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

Issue 9 - Evidence, March 22, 2000

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 3:35 p.m. to examine the state of the health care system in Canada.

Senator Marjory LeBreton (Deputy Chairman) in the Chair.

[English]

The Deputy Chairman: Honourable senators, I see a quorum. I will start by reading the order of reference to remind people why we are here. We passed an order of reference in the Senate in December 1999, that the Standing Senate Committee on Social Affairs, Science and Technology be authorized to examine and report upon the state of the health care system in Canada. In particular, the committee shall be authorized to examine: first, the fundamental principles on which Canada's publicly funded health care system is based; second, the historical development of Canada's health care system; third, publicly funded health care systems in foreign jurisdictions; fourth, the pressures on and constraints of Canada's health care system; and, finally, the role of the federal government in Canada's health care system.

This is our committee's second meeting with witnesses. Our first panel this afternoon will discuss the concept of population health; that is, the social and economic factors that shape the health of Canadians. We have Sholom Glouberman and Dr. Fraser Mustard with us today, who are both well-known experts in that field.

I understand Mr. Glouberman wishes to speak first.

Mr. Sholom Glouberman, Director, Health Network, Canadian Policy Research Networks: Honourable senators, I will go through the results relatively quickly of some research we have done. I would like to first talk about how government came to invest in health through health policy.

Firstly, in the early 19th century in Britain, and the later 19th century in Canada, there were many epidemics, and the question was, how to end them?

The first area of large scale investment by government was in policies that would reduce environmental hazards, begin the process of inspection, and introduce public health nursing. Of course, with that, the population's health status improved.

Academics argue about whether that was due to these policies or to a general improvement in prosperity. There is a significant amount of debate about that subject. The next question was, how do you go about diagnosing and treating illness? At the end of the 19th century and, in Canada, at the end of the Depression, the health status of many people who entered the military before the Second World War was quite poor. The question was, how to provide health care for people? That resulted in the second tier of health policies that had to do with universal health care coverage, which occurred in Britain in 1948 and in Canada in 1968. That was accompanied by improved health status of the population. Once more, academics dispute whether that is due to the introduction of universal health care coverage or to improved prosperity.

The next question is, once you have these two aspects of health policy in place, how do you improve people's health beyond that? This is from Thomas McKeown, taken from the Lalonde report, which came out in 1974. It says that in order to further improve the health of the population, you have to go beyond prevention and beyond medical services.

In Canada, two paths came from McKeown. The first was the health promotion path, which happened immediately after the Lalonde report. The second was research into inequalities in health. That is the path taken largely by CIAR in Canada and in the work of Fraser Mustard.

It is worth distinguishing between these two paths. They are not completely incompatible, of course, and they both contribute to aspects of population health. They both adopted that term, "population health", but to a certain extent there is some confusion about what the term means because of these two paths.

The health promotion path increased the number of health determinants from four in the Lalonde report to a possible 28 that we find in this meta-analysis of the literature. This new building block of health policy, the introduction of health promotion policies in Canada, resulted in improved health status of the population. Again, academics dispute whether health promotion or a general increase in prosperity is the cause.

Now the question is, why are some people healthy and others not? That question comes out of a CIAR-sponsored book that looks at inequalities in health and what to do about them.

We can go back to the 19th century in looking at health inequalities. We will find that there are gradients of health status that are correlated largely with socio-economic status -- with income, with the kind of work that people do. This finding is from the work of Edwin Chadwick, the "father of public health", and was written in about 1840.

There are many other examples. The above reference is from a 1957 epidemiology textbook that looks at gradients of infant mortality in England and Wales in 1930 and 1950. There are many examples in Canada that look at the correlation between certain healthy practices and levels of education, for example.

The overall picture from these analyses is that the higher the economic status of the people, the better their health status and the lower the level of mortality. That happens along a gradient. At every level, the health status of people deteriorates as they go down the socio-economic scale.

The second thing that is beginning to happen with this kind of study is that with more computing power, more long-term databases, and more statistical analysis, we gain far more detailed information. The analysis of the results is much deeper.

Michael Marmot studied 25,000 civil servants in the U.K. and discovered that the most critical factor correlating with cardiac illness was control over work. Susan Everson from Harvard looked at a cohort of 2,500 Finnish men and discovered that hopelessness was the strongest correlate with the onset of cardiac disease in that group.

Why are some people healthy and others not? What kind of policy consequences come from the answer? It appears that, to a certain extent, we are not clear about how to develop those policies. That is the issue that many policy groups are facing today.

These are some, not all, of the issues in the logjam. What are determinants and how do they relate to causes? What are some political responses to the inequality in health, and what is the role of the Ministry of Health?

The correlation between health status and socio-economic status is just that -- a correlation. It is very hard to show the actual causal interface between them. Someone, for example, can smoke and lead a careless life and still live long and be healthy. Other people can lead healthy lives and still contract particular diseases. Those correlations have to be understood for what they are. Misfortune can strike anyone, and when risk factors are mentioned, they are often for fairly small numbers. The question is whether or not a full causal account here is possible, and some philosophers would argue that it is not.

There are very strong ideological responses to this literature. The left wing says you have to focus on the social environment and reduce disparities in wealth in order to reduce disparities in health and improve overall health. We must equalize wealth and target those who are the worst off. The right focuses on individual choice. Their position is that overall wealth must be improved to improve overall health. All that is needed, in addition to wealth creation, is a safety net for those who are worst off.

There is plenty of data to support both positions. For example, from the position of the left, Richard Wilkinson studied infant mortality in Britain and Sweden. He found that infant mortality follows the gradients in Britain, but not in Sweden, where there is lower infant mortality overall. Therefore, better health status occurs if you have less disparity in socio-economic status.

The example from the right is that which I mentioned earlier, from the study in England and Wales. In 1930, there was one description of infant mortality. In 1950, it drops to another description, with a shallower gradient. The argument is that this is a result of the improvement in overall prosperity.

The left wing argument is about mortality by social class. They say that mortality has a trumpet-like effect. There is a growing disparity between the best off and the worst off, and a growing disparity in their mortality rates. However, if you look at the long-term picture, there is a reverse "trumpet", where longevity rates become closer between different social classes over the long period of time. There is less disparity. Arguments on both sides can be supported by data when looking at these issues from an ideological perspective.

The Ministry of Health has a problem because the most critical contributors to health are not health related by this account. They have to do with social status, control over work, level of education, and the Ministry of Health has no authority over these matters. If they take responsibility for this, they risk being viewed by other government departments as "health imperialists". How do you deal with those kinds of problems?

We have tried to look at some broadly changing ideas about how we understand the physical world and relate to the physical environment, and how we understand the interaction between individuals and their social context. We now know that the physical world is not deterministic. We have a much less deterministic account of causality, and we know that there is a role for uncertainty in understanding the physical world.

We also understand now that our relationship to the physical environment is not one of command and control, but rather one where interact with it in a much more interrelational way. In studying human beings and their growth, we understand that the development of people has to do with the way in which they interact with their environment. The most recent publications that resulted from CIAR research addressed the developmental health of children, and what that has to do with this kind of interaction.

We started to look at our ideas about health and discovered that there were three ways of looking at it -- three kinds of focus. One was to look primarily at the individual and the human being as an organism. The second was to focus primarily on the environment, and look particularly at the social environment of people. The third is from that small part of the literature that looked at the interaction between the two. Thus, people were looking at boxes, and not at the connection between those boxes.

We realized that there were three things that contributed to health -- the individual, the social context of that individual, and the interaction between the two. From that, we derived the hypothesis that the quality of the interaction between the individual and his or her social context is a major contributor to health that should be examined in the context of policy.

We can look at many health policies and divide them into three groups: those that focus on the individual and the body -- the organism -- those that focus on the environment, especially the social one, and those that focus on the quality of the interaction between the two. The first two sets of policies clearly have had a positive effect. We think that a third set of policies can link them and create further gains.

We have lots of examples to support these three sets of policies. We can look at Marmot's study on control over work, where it is clear it is not just the work environment, but how an individual interacts with it, that makes a difference. I have other examples that I will not be able to go through because we have only 10 minutes.

I will discuss the Everson study, and then the role of health care coverage. Also, I will talk about child policies.

Everson studied 2,500 Finnish men. The focus was on hopelessness as an emotional state of people. However, the test that she used for hopelessness was really about people's beliefs on what would happen to them in the future. It had to do with their interaction with the outside world.

There are three distinct sets of policies that arise from those findings. The first one focussed on the individual and the organism. Everson tried providing prophylactic treatment for the onset of atherosclerosis by prescribing drugs. That works.

The second was to focus on the environment. That is, more opportunities should be provided for people. That works, also.

The third is to make sure that there is an interaction and the possibility of people making use of the external resources. There are three different types of policies that emerge from looking at these kinds of cases.

If we think about the role of the health care system, we can think of it in the following way, as well. Universal health care, in a way, is a precondition for talking about these kinds of issues. It is part of the structure of health care policy and health care investment.

The health care system is a resource, not simply because it provides services, but because it provides security. It improves people's interaction with the larger society of which they are a part. That sense of security also results in improved health status.

Countries that have universal health care coverage generally have better health status than those that do not. In the United States, health promotion is not as well established as it is in Canada, largely because the major issue in public health is coverage. Large numbers of people are not covered for health care services. The question becomes one of determining the policies that would restore confidence in Medicare, rather than thinking about simply re-jigging the system.

