Proceedings of the Subcommittee to
Update "Of Life and Death"

Issue 10 - Evidence

The Subcommittee to Update "Of Life and Death" of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 3:30 p.m. to examine the developments since the tabling in June 1995 of the final report of the Special Senate Committee on Euthanasia and Assisted Suicide, entitled "Of Life and Death."

Senator Sharon Carstairs (Chairman) in the Chair.

[English]

The Chairman: Honourable senators, I wish to welcome to our table this afternoon the Honourable Allan Rock, Minister of Health. He is accompanied today by Dr. Christina Mills, Cliff Halliwell, and Barbara Ouellet.

We welcome you all. I understand that the minister will begin with some opening remarks; and then, if we ask questions for which he does not have the detailed answers, we will allow him to turn to the other witnesses.

Hon. Allan Rock, Minister of Health: Madam Chairman, honourable senators, thank you very much. I want to say how delighted I am to have this chance to appear before you today.

[Translation]

You considered at some length the issue of palliative care in the health care system. Today, I am pleased to report on Health Canada's efforts to weigh and respond to the needs of Canada's health care system in terms of palliative care.

[English]

I should say first that some years ago, when you produced your report, I was extremely impressed by its depth and the sensitivity of its analysis. At that time I was in a different portfolio, but I remember welcoming your recommendations on palliative care. Although it was difficult for the committee to find consensus on some of the other issues, certainly in relation to palliative care, there was broad support for your recommendations about Canada-wide discussions on standards and approaches. They struck me as extremely sensible. Also, at the very beginning, I will say that, as I look back over the years since your report, I think there is much more that remains to be done. I wish that I could come before you today and say that we have done everything you recommended and that we have made as much progress as you thought possible when you reported, but we have not. I will refer to some of the things that we have done, but I want to be frank with you and say that there is much left outstanding.

I do not pretend for a minute that we have complied with all of your recommendations or achieved everything that you had in mind when you reported. There is a lot more that has to be done.

I think that part of the reason for that is that the whole health care system is in a period of transition. Twenty-five years ago, almost half of health spending in Canada took place in hospitals. Now it is less than one-third. Much of health care has moved outside the institution and into the community, but the Canada Health Act only insures services that take place in the hospital and are provided by doctors. Therefore, public coverage has not expanded to catch up with the disbursal of the services. The whole area of home and community care has, therefore, been calling out for more attention. Of course, provincial governments are responding, each in its own way, and some of them are doing a wonderful job. However, it is an uneven response across the country, and that is why, as we meet with provincial governments to talk about renewing the health care system, care outside the hospital is an important subject.

Care outside the hospital has particular significance for the subject that I am speaking about today, which is palliative care. Typically, we are talking about the hospice or the home or some non-hospital setting where the end of life occurs and where palliative care is delivered. I for one see home and community care as part of a continuum, with palliative care being one end of that. There is still a lot to do, but I think we are in the process of looking at, with the provinces, the renewal of medicare. We will have to bear in mind, as we do that, the extent to which care is provided outside the hospital and that palliative care is an important part of that overall scheme.

[Translation]

At this time, I will briefly review for your benefit the department's efforts to comply with your recommendations. Mention should be made of the health services restructuring fund. Three years ago, we established a $150 million fund to enable the provinces to carry out pilot projects in four areas, including community care, home care and palliative care.

Pilot projects on palliative care in rural areas were funded in Nova Scotia and Prince Edward Island. Our department helped finance pilot projects in Quebec, working in cooperation with the CLSCs. The projects involved training palliative care workers.

We expect the results of these pilot projects to be available within the next few months. Once the evaluation process is completed, a report will be produced with a view to drawing the provinces' attention to the important lessons to be learned from these different experiences. This is the primary objective of the health services restructuring fund.

The aim of the pilot projects is to test different approaches, to get an idea of the best practices and to enable the provinces to publish results and adopt effective courses of action.

You made it clear in your report and recommendations that the federal government has a special responsibility to assume in the field of health research.

You are no doubt aware that with the passage of Bill C-13, the federal government launched the Canadian Institutes of Health Research initiative. Several institutes will be up and running in a few weeks' time and the Prime Minister will be announcing the members of the boards of directors.

