Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue No. 25 - Evidence - May 30, 2017
OTTAWA, Tuesday, May 30, 2017
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 2:15 p.m., to continue its study of the subject matter of those elements contained in Divisions 5, 9, 11, 13, 14 and 16 of Part 4 of Bill C-44, An Act to implement certain provisions of the budget tabled in Parliament on March 22, 2017 and other measures.
Senator Kelvin Kenneth Ogilivie (Chair) in the chair.
[Translation]
The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
I am Kelvin Ogilvie from Nova Scotia, chair of the committee. I will invite my colleagues to introduce themselves.
Senator Eggleton: Art Eggleton from Toronto, deputy chair of the committee.
Senator Dean: Tony Dean from Toronto, Ontario.
[Translation]
Senator Mégie: Marie-Françoise Mégie from Montreal, Quebec.
Senator Cormier: René Cormier from New Brunswick.
Senator Petitclerc: Senator Chantal Petitclerc from Quebec.
[English]
Senator Stewart Olsen: Carolyn Stewart Olsen from New Brunswick.
Senator Seidman: Judith Seidman from Montreal, Quebec.
The Chair: In order to introduce today's meetings I will remind us that we are here on a pre-study of Bill C-44, An Act to implement certain provisions of the budget tabled in Parliament on March 22, 2017, and other measures. This afternoon specifically, we are dealing with the subject matter of Division 9, funding to provinces for home care and mental health services.
We have two witness groups with us for this session, which will end no later than 3:15 p.m., and I'm going to invite them to make their presentations in the order that they appear on my agenda. I will call on them in a second. I will remind us all that our witnesses will make their presentations, and then I will open the floor up to questions from the senators.
With that, I'm going to invite Patrick Smith, National Chief Executive Officer, Canadian Mental Health Association, to make his presentation.
Patrick Smith, National Chief Executive Officer, Canadian Mental Health Association: Thank you Mr. Chairman. Good afternoon members of the committee. Thank you for inviting me here today. My name is Dr. Patrick Smith, National CEO of the Canadian Mental Health Association, celebrating 100 years in 2018. We are a Canada-wide organization with over 15,000 staff and volunteers in every province in over 300 operational locations in the country. We're often described as the community-based mental health organization with boots on the ground.
Everywhere we have gone, we recognize that mental health, including addictions, is a non-partisan issue. The Trudeau government has demonstrated unprecedented leadership in recognizing and working to redress dramatic gaps in mental health. Prime Minister Trudeau has signalled this understanding of the whole-of-government approach necessary with specific mental health deliverables included in multiple ministers' mandate letters. The 2017 budget demonstrated a commitment to beginning to close the many gaps in proportional funding and to begin to transform our country's response to mental health and mental illness.
CMHA called on the government to target and earmark dedicated funds for mental health in their transfer to the funds for the provinces.
CMHA was pleased to see funding from the federal government earmarked for mental health and to see this government's targeted funding for high-risk, high-need communities, such as veterans, active duty military and military families, as well as indigenous peoples, caregivers, children and youth, and individuals living with substance use disorders.
However, there is some way to go before mental health care is funded on par with physical health care and in proportion to the burden of illness. Canada spends the lowest proportion of their health care funding on mental health among all G7 countries. This historic under funding has led to significant gaps in access to basic mental health services and supports. This gap wasn't created overnight, and it will take concentrated effort and ongoing commitment to address it. The Canadian Mental Health Association calls for continued investment in mental health, especially in community-based services, and supports to bring Canada in line with other G7 countries, where it still lags behind.
We're calling for dedicated funding to be focused on five key fundamental areas that are furthest behind other G7 countries, and that with targeted investment, we will achieve the greatest impact on people's lives, biggest bang for buck. These investments and community-based services and supports will improve outcomes and reduce the need for hospital beds and acute care services. There is one fundamental issue in Canada that needs to be immediately addressed, and that is who is funded or covered in our publicly funded system?
I'm going to shamelessly quote two well-respected colleagues. Dr. Karen Cohen has helped us to understand that in Canada we have universal medical care, not universal health care. When it comes to primary mental health care, the very basic evidence-based services, such as counselling, psychotherapy, widely accessible structured interventions based on cognitive behavioural therapy and other therapies, and other basic community-based mental health supports, which other G7 countries take for granted and rely on as fundamental to their mental health response, are mostly not available in Canada, unless you can pay.
Starbucks Canada made the news when they modified their coverage for their employees and moved from $400 per person per year for counselling and psychotherapy to $5,000 per employee. So, in a country that has universal health care, you get basic mental health care if you're lucky enough to be a barista at Starbucks Canada.
Ian Boeckh says that mental health is a team sport. He is right and he is one of the best role models for that. But in Canada, the vast majority of the most valuable team members that other developed countries have in the game are sitting on the sidelines. Psychologists, social workers, specialized peer support workers, addiction counsellors — we have them here in Canada, but they are mostly sitting on the sidelines outside of the publicly funded system.
Getting them in the game, like they are in other developed countries, practising to their full scope of practice and funded to do what they are trained to do, will dramatically and immediately have formidable impact. CMHA acknowledges and applauds the government's proposal to support the services of traditional indigenous healers to address mental health needs. We also call upon the federal and provincial governments to work together to ensure primary mental health care professionals are also included and supported.
I'm hoping we'll have a chance to more fully discuss the stepped care model you see today, but in a nutshell, the tiers at the bottom, the foundational components of a properly resourced mental health system, have had the most dramatic lack of funding in Canada.
Earlier access to services at the lower tiers is more cost effective and can prevent individuals from needing more cost- intensive and time-intensive intervention. We treat cancer before stage 4. Better outcomes are possible with earlier intervention. We need to do the same for mental health, so for targeted mental health funding, we're not talking about building more mental health hospital beds. If that's all we have in the system, it's no surprise that it seems like we need more. Instead, we need to invest in the basic services in the community and redefine primary care when it comes to mental health to include primary mental health care providers.