The best policy mix for children is from some work by CPRN. It goes together with the longstanding work by CIAR and Fraser Mustard. The issue is identifying the policy mix that includes all three foci. The focus on the individual includes things like inoculation, which we have already done, and the notion of nutritional intake. The focus on the environment includes the need for enough schools and daycare facilities and good environments for children, like good housing. The focus on interaction needs to be addressed in the policy mix.

If you examine our current policy mix, much of it talks about daycare that supports development and strong relationships between mothers and fathers and their children. The notions of parenting training and developmental daycare all go together in focusing on and thinking about what these interactive elements are.

We believe that policies must provide short-term, medium-term and long-term returns on investment. We believe that policies must satisfy these elements.

The third area is the most difficult to satisfy, but probably would bring the greatest return. We believe that we are required to work through case studies, using some of these ideas, to improve linkages across departments of government in order to allow that to happen. As well, we believe that we need to build a shared agenda with other sectors in order to accomplish that. Thank you.

Dr. Fraser Mustard, The Founders' Network: I will continue the presentation with a slightly different tack. Having been a physician, I grew up in the health care system, and knowing some of the debate that has been going on, I would like to make a few comments on what I call "myths about our health care system". I will return later to the broader question of the determinants of health.

One of the intriguing things is that in 1974, a document entitled "The Mustard Report" stated that community-based health care should be integrated with institutional health care services. That was finally accomplished by getting two rather tough nuts to come together. One of those was Bette Stephenson, who was on her way to becoming president of the CMA, and the other was Duncan Gordon, who was chairman of the board at sick kids hospital. Mr. Gordon was quite elitist in his belief that he ran a first class hospital, and he was not interested in family practice, unlike Dr. Stephenson. For three months, I listened to their warfare. Finally, I figured out an approach to the problem. I went to a meeting and asked: "How would you prefer to be handled when you become ill?" Mr. Gordon and Dr. Stephenson finally reached a common point of view. The reason I mention that is because that battle continues today. When we released the report, the outside audience had not gone through this process. Thus, the hospital boards rejected the idea of coming under some kind of local management structure, which they were a part of, and my good colleagues in medicine soon did not want to come under the control of the local management structure. That is the background for you as you try to rationalize the process.

In conclusion, the reason that you cannot effect change in a publicly funded insurance system, not socialized medicine, is because each time there is institutional change, those that will be affected by it try to prevent the change and the ministers of health become lightning rods for that response. I saw it in spades in Ontario at the time and I see it constantly in the present.

I will discuss the myths and, rather than reading the text, which covers them, I will direct your attention to the charts. I will refer to these charts for some of the myths and some of the facts.

The first chart deals with the economic facts. You have a technology mandate. I am a firm believer, since we first pushed the new concepts of economic growth at the institute I used to head, that the only measure of how well profound technological change is handled, is the change in total productivity. That has been done by Martin and Porter and Hlepman and Fortin in their study of Canadian competitiveness. It shows that Canada's total productivity became flat about 1975, which means, in essence, the wealth-creating capacity was no longer increasing.

The relative standard of living actually slides with this activity, and as Martin and Porter and Helpman et Fortin show, the productivity slid about 30 per cent. It means that the wealth base to run non-wealth-creating functions, which health care is, is eroded. Therefore, it is important to understand that pressure in the system.

The second chart shows population growth, and is almost referred to in terms of people living longer. It was prepared by Mr. Fogel, who is an economic historian. His analysis of what occurred over the last 250 years is probably the most powerful. There is no more debate, except amongst the professional colleagues.

Mr. Fogel tracked the records of western countries and showed that as the mean height of populations increased, so did life expectancy. He realized that mean height is a product of genetic makeup and good nourishment. He quickly spotted that changes in health, particularly diseases in adult life, were being affected by early childhood.

That was powerful work that was done in this century and he makes another powerful argument relevant to your work. He said that the quality of the population in Great Britain produced by this effect accounted for 50 per cent of the economic growth in the United Kingdom, following the start of the Industrial Revolution. This is a point that is totally neglected during most of the public policy discussions and ignored by most neo-classical economists. This chart shows you the extraordinary drive of new knowledge and technologies that are affecting the world.This is driving our capacity to create wealth and it is a paper that you should have and consult. The paper is his address as president of the American Association of Economists and contains powerful messages for your work, including health, the change in wealth, and the change in the economy and its effect on people.

We have been in a changing economy and not doing very well. What has happened to health care expenditures? The next chart shows the usual story. Governments eventually had to cut back on publicly financed systems because their tax bases were not growing. Programs that were developed for more stable economies and business cycles are totally inappropriate for periods of profound economic change, which we are in.

It is interesting that even the United States has been affected by this. It has curtailed its spending, both private and public. Canada also does a good job of dipping it down. The OECD reached a plateau, and the U.K. has been well behind us in terms of those expenditures. Thus, in public policy, there is a constraint on public finance. That puts a constraint on the financing of health care in our society, which creates a series of problems for the providers of care and the system as a whole. They cannot operate under this kind of stress, and their capacity to adjust to the kind of things that we argued for in the report becomes blunted. There is no incentive for that change to take place, and the entrapment in the old system, which is not as efficient as it should be, continues.

How is that damaging our health? The OECD has published a recent report illustrated in chart 4. That report shows that in 1995 and 1996, when they prepared all the computations, Canada is not as good as Sweden and Japan in terms of years lost for 100,000 life years, but it is slightly better than Germany, the U.K. and the United States. That is rather impressive. In terms of life expectancy, we are not at the top of the list, but we are not doing badly. In respect of infant mortality, we could do better but we are not bad.

Our health care expenditures are not the massive figures you see at the bottom, but rather, these expenditures are both private and public. It is important to understand that. In the United States, health care expenditure is about 50 per cent private and in Canada it is about 25 per cent.

Despite the myth, our health status has not decreased. For Thorsell to write an article in The Globe and Mail earlier this month saying that the quality of care in Canada has deteriorated, is a pile of garbage. I am offended by anyone writing that in face of the real evidence about what takes place in this country. It says something about journalism.

The next data is real Canadian data that is relevant for you. This information is from Noralou Roos. The Manitoba Centre for Health Policy and Evaluation is the world's only totally linked health care record system for the purpose of looking at a population of 1 million people. It is a disgrace that the rest of the country does not have such a full-fledged program in place. Your committee can recommend that the Canadian Health Information System promote this and run with it. People ignore the Winnipeg data, but not in Manitoba. In this case, they are using administrative records to generate real information. Therefore, the health status of people in Winnipeg in 1986 and 1996 is recorded by level of education. For example, people are given a status from Q1 to Q5, with Q5 being the most well educated. The mortality rate per 100,000 is a gradient. The people at Q5 and Q4 show improvement; premature death, the same level of status; and with life expectancy, the same pattern.

An interesting conclusion drawn from that was that the gradient, which represents inequalities in health, cannot be changed by health care. That is an important message for you.

The delivery of service, however, goes where the people are sickest, at the bottom, or those with a Q1 status. Our system works well for that, better than the American system. It is a very powerful database. That paper says that you cannot improve the inequalities in health through the health care system. That does not mean it is unimportant, but rather that the cause of the gradient must be wrestled with.

The next myth is waiting times. I love that story. I see my friend Senator Keon here. There were waiting times when I was an intern in 1953, for heaven's sake! It never changed. You found ways to get around it. I got people into hospital despite administration when I felt that they should be there. I am not sure what administration is like these days; they would probably fire me.

The Fraser Institute dumps out information about waiting times, which it gathers through an inappropriate survey that asks people questions. The Manitoba data is taken directly from their record system. On chart 6 you will see that the waiting times for cholecystectomies, hernias, breast lesions, varicose veins, carpal tunnel release, TURP, tonsillectomies, and so on, have not changed very much, despite the acute care beds being reduced by over 25 per cent in Winnipeg. That is important information. As Noralou Roos pointed out, when you get this information to the media two days before the Fraser Institute's usual publication, at long last the press pay attention to it and ignore the Fraser Institute. When you are talking about myths that are generated by the press and put pressure on public spending, you must exercise some pressure to get Her Majesty's governments across Canada to do a better job of getting real information and facts out about what is taking place in the system.

If you come from Mr. Klein's country, you will like the next chart. This is the Winnipeg data on optomologists doing private surgery for cataracts. You will notice the wait time when physicians are doing both private and public sector surgery has increased compared to the surgeons who are only operating in the publicly financed sector. That is a neat trick. You can probably have your own debate about it, but the methods of payment and running the system do affect waiting times. It is all in the papers.

Having gone through that, one of the striking things is: How much money do you spend on health care and what is the value of privatization? I included a fair amount in this document about the real nature of what is happening in the United States. Basically, the United States is in a chaotic situation. The private insurance system there is unable to cope with the cost of health care except by putting a huge cap on it. They have decided to manage physicians who have managed care programs, which is causing huge repercussions in the attitude of physicians toward their own system and huge tensions in the United States.

I have referenced all the material here. You can read it if you want to, but if you are to talk about private health care, you need to talk about how the people in the system are reacting to it -- that is, the people who provide the care. Dr. Keon and Dr. Mustard do not want to be taught by some manager about what we can and cannot do. Unless you were to change, you would never give in to that. The managed care process is trying to do that. Our system has done a much better job because it puts pressure on the amount of money, but still leaves flexibility in the system for good management to do a good job of getting things done. It is important to read through that literature and think about it.

