Past Session:

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

Issue 37 - Evidence

TORONTO, Monday, October 29, 2001

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 9:05 a.m. to examine the state of the health care system in Canada.

Senator Michael Kirby (Chairman) in the Chair.

[English]

The Chairman: Senators, our first witness this morning is Dr. Tom McGowan, President and Medical Director of Canadian Radiation Oncology Services. Thank you for attending here, Dr. McGowan.

If you can begin with a brief opening statement, we would be delighted to ask you some questions.

Dr. Thomas McGowan, President and Medical Director, Canadian Radiation Oncology Services: I am appearing before you today to present my company, Canadian Radiation Oncology Services, CROS, as a model of 21st century health care delivery. As well, I should like to address the critical issues of access to treatment and waiting lists. I shall provide you with background about my company and our organizational structure, highlights of our first six months of operation and my recommendations to improve health care in Canada.

First, I want to emphasize why the existence of waiting lists for treatments threatens universal access. When treatment waiting lists become too long, those with connections to the medical profession will try to exploit them and queue-jump. Canadians with money will seek treatment in private clinics in other countries. Patients who receive private treatment see no personal benefit from the public system, and their support for the system will likely wane. Others left to linger on waiting lists feel ignored and ill-treated by the system. Therefore, the priority for maintaining a fair, universally accessible public health care system is to reduce waiting lists.

Innovative solutions like CROS have been instrumental in reducing out-of-country referrals and waiting lists for cancer radiation therapy in Ontario. Although we are a privately run company, CROS is contracted by Cancer Care Ontario, so patients do not pay any fees. Our operational model fits within the principle of public administration as defined by your committee, a single, user-pay model administered by the province.

Last summer, Cancer Care Ontario, CCO, felt the need to increase radiation treatment capacity and to improve patient access to radiation therapy. CCO issued a call for proposals in the fall of 2000, and we were the successful bidder.

We started our operation in February 2001 to treat breast cancer patients who otherwise would have been referred to the United States or Thunder Bay. Very soon after opening, we were able to see up to 20 new patients per week. This is the same number of patients who were previously referred to the United States. In May, we expanded our services to prostate cancer patients.

Let me just highlight some of the important points in the remainder of my written presentation. Our working hours are evenings and weekends. This is a more convenient time for patients, and it allows them to continue to maintain their normal daily activities. Often, patients who receive radiation treatment, especially for breast and prostate cancer treatment, are otherwise well and are able to continue their work.

When patients from Toronto and the GTA were sent for treatment down to the United States or up to Northern Ontario, their lives were extremely disrupted. It is less disruptive for patients to receive health care at a time that is convenient for them and to receive that care closer to home. It also saves the provincial government a significant amount of money.

Patients are not referred to us directly. A patient who needs radiation treatment will be referred to his or her designated cancer centre. If the wait at the designated cancer centre is too long, the patient's chart will be sent to Cancer Care Ontario, who will then refer the patient to us.

I would like to talk a little bit about our organizational structure.

Operationally, CROS exemplifies a modern service organization. I believe that the top-down doctor-led hierarchy of current medical practice is an out-of-date model. At CROS, we have reorganized and flattened the traditional approach to radiation therapy for patients. Radiation therapists are the people who actually deliver the radiation treatment and deal with the patients on a daily basis. They are included in the executive decision-making process affecting all aspects of our operations. This direct control and responsibility of radiation therapists has led to greater operational efficiencies in patient and staff scheduling, thereby optimizing machine utilization.

I am particularly proud of CROS's operational model and believe that, if more medical services were reorganized, greater efficiencies for the health care system would be achieved.

The cost savings have been substantial. Previously, when patients were being sent to the United States, the cost was approximately $15,000 per patient per treatment and another $5,000 for travel subsidies. To treat the 534 patients we treated in our first six months of operations cost $1.9 million; this compares to a total cost of $10.7 million for those patients that we referred to the United States and Northern Ontario.

I should like to make some recommendations regarding monitoring. It is particularly important for breast cancer patients to receive radiation treatment as soon as possible, to reduce the rates of recurrence. Early treatment through lumpectomy and radiation greatly reduces a recurrence and the possibility of a mastectomy. We see a key performance measure for breast cancer treatment as the reduction of the rates of mastectomies across the province. We recommend that these incidences of mastectomy be monitored nationally to ensure that the current system is achieving the objective of reducing mastectomies.

Current thinking in the field of radiation therapy targets 50 per cent of cancer patients for radiation. In Ontario, about 35 per cent of cancer patients currently receive radiation therapy. We recommend that the percentage of patients utilizing radiotherapy be monitored, with the goal of meeting this international benchmark of 50 per cent utilization. I should note that the Radiation Oncology Research Unit at the Kingston Regional Cancer Centre, led by Dr. Bill Mackillop, has been working on this for many years now.

In conclusion, cancer care is a challenging field. Timely, high quality treatment is important for patients, both physically and mentally. CROS delivers results for its patients, Cancer Care Ontario and the province. I hope that your committee recognizes that innovative solutions like CROS help maintain a publicly administered health care system to benefit all Canadians.

The Chairman: Is it fair to say that what you are effectively doing is extending the hours of operation of equipment, which, when you have invested in capital equipment, makes a lot of sense?

Dr. McGowan: Yes.

The Chairman: It is the same principle of people trying to run computers 24 hours a day.

I was surprised to learn that you do not do any treatment on Saturdays or Sundays.

Dr. McGowan: Right.

The Chairman: Why?

Dr. McGowan: There are two reasons. One is that the radiation treatment schedules that are given to patients for curative treatment have evolved over decades, and the way they have evolved have been five days in a row with a two-day break. It appears that the patients need this for recovery. There have been studies that have tried to use continuous radiotherapy, and the toxicity became unpredictably great.

The second is the need to have the same treatment capacity every single day. Hence, weekly capacity is defined by the lowest capacity in a single day. We are not convinced that we could attract sufficient radiation therapists to reproduce full staffing on Saturdays and Sundays.

The Chairman: Are your therapists employed only by you, or are they, effectively, people working overtime from other institutions?

Dr. McGowan: Most of our therapists are people that are working overtime from other institutions. However, approximately one third of our treatment capacity comes from people who are working only for us and otherwise would not be working in the system. These are all people that are home with their children during the daytime. In fact, we brought some people back into the workforce who had had part-time jobs. One person had been working as an aerobics instructor; others were working as waiters and bartenders.

The Chairman: Effectively, you brought people back to use their acquired skills.

Is the situation the same with your doctors? Are they people who Monday to Friday during normal working hours would be practising oncologists but who do extra work in the evening?

Dr. McGowan: Yes. We bring in a Windsor oncologist for Friday and Saturday. Two people come up from Hamilton. One person who is currently working part-time in Toronto works for us; and we have another doctor that comes in from London.

The Chairman: Your model fits exactly the model we described - I think it was in chapter 5 - where we talked about extending the service, specialized organizations units and improving patient service.

Dr. McGowan: Yes.

The Chairman: It seems like such an obviously attractive idea. Why, then, have you not done it at the Ottawa Regional Cancer Centre, just to pick another example?

Dr. McGowan: We just started in February. We have been approached by Cancer Care Ontario to look at extending operations.

Senator Robertson: You said that referring patients out cost $10.7 million, against $1.9 million to treat patients under your program; is that correct?

Dr. McGowan: Yes.

Senator Robertson: I assume those waiting lists are there because hospitals cannot attract extra staff? If the hospitals could attract extra staff, how would the costs of that compare with your staffing costs?

Dr. McGowan: That is a question that is asked. Remember, we are an after-hours clinic.

Senator Robertson: Yes, I understand that.

Dr. McGowan: We pay a 15 per cent premium to have people work extended hours.

Senator Robertson: You charge the public health system, however; correct?

Dr. McGowan: Yes.

Senator Robertson: Why cannot the hospitals attract people, thereby savings the difference between your costs and theirs? I am sure it is not just because they do not want to do it. This is confusing.

Dr. McGowan: We are different in a couple of ways. First, the organization is solely focussed on delivering patient care. That is our number one and single-most important priority. We do not have competing priorities; in other words, we do not have trade-offs between treating patients and doing anything else.

Second, when you are looking at a single department, the staff come from that single department and your capacity is defined by the lowest common denominator or the area with the lowest capacity. We have been able to attract the key staff, which are therapists and oncologists and physicists, from different organizations. One third of our staff came from other organizations, and we are able to have them work in the evening because we can develop a staffing structure that allows us to deliver full treatment capacity in the evening. For the daytime departments to use these people that were not otherwise working would have required them to extend by a full four hours a night to make it attractive enough for them to come in in the evening.

Third, we brought people from Sunnybrook and Princess Margaret Hospital to deliver the radiation therapy. The oncologists come from different cancer centres. There has to be a match of the key staff. Hence, I think that there was an operational barrier to the daytime operations using the staff in this way.

Senator Robertson: Operational barriers in the health system seem to be costing a lot in all areas, not just oncology.

Dr. McGowan: Right. They were costing substantially more when we were referring patients out. This is a way to directly deal with the operational barrier.

Senator Robertson: As opposed to insisting that the hospitals take the barriers down.

I am not complaining. I think your aggressiveness is good, but it points out, I believe, a failing, Mr. Chairman, where the traditional hospitals and other health care deliverers put these walls around themselves. There seems not to be the type of cooperation there should be.

On the last page of your document here, you say, in part:

Current thinking targets 50 per cent of cancer patients for radiation. In Ontario, about 35 per cent of cancer patients receive radiation therapy.

Dr. McGowan: Yes.

Senator Robertson: Do you have any statistical evidence of what is happening with those percentages in other provinces?

Dr. McGowan: No, I do not. It is a very difficult figure to get at. The Radiation Oncology Research Unit at Queen's in Kingston has looked at this. They have focussed on getting this research and these figures out of Ontario. It is a very difficult figure to get at.

Senator Robertson: With the exception of a couple of provinces, I would imagine, I do not think they would be reaching that 35 per cent.

There will be a witness here tomorrow who will present some statistical evidence. We will wait to see whether we get this information.

Senator Keon: I hear quite a lot of discussion about the devolution of authority and services from Cancer Care Ontario into the hospitals.

First of all, how much of this is real? How would that affect your ability to do the kind of innovative thing you have been doing? I have been aware of your program for the last number of months and have had an opportunity to talk about it to Dr. Hollenberg on occasion.

If Cancer Care Ontario were devolved into the hospital sector, would you have the capacity to continue what you are doing, to broaden your services to try and avoid people going out of country, for example?

Dr. McGowan: I am not sure that I would. I am also not sure that I would not.

I understand the environment that we are working in, and Cancer Care Ontario is the agency that I have a contract with. Cancer Care Ontario has the mandate to ensure that all patients get radiation treatment as required. With Cancer Care Ontario's backing and support, I am able to do this, and it is an easy extension.

If we had to deal with a variety of hospitals, we would then have to sign a contract agreement with each institution. It would certainly change the nature of the relationship in a way that I am not entirely sure I can predict.

Senator Keon: I take it that in your long- and short-range planning you rely fairly heavily on population health data that arises out of Health Canada, out of CIHI with the so called "cancer maps." Again, how would it affect your ability to do long- and short-term planning if cancer care were shifted to the broad institutional sector, if cancer care were shifted from Cancer Care Ontario to the broad institutional sector?

Dr. McGowan: One of the things I have seen in long-term cancer planning is that one of the only truisms in cancer planning is that the incidence of cancer always increases. There are always more cancer patients than there were the year before, and there are always more patients that need radiation therapy. On a long-term basis, we can be sure that this number will increase by somewhere around 3 per cent to 5 per cent in a predictable way. Where we have a problem is in the year-to-year fluctuation, the random variation around the mean.

Our model of care is to provide the protective capacity or short-term capacity. We can increase our capacity through our model, our staffing model, quickly by three or five patients a week, or we can decrease it in the same way. We have a lot of flexibility.

Cancer Care Ontario's long-term planning involves where to put cancer centres and where to expand capacity in a significant way, when to put in new machines, et cetera.

Our capacity is really dependent upon exploiting the unused machine capacity that is available in the evening or perhaps some slight unused capacity that occurs from year to year. If the planning capability is gone and the capacity planning is very poor and we are off by 10 per cent or 15 per cent, then no amount of innovative staffing strategies is going to get around the fact that there is insufficient capital equipment. We really rely on there being sufficient and proper long-term capital planning to allow us to utilize short-term staffing strategies.

I am not sure if that answers your question, but that is my perspective on the planning issue and how it relates to us and long-term planning.

Senator Keon: I would like to bring you back to a comment you made about the innovation of your personnel.

I get the distinct impression, from my own years of experience and from the testimony I hear at this committee, that one of the big defects in the health care system is the improper use of personnel. There are highly skilled personnel doing things that they do not have to do at all, things that could be done by less skilled personnel.

First of all, I want to ask you what flexibility you have vis-à-vis the integration of your personnel, in cross-training and in the shift of responsibilities from one group position description to another group position description? How successful have you been in doing that?

Dr. McGowan: I think we have been surprisingly very successful in shifting responsibilities between professional groups. The limitations we have are on the licensing issues. There are certain tasks that only a person who has a medical licence is qualified to do; it is similar with respect to a therapist licence.

Beyond that, all of the operational tasks, we have complete flexibility in how we operate. We operate as a true group medical practice, with the physicians covering each other for all of their patients. We have developed true commonality in treatment protocols and treatment approach.

By bringing the radiation therapists into the organization at an executive decision-making level, we are able to - I do not pretend to know how to operate a radiation therapy department - allow them to best decide how to organize their own work life; they are highly skilled professionals.

Thirty years ago, when the educational difference between physicians and allied health professionals was great, it made sense for the physicians to take the lead, because very often the allied health professionals came into the workforce for 10 years and then left to pursue a family life. Over the last 20 years or 30 years, in the fields I deal with, there has been growing professionalism and increased educational requirements for the allied health professionals. For many of them, their job is no longer just a job; it is a career, a profession that they stay in for a lifetime. We need to recognize that increased professionalism of all the allied health professionals.

The number one thing we have done is to recognize that and shift the responsibility accordingly. If the radiation therapist who heads the planning says to me or to one of the other physicians, "This is going to cause us an extra two hours of work and planning; is there any way to change the process?" that person has the mandate, the authority and the responsibility to look at the process and try to change it. That is a very difficult thing to do in a traditional structure.

Senator Keon: Let me push you a little further on that one, that is, to deal with the physician in the integration of the health care team. With respect to method of remuneration, as to whether fee-for-service remuneration works or whether alternate payment plans work better in an integrated team, what is your opinion?

Dr. McGowan: I do not think that any single method of payment is necessarily the best. We just have to be very careful in the way that we design them. As long as the goals of the payment system are aligned with the goals of the organization, I think it can work. I think different models work.

My model is on a fee-for-service basis. That focuses the physician on the main shortage in radiation oncology, which was radiation oncology consultation and treatment planning.

I will give you an example. In many of the current models of radiation oncology remuneration across the country, people receive a flat fee for the radiation treatment planning, which is their scarce skill, and they receive a fee for service for the follow-up with patients. Hence, the only way to enhance income is to maintain a large follow-up practice, and I think we see that happening in that there are large follow-up practices.

I think a well-defined alternative payment plan can work, a focussed fee-for-service payment plan where the incentives are appropriate, where they do not incent large volumes of relatively straightforward problems but rather incent people to treat and see those patients where their scarce skills can be used most effectively. In our system, in radiation oncology - which is the only system I really have an in-depth understanding of - the scarce skill is radiation treatment planning - hence, where the incentive and payment system is based upon paying people to do that.

Senator Callbeck: You operate out of the Toronto Sunnybrook Regional Cancer Centre. I read here somewhere that the recommended time from the time of referral to therapy is four weeks?

Dr. McGowan: Yes.

Senator Callbeck: In your written document, on the second page, you say: "If the wait at their designated cancer centre is too long, the chart will be sent to Cancer Care Ontario."

Does that mean that everybody in Ontario is reaching that target now?

Dr. McGowan: No, they are not.

Senator Callbeck: Does it mean that if the waiting time is in excess of four weeks at a patient's designated centre, the patient goes to you?

Dr. McGowan: Yes.

Senator Callbeck: What about transportation? With respect to a patient in Thunder Bay, say, would the patient pay his or her own way, or does the government pick that up?

Dr. McGowan: People from Thunder Bay are not travelling down to see us. In fact, Thunder Bay has sufficient treatment capacity, so the people who live in Thunder Bay are not waiting. In fact, Thunder Bay had excess treatment capacity and, as such, were taking people from Southern Ontario.

The people we are seeing live in the local area; therefore, we see people from the Hamilton region and the GTA. They travel on their own. They fall into the same travel requirements that patients that are treated in the daytime do. If accommodation is needed, they can stay at the Canadian Cancer Society Lodge.

Senator Callbeck: I see that your annual target was for 500 patients. You have already treated 534 patients, which is quite a lot over what you projected. How many can you possibly take?

Dr. McGowan: Our capacity is limited by the availability of machines and the availability of staff.

At the cancer centre that we are operating right now, because of the requirements for machine maintenance and so on, we are essentially close to the maximum machine capacity. We are somewhere around 1,000, I would say, in a year, maybe a little bit more.

Senator Callbeck: Has there been any interest from any of the other provinces in your company, or is it too early to tell?

Dr. McGowan: No, there has not been any interest from any of the other provinces.

Manitoba has just announced that they will be sending patients from Winnipeg to Thunder Bay for treatment, and I think geographically that makes a lot of sense. There has not been any interest from any other provinces yet. No one has contacted us.

Senator Callbeck: You have not contacted them, either; correct?

Dr. McGowan: No, I have not contacted them. The first six months of operation I focussed on making sure that we were delivering good and appropriate clinical care in our location. That was my first and foremost priority.

Senator Cordy: Thank you very much for attending here this morning. I would agree with the chairman in saying that is a common-sense solution to things. With Senator Callbeck's comment about other provinces, perhaps we can encourage other provinces to take a look at this model, because it certainly seems to be one worth pursuing.

I have a couple of clarification questions. Patients do not call you directly; correct?

Dr. McGowan: That is correct.

Senator Cordy: How does that work?

Dr. McGowan: Radiation is a tertiary care specialty. Patients are generally first seen by a surgeon for a biopsy. We do not see people for a diagnosis. We are a therapeutic specialty. Patients are referred from their community physician, their community surgeon, their community medical oncologist in one of the cancer centres for consideration of radiation treatment.

In the GTA, patients would then be referred to the Hamilton Regional Cancer Centre, the Princess Margaret Hospital or the Toronto Sunnybrook Regional Cancer Centre. If the waits at those cancer centres are too long, patients are then referred to us through Cancer Care Ontario's referral office.

Senator Cordy: Just dealing with the issue of equipment, and you talked about it earlier, we have heard comments from so many witnesses before us about the state of disrepair of equipment in Canada.

Is that a concern to your operation?

Dr. McGowan: No. Actually, the radiation equipment in Ontario is, by and large, in good shape. It is well-maintained and operational. The state of the equipment is not an issue at this time.

There is, nevertheless, an issue of ongoing machine replacement. These machines need to be replaced every 10 years. We are reasonably close to being on that target in Ontario.

Senator LeBreton: I apologize for being a little late. If my question has been asked, please just say so and we will move on.

In your paper you talk about operating out of Sunnybrook and having your own physicians, radiation therapists and support staff and that these people all work during the daytime in other cancer centres. Does that not cause a problem in terms of workload and stress levels?

If there are people who are working during the day at a cancer facility and then working in the evening for you, how do you get around that?

Dr. McGowan: One of the points I made earlier is that one third of our treatment capacity is provided by people who would not otherwise be working in the system, because they are at home with their children during the daytime. We get around it for therapists by having them work a maximum of one or two shifts a week. Second, we review with Toronto Sunnybrook shift scheduling and the incidence of absences, to see whether there is a correlation between being scheduled on a shift for us in the evening and an absence the next day. With those two mechanisms in place, I also believe people need to have autonomy and respect for their ability to decide for themselves if they are able to work.