The five areas include structured, community-based interventions like widely accessible evidence-based structured interventions based on CBT and other psychotherapy, such as Bounce Back or Living Life to the Full. These services are provided by specialized peer support workers supervised by licensed mental health professionals. They can be available by phone and on line and can reduce barriers for people in rural and remote communities. Other countries, like the U.K. and Australia, who have recently found themselves in a very similar situation to Canada's, have demonstrated huge increases in numbers of people served and decreases in more expensive services.
Primary mental health care is a truly interdisciplinary approach that includes psychologists, social workers, addiction counsellors, recovery coaches and specialized peer support workers.
Community-based services and supports are a full continuum of employment supports, housing supports, peer and family supports, recognizing that mental health does not only require a health response.
Wraparound services are for individuals with complex mental health needs requiring more specialized and intensive community-based treatment models.
Finally, there is a full continuum of illness prevention and mental health promotion through a whole population approach, recognizing that mental health is not simply an absence of illness.
This approach is based on the least burden. Upon assessment, effective low-intensity treatments that are likely to match the individual's needs are offered to patients first, while higher intensity treatments are offered only when the need determines. In Canada, fundamental gaps in the lower tiers of services means that individuals inappropriately end up in intensive and costly services. You get services when you are in crisis.
Greater investment in tiers 2 and 3 means there will be far less demands for tier 4 and 5 services, allowing these services to focus on those who need them.
The Chair: Thank you very much. I will now turn to Dale Clement who is a board member of the Canadian Home Care Association.
Dale Clement, Board Member, Canadian Home Care Association: Good afternoon, members of the committee. As a member of the board of directors of the Canadian Home Care Association, it is my privilege to share our work and thoughts on Bill C-44 specific to the area of home care funding.
The Canadian Home Care Association in a national not-for-profit membership organization representing home care stakeholders from governments, health authorities, publicly funded home care programs, service providers, and medical and technology companies.
Publicly funded home care provides health and support services in individuals' homes, retirement communities, group homes and other community settings. These services are offered to individuals with acute, chronic, palliative or rehabilitative care needs. The types of services provided through publicly funded home care programs include assessments, education, therapeutic intervention, which includes nursing and rehabilitation, personal support assistance with daily living activities, and help with the instrumental activities of daily living, such as banking and shopping and things like that, as well as caregiver respite and support.
Canadians believe that home, not hospital or long-term care facilities, is the best place to recover from an illness or injury, to manage long-term conditions, or to live out one's final days. For many Canadians, this isn't possible because the demand for home care services is outpacing the resources and the funding, resulting in limited and sometimes no access to the necessary care and supports. That said, long-term care home capacity is insufficient to meet the growing number of seniors as well across the country. However, with strong, sustainable and predictable investments in home care, we feel this can be mitigated.
Home care is a priority for all Canadians, for patients and their carers, for health care providers and for governments. The federal government has identified home care as a key health priority as reflected in Minister Philpott's mandate letter to support the delivery of more and better home care services. This includes more access to high quality, in-home caregivers, financial supports for family care, and, when necessary, palliative care.
To put this into context, when you think about our country, in a report that was done by the Canadian Home Care Association last year, roughly 14 per cent or 15 per cent of Canadians aged 15 years and up reported disability. When you go to the age of 75 and older, that number changes to 43 per cent. With our changing demographics, that will only grow. To link that to my colleague, Dr. Smith, most people that have a chronic disability — about 60 per cent — end up with some kind of need for mental health care and support. So we have some very strong connections within the two systems.
What does better home care look like? For individuals with complex chronic and disabling conditions affecting their health, mobility and cognitive activities, better home care means they can stay healthy and independent in their own home. They can return home safely after a hospital visit. When the time comes, they can choose to have their last days in the familiar surroundings of their home and surrounded by their loved ones.
As you know, home care is not a central service nor does it look the same across the country. So what do we need to do to make better home care?
In 2016, the association, in partnership with the Canadian Nurses Association and College of Family Physicians of Canada, held a series of consultations with front-line stakeholders across the country, wanting to understand what is working well and what is not at the front-line, and listen to patients and their carers on how we improve home-care services.
We hosted four invitational consultations in Halifax, Ottawa, Whitehorse and Calgary, with more than 160 participants representing all levels of government, health administration, home-care providers, recipients, doctors, nurses and other allied professionals. Recognizing that we couldn't hold consultations everywhere, we hosted an online survey, through a dedicated website, to gather more stories and information. Adding a breadth of perspective, we received over 180 responses, many from home-care recipients and their careers.
Better Home Care: A National Action Plan — I brought a copy of the work that was done — is the outcome. It includes 16 action plans and a number of measurable indicators in order to help to make decisions around where home-care priorities are.
So what do those opportunities look like and what could be advanced through targeted federal investments? The need for increased access to high-quality home-care services; greater integration and collaboration with primary health care to better service individuals in the community; accelerated implementation of technology to increase efficiency and make accessing information easier for patients and providers. A great example is pharmacy and the ability to understand even what somebody is taking and prescribed. National principle-based home-care standards are the final large opportunity in order to provide clarity for patients and families, set norms for high-quality care, and establish provider competencies and skills.
So we know what better home care is. How do we make it happen? Our challenge now is to take the words from Nike, "Just do it.'' As of March 10 of this year, the federal government has agreed to the new targeted federal funding over 10 years. The federal budget reinforced these agreements through the announcement. Statements that these targeted investments have the potential to make a real difference in the lives of Canadians and that, through this funding, Canadians can expect improved access to home care and community and palliative services make this a very exciting time.
