THE STANDING SENATE COMMITTEE ON SOCIAL AFFAIRS, SCIENCE AND TECHNOLOGY
OTTAWA, Thursday, September 29, 2011
The Standing Senate Committee on Social
Affairs, Science and Technology met this day at 10:30 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: Welcome to the Standing Senate
Committee on Social Affairs, Science and Technology.
I am Kelvin Ogilvie from Nova Scotia, chair of
the committee, and I will ask my colleagues to introduce themselves to you
by starting on my right.
Senator Seidman: Judith Seidman from
Senator Martin: Yonah Martin from
Vancouver, British Columbia.
Senator Demers: Jacques Demers from the
beautiful province of Quebec.
Senator Merchant: Pana Merchant from sunny
Senator Verner: I am Josée Verner, and not
only do I come from the beautiful Province of Quebec, but I come from the
beautiful City of Quebec.
Senator Callbeck: Catherine Callbeck,
Prince Edward Island.
Senator Eggleton: Art Eggleton, Toronto,
and deputy chair of the committee.
The Chair: Thank you, and welcome to our
witnesses today and to the audience.
This committee is charged with examining under
this current study the progress in implementing the 2004 10-year plan to
strengthen health care. I will take just a minute to review, since this is
our first meeting of the new session here. I remind everyone that this is an
ongoing study, which we actually began with our first meeting on March 10.
The theme of that particular meeting was accountability and reporting on
progress, where we heard from the Health Council of Canada, the Canadian
Institute for Health Information, Health Canada and Statistics Canada.
I should also inform everyone so they are aware
that all documents received from our first meeting and the first act of this
committee have been referred to us as continuing with regard to our study
under our continued order of reference, under which we are operating today.
Today's meeting will deal largely with reduced
wait times and improving access. We have four different groups presenting
today. From the Association of Canadian Academic Healthcare Organizations,
we have Christine Power and Glenn Brimacombe. I understand, Ms. Power, that
you will be making the presentation.
Christine Power, Chair, Board of Directors,
Association of Canadian Academic Healthcare Organizations: That is
The Chair: From the Wait Time Alliance, we
have Dr. Chris Simpson, chair, and Stephen Vail. I understand, Dr. Simpson,
you will be making the presentation.
Dr. Chris Simpson, Chair, Wait Time Alliance:
That is correct.
The Chair: Welcome also to the Institute
for Clinical Evaluative Sciences and Dr. Michael Schull. Appearing as an
individual is Dr. Brian Postl. Welcome to all of you. With that, I will ask
Ms. Power to begin her presentation.
Ms. Power: Good morning and thank you for
the invitation to be here with you today.
I have the privilege to serve as the president
and CEO of the Capital District Health Authority in Halifax, Nova Scotia,
but today I am here as the board chair of the Association of Canadian
Academic Healthcare Organizations. ACAHO is the national voice of the
country's research hospitals, academic regional health authorities and their
research institutes. Members of ACAHO are leaders of innovative and
transformational organizations with overall responsibility for the provision
of timely access to a range of services, from specialized care to prevention
of disease, educating the next generation of health providers and leading in
research discovery and the early adoption of innovation in the health
For purposes of my remarks, I will speak to
three areas: our assessment on progress related to the wait times since the
2004 health accord, what factors are critical to build on our progress to
date and what promise could 2014 hold for us.
ACAHO has been and remains a strong supporter
of the 2004 health accord. At that time, the accord was an important step
forward in terms of focusing attention, resources and an accountability
framework on five priority areas related to access to care. The accord has
not been an unqualified success or an unmitigated failure. Our brief notes a
number of areas where progress is being achieved to improve patient flow and
system performance across the continuum of care. However, there continues to
be more work required to improve access to care, overall system performance
and its measurement. Real-time innovations are occurring at the local level
and are making a difference in the manner in which patients are prioritized,
the speed at which they are moving through the system, and they underscore
the need for different parts of the system to be integrated.
While ACAHO members have demonstrated progress
in a number of areas related to access to care and wait times, we have
identified eight policy challenges that can be grouped across the headers of
community-based and primary health care, health system capacity building and
research and applied health system innovation. Given that we are seven plus
years into the 2004 health accord, we believe it is time to open a dialogue
on what a 2014 health accord might look like. Noting the recent comments by
the Prime Minister and Minister of Health, how can we improve accountability
in overall system performance in terms of value for money? Are we making a
difference? How do we know?
While the views of the association are still
forming, we have identified a series of policy options where the federal
government can play an integral leadership role in working collaboratively
with the provinces and territories in facilitating health system renewal.
When it comes to accountability and system performance, we believe that it
is essential to continue to advance the ongoing dialogue when it comes to
comparable national indicators for wait times and benchmarks across all
jurisdictions, and that public reporting on all defined priority areas
While the access agenda has been the central
focal point of the 2004 health accord, it is time to have the 2014 health
accord focus on quality, of which access is one important dimension, with
the others being effectiveness, safety, efficiency, appropriateness,
provider competence and acceptability.
Given the important work that has been advanced
across the country by provincial quality health councils, is there an
opportunity to consider how we can develop a set of national quality-based
health indicators that are comparable across all jurisdictions? For example,
the Canadian Collaborative for Excellence in Healthcare Quality, comprised
of 11 academic health science centres, has agreed to 16 indicators across
five domains, which will be released later this year. Furthermore, there are
a number of federally funded agencies that focus on select dimensions of
quality that can make an important contribution in this area.
In addition to the un-earmarked federal cash
that will undoubtedly be part of the 2014 health accord, we also propose
three specific funds that are strategically focused in areas that can
contribute to improved access and wait time.
While we talk about reducing the impact of
overcrowded emergency departments, this is only the symptom of a system
under considerable stress due to an insatiable demand for services. The real
issue is the lack of capacity to move people appropriately through the
continuum of care because of insufficient post-hospital care resources and
poor attention to preventive and supportive measures. Can the 2014 health
accord act as a catalyst to ensure appropriate post-hospital supportive and
preventive care strategies, facilitate integration of primary health care
with the rest of the health care system and enable innovative approaches to
health care delivery? Is there an opportunity to move forward with new
models of primary health care that focus on personal accountability for
health, encouraging citizens to work in partnership with their primary care
providers and thereby alleviating some of the stress on emergency
Given that one in five hospital beds are being
occupied by those who do not require hospital care — these are known as
alternative level of care patients, or ALC patients — we must find
innovative solutions so that 20 per cent of hospital beds occupied by ALC
patients can be used more effectively. In both instances, perhaps part of
the solution lies with the creation of an issue-specific strategically
targeted fund designed to move beyond pilot projects and accelerate the
creation of primary health care teams — for example, team-based primary
health care funds could be established — and the creation of an
infrastructure fund, which we call a community-based health infrastructure
fund to assist in the development of post-hospital care capacity, coupled
with tax policies designed to defray expenses associated with home care.
Finally, a challenge that has been addressed
earlier in our brief is the recognition that there are a significant number
of pockets of excellence when it comes to innovative ways in which
high-quality, cost-effective care is delivered to Canadians. That said, one
of our ongoing challenges is to find more effective ways in which we can
share these applied health system innovations from coast to coast to coast
in real time. In other words, these innovations need to be driven
horizontally across the country.
One way to do so is to consider establishing a
national health innovation fund, of which one of its stated objectives would
be to promote the sharing of applied health system innovations across the
country with the goal of improving the delivery of quality health services.
This concept would be closely aligned with the work of the Canadian
Institutes of Health Research in developing a strategy on patient oriented
Combined, we believe our recommendations focus
on strengthening the structure of the health system, the process by which we
improve the cost-effectiveness of delivering care, and improving overall
health outcomes by focusing on a system performance through the prism of
These are our preliminary thoughts as we move
closer to 2014. We hope that they will contribute to the policy thinking
about what is the role of the federal government when it comes to health and
health care and, more important, look to focus the discussion on what is
needed to ensure that Canada is a high performing system with an unshakable
focus on quality.
That concludes my remarks and I look forward to
The Chair: Thank you very much. Now
proceeding through the agenda, I will invite Dr. Simpson to present on
behalf of the Wait Time Alliance.
Dr. Simpson: I am very pleased to be here
today on behalf of the Wait Time Alliance in support of this committee's
review of the 10-year plan to strengthen health care.
The Wait Time Alliance, or WTA, is comprised of
14 national medical organizations concerned about Canadians' access to
necessary care. In addition to developing evidence-based wait time
benchmarks and targets in the five priority areas identified in the 10-year
plan, the WTA grades provinces' performances against both the pan-Canadian
benchmarks adopted by provincial governments and the WTA's own medically
determined benchmarks. It issues these grades in an annual report card, the
most recent having been issued in June.
My remarks will focus on two areas. First, I
will talk about the progress that has been achieved to date against the
commitments set in 2004, and second, I will describe what we believe are the
key areas requiring attention in any future health accord.
First, about the progress to date, I will say
point-blank that the commitment of governments to improve timely access to
care is far from being fulfilled. Canadians are still waiting too long to
access necessary medical care.