The issue of burnout is a real one. If there were an increase in absences, then that person would not be rescheduled.

In addition, given that we have no long-term sustainability, it is very important for us not to burn out our staff. We try not to operate the machines beyond 10:30 at night, so that people can get home in enough time to get a good night's sleep. They do not get free time at home after their shift, but they get home early enough to get a good night's sleep to start work the next day.

People have asked us, "Why don't you extend your capacity by operating until 11:30 or 12:00 at night?" That might be fine for those people on our staff who do not have another job; however, for those who do, I do not think it is sustainable.

Senator LeBreton: Are you planning to set up other facilities around Ontario?

Dr. McGowan: There are ongoing capacity issues across Ontario, and we have been discussing the possibility of looking at other potential operations with Cancer Care Ontario.

Senator LeBreton: I told our chairman that I have a cousin in the Ottawa area who had to go to Thunder Bay and spend quite a lot of time there, with very little support other than the good support that they provided there.

Dr. McGowan: Yes, it is a difficult thing for patients to face to have to travel. We did treat people from Ottawa for awhile. We had a number of prostate and breast cancer patients who came to us from Ottawa to be treated.

In the first six months of operation, we focussed very much on ensuring that our operation was sustainable, that our staffing structure was sustainable and that we had good clinical quality. At the beginning, I was maintaining most of the clinical load myself, until other physicians came on board.

The Chairman: I have three or four technical questions, and then I will ask you to speculate a bit.

Have you had any trouble with public-sector unions? I ask the question because, in theory, it seems to me that a union could take the position that you are using public facilities and a non-unionized workforce, and then proceed to make the argument that in a sense you are taking away unionized jobs. Has that issue been raised?

Dr. McGowan: The unions have not raised the issue that we are taking away public-sector jobs.

The unions have raised the issue that this model falls outside of the Canada Health Act, that it should not have been done in this way, that it should not have been awarded this way, but they have not made the argument that it takes away public-sector jobs.

I do not believe it does; it is not as if there was not the will to increase capacity as much as possible. I think there are organizational blocks.

The Chairman: Given all the flak that surrounded Alberta's Bill 11 - and by the way, what you are doing is essentially more or less what the final version of Bill 11 allowed - how have you done this without any flak? It is extremely impressive that you have done it without flak.

Dr. McGowan: I am not sure I would say I did it without flak.

The Chairman: Perhaps I just did not notice the flak.

Dr. McGowan: I did.

The Chairman: Welcome to the club. We are always willing to get people who get flak into our tent.

Seriously, was there opposition?

Dr. McGowan: Yes, there was. There were groups opposed to it. The prime objective of the group Friends of Medicare, which established itself after the contract was awarded, was to get the government to cancel the contract.

There was a letter from CUPE, I believe, to Allan Rock, stating that the process of awarding a contract should be looked at. There were letters and articles in newspapers, editorials, essentially from people who objected to the operational administration, a private company using public facilities, rather than having the services comes from continued public administration.

I think your definition of "public administration" is the one that is most important - the single payer. From the patient's perspective, the system is transparent; the patient does not care, as long as he or she is well-treated and gets good treatment.

The Chairman: Has the flak disappeared?

Dr. McGowan: It has improved. I think our success has helped to mute it.

What is interesting is that we are getting good press outside of Canada. There was an article in The Wall Street Journal in May about this initiative. The Irish Times featured an article a week ago Saturday about a reporter who came to Canada to look at the Ontario health care system. The reporter said that the system was pretty good. The article referenced this committee in a way that was supportive of this initiative as a way to improve treatment capacity.

The Chairman: We would appreciate you sending the committee copies of those articles, at some point.

Dr. McGowan: Sure.

The Chairman: How is the company paid? Is it paid on a per-patient basis, or does it depend on whether you are seeing a breast cancer patient or a prostate cancer patient?

Dr. McGowan: It is a flat fee per patient.

The Chairman: A flat fee per patient?

Dr. McGowan: Per patient, yes.

The Chairman: How is that fee arrived at?

Dr. McGowan: It is the fee that the Ministry of Health pays Cancer Care Ontario per patient.

In addition, given the operational barriers and the fact that we needed to pay people more, the contract also allows for a bonus incentive, based upon volume of patients treated, of $250 per case once we hit a target of 500, rising to $500 per case if we hit 750.

The Chairman: Just help me a bit; I may also need Senator Keon's help on this.

Typically, in Ontario and elsewhere, hospitals get global budgets.

Dr. McGowan: Yes.

The Chairman: Hospitals are not paid on the basis of fee for service.

Dr. McGowan: Yes.

The Chairman: You are paid on the basis of fee for service, I understand that.

Let's take the Ottawa Regional Cancer Centre as an example. It is included in the global budget of the Ottawa Hospital, or does the centre receive a per-patient fee?

Dr. McGowan: Organizationally, the cancer centres have separate governance from the hospitals.

The Chairman: Like the Heart Institute.

Dr. McGowan: I am not sure about the Heart Institute.

The Chairman: In this case, it does.

Dr. McGowan: Separate governance. There are two organizations that deliver radiation therapy, Cancer Care Ontario and University Health Network. Hence, the budget for the Ottawa Regional Cancer Centre, for instance, flows from the Ministry of Health to Cancer Care Ontario and then from Cancer Care Ontario to the Ottawa Regional Cancer Centre.

The Chairman: In other words, you are reimbursed on the same fee-for-service basis that the Regional Cancer Centre would be if that patient were treated during the daytime; correct?

Dr. McGowan: Yes, plus the bonus based on volume.

The Chairman: Right, but that is an incentive to get more patients?

Dr. McGowan: Yes.

The Chairman: Last question. Do you want to speculate for a minute as to what other areas of medicine this system would work in? It obviously would not work in very unique one-off cases; correct?

Dr. McGowan: Right.

The Chairman: It would only work in something in which you have a reasonable ongoing volume with a consistent type of treatment.

Dr. McGowan: Yes.

The Chairman: So where else would it work?

Dr. McGowan: The characteristics that make this work, are, number one, it is capital intensive. Second, there is unused capital. I believe it has to be in an area where staffing shortages are a result of there being multiple professions involved - not so much of there being a staffing shortage but a staffing integration issue. And the third characteristic would be related to the staffing shortage of the allied health professionals, where there has been growing professionalism - something like diagnostic imaging, where there is a very straightforward staffing relationship, where there is a technician on the machine and then the information goes to a radiologist, one-off. There has to be relatively complex interactions.

I would say that the model would primarily fit in the surgical specialties, where there are ORs that are underutilized in the afternoons and evenings, where there are significant staffing issues, relationships between nursing, anaesthetists, hospital beds - a model where a lot of different professionals need to be brought together.

What I would do in that instance is bring a group of people together and say, "How can we do this in a slightly different manner? How can we organize what we are doing?" In addition, it has to be a very focussed area. There are issues such as vascular access, where it is a problem when people need vascular access for dialysis or for portacaths, for chemotherapy, other surgical procedures, perhaps medical oncology.

I have not thought enough about it, but those are the key characteristics. It has to involve multiple professionals, where it is always reported that the problem is a staffing shortage but where really I think it involves more of a mismatch.

I met with the Provincial Chief Nursing Officer of Ontario a couple of weeks ago. She said that, in Ontario - and I cannot remember the exact figures - millions of dollars are being spent on overtime and agency nurses. There are very large numbers of nurses - and I do not remember the figure, but it was somewhere around 2,000, 3,000 or 6,000 - who were not working in the profession but who were maintaining their licence. In a time of nursing shortages for beds and ORs, this is an ideal opportunity to bring together these people who obviously are interested in their profession, because they maintain their licence. It would make sense, given the money that is spent on overtime and hiring agency staff; there appears to be a willingness to pay premium rates. It may not be possible, however; one of the specialties may be working to full capacity.

Until we look at how we can raise the allied health professionals to a level of decision-making, I am not sure we can say that there really is a shortage.

The Chairman: Thank you for attending here this morning. Your testimony was fascinating.

Senators, I will introduce our next set of witnesses. We have with us Walter Robinson, the Director of the Canadian Taxpayers Federation, Stephen Allen, on behalf of the Canadian Council of Churches, and Mr. Edward Buffett, the President and CEO of Buffett Taylor, Employee Benefits and Workplace Wellness Consultants.

I would each of you to make a five-minute presentation, and then we will turn to questions. We will begin with Mr. Robinson.

Mr. Walter Robinson, Federal Director, Canadian Taxpayers Federation: Mr. Chairman, it is a pleasure to appear before you and your colleagues here this morning to share our views on Canada's number one social policy challenge.

The CTF was founded in 1990 and has grown in 11 short years to become Canada's largest and most effective taxpayer organization, now boasting some 61,000 members. Our organization is non-partisan and not-for-profit; nor do we receive financial assistance from any level of government.

Although I appear before you in my capacity this morning as federal director, I wish to note that in my community I have served as a trustee on the board of the Ottawa Hospital and currently am a member of the Ottawa Regional Cancer Centre Foundation Board of Trustees.

Allow me to formally begin by commending your activities. To date, your research, hearings and publications have created room on the public policy playing field for an emergent, broad and inclusive debate. This inclusion is fundamental because the health care debate, until recently, was dominated by a limited number of public policy surrogates. Sadly and regrettably, this group has diminished the complexity of health care reform to facile, bipolar country comparisons and/or left versus right ideological disputes. These surrogates have also created a climate where invective rhetoric, slippery-slope logic and personal character attacks have combined to mimic a sustained Arctic cold front that freezes out new entrants or ideas when it comes to health care reform.

Still, Canadians yearn for an ideas-based discussion about all possible options for health care reform. Collectively, we know that we will spend $95 billion, or 9.3 per cent of our GDP, on health care this year. With health care costs consuming 62 per cent of all provincial budget increases over the last three years, it is clear that health care is a taxpayer issue.

Last month, we released a major research and position paper entitled "The Patient, The Condition, The Treatment," copies of which were provided to you last week. In that paper, which we hope to discuss in greater length during our interactive dialogue this morning, we outline seven core beliefs: the first is that health care is in a state of crisis; second, Canadians are ahead of their politicians on the need for reforms; third, health care is a shared jurisdiction between Ottawa and the provinces; fourth, the Canada Health Act is not the Bible; fifth, it is impossible to measure health care systems by numbers alone; sixth, our present debate is too continental and not global; and seventh, quality and excellence must be the primary focus of options for reform, not cost containment.

The development of health care policy in Canada over the past century reveals that Canadians can handle exhaustive and sometimes painful debate; hence, we owe it to ourselves to mirror and build upon this history by objectively considering all options for reform. The logical starting point is a review of the Canada Health Act, since it is the de facto standard by which all reform options are judged.

Increasingly, scholars and medical practitioners have converged around one dominant school of thought about the act; that is, that it constrains provincial initiatives and its core principles are often in conflict with each other. Meanwhile, public opinion reveals a thirst for fundamental changes, even if these changes contravene some of the act's principles.

The act, in part, has also fuelled the fight between Ottawa and the provinces over historic and recent funding levels. While some jurisdictional tension, we admit, is inherent and necessary for our federal system to work, it has reached a counterproductive level.

In the provincial capitals, health ministers, regardless of partisan stripe, have all stated that health spending increases that double or even triple annual revenue growth are unsustainable, yet they continue to do so in each provincial budget. If this spending continues unabated, today's tax cuts versus social investments debates, which we all are well aware of, will quickly give way to tomorrow's spending cuts versus spending cuts debate. Legislatures will be forced to choose between MRIs and textbooks or, worse still, coronary bypass versus cancer tumour resection. Provinces will need only two ministries, finance to collect the money and health to spend it.

Our estimates point to this troubling tomorrow coming as soon as 2007 for the provinces of British Columbia and Newfoundland when health care spending is projected to consume 50 per cent of all resources. Similar fates await Alberta, Manitoba and Saskatchewan in 2012, 2014 and 2019 respectively.

At the root of this problem is medicare itself and its flawed economics. Its present pay-as-you-go funding configuration is unsustainable. In this context, it is somewhat similar to an illegal pyramid scheme. Today's surgeries are paid from yesterday's tax collections, but we know with demographics that the pyramid at the bottom is getting smaller, not bigger.

Funding flows from taxpayers through a variety of intermediaries - government, insurers, et cetera - and insulates patients from the financial ramifications of their consumption decisions. As a result, we are left with a patchwork system of perverse incentives for patients, doctors, bureaucrats and politicians - and you can refer to appendix C of our paper for specifics. This perversion serves to drive up costs and vaccinates the system against innovative options that could improve quality and health outcomes.

Even more damaging is the assessment by the Word Health Organization that last year rated the health care systems of 191 countries - Canada ranked 30th. Dr. Chris Murray, the director of evidence-based medicine for the WHO, put it bluntly: "Canada does not have the best health care system in the world."

The lesson is clear. We should examine the best practices in terms of funding, service delivery and financing from these other countries and adopt them to our own Canadian situation - and the sooner, the better.

Turning to system cost drivers, demographic pressure is already upon us and, by 2020, will ensure that 60 per cent of health care expenditures will be consumed by those aged 65 or older, compared to 45 per cent now. Societal aging is irreversible, and we all know the ramifications as well for the practitioners of health care.

On the technological front, advances in rational drug design, genetic mapping, artificial blood, just to scratch the surface, bring exciting promise and hope to millions, if not billions, worldwide, yet they come with a cost.

Pharmaceuticals now consume more resources than physician billings. With new and aggressive drug therapies in the works to treat a variety of conditions, from cancer to the protein-based diseases of aging like Parkinson's and Alzheimer's, it is axiomatic again that costs will only escalate.

Finally, patient demands and expectations for right here, right now services will magnify exponentially. To date, the reforms in our system have been supply-side driven. To be fair, some modest economies have been found, but patient demand, patient responsibility and the perverse incentives inherent in our system have largely been ignored as focal points for reform.

Health care is complex and there are no magic-bullet solutions, but at the legislative level, we believe that a modernization of the Canada Health Act is long overdue. Its five current principles should be replaced by the following six: public governance, universality, quality, accountability, choice and sustainability.

At a structural level, guiding principles of reform include: individual accountability and responsibility, perhaps co-payment, like every other OECD nation; intergenerational fairness - pre-funding of health care expenditures, such as Singapore; and the embrace of innovative approaches with respect to capital construction, service provision and technology renewal.

Mr. Chairman, the principal and laudable aim of medicare was to provide health services without hindrance. The greatest hindrance to reform to date are those who have the intransigence to refuse and accept that the problem with health care is the system itself.

I should like to conclude on a personal note. Thirty-five years ago, I was born in this city at the old Doctors Hospital. As a very sick three-year-old, 32 years ago health professionals at The Hospital for Sick Children worked for four years to save my life from a very serious illness. My family received great health care in this community, and the cancer services that my father received at Princess Margaret allowed him to die with a degree of dignity.

Today in Ottawa, the story is the same for my family, as I hope it is for everybody in this room, at this panel and behind me, but we can and must do better.

The sign of a healthy democracy is one that finds fault with itself, for if it cannot, it has ceased to be a democracy. We must succeed in this debate. Anything less constitutes a disservice to those who went before us, to the health care practitioners who work so hard for us today, and it would be an inexcusable abdication of our responsibility to future generations of Canadians.

We urge you to consider our ideas for reform and options to build a better health care system.

Mr. Stephen Allen, Member of the Commission on Justice and Peace and Co-chair of the Commission's Ecumenical Health Care, Canadian Council of Churches: Members of the committee, on behalf of the network I thank you for this opportunity to comment on some of the options that you have suggested in "Issues and Options."

Historically, Canadian churches have contributed to the development of Canada's publicly funded and administered health care system as service providers, stakeholders - pastoral ministries, chaplaincy services - and as supportive advocates of new ideas and approaches - community-based programs such as parish nursing. For Christians, Jesus has taught us that illness or, more important, wellness requires spiritual as well as physical well-being.

Our written presentation comments on six areas: first, principles for the provision of health care; second, financing health care; third, accountability of all levels of government; fourth, the need for evidence-based research; fifth, expanding health care to include pharmacare and home care; and sixth, our support and acknowledgment for the work you have done in focussing on the determinants of health in ensuring integrated strategies and programs.

Members of our network support the five principles of the Canada Health Act. These five principles enjoy public support and must serve as a starting point in our discourse on reforming health care in Canada.

Our support is based on the following principles and values, which we believe serve to uphold those included in the Canada Health Act. The first is the dignity of the person. The second principle is the right to health care, regardless of one's wealth or status in society. The third is health care as a service available in response to need; in other words, health care service should not be viewed as a product or a commodity. The fourth is that health care providers should not be diverted from their primary responsibility - the relief of suffering, the prevention and treatment of illness and the promotion of health. Underlying this responsibility, in our view, is a relationship between provider and patient based on trust. The fifth principle is wise stewardship. It is not possible, and we recognize this, to do everything we might wish to do in our health care system. Making decisions about priorities will involve public policy debates involving citizens and Parliament. Finally, equity, collective responsibility to each other, compassion and caring are the values we consider fundamental, and these values should guide us in reforms that we acknowledge need to be made.

I would like to acknowledge the four objectives that you have outlined in chapter 8, "Financing Health Care in Canada" - and I will come back to those a bit later.

Our health care system is based on the value that all citizens share the risks. No one wants to have an accident. No one wants to become ill or to develop a life-threatening disease. We draw comfort in knowing our health care system is there should we need it. Sharing this risk represents something of a social covenant among citizens. It is a value to be lifted up, protected and cherished.

In our written brief are questions about the spending in this country as compared to other countries, and we look forward to further reports from this committee.

Let me quote Joseph Stiglitz, a Noble prize winning U.S. economist. He was commenting on the growing unemployment in the U.S. prior to the tragic events on September 11, and he said, in part: "What worries me is that we don't have a safety net. We don't have adequate welfare or unemployment insurance." He went on to say that, worse still, U.S. workers who lose their jobs typically also lose their health coverage, exacerbating the pain. You know well the number of citizens in the U.S. who either have no coverage or very limited coverage, and most of them work. Our system, as imperfect as it is, we believe provides a measure of security and comfort to citizens in this country.

Let me also quote Steven Derks, the Vice-President of Advocate Health Care, a religious-based health care provider in Chicago. This quote is taken from a October 13 meeting in Chicago of public policy directors of the Evangelical Lutheran Church in America. They provide over $2.7 billion in care annually in the Chicago area. He said of U.S. health care the following:

We do not have a health care system in the U.S. What we have is a constellation of services that exist in separate silos, that are hard to trade off and which are responsive to the reimbursement mechanism... Whole patient care is good but it is awkward for U.S. providers.

As we consider the options of expanding for-profit provision in our health care system, we recommend and hope that much more evidence will be provided that avoids fragmenting our health care system.

In terms of some of the options that you have outlined, and I must say, you have provoked our thinking, we would ask if the proposed options outlined in chapter 8 enhance the availability of publicly administered services to the vulnerable sectors of our country and to the vulnerable regions of our country. Your committee's own research helpfully points to some of the flaws, for example, in user charges. The system would not necessarily generate much revenue. It can be a disincentive for poorer citizens seeking care, and my own experience outside of Canada certainly substantiates this. Would a user fee system based on income further stigmatize poorer citizens in our community? If poorer people were excluded from user charges, would this lead to resentment by those who pay user fees?

Your report helpfully cites some evidence from Sweden. The system is not designed to generate revenue, but, as you note, it is intended to change the behaviour of citizens to prevent misuse of the system. We would ask the following questions: has it in fact done this? Do Swedes, as a rule, misuse and abuse their health care system? Do caregivers contribute to this problem?

As you consider various options and as you present those options to the Canadian public, we ask you, as much as possible, to draw on evidence-based research.