This is all great news for seniors with frailty, individuals with chronic disabling conditions, and individuals at the end of life who want to receive care, and it was welcomed very much by home-care providers, doctors, nurses and caregivers, who are struggling with their increased demand.
So what is the opportunity, and what do we see as some of the challenges with Bill C-44 and, specifically, Division 9? The challenge that we have identified in three areas is extremely small funding allocation. So the current formula being used, A times B divided by C — so $200 million times the population of the provinces divided by the total population — is an average of about only3 per cent of the total commitment this year in the funding. This equates, as an example, to about a million dollars for P.E.I., and about $77 million for Ontario, whose provincial home care budget is more than $3.1 billion.
This challenges, with the limited funding, the ability to make a demonstrable impact in this first year on front-line services. It's not large enough to impact significant change and, given the formula and limited funds, it might be difficult for the government to ask the provinces to commit to outcome indicators and home-care measures in this type of environment. Instead, the first infusion of money could act as a stimulus for focused planning and identify and focus on new ways to provide home care that could be piloted and tested by the province.
It's our understanding that the government was to back-end load with significant funds released later in the 10 years. However, an investment of 10 to 15 per cent would be more effective in the earlier days in gaining ongoing commitment from the provinces and improving access to home and community care.
The second thought was around the home-care client base being mainly seniors. The funding formula, unfortunately, doesn't take into consideration the aging population and it is clearly documented that the majority, over 70 per cent, of home care recipients are over 65. In fact, the focused increased demand areas for home care are in the seniors with frailty and often complex conditions.
Bill C-44 is based on general population numbers. As a result, New Brunswick, a province with a significantly older population, is receiving $28 per senior, while Alberta, with a younger population, is receiving $47. A more realistic, equitable formula could include an acceleration that reflects the aging population or a slightly separate stream to address that demand.
The last concern was around the nature of home care, including rural and remote considerations. Home care by nature in rural and remote communities is more expensive. It costs more to travel. It costs more to get people there. It costs more to deliver. In terms of the current equation, again, there is no calculation for the rural areas and that could present some challenges in terms of how those areas and the provinces with those significant rural areas are going to be able to respond.
In conclusion, I just want to reiterate that Canadians believe that home, not hospital or long-term care, is the best place to be to recover from illness or injury, manage their long-term conditions, and live out their final days. To make this statement a reality for Canadians, no matter where they live, we need to consider the following: Ensure sustainable and predictable funding; address the most pressing need, which is our aging population; manage expectations — how does this initial funding for patients solve critical home care programs like supporting patients to be discharged from hospital or technology implementations to streamline processes — and, finally, recognize the uniqueness of home care, the geographic aspect — travelling to rural and remote locations is a fact of life in home care and it does require some special considerations.
Thank you for allowing me to share the opportunities from the home care perspective.
The Chair: Thank you very much. I'll now open the floor to my colleagues, and we'll ask one question per round as we go forward.
Senator Eggleton: Thank you for your presentations. I think we all agree that it's long overdue, the investments that are coming in both of these areas.
We get an opportunity, within the budget framework, to make observations back to the Finance Committee. If there was one observation in each of your areas that you think is the most important to make, either in something that is lacking here — and I think, Ms. Clement, that you've talked about a few of them. I was quite impressed with what you were talking about in terms of the funding formula and how it discriminates against the provinces that have the bigger part of the aging population, but you also named a few other things. If there is one thing in each of your areas that you think should stand out for immediate attention, what would it be?
Ms. Clement: Based on the comments that I prepared, I think the escalation or the consideration particularly for the senior population is one of our most growing demands. The funding, as you look at the allocations provincially, should take some of that into consideration, even in the earliest of phases, because, as we know from the population-curve predictions, the baby boomers coming through the system are going to be creating quite a demand. We need to be able to respond to those individuals because, otherwise, they will be putting pressure on the emergency departments and/or inpatient beds because they can't get back to the community. I think that we do need to give consideration to how the funding models can consider those aspects. Without dipping into Dr. Smith's territory, many of those individuals then suffer from isolation, depression and other issues in relation to their disease, their ageing and other factors, and the two are not necessarily mutually exclusive.
Senator Eggleton: Dr. Smith?
Mr. Smith: I think that the one thing that we and most people in the mental health field believe is that there is still an opportunity to do some direct funding federally. I know it's not an easy thing in our federated model. I lead a federated organization myself, so I understand the FPT complexity. But imagine if we found out, in Canada, that, in some provinces, in one town, looking at the educational system, you had second grade and fifth grade only, just because that's what developed in that community. Imagine that, in a town 30 kilometres away, you had only junior high and, in a town 100 kilometres from that, you had fifth grade, eighth grade and university. That's all you had access to.
It's shocking because there has been so much focus on anti-stigma and reducing stigma. The average Canadian can sometimes believe that, when someone gets over their stigma, there is a well-organized system of services and supports to meet their needs, just like there would be if they had a new diabetes diagnosis. The first thing that Honourable Norm Lamb did in the U.K. when he led the transformation — and that's what we've heard the leaders in Canada talk about, the transformation — was to say: The first thing we need to do is to stop trying to justify the unjustifiable. We have to acknowledge how big the gaps are with this lack of funding over this many years.
We wouldn't have a task force to figure out what to do educationally. We would go in and plug in the basic building blocks that are necessary. Worldwide, the jury is in that you need in first grade, then second grade, then third grade and some of those basic fundamental building blocks.
The federal government had precedents where they've done that with a drug treatment funding program and other health transfer transition funds.
There are some core transformational pieces necessary in every single province, recognizing that there are differences in levels of gaps in some of the provinces, so having direct funding federally for some of the basic pieces so that the provinces could then build on what else they need with those fundamental building blocks in place. Those fundamental building blocks would be evidence-based, widely accessible, community-based services that are available across the geography, with low barriers so that you could then see what else we need to build on.
