. I do not know if it is right or not, but my employees believe in it. They go for little surgeries like for the meniscus, cartilages, and so on. I ask them if they want it done and then we pay for it. There are ways to tackle problems, if minds are put together and if they work together and provide the leadership and management to the system to get it done.

That is just a comment. I do not know whether I am right or wrong; it is just what I feel inside.

Senator Martin: There is incredible expertise around this table. I think we have some excellent points to summarize and produce the kind of report that we need to give to the minister.

I want to make one comment and then ask a question. The comment is regarding health and education. As a former educator, I believe there is a great opportunity for a generational change. As my colleague Senator Braley said, it starts from day one. You have a captive audience in the classroom. As a teacher for 21 years, I know that. When the kids go home, they will educate their parents. This generation are already tech savvy and they will be able to do what some of the professionals now are not doing. I believe that is a key component. I hope that health and education will be partnered all the way through. That is the opportunity.

We have three years remaining in this current accord. I know the importance of looking ahead because this is a very enormous need and it is of great importance. My question is this: In this time remaining with the current accord, what can be done today, or in the next three years, to make further progress such as in the Canadian Infoway, identifying the best practices and the innovation that exists today? With the current targets that are in the 2004 accord, what further progress and what readiness we can make, including the study? What can we do in the next three years with this current accord?

The Chair: I do not know if we can answer that totally in the time remaining but I will allow two interventions.

Dr. Kitts: I would say focus on one thing. If it will service well for the next accord, focus the next three years on putting in the systems to measure outcomes and cost. If we can do that, we can move mountains.

The Chair: I see a lot of nods on that one.

Dr. Schull: You made a comment that has been raised several times, namely innovation and transmitting information widely. We have to distinguish between two things. First, is innovation something that we need to push out to providers or do we need to design systems that will pull this information in naturally? Currently the way the system is structured, the reason why some of this innovation is not disseminated is that it is not realigned with what a particular provider is doing.

We need to start by reducing the system redesign integration that we have spoken about. As Dr. Kitts was commenting on the academic hospitals looking for innovation that is helpful to them to function more effectively and that if you design a system that is integrated, that system will begin looking across Canada and across the world for the kinds of innovation that can allow them to work more effectively.

I do not think it is a chicken and egg thing; we have to start with getting the system alignments right. We can then start to benefit from the innovations that are already occurring.

Senator Merchant: I will ask a question not just necessarily to do with the accord, but to do with health outcomes. It is a conversation that Canadians are having.

We do not have enough specialists; we do not have enough nurses. Sometimes we lose people to the U.S. or to other jurisdictions. Perhaps you have these conversations and know the reasons for that. The other thing that is happening — and Senator Braley mentioned this — is that when people need medical care, they sometimes choose to go elsewhere, to where they think they will get better quality of care. They might want to go to the Mayo Clinic; they might choose a hospital and pay themselves.

What is the cost to our economy when we are losing, first, specialists, nurses and medical people; and, second, when people go elsewhere to get the services that they are not able to get here? Do you have conversations? You are people in the medical field. What kind of conversations do you have? This does relate to health outcomes?

Mr. McNamara: I am not sure that we know the number of nurses we should have; the number of doctors. We are going through a physician manpower plan in Nova Scotia and the outcome will be a surprise to a lot of people.

In terms of losing people, it is interesting to me that the highest paid nurses in this country are in B.C., Alberta, Ontario and Nova Scotia. Do you know where the highest turnovers are? They are in those same four provinces. That says that money is not the answer. We have to do the human resource part to see what we need and put people in the appropriate place. We have too much urbanization of nurses, doctors and others because they like to move to the centre and leave our rural communities. Our problem is distribution rather than numbers.

Dr. Haggie: Ditto. We have no clue how many specialists we need and how many GPs we need. We certainly are not self-sufficient in terms of physicians. We do not actually have a handle on what the training requirements are in terms of meeting those needs and going backwards. We have the same number of residents we have because we always had them, kind of thing.