We concur with this committee in its observation on page 56 that it is impossible to trace how provinces and territories use federal funds. Citizens need to know that if they are presented with tax cuts it could mean fewer dollars for health care or, for that matter, for social programs or post-secondary education. We welcome a national transparent annual reporting on how provinces use federal funds for health care and, for that matter, other programs that are provided through the CHST. It is our hope that your committee will offer models that are beyond voluntary, models that will provide for mechanisms to ensure the mutual accountability of all levels of government to each other for the principles, values and objectives of our health care system.

Thank you for the focus you have given, not just in volume 4 but in volume 1, to the social determinants of health. In volume 1, I was struck by figures that suggest that only 25 per cent - I think that was the figure, but I am not sure how you arrived at it - of the health of the population can be attributed to the health care system, while 75 per cent is attributed to the social determinants of health care. At page 87 of volume 1, you say that improving health and reducing disparities in literacy education and income distribution is an objective, that due attention must be given to the social determinants of health in this country.

In conclusion, we affirm all five principles of our health care system. We welcome an expansion of the program and we acknowledge the need for debate in terms of choices and priorities. The values I have articulated in my introduction provide a solid foundation for our health care system. Our health care system has a vital role in building a society where we are committed to healthy individuals and healthy communities.

We are uncomfortable with the emphasis given to market-based options. The growth in private expenditures as a share of the health dollar warrants much more public debate and discourse, and we welcome that. We need to remind ourselves that we enter the health care system as citizens requiring care and compassion, not as consumers shopping for a product. Health care need not be treated as a commodity.

We acknowledge that our health care system can be improved, and we support policies and programs that improve health outcomes and that result in wise stewardship of resources.

We live in community. We are interdependent. We need to support each other. Such notions as human solidarity, care, and compassion for the weak are foundational issues of justice for the churches. Health care is a public good, vital to the common good, a vision that we believe is important to Canadians and a vision worth holding up to the world.

For our part, we plan to participate in the Commission on the Future of Health Care in Canada. We look forward to reports from this committee. We hope to engage in further discussions with our members, and we are planning a roundtable in Ottawa in late February or early March.

On behalf of the Ecumenical Health Care network of the Canadian Council of Churches, thank you for this time to be here with you this morning.

Mr. Edward Buffett, President and CEO, Buffett Taylor & Associates Ltd., Employee Benefits and Workplace Wellness Consultants: Thank you, Mr. Chairman and senators. I appreciate your providing me with this opportunity to make a submission to you.

Buffett Taylor & Associates is involved in the provision of worksite wellness and health promotion. I am also the chairman of the Wellness Councils of Canada, a not-for-profit organization that acts as a forum for the dissemination of information related to the promotion of healthier lifestyles, utilizing the workplace as a mechanism to accomplish that objective.

I am the former chairman of the Whitby General Hospital and the Durham Foundation. I am currently the vice-chair of McMaster University, which, as you all know, is one of this country's leading medical schools and research-intensive institutions.

In particular, I want to thank you for the opportunity for enabling me to speak to you concerning volume 4 of your report, and particularly that section dealing with health promotion.

There is, as you will know, a significant body of research that suggests that the reactive nature of our health care system has had a dramatic impact in terms of the cost associated with its delivery. Simply stated, too much of our focus is on curing and managing illnesses as opposed to preventing them in the first instance. I can speak to that on a personal level as an individual who is a heart attack survivor. Although the federal government, through Health Canada and its Health Promotion and Programs Branch, does play a meaningful role in the population health, that role, in my view, needs to be broadened considerably.

In preparing my comments for this morning, I endeavoured to determine exactly what portion of Canadian health care expenditures is allocated to health promotion and disease prevention; however, frankly, I was unable to find a definitive response. I contacted both Statistics Canada and Health Canada, along with a number of provincial jurisdictions, but was advised that the number was not available, although it was suggested that it was likely in the range of about 5 per cent. This number seems to be consistent with U.S. health care expenditures allocated to disease prevention and health promotion.

Intuitively, most Canadians recognize that the pursuit of a healthier lifestyle results in improved health, a reduction in the number of illnesses, which in turn results in reduced pressures on the health care system. A significant percentage of the Canadian population spends about 8 hours to 10 hours a day at its place of employment. In fact, working Canadians spend more of their waking hours at work than anywhere else. Tremendous opportunities exist to utilize some of this time to promote health and well-being, and this is a trend that is being evidenced in the United States, in New Zealand and Australia.

Here in Canada, Health Canada has developed a program to encourage worksite wellness and health promotion and to recognize those employers who have demonstrated excellence in this area through their Healthy Workplace Award program. Although well-intentioned and a great initial first step, this program simply does not go far enough, nor is the scientific and financial data readily available that would substantiate the business case for wellness and health promotion at the worksite. A tremendous opportunity exists to utilize the worksite as a forum to promote health and well-being. It is in an organization's best interest to do so.

The Health Management Research Centre at the University of Michigan, a very well-respected university, has studied over 2 million employees at 1,000 worksites for a period of over 15 years, and their research has enabled them to conclude that worksite wellness and health promotion, when delivered as a comprehensive health initiative, results in healthier lifestyles, which in turn translates into less incidental absenteeism, fewer long-term disability claims, increased productivity, improved employee morale and lower overall health care costs.

Unfortunately for us, this research has been developed utilizing the American health care model, and frankly it has been my experience that Canadian employers will challenge this data and question its relevancy because it is based on the American model and not the Canadian health care system. Some enlightened Canadian employers, employers such as Nortel, Telus Corporation, MDS Nordion, Husky Injection Molding and the Town of Richmond Hill, have forged ahead with very aggressive comprehensive wellness initiatives because they know intuitively that these programs make good business sense.

Nevertheless, the vast majority of Canadians want to see data. They want to see scientific research that clearly demonstrates the economic benefits associated with these types of initiatives. We desperately need to access research and meaningful data that substantiates the benefits of these programs.

The benefits that I am referring to, again, are an improvement in population health, an improvement in our global competitiveness and a reduction in overall health care expenditures.

I urge you in your final report to consider recommending a far greater role for the federal government in developing this necessary research, which needs to be undertaken in order to encourage much greater participation by employers in programs of this nature.

In conclusion, during the last century, the life expectancy of North Americans increased by 30 years. Science has determined that 25 of those years are applicable to healthier lifestyles; only 5 per cent relate to clinical interventions. We simply cannot afford to overlook the tremendous potential impact of prevention on population health.

The Chairman: Mr. Buffett, I found that last statistic so amazing. Do you have a reference for that?

Mr. Buffett: I do indeed, sir. In fact, I have referenced it in the material that I have provided.

The Chairman: It is an amazing statistic.

Senator LeBreton: I will start with you, Mr. Robinson.

When we were in Alberta, quite a few people used terms such as "consumers of medicare" and "medicare marketplace."

On page 7 of your written presentation, you say: "Funding flows from taxpayers through a variety of intermediaries - government, insurers, et cetera - and insulates patients from the financial ramifications..."

How would you correct this? I personally believe that most people have no idea what is being billed by doctors, technicians and other health practitioners. How do we educate the public? How do we determine from them how they want the health care system to work and make them realize the costs that are already there?

Mr. Robinson: We have included in our materials a diagram of the funding model. It is actually a Health Canada diagram that we adapted, as did the B.C. Medical Association.

Your question, Senator LeBreton, concerns how we make people more aware of their consumption decisions. Mr. Allen and I would obviously disagree as to whether we treat health care as an expenditure, a commodity or just a pure public good. Let me answer your question three ways.

First, we surveyed our own supporters and asked them, "How much do you think you are spending on health care?" If we take the $95 billion expenditure and divide it by 30 million, our population, we arrive at $3,000. Of course, that figure varies. For me personally, the figure would be lower; for somebody who is 65 and has health ailments, it is a lot more. It also varies geographically.

We received a variety of responses, so I agree with the premise of your question that people do not really know what their health care cost. They do not know, for example, the difference in cost between a flu shot at a doctor's office and one at an emergency ward. User fees or a co-payment would solve that. They are in place in every OECD nation, much more extensively than here in Canada.

As my colleague has pointed out, it is an issue of controlling costs; it is an issue of making people aware that health care is not free. Health care comes with a price. A free product of value will fundamentally be over-consumed, a law of economics that has not been disproven, as far as I know anyway, since The Wealth of Nations was published.

The other way to do it, as we talked about, is the Singapore example, where they pre-fund a variety of expenditures. Intergenerationally, they pre-fund through health care savings allowances. In Singapore, there are four: Medifund, Medishield and Medisave, and now Eldershield to deal with their aging population. We are attracted to health care savings allowances because you can income test it for low-income Canadians, who will always be reliant upon the state for the majority of their medical expenditures, and for those of us who will always be reliant for the catastrophic coverage. No market mechanism will cover a malignant gastrocytoma grade 4 cancer tumour. There is no insurance company that will cover that.

We are talking about having people pay throughout their lives. We do it for our housing. We fund our housing costs over a generation; it is called a mortgage. We fund our retirement income. The government has already said that CPP is one small pillar. You as Canadians have a responsibility through your own savings to fund through a variety of other ways. Only in health care do we not do that.

To answer your question, then, I think we could make people more aware of their lifetime consumption of health care if we were to implement intergenerational funding.

Senator LeBreton: A very good point.

Again to you, Mr. Robinson. On page 4, you say that the modernization of the Canada Health Act is long overdue, and you advocate replacing the five principles of universality, accessibility, comprehensiveness, portability and public administration with public governance, universality, quality, accountability, choice and sustainability.

In those suggested principles, for instance, portability, where would portability fit within the six principles that you advocate?

Mr. Robinson: As we set out in our paper, we could incorporate the other principles into a broader, a more comprehensive definition of universality. The Conference Board of Canada has shown that support for universality has remained fundamentally constant, and that is a principle that we all support. The issues of portability, comprehensiveness and accessibility vacillate over a 20-year time period, according to the Conference Board of Canada, and support for public administration has consistently declined, to about 59 per cent.

Define "portability". Portability to some Canadians would mean that if the Ontario government covers fertility treatments, then that same coverage should be available in Quebec. In reality, however, that is not the case. Those fertility treatment would not be covered in Quebec; hence; no portability.

There is also the issue of de-listing of various services, of what is covered in one province but not in another; there is not portability in that sense.

Accessibility was brought into the Canada Health Act in 1994; however, accessibility is a principle that is violated every single day in this country. It is better to be a cancer patient in Ontario than it is in Saskatchewan. Saskatchewan has the greatest migration of cancer patients, to Calgary and British Columbia; they cannot get access in Saskatchewan.

In terms of universality, those are some of the principles we wanted to talk about.

Those are not proprietary to us. Other organizations, such as the IRPP and the OMA, have coalesced on the left and political right around some of those new principles of governance, which is a truer reflection of where our health care system is now and where it is going to go, freeing up the state-provided provision of medicine.

The government has a role to govern and to ensure that a public service is provided; however, it does not necessarily follow that they must provide all of those public services. Our opinion is that if you free up the back end for a variety of ecumenical, private and public providers, as has been the fundamental history of the health care system, it would more truly reflect the reality of where we are and where we are going.

Senator LeBreton: You could probably make the same argument about comprehensiveness. It might have meant something in the 1950s and 1960s; it would mean something completely different now.

Mr. Robinson: If I could just add to that, it does. The Diagnostic Services Act and the Medical Care Act were introduced in 1957 and 1966, respectively. We must remember that back then the majority of health care services, as your research has pointed out and as we point out in our paper, 65 per cent, was delivered in hospitals and by doctors. Today, that number is below 50 per cent, in the growth of partial privatization. An individual does not have to go to a hospital for cataract surgery anymore; it gets done at a laser eye clinic.

The legislative framework, the technology and the evolution of delivery of health have not reflected that.

Senator LeBreton: Mr. Allen, on page 5 of your presentation, it says:

While a national home care program would be an important expansion of health care, home care is not necessarily the preferred option for all those requiring care and for those family members providing the care. Home care needs to be implemented in a way that does not unrealisti cally unload responsibilities onto the caregivers. This responsibility generally, but not always, falls to women.

And I totally agree with that.

That begs the question: what should be done, in your view, to correct this? How would you approach the whole issue of home care under the health system we have now?

Mr. Allen: There may be instances where, for the caregiver or for the patient, it is preferable that they remain in palliative care.

In other cases, and I think of my own experience with my father. My mother could not have looked after him; it simply was beyond her. He received very good palliative care in Ottawa. For others, and I guess this is an intensely personal choice made with families, there are those individuals who prefer to be at home and to die at home. An element of the system needs to recognize those kinds of important, ethical decisions, and for those families and individuals who wish to be at home, there must be provisions in a home care policy to provide the support.

There are many facets of care that are covered in hospitals but that are not covered at home, and as we look to the future those costs could become quite burdensome for families, particularly for low-income families.

The committee needs to wrestle with how that choice can be given in a way that recognizes profoundly personal and ethical moments in people's lives.

If a caregiver has to leave the workforce - and it is usually women who provide the care - what is the impact of that on her CPP? If an individual is out of the system for longer than two years, does the individual suffer in any way; and if so, is that something this committee could be looking at? I know there have been also studies to show that home care can be cheaper than hospital care.

Given all of the changes that are needed in our health care system, which is very complex, involving the provinces, the federal government, regional bodies, municipalities, these changes must be made at a reasonable pace. Over the past few years, the system has been under a great deal of stress to change. An institution is generally better able to absorb the changes and retain what is worthwhile if there is the space and time to absorb those changes.

Senator LeBreton: Mr. Buffett, you say that we desperately need access to research and meaningful data on the whole issue of health and wellness - and I guess you are dealing with private research and U.S.-based research. The last paragraph of your presentation was obviously based on some research, where you talk about the life expectancy of Americans having increased by 30 years.

Is there no research available in Canada to convince the public that proper diet, not smoking, and common sense health management issues are the routes to take?

Mr. Buffett: Absolutely, that type of research exists. Beyond that, both Martin Shain, who you may be familiar with, and Linda Duxbury at Carleton University have done some groundbreaking research in the area of health promotion.

The kind of statistical data and research that we are missing and the obstacle to introducing these programs effectively at the worksite is our inability to demonstrate to the CFO or the CEO of an organization that it makes good economic sense to do this. Hence, what we desperately need is research that clearly demonstrates the cost benefits associated with these interventions.

We have a lot of American data right now that makes it very clear that not only are there savings, but they are very significant. We are looking at organizations like IBM and others claiming that for every $1.00 they spend on disease prevention at the worksite they get a $6.00 return on their investment.

I think there is recognition. The Executive Editor of Fortune magazine wrote an interesting article two years ago about how CEOs would be spinning in their graves because, as we move into the 21st century, wellness and health promotion are what will separate the winners from the losers, that the intellectual capital represented by our employees in the new society becomes an organization's most valuable asset.

Where we are falling down as a country, in my view, based on my experience in Canada and the United States, is in that area of research. There are some organizations that are enlightened, that have said, "Notwithstanding the absence of this research, we know intuitively this makes sense." There are others that have said, "Show me that data." I believe that the federal government has a very significant role to play in that area, and it needs to be identified as an opportunity area.

Senator LeBreton: Yes, it comes down to leadership.

Mr. Buffett: Yes.

Senator Cordy: My first question is for Mr. Robinson. In your presentation, you talked about innovative options in dealing with health care. The whole exercise of this committee is to discover innovative options.

Innovative options can succeed or they can fail, the very nature of being innovative. Inventors have to go through many steps before they reach the final result.

In Canada, how can we look outside the box, in terms of delivery of health care, which, by its very nature, can lead to failure, when we have got health care dollars that are being stretched to the limit at this time?

How can we tell the Canadian public that millions of dollars have been spent on something innovative but it has not worked the way we thought it would? How do we deal with those types of things? I agree with you that we have to look outside the box.

Mr. Robinson: With respect to innovative options - and to pick up on Mr. Allen's presentation, where he discussed evidence-based medicine. Dr. Keon has spoken about the issue of innovative options, something as simple as falls prevention, which is the number one cause of hospital admissions, other than co-morbid or chronic diseases, for seniors in this country. Falls prevention is an example of an innovative option. It is something that can happen in and of itself; it does not need any legislative or policy direction.

In terms of innovation, I think we have to realize, and this is where the Bill 11 fight in Alberta is very instructive. Alberta chewed up a lot of political capital for infinitesimal changes in terms of how they deliver health care.

The beauty of federalism is that it allows us, with 10 provinces, to have a province experiment. To be fair, if it does not work in one province, the moral hazard of that is that the other nine provinces do not implement it. They learn and they do something else.

At the federal level, we need a more interpretive reading of the Canada Health Act, in terms of the spirit as opposed to the letter of the law. Claude Castonguay, the father of medicare in Quebec, told your committee that the innovative co-payment Quebec drug plan violates the Canada Health Act. It falls outside the Canada Health Act. Should it, in the spirit of the act? No. In the letter?Yes. You need to resolve that at the federal level.

Another option is the New Brunswick innovative approach of extramural hospitals, which is basically what they were trying to do in Alberta. They are not ultimate-level-of-care facilities, they are not full hospitals, but they can do minor surgical interventions and have people stay overnight and not be in an acute or tertiary care hospital. That approach is outside the Canada Health Act. It falls within the spirit but not the letter in terms of the funding. We think with some of our principles, in terms of choice and sustainability, those sorts of things can happen.

Let me talk about off balance sheet financing. The Royal Ottawa Health Care Group is currently looking to have - and the government has agreed to this - a private consortium build a hospital and lease it back to the hospital corporation and the ministry.

That approach will allow the private-sector consortium to get a return on its investment over 50 years, 75 years, 90 years, however long the institution will be around and modernized. That innovative approach helps the taxpayer, by spreading the cost of that institution over 50 years or 90 years, but at the same time meets an immediate need for psychiatric and psychogeriatric services in the Ottawa region.

Senator Cordy: Mr. Allen, you said that our health care system is based on the value that all citizens share the risks. If you look at that and interpret that as being that we have the social responsibility for those who are ill and we care for them, I would agree with you. I am not sure that citizens and the health care system have actually looked at wellness in assuming responsibility for their personal health and the health of the citizens.

I would like to talk to you about that, and perhaps Mr. Buffett can also talk about it.

Should we have incentives for citizens and for corporations who are willing to focus on wellness at their worksites or just individuals looking at wellness?

Mr. Allen: No one can predict what their health will be a year from now, two years from now, 15 years from now. I have stopped smoking. I run everyday. I have no idea what disease will befall me or what accident will happen to me.

Surely, there is a societal role and an individual role to take care of ourselves and to know how we can best do that. That issue needs to be in the context of the unpredictability of our health.

I think that is the advantage of sharing the risk in our society.

Senator Cordy: I am aware of the unpredictability of health. We are unable to predict it, but there are certain factors, such as diet, exercise and smoking cessation, that an individual can assume responsibility for.

Mr. Allen: So how would you weigh that? Would you apportion a certain number of health points to people who did not exercise or to people who smoked?

Senator Cordy: I am not sure. I am just wondering if there should be incentives.

Mr. Buffett: I think there is a real risk with incentives in a number of respects.

First, I believe that there will always be those employees who work for organizations that are not as enlightened and who will not engage in those kinds of programs that will entail incentives or the delivery of the kinds of educational information that you are speaking to and, as a result of that, will find themselves in a disadvantaged position as it relates to this.

Getting back to my comment about the data, the real incentive here for Canadians, and not only for employers but individual employees, is improved health.

For employers, we are seeing in the United States, for example, organizations that have absenteeism rates significantly lower than their competitors, the result of which is that they are able to price their goods and services far more competitively.

