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