I would agree very much with the distribution. The flip side of Mr. McNamara's comment is that some of the lowest turnover of nurses and physicians are in actual fact in Labrador, in Maine and in Natuashish, where people have been working and living for 15 to 20 years. They fly in and do their four weeks; they go home for another couple of weeks. They live somewhere else, but they keep coming back.

Senator Seidman: It has been an incredible morning of frank discussion. It is evident that there are big issues for the system in terms of a culture of care and the system's ability to update itself and respond to a changing society.

If I have only one question, I would put this one: During this review, issues of financing, accountability and reporting have been approached largely in terms of federal-provincial-territorial relationship. That has been one topic that has demonstrated its challenges.

In the name of a truly patient-client-consumer model, however you refer to the user of the system — and you can refer to them in any one of those three ways or maybe others — of health care delivery, which we have talked about a lot, I would like to posit the following for your reaction. It is in consumer taxpayers' interests to hold their provincial government and physician providers accountable, both in terms of how taxpayer money is spent and the quality of care received. Also, the consumer of health services must take responsibility for their own health and how they use the system.

Here is a what-if question. What if every taxpayer or individual with a medicare number would receive a paper statement detailing their health expenses for the month? This statement, much like a monthly credit card statement, would include a breakdown of all costs they had incurred in the public health system, all charges made to their medicare number.

Would this approach encourage more responsible use of the health system by the consumer taxpayer and promote better accountability from physicians and the province? Perhaps we could even add a satisfaction survey each month to get at the quality of service.

Mr. Morgan: The idea of giving people an annual statement of health system resources they consume on one hand has merit in that to make people aware about the costs of the services they use, but there are two problems with that. First, as we have talked about, a very small number of people actually account for a vast majority of expenditures, and there is no evidence that there is a great deal of patient-level abuse of the system. We have to be mindful that those 5 to 10 per cent or 20 per cent that account for 80 per cent of our health care spending in Canada should probably not change their behaviours.

Second, they are not the agent that makes the most critical decisions; those are health care providers. The incentives that we provide to physicians and other health care delivery professionals is really where the action is, if you want to eliminate waste or improve efficiencies.

I appreciate the notion of patient-reported quality. I think that we need to start shifting focus in addition to all the support that has been put forward today for electronic medical records and getting system information about who is getting what and what the outcomes are. Critically important to that are patient-reported outcomes and experiences. As we emerge in developing platforms for an electronic health record and accountability frameworks, let us not forgot the patient-reported outcomes as well.

Mr. McNamara: I would prefer if we provided the cost of options to physicians and other care providers so they know when they are making their choices.

The second part is to encourage self-care. We also have to provide more information to those folks who provide advice to people. You would be amazed how many individuals get advice from their neighbour, even to the point of sharing prescriptions. One of the things we he have to look at is how to help them. How do we help them?

I go back to The Cochrane Library idea where people can go somewhere and get information, or at least tell someone else to go somewhere that is appropriate.

The Chair: We could sure have a lot of fun if we went down that road today and discussed where people get their information from. The relationship of advice to credibility would be a possibility.

As my colleagues have all indicated, we have a remarkable group of talent around this table today. I will go around the table and give each one of you an opportunity to give us one final piece of advice. I will start with Ms. Henningsen.

Ms. Henningsen: I would say this new health accord needs to reinforce integration and the continuum of care. The old one, as we heard, targeted specific areas, but it really targeted silos. What we need to target in this health accord are issues on getting to integration. I would challenge looking at adopting the high-level principles of the Triple Aim, which is to enhance individual care, improve the health of populations and reduce or maintain costs. Everyone can understand that, and they can work with flexibility to be able to achieve it.

Ms. Delancy: I would recommend that the new health accord acknowledge the importance of EMR and EHR in improving our system and build on some of the ideas we have heard today about providing incentives or motivation to ensure that all practitioners move to the EHR, as well as acknowledge the critical role the federal government through Canada Health Infoway has played in allowing jurisdictions to be able to afford those initiatives.