The best example I can give you here in Canada is Husky Injection Molding Systems Ltd. The average rate of absenteeism for their industry is 9.7 per cent. That particular organization, which is a worldwide entity based here in Canada, now has in excess of 2,000 Canadian employees, primarily at their Bolton operation, and has a rate of absenteeism of 1.2 per cent. The savings are phenomenal. Husky Injection Systems provides on-site naturopathic services. They have two physicians who visit the plant on a regular basis. They have a child care centre. Their enlightened initiatives, frankly, have made them a world-class competitive organization. That is the pay-off.

What we need is more broadly based research that makes the case to convince industry and the private sector that the incentive here is a more productive, healthier workforce, which translates, frankly, into greater profitability.

Mr. Robinson: People have talked about tax credits for companies that put in gyms. Mr. Buffett has articulately made the case that the incentive is a market incentive already, and there does not need to be any government tax policy interference in that regard.

If we walk the tax-credit road for putting in a gym and having a healthy work force, why do we not have a tax credit in terms of social engineering because I held the door open for Senator LeBreton this morning or something like that?

Through the tax code, people cannot be made to be smarter in terms of taking care of themselves.

Senator Cordy: Would the role of the federal government be to provide research data and to educate the public and businesses?

Mr. Buffett: Absolutely.

Mr. Allen: I have seen newspaper articles in the past few months about children and teenagers in Canada and the growing problem of obesity in this country and in the States. You do not change that overnight, but I think there is a role for governments, for schools, our educational system, to address that issue. The amount of time that is spent in front of the television, the computer, the type of food that is eaten, are all habits that cannot be changed overnight.

I think there is a role for the provincial and federal governments to work with the educational system in convincing all of us that good health has a value in and of itself. You may not live longer, but you will feel better.

Senator Keon: I would like to pursue a theme with Mr. Allen and Mr. Robinson and then enter into a discussion with you, Mr. Buffett, about clinical trials and so forth.

Mr. Allen, in the third bullet of your conclusions you say:

We are uncomfortable with the emphasis Vol. 4 gives to market based options.

I believe the tremendous preoccupation in the minds of the Canadian public with tampering with our so-called health care system now is that we have pushed them back to where they were in the 1950s, where they had catastrophic illness and bankruptcy due to medical fees and hospital fees.

If one were able to separate the payer from the provider and the evaluator from both the payer and the provider, would one still have the same objection to private initiatives that could deliver health care services in a more proficient and cost-effective manner and with the same quality control as the public system is doing now? In other words, if we preserve the single payer concept or at least the government responsibility to pay for health care in one way or another for every citizen, and then separate the provider and simply allow government, or whatever supplemental insurance companies exist, the option of going to the lowest bidder who can satisfy the criteria of the evaluator for quality control, would you still object to private people, private organizations providing health care?

Mr. Allen: What we have said is that we are uncomfortable with the thrust or the spirit of volume 4.

In the second paragraph on page 5, we briefly refer to a report that was in The Globe and Mail a couple of weeks ago based on a report by the Alberta Auditor General who said that there is growing potential for conflict of interest in light of increasing private ownership of health care facilities, and he called for more stringent controls on the contracting out of surgical services to prevent senior doctors from diverting public health dollars to clinics in which they have a financial stake.

This is not a discourse or debate about the market system that we are having in the course of these hearings, it is about the appropriate role for the public sector and the private sector in delivering health care. We must ask ourselves: What are the values that underlie health care and care; and what is the appropriate role for the private sector in that health care system?

Henry Mintzberg, who is a management theorist at McGill University, has said on a number of occasions that there are certain things that should be done in the private sector, and be done more effectively, and that there are certain things that should be done in the public sector.

The questions that we would ask are: What are we looking for in altering or changing the health care system? Are we looking to contain the costs? We now spend about 9.3 per cent or 9.4 per cent of our GDP. That is not very different from what we were spending 10 years ago, so do we have a crisis of costs? Is the issue a value-based one such that that there has to be a role for the private sector in the delivery of care to citizens?

How will you measure efficiency if the system changes in that direction? What are we looking for? If we are looking to reduce costs, how will that affect those who work in the system?Those are the kinds of questions we would ask.

Senator Keon: Do you think that your organization would tolerate private sector involvement in the delivery of services, provided they were delivered to the standard of an evaluator that was publicly controlled and provided they were paid for by the single-payer concept at least, the guaranteed payment by government?

Mr. Allen: If it meant that those who are vulnerable, who are poor, who live in poorer regions of the country were not excluded, then we would certainly look at it. I cannot speak on behalf of all the members of the Canadian Council of Churches. If this committee can make a case, a values-based case for the point that you are raising, then it would be unfair for us not to consider that.

Senator Keon: Thank you. Mr. Robinson, what is your view on this?

Mr. Robinson: We believe that, on the issue of payer and provider, the patient needs to be aware of the choices. It can be done through health care savings allowances, through co-payment options, with the appropriate income contingent areas for lower- and lower-middle income people, or through the insurer. We want to see that.

Dr. David Gratzer, in his Donner Prize winning book, Code Blue, makes the point that we have separated and severed that payer-patient-doctor relationship. On a primary care level, yes, that may be so. I see Dr. Rachlis in the room who may disagree with me in another presentation.

To get back to my previous point about the Medisave fund in Singapore and acute care and catastrophic issues, private individuals in Singapore fund that through at-source deductions and it is backed by the government for catastrophic illnesses in the latter years of life. We recognize the limitation of that.

To pick up on Dr. Allen's questions, I talked about the facile public-private or bipolar ideological things that this debate has been minimized to, to the exclusion of all others. I think we need to put back on the table the fact that hospitals in this province are private corporations. They are incorporated under the Ontario Business Corporations Act and under the Ontario Hospitals Act. Those are the two governing pieces of legislation. They are private corporations managed by community trustees as a public trust.

We should also remember that, in terms of this public-private distinction, doctors are private entrepreneurs. They are businessmen. Some may disagree, but I believe that they are business people, businessmen and businesswomen, offering a pre-eminent societal public-good service.

The public-private distinction is not a question of yes or no; it is a question of the appropriate balance and mix. I think that moves the debate onto another plane.

Senator Keon: I noticed that in your presentation you did not deal with the population health and a suitable evaluation of that being done. Can you deal with the concept that any evaluation should be done on the basis of population health, and every move we make should be reflected in a measurable outcome that would improve population health.

Mr. Robinson: We do touch on that in our paper, although we did have time limitations.

The population health concept has been flourishing in this country for almost 30 years since Mr. Lalonde's paper. There was an update of that by Mr. Epp under the Conservative administration, and then by Mr. Rock in the Population Health Directorate which now exists Health Canada.

The factors that you list in volume 1 of your report were brought home to everyone with the issues that were raised in Walkerton and North Battleford. You can have the best hospital system in the world, but if you do not have clean drinking water, good luck.

We say that we are dealing with health care. We would make the point that you, as a committee, must see the health care envelope in the context of population health and how it relates to finance, how it relates to the environment, to the food inspection agency and so on.

We also make the point that you should not focus on cost containment. It was Dr. Fyke, in his submission in Saskatchewan, who pointed out that good quality in health care actually costs less, not more. If you focus on quality and excellence within a population health envelope, we think you can build a very good system.

I am not sure if that answers your question, but we have addressed it and we are aware of the issue.

Senator Keon: It does. Thank you very much.

I will move to you, Mr. Buffett, and then deal with the evaluator portion of the triad, so to speak.

You expressed your frustration with the fact that frequently the information about things we do is just not available. You are one of the senior officials of McMaster University, which is Canada's hotbed of clinical trials. I believe that one of the traps we fall into in science is that, if we cannot prove something statistically, we ignore all the other information that has unfolded over the ages.

In my debates over the years with statisticians and clinical trials experts at the scientific table, when losing arguments I would repeatedly point out that there never was a clinical trial on parachutes before they were used. The army never sent every second soldier out without a parachute to see if they worked.

The same applies to population health. The evidence is absolutely overwhelming that rich people are healthy; poor people are unhealthy. Sometimes I think we are preoccupied with trying to design clinical trials that prove that snow is white.

What do you think would be the ideal evaluation system in Canada? Should it be led by the federal government? Should it be a federal-provincial initiative in concert with the universities? Should the federal government be responsible for quality, and should the evaluators work on contract as private agents? How would you see this whole evaluation system being set up?

Mr. Buffett: My thinking is that the leadership role would be played by the federal government in concert with, in particular, the universities.

In looking at the recent initiatives by the federal government in funding a multitude of research chairs, I wonder if the same mechanism cannot be utilized with a narrower focus specifically directed towards the whole population health worksite wellness milieu.

Senator Keon: Do you not think that you would have to take a broader approach and look at our pockets of population, for example, some of our northern populations?

Mr. Buffett: Absolutely. In responding to your question, I am simply, in the broadest possible sense, trying to indicate where I think the activity must take place. We certainly need to look at some of our more northern groups. There is a phenomenon now that we are recognizing for the first time in a multicultural society, and that is, frankly, people from different ethnic backgrounds respond very differently to health promotion initiatives.

A whole area of learning needs to take place for those of us who are not of a particular ethnicity so that we can identify how we can communicate effectively about health promotion with people who are, for example, from East Asia, because it would be markedly different from how we would communicate with people from South America. A tremendous amount of learning needs to take place, not only about some of our Native peoples who live in remote communities, but also as it applies to that broad mix of people who now comprise the Canadian populace. There must be a far greater degree of sensitivity in delivering this message.

My focus has been, for the most part, on how to utilize that worksite as a means of not only disseminating health promotion related information, but also encouraging people to participate. As I mentioned earlier, there would, potentially, be an enormous payback for the employer. The investment, when viewed against that potential payback, would be rather nominal.

The multicultural nature of most workforces means that we need to be far better equipped to deal with a diverse population. I am married to an East Indian woman, and her response to health prevention and health promotion is markedly different from many of her peers who are native Canadians. There must be a far greater consciousness of that reality.

Senator Robertson: Your oral presentations have been excellent. Unfortunately, we have run out of time. We will study the prepared texts that you have provided to us. Many people now understand that, perhaps, the best delivery of health care is found in the workplace, the community and the schools, that is, where we live, where we work and where we play.

Is there anything that governments, federal and provincial, can do to help encourage the workplace to get involved in these good programs?

Mr. Buffett: We spoke briefly about incentives, and I am not a proponent of incentives. I believe that there are sufficient incentives.

The federal and provincial governments have a role to play in educating the business sector about the financial benefits associated with the delivery of health promotion at the worksite. I never fail to be astounded at how difficult it is to locate or identify anyone in a senior capacity in a Canadian private corporation who thinks in any great depth about the role his organization does or does not play in financing the Canadian health care plan. As you know, in this province, we have an employer tax, and yet the perception is that health care is free.

We do a terrible job of making the point that we all pay for health care through our taxes. We also pay indirectly through such things as payroll taxes. We have little information that will tell us how organization A functions versus organization B, C or D.

One of the questions I would suggest that the federal government in particular must wrestle with is to what extent the government will intervene. I want to stay away from the word "incentives" or any word that would mean "incentive." A tremendous educational role needs to be played by the federal government in encouraging captains of industry to recognize that this is not unlike training.

In the 1960s when I finished university, training was, for want of a better word, a joke. You worked in an organization and they told you they would train you. Of course, you trained yourself or you would not get ahead.

That is where we are today relative to issues such as health promotion. We need to make that organizational commitment to employee health for the simple reason that it makes great business sense. It also makes great sense in terms of preserving our national health care system.

You are aware of these statistics. You know that 35 per cent of the Canadian population are considered to be obese. Over 50 per cent of Canadians live sedentary life-styles. I believe that 35 per cent of working Canadians indicate that they are experiencing severe stress. According to the Roundtable on Mental Health, 20 per cent of Canadians at some point in their life will suffer from depression. In the last month two individuals whom I knew, although somewhat remotely, who were in their 30s, took their own lives. These people who were successful in their careers, for all intents and purposes, and yet, unbeknownst to those of us who associated with them, they were afflicted with depression. They kept it to themselves and, ultimately, they took their lives.

There is an incredible need for the government to play a significant role in educating people about the opportunities that exist for them and for this country, if we can become a healthier nation.

Senator Robertson: Mr. Allen, the council, understandably so, is generally concerned about those people in our country who are poor, who are disadvantaged, and who do not have the benefits enjoyed by a certain other group of people.

There is the concern, rightly expressed by the council, that should changes in the health care system, for instance, require participatory action by citizens, that might hurt those less fortunate people. They may feel that they are receiving a poorer quality of care.

Not that many years ago, universality was a sacred cow in this country. Not that many years ago, and in fact, it was this committee with a different membership, recommended to the federal government that family allowances, money going from the federal government to children, and payments to senior citizens, should be targeted to those who needed the money the most and that it should not be a universal payment. That was the first break in the story of universality. We no longer hear anything about family allowances or pension monies going to those who need it most.

If we could design a health system along those lines, without stigma, and provide health care that ensures certain participation for those who need it most, would that be offensive to the Council?

Mr. Allen: We have hardly made a dent in child poverty in this country since 1989. The fact is that the gap between those who have and those who do not have has grown in this country.

Senator Robertson: I understand that.

Mr. Allen: In looking at what we spend on health care as a percentage of our GDP, we compare favourably with most OECD countries. Some may argue, in fact, we are on the low end of the scale; that we are not spending too much.

If we are concerned about the health and well-being of citizens and communities in this country, then health care is only part of the mix, if you like. I am not an economist, but it may be possible to actually reduce what we spend on health care if we had better social programs. Over the past five or six years, the social programs in many provinces in this country have been eviscerated. Our denominations have more people using out-of-the-cold programs, more people using the food banks, and not just individuals or not just individual males but families.

I think the Committee needs to look at that issue. You must weigh what we spend and where we spend it, to remind all of us that other social programs have an important bearing on our health as individuals and as communities. That, for us, would be fundamental.

Senator Robertson: You are talking about the restructuring of all the social programs. We will deal with that at another time.

The question that this committee has asked on different occasions is: If more money is needed, should it come from the taxpayers in the form of higher taxes or directly from the users of the system through some form of partial payment for the services rendered? How would you respond to that question, Mr. Robinson?

Mr. Robinson: Either way, it will come from the taxpayers who use it.

Senator Robertson: That is right.

Mr. Robinson: The issue for us is that there be a greater individual accountability at the primary care level, if not direct payment, at least an understanding.

Two provinces are now doing point-of-service verification where they are double-checking and auditing, The will ask patients: "Did your doctor do these procedures? Do you know how much they cost?" That is an appropriate step in the right direction.

We think the system is focussed too much on the supply side of the equation and not the demand side of the equation in terms of our utilization of health care.

At the end of the day, there should be greater individual accountability, again, respecting our principles and respecting the issues of low-income needs, access needs and disease-specific extraordinary costs which nobody can afford to pay.

Senator Robertson: Earlier you mentioned the extramural hospital in New Brunswick, that is, working outside of the system. It does not work outside the system, sir. It is registered under the New Brunswick Hospital Act and works in the system. The only thing we removed was the hospital.

Mr. Robinson: I understand that, Senator, but it falls outside the Canada Health Act because New Brunswickers have made the decision to pay for that themselves through their provincial taxes, and CHST transfers do not pay for the extramural hospitals.

Senator Robertson: No, that is wrong.

Mr. Robinson: Mr. Robichaud from the National Advisory Council on Aging, in his presentation to Elsie Wayne's committee - and it is a government-funded commission - has said that the CHST does not fund New Brunswick extramural hospitals.

Senator Robertson: Perhaps that was a very recent change. I will check on that. Thank you.

Senator Callbeck: Mr. Allen, in your brief you talk about accountability of governments, the fact that governments should have to tell the taxpayer how the money is spent. If provincial governments sent out a statement to each person at the end of the year explaining how much that person had cost the system, do you think that would be effective? Would it be worth the effort?

Mr. Allen: I think you will get much better advice on that from other briefs. However, I believe you would need standards across the country so that the same questions are asked and the focus is on the same issues, whether you live in Newfoundland or British Columbia. There should be one standard, in a sense "report card." I do not think is the appropriate term, but you would need standards that the federal government and the provinces could agree on. As to how you would achieve that consensus across those two jurisdictions, is a matter you may want to think about.

There must be some common denominators across the country that would include not only costs but also some standards or data on wellness. Why should citizens in one part of the country not hear about innovations in another province, innovations that have enhanced the care of the individual and the care of the community?

The Chairman: I would thank all of you for coming. As you know, we could have continued for a considerable amount of time.

Senators, our last panel before lunch will consist of Dr. Michael Rachlis, who is one of the most prolific writers and speech-makers, and so on, on health reform issues; Dr. Joel Lexchin from the Medical Reform Group; and Dr. Arif Bhimji from At Work Health Solutions Inc., and he is accompanied by Gery Barry, who is the CEO of Liberty Health.

Dr. Lexchin, I will begin with you. Since we have a lot of questions to ask you, perhaps you would just touch on the highlights in your paper.

Dr. Joel Lexchin, Medical Reform Group: On behalf of the Medical Reform Group, which is a group of about 150 physicians in Ontario, we will make a couple of points that are elaborated on in our brief.

Earlier, I heard Senator Keon asking whether it would be acceptable to ask the public to pay for private delivery. The United States example is an excellent illustration of why that would not be a good choice.

I know that the committee has not been particularly interested in hearing evidence from the United States because they believe that our systems are too divergent. However, I would draw your attention to the dialysis clinics in the United States. All renal dialysis in the United States is paid for under medicare, regardless of the age of the person. About two-thirds of the dialysis is delivered by private facilities; one-third is delivered publicly. A recent study in the New England Journal of Medicine looked at mortality rates in these two sets of clinics and at the referrals for renal transplantation from these two different kinds of clinics. The results show that mortality rates are significantly higher, about 20 per cent higher, in the private clinics, despite the fact that they are being funded publicly. It is the same source of money. They also showed that there is a lower rate of referral for transplantation from the private clinics than from the public clinics. This is only one study that has looked at differences between private and public delivery, but in this case it is particularly apropos because the money comes from the same source. It is public money.

The interpretation is quite simple. Private medical delivery is not as good as public medical delivery. That is a major reason to reject the private delivery of health services.

Earlier, someone was talking about how the Quebec drug plan respects the spirit of the Canada Health Act. Respectfully, I disagree. The figures in volume 4 of your report on the percentage of people who have drug insurance are grossly inaccurate. Not 100 per cent of people in Ontario have drug insurance.

In Quebec, while nominally 100 per cent of people may have drug insurance, given the user fees that are charged in that province to the elderly, which can go up to I believe $750 per year, de facto a large percentage of people there do not receive any benefits from drug insurance. The public-private model of drug insurance delivered in Quebec has been shown to result in significant problems for Quebecers.

A study done out of McGill showed that, after the institution of the Quebec system, hospitalizations, doctors' visits, and visits to emergency departments by people on welfare and people over the age of 65 went up dramatically because they had to pay a user fee. User fees defeat the purpose of drug insurance. If you pay user fees, you will forego the use of necessary drugs and that will make your health worse. That was demonstrated in Quebec.

Finally, the Medical Reform Group has to wonder why it is that volume 4 of your report ignores or downplays the principles in the Canada Health Act and puts forward positions that are more in tune with the American system.

We have to look at whether or not there is a conflict of interest here amongst certain members of the committee, specifically the Chair of the committee, Senator Kirby, with his position on the board of Extendicare. Extendicare is a private delivery system, and volume 4 of the report seems to be in tune with supporting private delivery, private sources of money. We think there is a major problem there too.

The Chairman: Since you raise it, let me make two comments on that.

First, the report is a unanimous report of a dozen people, not just me, including Senator Keon who is, as you well know, in the medical profession; Senator Yves Morin, who is former Dean of Medicine at Laval; Senator Brenda Robertson, who is a former Minister of Health; and Senator Catherine Callbeck, who is a former premier. That is the first point.

The second point is that the document puts forward options. It does not put forward particular solutions. I think you are being unfair to my colleagues. Whatever you want to do with me is your business, but it is unfair to my colleagues for you to take the position that, because of something that I do, this report reflects only the view of one person and not in fact what it is, which is the unanimous view of the committee.