Table 1 of our 2011 report card shows how
provinces have performed in addressing wait times in the 10-year plan's five
priority areas. Of note is the fact that we found no overall change in
letter grades this year over last. Wait times for both cataract surgery and
hip replacement increased over 2010, albeit not by enough to affect the
letter grades. Those for knee replacement continue to receive the poorest
grades. Diagnostic imaging wait times, however, improved over last year in
several provinces, although some provinces still do not measure their
performance at all in this area.
The progress that has been made varies by
province and by region within provinces. Smaller provinces often experience
longer wait times than the larger provinces do. Within a generally high
performing province such as Ontario, the median wait time for a hip
replacement in the Ottawa area is 125 days, almost double the Ontario
provincial average of 65 days. The median wait time for cataract surgery in
British Columbia's Fraser Health Authority is 12.1 weeks, more than 70 per
cent longer than the provincial median of 7 weeks.
An appendix to our brief highlights several
issues raised by the WTA during the 2008 review of the accord, many of which
have yet to be addressed. One such issue is the lack of attention given to
timely access to care beyond the initial five priority areas. The WTA has
developed benchmarks and targets for an additional seven specialties and
uses them to grade progress. These data can be found in Table 3 of the 2011
Notwithstanding a lack of data, all indications
are that wait times for most specialty areas beyond the five priority areas
are well beyond the WTA benchmarks. On the other hand, we are somewhat
encouraged by the progress towards standardized measuring and public
reporting on wait times. All provinces, for example, now have a wait time
website, some of which report on a wider array of treatments and in greater
detail, but this is something that simply did not exist back in 2004.
Leading the way is Nova Scotia, which reports on a range of diagnostic
services, including nuclear medicine and consultation wait times for some
I would now like to look ahead and discuss how
the wait times agenda could be supported by a new health accord. With a
better understanding of the causes of wait times and how to address them, we
believe it is now time to raise the bar in our efforts to meet patient needs
appropriately. This means there must be a commitment on the part of
governments to continue the work that has been done so far. We have three
recommendations for supporting such a commitment.
The first is that governments must improve
timely access to care beyond the initial five priority areas, as a start, by
adopting benchmarks for all areas of specialty care. Further, an approach
that centres on patients requires us to look at the total wait time
experience. The measurements we use now do not include the time it takes to
see a family physician, which is a significant omission given that millions
of Canadians do not have access to a family doctor.
Second, we believe stronger accountability
measures must be a key element in any new health accord. These would allow
patients and providers the means to assess progress on wait times and help
them navigate the health care system more effectively. These should include
appropriateness guidelines, comprehensive wait time websites and a patient
charter with access commitments.
Third, while the WTA believes the targeted
funding under the 10-year plan has helped improve timely access, we equally
believe that money is only part of the solution. Efficiency strategies, such
as the use of referral guidelines and computerized clinical support systems,
can contribute significantly to improving access and a transformed health
care system. In particular, we note the significant impact of alternate
levels of care, or ALC stays, on wait times. ALC, of course, refers to
hospital patients who no longer require acute care but who are waiting for
more appropriate placement elsewhere. In Ontario, for example, ALC patients
occupy one in six hospital beds, creating damaging backlogs in areas such as
emergency departments and elective surgery.
We believe that addressing the gap in long-term
care is the single more important action that could be taken to improve
timely access to specialty care for Canadians.
Our biggest fear is government complacency in
the mistaken belief that wait times in Canada largely have been addressed.
It is time for our country to catch up to the other OECD countries with
universal, publicly funded health care systems that have much timelier
access to medical care than we do.
The next accord represents an important
opportunity for positive and lasting change for Canadians. We therefore are
following this committee's study with great interest and extend an offer to
help you in any way that we can.
The Chair: Thank you very much. I will now
invite Dr. Schull to present.
Dr. Michael Schull, Senior Scientist, Institute
for Clinical Evaluative Sciences: It is a pleasure to be here. I
appreciate the opportunity to represent the Institute for Clinical
Evaluative Sciences in Toronto. ICES is an independent non-profit
corporation that uses information derived from health administrative records
to assess the performance of the Ontario health system. We receive funding
from the Ontario Ministry of Health, but we are independent from the
ministry and we have our own board. The board does not have a ministry of
health representative on it.
ICES conducts extensive evaluation and research
into the delivery and outcomes of health care in Ontario and elsewhere. Much
of the work is done in collaboration with major health agencies, including
Cancer Care Ontario, Health Quality Ontario and Public Health Ontario. The
outputs include atlases, technical reports and scientific peer-reviewed
papers. In the slides that are attached to my notes, most of that work is
from ICES scientists — not all but most of it — and they are all attributed.
Since 1992, scientists at ICES have carried out
extensive analysis and research into access and wait times. After pioneering
work on access to cardiac surgery in the 1990s, this has extended to a range
of surgical procedures, emergency department utilization and primary care.
Many provinces in Canada, and Ontario in
particular, have made progress since the 2004 health accord following large
investments in health system performance that targeted the following:
linking more people with family doctors; organizational changes in primary
care, such as the creation of inter-professional teams and important changes
to remuneration models for physicians, for example, having a roster of
patients; access to select key procedures like total hip replacement and
better access to diagnostic tests like computer tomography. As well, we have
seen progress in reducing waiting times in emergency departments in some
jurisdictions in Canada and improving access to community-based alternatives
like home care for seniors in place of long-term care. These have been
achieved through new investments such as pay for performance incentives and
policy change. They have had some important successes, but the work is
Examples of the ongoing challenges that we face
include substantial proportions of the population who do not have easy
access to a family doctor when needed, even if they have a family doctor;
little progress on improving rates of eligible patients receiving important
preventive care measures such as pap smears and mammograms; continued high
utilization of emergency departments and walk-in clinics compared to other
countries; long waits, which remain a problem for many types of care. For
example, in emergency departments, long waits have been shown to result in
poor patient experience and increased risk of adverse outcomes, including
Another example is unclear accountability and
antiquated mechanisms to ensure smooth transitions in care between providers
and provider organizations. An example of a care transition problem is the
frequent lack of adequate follow-up with a family doctor or a specialist
after an emergency department visit because of exacerbation of a chronic
disease. There is good evidence in Canada showing the prompt follow-up can
save lives in some diseases, such as congestive heart failure.
A similar problem exists following discharge
from hospital. Who is responsible for follow-up? How is information to be
transferred? Who is accountable among community-based organizations to
provide rapid access to home care? Poorly integrated and coordinated care
leads to readmission to hospital, which is a revolving-door-phenomenon. This
happens despite having tools to predict which patients are at higher risk
and could benefit from more intensive follow-up.
Perverse incentives and disincentives exist,
such as no adjustment in primary care remuneration to care for the sickest
patients, thereby disincenting doctors to roster patients with chronic
illnesses. Penalties when rostered primary care patients visit walk-in
clinics but not emergency departments might incent doctors to direct
patients to ERs when they cannot see them promptly.
Providing high-quality patient care requires
that health care providers within one part of the system, for example,
primary care, can effectively communicate and efficiently share information
with providers in other parts, such as the hospital or community-based
agencies. This is especially important at critical moments, such as when a
change in health status results in an individual transitioning from one part
of health care system to another. The examples I mentioned include after an
exacerbation resulting in a visit to an emergency department or after
discharge from hospital.
Making these changes requires integration
across different parts of the health care system, which currently function
in silos. So what is needed? Critical reforms needed to achieve health
system integration include governance, information enablers and incentives.
Achieving them will require political engagement at all levels.
We need reforms in governance and
accountability. We need formal accountability and governance structures at
population and local levels for patient care and outcomes that include
providers and health care organizations. Such accountability and governance
structures need to include primary care providers, regardless of practice or
We need key information enablers. We need
electronic information systems that provide meaningful real-time patient
data to facilitate clinical decision making and measurement of local health
system performance, including patient experience. Electronic information
must be efficiently and securely shared between relevant providers and
organizations across the local health care system. Data must also feed into
administrative health datasets in a timely manner to allow for public
reporting and a rigorous, independent evaluation of the health system at
local, provincial and national levels.
We need appropriate incentive structures. We
need reforms to incentive structures for providers and organizations in
order to remove perverse incentives and disincentives and encourage
coordination of care across sectors to achieve better patient outcomes.
Finally, we need an engaged federal government
investing in the development and implementation of a national health system
integration agenda in collaboration with provincial and territorial
About eight months ago I attended an
international health policy forum in Washington, D.C. It was sponsored by
the Commonwealth Fund in the United States. The meeting focused on
innovative reforms to health care delivery and financing that were occurring
in OECD countries. Numerous health ministers and leading health system
leaders were present. No Canadian health minister attended, despite
invitations. The only official Canadian delegate was a Health Canada
By the third day of the conference, what was
most striking to me was the complete absence of any mention of Canada as a
place where innovative health system reform was happening. The reforms
happening in Canada in the last few years happened years ago in other
countries. The only places I saw the word "Canada" was in graphs that
generally showed us performing poorly compared with regard other OECD
countries on many important indicators, including the United States.
At the break I asked Uwe Reinhardt, the
renowned health economist from Stanford, who had just moderated a session,
about this fact. I will never forget his comment. He said, "Forty years ago,
Canada had the best health care system in the world and was a model for the
world. Since then, you have sat on your hands, and many other countries have
passed you by."
Perhaps the key question for this committee is
whether the federal government will sit on its hands for the next four
years. Thank you very much.