Mr. Manion: I would say our current health care system is not sustainable. If we have to change the fundamental health of Canadians, we have to start with this generation of children and youth so that when they are middle aged and elderly, they are having a different health status requiring different kinds of care. The investment right now in children and youth will make a huge difference. Obviously, I also believe that investment in mental health at an early stage may have the greatest of outcomes.

Dr. Kitts: I probably sound like a broken record, but I would start with strong governance, strong management and clearly identifying roles and responsibilities. There is a lot of talent around this table, but most of the talent is still out there. Mobilize that immense talent, focus on outcomes and try to get down to the individual patient level, not these aggregates that you can debate back and forth.

One thing that did not come up a lot here but I think will be essential to success is transparency. Once you have that focus on outcomes and clear directions and targets, make them transparent.

Dr. Taylor: In the current accord, there were real success stories, including the Pan-Canadian Public Health Network, how we responded to H1N1 and the National Immunization Strategy. Let us build on those strengths and the things that worked well as we continue forward.

Ms. Hoffman: I will comment also in the spirit of observing what was in the 2004 accord and how it was pursued, specifically around reporting.

As other witnesses and I have said previously, I think we kind of missed the boat on a couple of things with respect to reporting. The first is true comparability so that we can see what is going on across the country and learn from the areas where things are being done well.

Second, inasmuch as the accord was very much, as others have noted today, about renewing the system or about change, it is critical that the indicators that are reported on are those that actually have to do with change, change processes and the enablers of change.

Finally, again as others have said about "patient-client-taxpayer-or-citizen centredness," however you want to characterize it, we need to be sure we have indicators, that those are reported on consistently and that are of interest and meaningful to Canadians. Those may not be exactly the same ones as that first category I mentioned, but that is fine. We need to ensure that there are indicators and comparative assessments of progress that are of interest to decision makers and providers and that there are indicators that make sense to Canadians so they can tell whether systems are improving and whether they feel as citizens and taxpayers that they are realizing value for money spent.

Mr. Morgan: To answer Senator Martin's question about what we could do in the next three years on the pharmaceutical file, I would call for that national conversation so we can get a clear and principled vision of what the model should look like, which we currently lack. We at least lack a vision that is principled and clear enough to mobilize the probably tens of billions of dollars required to achieve the goals. That could be done in advance of 2014.

At 2014, I think we need to focus strategically on buying change, and I would encourage investment in the platform issues that we have talked about, such as information systems, which I think is critical. Buying change in there includes making sure those data are available for health systems managers, researchers and the accountability organizations that should serve the watchdog roles in this system.

There should then be focused investments on specific initiatives. In the pharmaceutical strategies, there are three or four of them that could be invested in to effect change and bring provinces further along than they either can or would go on their own.

Dr. Schull: I will go back to something Dr. Kitts said in terms of what the focus of the next accord needs to be. Let us start with governance, and I would start with governance and leadership at the federal level. We need a federal government that is again engaging in health care. The federal government has been insufficiently engaged in this issue in the last few years and cannot just assume that leadership means cutting a cheque every year with 6 per cent more dollars.

The goal of the next accord needs to be focused on the issue of health system integration at a level that is appropriate, meaning not an entire province, unless we are talking about a very small region, but at a population level that is functional from the point of view of effective and efficient delivery of care.

Finally, unlike the previous accord, and echoing Ms. Hoffman's comments, the new accord needs to ensure that the tools are there to measure the progress that has been bought and paid for and that the change that has been bought and paid for is occurring, and, where it is not, the powers that be are being held to account.

By the way, one of the key indicators is about patient experience, and we will need new systems to gather this information. That is critical, and we are doing far too little on that file.

Mr. McNamara: The bottom line is to remember that there is one taxpayer, one patient. We have to make the system much better for Canadians overall. Looking at integration to me is extremely important, going from mental health, to children and to seniors, and also looking at how our services are brought together so we are not repeating even within our own provinces.