I do not want to debate it with you. I am just responding to your point. Continue.

Dr. Lexchin: Yes, that is fine. I am finished. Thank you.

Dr. Michael M. Rachlis, as an individual: Senators, it is a real pleasure to be given the opportunity to speak to you this morning. I have met some of you previously, and I look forward to renewing my acquaintance with you.

I have given a copy of the outline of my presentation to your staff. I hope you have copies of it. I have also provided a floppy disk with three of my recent papers to which I may refer.

Firstly, I want to make the point that I believe that medicare was the right road to take, although there is a lot of concern that we may have gone on the wrong road. Some people have said that it was a good thing for us to have done years ago when we were young and healthy. Now that we are old and decrepit, we can no longer afford it.

Canada and the U.S. had similar health systems, a similar health status 50 years ago when Tommy Douglas started the road to medicare in Saskatchewan. We were paying similar amounts for our health system at that time. Now Canadians spend 50 per cent less of their GDP on health care. Approximately 42 million Americans have no health insurance whatsoever. Tens of millions have such inadequate coverage that 500,000 declare personal bankruptcy because of health care bills. Canada's infant mortality rate is 30 per cent lower.

Despite the fact that the committee has been at pains to say that you are looking for policies outside the United States, we must remember that there was a fork in the road 50 years ago; and while the rest of Canadian society has become more American in the last 50 years, our health system has actually become more Canadian. That should be a great point of pride, and we should not forget the impact of making that correct decision 50 years ago.

Secondly, the real problem with medicare is not that it is publicly financed or that we rely upon not-for-profit delivery, but rather that it was designed for another time. We first started to debate medicare in this country about 100 years ago. In 1919, Mackenzie King forced the Liberal Party of the day to include medicare in its election platform. God bless you and them, it only took another 47 years before the legislation was passed.

The Chairman: Things move slowly in government, as they do in universities.

Dr. Rachlis: For those who are wondering about that 1997 promise of home care and pharmacare, we only have to wait until 2043, although I hope that your committee will make it happen sooner than that.

The real problem is that we designed medicare for another time - a time when tuberculosis, diphtheria, polio, et cetera, were rife. Accidents and injuries were much more common on a per capita basis than they are now. Even in the last 10 years, tremendous advances have been made which, unfortunately for people awaiting transplants, has meant that there are fewer organs available because trauma is less common.

Our major problem is that we are not coping well with the transition we have made to dealing with, mainly, chronic illness. Our acute care services are some of the best in the world. If you are going to have a serious heart attack or a serious car accident, there is no other place in the world where you should have it than in Canada. God forbid you should have it at all, but if you do have anything serious that requires acute care, you will get as good or better care in Canada than anywhere.

However, our care for chronic illness is anywhere from poor to appalling. Currently, our diabetic control program in Canada is mainly bypass surgery and kidney dialysis. Interestingly, we see good examples of diabetic care - in fact it is the best I have seen in the country - in the Northwest Territories. They started their dialysis program in 1997 with seven patients. My most recent information is that they have three or four now, and this is at a time when, in the rest of the country, the dialysis rate has gone up by over 40 per cent.

The real problem is that we take care of chronic illness so badly that thousands of people die prematurely every year because they need physicians and hospital care.

Another example is hypertension. At best, 30 per cent, probably closer to 20 per cent, of Canadians with high blood pressure have their blood pressure properly controlled. Thousands of Canadians are dying every year simply because of that.

Thirdly, the system is neither too costly nor grossly underfunded. Canada spends about the same proportion of GDP as other wealthy countries. We spend a little bit less than France and Germany, more than Denmark, Norway and Sweden, and much less than the United States, who is wasting a lot of money in their system on overhead costs.

The distribution of costs has changed with the federal government paying much less, the provinces more, and this has limited the federal government's ability to enforce the Canada Health Act.

My fourth point is my major point. We can and are fixing medicare's problems. There are literally thousands of examples of this. If I had a few days with your committee, I believe that I could give you, on paper, solutions to every single problem that you believe we have with access and quality in this country. The political implementation is tricky, but on paper I feel I could solve all these problems. The recommendations to solve these problems have been extant for 20 or 30 years.

I know that the Senate is and has been very concerned about palliative care. Far too many patients in this country with predictable deaths due to cancer are dying in acute care beds or in emergency departments.

In Edmonton, in the midst of a big budget cut, the regional authority developed a comprehensive palliative care program which led to better quality care and lower costs. If this program could be swiftly applied across the country, my back-of-the-envelope calculation is that it would free up roughly 1,800 hospital beds, as many as are found in the entire city of Winnipeg.

Waiting for care is a big problem in this country. Some wait list problems we probably cannot solve without more resources. For example, based on the epidemiology of hip disease in this country, we probably should be doing more hip surgeries. However, the demand for most other procedures is the same now as it was last year; and it will be the same next year as it is this year.

Built-in administrative delays reduce the rapidity of care that can be provided. When we remove these administrative delays, as was done in Sault Ste. Marie, we can reduce waiting times, particularly for cancer care, by 80 per cent plus. In Sault Ste. Marie, simply by going to more centralized booking for procedures, they were able to reduce the median time from mammography to definitive treatment for breast cancer from 107 days to 18 days. It took them only three months to do that. We could do that everywhere across the country. I can go into details as to how this could be done. Almost all the waiting times in this country for cancer care could be slashed by 70 per cent plus, without new resources.

Fifthly, private finance and for-profit delivery would aggravate our problems. Private finance raises overall costs, particularly administrative costs, and tends to injure vulnerable patients. For-profit delivery tends to increase costs, particularly administrative costs, and tends to decrease quality. There are some private for-profit operators in this country who are doing a very good job. On the other hand, I do agree with Dr. Lexchin that the weight of evidence shows that this approach is nothing close to a panacea. Almost all the studies show increased costs; decreased quality.

Given that we could fix medicare's problems within our historic policy framework of public finance and not-for-profit delivery; given that private finance and for-profit delivery would likely make things worse, and given that even most of those who suggest private options claim to share the values of medicare, should we not first implement the proven interventions which would improve quality and access while holding the line on costs? Should that not be the first thing we should do?

I can give you hundreds of examples of what we can do to improve quality within that traditional policy framework and that would not result in increased costs. Should we not first do those things and then see if we really need to go private? I do not think we will have to go private.

I would close my testimony by urging the committee to consider solutions within our traditional value framework of public finance and not-for-profit delivery; and recommend those solutions to the Canadian public instead of those that involve private finance and for-profit delivery.

The Chairman: We will next hear from Dr. Arif Bhimji from Work Health Solutions. With his is Mr. Gery Barry who is the CEO of Liberty Health. Will one or both of you make the presentation?

Dr. Arif Bhimji, President, At Work Health Solutions Inc.: Thank you very much for inviting us to be with you today and to share our perspectives on what has happened to health care in Canada.

First of all, let us introduce ourselves. I am the founder and President of At Work Health Solutions Inc. an independent provider of occupational medical, health and safety and health promotion services based in the Greater Toronto Area. Previously, I was responsible for managing health care initiatives for Magna International's global operations as a vice-president of health services, a position I held for the past nine years. For the past six years, I have also held the position of medical director at Liberty Health, one of Canada's leading health insurance companies. I am a graduate of the University of Saskatchewan with a Doctor of Medicine. I have also completed a Masters in Business Administration and hold an academic posting within the Department of Health Administration at the University of Toronto. In my spare time, I continue to work as an emergency room physician at the South Lake Regional Health Centre in Newmarket.

With me today is Mr. Gery Barry. Mr. Barry has a B.S. in Mathematics, magna cum laude, from the University of Notre Dame and a Master of Science degree in Applied Mathematics from Rutgers University. He is a Fellow of the Society of Actuaries, the life and health actuarial profession's chief credentialing organization for both the U.S. and Canada. In his prominent actuarial career, Mr. Barry has specialized in group pension and group health insurance plans, including 21 years in the U.S. at Aetna's head office and the last five years as president and chief executive officer of Liberty Health, a Canadian-based health insurance and group benefits company here in the Greater Toronto Area.

Liberty Health was initially Ontario Blue Cross, a voluntary, government-subsidized health insurance program established by the Government of Ontario. To date, Liberty Health is the largest supplier of individually purchased supplemental health insurance in Canada. We are also one of the handful of companies competing for major group insurance accounts on a national level.

On the basis of our joint professional expertise in insurance and occupational health, and our practical work experience and personal involvement in a wide variety of Canadian health care forums, we have drawn the following key conclusions that we should like to share with you today.

The most helpful way to think clearly about the health care issues we face is to go back to basics. The key is to examine what we call medicare today precisely for what it is and has always been - a health insurance program. The Canada Health Act did not establish a population health management program, although it has implications for population health.

Though it has implications for the structure of health care delivery, neither did the Canada Health Act establish a program for the delivery of health care. What the Canada Health Act did was to establish an exclusive, government-controlled and operated, universal health insurance program that we affectionately call medicare.

The root cause of the problems we see today is that, as an insurance program, medicare is failing. It is failing simply because it is no longer paying for the full level of benefits which are owed to the group of people it ensures, the Canadian people. The value of the insurance coverage provided by medicare has been diluted to the point of inadequacy. Most people know it and, unfortunately, many directly feel it.

Just how much are we shortchanging the medicare program? What is the actual level of health care being paid for versus what is necessary? We cannot know exactly, but a number of reasonable methods for projecting this, including one that is consistent with what we do to price future health premiums in the private sector, all point to a 20 per cent to a 25 per cent shortfall, or approximately $20 billion worth.

What is the fallout from this? If we are only funding 75 to 80 per cent of the necessary doctor services, hospital services, nurses, labs, and so on, what is happening? The answer is that we are restricting access. Restricted access is the price for inadequate funding, and it is a painful one, particularly in clinical terms.

There are a few telling examples of this. Only 60 per cent of cardiac patients requiring an angiogram get one within the maximum waiting time, and 6 per cent of those who are waiting either have a heart attack or die while they are waiting. An Ontario cancer treatment study has shown that waiting times for cancer treatment in Canada are substantially longer than the time radiation oncologists consider the medically acceptable maximum. On January 2 of last year, 23 of 25 Toronto emergency rooms were closed to all patients, regardless of the severity of their illness. My last example for today is: The waiting lists for joint replacement surgery have grown to such an extent that health system administrators now contemplate a comprehensive registry and program just to manage it.

Restricting access results in rationing of services, employing ad hoc, inconsistent criteria at the local level for deciding who gets care and who does not. This compromises medicare's fairness, equality and equity provisions.

How do we fix this problem? The simple answer is that we need to adequately fund the benefit levels that medicare has always promised. This might not be as impossible as it seems. If Canada were able to sustain our recent year-over-year improvements in productivity levels, government revenues would be able to keep up with the necessary real increases in per capita health care spending and even start making up some of the ground that we have lost over the last decade or so. This would begin to put medicare back on a sound actuarial footing. If we cannot do this, or if we choose not to do this, then we need to redefine medicare's commitment in a way that re-establishes equilibrium between its health care benefit commitments to its citizens and the revenues that it generates.

There are various ways of doing this while preserving universality for medically necessary acute care. Anything short of increased funding or a redefinition as to what the Canada Health Act covers, while it may be helpful, is likely to be of marginal value. This includes things that have already been presented and discussed in the volume 4. I am referring to primary care reform, modest user fees and the like.

From a fairness perspective, we must ensure that Canadians have options for alternate care if we are to continue limiting their access to services and keep on rationing medically necessary care through a publicly funded system.

Are there other sources of funds that can be brought into the picture quickly? Perhaps there are. Employers, in particular, already have a vested interest in health care by virtue of their dependence on employee productivity. While employers are already covering a large portion of the cost for supplemental insurance, there are economic advantages to them in paying for some additional health care services in order to reduce absenteeism and disability costs, and to improve at-work performance.

In many cases, our studies, reviews and reports on the state of the Canadian health care system forget to address the cost to society of lost time from work, morbidity, lost productivity and the loss of quality of life for the 14 million Canadian workers who are unable to access health services and return to work in a timely manner after illness or injury.

These are the true hidden costs of the health system and they by far outweigh the costs of our medical care system, according to research carried out by the federal government. Employer-funded health programs include short-term disability, long-term disability and workers' compensation. These programs cover the majority of Canadian workers and are all provided outside the auspices of the Canada Health Act.

Unfortunately, the closed nature of our current health delivery system means that all individuals must seek care through the publicly funded system which we acknowledge already has capacity restraints. This limitation adds to the productivity shortfall that I spoke of earlier. As the provision of workers' compensation and third party services are not covered by the Canada Health Act, a strong private sector health delivery capacity could be added to take this load off the existing public facilities. Private sector organizations could be encouraged to capitalize existing or new facilities to service the needs of workers specifically. This, in turn, will allow public institutions to service a greater number of Canadians' everyday needs as promised under the Canada Health Act.

By embracing and strengthening the private sector, the public sector will have a complementary available resource to use as it chooses to optimize its own requirements for access and efficiency. The implicit promises of the Canada Health Act can more readily be realized if publicly funded coverage is clearly defined and the private sector is encouraged to service those individuals not covered by the provisions of the Canada Health Act.

I thank you very much for listening. We look forward to your questions.

The Chairman: Dr. Lexchin, would you send us the data on the health care coverage? I say that because when we saw the 100 per cent number in reference to Ontario, we were as surprised as you. Frankly, I cannot at this point remember where the committee researchers or I got it from, but if you have more accurate data on that, it would help us a lot. If you would send that to us, it would be most helpful.

Dr. Rachlis, where in fact waiting line reductions could be made, if they are as simple to do as you say they are, and I have no reason to believe you are not right, why have they not been done? I am always concerned when there seem to be simplistic solutions to complex problems and those solutions have not been implemented. That is my first question.

The other question relates to what you say at the end of your paper. You ask: "$should we not start Medicare's renewal by quickly spreading the best practices across the country?" Again, we would agree with that, which is why we talked about primary care reform. The question that the committee grappled with, as you can tell, is: What happens if that is not enough?

There are two schools of thought. One school of thought says worry about that problem when you get there. Our concern as a committee, and I think we tried to express it reasonably clearly, was that we ought to start thinking now about what we do if it is not enough, rather than waiting until we get to the crisis and discover it is not enough.

Even using our data, let alone Dr. Lexchin's data, it is very clear that there is a growing gap in the safety net with respect to drug costs. One clearly needs consider how you expand the system to at least provide catastrophic drug coverage, if not drug coverage below the catastrophic level. That led us to the conclusion that we ought to think about how to handle the problem if the changes are not enough.

That is the real issue that we grappled with as a committee. If you can enlighten us on both those points, that would be helpful.

Dr. Rachlis: As to your first question about why we have not implemented better wait list management specifically, and other best practice as well, I think there are several reasons for that. The main problem with any of the best practices that I am recommending, some of which have been implemented, relates to providers. Understandably, like many of us, they do not necessarily want to work differently, even if their future work life would be made better. No one wants to change the way they work.

That dovetails with another problem which is that there is not the political support for those changes because the public does not understand these issues. I am embarrassed to say that, up until about a year ago, I did not know specifically about these administrative delays that are inherent in wait lists.

As was recently described in an article in the Canadian Medical Association Journal over the summer and in a previous article in the Canadian Journal of Public Health a year ago, in Ontario, where the situation seems to be the worst in this regard, typically, a woman will have a screening mammogram done in a private radiologist's office. The radiologist will read that mammogram with others. If the test is positive, the radiologist will dictate the findings, which have to be transcribed, and send those to the family doctor's office. There are many dozens of steps along the way.

The family doctor will bring the woman in. Understandably, she will be upset and want a biopsy to be done as soon as possible. It is not until after the biopsy, which can be weeks later or longer, when the family doctor gets the biopsy back, that he or she can then make a referral to the surgeon for definitive surgery. Then the patient has to start in the next line. You have these built-in delays.

However, we could plan on the basis of need. We know that if we do 1,000 mammograms this week 50 or 80 will be positive. Those women will want their biopsies as soon as possible. We could keep 50 slots open next week and fill those slots after the women have had their mammograms.

In a similar fashion, perhaps five or eight of those women will have breast cancer and want their surgery as quickly as possible. We could save five to eight slots the second week so that they would be available. That is how it was done in Sault Ste. Marie.

Why is this not happening everywhere? I presented this information to some senior managers in the health system in the spring, and I have presented it to others. What I have heard back quietly is, "We know we could do some of this stuff, but the present booking of surgical slots depends on the community." In fact, it is almost always done through the Department of Surgery, but in some communities it is very democratic and everybody knows what is going on, including the administration. In other communities, even senior administrators in the hospital do not know how the surgical time is allocated.

To implement this kind of wait list management you must somehow be able to centralize bookings, not for all procedures but some of them. You need not disrupt normal referral patterns, because, in conjunction with the physicians in a community who do breast cancer surgery, you just ensure that you save the number of slots you need that week for women who have had their diagnostic procedures the week before. You do not have to disrupt normal referral patterns.

Administrators may be reluctant to do this because there may already be an ongoing conflict between the administration and the physicians and they do not want to add to it. If there is no public demand, then they will not get into it.

That is my understanding of why we have not implemented this.

Where it has been done, it has worked like magic. I heard last week that Winnipeg has recently started this in their breast cancer surgery, and it works just as I have described in Sault Ste. Marie.

The Chairman: The answer is that it works, but there is the resistance of - let me call it "the system" - the current players in the system, and that is huge.

Dr. Rachlis: There is resistance, as has been documented many times, and that is why I was hoping that your committee would be a leader in the country in highlighting these issues and then getting the political support we need to make these changes.

The Chairman: "Force the changes," is what you are saying?

Dr. Rachlis: There are numerous ways of doing this politically, and again, I know your time is short this morning. If I had a day, I could give you all the examples in the world of how to make this happen politically. Clinical practices need to be changed. You need public policies to support the change in clinical practices, and then you need to have the political process to make sure it happens.

As to your second question about what happens if this is not enough, I am a community medicine physician, and I would try to prevent ethical and policy dilemmas rather than treat them.

On the subject of drugs, I can tell you that I am taking the number one or number two recommended drug for hypertension in this country and in the United States by professional societies. It is hydrochlorothiazide. Almost no one takes it because it is 45 years old. It is off patent. When it is tested head to head with newer drugs, it has fewer side effects, there are fewer drop-outs, and it has more effectiveness. It is prescribed to less than 5 per cent of Canadians with hypertension because the drug companies spent twice as much on marketing as they did on the research and development of it.

The Chairman: "Pushing it" is not the right adjective here.

Dr. Rachlis: I will let you use that word.

Some people with diabetes and congestive heart failure should not take hydrochlorothiazide, but probably at least half of the Canadians with hypertension could be started on this drug and most of them would stay on it. It costs me about $1.00 a year for 12.5 milligrams a day. It costs me less for two years of my medication than what the average Canadian spends for one day of their hypertensive medication.

There are many examples like that. If we simply improved the quality of prescribing, there would be many examples of where you could dramatically improve quality of care and reduce costs at the same time. I think we should spend at least a year or two implementing those kinds of programs. Then we could assess whether we really need more money. If we do need more money, then we can decide whether it should come privately or publicly.

I would favour publicly. If you start to implement the programs that provide better quality and reduce costs, you will get so much more efficiency that you will not have to worry about money. You can just focus on quality. That is what I would like to see.

For me, back to basics means not looking at how we finance the system; it means providing improved quality of care, and as Fyke said, that is almost always less expensive.

Senator Keon: Michael, are you convinced that hydrochlorothiazide is as effective in preventing progressive atherosclerosis as ACE inhibitors?

Dr. Rachlis: We do not have the long-term data on that, and that is why ACE inhibitors would be recommended for patients with congestive heart failure and diabetes.