Many people say don't back down to having the ability to do some direct transformational funding and to develop a mental health transformation fund. That is what's needed to be able to sustain the kind of changes that we need.
The Chair: Dr. Smith, I think you are referring to a larger issue than the 100 million in this current division. We take your point, which is direct targeted areas from the federal to the area. Was there a specific issue around the 100 million and its current distribution, and could you give me a quick answer, not the same amount of time you just spent?
Mr. Smith: Yes. The 100 million is to build community-based services in all the provinces.
The Chair: Thank you.
Mr. Smith: In the community, not in the hospitals.
The Chair: Thank you very much.
Senator Stewart Olsen: Thank you for your presentations. Both of you specifically detailed your priorities, where the money should go. You have a pot for home care and you have a pot for mental health, but I think what you indicated, Ms. Clement, was the outcome indicators. That's what I'm wondering about and what I think we should be looking at in observations. We know this money is made available, but how do we know how it was spent? Do your organizations keep track of that? How do you watch outcome indicators?
Ms. Clement: In terms of outcome indicators, the gist of my comments was that in this first year with the funding the way that it is structured — it's a fairly small starting amount in the scheme of things — it's really about being cautious of what types of outcome indicators are being expected. The type of change you could enact when you look at it across the province and the way that the spending is delivered is not going to be necessarily hugely noticeable or in a way that you may be able to monitor.
One of the big things we were suggesting is maybe an indicator that would be helpful is using this initial year's funding as a planning year and making sure each of the provinces comes back with what the next 10 years will look like and how we will actually make change and what those indicators are that we should be seeing per province. It is so different in each province. Even within the health regions within the provinces and the various communities, you're going to see different needs and different priorities.
One of the thoughts that we had as an organization was this would be an excellent opportunity. There may be some quick wins, but more importantly would be the strategy for the next 10 years so that the federal government can actually see the change and see how the funding will be used to drive those changes to support Canadians and the changing needs in health care.
That being said, the Canadian Home Care Association has access to general information through CIHI, the Canadian Institute for Health Information, in general, but we don't actually have the operational data that might come through to the health authorities or the various ministries in the provinces.
Mr. Smith: We have consistently said that you can't manage what you can't measure.
The first thing is to have outcome indicators and to invest in standardized outcome indicators. It's surprising for many people to find out that if an area of health is a priority then we usually measure wait times. It's not the best and only measure, but it's a good measure. In mental health, we don't even know what the wait times are because we don't track it.
The first thing we need to do is have every province be able to demonstrate that they're putting in place a tracking that we can manage and measure outcomes because we're actually investing in the development of indicators, basic indicators such as the number of people who have access, the number of youth who wait two and a half years to see a psychiatrist, and those kinds of things. If we don't track it, we can't measure it.
Senator Seidman: You have begun to try to answer my question, and that has to do with accountability transparency in using these funds. Of course it's very challenging because the federal government has undertaken a series of bilateral agreements so that it seems as if there really is no way to ensure the kind of thing perhaps you're talking about, Mr. Smith, and that is across the geography. I'm not sure how we could ensure anything across the geography.
First of all, we have issues of provincial jurisdiction at the very outset, but I am mindful that in the health accord, in the previous health accord that we had which is now no longer in existence, there were outcome measures clearly designated by the federal government and those were wait times, as you put forward.
I understand the need for sustainable funding when you're trying to plan, both in home care and in mental health care, and I understand the crisis issues in both of those areas. We read about them every day in the paper, and in the Montreal Gazette just this past weekend we read about the universities in terrible crisis with students who are experiencing serious depression, hopelessness and suicidal tendencies, and they have no services to offer.
Given all the handicaps here, how can we ensure that the money we're putting in these two pots will actually be used for those services? How will we be transparent and accountable to Canadians and ensure that we have the services we want?
Mr. Smith: When Minister Philpott was working to get a health accord, at the first health minister's meeting in Toronto we had the Canadian Medical Association, Canadian home care, Canadian nursing et cetera. Every one of us, all national organizations were saying hold provinces accountable. A psychologist will tell you that the best predictor of future behaviour is past behaviour. There's been a 6 per cent increase in Canada Health Transfer for 12 years, but the money didn't trickle down to home care and mental health. Some may have not trickled down to health.
The reality is we're saying it's your money, be bold. I know it's easier said than done, but don't back down because there's precedent and Canadians need that kind of accountability. This is the deal: You have to demonstrate that you're measuring and holding to these standards, or you don't get the additional funding.
Ms. Clement: My previous response as well talked about what is the province's action plan and then perhaps aligning with Dr. Smith's comments the two could go together. It is going to look different across the province. It isn't a cookie-cutter solution because the needs are so different, but what are they committing to in terms of the funding and then how does the federal government monitor that.
Senator Raine: Thank you very much. It's good to have you with us today so we can ask some questions.
I'm interested, Dr. Smith, in the stepped care model you referred to. In reading your notes, you started with tier 2 being structured community-based interventions, but I don't know what tier 1 is.
Mr. Smith: I co-chaired Canada's National Treatment Strategy.
Senator Raine: I don't know what that is.
Mr. Smith: Basically, we looked at tiered models across all jurisdictions, and we found that the U.K. had a four- tiered model. So our tier 2 starts with their tier 1.
What we recognized in Canada is that their model wasn't embracing volunteer unpaid services and supports that we need to galvanize. For veterans, that's the legions and other support groups. For addictions, it's the NAAA. Tier 1 would be what we can leverage that is of no cost to the publicly funded system.
Senator Raine: That makes tremendous sense.
I'm concerned because we already have a lot of issues facing society in terms of mental health, but when I look at what's coming with computer games and what they're doing to kids, and with ADHD rising and those kinds of things, it seems like we need to get tier 1 and tier 2 activated as preventative mental health. Is your organization focusing on that at all?