In addition, we have doubled the health research budget, which now totals $500 million a year. I am confident that an institute dealing with palliative care will be on the list of announcements by the board of directors. I know that research into this particular field will increase. As a result of additional funding, the establishment of institutes and increased research, we will gain a better understanding of the needs of Canada's health care system in the years to come.

[English]

Briefly, a list of infrastructure investments by the Government of Canada: tele-medicine, which has been adapted to tele-hospice services; aboriginal health, where we have devoted $90 million a year, commencing in 2003-2004, for home and community care in First Nations communities, including end-of-life care; and the work we have done in respect of HIV/AIDS. I think that all of these have been helpful and responsive to your recommendations in a general way.

I will close as I began, by saying that there is much more left to do and I do not pretend that we have fulfilled your recommendations to their fullest in the years since you published your report. We acknowledge the need for more attention, and that, particularly with the aging of our population, there is more work to be done, and we will do it. I am grateful for this chance to engage in a dialogue with the committee and I look forward to any comments and questions that you may have.

Senator Beaudoin: It has been a great experience to be a member of the subcommittee regarding those questions. We have, of course, focused on those issues on which we were unanimous, so it settles most of the legal questions.

[Translation]

Much has been said about refusing treatment and withdrawing measures. When it comes to palliative care, the law is very clear. For the most part, this comes under provincial jurisdiction. Federal legislation is in place covering the unplugging of machines and the refusal of treatment, but perhaps it needs to be more specific. Mr. Minister, would it not be better to have somewhat clearer legislation governing this field so that we are not always waiting to see how the courts react? I think we should take the initiative and set about addressing these issues.

I do not wish to get into a discussion as to what areas come under provincial or federal jurisdiction. However, provincial jurisdiction over palliative care services must be respected. There are certain steps that you could take. As Health Minister, you oversee the enforcement of the Canada Health Act. Should this legislation remain in its present form or should it be improved upon, given the circumstances?

Mr. Rock: I do not care to comment on that. However, as Minister of Health, my concern is the accessibility of health care services. As I said, palliative care is part of community care and home care services. Palliative care is provided in a hospital setting, as well as out in the community.

Senator Beaudoin: At home?

Mr. Rock: Yes, at home, or in hospices or at other locations within the community. We are currently discussing with the provinces the initiatives that could be taken as part of a government partnership to renew and strengthen our health care system. Community care is one area being discussed. The important thing to ensure is that all people in all parts of Canada have access to quality services.

Palliative care is one such essential service. I intend to work with my counterparts to ensure that these objectives are met.

Senator Beaudoin: Will these objectives in fact be met as a result of the federal spending power or through the normal collaborative effort between Ottawa and the provinces?

Mr. Rock: Cooperation is always critical in the field of health care.

Senator Beaudoin: That is the problem. However, there is a way of cooperating. The provinces always want more and the federal government is prepared to spend more on health care. Could some kind of agreement possibly be reached?

Mr. Rock: Possibly. A few months ago, I wrote to the provincial health ministers and invited them to sit down at the table with us to discuss ways of working together to improve the system. I met with my provincial counterparts a few weeks ago in Markham where they requested additional funding, to which I responded that we also need an integrated plan. We are now in the process of working on such a plan.

Senator Beaudoin: I concur with this approach.

[English]

Senator Corbin: I do not want to misrepresent the minister's statement, but in commenting on our 1995 report, did he say that much more could have been done?

Certainly a lot more has to be done, but speaking for myself, and the sentiment may be shared by some of my colleagues, we feel that your department could have done much more in terms of our specific recommendations. There may be a reason why more was not done. Is it a jurisdictional problem?

You have given us examples of ongoing programs that I am sure will make it possible to resolve some of the issues and challenges, but why was more not done in the intervening five years? Is it because of the continuing hassle between the federal and provincial governments in the field of health?

Surely it cannot be simply a money matter, because even in dire circumstances one still has to look after the sick and dying, but usually one implements the latest science, the latest technology. One reallocates one's resources to the people who need help most. I would suggest that surely dying people, leaving aside disease control and that sort of thing, are the ones who are in greatest need.

We must still repeat many of our 1995 recommendations in the hope that, now that you are Minister of Health -- you spoke to us previously in your capacity as Minister of Justice -- you can tell us what you think can be accomplished in the next five years on this front.