Dr. Brian Postl, Dean of Medicine, University
of Manitoba, as an individual: It is a pleasure to be here. I am
presently the Dean of Medicine at the University of Manitoba. I spent the
previous 11 years as the CEO of the Winnipeg Health Region. I had the honour
of authoring a report on wait times for the Prime Minister in 2005 at the
beginning of this process. I also serve as the chair of the Canadian
Institute for Health Information and the chair of the Canadian Health
Services Research Foundation.
I thought I would give you a little background.
Clearly, the five key areas of interest were hips and knees, radiology,
cancer care, cataracts and cardiac. They were of grave interest to ministers
coming into the accord. It is fascinating that no one is quite sure where
those five areas came from, in view of the many other options that were
available. There was no evidence that these were the most in need, but
clearly the public impression was these areas were key for intervention.
That was, of course, transmitted into the political process.
As part of the accord, benchmarks were
required. As we began the process it became clear there were no benchmarks
available. There was no scientific base or evidence to support any of the
benchmarks that were put in place. At best, they were a guess based on some
consensus building, or a review of literature. The Canadian Institutes of
Health Research came to the table with some research based on contracts with
the collection of provinces. Once again they were not able to produce
evidence in that short period of time to support the benchmarks that exist.
I think there is much less than meets the eye when we talk about what
appropriate benchmarks are.
Benchmarks were set once again without
evidence. Perhaps the best evidence was in curative radiotherapy, where
there was some evidence that if you waited beyond four weeks, both morbidity
and mortality increased. The rest were based on consensus efforts of
physician groups, administrative groups and whatever could be gleaned from
The one issue that was added was hip fractures
in the process, not just hip and knee replacement. This was partly because
there was evidence that prolonged waits for hip fracture repairs did lead to
significant increases in morbidity. The evidence at that time was that there
were long waits for hip fracture repairs, with long waits in emergency rooms
and long waits prior to surgery. That was the second area where there was
I think the other myth that we began with is
that there were actually waiting list that existed. In most jurisdictions,
the system was blissfully unaware of what the waiting lists were. Waiting
lists historically resided in physician pockets. They may have been at a
desk, in an office or in a file, but the health system did not have access
in many ways in most jurisdictions to the actual waiting lists. It is of
some interest that as this process moved forward, with variable
effectiveness, in some areas, when wait-lists were centralized and grasped
systematically, the list was reduced by 30 per cent by the act of going
through it with any rigour.
I think the physician role in this was, and is,
enormous. I think there has been considerable progress in role and attitude
of physicians in the last five or six years. When we started, wait-lists
were used by most physicians as evidence that they were best of breed,
thinking, "If I have the longest wait-list, it must mean I am the best
That was a widespread use of the information,
which was then levered into more OR time or more patients being convinced
that if you have the longest wait-list you must be the best, because
everyone else was waiting. That phenomenon made it difficult to this day to
move into a single wait-list phenomenon, where the next in order in line
gets the next surgeon availability. That continues, not in all areas, but in
many areas, to be a key issue.
The capacity of physicians to give up waiting
lists into more of a pool was difficult because they saw it very much,
understandably, as their future income. It was how they would make the
mortgage and other payments for the next 10 years: "If you erode my
wait-list or if you share it with others, my income capacity would be more
limited." This failed to recognize, of course, the phenomenon of which we
are all aware — the wait-list keeps filling up. It is not as if it is static
or that if your wait-list gets any shorter you will run out of patients.
There were almost no efforts in the country at
the time to use basic queuing theory, which in simplest terms is what
Disneyworld uses. When you stand in line it is a single line. You go to the
next wicket when it is available, and you are always moving. These are very
basic techniques in queuing that have not been part of the health system
until very recently.
We made a series of recommendations, including
much more work on the research about benchmarks. Can we actually define a
legitimate benchmark where, if missed, the evidence would be that morbidity
or mortality is increasing? There remains very little work done in that
area, and that becomes a major problem in moving forward into other
We thought the whole process needed to be much
more multidisciplinary in its focus and nature, much more team-based. Care
had to be part of this because it is the only way of moving issues forward.
Lots of education of health care providers and
the public is needed. Most importantly, the use of single lists is needed.
This is still not in place in most jurisdictions. Each physician continues
to keep, in most areas though not all, their own lists. Therefore, there is
huge variability among surgeons in most areas about how long their lists
are. If pooled, lists would be shorter. We have to be much more
patient-focused. The system around wait-time management, historically and to
this day to some extent, is much more professionally focused. How you serve
the hospital and physicians and fit into their schedules is not as
coordinated around the patient focus as it needs to be.
One word that was mentioned, but that we
continue to pay far too little attention to, is the issue of
appropriateness. How do we know all the surgeries being done are in fact
needed? There is, once again, very little evidence that we know that
material well. Some research suggests the number of cataracts being
performed in some jurisdictions is way beyond what would be expected to be
needed, but we need more research in that area to either confirm or refute
that. That is clearly a disputable point, certainly if surgeons do not
acknowledge that there are too many cataracts being performed in any
The real issue was not what we do but how we do
it. How do we rebuild systems to improve patient access, patient flows and
appropriateness of care and to be more patient-centred? I think, ultimately,
the accord did a very good job with what we do, but a much poorer job around
how we do it.
In essence, the accord has bought a large
amount of volume and a little bit of change. I think any future accords need
to lever any purchase of volume or anything else with some capacity to
The data would suggest that, for the most part,
we have managed, in most provinces, to function reasonably within the
wait-times that were set. We have seen volumes increase substantially across
all provinces, without major detriment to other surgical or health care
areas. I think it is a mediocre performance. Volume has increased, but we
have not changed how we do business very much. I think that has to be the
focus of any future change.
Senator Merchant: Thank you for your
presentations. You presented us with a plethora of ideas and areas and
problems to deal with, but we are here as federal government. Because the
powers are split between the federal government and the provincial
governments, if you are helping us to have a report for the federal
government, what is the most important thing to do in sitting down with the
provinces? Is money the main issue, or is that, in your mind, no longer the
issue? Can someone start us off?
Ms. Power: Perhaps I could start. There are
some resources that are required, but I think it is more about focus. You
can pour lots of money into the provinces, and we could be going towards the
wrong things. In our brief, we have been trying to get across what I think
has been common to everything we have heard today: strengthening of the
primary health care, the appropriateness of care, what we are doing and how
we are doing it. I think if any dialogue were to happen, it should be along
those lines. Any monies that are transferred to provinces around specific
funds, for instance to make things happen, should have some metrics and
accountabilities attached. We have seen that happen with the last accord.
Monies have gone into provinces and there has not really been
accountability. Has it made a difference? We have not always been able to
Areas of focus like appropriateness, the
strengthening of primary health care, and transitions of care, about which I
think we are seeing a lot of work being done around the country, are where
we are focusing our attention for the future.
Dr. Postl: I think it is important that the
federal government needs to continue to be a partner. I think, failing that,
we will see enormous fragmentation of the many health systems we now have
into more disparate health systems with less and less connection. I think
the key issue in that partnership is to work with the provinces to decide
what needs to change in the structure and systems, and then to reward the
change, not just the activity. We have put lots of money into health care
for many years and not bought any change in the process. In some ways, the
sitting on our hands comment is exactly that issue. It has not been a lack
of investment, but a lack of moving forward.
Dr. Schull: I would agree with my
colleagues. The federal government needs to play a key role, a leadership
role, alongside the provinces in recognizing the split jurisdictions. There
is no doubt that the 2004-14 health accord has had a positive influence on
health care delivery across the country. It has not been an unqualified
success, but nonetheless a positive force. There is an opportunity for
another health accord to have a similarly positive effect.
The point that Dr. Postl just made around
buying change is critical. If you combine public and private expenditures,
Canada already spends about the same amount as most OECD countries, with the
exception of the U.S. and Switzerland, on its health care system. It is not
a lack of money, in my view. I think just continuing to increase what we are
paying without buying change, as Dr. Postl said, would be a mistake.
The question is what change we need to buy. In
my view, that change needs to focus on the systemness of our system. We do
not really have a system at the moment. We have a bunch of parties that are
all part of delivering care and that all bill the provincial governments for
that care and so on. However, they do not work together in an effective
manner in many instances. It is that integration of care, and that comes
down to governance and accountability. Who is responsible for the care being
provided? We need to define that. What are the outcomes we need to achieve
as a health care community? We need to define that.
We currently have a structure where physicians
who work in primary care are increasingly isolated. Even though they are in
family-health teams — multidisciplinary, which sounds great — they are very
isolated from the rest of the health care system. There is no accountability
shared across primary care providers and other providers elsewhere in the
health system. That is a critical mistake, in my view.
Dr. Simpson: The key is exactly what
everyone else has said, and that is changing the way we do business. The
issue in the debate has matured beyond just a simple request for more money.
We are all talking about accountability and targeted change.
From our perspective, it is the coordination
piece that is missing. We call them the bottlenecks in the series of
diagnostic and therapeutic events that is a care experience for a patient.
It is at these transition points, between the emergency room and being
admitted to hospital or back to the family physician, where the efficiencies
are lost and where the expectations are not met. That is where medical
errors are generated. The target for improvement is at these transitions of
Coming up with national standards or national
encouragement to develop IT solutions to help us have those tools to ease
those transitions of care will introduce more transparency into the system.