In the short term, we can see it is at least as effective, if not more effective, than ACE inhibitors in controlling blood pressure. Quite frankly, I am very comforted when I take my pill in the morning that it is a drug that has been out for 45 years because, as you may know, within a few years of new drugs coming out, we often find out about side effects that were not found in the few thousand patients who were given it during clinical trials.

I am very comfortable taking this drug. It is the number one or number two drug recommended by professional societies in the U.S. and Canada.

Senator Keon: Let me start with Dr. Bhimji and bring you back to something that the whole panel will comment on.

The Canada Health Act fundamentally set up a system that placed doctors in hospitals, and as it relates to doctors in hospitals, people are pretty secure. They are pretty well covered, not all, but most of them are.

When you examine it closely, you discover that they are certainly not covered. I have had extensive experience with this in trying to implement prevention programs in cardiovascular disease where there is no funding for it, and your competitor is an American firm that blows into town, gives cooking lessons, hires impressive speakers, and gets people to enrol and pay the fare.

At the other end of the scale, you have the end-of-life and the chronic situations where coverage is just not adequate. Any practising physician will tell you, hopefully, of the difficulties that are being encountered now where people are discharged from hospital; they get some home care; it runs out; and then they have to pay the fare. Many of the chronic institutions are not completely funded.

Should we level the system that is now, fundamentally, 70 per cent publicly funded and 30 per cent privately funded? Should we level the system so that everything is 70 per cent publicly funded and 30 per cent privately funded?

Dr. Bhimji: That is certainly one option that could be made available.

I speak somewhat on behalf of employers when I say that the current system does not work well for employers. Employers are picking up specific costs within the health care system as a whole. For example, 70 per cent of the cost of drugs is paid for privately in Canada and 30 per cent is paid for through public vehicles of various sorts.

If we were to come up with a system that said that we need to share the cost across society as a whole, and that includes workplaces, then I could be fairly supportive of that, provided we define what the contribution will be from each side and what services we can be expected as a result of that contribution.

We must remember, as Mr. Robinson earlier pointed out, that there is only one taxpayer, and in a sense, there is also only one consumer.

It does not matter what scheme we use, but we must ensure that we have adequate funding for the services that we state we are going to provide. That is a basic principle of insurance, regardless of whether that insurance is done from a public sector perspective or a private sector perspective.

As I indicated earlier, the concern that I have with the health care system today is that it is actuarially unsound. It does not fund what it purports to provide to Canadians, and I have given you clear examples of where that failure has occurred.

The Chairman: That is in part, though, because people in public life always talk about our publicly funded health care system when what we really have is a publicly funded hospital and doctor system. The terminology that is classically used is not descriptive of what the system really is.

Dr. Bhimji: Ultimately, it comes down to how many dollars there are and what those dollars will be used for. I have no disagreement with Dr. Rachlis' ideas of introducing further efficiencies to the system. However, I do believe that the system is underfunded, based on our expectations as Canadians as to what our health care system is to provide.

That is what we should be focussing on, not the 9 per cent that is being spent out of GDP or the like. We must decide what services we want; what services will be covered; and who will cover them, private sector or public sector. Then we must ensure that there is an alternative for those services that we choose not to provide in a publicly funded system.

Senator Keon: Michael, before you address this, let me broaden the situation a little for you.

In my own life as an administrator, one of the frustrations I have encountered is, because we have a salaried staff at the Heart Institute, I could always introduce new programs because it did not impact on physicians' incomes. When we would go extramural, we were scuppered because it takes years to get others on the billing system for OHIP. There was simply no way of dealing with this.

Let me present you with a double-edged sword here. I would ask you first to address the question I asked of Dr. Bhimji and then to address this whole issue of physician remuneration as it relates to progress and how we can overcome this tremendous barrier we have to progress right now.

Dr. Rachlis: The first question I will answer briefly so I can spend a little more time on your second question.

To reiterate what I said earlier about public payment, I think that it is more efficient, it reduces overheads, and it is more equitable. It seems to me that, rather than looking at introducing private payment for hospitals and physicians' services, we should be looking at the 1997 promise made by Mr. Chrétien that we would move to home care and pharmacare being publicly funded. The same advantages would pertain there.

As Dr. Lexchin has pointed out, the examples we have in Canada with mixed public-private drug coverage such as in Quebec indicate that that move seems to have resulted in thousands of extra hospital admissions and probably some deaths. It does not look like as if that is a profitable way to go.

In general, I believe that the advantages of public payment mean that we should be moving towards more public coverage.

In terms of how we do this logistically, I do not recall the details from Malcolm Taylor's book - although I could look them up just as your staff might - but as I recall that, when we moved to hospital insurance in this country and then medical insurance, because most large firms were paying for coverage for their workers, there was a tax adjustment situation. When we moved to more public payment, some increased taxes went along with it.

Although I certainly would not speak for large employers in this country, I think that many of them would likely be interested in some trade-off, because most large employers are probably paying more now for direct benefits for their workers than what they may pay if they have to pay increased taxes to support a government plan.

Typically, in these kinds of situations, it is the small employers, who are not paying benefits, who are caught in a squeeze. In the U.S., in fact, they have been major opponents to public coverage for that reason.

On your second question, Dr. Keon, regarding physician payment, I feel strongly that, if we are to move to many of the new delivery models that people have been talking about for decades, we have to look at a change of the physician remuneration to make the rest of the programs work better, not just for its own purpose. There are two reasons for that.

One is that you just cannot run certain programs when physicians are mainly on fee for service. For example, over the last 10 years we have had clear evidence from the diabetes care and control trial, a U.K. diabetes study, and other diabetes control experiments which indicates that, if we move to a model of diabetes care where the patient's usual point of contact is a nurse who is then backed up by physicians and dieticians and others in a multidisciplinary team, just like the diabetic clinics that we have in many Canadian cities these days that serve a very small minority of diabetic patients, you will get better monitoring. Consequently, there will be dramatic reductions in the rate of kidney failure and other complications.

Physicians working in those kinds of programs they mainly play a consultative role and they receive alternate payment. We cannot move to where we need to go, particularly for the management of chronic illness, unless physicians are paid differently.

The second reason to support changes in physician payment is because the fee-for-service system for physicians is extremely unfair to doctors. We have a situation where the Canadian public thinks that medicare is the height of an example of Canadian fairness, and that we are different from our American cousins because of how much we care. It is true that, compared to Americans, Canadians of all income classes get some of the best quality health care in the world.

For physicians paid on fee-for-service, the best doctors make the least money and the worst doctors make the most money. In Ontario, a family physician can work 70 hours a week doing all the right things, spending long appointments with patients, making long calls, and that physician would never net $100,000 a year. That is the reality.

That doctor looks across the hall and sees another family physician only working 9:00 to 5:00, seeing 60 patients, 80 patients, or even more. In New Brunswick studies have shown that some doctors see over 100 people a day. That doctor may provide very bad care and generate high costs for the system but, in Ontario, that doctor would net $250,000 or $300,000 a year, two and a half to three times what his conscientious colleague would net.

A major problem we face in Canada now is that Canadian physicians see the medicare system as corrupt because it rewards bad medical practice, and of course, even within specialties, there are tremendous disparities. Of course, within medicine, people have tried to address these disparity issues. Typically, the potential losers, the sub-specialist surgeons in particular - not cardiovascular surgeons, I should say - ear, nose and throat doctors and ophthalmologists and others will fight these changes to the death. The doctors who would benefit will not fight hard.

As most of you will know, in Ontario, Dr. John Wade spent two and a half years writing an excellent report. Now, like so many others, that report will be put on the shelf to gather dust because it could not correct the disparities.

Canadians do not know how the present perverse incentives for physicians reduce the quality of care being provided and result in thousands of Canadians losing their lives every year because of the poor management of chronic illness. They do not realize that many doctors are treated unfairly by the payment system. I would like to see this committee bring these issues to the attention of the public and, hopefully, galvanize some public opinion that will lead to change.

Senator Keon: Dr. Lexchin, would you care to address that issue?

Dr. Lexchin: I would be happy to do that.

With regard to the 70-30 split, I would point out that the 70 per cent public funding by Canada puts us at the low end of the OECD average. Public funding in European countries, by and large, is much higher as a percentage of overall health care spending. In fact, in Denmark I believe it is up around 92 per cent.

The Chairman: Am I correct that OECD countries also cover more?

Dr. Lexchin: They do cover more services and, with a couple of exceptions, they spend less of their GDP on health.

We have to question whether our system is underfunded. What does that say about the European systems? If we are considering spreading the public-private split over the range of services, then before we start that one of the things we need to do is raise the percentage of public funding. Somebody said that we must remember that there is only one taxpayer. I agree with that but, when you start to add in private funding for health services, you must ask: Who actually pays the money?

The more you have a public system of funding through taxation, the more it is progressive. In other words, the people who have the most money pay, and the people who need the services the most who, generally speaking, are the poor, benefit from that. When you start throwing in user fees and private funding, then the poor people start to pay more for their health services because they are the heavier users.

When talking about a single taxpayer, you have to consider how you will distribute the money. A public system is the most efficient and the most equitable way of distributing the money.

I have done some work in the area of pharmacare. Using 1996 figures for prescription drugs, we were paying about $6.6 billion or $6.7 billion a year in 1996 for prescription drugs. That does not include dispensing fees, markups, et cetera. If you went to an all-public system, yes, the public would be spending more, probably about $3.1 billion more than we are now, but we would end up saving around $600 million per year on prescription drug costs.

Those efficiencies would be realized in two ways: First, there would be lower administrative costs. The figures I have seen suggest that private insurance companies are spending about 8 per cent of the dollar on administrative costs versus 2 per cent in systems such as the Ontario Drug Benefits Program. There would be a saving of about $100 million per year on administrative costs. You would also save money because you would have a monopsony buyer.

To illustrate that, consider the difference between drug costs in Canada and in Australia. Both countries have roughly similar economic systems. Both countries have roughly similar health care systems. In 1993 or 1994, the average price for drugs in Australia was 30 per cent below the OECD average; in Canada it was about 30 per cent above the OECD average. That difference was largely in favour of Australia because of their position as a monopsony buyer. They had a single drug plan for the entire country and, as a result, they were able to reduce drug costs.

The Chairman: That is why one of our options is a national formulary. Would you agree with that?

Dr. Lexchin: I would agree with that, yes.

As regard to how physicians are to be paid, again drawing from the area of prescribing, there is some evidence to indicate that doctors who are not on fee for service are better prescribers than physicians who are on fee for service.

I agree with Michael that moving off of a fee-for-service system would be beneficial in terms of quality of care. You can deliver better quality of care, I believe, through other methods of payment than you can through fee for service.

Senator Cordy: Dr. Lexchin, you mentioned surveys that had been done. Can you provide us with that data?

Dr. Lexchin: Which survey?

Senator Cordy: I am referring to surveys of Canadians who support the principle of increased general taxes rather than user fees.

Dr. Lexchin: I will try to get that.

The Chairman: We may have mentioned that in our first report. I have certainly mention of such surveys in the newspapers. If you have something else you can provide to us, Joel, that would be helpful.

Senator Robertson: When you are talking about moving from fee for service to salaried positions, how long would it take us?

I understand very well what you are saying about some physicians seeing patients for five minutes and rushing on to another one. How long would it take us to train a sufficient number of physicians so that there could be a better time ratio, a better care component, a better relationship between the physician and the patient?

Dr. Rachlis: Are you asking how long it would take to train the physicians to work in this model?

Senator Robertson: No.

In some parts of the country you cannot find a family physician. If you are lucky enough to have a family physician, he or she squeezes you in for a three or four minute consultation. If the physician does that all day long and into the early evening, then his or her income can be sizable. Conversely, the patient who is seen in a normal time ratio is provided with very good medical care. If there are not enough doctors to go around, how long will it take us to catch up so that we have an adequate supply of physicians?

Dr. Rachlis: If we do not change the way we pay doctors and the way that they provide health care, family doctors in particular, we will never have enough.

I, respectfully, strongly disagree with the Canadian College of Physicians and Surgeons report last week which stated that we are 3,000 short. Dr. Ben Chan, from the Institute for Clinical Evaluative Sciences in Toronto at Sunnybrook Hospital, did a good survey about two years ago where he found that, in just six years, between 1991 and 1997, there was a 55 per cent relative increase in the proportion of Ontario family doctors who did no care outside their offices; that is no hospital care, no nursing home care, no obstetrics, no emergency work, et cetera.

The number of family doctors per capita in this country has gone down by about 4 per cent in the last decade, although it is going back up again now. The number of family doctors has not changed much, but what has changed dramatically is that family physicians are finally responding to those perverse incentives. It is not strange that so many family physicians practice that revolving-door type of practice.

The real mystery is why there are so many dedicated Canadian family doctors still providing comprehensive care despite the financial penalties and the penalties to their personal life, given that we have approximately one full-time equivalent family physician for every 1,400 people in this country. We do not know the exact numbers of course, but I can point to numerous examples where one family physician working as part of an interdisciplinary team can manage 2,000 patients or more.

The best example of that is Dr. Tony Hamilton in Beechy, Saskatchewan, north of Swift Current. When the other family doctor in the community left, he was skeptical of working more closely with nurses, but he gave it a try. Now he is working with three advanced clinical nurses and the other home care and mental health staff as part of the District Authority, and between all of them, they are managing 4,000 patients. That is one family doctor. They also have a diabetic registry in their program. They provide good quality care. If every doctor in this country worked like Dr. Tony Hamilton, there would be an excess of 10,000 family doctors in this country.

The solution to the problem is not to find more doctors to work in this terribly inefficient system, the solution is to change the system. I think that most family doctors would find those new practices much more professionally rewarding.

Senator Robertson: It is that thrust to a multidisciplinary practice that is so important.

Dr. Rachlis: Of course. We also need specialists to work differently. They have to be much more consultants to the primary health care team, and to integrate their expertise into that practice. Then we might easily find that the number of specialists we have is more than adequate to provide us with great health care.

The flipside of that is, without changing the way we pay doctors, without having them work in a team, as Dr. Keon was describing within his Heart Institute, we could add 30,000 doctors to the Canadian complement and we would still have many gaps in services.

Senator Robertson: Thank you for reinforcing that.

The Chairman: Just to echo your point, last week we heard evidence - and I cannot remember if the number is 195 or 295 - that there are either 195 or 295 fully trained, fully licensed nurse practitioners in Ontario who are unable to practice because of scope-of-practice rules. That absolutely confirms, in terms of a specific number, everything you said.

Dr. Rachlis: I think that Ontario has some of the most progressive legislation to allow nurse practitioners to work.

The real issue is, rather, that the Ontario government, because of some strategy on primary health care reform, has not insisted on the use of interdisciplinary teams.

As you will hear this afternoon from Mr. Gary O'Connor, there are upwards of 50 Ontario communities who would like an interdisciplinary community health centre, but the Ontario government is not responding to that. Many of us are very concerned that their primary health care strategy will not work for patients, and that it will not work very well for doctors.

The Chairman: Thank you all for coming.

The committee suspended its proceedings.

The committee resumed.

The Deputy Chairman: Senators, our first witnesses of the afternoon are from the Consumers' Association of Canada and the Ontario Association of Optometrists. I would like to welcome Jean Jones, Chair of the Health Committee of the Consumers' Association of Canada; Mel Fruitman, President of the Consumers' Association of Canada; and Dr. Joseph Chan, President of the Ontario Association of Optometrists.

Mr. Mel Fruitman, President, Consumers' Association of Canada: Thank you for inviting the Consumers' Association of Canada to appear before this committee to contribute our consumer views to your study of Canada's health care system.

The CAC is a 52-year-old independent, not-for-profit volunteer-based organization with a national office in Ottawa and provincial and territorial branches. Our mandate is to inform and educate consumers on marketplace issues, to advocate for consumers with government and industry and to work with government and industry to solve marketplace problems in beneficial ways.

CAC focusses its work in the areas of health, food, trade, standards, financial services, communication services and other marketplace issues as they emerge.

All of our policies on specific issues are framed within a set of general consumer-oriented principles. Eight such principles govern consumer associations worldwide. Among these principles are the right to choice, safety, information and a healthy environment. The attached CAC "Policy Statement on Consumers and Health Care" is based on these principles.

For more than a decade, delegates at our annual general meeting have identified health care as a priority consumer issue to be addressed by the association in the coming year. Each year the issue presents a more critical challenge.

Ms Jean Jones, Chair of the Health Committee, Consumers' Association of Canada: In 2001, CAC consumers give the highest prioity for action to the inclusion of home care and pharmacare within the parameters of the Canada Health Act. The shift of necessary treatment and care from the insured hospital setting to the uninsured community setting has placed a heavy - often overwhelming - financial burden on the individuals and their families at a time of great vulnerability due to lost income of a patient and/or the family caregiver at the stressful time of coping with the illness.

It is recognized that in many instances home care is the preferred or feasible option only because of the availability of drug treatment that can be administered outside a hospital. This dependence of the home care option on the accessibility of drugs demonstrates the urgent need for a pharmacare program to be put in place concurrently, in order for home care to provide the required level of health care at the time needed.

One successful aspect of the British health care system has been the provision of both home care and pharmacare within the public health system.

Certainly, the introduction of publicly insured home care and pharmacare programs would have cost implications for the health care systems, yet over time could prove cost-efficient by expediting the movement of patients through the expensive hospital system, thereby reducing waiting lists and pressure for expansion of high cost facilities.

From a consumer point of view, the major flaw in the government's initiatives in closing hospitals and beds over the past decades has been the failure to have an adequate home care program in place prior to undertaking the downsizing. Costly bottlenecks and waiting lists have been the consequences.

Now, our next comments will focus on matters raised in your report.

The role of the federal government: Consumers emphasize the federal role in health protection and place high value on its responsibility to provide thorough, expert assessment of the safety of both drugs and medical devices before they come on the market and also to monitor their safety record while they are in use. Consumers also expect a strong role for the federal government in the development of standards to ensure a healthy environment and safe drinking water across the country.

Primary care reform: Consumers concur with the report's definition of the need for changes in the practice of primary care. Success in shifting treatment and care from hospitals to the community and to the home depends on structural changes that would provide 24-hour seven-day-a-week professionalconsultation services to consumers.

Delivery of primary care by community health clinics and health service organizations are meeting these needs of consumers in some communities by providing easy access to the services of other more appropriate health professionals as well as physicians. However, lack of timely access to needed health services and waiting lists continue to be experienced universally.

With regard to the Canada Health Act, consumers continue to strongly support the principles contained in the act and would like to see the political will to apply rigid consequences to those who do not follow the principles.

There is also support for a stronger role for the federal government in setting national standards, both measurable and accountable, allocating resources for comprehensiveness and equity, and monitoring accountability to report back to the taxpayer/consumer.

As long as the provinces deliver the services, they need to be pressured to deliver the services consistently across the country and ensure their accessibility to all Canadians and be accountable for the performance of their responsibilities.

In the report's discussion of the prohibition of extra billing, the fairness of "preventing individuals from purchasing the service" is questioned. Critics of extra billing - and certainly CAC is one - however, see the transaction as the purchase of the privilege of gaining access to service when payment of the service itself is charged to medicare. There is no constraint preventing individuals from purchasing the service when the transaction is entirely independent of the medicare program.

In considering the pros and cons of a privately funded system parallel to medicare, consumers look to the example of such a situation in Britain and see the deep erosion of the public system capacity and waiting lists that are far longer than those in Canada.

Another example of the deleterious impact on consumers of alternate private payment for a publicly provided service appears in the Alberta CAC's "Canary" report. This report documents the longer waiting lists for cataract treatment provided under the public system in cities where alternate private public payment systems were available from the same physicians.

In contrast, an example of the positive impact on consumers of improved management within the system is demonstrated in the reduced waiting lists for cardiac care after the Cardiac Registry was introduced in Ontario.

It is certainly apparent that there are already aspects of a two-tier system already existing in Canada. Consider the disparate situations of one worker who is injured at work and his neighbour, also in the work force and similarly injured at home. The first worker is likely to receive accelerated access to treatment and rehabilitation services due to the purchase arrangements that the Workmen's Compensation Boards may make.