We will all die, Mr. Minister. Most of us, unless we drop dead on the street because of a ruptured artery in the brain, will go through some excruciating pain and extended illness. Surely that is one of the great challenges right now in the minds of many Canadians, the provision of the best possible palliative care services.

Mr. Rock: It was in late 1994 and early 1995 that I learned those lessons for myself. One after the other, my mother and then my father died, each of them of cancer and each of them at home. My sisters and I discovered for ourselves how difficult it was to find out what home care services were available, which ones were paid for by public insurance, which ones we had to pay for out of pocket, and which were available through private insurance.

We also found out that palliative care in the end stages of cancer -- and most palliative care arises in the context of cancer -- requires much attention and presents some difficult questions.

The easy answer to your question, senator, is that the actual organization and delivery of services is a provincial responsibility. Do not grimace.

Senator Corbin: I shrug.

Mr. Rock: Do not shrug either, with respect, because whenever I talk about my ambitions for improving the health care system, the first people to tell me to sit down and shut up are the provincial officials, ministers and premiers, who say, "That is our problem. Do not get into your boutique programs and do not tell us what to do. Mind your own business and just send the money."

We have to deal with that reality every day. I say that not because I am trying to evade your question, but because I am trying to answer it in part. Part of the reality is that it is the provinces that organize and deliver care. That is the way the Constitution is written and the way the country works.

Does the Government of Canada have a role to play? Absolutely. What is that proper role? The very things that you have recommended -- national approaches, guidelines, research, increasing the visibility of this on the pan-Canadian scene.

I know my officials have taken you through the list of things we have done and I think you would find it tiresome if I went through the details. We have not been inactive over the last five years. We have done a lot of things in terms of financing projects, funding conferences, publishing guides, bringing people together, and trying to focus attention. That is an important role for the Government of Canada.

I guess my frustration comes because I would like to see governments make more progress more quickly on a coherent approach to renewing medicare, developing objectives for strengthening services, and working together to achieve those objectives. We are involved in that very process with the provinces.

Why has this not happened before now? There are all kinds of reasons -- political, fiscal, and practical. However, we are involved in it now; we have engaged. The first session in Markham was a little difficult, but we are underway and there are talks going on. We hope to get back to the table. I will bring to that table my concern that, working with the provinces, the appropriate attention is paid to a number of issues, including palliative care.

Senator Corbin: Just one comment. I thank you for that, Mr. Minister. I know that you are not in an ideal situation to deliver all of the goods. We are being televised. Canadian families, dying Canadians, and Canadians in pain could not care less about politics and shared jurisdictions.

Unfortunately, we cannot, as a committee, talk directly to the provinces. However, Canadians want good end-of-life palliative care. They could not care less about where the service comes from. However, they think that, in a country such as Canada, there is no reason why caring governments cannot get their heads together and come up with programs, training, facilities, hospital care, and community and home care, because they all want it.

Canadians want to be assured that after working 35, 40, or 50 years, giving their best to this country, that it will come to their assistance in their dying hours and make the passage easier. That is what this committee wants to tell you, the provincial ministers, the medical profession, and everyone.

I think you are also part of the solution, as well as your provincial counterparts, the deans of medicine, community colleges, and everyone else. However, there must be a clear will and a concrete effort to put this thing together.

This committee has identified palliative care, leaving aside the financial questions, as the one area where Canadians would like to see some action.

Mr. Rock: It is one of many, and I could not agree with you more. We cannot allow jurisdictional issues or squabbles between governments to stand in the way of providing the care to which Canadians are entitled. That is particularly dramatic in end-of-life and palliative care contexts.

I can tell you, senator, that I am absolutely determined to see that we come out of this process with the provinces with concrete approaches to making those services available in a way that responds to the needs of Canadians. I believe that the provinces want to get there too, and I think that it can be achieved through working together. That is certainly what I am determined to do.

Senator Roche: Thank you. Minister, I flew from Edmonton to Ottawa this morning and picked up the Edmonton Journal on the plane, in which I read a headline that states: "Rock faces heat over palliative care, euthanasia policies."

I do not know about you, but I find the temperature in the room fairly agreeable at this moment.

Mr. Rock: Perhaps the people with their coats still on are feeling the heat back there. I do not know.

Senator Roche: The other part of the headline stated: "Senate committee set to attack inaction when he gives progress report."