Mr. Smith: We are. That is a huge piece. Some of our provinces are almost exclusively focused on mental health promotion and illness prevention. Where do kids spend their time? Schools. There's social and emotional learning. There is so much we can do, and I'm trying to figure it out. The evidence is there. There are good examples across the country; it's just not standardized.
We do need to move upstream and quit waiting until stage 4. More than any other G7 country, we've treated mental illness like, "Don't come to us until you have stage 4 cancer and then we can treat you. Then you will have to meet the admission criteria to get into our psychiatric facility.'' We didn't meet those needs earlier and focus on prevention, so mental health promotion prevention is a huge part of the continuum.
Senator Raine: One question.
The Chair: Is it related to the first one?
Senator Raine: Yes.
You will look at spending some of the new money on national sharing of best practices with regard to prevention?
Mr. Smith: I would suggest that.
[Translation]
Senator Mégie: Thank you for your presentation. I am going to ask my two questions in French.
Are separate budgets allocated to home care and palliative care? Because, in everything I read, home care and palliative care are separate. I know that both components need significant funding. Are home care and palliative care part of the same budget?
[English]
Ms. Clement: In terms of how it's rolled out, it's looking at it as one, not separate, in terms of palliative and home care, because the home care needs are all bundled as one. That's how we've looked at some of the solutions and the demand, because as people age and want to age in place, palliative becomes incredibly broad in terms of end of life. It could just be through aging or it could be through a disease process. So we look at it as a whole and as a continuum in terms of the funding.
[Translation]
Senator Mégie: Hence my second question. When you transfer budgets, do you have a plan with outcome indicators? For accountability, we need to know that provinces have to indicate that they have done 1, 2, 3 or 4 in a certain time, six months, one year, five years. If the two are mixed together, it seems to me that the work will become complicated in terms of the outcome indicators. Did the money come with a federal government plan?
[English]
Ms. Clement: The Canadian Home Care Association does not receive any of the funding. It actually goes out to the various ministries in the provinces. So the Canadian Home Care Association doesn't have any oversight to the planning or the indicators that the provinces choose as a result of the funding. Therein lies the challenge of what we need each of the provinces to be communicating back.
My suggestion around this initial year as a planning year, to come out with a very concrete plan for the next 10 years, might be a great opportunity from the federal government's perspective to actually be able to then monitor and track and understand how the dollars are going to actually address some of the burgeoning needs and the demands that we can see today and that will continue to grow, including palliative care as well as general home care and supports.
The Chair: I think we've covered a number of the issues. I want to try to pull a couple of them together here.
First of all, I see no indication in this division, the document that I have, of any guarantee of ongoing funding, and yet there is an indication that it is supposed to be part of a long-term strategy. Have I read it the same way you have read it?
Then I guess the issue comes back to some of the questions that have been asked that relate to necessary components to give structure to a longer-term plan and infusion. I think we've got those. We've picked up what those issues are.
The question then comes down to how seriously the provinces are going to take this funding if they have no indication that there will be a long-term commitment.
Let's suppose, in a given province, you try to argue through your respective associations that there should be indicators developed. That's going to take resources and yet there is no indication here that there is going to be sustained funding. There is an indication that there's a strategy or something over a period of time, but without funding that would be an empty kind of strategy in these two areas.
So I want to make sure that you had read it the same way that I read it in that regard.
What I sense is that we've gotten from you the very clear issue of indicators. We recognize the points you've made with regard to distribution of need on a per capita basis within provinces. This act doesn't cover those particular issues, but obviously that is an observation in a number of areas as it relates to the demographics in provinces with regard to funding.
We have looked at the issue through our dementia study and, of course, with regard to the medical assistance in dying we got into the idea of palliative care and so on.
I think the point that you were making, Ms. Clement, is when you're talking about home care, you also include the idea of the palliative stage of health care in the home care where it exists. We recognize there are other centres where palliative care is held, but we're dealing here with the home care kind of circumstance.
I think, Dr. Smith, you made your points very clearly with regard to the issue that you are facing. Ms. Clement gave what the amount would be of the $200 million in Prince Edward Island, but you're down to $500,000. With some of the issues that you've raised, that would barely get a good discussion group together to develop a plan over a period of time.
It will be interesting to see what you can come up with on your observations across the province to guide future investments into this area.
With that, and seeing no further questions, I'm going to suspend the meeting and go to the next witnesses.
We thank you for your very clear and articulate issues on this. I'm sorry, Dr. Smith, that we're not going to be able to take this to the larger stage that you so correctly identified.
Thank you very much.
We are very pleased to have with us two departments important to this division. We have, from Health Canada, Jocelyne Voisin, Executive Director, Health Accord Secretariat, Assistant Deputy Minister's Office, Strategic Policy Branch, Health Canada, and Marcel Saulnier, Associate Assistant Deputy Minister, Health Care Strategies Directorate, Strategic Policy Branch, Health Canada.
We also have Finance Canada present. From the Federal-Provincial Relations and Social Policy Branch, we have Omar Rajabali, Chief, Canada Health Transfer (CHT), the Canada Social Transfer (CST) and Northern Policy. We welcome you to the meeting. I understand that Ms. Voisin will make a statement, and then we will open the floor to questions of all three of our guests from my colleagues. Please proceed.
Jocelyne Voisin, Executive Director, Health Accord Secretariat, Assistant Deputy Minister's Office, Strategic Policy Branch, Health Canada: Thanks very much for having us here today. I'm going to give you a brief outline of the legislative provision in the context of the budget.