The consumer who understands how the system works does have an advantage in accessing its services and provides the rationale for the constant efforts of the CAC to promote ways of informing consumers about their rights in health care and how to exercise them.

On the subject of financing, it has been disappointing that the report, once again, is suggesting consideration of user fees at point of use as part of the financing solution - particularly in view of the repeated studies that have documented the negative impact on the economically vulnerable seniors and low income earners in limiting their use of necessary health services. As yet, CAC has found no convincing evidence on the merits of user fees to consider changing its long-standing position that rejects user fees in the medicare system.

Suggestions in the report that mechanisms are needed to make the individual aware of the cost of their care to medicare are consistent with the proposals of the CAC in the early 1970s that consumers receive statements of expenditures on their behalf by medicare. Such a procedure would also allow the individual to monitor that he has received the services that were billed to medicare, thus providing one measure of accountability for charged items.

The prohibitive cost of implementing such a procedure and the hospital systems' inability to assign individual costs were reasons given at the time for rejecting the proposal. They may still be valid objections if, even in the present computerized systems, the administrative costs remain high in relation to the benefits.

The options that are suggested in the report for reducing drug costs - namely, a national drug formulary, which required use of least-cost therapeutically equivalent effective drugs andmaintaining current prohibition of direct-to-consumer advertising of prescription drugs - are all strongly consistent with established CAC policies.

Further suggestions from consumers to reduce the increasing costs of drugs include: Assessment of the cost effectiveness as a component of the new drug approval process; an effective post-market surveillance of drug performances to identify drugs having adverse side effects that require treatment in the emergency room or a visit to a physician or hospitalisation - all of which add cost to the system; expedite the approval process for lower priced bio-equivalent generic drugs to enter the market; and stronger monitoring of advertising of over-the-counter drugs.

With respect to research, consumers recognize the importance of the federal government's role in providing adequate funding for research and its responsibility to regain its position as the dominant funding source for health research to ensure that the research is directed to issues of public interest. Consumers appreciate research that contributes to the reduction of social and economic costs for either the individual or the health care system.

Consumers also see the need for an "awareness campaign to inform Canadians about, for example, genetics research, animal cloning and embryo research," as suggested in the report. It is of utmost concern for consumers that the campaign be undertaken by an unbiased, credible organization that is adequately resourced and accountable for its public funding.

CAC has long contended that consumers need to be fully informed to participate in their decision-making on health issues affecting them individually or collectively.

Thank you for your attention, and we look forward to discussing these issues with you.

Dr. Joseph Chan, President, Ontario Association ofOptometrists: Madam chair, senators, on behalf of the Ontario Association of Optometrists, I extend our deepest gratitude for this opportunity to speak to you today.

We are pleased to be able to offer you our perspective on this national debate on health care delivery in Canada.

The Ontario Association of Optometrists, OAO, is aprofessional association representing the over 1,000 optometrists who practice in Ontario. Optometrists are widely regarded as the primary eye care provider in this province. In this position, we have a unique perspective on eye and vision care delivery in Ontario.

In our presentation today, I hope to touch on several key issues discussed in Volume 4 of your committee's report, which have particular significance for optometrists and the patients that we serve.

The OAO joins the committee in their support of the patient-oriented principles espoused in the Canada Health Act, namely, universality, accessibility, comprehensiveness andportability.

We also support the concept of a patient "bill of rights" to further define these values. Notwithstanding our support for these principles, we believe that changes are both necessary and possible within this framework.

We strongly agree with the suggestion put forward by the 1997 National Forum on Health that said "public coverage should be refocused to follow the care and not the site." To this, we would add that public coverage should be focussed on the service, not on the provider.

The OAO believes that the current statutory provisions in the Canada Health Act are obstacles to the use of non-physician services by virtue of their exclusion. In other words, funding seems biased towards physicians and hospitals.

We would support amending the Canada Health Act to redefine "medically necessary" services to include those services deemed necessary for the continued or improved health of the patient, regardless of the provider.

With respect to primary eye care, inter-provincial differences in the coverage of optometric diagnostic services have led to limitations in patient access to optometric care. Certain provinces do not have coverage for all medically necessary services provided by optometrists. Instead, patients are channelled to utilize insured specialists and institutions for the delivery of primary eye care services, which could have been provided more cost effectively, more locally and usually more quickly by optometrists.

Optometrists are more widely distributed geographically and have the appropriate training, equipment and experience to provide these health necessary services. Having optometrists provide the insured services would ease the burden that is now being placed on emergency rooms, ophthalmologists and family physicians, and on the patients themselves who have to travel or wait in discomfort to obtain the service from an insured provider.

In your most recent report, you recognize that health services are often not coordinated, nor are they provided by the most appropriate practitioner. The knowledge and skills of many practitioners are not being fully utilized. This is particularly true for optometrists.

For example, the ability of optometrists to prescribe drugs for the treatment of eye disease is not equal in all provinces and territories. Although optometrists are fully trained inpharmacology and in the appropriate use of therapeuticmedications for treatment of eye disease, only five provinces and one territory have currently authorized optometrists to provide these services.

The four patient-oriented principles articulated by this committee are compromised in the more restrictive provinces - including Ontario - since patients do not have access to the same level of care. In Ontario, patients get a referral to obtain a written prescription, resulting in extra expense to the system and delays in treatment.

For the most effective use of resources, each health care provider should be permitted to work at his or her highest level of recognized professional training. We encourage the Senate to make it a priority to encourage provincial governments to enact the necessary changes so that practitioners can provide their full scope of practice.

In addition, the OAO supports the committee's suggestion that there be a move away from the hierarchical structure that exists and move towards the "spectrum" approach where all health care providers are recognized for their strengths and more properly valued and deployed. Coupled with this, the OAO believes that long-term health resource planning needs to be undertaken on a national level with global consideration.

With regard to future planning for health care delivery, we support the Senate committee's concept of primary care reform. The reform will embody the following principles: it iscoordinated; accessible to all consumers; is provided by health care professionals who has the right skills to meet the needs individuals and the communities being served; and is accountable to the local citizens through community governance.

As we move forward on these reforms, though, it is important to ensure that health care providers are paid fairly for their efforts. While funding may be rationalized, efficiencies should not be achieved at the providers' expense. Adequate funding is critical to sustain the system and to encourage the graduation and retention of new practitioners to our country.

The OAO also recognizes the unique challenges related to providing health care to our Aboriginal population. This group is particularly at risk for many sight-threatening eye diseases, such as diabetic retinopathy.

The OAO recognizes that there is an unmet need for services and is prepared to work with the population health strategies aimed at providing a more multidisciplinary coordinated approach to reach this group.

In summary, the OAO has made eight recommendations. First, that the services, not providers or locations be funded. Second, that bias in the definitions of insured services, which restrict accessibility, be removed. Third, that all barriers to creative and efficient delivery of health services be removed. Fourth, that the use of non-physician health care providers be encouraged, particularly where it can be shown to be cost effective and such action would enhance accessibility and reduce waiting times. Fifth, that the knowledge and skills of health care providers be fully utilized. Sixth, that a "spectrum" approach to health human resources planning be adopted. Seventh, that primary care reform includes the coordination and integration of non-physician providers, and finally, that the federal government has an obligation to increase funding for, and coordinate the delivery of, eye care services to Aboriginal people in Canada.

Thank you for this opportunity to share our thoughts on these important issues.

Your committee has an enormous task, but by facilitating this meaningful discussion on health care in Canada, your efforts can already be considered a success.

The Deputy Chairman: I would like to clarify one pointMs Jones. We are not suggesting user fees in this committee. User fees were on the table as a consideration. I just did not want the record to suggest that we were suggesting user fees as a committee. We are not.

We cannot address this issue without putting everything on the table for discussion, and that is how we approached it.

Senator Callbeck: Dr. Chan, you mentioned that in five provinces optometrists can write prescriptions. What is the reason given in the other provinces why they cannot?

Dr. Chan: At this particular point, just for information, all U.S. States also allow optometrists to provide prescriptions.

In many of the other provinces, this movement towards authorizing optometrists to write prescriptions has only occurred in the last three to five years.

Currently, in Ontario the Ontario Association of Optometrists has a proposal in front of the government, and we are moving forward with the Ministry of Health to try to allow that to happen in Ontario as well.

I do not think there is any specific reason why it has not occurred. I think it is partially due to the political process in each of the provinces.

Senator Callbeck: What are the five provinces?

Dr. Chan: The five provinces are Alberta, Saskatchewan, Quebec, New Brunswick and Nova Scotia, and the one territory is the Yukon.

Senator Callbeck: I have a couple things marked here on the Consumers' Association of Canada brief.

You mentioned about the workers getting preferred treatment under the Workers' Compensation Board. I take it you do not agree with that?

Ms Jones: Well, it is a little hard for us to understand. If the goal is to get the worker back to work as soon as possible, why is the worker who is injured at home not eligible for the same care as the worker with a similar injury because he is at work? There seems to be a disparity there when we claim that equity in the health care system is one of the fundamental principles.

Senator Callbeck: I do not disagree with you. I just wanted to confirm your position.

You also suggested that consumers receive statements of expenditure on behalf of medicare. Do you have any evidence of where this has been done that it has really been beneficial to do so?

Ms Jones: I cannot. I am trying to think back to the 1970s when we were preparing our proposals, whether we had any examples then or not. Mr. Fruitman is telling me that apparently there is some reporting of this in Alberta, but I think that is quite recent.

Senator Callbeck: I believe that Saskatchewan did it at one time. I do not know why they did not continue it.

Ms Jones: That was my impression about the Alberta situation also - that it had been discontinued because the high administrative costs are a consideration.

Senator Callbeck: With respect to suggestions from consumers to reduce increasing costs of drugs, one of the things you say here is "stronger monitoring of advertising over-the-counter drugs." Would you please elaborate on that?

Ms Jones: That there be clear indication of potential side effects in relation to the over-the-counter drugs, because when consumers are taking over-the-counter drugs, they do not have the benefit of the professional advising them. Therefore, theinformation has to be all there.

In a review of advertising, we found an imbalance between the claims of efficacy and the reporting of possible side effects as well as alerting consumers to the adverse consequences of the medication if it is taken with certain other medications.

There has been a long effort on the part of CAC to get full, informative labelling on OTC drugs.

Senator Callbeck: In other words, you feel that in certain situations, if consumers had the proper information, they would not be buying the drug and that would reduce the cost of drugs?

Ms Jones: Right. In addition, as we mentioned earlier, adverse side effects could mean a costly hospitalization and, at a minimum, a pretty miserable feeling consumer.

The Deputy Chairman: I have a quick supplementary to Senator Callbeck in regard to a point on which we heard testimony earlier today

Has the Consumers' Association of Canada actually looked at this notion of consumers receiving statements of expenditures in view of the new technologies? We can get gas bills now and bills that are itemized and broken down, and I am just wondering if the Consumers' Association has taken a look at that again?

Ms Jones: Well, we have not again, but that is why we are rather tentative in promoting the idea that this could be an answer.

I believe that, had it been introduced back when we were suggesting it in the 1970s, the system would have adapted to that and it would no longer be a costly administrative problem. It should be explored again.

The Deputy Chairman: The assumption appears to be that because it did not appear to work then that it would not work now. I do not think that is a proper assumption.

Ms Jones: No. We are suggesting is that there needs to be reconsideration in view of the computerized systems.

The Deputy Chairman: It would also inform the public that health care is not free.

Ms Jones: That is one important aspect. As well, the benefits payer could be certain that the service for which a reimbursement is requested has been provided.

There is the recent situation in Ontario where the consumer had great difficulty in conveying that the physician had billed for services extensively that he had not received.

The Deputy Chairman: Exactly, thank you.

Senator Robertson: With respect to your concern about the improper use of drugs, I expect that re-emphasizes the importance of moving to an interdisciplinary approach to the consumer.

It would seem that the pharmacist is probably one of the most important keys to giving advice about medications. It appears that many medical doctors - especially the family doctors - do not seem to have the time to explain the side effects. I think we will have to look at that very carefully.

I would like to move to another concern that some of us have had for some time. Has your Consumers' Association done an appraisal at any time about the quality of assessment of new pharmaceuticals by the Department of Health? There seems to be a lengthy period in comparison to some other jurisdictions, that the approval of some of these drugs is done in a circuitous manner, although we certainly want to make sure it is done well.

From time to time there seems to be evidence that perhaps that division of the Department of Health needs a little shaking down - not for speed, in particular, but for the type of testing that they do.

It is difficult, we know, to keep up with the most up-to-date developments in the testing and in the approval of drugs. I am not sure if those departmental people have the opportunity for continual additional training to maintain a level of confidence that the Canadian people demand.

Ms Jones: The Consumers' Association of Canada has not done a particular study on that, however we were engaged when there were hearings on the transition process and the changes within the former Health Protection Branch.

We got a reading from consumers at that point that there was lack of confidence. I think it is time again to review whether the changes and the increased resources to the assessment program have really made a difference.

The most impressive finding that we heard from consumers at that time was the lack of confidence. The CAC has taken the position that the emphasis within the assessment process should be on safety, not on expediting the approval. We are aware that there are consumer groups with specific diagnostic problems that are pressing hard for early approval of new drugs. However, our approach has been that we cannot sacrifice safety for the speed in approval.

There is also considerable awareness by consumers that the faster the new drug is on the market, the more profits for the pharmaceutical company. They are also aware that this can be added cost to the system.

We need to have close assessment that the effectiveness of the new drug surpasses that of the similar type drugs that are on the market, because in too many instances consumers in Canada are paying for their drugs out of their own pocket. They are very aware of those costs; that is why we have so many suggestions on how to reduce them.

Senator Robertson: If we could move to a decent pharmacare program so that the consumer would not be hit with these excessive costs, and if we could move to coverage for community and home care rather than in the hotel-type hospital, it would make a significant difference.

Do you believe we could do that within the existing framework of the Canada Health Act? How do we pay for it?

Do you believe we could make sufficient savings by better design delivery to help pay for those programs? Or do you believe that Canadians would have to come around to some form of - I do not like the word "user fees" - a participatory process for certain levels of income?

Our governments are saying they have no more money and that they cannot increase dramatically to the system. I suppose a problem for us to address is whether we can get sufficient savings by doing things differently now or would we have to go to some other means - a blend of something else?

Ms Jones: We might question how you could determine that until you have tried.

It would put a much heavier responsibility on the drug assessment system so that we were sure that it was operating effectively. That is really the rationale behind our suggestion that the cost effectiveness of the introduction of new drugs be part of the assessment program. It is not now. Australia had it for a time - with great opposition.

We have indicated our concern that there would be heavy cost implications by doing it. However, we also see the importance of health promotion and health prevention in reducing costs in the long term. Those areas have been cut back the most and are always the areas that are cut back when there are any constraints on the system.

There is evidence now that the older population is going to be healthier in the future, and I think that has relieved people of some of the concern of that high cost down the road. I think the health promotion in promoting self-care could be very effective as a cost-reduction technique.

Senator Robertson: Well, thank you. I shall not go further with this.

Dr. Chan, thank you for coming. You have five provinces under your belt now, so good luck with the rest of them, and may we have more acceptance of other professions in the health system. Thank you for coming.

Senator Cordy: I would like to talk about the issue of pharmacare and pharmaceuticals.

Has the Consumers' Association done any work in terms of the amount of money that pharmaceuticals spend on marketing? In your brief you talked about maintaining restrictions on direct-to-consumer advertising, but the reality is that with television - particularly in the American channels - Canadians are receiving direct-to-consumer advertising by the pharmaceuticals.

In addition, I have a number of who are in the pharmaceutical industry and there is - it certainly appears to me as an outsider - a tremendous amount of money spent by the pharmaceuticals in direct marketing to the health care professions. I am talking marketing in terms of trips, golf, and that type of thing.

Have you done any work in that area?

Ms Jones: We have not, but I recently saw a report from the Families USA, a health consumer advocacy group in Washington, and they identified that the pharmaceutical companies spend twice as much on marketing and promotion than on all of the research that they sponsor.

We are dependent on the research findings of other consumer groups, and that has been reported in other places as well. It was just this very recent report that I read that immediately came to mind.

There are concerns relating to any changes to our policy on the prohibition of direct-to-consumer advertising. We see that as adding tremendous cost to the system. I know of another finding on the U.S. system - about four years ago in 1997. After they allowed direct-to-consumer advertising, the pharmaceuticalcompanies were spending more on advertising to consumers than to the health professionals. That is pretty scary, considering how much they have spent on that.

Indeed, we see the television advertising from the U.S. as a real deterrent to the consumers' evaluation of the drugs. We do know that that promotion has prompted consumers to ask their physicians about changing their prescription to this great new advertised drug. We certainly see it is a very important restriction to maintain if we are ever going to restrain the drug costs.

Senator Cordy: I had also heard those statistics. The amount of money spent on marketing is quite alarming - especially when you consider that in discussions about the high costs of drugs, the costs are usually attributed to the amount of money that is spent on research and development, not marketing. I am alarmed by those statistics.

Dr. Chan, my next questions is an offshoot as to why you appeared today - to include optometrists within the realm of the health delivery system. People very often tend not to think about eye care when they are thinking about receiving health benefits. How do we ensure that children, particularly, are receiving proper eye care?

I know many years ago in the school system the public health nurse would do an eye check on the children. Children were given referrals if it was considered necessary. Lately, I have not seen the public health nurses in the schools doing that. How do you ensure that children are receiving proper eye care?

Dr. Chan: You are correct in your observation that primary students are no longer screened in the schools. The community public health units no longer do this because of funding.

In terms of ensuring that children do receive proper eye care, there is probably a two-prong approach.

First, as we move forward on health care reform and adopt a multidisciplinary format for care, I think that the health care team will expand to include other non-medical members, including optometrists. In a community health care clinic, for example, if you had an optometrist on staff, it could be part of an annual assessment. When the child comes in for a check-up, the optometrist would be readily available within the location. This would apply to a hospital, clinic and so forth. From that viewpoint, it makes the services of an optometrist more accessible.

Ensuring that those services are covered is certainly part of it. Currently, in all provinces, from what I understand, those services are covered.

The second prong is patient education. I think that is part of what your committee will be looking at as well. A well-informed patient, or in this case, a well-informed parent, will seek out these services.

The Ontario Association of Optometrists has been vigilant in this respect, and we acknowledge the fact that many of these children are not getting caught early enough. We have participated in many public service campaigns, public education campaigns to help educate parents about the need to have their children's eyes checked.

In Ontario, the "Healthy Babies, Healthy Children" initiative serves to address some of the concerns that you mentioned. This program includes not only eye care but also the full range of services that need to be administered to a child at a very young age to try to catch problems that could have long-lasting effects on their ability to be properly educated and properly adapt to society.

Senator Callbeck: Dr. Chan, your brief contains a suggestion to amend the Canadian Health Act to expand the definition of "medically necessary services." If we do that, those services have to be paid for. The only reference I see to the financial aspect is when you say, "Introducing a financial barrier by requiring the patients to pay for a service restricts their ability to access that necessary service."

I would like to hear your thoughts on how you think these extra services can be paid for?

Dr. Chan: What we want to address with that amendment to the Canada Health Act has less to do with allowing additional services, for example, but to have more equity in terms of where those services are provided.

In Saskatchewan, for example, where medically necessary services are not covered, a patient may walk in with an acute red eye. If this patient sees an optometrist, the visit will have to be paid for out-of-pocket. However, if the patient travels to Saskatoon to see an ophthalmologist or a medical doctor for treatment, the costs would be covered.

In our recommendation, we do not believe that the number of patients who require those services will increase just because optometrists are permitted to treat those patients. We feel that in some respects there might be some efficiencies where, in fact, you may be able to reduce the cost of treating these common ailments that occur.