The other thing is to stop reinventing the wheel province by province because we are spending the same dollar to do the same thing when it could be a better partnership. I would agree there has been more cooperation than I have ever seen before between provinces and the federal government in the last couple of years in starting to breakdown silos. That has to be encouraged, enhanced and moved forward so that we can use that scarce dollar for the best of everyone.

Dr. Haggie: Going last is a little difficult when Ms. Henningsen and Ms. Delancy have stolen my themes. Just to reiterate what other people have said would be pointless.

One observation I would make is 2014 is a means to an end; it is not an end in itself. As an optimist, I like to think you can then say that this new accord becomes a turning point, so that by the end of that accord you could turn around and say in 2025 that Canadians have the best health and the best health care in the world. I think that is all I would offer to close.

The Chair: I would like to make a couple of observations before I start to wrap up this remarkable morning.

First, the issue of management, leadership, accountability, who is in charge and so forth, has come up at every single meeting in one way or another. It is fascinating to me, and I am picking up on Mr. McNamara's last comments, that the thing that has come up continuously is, in spite of our constitutional situation, which gives very clear powers to municipalities, provinces and the federal government in this specific area, among others, everyone is saying that there is a role for the federal government in this area. They are not looking to it as the head, but as someone to work together with to help pull these things together with regard to leadership. That is an unusual situation during my lifetime of experience with regard to these kinds of issues. There is a real opportunity here for the provinces and the federal government to work together on that key issue of overall management of the total system.

Finally, as an anecdotal observation, I have been told by someone about a situation that just occurred. If an individual shows up at an emergency unit with the signs of perhaps having a kidney stone, the body scan that occurs needs to look for an aneurism because, apparently, the pain symptoms are very similar. The scan is done over a certain part of the body. The question I asked was: As there are many parts in there in addition to the two that are immediately suspected, does the radiologist or whoever looks at this look for other things that may be popping up? The answer I was given was that they do not, not because they are not interested, but the person I was speaking to gave me a spiel on the limitations and restrictions as to why they should not perhaps go looking for other kinds of issues. I do not want a discussion. I just throw that out, and it may be totally wrong or whatever. However, there might be issues like that one where modern technology would give rise to the opportunity to facilitate prevention in areas that are totally unexpected. We all know patients who go to hospitals with particular symptoms, and in the course of investigation, it is found that they have colorectal cancer or something else that was not even suspected and perhaps saves their lives. If there are ways that our technology is being under-utilized in terms of access to information, that could be something to come out. That is just an observation.

I want to turn now to this period, this 13-meeting sequence that we have been through, culminating with today. I think I can speak for my colleagues in saying it has been quite a remarkable study of a very important part of the Canadian social structure around the health accord. All of you have had a great opportunity to make an impact on our discussions and provided us with observations which, ultimately, will help a great deal in developing a report. That is now our challenge, to pull all of the wisdom, experience, examples and issues that have been brought before us into a document that can provide advice to the federal government with regard to its role in moving towards 2014. Our primary charge by the minister was to look at the 2004 accord, and, under the 10 principal elements in it, to see how it is done. However, clearly, things have arisen in doing that that would point to advice into the future.

I also want to say to those assembled here today, on behalf of my colleagues — I know from their comments throughout this process that I can say this with considerable confidence — that we collectively have been very impressed by the witnesses who have come before us. The contributions have been almost without exception without vitriol on one of the most important and significant issues in the Canadian social fabric, the health accord. When you think of the amount of conversation that occurs around our health system in all forms of media, I have to acknowledge that our witnesses have been remarkable in their ability to focus on the substantive issues and to bring us advice in those areas.

Today, it has been a truly remarkable round table, again, in the way that you have approached your answers to the issues, and I could not be more pleased on behalf of my colleagues than to see how you have contributed to this discussion today.

On that note, I want to thank you again on behalf of my colleagues.

Finally, to my colleagues, you have been quite remarkable throughout this process. We could have spent days on some of the issues, such as the social determinants alone, if we could have broadened out into that, and in many of the areas you have taken, but you have worked together to make this happen, so thank you again to my colleagues.

(The committee adjourned.)