Budget 2017, Part 1 of Chapter 3, outlines the government's commitment to work with the province and territories to strengthen health care so that the system can adapt, innovate and address new challenges. It confirms the offer tabled by the federal government on December 19, 2016, to provide $11.5 billion over 10 years to support key priorities under a new health accord, including $11 billion over 10 years directly to provinces and territories to support improvements to mental health and home care.
Part 4 of Division 9 outlines the authorities and conditions to flow the fundings for the first year only of this $11 billion commitment. That's in fiscal year 2017-18. They would flow that money to provinces and territories as an immediate down payment on the investments in home care and health, which are longer term. This includes the $200 million for home care services and $100 million for mental health services, and this is allocated to provinces and territories on equal per capita basis, the formula you see outlined in the legislation.
As set out in the legislation provision, a province or territory would receive its share of the funding. If the federal Minister of Health notifies the Minister of Finance by December 15, 2017, then, in her opinion, the province or territory has accepted the federal proposal to strengthen health care as it was made by federal government at the meeting of finance and health ministers in December 2016.
This December proposal envisioned a pan-Canadian approach and that provinces and territories would work with the federal government on how to measure results for this funding, and on how exactly the funding would be spent in these areas.
Since then, you have seen that almost every province and territory has accepted the federal funding offer, and now, with those discussions with the Minister of Health and federal officials, we are entering into discussions on the policy elements of these investments. That would be a common policy framework on how those funds would be invested and how we would measure improvements and show results to Canadians. This common framework would form the basis for bilateral agreements that would flow funding for the remaining nine years of the 10-year commitment.
Some of the areas that we're talking about in the common framework are, interestingly enough, areas that you just heard about from Mr. Smith and Ms. Clement, like integrating primary health care, home care, looking at youth mental health services, and definitely focusing on the shift from acute care in hospitals to community-based care in both mental health and home care.
With those brief remarks, I will open it up to any questions.
The Chair: Thank you. Before I go to my colleagues, I want to make sure that I have understood what you have just said. I want to start with the numbers. Was I correct in hearing $11 billion over a total of 10 years?
Ms. Voisin: That's right, yes.
The Chair: With a modest $300 million this year, that means that in subsequent years there could be over a billion dollars a year allocated in these two areas?
Ms. Voisin: Yes. The budget outlines the five-year profile, for first five years of that funding, so I can give you that profile if you would like.
The Chair: We have not had that, so could you run off the numbers? Our job is not to analyze it in absolute detail; it's to get a sense of the direction and character. We know it's $300 million in total in the first year.
Ms. Voisin: Yes: $300 million in the first year; $850 million in the second year; $1.1 billion in the third year; $1.25 billion in the fourth year; and $1.5 billion in the fifth year, for a total of $5 billion in the first five years.
The Chair: That certainly answers one of the questions I put to the previous panel, to which you were probably saying, "We sure have the answer to that.'' There is a clear incentive here.
Now, the second thing that I want to pick up on what I think I heard you say is that, right now, discussions are occurring with regard to the overall policy strategy with allocating the funds over the coming years, and that elements such as the things we heard in the first session are part of those discussions that you're looking at.
So, to be specific, that's the idea of accountability indicators. Has the notion of the demographics of provinces come up as a consideration for subsequent allocation? I know the pure population model is very easy, and it's very easy for the departments to finance and account that and to deal with it, but the change in structure of demographics would add some complication. Is there any discussion of that to this stage in the policy discussions?
Ms. Voisin: The policy discussions are very focused on how the existing funding would be spent in areas of home care and mental health. All the provinces and territories that have already agreed to the funding offer have agreed to their level of funding, so there is no discussion about changing the funding allocation or level of funding to different provinces. It's simply about how they are going to spend the money that they have been allocated and that they have agreed to in the press releases that you have seen.
Omar Rajabali, Chief, Canada Health Transfer (CHT), the Canada Social Transfer (CST) and Northern Policy, Federal-Provincial Relations and Social Policy Branch, Department of Finance Canada: Just to build on Jocelyne's point. In the context of the $11 billion we were talking about before, I know Jo talked about the five-year profile, what is in the budget plan, but the 10-year numbers are in the press releases for the provinces and territories that have accepted the offer, and the acceptance of the offer is on an equal per capita basis.
The Chair: Okay. That was understood at the outset, so that's not an issue for discussion.
Ms. Voisin: No.
The Chair: That clarifies the things that I wanted to be sure of right up front, because they arose previously. I'm going to thank you for that and I'm going to turn now to my colleagues.
Senator Eggleton: I want to clarify the numbers as well. It's $11.5 billion over 10 years for combined home care and mental health, is that correct?
Ms. Voisin: It's $11 billion directly to provinces and territories for home care and mental health. The remaining 0.5 billion — so it's $544 million, to be precise — is for the two other areas that were shown as priorities for the Health Accord, in innovation and pharmaceuticals. That funding is not going directly to provinces and territories, but it will support them in advancing and strengthening health care.
Senator Eggleton: Ms. Clement, who appeared for the Canadian Home Care Association, talked about the fact that there are provinces that have a greater population of seniors, particularly in the home care component of this, and that that should be taken into consideration. You have said that it's an equal per capita basis, but what about considering provinces that have higher seniors numbers? In that respect, perhaps they are not getting as much per capita as they really need.
Marcel Saulnier, Associate Assistant Deputy Minister, Health Care Strategies Directorate, Strategic Policy Branch, Health Canada: I could comment on that. I think it's fair to say that there are many factors that drive health spending in areas like home care and mental health. I think you could argue that there is an older demographic that is perhaps the clients of home care. On the flip side, the federal government's intention with the mental health money was to target a younger demographic, and so you might make the opposite argument for mental health. I think that if you put the two together, you could make the case that an equal per capita allocation is probably the fairest allocation.
Senator Eggleton: So they are not being allocated separately, the home care and the mental health care; they are all on the same basis of an equal per capita basis. And there is no carve-out, then, for youth mental health?