Chart 8 shows what countries spend on health care in relation to their actual wealth. That is the relationship and it will not change. As your wealth base shifts and your costs increase, you are squeezed by this very fundamental relationship.

Chart 9 shows you an interesting study done in the United States on privatizing hospital structures. What you see is stable, not-for-profit institutions converted to profit institutions. The increase in spending went up dramatically. The for-profit institutions then converted back to not-for-profit and went the other way. I want you to read through that if you want to look at public and private expenditures in the health care system. In Adam Smith's argument, Dr. Keon and Dr. Mustard are menial servants. He made a sharp distinction between productive and unproductive labour. I was insulted when I read the chapter, but then I realized what he was saying. The relative wealth of a society determines how much you can invest in the non-wealth-creating functions. That is not to say, however, that we are unimportant. He included lawyers and opera singers in this language. I did not think that opera singers were menial servants, but if you understand the determinants in economic growth, then what Mr. Smith says is exactly right. You must be very careful to realize that the expenditures in health care are heavily related to how wealthy your society is. If you over-invest in that, you will create deficit problems and you may under-invest in the new economy being created by the technological change.

The next reference is from that master of logical economic action, Bob Evans. When I first met him, I thought he was hostile to all physicians, but I gradually became a little more comfortable with him. He points out that you only have three basic groups to fund health care: the government at the top, through some kind of system such as we have; other insurers; or direct charges to households. That is all you must have. If a system is squeezed, the providers of care have to look for alternate sources of funds. Alternatively, if you are in a business and you are squeezed financially, you have to re-jig your business to make it more efficient. That is the basic tension we face in our system as we try to come to grips with this situation.

When you try to produce change in the system -- a change in any institution, be it a business or a hospital -- you are affecting people and their careers. The private sector and businesses do that because they have to. When we get caught in a publicly financed world, those of us who are affected by it rise up and create a political storm that affects the ministers of health, who become lightning rods to prevent change. I have seen it happening for 30 years and it is still there. One of the tough issues to face is: How can you decentralize the system to give communities the independence to make the decisions that will prevent the polarization that politically prevents your ministers from letting some of the changes take place? It is a tough question. Experiments are taking place in different parts of the world. At the present moment, the United States' experiment, where managed care is trying to produce caps on it, is in deep trouble. The U.K. may have a better solution, or, perhaps, we can be more creative in our own country as we face these facts.

If you go through the reports of the National Forum on Health, it says lots of good things should be done, et cetera. I would support them. It comes to a very important conclusion, namely, that you must deal with the real determinants of inequalities in health, and that is related to where you live and work throughout the life cycle.

Chart 11 is from an Acheson document. It has "social class" on the left-hand side and is entitled "Standardized Mortality Rates". Again, you see a perfect gradient. That gradient has held from 1970-72 to 1991-93. There has been substantial improvement in the upper social classes, but not in the lowest social class. That matches the data I showed you from Winnipeg by Noralou Roos. We have the same phenomena here.

That takes us to the final battle in this whole business. I did not read it all, but I brought two copies of the earliest "Ontario Early Years" report -- one in English and one in French. If you would like more copies, contact my office and we will send them to you. They articulated clearly how the early years of life set the level of health risk throughout life. It brutally sets out for me the problem the government faced. I would have argued in this present budget, despite the strains on the health care system, that the benefit to the future would have been huge if you could have put at least $1 billion into supporting early childhood development. You did not do that. I know what the counter pressures were, but I think it was wrong, because the myth that I have been talking about dominated the press. This tells you what to do, and it comes back to the options.

Margaret McCain and I have been having great fun. We said to Margaret Marland, a minister without any power, that we would continually wander around talking to communities about what is in this report. Ms McCain is currently in New Brunswick, another community that is desperate for advice. We have at least two demands a week, from regions in this province and in Canada, to talk about this with people and communities. These are audiences of 400 to 600 people -- mixed audiences, comprised of both business and community people. There is an understanding of the importance of what is contained in this document. It comes back to all the steps in the process.

To summarize this in a simple form for you, I included a sheet in the back, because there is a book entitled, The Myth of the First Three Years, to which the media have been giving huge press. It has one important message, but it distorts all the other evidence. Basically, it is wrong. You should know that the World Bank is holding a session on April 10 and 11, in Washington, on early child development in the developing world.

The president of the bank will open that and the Ontario minister will chair one of the sessions. I invited the federal minister responsible for CIDA to attend this meeting. I hope she will do so, because there is a world movement on this subject, which is enormously important.

In conclusion, in thinking about health for the future, we must get rid of the myths and redeploy resources. The brain is the pathway to health, learning, and behaviour throughout life. We know much more about the process than we did 50 years ago. The scientific side of the story is now well documented. I believe that the findings of Michael Marmot are partly driven by the early childhood story. Michael would not agree with me on that, but I think there is a strong case for it. The gradient I showed you for Winnipeg, of older people dying, may be heavily influenced by what happened in the early years, and that is why it is very difficult for the health care system to change it.

That is probably the real story. That is speculation, but the weight of evidence is very powerful. You will do a good service for the governments in Canada if, in your work, you get the message out to a broader group in the country. I argue strongly that communities are more receptive to this than most people believe. The media is a huge problem because it does a very poor job of discussing this subject.

Senator Keon: It is difficult for me to question these two gentlemen because I totally agree with the philosophical approach they have been presenting. However, there is a practical problem for us if we are to do anything worthwhile after these hearings, and that is how to get our priorities, and the system, changed. Our elected politicians can rightfully brag that our health care delivery system is a very good one. Consequently, the population is nervous about any change in it, although there is now much pressure for change because service is not as fast for the rich as it is in the United States.

How can we stop making enormous expenditures on health care facilities and programs that stand passively open, waiting for the sick to fall into them, instead of doing what you both advocate? Have you any ideas on how we can do this?

Mr. Mustard: I can give you one example that you may want to explore. Manitoba has tried to decentralize decision-making functions about health care. Their database can be used by the community. The actual status of their populations by socio-economic class and use of the health care system is available to the communities, but in aggregated form so that it cannot be used to label anyone. Manitoba is in the process of putting into that database a measurement tool of child development in the first five years. It measures physical and cognitive development of the child and will likely have huge predictive power. We will see what those gradients are like when we have some information on the different communities. They will probably also include educational performance in the school system in an aggregated manner. That will show the mental pathway to health, learning, and behaviour. It will be the first administrative life cycle file in our country, and it will be sensitive down to the community level.

In Southeast Manitoba, after looking at their overall figures, they decided to shift some of their health care resources into early childhood development. This was not a government decision, but one made by the structure created in Manitoba for this purpose.

If you can get it to that level, you may have some chance of success. The new information systems, the opportunities and the understanding, transferred to community bodies does seem to have some effect. As we were addressing this question while doing the report for Mr. Harris, we learned that there are many entrepreneurial people in communities in Ontario, who are not arms of government, and who are starting to tackle these problems. They know how to integrate functions. We suggested to the Government of Ontario that it learn how to mesh with them and how to create public and private sector cooperation in communities to move these agendas forward. The tradition in the health care system of good hospital boards achieves that.

We must move into the modern world of electronics and information systems and transfer that capability to the communities. This is relatively easy for them to understand, and they can then make the choices.

Mr. Glouberman: There is a bit of confusion between the actual performance of the health care system and people's lack of confidence in it. The response to people's lack of confidence in the health care system is often to add more resources to the system. That does not tackle the problem, because the problem is about confidence. The question is: What strategies can be used to increase confidence in the health care system? Part of it is information. Another part is an assurance that the health care system will there be when people need it. That has been a big part of the struggle.

There are many aspects to this. Much of the reduction in government expenditure has cut access points to support and help. We have seen that happening day by day over the past few years, as various community agencies close down, and some communities are sealed off from certain resources. If you reduce the number of access points, people turn to the police and to the emergency room, both of which become overloaded. The solution is to increase access points to support and health care.

As well, giving people assurance that they will be serviced in a reasonable period of time, which is defined, as in the Manitoba study, is a way of telling them what their level of confidence should be. Part of the issue is the changing expectations of people, as you say. Rich people want instant response and believe that they should have it.

When medicare was introduced in Canada, people recognized that there was a cost to it in terms of response. The outcome was slower response but greater fairness. I believe that Canadians have broadly accepted that, as long as there is no threat to life and, ultimately, security. Those are trade-offs that Canadians have been prepared to make, but we have not made that as explicit as we could.

Making many of these things more explicit, creating more assurances, having more and different access, are all things that would help. We are beginning to do that. I am not as pessimistic as some. I do think that we have to improve people's confidence in the health care system and their belief that it will be there for them. That is a serious issue. It is not just a myth.

Mr. Mustard: On that point, I do not agree there is a problem in the response time, based on the data and observation in Manitoba. I do not wish to go through that here.

I serve on the advisory committee of the Manitoba centre, so I will declare my bias and self-interest. However, on that board are business people who understand this, and so we had a meeting with them last June, about 12 of the business leaders in Winnipeg, about the actual information from the Manitoba centre and the response of the press.

They were concerned that the press was totally and wrongly changing public expectation. It seemed to me that is an extremely important message. They are quite comfortable with and confident in the data that now comes from the Manitoba centre. I do not know what they have done, but they are trying to take steps to block the myth-making which creates the undermining of the Canadian health care system.

If you compare the Manitoba data to the situations for the population to the south, you certainly know that you live in Manitoba and not in Minnesota.