It will empower patients if we allow them to see where they are waiting and
where the problems are. They will tell us what we are doing wrong and
declare the issue much more starkly.
Senator Eggleton: I want to pick up on what
Senator Merchant asked and the response from Dr. Schull. If I understand
what you are saying, we do not need to spend more money but to spend it more
efficiently and effectively; we need to shuffle it around how we do
business. Do you agree with that?
Dr. Schull: I am not sure I agree with your
characterization of what I said. I said that Canada currently spends about
the same amount as OECD countries, with the exception of the U.S. and
Switzerland, which are sort of off the map. All of those countries are
increasing their spending annually above inflation, and Canada will have to
continue to do that.
I am not saying to turn off the tap. I am
saying to simply add more money without having that additional money, which
will be required anyway, buying change in the system would be a mistake.
Spending more money is not a mistake; rather, the way we spend it is
Senator Eggleton: With respect to spending
more money, the government has announced, for example, a 6 per cent increase
over the next two or three years. Is that a sufficient financial framework
to deal with?
Dr. Schull: I am not a health economist. I
will not say 6 per cent is enough or not enough. To simply spend an
additional 6 per cent in the same way we have been doing business for the
last 10 years would be a mistake.
Senator Eggleton: I understand that.
Let me ask you about the five priority wait
time areas. What can we do better? I guess we could say the cup is half full
and perhaps better. We have a lot of compliance, but not entirely. What do
we need to do to get better compliance on the five priorities that exist?
Second, have these five areas, the wait-list,
affected other areas? Have the provinces tended to do other areas at the
same time? Third, if not, what areas do we specifically need to focus on to
add to the five areas?
Dr. Simpson: From my experience, I am a
cardiologist, so cardiac was one of the five original areas. One thing that
is not commonly understood is that about 99 per cent of patients who come to
cardiac attention do not have bypass surgery. We are only measuring bypass
surgery as a target, so right away we have excluded 99 per cent of the
cardiac patients from any kind of wait time measurement in this context. You
talked about shoring up the existing five. That is one glaring error.
There are also some problems with the so-called
government benchmark of 26 weeks, whereas the medically determined
benchmark, based on evidence — this is one area where there is hard evidence
that people die while they are waiting — is six weeks. There has not been a
bypass surgery patient wait time of 26 weeks in Canada for many years, but
that is the government benchmark we are reporting against. These are easy
things we can fix if we can focus attention on it.
What we need to do in terms of making this a
more patient-centred experience and something patients can say, "That looks
like me," when we are talking about this issue is to focus on the entire
patient journey from the start of the time they require medical attention —
or even before the time they require medical attention, if we are talking
about preventative strategy — all the way through to acute care, chronic
disease management and end-of-life care, and start to build a wait time
profile around that journey. That means coming up with sensible benchmarks
that we can measure, count on and that patients can see. What does this
centre look like? What are their wait times? Let us look at that one. If we
can move to that, we can empower patients, and that is what will create the
tipping point for change.
Senator Eggleton: Remember, I asked a
The Chair: We have two minutes for the
Ms. Power: In terms of compliance, your
first question, on the ground what the issues are that face us is here there
are five strategies put out amongst a myriad of other huge needs in the
health care system. One of the issues for us in the real world is dealing
with all of our other physicians and patients, most important, who require
other services. Many of our physicians are saying these five are not the
most important anymore. They are important, but not the most important.
Can we get more compliant in those five areas?
It is a hard case to sell to say these are the most important with
everything else that is happening.
In my world, where I have to look at the entire
picture and the entire budget that is there and how we utilize that most
appropriately, we are putting a certain amount of resources to these five
areas, but they are not our top five priority areas anymore and frankly
never were. That is an issue for us.
It has been a detriment to other services. If
we think about, for example, bariatric surgery — we see obesity as an
enormous issue in this country — bariatric surgery for people we know are
using a lot of our resources and have a lot of co-morbidity is three years
waiting time. That is one tiny example.
It is trying to look at the entire system and
understanding where we have great evidence that waiting lists are
problematic, we are moving towards trying to bring those down. Where there
is not so great evidence, we are trying to look to the evidence to suggest
where we need to put our time and limited resources.
Dr. Postl: The evidence is that not very
much was missed, that there were things dropped because we were spending
more time. Locally, there is evidence in the orthopaedic areas that it is
tougher to get an arthroscopy as opposed to your upper knee done because the
surgeons are busy. What is amusing to some extent when you are in the middle
of it, this group of surgeons became wealthy in a short period of time
because of the $5.5 billion being spent, and the envy that caused in every
other surgical group escalated the costs of paying physicians because they
all went back to the market saying, "You have left us out," and that became
the focus of negotiation and the next fee settlements across the country. It
was an unintended consequence but a very real one.
Senator Martin: Thank you for your
presentations this morning. They speak to the importance of what we are
doing in evaluating and bringing together the key stakeholders to then
recommend to the minister, as she prepares to examine the renewal of this
I hear all of you saying, from your experiences
where you have the national and global perspective on this, some keywords
and phrases like accountability and the need for integrated systems and a
refocusing. In fact, you mentioned shared accountability. These are
important words and phrases.
You have given us much to reflect on and for
our analysts to look at in our report, but perhaps you could provide some
sort of indication focusing on the accord itself because I think it is an
important mechanism to try to integrate and coordinate as we are all saying
how important that would be for each jurisdiction. The provinces have this
jurisdiction, and yet we are best positioned federally and all of you as
global and national experts to suggest what some of the enabling factors in
the current accord are that have allowed certain jurisdictions to be more
successful. For example, those are the things we must keep.
What are some of the gaps? What needs to be
added to further the effectiveness of this accord? I would love to hear all
of you, in the presence of each other, agree on identifying some of the
gaps, as well as saying these are some of the enabling factors that have
been very good so we must keep them. That is a question to all of you.
Dr. Schull: As to why some jurisdictions
were more successful than others, I think the reasons vary from jurisdiction
to jurisdiction. I would not claim expertise on this particular question. In
general, I think that health system management is actually very complicated.
The capacity of jurisdictions to do it effectively varies tremendously. Some
of the larger provinces that have perhaps more administrative capacity have
done better in some instances than some of the smaller jurisdictions, but
there is tremendous variability even within provinces in terms of how
successful those provinces have been.
What are some of the success features of the
first accord? Focus, for one thing. There was a clear focus on wait times,
for better or worse. Some said it is the wrong five targets. Some asked why
we are just focusing on wait times. However, at least it was focusing on
something. That is a key element of success. The amount of money that was on
the table was substantial, and that is a key element of success. It buys
activity, and certainly it did so in this past instance. Those are at least
two elements that are critical going forward.
My personal view is that, if the focus were to
shift more towards system integration and accountability, I believe we are
not going to lose the focus on wait times. We have seen in some
jurisdictions, like Ontario, that the attention to wait times has gone
beyond those top five. There have been substantial efforts to reduce
emergency department waiting times, as one example, and with some success.
That has not been copied elsewhere.
I think you can get change outside the specific
parts that are named in the accord but, if you were to ask me what would be
the most critical area to be focusing on, it would be the ones I mentioned
around integration of care and accountability.
Ms. Power: I would echo the comments of my
colleague. We have tried in health care to boil the ocean and to be all
things to all people for so long. A great part of the 2004 accord was to
start to focus our attention. Rightly or wrongly, we needed to start
somewhere. The dollars came with it, because there is that upfront
investment that is required. We have had varying success across the
provinces, but that is just life and that is the way it is.
As we go forward, we need to get more to the
root of what the issues are in the health care system. Wait time, as we
mentioned, is just one dimension. It is hugely important to our citizens,
though. It truly is hugely important. We cannot take our eye off that. We
all know that. We are trying to bring those down to whatever the national
I think it is more trying to get to the root of
what the issues are as we go forward and really starting to invest in the
foundation of health care rather than pick off the one-ofs here and there.
Senator Callbeck: Good morning, everyone.
Thank you for your presentations.
The first question I want to ask is about a
problem that we have talked about for years. Ms. Power, you mentioned it,
and I believe it was in one other brief. The question is about people in
hospital beds who do not need to be there, because a hospital bed is so
expensive compared to the alternatives.
I do not know whether we are making any
progress in this regard or not. Ms. Power, you mentioned in your brief about
having an infrastructure fund and maybe tax policies regarding home care and
so on. Are we making any progress? Are there provinces that are doing things
that are improving the situation? As I say, this makes common sense, and it
seems that it has been a problem we have talked about for years. Are we
making any progress? If not, why not? Why can we not do something about
Ms. Power: The answer to your question is
yes, we are making some progress. There has been a huge infusion of funds
and nursing home beds in Ontario, Nova Scotia and many places. However, the
problem is that there is no silver bullet. There is no one thing. Ontario is
leading the way here with their home first program and looking to how we can
keep people safely in their homes. There was a period of time where we
looked to nursing homes as the answer to everything. Just build more nursing
homes, and everything will be fine. There is a need for some nursing home
beds, but I think our attention needs to switch to the community resources
that are out there. It is not so much always building more beds or nursing
home places, but how do we keep people in their homes? How do we keep them
well? What are the resources that need to be there? Sometimes it is as
simple as having someone come and chop your wood so you can have firewood
and stay safe, or someone to get your groceries. Sometimes it is much bigger
than that and much more complex.