Mr. Saulnier: The amounts for mental health and home care are defined separately. How they will be transferred to provinces, I would leave to my colleague from Finance to answer that question.
I guess I would say that, on the mental health side, the federal minister, Minister Philpott, has been fairly clear that she would like that money to support provincial initiatives that address youth mental health in particular.
It remains to be seen, as we engage with provinces, what sorts of initiatives they will put on the table and what kinds of projects they will use that money to support.
Senator Eggleton: Could I ask one other related question? Some of the services in terms of mental health are not provided in the publicly funded system: psychologists, social workers, specialized peer support workers and addiction counsellors, et cetera. This was in Dr. Smith's brief. Is the federal government going to undertake any effort to get those as part of the system? They are all vital in terms of the services that are needed for people's mental health challenges.
Mr. Saulnier: With the position that the government put out in the budget and in subsequent pronouncements by the minister, there is very much the intent to try to address an unmet need in the youth mental health population. There are statements saying that as many as 500,000 youth who need mental health services could have their needs addressed by the $5 billion over 10 years. That would imply having the providers that provide the cognitive behavioural therapy and other counselling-type services be involved in provision of those services. So, I think, by definition, it would involve engaging those providers and those communities in the provision of publicly funded services. Now, whether the provinces will be willing to go in that direction, and to what extent,that remains to be seen in the negotiations that are under way.
Senator Dean: Thanks very much for being here and for the work you do. I always like to see policy people and finance people at the same table because this is a question that I think would go to both of you.
The infusion of new dollars for critical social services is always welcome, and I'm certainly supportive of that. But we have also heard from the previous panel — and it was alluded to by you today — that innovation and transformation is important as well. We have heard about wraparound approaches, better integration, place-based care and early intervention often saving people from higher cost-intensive services later. These are all terrific things. They would be things that we would want to be doing even without the infusion of new money.
From an inside government perspective, when you think about inventing transformation and what government can do in each of these areas, other than providing money as an incentive, is there policy work under way that would help providers in these new integrated wraparound models? What are your departments doing to help transformation on the ground, aside from the infusion of new money?
Ms. Voisin: In terms of our discussions with the provinces and territories on what these bilateral agreements will look like and where they will spend the money, we have put an emphasis with them — and they welcome this, because this is the direction they are moving in as well — in terms of focusing on initiatives that will shift the care from the expensive hospital care to community-based care, in home care and mental health, and look at innovative models for serving youth, for example, where it's a one-stop shop where youth can go in and get all sorts of different mental health services.
Health Canada is also working on other ways to support innovation and transformation. I'm going to hand it over.
Mr. Saulnier: To add to Jo's comments, the information and performance measurement is a huge driver of change, and that's why it's so prominent in the discussion that we're having with provinces on the mental health and home care investments. As the previous witnesses have said, if you can identify the areas that are most transformative and the metrics associated with that, that will allow everyone to see how they are performing relative to those metrics and to aim higher every year, which can be a huge motivator for improvement.
To facilitate that process, in the budget, there were investments in the $544 million that Jo mentioned, directed to the Canadian Institute for Health Information to invest in data gathering and reporting capacity for both mental health and home care. There were also investments in the Canadian Foundation for Healthcare Improvement, which is a national organization that is out there working with provinces and regional authorities to scale up projects to improve the quality and accessibility of care. There was also an investment of $300 million in Canada Health Infoway, which is the organization that is focusing on expanding and accelerating the use of digital health technologies across the country.
Those are both investments and ways of mobilizing the players and stakeholders out there to target specific areas of improvement, and they feature widely in our overall health care improvement strategy.
Senator Seidman: Thank you very much. Ms. Voisin. You touched the surface of this, because it relates back to a previous panel we had and our issues around transparency and accountability.
You talked about developing a policy framework that might include common standards and outcome measures, if I understood correctly what you were saying. This policy framework would be across the board? The government has bilateral agreements. How would this function to ensure what Dr. Smith referred to, which was across the geography, so to speak.
Ms. Voisin: The policy discussions we're having with provinces right now are looking at what pan-Canadian commitments all the provinces and territories could agree to in terms of what are the priorities under mental health, for example. Can we all agree there should be a focus on youth for this investment? What are the priorities under home care? Can we all agree that some of that will go to palliative care; that we will focus on primary care integration, for example?
We know that the provinces and territories have their own identified priorities, but many are moving in this direction already. Those are the kinds of discussions we're having. Those negotiations are under way.
Ideally, our minister has been very clear that she would like to see results for these investments. The objective would be to have provinces and territories agree to some common metrics that would be able to show progress in certain areas. All of that, of course, is subject to those negotiations as we move forward. We know that provinces and territories already report data to CIHI, as Marcel was talking about. We want to improve on that data collection so we can report specifically on progress for these investments.
Those metrics would be in the bilateral agreements. Moving forward, we're going to have bilateral agreements with each province and territory to flow the funding for the remaining nine years. The specifics on how they will spend the money and what they will report on will be in those bilateral agreements.
Mr. Saulnier: If I could add to that, perhaps to correct any misunderstanding that may be out there — because there have been a lot of talk about bilateral agreements already in place — as Jo was saying, there is agreement between the two orders of government around the funding levels. That was the subject of the press releases that we saw earlier this year. That is what some people are calling bilateral agreements.
However, from our perspective and looking forward, we are trying to get agreement on this common framework, from which will flow a more formalized bilateral agreement that will be signed by both governments. That will govern the flow of funding for the remaining nine years. Those, in our minds, are the more formal bilateral agreements as compared to the political agreement on the funding that came before.
Senator Seidman: That's really helpful.
The Chair: You have signed one with each province, as opposed to 10 signing on a line to a common agreement?