Senator Keon: I wish to return to the subject of access. In the other side of my life, as the CEO of the heart institute, access has become a buzzword. It is very curious that it just appeared about two years ago. The inquiries that filter up to me ask: "How can I get access to the hypertensive clinic or the lipid clinic, because I am being told I do not need that service because my GP can do it."

There is a real problem. I do not know where the word came from. I would like you to comment on it a bit further and on how we should try to solve this. We are not giving the right information at the access points.

Mr. Glouberman: There is a reduction in the number of access points to all kinds of support. That makes a huge difference. As there is that reduction, and you get things concentrated into very much fewer points of access to support, then very often there is not as much expertise, not as much information given to people, and the service is not always appropriate to the needs of the particular people who come for it.

Some good examples include young people who are in trouble. There used to be support lines for them or ways in which community agencies would be able to pick up on some of their problems. Without those agencies, young people will very often end up in emergency rooms or at the police station, neither of which has the expertise to deal with things.

There are many questions about the multiple access points that occur in funded community agencies. As they disappear, you get the reduction of broad community support.

The more specialized and the more emergency oriented the response areas are, sometimes the more difficult it is for them to deal with the broad spectrum of complaints people bring. They think people come inappropriately, but it is the only place they have to go.

Mr. Mustard: This is not a new issue. I can remember the dark days before we had publicly funded health care. Most doctors lived on pretty small incomes. In the whole system, access was a continuous problem. The two things that drove it were the quality of the professionals engaged at the access point and the administrative structures in which they worked.

I have been hugely discouraged, and I should not say this publicly, but I will. I do not believe the quality of the administration in many of our institutions for care is up to the quality of the providers of care. You have a huge mismatch in ability, which creates problems. That is the problem the United States is getting into, the managed care system. There is great friction created when a group of people who are professionally trained, with high skills, have to operate in a managed structure with people of different backgrounds and abilities.

One must recognize that the provision of care advice to a person who is ill requires an extremely sensitive individual, who must have the power to make the decisions that are appropriate and not be pulled away from it, which is getting at the access point.

When we experiment with nurse practitioners in primary care, we can make that work, but no one ever put the programs forward to enrich that kind of capacity in the system. This is part of the battle I had with Duncan Gordon and Bette Stevenson when constructing that report.

The real change here is, as a profession, perhaps we should do something to push the re-jigging of the administrative structures in the system to get at that point. I do not think the administrative structures themselves can do it without full professional support. I do not see that emerging.

Senator Fairbairn: I have a question on the early childhood enhancement issue. However, just to follow up on this discussion that we have been having, in the so-called newly managed system, there is supposed to be a higher degree of efficiency leading to what is believed to be the best solution for individuals, and that is to be able to cared for in their homes, or through other agencies, rather than in the primary institution.

As a personal observation from experiences that I am sure every one in this room has had with family members, one of the other difficulties in terms of access points is the fact that in putting the systems together, there has been a failure to place importance on the connecting links. Individual parts of a system of care, from the emergency rooms, through the hospital out into the community services, may be okay, but individuals of all ages, and particularly seniors, who are in great distress and, indeed, risk, find that with the best will in the world, these systems are not connected.

I am not sure where the answer to that lies, but we need a mechanism to make sure that as a person moves through the system, those connecting links exist. If they do not, then you can be in a situation of tremendous risk, out in the community or in your home, if what you thought was supposed to happen does not because someone has missed something along the way.

I do not know whether the same situation exists across the country, but certainly in my experience, both here and in Alberta, the lack of connection is almost a danger to the way our current medical system is supposed to be progressing in order to serve people better.

Mr. Glouberman: I agree. Part of what we have been saying is that the linkages are critical. What happens is that health care systems are viewed very much like health is viewed, in a number of boxes. The boxes are connected by lines and the question is, what happens in the lines? Those lines are often problematic and how you create and improve those linkages is part of the problem.

Historically, it seems to be true that many of these linkages were informal. At the bottom of the health care system, there tends to be quite a smooth movement of patients through the various stages of care.

When you start to create more formal links, and you begin to structure the system by, for example, getting rid of some kind of theoretical boundaries, by regionalizing, for example, you can create more problems in transition of patients because many of the existing informal links disappear.

I did interviews in a series of GP offices and spoke about how elderly patients were cared for by the GP, both in the community and in institutions. I work at Baycrest, too.

One of the things we discovered is that all those linkages, and the transition of patients, worked very well as long as the doctor had a certain practice nurse. When the practice nurse disappeared, it did not work any more.

Many of those transitions happen because of informal connections, because people know each other, know what to do, and how the system works. That is the way it actually works in most systems.

The idea that you can formalize a significant amount of that and declare it by getting rid of certain structures can make it more difficult. Understanding how it actually works, and where the transitions actually happen, is a big part of what has to happen.

We have just completed a study on the transition from hospital to home.

We discovered that many obstacles have to do with not understanding beyond your own boundaries and things beyond your institution, or beyond your discipline or profession. Creating links between professions and disciplines and institutions happens all the time. It happens mostly very well. When it breaks down, it is often because of changes in formal structures or because of the creation of new organizations.

Much of this stuff that has been happening in Canada has made those transitions more difficult rather than easier.

Senator Fairbairn: If you look under "H" in the phone book, you will never find home care. It will be in a green section called something else, which makes it very difficult.

Mr. Mustard: You need to also face up to the huge social/demographic changes in society. Intergenerational family support systems 50 years ago were real, which helped handle part of this. Today, things have changed dramatically. It not only affects the older age group and the sick, it also affects children. We need to think through how we can capture that. It has to be some kind of locally based structure. How do you capture the capacity of human beings to build those interactive functions?

One thing we learned is not relevant to health care specifically, but if you accept the brain story, it is, in terms of health. We watched what I will call "the repair shop functions". Children's mental health, welfare, and children's aid societies were all fragmented functions in communities, not integrated. We then found people who knew how to integrate them. One of the clever ideas that allowed communities to integrate was the CAP-C, or Community Action Program for Children programs, which created local boards and got things together. You can learn something by looking at those programs, because their application goes all the way up through the life cycle.

Once these programs were in place, then the communication transfer story is extremely important. I would come around to believing that CAP-C has done more to build community capability than any other program that the Government of Canada ever launched in the system. You might want to explore ways of expanding that into the subject matter you are discussing.

I do not mean the way in which CAP-C is technically targeted, but as a broader function of building community capacity. Communities can come together to create the instruments to do this. The real problem is that when you want a community health centre, it is more than a community health centre you want. You want a whole bunch of things to be folded into that function. You want to broaden that base. It needs to have some kind of board. You must make sure the government programs that fund people to work in that, can now work comfortably in a new shop, and that professional barriers to cooperation and collaboration are eroded.

The length of time my children have to work to put roofs over their heads and feed themselves is about one-half the time of my generation. The amount of time available for leisure has gone up, but so has the time for volunteer work. Societies need to find ways to draw that back into the system. I even suggested that the government should give a tax credit to retired people, like me, who are willing to commit three days a week to an early childhood development centre. Why not make use of me? It gets back to your story; I will live longer and be less of a burden because I will be doing something useful.

I believe you have to think imaginatively about where the world is today, and the opportunities, and use government programs as incentives to build the kind of integration that is do-able. If you couple that to the information systems that exist, you can do a lot, because you can use the electronic system.

The Deputy Chairman: Colleagues, I would ask you to keep your questions a little shorter. We do have another two witnesses following this.

Senator Fairbairn: I will be brief. The early years study has been one of the most dramatic things to occur in terms of health care, and in a great many other things. I have worked in literacy for about 16 years. The hottest topic now in literacy has gone from the adult to the family to the child. What you talk about in terms of children before or around the age of two, we are now hearing ministers of finance talk about in speeches, and they are using your words.

What is your advice to us, Dr. Mustard, on how we can use this information to put a major emphasis, which requires money, on this period in a human being's life in order to get them going the way that our society needs before the age of six. You say in here that after that age, you have missed the boat in many respects in influencing the direction of a child.

Mr. Mustard: You do not have the chart in front of you. The reference group had to address a question on the fact that the subject matter we are talking about actually begins with conception. The first year of life is a very powerful period. Daycare is not identified as a child development issue by many people. We had to think of a conception-to-six framework for this because that is a very important period. We chose the term "early child development centre", because parents have a huge effect on that. We learned, as we wandered around the province, that there are quite good parenting centres that actually provide non-parental care illegally, but they have to get around the regulations. The parents are involved in the process, such as in a nursery school, and they are able to use that information when they are with the children in their own homes.

The first thing you can do is try to create a framework for what is meant by the concept of early childhood development and making parenting centres accessible and available to all in society with young children. The second thing to remember is that 65 per cent of women with children under six are in the labour force. Therefore, it is idiotic not to have that capability built where it is relevant to where people have to go and work. The building in which I work is run by a nice woman who has put in an early development parenting centre. It is a huge success, open to the people in the building, but other people can use it.

Governments could issue tax credits for private sector investment in early child development and parenting centres for their employees that would also be open to other people in the community. You would start to move this hugely down the road if you were to put that into place. Do you not try to put this in a government program, top down? Daycare is a regulated system, and the people in the field who want to integrate will tell you that the regulations are a pain. They have to get rid of them to be able to build a more integrated system. It comes back to the same thing. The report spells it out.