I do not know whether this committee will attack you or not. What I do know is that the overwhelming amount of evidence received by the subcommittee and that brought us to this point, made the observation, from several different perspectives, that the government did not respond to the 1995 report in anything approaching a satisfactory manner.

In addressing that this afternoon, I understood you to say that while the government has done certain things, you agree that much more needs to be done -- put it that way.

Mr. Rock: Absolutely.

Senator Roche: I understood you to say that the 1995 report was sidelined for a combination of political, fiscal, and practical reasons. Did you mean to give equal weight to the words "political, fiscal, and practical," and would you explain what you really mean by "political"? Is this the jurisdictional or the provincial issue, or something else? How serious is the fiscal issue with respect to palliative care's share of the overall health budget? What does "practical" mean?

Mr. Rock: The amount for palliative care in the overall health budget is for the provinces to decide, of course. I was referring to the fact that over the last almost three years since I became Minister of Health, we have been focused on putting more money into the health transfers to the provinces.

Indeed, we have increased the transfer very significantly since 1997. We have increased the health transfers to the provinces in each of the budgets since that year. In the February 1999 budget, there was a commitment of $11.5 billion over five years, which was just for health. In this past budget, $2.5 billion was made available for health and education.

We are even now in discussions with the provinces on increased transfers for health. As the Prime Minister has said, we want to sign on to a long-term commitment for increased transfers for health in coordination with a plan for strengthening the system into the future.

I guess my reference was to the fact that much of our attention has been focused on putting more money into the health transfer. That has been a preoccupation. Of course, how much of that money is for palliative care is for the provincial governments and ministers to determine.

We have also been busy in other areas, and I mentioned health research. We took your recommendations on research and have actually made very significant improvements in the research enterprise federally with the creation of institutes and increased funding throughout the country. I think that that has been very good.

In our own jurisdiction, which is aboriginal health, First Nations health in First Nations territory, we have devoted significantly more money to home and community care. Funding in that context will rise to about $90 million a year starting in 2002, including end-of-life care.

However, the difficulties that I have raised have been in each of those areas. There has been work done on the fiscal side. Politically, it has been an issue between Ottawa and the provinces on who does what, and what is Ottawa's role in saying that more attention should be paid to palliative care by the provinces.

Issues involving Ottawa's role have arisen. You are right to say that I noted from the beginning that there is still much work to do on the recommendations that you made. We do not consider the job completed and we are determined to address your recommendations on a continuing basis.

Senator Roche: I do not ordinarily quote newspaper stories as the basis for my questions in committees. However, I will make an exception in the next question because I think the lead story across Canada today, which has shown up in several newspapers, points exactly to the dilemma that we are facing. The writer in the Edmonton Journal states:

Thousands of Canadians are suffering needlessly as they die because governments are afraid of legislating rules for euthanasia and don't have the political will to make palliative care a priority...

All of us in this room recognize that the reporter has his apples and oranges mixed up in that one sentence. Indeed, the subcommittee has gone out of its way to emphasize to all the witnesses that we are concentrating on ways to enhance palliative care because we think that is a necessary thing to do for the sake of Canadian human dignity and so on. Yet the committee was divided in 1995 on questions related to euthanasia and assisted suicide.

I have placed the issue before the committee, and it is highlighted precisely by this reporter's language; namely, that governments are afraid to move on palliative care because they fear they will get into the realms of assisted suicide and euthanasia. That is a completely different situation, recognizing that there is a certain blurring between good palliative care on the one hand, which allows a person to die in dignity, and active steps to terminate life on the other, which falls into the categories of euthanasia and assisted suicide.

I should like to hear from the minister whether or not there is any truth to the rumour about governments holding back on putting needed resources into palliative care because they are afraid of getting into the subjects of assisted suicide and euthanasia.

Mr. Rock: I can only speak for the government of which I am a member. I do not speak for any other government in the country, nor do I attribute any attitude, concern, or belief to any other government in the country.

I have not discussed it with them and I have no idea if it is true. I can tell you that as far as the government of which I am a part is concerned, there is no hesitation about dealing with palliative care issues for fear that we might have to deal with euthanasia. They are two different things.

Palliative care, senator, is medical care for the dying. It has nothing to do with euthanasia or assisted suicide or any other such issue. Care for the dying is part of health care services and should be treated that way.