I think this is something that is coming at us.
We have known it for a longer time with the baby boomers. We know that in
the next 20 years the impact on the health care system will be very intense
with the increased needs, because we are getting older and we are not a
healthy population, generally speaking.
In our minds, we really need to start to focus
and invest in that infrastructure, whatever that looks like — from just
supporting you in your home right on through to end-of-life care. It is not
that we are not making progress; it is that the demand is insatiable. We
have been doing a lot of things. If we had not done anything, we would be in
bigger trouble than we are today, but this is an ongoing issue for us. We
need to address it in a major, systemic way.
Dr. Simpson: To tie the wait time aspect to
the ALC issue, I think it is perhaps not appreciated fully that we actually
create ALC patients by making them wait. I see this every day in my
hospital. Many Canadians are waiting for their hip or knee replacement or
waiting for a cardiac procedure, sometimes even for a test. Since some
jurisdictions do not have a robust outpatient infrastructure, they wind up
coming to the emergency room for lack of anywhere else to go. We then admit
them to hospital to get the test faster. The weekend goes by, and they are
in bed. No one is getting them up because the physiotherapists are not
working on the weekend. Before you know it, this person who is just
functioning on the edge is now institutionalized. We have done this to them.
Then they get C. difficile and, before you know, it is a one-way trip
and they become ALC.
The whole thing is interconnected. We cannot
just solve the ALC problem by saying we need more long-term care beds and
better supports. All of those are important, but waiting for care generates
these unintended consequences of admitting people to hospital simply so they
can get care that could be easily delivered and better delivered in an
Dr. Schull: I would echo the comments
earlier that we are making some progress. The home first program is an
example in Ontario. The idea there is that a patient who is designated as
ALC, needing alternate level care, actually goes home to wait for the
long-term care bed. In a large proportion of cases, they no longer need the
long-term care bed once they get home and the support services are put in
place in the home. That has been a success story.
If you think about the problem, you have a
patient in a hospital bed who does not need to be there. They need to be
somewhere else, whether it is long-term care or home care. Who is
accountable for providing that? We have a system now where the hospital
wants to get the patient out because they need that bed, so they are
incented to get that patient out. However, there is no accountability in
terms of the long-term care home to take those patients in with any sort of
performance metric. There is no accountability on the part to the
community-based home care services to provide home care more rapidly. There
are efforts to do so, and I am not suggesting people are not trying to do
so, but there is not any sense of shared accountability across our system
even at the local level. This is just one example of one of the critical
problems we face. We are not all working on the same team, effectively.
I believe that many of the building blocks to
create a system where there is shared accountability are already there. We
have regional health authorities with defined geography and populations. We
have health organizations that have a history of working together, but they
do not have that shared accountability. I believe that is a key reason we
are not making more progress than we could be.
Senator Cordy: I spent Monday morning in
Nova Scotia at the signing of the palliative care coalition. I congratulate
all of these organizations for coming together for a stronger voice. They
asked me to use my voice in Parliament to talk about palliative care.
We have talked about long-term beds being used,
and we know that 80 per cent of Canadians want to die in their homes. It is
not a question of if we die; it is when we die. Eighty per cent say they
want to die in their homes, yet 70 per cent are dying in hospitals. This is
an area where we really can do what Canadians want and save money at the
same time, which is a crass way of phrasing it, but at least we would be
doing what Canadians want.
A number of you have mentioned reforms with
incentives, and you have talked about stronger accountability. How do we get
the incentives in place to make changes that Canadians want? Someone
mentioned it earlier; I was on the Kirby committee when we studied the
health care system, and Canadians were not nearly as open to changes at that
time as I think they are in 2011. How do we get the incentives?
Ms. Power, you talked about a national health
innovation fund where we share best practices and innovation that is
happening across the country. This was sort of a double or triple question,
dealing with the incentives, the accountability and the innovation fund,
which was one thing that you mentioned, if you could expand on that.
I truly believe Canadians are more ready for
change, and there are a lot of things that Canadians want. I do not think
Canadians want to be in hospital beds for months and months on end. They
would like to be in more of a home setting or in their own homes. One thing
I heard on the Aging Committee was that we should really have in place
something like the Veterans Independence Program, where people can stay in
their homes longer. I think we are always looking at the hospital-doctor
model, where some people just need someone to make a meal or, as someone
mentioned earlier, shovel the driveway or mow the lawn, housekeeping types
We have to get away from it being just
hospital-doctor-medical and use other agencies in our communities. Could you
comment on that?
Dr. Postl: I think palliative care is not
an innovation any longer, frankly. To kind of categorize these issues as
innovations is counterproductive. It is just a program that makes sense and
needs to be implemented which therefore needs funding and some action.
I think the risks of trying to tie every change
into innovation, if we know the change needs to happen — and there is lots
of evidence to support it — it stops being an innovation at that point and
it really is a change. The more we pretend everything is an innovation, the
more we start pilot projects we test in one or two places and they stay as
pilot projects. Things like palliative care and the proportion of people
able to die at home is not a news flash. That is something that should have
been in place many years ago and it is something that should happen.
Ms. Power: Thank you for the question. It
was a great question. I agree with Dr. Postl for sure.
Our reference to the innovation fund was to
look at other areas where those pockets of excellence are happening across
Canada; we know they are happening. We do not have a good clearing house or
a good place where we can start to share what those innovations are to
really make the change. I agree that palliative care is not an innovation.
I want to share with you, as an example, a
palliative care program in terms of where we could be headed. It is
something that comes out of Halifax, but we are trying to share this across
the country. We call it the PATH program. It is meant to be palliative and
therapeutic harmonization. It is focused on the frail elderly, particularly
people with dementia. We use, for example, a case study of a man with
dementia in his seventies who is on the waiting list for cardiac surgery.
The cardiac surgeon will go ahead and do it because he is looking at the
heart and his ability to make that better. However, when you look at it in
the context of the person, you recognize that going through surgery will be
hugely detrimental to that patient; it will increase their dementia and
there will be lots of co-morbidities that could happen. In the conversation
with the patient and family, we must recognize that this is not the most
appropriate way to go. How do you help the patient and family live with the
condition? A whole program was put in place around that, which has been
wildly successful and has cut down incredibly on lengths of stay and
inappropriate care, et cetera.
I think there are wonderful examples of
innovation around palliative care and all kinds of other things that as
Canadians we need to share and be able to tap into to really make a
difference in what we are doing.
Senator Seidman: I think we all recognize
that undoubtedly we are at a serious crossroads here. I too have tried to
listen very carefully to what you have all been saying. It is very evident
to me and probably to everyone sitting around this table that you have all
been emphasizing the same things.
Ms. Power, you were very focused on
accountability; Mr. Vail on efficiency; Dr. Schull, you were very
patient-centred; and Dr. Postl raised very serious issues about
accountability and scientific evidence.
In that spirit, I would like to ask about
reporting, comparability of data and electronic records. Very specifically,
the kind of impact that a coherent plan could have on these three themes you
have put forward today: accountability, patient-centred and efficient
Dr. Schull: I am a clinician wherein I see
patients in the emergency department, and I am also a health services
researcher, so I use data every day in my work.
One of the four things I mentioned in my brief
was a critical reform. We need to make progress on electronic data systems
in Canada. We have made far too little over the last 10 years. There are
jurisdictions and hospitals that have made more progress than others, but as
a country and when you look at individual private practitioners and the use
of electronic data systems, we are far behind most other comparable
countries in the OECD. Actually, that distance I think is getting worse, not
better. We need to make more progress. I will not claim expertise in
understanding why we have not made as much progress as we could, but I would
say that is absolutely critical.
Where we may have gotten off track a little bit
is that at the outset, there was the idea that it would have been ideal to
have some kind of national electronic health record, wherein if I came from
Toronto to Ottawa today but suddenly had chest pain, I could go to the
Ottawa General and someone could pull up my record from Toronto. Would that
not be wonderful?
All I want as a practising clinician, when
someone comes into my emergency room at Sunnybrook, I would like to at least
be able to pull up the records from the clinics in Sunnybrook Hospital. I
cannot do that right now, let alone the records of their primary care
physician or outpatient records.
A few weeks ago, I had a woman come into the
emergency department with her husband who had a number of chronic issues,
and when I asked for results from the battery of previous tests he had had,
she asked, "Can you not pull it up on the computer?" It made perfect sense
for her to say that. I said, "I wish I could but I cannot."
The point is, we need those data systems at the
coal face, when we are seeing patients. We also need that data to feed into
electronic data systems in a timely manner in order to judge how well our
system is performing, and we can report that to Canadians. Right now, we
have that in places, but it is spotty, there is not good national public
reporting, on top of which it really is not timely enough. The typical
report at the Institute for Clinical Evaluative Sciences is probably at
least 18 months old by the time we report the data. By then, most people
say, "That is old data."
Dr. Postl: I would agree with that
entirely, that it is almost a no-brainer that you need to be able to access
information about patients while you are caring for them from wherever that
data may exist.