If some of you want to have someone guide you through this, we would be glad to do that so that you could use it as a weapon. Premier Harris wants to do this. Whether his political structure will let him do it or not, I do not know. He believes it is very important, despite what you read in the newspapers. That tells you something. If you can get the right formulations out, a lot of people will buy into it.

Senator Cohen: Dr. Mustard, I have wanted to speak to you. You mentioned on the first page of your report the decline in the standard of living. We all know that it began to drop in 1975, and today we have a population in poverty that is staggeringly high. If we go on your premise that the diseases of old age are the result of what happens during early childhood, what kind of crisis will we face when the children who were born after 1975 into the ranks of poverty, with the socio-economic problems that are facing them, grow old? What will that do to our health care system? They are only 25 years old now. If your premise is real, we will be faced with a crisis.

Mr. Mustard: When you look at the report, you will find that our measurements are all gradients. It is a very important point. Yes, the economic shift in the population is substantial, particularly for people under 45, which is the child rearing population. A gradient tells you something. It is not really poverty. It is much broader and it affects all of society. The biggest number of children in difficulty by these criteria is actually in the middle class.

Any solution has to be available and accessible to all. It is important to put that in place. Politically, that is important because the stresses on young families are not trivial. If you just target one group and exclude the others, you run into problems of acceptability. It is better to make it available and accessible to all parties. That is the issue.

I will discuss two points. First, we can now say with some confidence that if a female is raised in a dysfunctional family for her first five years, the risk of mental health problems, such as depression, in her 30s is much greater. That is a huge linkage.

Second, if a male is raised in a dysfunctional family for his first five years, his risk is functional illiteracy. Swedish studies have indicated that a male will probably not do well in school and will end up in the justice system.

If a child is read to at the age of eight months, the reader is driving the crucial development of five sensing pathways during this period. For example: smell, touch, temperature, sound and vision. These integrate into the controlling functions of the brain that govern arousal and emotion and actually feed into cognition.

We can now see why there is a linkage between illiteracy and the behaviour of males in the justice system -- something we could not see before. Put that all together and the answer is yes, if we do not pay attention to this, we will have a burden. When the present troubles in schools are examined, such as kids shooting people, that dysfunctional story is expressed in extreme violence. For the most part, it has been set in place before the age of five.

Senator Callbeck: Dr. Mustard, you presented a paper on myths. One of the myths was that cuts in health care spending are damaging our health. You went on to back that up with statistics from Manitoba to show that there is no deterioration in health as expressed through the health care system.

That was between 1986 and 1999, even though expenditures went down in hospitals and there was a decrease in acute-care beds.

Certainly a great many Canadians would not agree with you. If you look at the polls, Canadians have less confidence in their health care system than they had five years ago. Can you point to things that have really triggered this? Canadians, at one time, had confidence in the health care system. Is it a fact that the drop really started when governments cut back on funding and cut back on acute-care beds? I know many people feel that the health system is acute-care beds.

You presented statistics that show that health care spending has not damaged our health, but yet, as I said, Canadians would not agree. What has started this decline in confidence?

Mr. Mustard: I run the risk of being sued by the owner of one of our national newspapers when I say this. If your ideology or values are taken over by individuals with no social accountability, and that, I will argue, is largely the philosophy behind one of our national newspapers, which shall be nameless, you run the risk of getting into the neo-classical economic trap as expressed by Milton Friedman, which states that ideology largely drives the instruments of society, and the reasons for doing that. Some people would argue that in health care, if you can privatize it, you are fitting that neo-classical philosophy. You will free the system up, and people believe deeply that is the way society should work.

I refer to Sen and Fogel, both Nobel prize winners: Neoclassical economics is probably dead in the water in this century, because you have to understand better how you create wealth and how you reinforce things in society.

What you have, I believe, is an agenda captured by people who are sometimes called neo-Liberals, who basically do not understand this relationship, which can be very destructive to society. I believe the other national newspaper is largely in that mode as well. The problem arises because the two national newspapers are not on the same wavelength. They obviously express a wavelength that their readership likes, and it is true that not all their articles are biased, but they selectively produce information.

The business community in Manitoba understood that the press was wrong. Whether they can change the media, I do not know. The other organization that I think does a poor job is the CBC, sadly. I was so cross with the CBC that I almost wrote the new president a letter saying that I would stop listening because it was not dealing with the issues in a balanced manner.

I think it reflects a strange value structure in our society, and perhaps nothing can be done about it, but I believe it can. If work is started with communities, you can fundamentally change the system. However, we are trapped in a spill-over of belief from south of the border. I am not referring to P.E.I. by the way, which is a different world.

Senator Callbeck: A better world.

Mr. Glouberman: The way you describe the puzzle is interesting, because it is not that the health care system is performing badly, it is that people have lost confidence in it. That is the point that I have been trying to make. The question is, how do you deal with the loss of confidence? The strategies for dealing with that are different from strategies for beefing up the health care system. No matter how much you beef it up, if the pressure is constantly on, it reduces people's confidence. The health care system will not respond to the question of what people believe rather than what exists.

Mr. Mustard: If you undermine public confidence, and if you are desirous of a private system for all kinds of reasons -- for your own economic gain and other reasons -- the public becomes more inclined to receive it, and you can say there actually has been a quiet campaign to do this. It may be right or wrong, but I think you have to look at that question.

Mr. Glouberman: There is an example of that preying on people. I was called into the CBC to comment on the fact that people are offering health insurance to junior executives, who can pay $1,000 per year and get immediate health care coverage in the United States. They are targeting people between the ages of 30 and 40. In fact, however, people between the ages of 30 and 40 will not have any contact with the health care system except under very unusual circumstances, in which case they would be treated just as well in Canada as they would in the United States. There is a way in which that lack of confidence goes all the way through society and people are prepared to act on it. It is good marketing.

Senator Callbeck: We are running out of time, but I would like to ask one more short question. Some people say that the Canada Health Act is too regimented to permit health reform. I would like to hear your comments. Do you feel that that is the case, that it is too regimented to bring in a system of population health in Canada?

Mr. Glouberman: That is a good question. I spoke to one of the people who actually drafted the Canada Health Act. About 50 people claim to have done so, but I met one who actually did. He said that it was quite clear that the intention of the Canada Health Act was: What is covered is "at least" what is covered; in the intervening years we have gone to: What is covered is "at most" what is covered. There has been a lot of cost shifting in the name of efficiency from institutions to individuals.

If, for example, people leave hospital earlier because there is a more efficient hospital system, the cost is transferred to families. Some of your drugs are only covered when you are in hospital. There is another cost shifting taking place. It is not a question of the framing of the Canada Health Act, but rather the interpretation of what should be covered. If it is "at least", we are okay, but if it is "at most", we are in trouble.

Mr. Mustard: To add to that, the other side of this is that it is not rigid. The problem is execution. It is the failure of provincial governments to design systems that are more community sensitive, to allow shifts to take place. Look at what is going on in Alberta, Saskatchewan, Manitoba, and some of the other provinces.

Ontario has a long way to go to get its act together in handling this. You must think hard about it. It is not the act that blocks it. It is innovation and incentives for innovation to work that are missing.

[Translation]

Senator Gill: This has to do with standardization of services. That is something I am always concerned with when information is collected. After information is collected and results are obtained, we tend to assess the situation and standardize. This is something that happens in many areas, and I imagine in health as well. As for services adapted to the population, for example, we have statistics on Manitoba.

On the basis of your data, can you establish services that will genuinely meet the needs of the people in the North and in remote areas? You have talked about decentralizing services. Yet communities in those areas have higher mortality rates because of social and economic status. So can we use the Manitoba data to say that we are meeting the needs of people in the North and in remote communities, particularly where health is concerned?

[English]

Mr. Mustard: That is a good question. The Manitoba data actually is used for this purpose. The highest demands on services are in remote regions of Manitoba, and that is exactly what takes place. Second, the referral system from those regions into the centre in Winnipeg is fairly sophisticated, as the tracking shows. The tougher problem in those regions is getting at the underlying causes of the health problems of these people. You will find that the Manitoba data is a pretty good base to ensure that that is not lost. Ontario does not have that data and therefore we cannot show you the real distribution of services here. That has led Manitoba to institute special programs to help people in the north gain access to systems.

The Deputy Chairman: This has been fascinating. You have given us much food for thought and we will have to work our way through the statistics that you have provided.

Our second panel consists of two witnesses from Canadian polling firms. The health care system, as we know, has received substantial attention from polling firms in recent years. This committee can surely benefit from the information they will share with us today.

Mr. Chris Baker, Vice-President, Environics Research Group: Honourable senators, the mandate of this committee is important and timely. Any observer of political institutions in Canada certainly respects the Senate in its investigative role on a number of matters. When there seems to be an issue emerging, the Senate has wide powers to consult and to investigate, and certainly the public policy process in Canada has benefited from the attention of senators to a variety of topics.

When I heard that this committee would be investigating Canadian attitudes towards health care, and especially when we received an invitation to make a presentation, I was very happy.

At Environics, especially in the Ottawa office, we do focus not only on public policy issues and their respective stove pipes, but also on how they interact with each other. Health care is a very important area that touches on a broad range of public policy issues. You can certainly hear some commentators saying our health care system not only contributes to our quality of life, but also to our economic competitiveness. It also touches some very deep values in Canadian society.

I want to give you a brief overview of some of the data that we have been tracking for some years. We have been looking specifically at work that comes from our Focus Canada quarterly. Every three months, we go into the field and interview about 2,000 Canadians on a host of public policy issues.