I am not sure I could devote more resources to palliative care even if I wanted to. We transfer dollars to the provincial health ministers, who do provide care and decide on their priorities. Thus, you might want to ask a provincial minister about the amount of money devoted to palliative care.

The Government of Canada believes that palliative care issues must be dealt with. We are not in any way reluctant to do so because of suggestions that someone might raise the subject of euthanasia. We are extremely involved in policy issues on palliative care and in pilot projects on how to better deliver it.

We do not deliver services, but we can fund pilot projects to help us learn from demonstrations what methods of delivery are the best and most effective. That is what the Health Transition Fund was all about. However, we have not been in the least reluctant to deal with the issue for the reasons suggested in your question.

Senator Roche: I welcome your answer. My final question is, do you or your associates here, or by extension in the department, have any research that would bring forward some informed views or evidence that the enhancement of palliative care reduces requests for assisted suicide and euthanasia? Did I put that clearly enough?

Mr. Rock: I think I understood your question. However, I am not aware of any such literature. Perhaps my colleagues might know if there is any research on that point. I invite them to respond if they do.

Mr. Cliff Halliwell, Director General, Applied Research and Analysis Directorate, Information, Analysis and Connectivity Branch, Health Canada: I am not aware of any.

Ms Barbara Ouellet, Director of Home Care and Pharmaceuticals, Health Care Directorate, Policy and Consultation Branch, Health Canada: I am not sure that there is research on that specific question. However, we do know that the converse appears to be at least a fear. Without available treatments, people may indeed fear dying at home and on their own. For that reason, one of the projects that we funded under our Population Health Fund looked at the use of sedation and some of the challenges and complexities in determining the fine line between providing adequate support during dying but not inadvertently hastening death.

Senator Roche: You said that you are inclined to view the converse as being true. How do you know that the demand for assisted suicide is increased by a lack of good palliative care?

Ms Ouellet: As I said, we do not have specific research on that topic. This is really anecdotal evidence that people are concerned about the consequences of dying without adequate palliative care.

Senator Roche: Finally, to the minister, is it possible that Canadian understanding of the need to resource palliative care and get all governments to give it a higher priority would be helped by adducing more evidence to support the belief that good palliative care reduces the demand for assisted suicide and euthanasia?

Mr. Rock: I think it is worth considering, senator. However, I do not think that we need to look for reasons to make good palliative care available. We have plenty of those, and that should be our focus. It is worthwhile in and of itself.

The Chairman: Before I turn to a second round, I wish to ask some questions.

Mr. Minister, there have been significant changes in the way health care expenditures have been made since the original Canada Health Act, if you want to go back to the 1960s.

The federal government decided to fund hospitals and physician services because that sector was consuming the greatest amounts of money and nothing else was even close. We now know that drugs are draining more out of the health care budget than physicians.

Yet in your discussions with the provinces, you made frequent reference to the need for funding for and a coordinated effort towards home care. I did not hear anything about the national forum's recommendation that we institute a national pharmacare program. Is there a particular reason why that is not part of the debate with the provinces or do you place greater priority on home care than on pharmacare?

Mr. Rock: In fact, Senator Carstairs, the provinces raise these pharmaceutical issues every time we meet. They figured very prominently in the discussions in Markham. Many of the provinces told me that their pharmaceutical costs are now rising at the rate of 16 per cent a year. It is a major cost driver. Right now the provinces are in the process of preparing a report for their premiers on cost drivers in the health care system, and I expect that pharmaceutical costs will be one of the main focuses of that report. Therefore, it is very much a concern.

The provinces also raise it in the context that Health Canada approves new drugs based on safety and efficacy. That is our legal mandate, but it is then up to the provinces to decide whether to add those drugs to their formularies -- in other words, whether or not to pay for them. The provinces find themselves under significant pressure to pay for those new drugs, some of which are extremely expensive, even though there might be a very marginal difference in their effectiveness compared to other drugs already on the market. They find this extremely difficult.

If one province accedes to the demand that a drug be added, all the others feel they must do the same, and hence costs keep going up. They want to talk about this and how to approach these pharmaceutical issues from the point of view of making sure that our system is sustainable in the long term. Indeed, a federal-provincial committee has been working on these pharmaceutical issues for some time, trying to find solutions to the dilemma of getting Canadians the most recent, effective, and current pharmaceutical treatments, but at the same time, in a way that will allow us to keep our public health care system.