One of the fascinating features that we have to
deal with is the issue of privacy, because for these records to be
effective, they must be part of a public system. They cannot just sit in a
doctor's office or a clinic or a hospital. They have to be widely shareable,
and we have to make sure we manage the issues of privacy to make that
possible. Without that, they will also be seen as mediocre in their
performance 10 years from now, when it is better implemented because we will
not be able to share the data effectively.
The Chair: Who should make it happen?
Dr. Schull: I do not think there is any one
player. The federal government, again, has a leadership role to play. The
Canadian government invested billions of dollars in Infoway and needs to
continue to take that leadership role.
My view is that where there has been most
progress is where local systems have taken this by the horns and developed a
system that works locally. I do not really care if I cannot get records from
when my patient lived in Edmonton four years ago. What I want to have access
to routinely is the local health care information in my system of care.
There are examples where systems locally, including different organizations
and so forth, have come together. Alberta has made huge progress in terms of
developing population-based data records.
Jurisdictions or organizations such as the
veterans administration in the U.S. have proven, and there is terrific
evidence, that having a coherent and smoothly functioning electronic health
data system, overcoming these issues of security — which are important, but
I fear are sometimes red herrings and are used to delay progress in this
area — demonstrated substantial improvements in quality and reduction in
cost. This is absolutely a no-brainer, and the federal government has to be
at the table leading the way in collaboration with the provinces and
Dr. Simpson: We have talked a lot about
personal health information and how important it is for practitioners to
have that and to be able to share back and forth. The other part of this, of
course, and I think you were alluding to this, is the system data and how we
can use it to make the system better. The key role for the federal
government is clearly assisting in the development of national standards and
national data definitions. We have 13 different political jurisdictions that
measure wait times in different ways and report them in different ways, so
comparisons across jurisdictions become difficult to interpret. That creates
a lot of noise and distracts from the mission of trying to all move forward
together. From a very macro-level, that kind of leadership at the top would
be a big step forward.
Ms. Power: I think there was gross
underestimation going into this of the level of sophistication in the IT
world in health care. We were starting with Rolodex, in some instances. We
were going back a long way.
You asked who should do this. I do believe that
the federal government needs to take a leadership role around a vision for a
national IT infrastructure. Yes, today, we are so far behind that all we
want to care for the patients in front of us is what is local, but we have
to be thinking bigger than that. We have to be thinking that, as a country,
we can start to share information and use it to compare ourselves and to be
able to care for the people who come through our doors.
Senator Demers: I found your answers to be
extremely honest with no sugar coating, and I like that. I do not like BS,
and you did not do that. Last year, at this time, I was not able to attend
the Senate because I was recovering from a medical mistake. We started with
a minor operation. It ended up being between life and death in 48 hours. It
was a tough situation. It became publicized because I happen to be a former
NHL coach, and it came to be known around North America. I am not bragging
I have a friend who is a doctor, and we have
discussed this over the years. The system is broken. It is not just the
Jacques Demers. In the United States, 180,000 people died last year because
of medical mistakes, and there are a lot of people in Canada. Where do we
start? By the way, the two doctors who operated on me were great doctors, so
no accusation. They are overworked and fatigued. The younger doctors, but
not all of them, are not willing to put the time in that they used to. The
nurses are overworked. There are people today fighting for their lives
because of medical mistakes, or they are sent home and they never recover.
Where does it start? Is the system broken? I feel for those doctors and
nurses. They have made a change at the hospital where I was so the doctor
does not come in for two minutes, "Hi, coach, how are you? Did the Montreal
Canadians win last night?" It is nothing personal. They look at my stomach
and walk out. Three days later, I am between life and death. That happens a
lot. Where do we start from there? It is not money. Where do we start? Thank
you for your answer.
Ms. Power: Is our system broken? I would
say that the system is not broken. By and large, as a health system, we do
great work and save lives every day. Are mistakes made? Absolutely. We talk
in our brief around quality and focusing on quality. How are we doing? How
are we measuring up? Where are we making mistakes? How can we stop them? If
you look around this country, there are a number of organizations dedicated
to looking at quality. In fact, there are a lot of them. Maybe something to
think about is how we streamline that whole look. There has to be a push on
quality. We have, through Accreditation Canada and the Canadian Patient
Safety Institute, recognized that these things are happening all the time.
I would bet my life that there is not one
health care organization that is not spending a tonne of time and money on
quality and being sure that we are doing everything we can to prevent those
errors. However, it still requires a much greater focus and a convergence of
all of the work that many organizations are doing around quality to ensure
that, the next time you come into hospital, we have learned from those
mistakes and have processes in place to prevent it from happening again.
Dr. Simpson: Senator Demers, I grew up in
New Brunswick when you were coaching the Fredericton Express, so I came to
know you then as someone who does not sugar-coat things.
Senator Demers: Especially when I lose.
Dr. Simpson: Listening to my radio at
night, I heard you in those post-game interviews.
Medical mistakes are huge. There has been a
culture change. There is a culture of patient safety that has penetrated
every corner of the country and every medical environment in the country.
Part of that is the commitment to disclose the error in an honest,
forthcoming and timely way so that patients and their families can
understand exactly what happened. They can prepare and deal with it, take
charge again and become in control again. They also need to know that the
system in the hospital and the providers and everyone who has been involved
in the adverse event are committed to learning from it so that things like
that do not happen again. Your comment is bang on.
It could potentially be part of a patient
charter. One of the things that patients are entitled to is having a safe
hospital stay or a safe medical experience but, when there is an adverse
event, they have a right to timely disclosure of that event.
Dr. Postl: The first thing about safety
patient issues is that they have always been here. This is not a new
phenomenon. It will never be zero. The environment is too complex. Where you
see patient safety issues come to bear is often in transition points, in
patient movement between ORs and ICUs, between emergency rooms and ICUs or
between hospitals and personal care homes. We have not done as well, and
people are working hard on, on how to systematize our processes so that you
consider patient safety in every step in the progression of care. That is
part of being more patient focused. When you are not patient focused, you
are moving patients as entities, not as patients, between units, between
activities or between functions. If we focus on the patient in that
movement, in that journey they have through the health system, patient
safety starts improving very dramatically.
Dr. Schull: I would argue that patient
safety is probably one of the bright spots over the last ten years in terms
of a general culture change. There has been real progress certainly in terms
of measurement, identification of indicators, measuring those indicators and
trying to address change. The problem is that most of that attention has
been within hospitals or within organizations or within one part of the
system. If a surgeon walks in and amputates the wrong leg, it is pretty
obvious who made the mistake. Where we are having ongoing challenges, as
Dr. Postl just said, is in diffuse responsibilities or in transitions of
care. When a patient leaves the emergency department and goes home, there is
no report that gets to the family doctor, and a blood test never gets
followed up properly. Who is responsible? When a patient is discharged from
hospital to a long-term care facility and there is never any good
interaction between the primary care physician and the specialist, who is
responsible? That is unclear in our system, and that is where there are a
lot of errors and safety problems occurring. While they can be measured, at
this point it is not that clear how we resolve them because the
accountability is unclear.
Senator Champagne: According to most of the
charts we see in the media and the ones for Quebec’s health care system, the
situation seems to be worse in Canada. I do not agree with that. Over the
past five years, I have seen the best in our health care system. I had
meningococcemia and I was in a deep coma for 42 days.
After being in the hospital for 65 days, I
wanted to go home. Yes, I needed a walker, but I wanted to go home. I was
finally allowed to go home instead of going to a convalescent home. For two
months, a CLSC nurse came to my house every day to change the dressings on
my legs, do the blood tests and send the results to the doctor so that he
would adjust the Coumadin dosage, and so on.
That is a great way to free up hospital beds.
They ended up letting me go home five or six days earlier than they had
hoped. After meningococcemia, the last thing I needed was depression. Do the
other provinces have this type of service? If not, should the government not
push to make a service like that available? The fact that they were able to
come to my house to change the dressing on my legs every day, since I was
not able to walk to a clinic, made it possible to free up a hospital room at
the time. What do you think about that?
Ms. Power: This is what we are talking
about for home care and there is home care in all of the provinces that is
working very well. The area where we need to strengthen that somewhat is the
degree of home care that is made available. If you are having your dressing
changed once a day, or a couple of times a day, that is pretty standard in
home care across the country and that is supported by most provincial
governments. If you require a lot of home care that is where the gap is, and
people are staying a long time in hospital because those kinds of resources
are not in the community.
We are talking about that when we talk about
enhancing primary health care and some kind of structural fund for the
community, and how we put additional resources there so we can let people go
home. They will recover far better than they will in hospital, surrounded by
the things that are important to them. That is a good point.
Senator Champagne: I was lucky to have a
husband who ran errands and took care of the rest at home. At the same time,
I thought it was great that I did not have to go to a clinic every day; they
were the ones coming to my house. That also helped my husband, since he did
not have to drive me and bring my wheelchair so that I could get around.
I have also seen the worst. I recently had to
go to the emergency room because I could not see a doctor. I was not dying,
but I was in a lot of pain. I got there at 11 a.m. and went to triage at
12:30 p.m. At 6 p.m., I was still in the room when I was finally called to a
second triage. This is what they told me: "Wait, you are not a priority". I
asked what process they used to determine who was a priority and they said:
"Accidents, people in cardiac distress, children, old people and others. You
are with others, so just manage!"