In July 1999, we conducted a fairly comprehensive study on health care in Canada. It is a regular study that we do through the Focus Canada vehicle. However, we also continue to track, on a quarterly basis, a number of top-of-mind issues related to health care.

The data that you will be seeing today is all very recent. The oldest is from July 1999 and the most recent is from January 2000.

I will go quickly through the data. You see a number of slides there. I will probably not go into some of the more detailed slides in depth, but I did want you to have the information for your consideration.

Looking at the Canadian context, we find that for the first time ever, health care is actually seen, along with unemployment, to be the most important problem facing the country. Fifteen per cent of Canadians say that unemployment and health care are the top issues at this time; 11 per cent say taxes are the most important issue; 11 per cent say other economic issues. Rounding out the top five issues of concern to Canadians are poverty, hunger, and homelessness.

What see that decreased concern about the economy and unemployment has really allowed other concerns to become more top of mind. It should be noted that there is a strong demographic skew on this issue. Women tend to be more concerned about health care, while men tend to be more concerned about taxes. Age and income level are also factors. The older you are, the more concerned you are about the state of health care.

One can certainly see how unemployment, which is the top line in this graph, has really dropped in the public consciousness. One sees that health care, which is the green line, has gone from where no one was concerned about it in November of 1992, to today where 15 per cent of Canadians are concerned.

There is also a strong link between health care and the Canadian identity. The universality of the system is certainly linked to strong Canadian values like egalitarianism and generosity. Although the system is seen to be under stress, it is also seen as a working example of partnerships. There is the traditional federal-provincial partnership, there is the partnership between a patient and the doctor, and also that between the individual and the state.

On this chart, one sees that of all the items that are important to Canadian identity, health care is rated number one in Quebec and in the rest of the country.

Looking at government roles and responsibilities, we find Canadians currently give both their federal and provincial governments low marks for their handling of the health care issue.

There has been a slight increase in these indicators over the past few quarters. This is a reflection of the higher priority all governments are starting to give health care. However, Canadians have a very poor understanding of how the system is financed. Certainly when I try to explain to my friends what tax points are and what they mean, I get this glazed-over look after the first 30 seconds.

Canadians are starting to become very short-tempered about blame-laying, people pointing their fingers at others. There is a strong interest in more positive results and, most importantly, intergovernmental cooperation.

You can see from this chart, which is a net rating, that is, those who approve of the government's performance minus those who disapprove, that the federal government and most provincial governments are in the doghouse when it comes to health care issues. Other issues they could do much better on, but health care certainly seems to be in a very difficult state at this time.

When we asked people about their spending priorities, three quarters of Canadians want to see more spent on health care. That figure is slightly ahead of education and child poverty at the top of the spending priorities list. It is important to note that the desire for increased spending has reached a plateau, which means it is high, but it is not decreasing. It is not abating in any way.

Once again, there are some slight demographic differences in spending priorities, but there is a strong consensus that more needs to be done in this area.

From my own experience with public policy, I know that sometimes spending priority is a proxy for effort and attention. However, I know that on health care issues, not only is there a desire for more money, there is also a desire for more effort and attention from decision-makers.

These charts show you some of the spending priorities. It is interesting to note that when we start asking about the federal government surplus, we find that program spending has remained fairly stable over the past three years. There has been some volatility with regard to tax cuts and debt repayment, but we find that about 40 per cent of Canadians consistently say that when it comes to federal government surpluses, they would like to see the money allocated to program spending, and the program they want to see it allocated to, of course, is health care.

Turning now to perceptions of the health care system, we find that two-thirds of Canadians say they are somewhat satisfied with the current system. However, those who are very satisfied only slightly outnumber those who are not at all satisfied.

More importantly, levels of satisfaction with our health care system have decreased dramatically during the 1990s. For example, in 1991, 46 per cent of Canadians said they were very satisfied with our health care system compared to only 17 per cent today.

We also asked a battery of questions about perceptions of the system. One of the issues is quality. It is interesting to note that Canadians tend to define quality in terms of access. Quality, of course, remains the most important concern.

Costs associated with the system, and the need for a publicly funded system, are secondary, with integrated community and hospital services coming in after. When I say that is last on this list, I point out that 51 per cent of Canadians, a majority, say they are very concerned about the integration of community and hospital services. It is interesting that concerns about cost and the publicly funded system have actually decreased since 1994, but the concerns about quality remain persistently high.

There is a strong link between accessibility and universality in the minds of Canadians. We find, in a variety of options that we tested with Canadians, that they strongly resist any measures that might potentially limit access to health services. As in the previous witnesses' discussion on accessibility and its importance, we find that it is a core value for Canadians. There is a preference for a needs-based access to health care rather than one based on wealth or any other status. We find that currently -- and this has actually been increasing since 1992 -- 84 per cent of Canadians strongly favour universal medicare for all Canadians regardless of their economic status.

When we look at factors affecting health, we do find a tendency to focus on institutions or external factors. Health care and physicians, sanitation and natural environment, rate very highly as factors affecting health care. Personal behaviour is also seen as important.

It is important to note that on housing conditions and income level, which have just recently been taken into consideration as health determinants, there is a very strong income skew. People at the higher income levels do not see housing conditions or income as factors in determining health, but certainly people at the lower end of the economic scale see it otherwise.

Looking at spending priorities within the health envelope, we find that there is still a strong preference for bricks and mortar and research activities. Community-based activities are assigned a secondary priority, and activities that are seen as remote from front-line care are assigned the lowest priority for new health care dollars. We see that 78 per cent of Canadians believe that maintaining hospital beds is a high priority, followed by funding research for women's diseases, and state-of-the-art, high-tech equipment. More community-oriented programs are actually lower down on the list of priorities. I believe that is because there is a certain immediacy to the anxiety about our health care system, and I will talk about that in a moment. Hospital beds and high-tech equipment will deliver immediate benefits, whereas community-based initiatives, population health initiatives, are seen as more long term. Canadians, because of their high level of anxiety, focus on those activities that will deliver benefits immediately rather than down the road.

Looking at options for our health care system, we find that, interestingly, many Canadians look to outpatient or non-institutional solutions such as home care, but once again there is very strong resistance to measures that will restrict or limit access to services. In fact, in recent years, support for some of the more invasive, obtrusive measures has actually dropped as anxiety over health care has increased. We certainly find that rationalizing hospital services, imposing a kind of fair market rate, or giving people vouchers or accounts, are finding less and less favour with Canadians.

There is also certainly a declining interest in a variety of options to control abuse and overuse. Once again, this ties into concerns about accessibility. We see that because Canadians are so concerned about access, they really are returning to a belief in, "Let us deliver core services and ensure they are there for Canadians over the long-term." We find that a strong majority believes that individuals should take more responsibility in this area, followed by governments, and a majority also believes that employers, doctors, health insurance companies, regulatory groups, and so on should play a greater role. Only 30 per cent of Canadians believe that voluntary organizations should take more responsibility, not because there is any lack of confidence in these organizations, but I would say because there is a belief these organizations are already doing their part and may be stretched to their limits.

Of course, there has been recently some discussion of Bill 11 in the Province of Alberta, and there is increasing concern that the introduction of privately run facilities will erode the health care system. Only a minority of Canadians believe that private clinics are a good way to reduce waiting lists. There is grudging acceptance of these clinics in the absence of other solutions.

You can certainly see, in this chart, how there has been increasing concern that these clinics will erode our health care system, and also declining faith that they are the solution to waiting lists. We find currently some tentative approval of what is being done in Alberta, and I would say that this is due to the absence of other solutions being offered either by provincial governments or other organizations. In public policy, there is a belief that Canadians would prefer a bad plan over no plan. I am not making any judgments on what is being proposed in Alberta, but certainly in the absence of alternatives, critics of Bill 11 will find it very difficult to oppose.

To conclude, our health care system is a powerful symbol of our societal values. Although concern about health care has peaked, it has not abated and still remains the number one issue. There is declining satisfaction with the system and critical assessments of all government performance in this area. There is a strong desire for governments to stop competing on the issue of health care and start cooperating.

Access and availability remain the top areas of concern, and any move to restrict that would be strongly resisted by Canadians. Spending, as I mentioned, is seen as a proxy for attention or effort, but there is a perception that more money is required. The bottom line is that Canadians are more interested in solutions than in laying blame. We see that individuals, as well as governments and employers, need to take more responsibility for health care. Although there is interest in community-based or population health initiatives, there are high levels of anxiety about the more traditional forms of service delivery, and certainly that is where Canadians would like to see some additional attention paid.

The question that comes to my mind is, what will trigger the changes needed in the health care system -- a crisis, stability, political will? If people are looking for money-oriented solutions or the immediacy of resolving health care issues, then a crisis will certainly draw attention to these areas. However, for the more innovative, long-term health care initiatives to take place, what Canadians really need is stability. Since anxiety about our health care system is currently so high, Canadians have very little desire for anything that is innovative, or that could be seen as undermining their access to the system, or anything that does not reinforce traditional modes of delivery -- hospital beds, high-tech equipment, bricks and mortar. That is where Canadians stand. Until they have more comfort with the system as it currently stands, there will be little appetite for some of the innovative health care initiatives that would actually lower costs or improve the health of our population.