I do not want you to think that pharmaceutical issues do not arise, because they certainly do. They are raised by the provinces because of this real concern. In fairness, I should also point out that sometimes a drug can either postpone or render unnecessary other forms of treatment, whether that be surgery or something else. Think about the breakthroughs in ulcer treatment, for example. It may be that the use of pharmaceuticals in the treatment of ulcers has coincided with a better understanding of how ulcers are caused and how they are best treated. Other forms of treatment, such as surgery, have perhaps diminished. Thus, I think we must bear in mind the overall picture. There are issues of utilization, prescription practices, and a better understanding, on the part of the public, of how pharmaceuticals are used. All of these factors play into a complex picture, but in responding to your question, I wanted to make clear that it is very much a part of our discussions. Was it the year before last that we had a national conference on pharmacare? The time has gone by so quickly.

Ms Ouellet: 1998.

Mr. Rock: We had a national conference on pharmacare to look at how to ensure that price is not a barrier when Canadians want access to the pharmaceuticals that they need. One of the findings at that conference was that 88 per cent of the population is covered in one way or another for pharmaceutical costs -- either by reason of their financial circumstance, their age, or public or private plans. That disguises the fact that many of those people are also paying deductibles or copayments, or there are rules within the insurance scheme that require them to pay something. These issues are very much alive in the discussions between provincial and federal governments and that we regularly have with the public and non-government organizations. We are talking about managing pharmaceutical costs. I do not want you to think that it is not on the agenda, because it very much is.

The Chairman: Witnesses have raised with us the inextricable link between the costs of drugs and the provision of home care. For example, palliative care patients who decide that they want to die at home not only need all of the support such as, perhaps, a hospital bed, a lifting machine, wheelchairs, et cetera, but they also need drugs. If they do not have coverage for drugs, then they are forced to return to a hospital setting, because if you are in hospital in this country, your drugs are covered, but if you are not, they may not be.

Interestingly enough, you have given me a much higher percentage than we have heard before with respect to the number of Canadians that are covered in any way, shape or form. That is something we will have to work out in the other study. The reality is that we were told that patients returned to the hospital not because they wanted to, but because they did not have coverage for their drugs.

Mr. Rock: One of the reasons I am interested in home and community care is that I think that it is very unfair to have a system of public health insurance that covers hospital costs, and then watch new technology and medical practices shorten hospital stays. Across the country, an average of 75 per cent of surgery is done on an out-patient basis -- in, in the morning, and out, in the afternoon. Then, as we see services move outside the hospital, coverage does not follow and people are left without the benefit of public insurance for things that used to be covered in the hospital. Drugs is a very good example. I have read the suggestion by some commentators that home and community care should be designed so that at least it picks up the cost of drugs that you used to receive in the hospital. I think that governments will have to look at that kind of issue eventually.

A kind of incidental de-insuring of services has gone on as service has moved outside of the places where the Canada Health Act provides for coverage. One of the reasons that we have seen private spending go up in Canada over the last decade at a faster rate than other OECD countries -- it is now over 30 per cent -- is that the focus of service has moved outside the hospital to other locations and coverage has not followed. It is a reality with which governments have to deal.

Senator Beaudoin: I agree with your approach that palliative care is such a valuable objective in itself that there is no need to ask questions about whether it is related to some other aspect -- for example, euthanasia and assisted suicide. I think our decision to talk only about the points on which we were unanimous was a very good one. That offers the best chance of success. If we all agree on something, we will find a solution. It is part of politics, of course, that we do not use the same way, the same means, et cetera. The provinces have their own objectives, and the federal authority may have the same objective, but perhaps the means are different.

The chances for success are greater on the points on which we will make some suggestions and recommendations. We all agreed on those points in 1995, and we still agree on them in 2000.

I do not think it is only a question of money. I think it is a little more than that. Money is always involved, of course, but there are the means we use to reach a goal. My guess is that the provinces are not unanimous on those means and objectives. However, you seem to be optimistic that we will succeed and I think we will too. The need is there and the population is strongly in favour. If we all agree on the objectives, then we should certainly find a solution somewhere. I would like to hear your comments on this. My impression is that it is a question of organization.