So I asked: "How old do you have to be to be
considered old?" I said that I was 72. "How long do I have to wait before I
am considered old?"
She finally looked at my file, which she had
obviously not done before, and moved me from the 12th
spot to the fourth, which meant that a doctor saw me at midnight. I had been
there since 11 a.m. I really want to believe that I was not dying, but it
was very painful.
Something is not right with that picture. If
the triage staff person does not look at the patient’s age, perhaps that is
one thing we could work on.
In short, there should be ads to help people be
better patients for their doctors, encouraging them to always bring the list
of drugs and allergies along with their health cards. I think that would be
a great thing to put in TV ads, for example. I think we would avoid
Dr. Schull: As an emergency room physician,
I have to say that I find your experience horrific. I apologize on behalf of
all the emergency room doctors. Is Quebec the worst? I do not think so, but
I must say that, in terms of emergency room wait times, Quebec is certainly
among the worst. We do not have the information for all the provinces, so we
cannot really tell. If I understand correctly, the wait time target set by
the Quebec ministry of health is 12 hours on average. So you waited for
12 hours, which means that you reached the target if that is the average.
As a doctor and as a patient, I find that
unacceptable. This partly has to do with the target that is set to begin
Ontario has been quite successful over the past
few years in terms of emergency wait times. Ontario’s target is that, on
average, 90 per cent of patients with serious problems spend a maximum of
eight hours in the emergency room. That means that the total amount of time
from the moment you arrive to the moment you leave is a maximum of eight
hours. It would be four hours in minor cases.
We have seen wait times go down because of a
policy that included major investments. I can tell you that, as an emergency
physician, I have seen a major change in emergency rooms over the past ten
years. I hope this will be the case everywhere, but that takes a government
willing to focus on the problem and ready to invest.
Senator Champagne: I wanted to tell you,
since you are an emergency physician, that an emergency doctor from my small
regional hospital was actually the one able to diagnose my meningococcemia
in 36 hours. And all the specialists who saw me afterwards gave him credit
for saving my life, and I thank him for that.
Senator Braley: I am going to tackle the
question a little bit differently. You are all experts and you are all
doctors, or at least you have the background in the medical profession. Does
the medical school, for example, teach from birth to palliative care? Do
they have a course for the general practitioner on palliative care?
In my business I would go and get the people,
such as the tool and die maker and other various people, to solve a problem.
You are the people most aware of the problem. Are you doing research on what
the doctor should do versus what the nurse practitioner should do, versus
what the next person in the line should do, so that you can have clinics
where you can handle double the number of people so they all have a GP? Is
the research being done on how to administer and prioritize?
You are a dean at a university. I would think
that those areas of applying how to make a business better would be perfect
research for some of the doctors, or some in the business schools or some of
the people working together to do, and the problems can be resolved between
the governments and the profession to better service the people. Customer
service is the only thing that matters here.
I am really asking whether the solution should
come from within. It is a crazy question, but when we solve problems in a
company that is exactly what we do. We tackle that as the priority. Then I
assign the best people who are part of a group. They could be from any
department. They work together and draw the people in that they need. Then
they go back to their own jobs after.
I would like a comment on that.
Dr. Postl: I believe the answer is yes, the
medical schools across the country are trying to focus much more than they
traditionally have on issues of accountability and how you teach social
responsibility to medical students. Universities generally are trying to get
a grip on multidisciplinary care, how to expand scopes of practices for
nurses, for example, or introduce new workers such as physician assistants
and clinical assistants. Certainly our province has done a lot of that. The
answer is yes, it is moving. However, health professions, historically — and
I do not think this is changing dramatically, despite the movement — are
vested and have strong interests. They have trouble sharing and playing in
the same sandbox, so that takes a lot more practice than we have had yet. I
think it is coming, but it has to be a growing and major emphasis.
Around the research, I think that is a key
question. We are not doing enough health services research as a country to
allow us to ask the questions. One of the real opportunities, building up to
the accord, are for governments to define the six or ten or twelve questions
they want answered, and then ensure that research is done so that when we
head into an accord, there is evidence to support potential change, that we
actually have some ideas of what will work in moving forward future changes.
We tend to do the research after the fact. The
barn door has been opened, the money has spent, and then we try to figure
out whether we had any impact. I think we can do a much better job of that.
Senator Braley: We have such great
Ms. Power: Thank you for raising that,
because it is a great question and an area that we have fallen down on over
the years. I am the only non-physician of my colleagues sitting up here, but
a nurse by background. We have traditionally been focused on our own
profession and what unique contribution we make to patient care. It has just
been in the last few years that we have really started to look at
interdisciplinary care. As Dr. Postl says, there is huge push-back from many
of the disciplines themselves about sharing that accountability and
responsibility for patient care. We need a lot more work in that area, lots
of work and research going on around different models of care.
Where we see it in action, it is beautiful to
behold, that, based on what the patient's needs are, we bring the right
practitioner to them. We have a long way to go, but it will be one of the
things that will change the face of health care. Whether we like it or not,
as professionals, our public are demanding it of us.
Senator Braley: The customer will be the
Dr. Simpson: I completely support
everything that has been said. Dr. Postl's comments are bang on,
particularly the comments about the need for more health services research
and the opportunity to perhaps define in a focused way what those might be.
I hasten to add, however, that there is a whole
lot of stuff we already know how to do and we are not doing it. Chronic
disease management is the perfect example of how multi-professional teams
can work together to get proven good outcomes, but we have not been able to
overcome these political and other barriers in order to make it happen.
Better care, and care that is cheaper, should be an easy sell to everyone,
but for some reason we are not doing it as much as we should be.
Senator Braley: Is that management? Is that
getting the research done properly so it is out there and they have to
Dr. Simpson: Part of it is just overcoming
those political barriers. We are all trained in silos and then expected to
work together after we are done training. We are now starting to train them
Senator Braley: The best teams are not in
Dr. Simpson: Exactly.
Dr. Schull: Thank you for the question.
Your analogy of a company CEO is apt. There is no CEO in charge of the
health system. There is no one in charge. There is a real governance vacuum
in terms of trying to determine who should be responsible. It cannot be a
minister of health. It cannot possibly be at that level. There needs to be
local governance that is established with responsibility and accountability.
Second, you mentioned that if there is a
problem, you go out and hire the tool and die makers. Let us assume that
analogy, that the tool and die maker is the physician. The physician does
not work for you. The physician does not work for the health system. The
physician is a private practitioner who bills directly to the health care
system. He does not work for the CEO of the hospital or for the local health
region. Therefore, your control and the levers you have with that individual
The truth of the matter is that the structure
of our system needs some fundamental reform. It does not require blowing it
up and starting all over, but it does require a layering in of new
incentives and new governance models, I am convinced.
Senator Braley: How to manage it,
basically, will become the research that has to be done, and the customer
will demand the service. In the final analysis, the customer is always
right, the person who is getting the health care. That is one of the most
important things to everyone in this country.
I think there are huge possibilities for the
medical schools to lead the charge on this for the country. They may be a
little different here and there, but when you put them together, you will
get something that is really special, and that is basically doing it without
having the doctors who have the silos, coming out of the medical schools
themselves. It is just a thought that has crossed my mind over the last
Dr. Postl: I point out that what we are
talking about — and something that we tend to forget — is that from the
start of intake to the point of finishing your specialty training, you may
be in a 15-year cycle.
Senator Braley: The demographics change, so
you have to keep moving that.
Senator Verner: First, thank you and
welcome to our committee this morning. It is refreshing to hear something
other than the usual "we need more money, we absolutely need more money for
that". Without denying the fact that, since the population and the
demographics are going to require it, we have to continue making significant
investments in health, I think we have to be realistic and come up with new
ways of doing things. That is a very refreshing speech.
My question has to do with another topic. Given
that we have some doctors and a nurse here with us, could you tell me how
this affects the provision of care? How many times have we heard, at one
time or another, that there was an outbreak of C. difficile or bacteria in a
hospital or in a seniors residence? I am not a microbiologist but, quite
frankly, we have been losing elderly people because of that. The numbers are
not high, but a loss is a loss. Anyway, as a result, my old mother keeps
telling me to wait for her to be really sick before bringing her to a
hospital. Have the bacteria outbreaks that we hear so much about always been
like this? Do we just hear more about them now because of media coverage or
are they connected to other factors beyond your control, such as the aging
The Chair: Who wants to start?
Dr. Schull: I am not a microbiologist and I
cannot say that I studied epidemiology and outbreaks, but based on my
clinical observations and the data I have seen, I think that, for one thing,
the patient population in hospitals has changed; the population is not just
aging, patients are much sicker today than they were when I started my
career. I am not very old, but I can say that the average patient on a
hospital floor — I am not talking about ICU — is sicker than patients used
to be 15 years ago. The shortage of hospital beds forces us to use them more
wisely. We also have better solutions in many cases. So the patients are
older and sicker, which means that they are more susceptible to diseases,
such as C. difficile.
The aging of the infrastructure can also play a
major role in some hospitals.
The cuts in the 1990s certainly had something
to do with the decision to cut support staff because they were not a
priority and cuts had to be made. I think we now know it was a mistake and
we are starting to reinvest in those basic services.
We cannot point to just one factor; there are a
number of factors. I also agree that we are better equipped to monitor what
is happening in hospitals and that perhaps we were not aware of outbreaks as
much in the past.