Of course, political will is always an important factor, but the era of a new sheriff riding into town and laying down the law on health care is over. We find that Canadians reject punitive measures to coerce provinces into obeying the Canada Health Act, especially when there is a withdrawal of funds attached. Political will should actually be demonstrated through more federal-provincial cooperation.

Of course, a better-informed citizenry, even if it does increase anxiety over the short-term, is essential to improving our health care system. Thank you.

Dr. Scott Evans, Senior Statistical Consultant, Goldfarb Consultants: I appreciate the opportunity to come and speak to your committee. This particular section follows nicely on what was discussed with Dr. Fraser Mustard, because we are dealing with a new environment in which there is a great deal of opportunity to move public support in one direction or another. The jury is still out on what direction that will be, because the proposals and the agendas being put forward have not yet caught on and have not yet been fully developed.

Our data confirms a general pattern that all of you perhaps recognize -- that there is a declining faith in the current health care system. The reason for the decline is still open to debate. Certainly much of the financial restructuring in the health care system, and the response of the media and the various advocacy groups to that, have all contributed to this general sense of declining faith. This is happening across the board in all regions of Canada. In particular, you can see in slide 6 the dramatic decline in affirmative responses when people are asked whether the health care system is working and we need not tinker with it. You can see that question was asked from 1989 to 1999.

By the way, these questions are asked generally in the February-March period of each year. You can see that there is quite a dramatic decline, from 45 per cent to 14 per cent. That represents a significant shift when you look at values, belief systems and attitudes.

In regard to some of the important regional differences, I have not shown all the regions on slide 7. Generally, I have looked at the two outlying regions. In Ontario, they tend to be less concerned about the health care system, whereas in Quebec you see greater concern. It is interesting that in Quebec you see a real spike in 1998. Part of that has to do with what was going on in Quebec during the negotiations with the various practitioners in the health care system. With all of that turbulence, you see a real shift in public attitudes. However, there is a consistent trend across time, which is important to note.

There are some income differences, to which reference has already been made. People who are more well off have traditionally felt the system is not working as well as people who are in the lower income levels. What is important is the convergence that is taking place. Therefore, by the time we get to 1999, you can see in slide 9 that there is a real convergence of all income groups. In other words, there is growing consensus that there is a problem with the health care system.

The same is occurring across the sexes. Traditionally, men have been more concerned about taxation, while women have been more concerned about the health system. Women have generally felt that the health care system is doing all right, but that trend is shifting. You can see now in slide 11 that the percentage of women who believe in the health care system, that it is working well, has dropped below men by 1999. You can see that the general decline is across the board.

Health concerns shift, which is important because there are many public policy issues on the public agenda. How have things shifted with respect to the relative importance of these concerns? In the 1990s, government spending, debt, and taxation issues were at the top of the list. They are still important, but there has been a dramatic shift, with health moving up into the "highly concerned" range.

In the bar graphs on slide 13, you can see that the red column is health care -- concern about health care as a policy issue. It was lower in 1993 than issues like taxation, national debt, and level of government spending. Those three have declined slightly over time, while the concern about health has risen. Education has been fairly consistent across time. You can see that there is a gradual shift. It is not that taxation and debt have completely disappeared from the agenda, they are still there in the public's mind, but health is grabbing a larger share of that concern.

You can see, looking at slide 14, that certainly the issue of taxation is still a hot topic today, but you can also see that health is moving up so that it is almost as much of a concern. That is an important shift, because it has taken place gradually but continuously throughout the 1990s.

Unemployment was a big issue in the 1990s, due to the recession. As the economic climate has improved, Canadians clearly have become more concerned about social programs and social spending. Health is an important component of their notion of social programs. When they talk about wanting more spending on social programs, quite often in those responses, it is health care that is in their minds. Therefore, when they are asked about the priorities for the federal government, you can see in slide 16 that health is climbing, although it levelled off a little in 1998 and 1999, and is considerably higher as a perceived priority than it was in the early 1990s. Some of the other issues, such as government spending, unemployment, and taxes, have gone down.

Respondents in the Goldfarb report also indicate that they expect provincial governments to do their part in maintaining social programs. In fact, if you ask Canadians about who has jurisdiction in what area, they generally do not have a good sense of who is responsible for what. Despite that, they still think that provincial governments should be playing a critical role in maintaining Canada's social programs. I will reiterate, part of what constitutes social programs in the minds of Canadians is health care.

The next item is user fees. Canadians are asked: Would you be willing to pay a moderate user fee in the health care system? Interestingly, in the early 1990s, there was some marginal support for that. For example, $10 when you visit a doctor is the amount used in the question. There is some support for that. However, you see a real decline in that support in slide 20 as you move into the latter part of the 1990s.

There is an interesting reversal in Quebec, where they seem to be a little more positively inclined towards that moderate user fee. However, they are following the national trend, by and large, in terms of declining support for that.

Items such as tax cuts are still important to Canadians, but now, unlike the early 1990s, health care is up there in terms of priority. Canadians are asked: What are your top two priorities for the budgetary surplus? This is actually from our Goldfarb update report, which took place in November and December 1999. Some of the suggestions were, to spend more on health care and cut personal income tax. Those are the top items. You can see from slide 22 that some of the other issues are much lower on the list.

A similar pattern exists across regions. While health is much more important among women than it is among men, you can see from slide 25 that there have been some important shifts. For men, spend more on health care, 36 per cent; for women, 62 per cent. In terms of budgetary priorities, there is an important difference between the sexes. That may be because historically, women have had more contact with the health care system than men.

They take greater issue with some of the services provided, or there is a perception of a greater likelihood of them encountering problems. There is more concern among women that this needs to be a priority.

The priorities are slightly different across income groups, with personal income tax being important. Spending on health care is also quite high. The only group with whom it is not the highest is those earning $50,000 per year or more, which should not be too surprising, given their historical perceptions of the existing health care system.

In conclusion, I believe that this is an interesting and volatile period with respect to public opinion. There is an opportunity to make great gains on the legitimacy of different kinds of approaches to health care that will be able to restore a sense of faith and confidence in the system.

The provincial governments must move in the direction of health care reform. However, they must be very aware that people are quite suspicious, and in some respects cynical, about health care reform. They are open to, and seem to recognize the need for, health care reform, and yet at the same time, there is some cynicism about what can be done or what governments are willing to do.

There does not seem to be much support for a privatized, U.S. style health care system. This point is not included in our presentation, but it is backed up by an earlier report of ours with respect to national identify, which confirms work done by Environics. Health care is an important part of the Canadian identify. People recognize that a publicly funded health care system is a critical part of what it is to be Canadian. There is a real reluctance to go, willy-nilly, down the private sector route.

Canadians want both levels of government to be involved in reinvesting in social programs. When I say "social programs", that includes, to a large degree, health care.

Canadians are also becoming impatient with the bickering between the two levels of government. When asked about their understanding of federal-provincial relations, they cannot seem to understand why there is such unwillingness or inability to reach agreement on what needs to be done. There is a sense of losing patience with what governments are doing.

Canadians believe that the budgetary surplus should enable the government to reinvest in Canada's health care system. They certainly give that a priority in terms of where dollars should be spent.

The Deputy Chairman: It was interesting to see in both of your surveys that Canadians really do have a low tolerance for blame-laying. I have one question before I turn it over to my colleagues.

When Dr. Mustard was testifying before us, he talked about the myths -- and I think that a lot of us are trying to still deal with the myths and realities. He said something interesting, namely, myths generate press coverage, which generates public pressure on governments and on the system. We read reports about crime that will have been generated by some particular incident that drew public attention to it. When you do your polling, how do you factor in media reports that perhaps generate some of the pressure down the line? In your broad polling, are those pressures that come and go in the system reflected in the data or not?

Mr. Evans: Let me use the Quebec example. You saw that spike on the chart on their confidence in the health care system. There was a lot of activity around health care and health care issues in Quebec at that particular point in that year. It is not so much the spikes that are important, as the longer-term trend. That is why it is useful to look at a 10-year period, because then you can see a consistent trend across time. Among different groups, you can see consistent trends, even though they might sometimes cross over each other as you move across time. There has been a lot of attention paid to health care issues in Alberta, for example, throughout the 1990s. There was a lot of debate and political activity around health care changes. It is the same in Saskatchewan, Manitoba, and British Columbia. In Ontario, it was certainly there across the board. It comes and goes.

If these things were not levelling out over time, you would see some dramatic spikes. However, when you view long-term trends, there is a consistent pattern. Even though top-of-mind issues will have an impact on attitudes and values, when you factor that across time, you see some fairly consistent patterns.

That is the important lesson to be learned from what we have talked about today. We are at a point now where people do not have a lot of faith in the system. They know that something needs to be done, but they are not sure what. They are open to suggestions. They say, "Convince us. Give us a good argument that this is something that will legitimately build a better health care system that is affordable. We will rank that up there with the priorities that we have been consistently setting for governments around taxation, government spending, et cetera."

Mr. Baker: I am reminded of a friend of mine who also works in public policy and public opinion research. He just received back some sensitive data on a health care survey. There was a story in The Ottaqwa Citizen, or maybe The Globe and Mail, stating that tax cuts, not health care, was a priority for Canadians. That was completely contrary to this very rich data set that he had. We talked the next day, and he said, "I was up all night looking at the data in all these different ways, and I do not understand it. My data was gathered using 60 questions. Why is it different from this poll in the paper?" I said, "Actually, to me, it is easy to answer. You are right and they are wrong."