Mr. Saulnier: Right.
Senator Seidman: That's helpful.
Senator Stewart Olsen: Thank you. Just for my information, regarding the $300 million this year, how will the provinces allocate that? You're giving it per capita, but where are they going to spend it? How are you going to decide where that money is spent?
Ms. Voisin: That funding is going to be allocated once Bill C-44 receives Royal Assent.
Senator Stewart Olsen: Before the bilateral agreements?
Ms. Voisin: Yes. We are asking provinces to provide to us a sense of how they want to spend the money over the first five years. We will get a sense of what programs they would see that money invested in for the first year. The government did mean it as a down payment in areas of mental health and home care going forward. Basically, they can use that money to plan for how they are going to invest the money later. Provinces and territories are already investing in mental health and home care.
Senator Stewart Olsen: Yes, I know, but how are you going to ensure that the money you're handing over is going to go to that program? You don't have an agreement in place. You don't have an agreement that they are going to strengthen the Canada Health Act. Do you see my dilemma here?
Mr. Saulnier: Maybe I can clarify a bit. The way the legislation is written gives the federal minister the discretion when to advise the Minister of Finance that province X or all the provinces have accepted the federal offer that was made in December 2016. In the legislation, that is what triggers the payment and is, in so many words, the accountability around the first year. Knowing that provinces are already starting to spend money and the fiscal year has started, we have to see the legislation go through Parliament. Once the provinces have signed on to the framework, then the money for this year can be released.
I think the assumption is that provinces will do exactly what they said they would do in the press releases that committed them to accepting the federal offer. As Jo has suggested, as we begin to work with them on the bilateral agreements, we expect to see five-year spending plans that will include the first year.
The Chair: To make sure that we have got it clearly, the understanding is that as soon as it's received Royal Assent, these first funds will go out as soon after that as possible and the provinces have an understanding it is to be spent during the current fiscal year.
In actual fact, part of the reason we were asking you the question on accountability and benchmarks is that — as you even saw from the first panel — there is the occasional suspicion that monies transferred within the health area may go to other areas — roads sometimes come to mind.
We want to be sure, because what you, as departmental officials, have testified is that indeed there will be this development of the agreements which will include accountability and reporting, and so on. It went on the record, because up until now we have a press release with the speaking points, so to speak, on this Health Accord framework and bilateral funding agreements, which will include performance indicators and mechanisms for annual reporting to citizens, as well as a detailed plan on how the funds will be spent over and above existing programs.
We take it from that that this will be a situation in which the provinces will account to the federal government the amount of money that they received has actually been spent in the areas that they agreed to spend it on within this agreement. Is that a fair understanding?
Mr. Saulnier: Yes, that's a fair understanding.
The Chair: Does Finance agree with that?
Mr. Rajabali: Yes. I think that is outlined in the budget as well.
The Chair: It's in this document, too.
Mr. Rajabali: Yes, I believe it's in the budget.
Senator Eggleton: One of the things you don't want to have happen is you give this money and you're accountable for it, as you just answered, but how do you prevent the provinces from taking money out of existing programs in the same area and channelling it into something else? In other words, you go in and make up for money they have removed and put somewhere else. Do you have a way of presenting that?
Mr. Saulnier: In the course of our conversations, in these bilateral agreements we'll be asking them what they are planning to do with this money that they are not already doing. It could be increases to existing programs, or it could be the creation of new programs to achieve the goals that are set out in the agreement. There is that info mentality test that was part of the press releases that came out that there is an understanding that this money is to add to existing efforts, not substitute.
Mr. Rajabali: Arguably, you need to have the same issue with any type of program that the government provides or funding the federal government provides to the provinces and territories. I think what Marcel and Jo were trying to allude to is the incrementality associated with the program. In addition, I think they are saying that there will be indicators against that money as well.
Senator Eggleton: Okay.
The Chair: We clearly understand your answer. The issue that Senator Eggleton is getting at is how you are certain in the reporting, so we know you can develop indicators that will tell you whether or not that has occurred.We know in the past it's been extremely difficult to see this. Mind you, language hasn't always been as clear as a statement that says the funds will be spent over and above existing programs, but the "this-pocket-and-that-pocket'' issues are always of concern.
I think, with your answers and your assurance that these things will occur, and based on studies that we've done in various areas of health in particular, we would be very pleased to see that this tranche of funding actually does get dispensed on the basis of a strategy, with clear accountability and indicators that generally are measured in some way that you can be certain they are stable.
We know, for example, that there were very interesting reporting of changes in wait times with the $30-odd billion the previous government put in to deliberately reduce wait times, that individual hospitals had some creative ways of dealing with that.
We now know that in most cases, at least the reports that I've seen indicate that the wait times in general are not decreased and they have actually gone up again once real accounting came back into play.
This is the issue when it comes to the transfer of large sums of money into areas where there has not historically been a careful review of how the monies were distributed on the basis of an agreement. It was really transferred and then the provinces dealt with it. So I, for one, am encouraged by this approach with earmarked funding. I'm encouraged by the statements around this and will be even more encouraged in two or three or four years when you're able to report that in fact have you good indicators, you have good accountability in place, and the monies are actually being expended to benefit Canadians in the direction that you're allocating here.
From the basis of our committee, we would certainly agree that both these areas are critical to receive focused areas. We have seen in a number of our studies how home care is a major issue and concern. Our dementia report, for example, is a case where this is highly indicated as a major issue in terms of helping people. People do the best, as our earlier panel indicated, when they can be treated in their home or their home community.
I find it very encouraging that this is being identified and we hope that indicators that can actually measure outcomes and allocation are developed and that it's part of a long-term strategy that you're able to put in place.
With that, I want to thank you for being here. We will continue in camera to give drafting instructions on this division to our analysts.
(The committee continued in camera.)