Mr. Rock: I think that is right, senator. The Canadian public will insist that governments get their act together and come up with a coherent approach to combining money with ingenuity to produce a better health care system. That is what we are determined to do. It is not just a question of spending more money and making our health care system more expensive.

Senator Beaudoin: To a certain extent, it may be.

Mr. Rock: Yes. I am an advocate for money for health care in the transfers to the provinces. However, at the same time, the Prime Minister has said that we want that additional money to go toward a coherent plan for producing better outcomes, which is what this is all about. It is not just a question of spending for its own sake. It is spending to produce better health outcomes for Canadians. There are broad areas of agreement between the federal and provincial governments on what those changes ought to be.

The health care system is even now being reformed by provinces. Innovation in the provinces is leading the way. The Government of Canada wants to get behind those changes, to broaden and accelerate the innovations provinces have already adopted, so that we can hasten the improvement of the health care system.

Senator Beaudoin: At noon today I was listening to Radio Canada. They spoke about the report released today in Quebec on palliative care. I was a little surprised -- even scandalized -- by the fact that we are not devoting very much money to the question of pain and suffering. That is something we can do. We are a very rich country, of which the provinces are part. We have that money.

Who is against palliative care? Everyone is for palliative care. How is it that we have spent so little on a subject which is of concern, to a certain extent at least, to everyone in this country?

Mr. Rock: That is a good question. Have provincial ministers appeared before your committee?

The Chairman: Not this time. The special Senate committee did hear them.

Mr. Rock: Did you raise with them provincial spending on palliative care? The same might be said of orthopaedics or obstetrics. How much money do the provincial governments devote to the treatment of diabetics? I think I would be reluctant to talk about the allocation of provincial dollars to priorities. However, I think provincial ministers might be prepared to do so.

Am I right in saying that during your first set of hearings in 1995 you actually had provincial ministers before you?

The Chairman: Yes. We wrote to all of them this time and solicited some information from them on the progress they have been making. We have, of course, heard from nurses and doctors with respect to what is going on in their particular provinces. Unfortunately, what we learned is that, with the health care cuts that were going on generally across the country, palliative care was almost hit harder because it was such a new field. There were few palliative care beds to begin with. When those few beds experienced cuts, the system broke down in some cases. There just simply were no resources available for palliative care.

We have also learned that palliative care is still not a legally recognized medical specialty in Canada. There are doctors who provide palliative care, but it is not recognized like obstetrics and gynaecology. It is not recognized as internal medicine. As a result, since we have few medical schools even engaged in the topic, there are few doctors trained in the field. Obviously, that has led to the significant dilemma of how to deliver care that, quite frankly, no one is trained to provide.

You will hear more on June 6 when we table our report in the Senate.

Mr. Rock: Madam Chairman, that is good.

Senator Corbin: Is the new medical research institute at arm's-length from you, the minister? Are you in a position, for example, to go beyond suggestions and instruct them to do research in palliative care along the line of the comments that will be in our report? Are you in a position to sort of coach these people, or are they left entirely on their own?

Mr. Rock: I believe the legislation that you approved in the Senate was considered by this committee?

The Chairman: No, it was considered by the Standing Senate Committee on Social Affairs, Science and Technology, of which we are a subcommittee. However, I sponsored it.

Mr. Rock: That legislation creates a governing council of the institutes. The governing council itself will decide what institutes will exist and will appoint advisory councils to each. Thus, the council more or less decides on the direction of the research. I believe the act also contains a provision that the Minister of Health can ask the council to devote its attention to specific areas -- I will look at that again, but I think I do have that authority.

I also want to emphasize what I said at the beginning of my remarks. I believe that when the governing council actually sets up the institutes, it will reflect what is an increasingly important area of inquiry, that is, palliative care. I believe it will find its place among the priorities that the council establishes.

The Chairman: I should say, Senator Corbin, that I did not feel the same ministerial bounds in sponsoring the legislation. I have been lobbying Dr. Fraser very hard on behalf of an institute for palliative care. There are certain advantages to being a senator rather than a minister, Mr. Minister.

I wish to thank you very much for coming this afternoon and answering our questions in such a positive way.

Mr. Rock: Honourable senators, thank you all very much, and thank you for the valuable work you do on these important and difficult issues.

The committee adjourned.