Looking at how Canadians form their opinions, we find that often the role of the press is overstated. Certainly, I can critique them at length on how they deal with public policy issues and public opinion research.

We see that when an issue surfaces, before Canadians actually reach a conclusion or a resolution, they go through a period of anxiety. This is troubling for decision-makers. On issue like biotechnology, or health care, or international trade regimes, as soon as the information begins to reach the public, the first response is anxiety or concern. The initial tendency of governments is to try to manage that. We do not want people to be anxious, we want people to have confidence in us -- that sort of thing.

What policy makers do not understand is that that anxiety period is what causes Canadians to go out and become more informed and reach their own conclusions. The only time that the media has the power to direct public opinion, rather than to inform it, is when they speak with one voice. We certainly saw that in the national debate on free trade in 1998, when both the business community and the press spoke with one voice on one particular point in the issue. That actually helped Canadians, or directed Canadians, to make up their minds in a specific way.

However, on health care, because there are conflicting voices, it is really up to individual Canadians to make up their minds. That is where we are now. We are going through an anxiety stage, which is prompting Canadians to become more aware of the issues and to start making up their own minds.

Senator Callbeck: I have two or three short questions. One is about slide 20, where you illustrate strong support for a user fee to visit a doctor.

Mr. Evans: Are you talking about my presentation?

Senator Callbeck: Yes. You show that in 1992, for example, 50 per cent in Quebec supported that and the total support was around 40 per cent. You then show it declining significantly. Does your polling data offer any explanation for this?

Mr. Evans: In the early 1990s, there was a significant reduction in government expenditures. They launched a fairly effective public relations campaign saying, "Look, there is nothing we can do except cut. Cuts have to go across the board. We will try to make it as painless as possible." There was general acceptance by the general public that we had to tighten our belts. That meant services would cost more and user fees might be implemented as a temporary solution. Temporary solutions were talked about until times got better, until we were able to find better efficiencies in how we deliver our social programs and services.

As economies become more healthy, and as governments become more effective at handling government spending and deficit issues, the public is less willing to accept the need for measures like user fees. The system may not be fixed, but it is much better. Why must we use user fees? That violates a fundamental principle of universal health care and its links to the national identify.

User fees were seen as a temporary, not long-term solution. Once we were out of the critical period, and as we moved into the latter part of the 1990s, where things were better -- government spending is under control, deficits are being handled -- why should user fees still be an option? It goes back to the original, root values of a universal health care system. That is my explanation of that trend.

Senator Callbeck: In your presentation, you showed the difference between men and women in their satisfaction with the system. In regard to age factors, is there more dissatisfaction among seniors than among middle-aged people and youth?

Mr. Evans: One thing that has been happening across time, and is reflected in some of the patterns here, is that there has been a general convergence toward less faith in the health care system.

Whether it is sex, age, education, or income groups, there have been differences historically, but those differences are declining. That is why this represents an interesting time for those of you who wish to advocate different kinds of health policy solutions. Right now, there is a general consensus amongst all groups that there is a problem. There is not necessarily agreement on one particular solution, but there is a general dissatisfaction.

There is a golden opportunity for those of you who want to launch initiatives to restructure and reform the health care system to have that legitimately supported by the public.

Senator Fairbairn: Following on your comments, Mr. Baker, on the anxiety level, do you believe that governments have misread the degree of anxiety, and that it has been there consistently for longer than we have been paying attention to it?

Travelling around the country, one almost gets the impression that we are chasing this issue, that it is ahead of us. Dr. Evans, you were talking about spikes in your charts. Do you think, if you conducted a survey in Alberta now, you would get a big spike, or is it flowing along more calmly than that?

Mr. Evans: I well address that quickly and then I will let Mr. Baker address the first question. I am glad you raised the Alberta case, because a couple of years ago, Ralph Klein embarked on fairly drastic cuts to the health care system and changes in how it was structured. There was a real public backlash. In fact, in one instance, in one hospital, there was a wildcat strike of health care workers that received some public support.

That is an example of how the Alberta government misread the willingness of the Alberta population to embrace these kinds of drastic and Draconian responses to health care reform. That provincial government quickly rolled back the measures and took a step back. Those particular points represent cusps in attitude. Suddenly, you get these issues flaring up and they seem to crystallize attitudes.

At the same time, the media started to publish stories about people not being able to obtain essential services in the hospitals. A little boy died because of some mismanagement involving a transfer between hospitals. These become flare points.

Suddenly, talk show hosts are saying that the system is in crisis. People are worried that if they get sick, there will be no doctor to help them. Will they receive the services they need? You will see a flashpoint, or a spike, in concerns over the health care system that will be temporary. It will level off somewhat.

What I think you will see is consistency with the overall trend. Even though you have that spike in concern, the trend will continue on. It is cumulative. The concern is no longer as high as it was at that flashpoint, but it is still greater than it was prior to it. It goes up and comes down, but it never goes lower than it was before, because there was no resolution to some of the issues.

Alberta is a good example, where the government tried to push through quickly some difficult changes to the health care system. They have had to step back a couple of times because they misread public attitudes. Perhaps they really were trying to push as far as they could, knowing full well that they would then have to roll back to some extent.

If you conducted rolling polls across time, you would see spikes at these flashpoints, but shortly thereafter they would taper off. If it is a consistent issue, you will see that gradual trend across time. If you took the average of a rolling poll, you would see a general trend.

Senator Fairbairn: There is a bill before the Alberta legislature now. Would you see this as just a passing flashpoint?

Mr. Evans: That is hard to say without actually having that data. I would expect it to build upon the existing concern over the health care system. You would likely see a slight spike, and it would contribute to the overall growing concern with the system. It would be temporary. Concern would slide downward a little, but the overall concern would be growing even more. That would be my guess.

Mr. Baker: To follow on Dr. Evans's comments, it is interesting to note that Premier Klein has learned from the lesson that he was taught a few years ago. The question is, has he learned enough?

He tried to make changes to the health care system unilaterally and to impose them rather than build a consensus. This time he has tried to bundle Bill 11 with some other initiatives. He has put additional money on the table for other services. He may have misread the situation and just not understood that the level of anxiety is so high, you need to give people some sense of stability and comfort before you can make major, systemic change.

The Government of Alberta certainly came out ahead of the pack on a number of issues, primarily on the fiscal side. However, they seem to be having more difficulty grappling with social issues. All governments are playing catch up on this issue.

When health care began surfacing as an issue, it was driven significantly by anecdotal evidence -- people describing poor experiences, or friends with bad health situations who got worse because of a lack of prompt attention, and so on.

When the number of these stories began to increase, the first reaction of governments was to rely on jurisdictional confusion and try to pass the problem on to another level. It became convenient for provincial politicians to criticize federal politicians, federal politicians to criticize provincial politicians, and provincial politicians to criticize each other. Rather than realizing that there might be a problem here, their first instinct was to "pass the buck" and say it was someone else's fault.

That attitude persisted until it finally arrived on your doorstep, and no one was ready to deal with it.

All the finger pointing in previous years led to a situation where now there is no atmosphere of consensus or cooperation amongst the various partners. The health care system in our country is a partnership, where all have their roles and responsibilities. Unfortunately, some of them were relying on the confusion and lack of awareness over who does what in our system to pass the buck. Now governments are in the unfortunate situation of having to play catch up. I am not saying that the people are far ahead of governments on this, but they are on a completely different track, and it is one where they are very anxious.

The Deputy Chairman: It is like the old story, "Stop bailing and start fixing the boat."

Senator Keon: I have one comment, and perhaps a question. It is interesting that your surveys are limited to the health care delivery system. Nowhere in there do you ask people how healthy they think Canadians are compared to other populations in the world. I would encourage you to do that. One of the major problems with health care is that people are frightened of any kind of reform of the system itself, rather than accepting that there may be positive things that could be done to improve people's health.

Mr. Baker: Definitely. I am reminded of an African proverb: "I wept that I had no shoes until I saw a man with no feet." Canadians know that we are very blessed as a country, but in some ways, they do not realize just how good we have it.

Certainly, in any of the work that we have done -- and we do a fair amount of work internationally -- when we ask Canadians how well our system compares to others, and how healthy we are compared to those in other countries, they certainly believe that we have the best system and are the healthiest people. The only people who can give us a run for our money on population health, and on the system, are the Nordic countries. Canadians have a high appreciation for the systems in place in those countries. In comparison with even the Western European countries, or our neighbours to the south, there certainly is a recognition that we have it good here. It is just that we tend to look at it in terms relative to only our own situation, and not to those of other countries.

Mr. Evans: Part of the problem has been that the debate has been framed as an issue of cost and spending. Quality of health care has been secondary, and has arisen because cost cutting has implications for quality in the minds of many people. Things are too expensive and we must reduce the cost of our health care system -- that has driven much of the discussion. When people view the health care system and the changes that it is undergoing, they understand it in the context of a cost-cutting agenda. There is fear there because cost cutting is not talking about quality, but about cutting costs perhaps even at the expense of quality. I do not think the health care debate has been framed in terms of quality, or even some of the things that Fraser Mustard has been talking about, unfortunately. It has been framed from the perspective of, how can we cut costs because it is too expensive? That has been the agenda, and that is why some of the other issues you have raised have not come to the fore.

The Deputy Chairman: If there are no other questions, I thank Dr. Evans and Mr. Baker for an interesting set of statistics. It was interesting to see that two different polling firms had the same trend line. That makes your data all the more relevant.

The committee adjourned.