The Chair: I would like to put a couple of
questions. One is with regard to the benchmarks using wait times. Clearly,
this is an obvious benchmark that can be measured. I want to know if, as a
broad stroke, it is a good one. You mentioned the issue of knee replacement
being one of the ones that had not progressed very much, I think, in an
earlier comment, or perhaps it was Dr. Simpson who said that.
Let us take the case of someone who is obese,
perhaps diabetic, who comes in and needs a knee replacement. My
understanding is one of the first things that may be required is the loss of
significant weight. However, that may take up to 12 months. That, I assume,
is included in the wait time for that particular patient to get to surgery.
Obviously, it would not be appropriate to carry out the surgery before the
surgery will be effective.
Are there aspects of these direct benchmarks
that need to be taken into consideration in using them to report to our
citizens on the delivery of health care?
Dr. Postl: We went through that while we
were discussing the system, such as when do you start the count? When does
the time begin? An important comment was made early in that should it really
begin when the primary care physician decides on a referral because they
suspect a knee replacement is required? Or is it at the point that the
specialist sees you and agrees that the knee needs replacement? Or is it at
the point that they actually book the OR because there may be other issues
intervening, such as getting blood sugars or blood pressure or obesity into
a better condition before actually being slated for surgery? When you look
at some of the anxieties that come out of the public with these long wait
times and you actually slice into them, you discover many of those things,
that the actual wait time was not out of sync based on how it was being
counted; it was all the other times that the patient was experiencing, so to
them it is still a wait time, but the count had never started until two
months before the surgery. That is part of the debate and discussion that
has to go into each wait time.
We began with the booking of ORs, in effect, as
the start time. When the decision was made that surgery was required, that
was the start point and the OR was requested. There is a good argument that
can be made in measuring at least two different times. One is the time of
the primary care decision to move into specialty care. You may want to
measure them as two different times, otherwise it becomes very complex. For
example, the primary care physician may think they need a specialty
referral. When the specialist does a review, they decide that surgery is not
required, so it would be a bit nonsensical to count that as a wait time for
surgery. We have to get better at agreeing on what we are measuring and then
measure it more routinely and systematically across the country so it can be
Dr. Simpson: Dr. Postl said it well. The
central issue is how to define these, and more precisely, how will we define
the components of the patient's journey? In your example, a patient should
not be on a knee surgery wait list if the decision has been taken to try
this other strategy first, such as losing weight, and once that strategy has
failed, then they will go on the list.
You can see the potential for creating
circumstances where it becomes difficult to measure across jurisdictions as
to who is doing better than others. Precise definitions of each component is
The Chair: The other question deals with
issues you have all touched on, which are the efficiency of delivery, the
coordination of specialists and so on. For example, a diabetic comes in for
a serious issue who may need access to several different specialists. When I
casually look at the scheduling of those specialists at a given hospital, I
see this one comes in on a given day, another on a given morning. The
possibility of the patient who requires input from several specialists
seeing them on a given visit strikes me as vanishingly small in certain
circumstances. Is that an issue in terms of the effectiveness and the
success in the delivery of significant health care?
Dr. Postl: Absolutely. It is clearly one of
the key issues about a patient's journey. How do you help patients navigate
a system that is so complex? How do you coordinate appointments, ensure the
appointments are necessary and make sure that the consultants are
communicating with each other so one is not taking care of the renal problem
and the other the cardiac problem, but they are not communicating about the
patient? That is frankly a frequent issue in the health system.
Dr. Simpson: That is a great point. There
are some typical patient pathways that require multiple components. There
may be a patient who requires Test Y, X, and Z, and most patients require
that package. It is possible to create a one-stop shop kind of model for
patient convenience and to shorten overall wait times for a lot of patients
that we do not see. There are some who are very complicated and who have to
be navigated through the system. This is where patient navigators can
The Chair: Since I have some senators on a
second round, I wanted to get that on the record. If you have additional
points to make, I would like to ask, with regard to what I will say next, I
have three possibly four senators on a second round. We do not have time for
the kinds of answers and the detailed preambles that we have had to this
If a senator has a significant question that
will not be able to be handled in just a quick couple of minutes, I would
ask them to direct the question specifically and ask if the witness could
respond in writing within a couple of weeks of this meeting.
To my colleagues on the second round, if that
is agreeable to you, I will start with Senator Callbeck.
Senator Callbeck: Senator Ogilvie addressed
the wait time issue, but I want to be sure of the definition. When we talk
about wait times, my understanding is that is the time from when the
specialist says, "I will replace your hip." You go to a general
practitioner, and probably two months later you get in to see a specialist.
However, those two months are not factored into the wait time at all. Is
Dr. Schull: That is right.
Senator Callbeck: Do you agree with that?
Dr. Schull: No.
Senator Callbeck: Two people are shaking
Dr. Postl: The patient does not know the
difference between what they are waiting for. They just know they are
waiting, whether for the specialist or for the surgery. In their mind, it
will be part of the wait time. We only count the point the decision is made
that surgery is required; that is the starting point of the wait time.
Dr. Schull: Part of the problem is we do
not have good data on when the referral took place. We do not know. As far
as I am aware, there are not any good data systems currently, with the
exception of the family health team, electronic medical records and so on,
that would allow you to measure the first wait. I think that is why the
second wait was chosen because it is actually measured. However, I think we
all agree that both of those are important, both need to be measured but
also separated so we understand where the delays are occurring.
Senator Eggleton: Following up on this,
when does the clock starting ticking in the different provinces? Does it
vary from province to province, or do they all have similar wait time
Dr. Postl: They are all similar. They are
not precisely the same. If you dig into it, you will find minor variations,
but the wait time clock was agreed to as part of the negotiations between
the provinces and federal government as part of the health care accord. It
was engineered or participated in with the Canadian Institute for Health
Information to build the definitions.
Senator Eggleton: The wait time clock is
more like Senator Callbeck described it; it is from the time you see the
specialist as opposed to the wait. You think it should be right from the
beginning of when you see the GP?
Dr. Postl: Yes.
Senator Eggleton: Can I clarify one other
thing? Ms. Power, with respect to the national health innovation fund, you
are saying this should be an opportunity to share pockets of excellence or
best practices kind of thing. How would that relate to the work of the
Canadian Institutes of Health Research? Would they administer this kind of
thing? How do you see that so it does not duplicate what they are doing or
what someone else is doing? Who would administer it? You would not set up a
whole bureaucracy to accomplish this, would you?
Ms. Power: No, we would not. That may be an
opportunity for that. We have not looked at how to make that happen. It is
more a concept for us as we start to work through what needs to happen.
Senator Seidman: I would like to know
whether there is available evidence on the appropriateness and overuse of
certain procedures and technologies. I am mindful of diagnostic imaging. It
has not come up here at all today, I do not think, and I know that there are
no benchmarks currently for it. If you could make quick comments about that.
Dr. Schull: There have been some good
studies that have looked at CT and MRI utilization in Ontario and have found
there are substantial portions where at least the decision to initiate the
test was questionable, if not inappropriate, by virtue of the fact that the
results are normal, it was a repeat of prior tests that have already been
done or the clinical indication was not there.
The appropriateness of many of these diagnostic
tests is difficult to establish, but I think it is possible to do so. There
has not been a lot of effort to do that yet. Designing a system to implement
gates, so to speak, so that you only perform tests when appropriate, is a
challenge. We know that in some instances those sorts of systems, where you
are dealing with limited access to, say, CT, and so someone has to review
the requisition and decide on its appropriateness, actually acts as a
further obstacle and can delay what are important tests.
The simple answer is that we do not have a good
approach to determining the appropriateness of the tests that are done. This
is a critical issue with respect to not just diagnostic tests but even
Senator Martin: I go back to asking about
the enabling factors, what we need to include in the accord to recommend to
the minister, and insertion of specific content language. You mentioned in
your presentation accountability matrices. I wanted to ask for your input,
in writing, of what those specific enabling factors should be. I have my own
list, but I would love to hear from each of you.
The Chair: We will look forward to that.
Senator Merchant: Perhaps you can let us
know as well if you think there should be conditions placed on money in
return for performance. I do not know how that would work exactly. Does the
federal government right now have any control over how the provinces spend
the money? Do they know how the provinces spend the money?
The Chair: Who would like to take that on?
Dr. Postl: The answer is that the federal
government has very little information about how the provinces spend money,
other than what the provinces report.
Senator Merchant: Should they?
Dr. Postl: To me, if I were using my
spending power, I would want it in exchange for something else. If that is
on the list of what the "something else" is, I think that should be a key
part of the discussion.
Dr. Schull: Does the federal government
know? I would say the answer is no. Should the federal government know, and
should the money be conditional? I would say absolutely yes.
The Chair: Thank you all for the precision
and frankness of your responses. Areas were explored today that got to a
number of very important aspects. As was indicated a moment ago, we would
certainly welcome further input from you in writing on matters like the list
of 16 items that should be on a checklist or a benchmark or whatever, and
other aspects where you can provide us with additional information and
suggestions in response to the issues discussed here today, based on your
experience, that you believe can help us in our deliberations.
I want to thank my colleagues for adhering
reasonably closely to their times and focusing their questions. With that, I
will thank you all and declare this session ended.