Senator Callbeck: If we expand the definition in the Health Care Act and the expenditures go up because of those added things, where do you think the money that pays for these should come from? Do you think it should come through the taxation system; in other words, should the government increase taxes?

Dr. Chan: I do not think the association has a position on where that funding to cover an increase in services needs to come from. I expect we are prepared to consider any model that meets the services.

We realize that it is becoming increasingly evident that we cannot be all things to all people in terms of the health care, and so there will be some requirement to prioritize the services. What is important, however, is once you have made those decisions about which core services are covered nationally, that those services are available to the public from whatever provider they choose. If, for example, an optometrist or an audiologist is more accessible in the community, then the patient should have the ability to see that person.

I do not think our association is advocating that we blow the barn door open and cover everything. I hope that that was not our impression. I think that our suggestion there was more to address the accessibility issue.

Senator Kirby: I have a brief question for Ms Jones. I will read you a paragraph and then you can comment on it, because I happen to agree with the paragraph. You say "The consumer who understands how the system works does have an advantage in accessing its services." Then you go on to say that you promote ways of informing consumers about how to effectively get into the system.

All my anecdotal evidence would absolutely agree that you are right, that if you know more about the system, you can take advantage of it.

My question is in two parts. First, have you ever done any surveys of your members to try to understand what they do and do not understand about the system? Second, if at some time you could send us just a couple of examples of the kind of communications you send CAC members in terms of explaining to them, as you put it, how to exercise their rights, that would be helpful for us to have.

Ms Jones: We have not done a survey recently.

Senator Kirby: I had thought you might have done some type of survey of your members.

Ms Jones: We are much more dependent on the spontaneous reporting by consumers.

We also have tried to get that message across in meeting with small groups. We have recently developed a brochure of the responsibilities of the doctor, the pharmacists and the consumer in their health care. This brochure has been useful in formulating the questions that the consumer should be asking and the answers they should be expecting from those two professional groups. Our theme is that an informed consumer is an effective consumer in relation to anything at issue or in the marketplace. This is just basic to our approach to the issue.

From the anecdotal reporting that we have, I think it is clear that even a short discussion with someone about how they can better use the system pays off the consumer in getting the service they want.

It is not always who you know; we are saying it is what you know too. I think that is a big area that should be developed.

Senator Kirby: Thank you. I would agree with you on that.

The Deputy Chairman: On behalf of the committee, I would like to sincerely thank our witnesses for a very enlightening hour of testimony, and I will now ask our next witnesses to come to the table.

They are, from Medical Devices Canada, Peter Goodhand; from AstraZeneca, Gerry McDole; and from Comcare Health Services, Mary Jo Dunlop.

Senator Michael Kirby (Chairman) in the Chair.

The Chairman: We will begin with Mr. Goodhand

Mr. Peter Goodhand, President, Medical Devices Canada (MEDEC): Let me begin by thanking the members of this committee for the opportunity to appear before you and to participate in one of the most important debates occurring today: the debate on the future of our health care system.

As you well know, the majority of Canadians feel the status quo of our health care system is not acceptable, and this committee should be applauded for taking a leadership role in shaping this debate.

Medical Devices Canada - better known as MEDEC - is a national association representing over 125 medical device and diagnostic companies. Our members are dedicated to serving the health care community through the provision of high quality medical products and services that benefit Canadians. Founded in 1973, MEDEC serves as a primary source for advocacy, information and education for the industry. Our members account for more than $2 billion of medical devices purchased annually in Canada.

Our members are world leaders in their own right, developing innovative technologies that are used around the world. Our membership develops technologies that work in concert withother health care technology sectors, such as imaging and pharmaceuticals. Our members are responsible for enabling hospitals to move from being a building of bricks and mortar to a fully functional health care centre. They put the tools in the hands of doctors and nurses and play a vital role in the delivery of health care services that Canadians expect.

As I mentioned previously, the committee has done an outstanding job on shaping the debate of health care in Canada. I would like to focus on four areas that are most significant to the medical device and technology industry: support for health care infrastructure; infrastructure and infostructure; funding forinnovative health research; and, health care technologyassessment.

I would first like to talk about support for health care infrastructure. Medical devices and technologies are instrumental in improving the quality of life for Canadians. While we often hear of the miracle drugs available on the market, we hear less often of the "cutting edge" technology that has revolutionized the way health care is practised. Better and more advanced technology means better and more accurate diagnosis, more success in curing disease and alleviating pain and, most importantly, improving the quality of life for Canadians.

It was not long ago that routine surgery would mean a patient would be in a health care facility for several days or weeks. Today, many of these surgeries are classified as "day surgery." More and more procedures are becoming less invasive,minimizing the recovery time for the patient and allowing a speedy return to work or independent living.

Allow me to illustrate a few examples. Gallbladder surgery a decade ago was an invasive and traumatic procedure. With the development of laparoscopic surgery, patients undergo a relatively minor surgery, and are usually discharged from the hospital within 24 hours. Scarring is minimal and the recovery of the patient is more expeditious.

Another example is cardiac stents. Prior to the development of stents, patients were faced with a temporary fix from angioplasty. With the development of cardiac stents, the effectiveness of the less invasive procedure was significantly improved. The next generation of stents are drug coated, and initial data suggests zero restenosis of the arteries.

Modern medical devices and technologies have not only improved health outcomes for Canadian patients, by enabling less invasive procedures and shorter hospital stays they have also supported cost effectiveness in the health care system.

MEDEC is pleased to see that the committee recognizes the important and essential role of medical devices and technologies in our health care system. Yet despite the recognition of the essential role it plays in our health care system, as noted by this committee, Canada lags behind other industrialized nations in terms of availability of health care technology.

We agree with the committee that the recent $1 billion investment in health care technology was a positive step by the federal government. However, we believe that it is still insufficient to ensure that Canadians obtain timely access to medical services they need.

We currently have a very ad hoc system in Canada in terms of employing the necessary technologies. While many technologies and devices are available on the market, they are not necessarily utilized by health care facilities due to the constraints on funding. Depending on where you live, health care professionals may or may not have access to necessary diagnostic equipment or devices.

A recent case in Winnipeg illustrates the consequences of silo funding and the restriction of medical progress. An OB/GYN surgeon left his practice and Canada because he was frustrated with the slow adoption of new technologies. The physician had championed the use of an innovative technology that would provide better care for his patients and replace a major surgical procedure. The technology - called TVT tape - is a minimally invasive approach to cure female stress incontinence. Due to silo funding, the physician was severely restricted in the number of patients that could be treated by this simple, more effective technology, at lower risk. In this instance, not only were Canadians denied timely access to technology, but a vital human resource also departed in frustration.

The committee has also identified a problem with the recent federal government funding initiative. The funding was provided for the purchase of medical equipment and technology, but did not provide for any operational funding. This has led provinces and territories to look for other sources of funding - sometimes from within their existing constrained health care budgets - to finance the operation of these technologies. We believe this is also meant that the uptake of this funding by some of the provinces and territories has been slow.

In our correspondence with the provinces and territories, we too found a wide variation in the utilization of these funds. Some provinces, Ontario for example, have provided an accounting of how these dollars are being spent, while others are still determining if and how their allocation will be spent.

MEDEC is also concerned about the re-use of single-use devices. Faced with overwhelming demands on their financial resources, some hospitals are re-using devices that are developed for single use. These products are developed, tested, and licensed by Health Canada for single use only. This practice means that a patient may be exposed to a single-use device that has been used several times on other patients. The re-use of a single-use device, such as a PCTA or diagnostic catheter, is potentially creating a risk to patient safety.

We believe that the health care providers should adhere to the same standards that are imposed by the federal government on industry in bringing these devices to market.

We would like to support the committee in its astuteness to put forward a recommendation for the federal government to commit to a longer term program of financing for innovative health care technologies, including support for the operation of these devices and procedures. This will ensure that our health care facilities have access to the latest technologies and have the funding to use these technologies and train the necessary health careprofessionals to use the technologies effectively.

Although the up-front investment in medical devices and technologies can sometimes be intimidating to our individual health care departments, physicians or professionals, the impact on the overall health care system frequently leads to greater efficiency, to a reduction in waiting lists, to better utilization of scarce human resources and a rapid return to a productive or independent living.

In your report, you have identified each of these areas as essential elements in creating a sustainable health care system. The "fault lines" of timely access and human resource shortages can be alleviated by sound investment in medical technology.

In terms of infrastructure and infostructure, in the "Interim Report" the committee identifies some witnesses that support the need to invest in infostructure at the expense of increasingly long waiting lists and denying Canadians access to modern medical devices and technologies. We would submit to the committee that this would be a mistake. We also believe that the two issues can be addressed in concert.

We support the need to implement a modern health care information system but do not believe that its implementation has to happen at the cost of reform in other areas of the system.

Allow me to provide an example to the committee where we see the potential for infrastructure and infostructure investment without impacting the existing health care system.

Industry has led the Efficient Healthcare Consumer Response, EHCR, and has also worked with the Ontario HospitalAssociation, OHA, on the re-engineering of the health care supply chain. Health care supplies are purchased and inventoried in an antiquated manner. The system is largely manual and is a catalyst for errors and confusion.

With the introduction of e-commerce, we will see a system where the right product will get to the right place at the right time. We will no longer see a situation where a hospital is without the supplies it needs or surgeries are postponed because the right equipment is not available.

The modernization of the health care supply chain will require investment in both infostructure and infrastructure, but the return on investment will be quickly realized, allowing the hospitals to re-invest in other areas of the health care system.

With respect to investment in research, Canada is privileged to have world class researchers and academic research facilities. You need look no further than the leadership in robotic surgery at the London Health Sciences Centre or the pioneering work of the Ottawa Heart Institute to appreciate that Canadians play a leadership in revolutionizing the world of medicine.

Canada also has research-driven industry partners, such as CryoCath in Montreal and the World Heart Corporation in Ottawa, with the skills and knowledge to turn brilliant concepts into successful, viable, safe and effective devices. Canadian-owned companies and leading multinationals are developing new technology from Canadian research that will benefit millions of people worldwide. Ironically, given current health care funding, Canada may be among the last countries to adopt these new technologies.

The development of world-class technologies and companies in Canada is in part dependent on the presence of a domestic health care market that purchases and fully utilizes breakthrough technology. The current health care funding model in Canada is, of necessity, focussed on providing adequate care at the lowest possible cost. Health care reform must include flexibility in funding that will enable health care institutions to both acquire and fully utilize modern technology.

With continued investment into research, we can ensure that Canada will remain a leader in the development of medical devices and technologies. MEDEC fully supports the committee's option on increasing the share of federal spending on health research to 1 per cent of the total health care budget.

We would also ask the committee to recognize and support the critically important aspects of linking together scientific research, academic medicine and innovative industry.

MEDEC believes that health care technology assessments can be helpful for government to adopt new and improved medical technology. However, we would like to point out that while Health Care Technology Assessment may be a useful tool in determining that the right technology is available to Canadians, it should not impede the development or perfection of medical devices and technologies.

Unlike pharmaceutical or biotechnology products, medical devices and technologies are rapidly upgraded and improved after the product is introduced. The nature of our industry is incremental innovation, and any change in the role or use of health care technology assessment should be sensitive to the evolving nature of the sector.

While all technologies introduced to the market are proven to be safe and effective prior to their introduction, their usefulness invariably improves over time. As physicians become more familiar with a particular technology or procedure, outcomes improve and efficiencies increase. Based on their feedback, changes may be made to modify and improve the technology. Health care technology assessments should not restrict this from happening.

Ideally, MEDEC and its members would like to see increased global harmonization in both health care technology assessments and regulatory approvals. Assessments performed in other jurisdictions should be given consideration. While health care technology assessment can be a useful tool in the environment of limited health care resources, we need enough flexibility in the system to allow adoption of new technologies.

In conclusion, I would like to thank the committee again for the opportunity to present to you today. We are encouraged by your forward-thinking approach to the health care system and your recognition of the importance of medical devices andtechnologies. Clearly, you understand and appreciate that, in reforming and improving our health care system in Canada and ensuring that Canadians receive the best health care available, a continuing investment in medical devices and technologies is required.

I thank you for your time and would be happy to answer any questions you have.

The Chairman: Our next speaker is Mary Jo Dunlop, the President of Comcare Health Services. I really should have encouraged Mr. Goodhand to do this too, but rather than read your report in detail, can you hit the highlights? I know there will be a lot of questions we will want to ask you as well.

Ms Mary Jo Dunlop, President, Comcare Health Services: Thank you very much. I apologize for not having my remarks to you ahead of time, but due to the sudden illness of a family member, I had a crash course in acute care over the last two weeks. Most of this was written at his bedside.

The Chairman: How is he now?

Ms Dunlop: He is very poor, but thank you for asking.

The Chairman: Oh, that is too bad.

Ms Dunlop: My expertise is home care, so I will comment only on that aspect of the "Interim Report." I will try not to repeat anything that is well documented but limit my comments to the role of the federal government.

Comcare is a community health service provider. It is a national for-profit company. It has 30 locations in Canada, starting in Montreal in 1969. We have over 6,000 employees.

You have heard a great deal about the diversity of home care programs in the provinces and territories. I would suggest that it is also very evident in the working conditions of our employees. Wage ranges still fall far behind the institutional wage ranges, and they vary a great deal between the east and west coasts.

An excellent example of the federal government's role in research is the recently launched study funded by Human Resources Development Canada, in collaboration with the Canadian Home Care Association and the Canadian Association for Community Care. This is a very important piece of work when it comes to understanding how we are going to plan and resource home care in our future.

Research funding through the more traditional health research programs and initiatives is seldom available to a for-profit company. As a result, organizations with valuable ideas about care models, including the need for investment in information and communication technologies, are often slow to make progress.

With better information, we could move to evidence-based practice in home care, which we do not currently observe, and in doing so, we could make our way towards standards in home care and also to a national home care program.

In addition, technologies that are already available and being used in countries other than Canada would allow us to see more patients with the same human and financial resources that we currently have.

As long as there is an accountability framework for research funds and the need for an evaluation plan, I do not see any reason to exclude for-profit companies from these research activities.

Comments made in the "Interim Report" about the need for timely transfer of knowledge based on the research are welcome and absolutely necessary if we are going to improve practice in home care.

In addition to research, the federal government can play a role in establishing the principles, if not standards, of a national home care program. The principles would be consistent with those of the Canada Health Act, thus ensuring that Canadians would have consistency in access, portability and comprehensivenessanywhere in the country, without jeopardizing their home care services. We frequently hear stories of patients who have been afraid to move from one location to another once their home care service has been established.

The federal government must decide on what core services are within the home care programs. That is a very difficult decision. It would be a shame if the program were exclusive to only medically necessary services, because social care and assistance with activities of daily living have proven effective in keeping the elderly in their homes.

With regard to national standards, our organization was the first home health care company to have a national accreditation award by the Canadian Council on Health Services Accreditation. Therefore we disagree with those who suggest that there cannot be national standards.

The approach can be standardized across Canada. However, if "standards" are limited to resource allocation, then other factors will influence how successful we will be at developing a national set of standards. Things like financial health of the individual province, physician practice in that province, other resources available, provincial regulations that concern other health care professions, and political will all complicate the ability to agree on national standards. Today, variation in practice is great, and provider incentives are not aligned with patient outcomes.

The place where we have the most opportunity to change our practice is to begin with the end in mind. We are not spending any more money; we are just looking after more people with the same money.

We need investment in information and communication technology in home care. Much of the technology already exists, but our home care models in Canada have traditionally been on a fee-for-service basis and they have only paid for a face-to-face visit. Use of telehealth or other mechanisms through which we can monitor patients are very poorly used so far in the country.

We have been pleased to see the candour with which the committee discussed the issue of private health care. As a private for-profit corporation whose largest client group is the provincial government, we believe in public administration and the principles of the Canada Health Act.

However, we see in practice every day a number of individuals who either do not qualify for government programs or who buy private service in addition to that provided by the government because the government allocation is insufficient for their needs. To suggest that provincial home care programs meet demand now is incorrect. Even now, our provinces are just one insurer of home care service. Obviously, Worker's Compensation and some individual insurance products such as extended health benefits also pay for home care services.

Long-term care insurance is an insurance product that is on the market, but in any practice we have seen in our company - and we do about 3.5 million interactions a year with patients - it is very expensive and limiting. The federal government should consider a variety of financial mechanisms to support caregivers, including tax concessions, employment insurance and related employment legislation.

We believe that the private sector is an important partner as we go forward. Our participation does not contradict the Canada Health Act, nor does it represent privatization. Privatization, in our mind, is the active transfer of accountability from the public sector to the private sector for regulation, financing and production. We work well within a publicly administered system. We have proven ourselves as valued stakeholder organizations providing excellent health care within the context of economic discipline. We focus on efficiency and effectiveness in administration in order to invest in clinical excellence. Profitability means re-investment in our system, which, as you have observed in your documentation, is badly needed.

We do need leadership from the federal government, both in research and investment in information and communication technologies. We are not asking for additional money; we are asking for some access to some of those grants and programs that are already available. I believe that we are just building on the principles of equitable treatment and equitable access to resources within Canada, and that investment will allow us to work towards evidence-based practice so we will be more appropriate in our utilization of human resources and financial resources. That can lead to standards and, by virtue of the information, will move towards a system of care.

Mr. Gerry McDole, President and CEO, AstraZeneca: Senators, I appreciate the opportunity to share my views with you today on such important public policy issues.

I have read with interest your "Issues and Options" paper, and I would like to comment on a few of the points that have been made. It is difficult to keep to five to seven minutes on a complex issue, but we will do our best.

Like you, I have always been very passionate about our medicare system. I am old enough to remember with as well as without, and I must tell you I prefer with. I remember the three years I spent paying off the debt of the birth of our first child.

Good systems can always be improved, and the single most important change that that the system needs is a re-orientation of the course, and by that I mean refocussing on the patient. Today our fiscal pressure seems to be building a new system that is more financially driven, and I believe that that is not in the interest of Canadians' health and one that Canadian health can ill afford.

Your work thus far has highlighted, among several other issues, the much- publicized concern of rising drug expenditures. I would like to offer my perspective on the debate of drug cost-containment policies and patient health outcomes.

I want to say up front that I understand the challenge that everyone has. Policy-makers must manage the limited public funds and balance that against their fiscal responsibility, while at the same time ensuring access to the proven medications.

Having said that, public policy studies being conducted at Harvard Medical School and at McGill University suggest that it is time for us to revisit the rationale behind cost-containment and other interventions since there are unintended and undesirable results of well-intentioned but perhaps too "broad brushed" approaches to drug management.

Their advice is that studies should examine the degree of inappropriate use of our medications before policies are introduced. For the record, I define "appropriate use" as the right drug for the right patient at the right time.

Our industry has a key role to play in ensuring that our scientific discussions with physicians encourage appropriate use, and the answer to these issues lies in a collaborative approach between industry and government. Policy-makers have, for too long, tried to resolve issues surrounding our health care system and rising drug expenditures alone. We need an evidence-based approach to policy development and intervention, collecting the data before, during and after implementation.

I would like to quickly address the issue of brand name drug prices, because we seem to remain in the media as a hot button.

Several recent studies have demonstrated that utilization rates and an aging population are behind the growth of the drug program budgets - not the drug prices, per se. We mix up drug budgets with drug prices.

As you know, the federal government reviews each new product through the Patented Medicine Prices Review Board. The latest report shows that prices for innovative medicines are about 10 per cent below the international average. In fact, in the basket of eight, there are only two countries lower than Canada. I , and I might add that my own company has the second lowest prices in the world after Korea.

While our prices are monitored at the federal level, at the provincial level we provide good cost/benefit studies each time we apply to the formularies for drug reimbursement. Therefore, I would suggest, honourable senators, that Canadians are already well positioned to get value for money when medicines are used appropriately.

Following the most recent health ministers meeting in Newfoundland, I read newspaper reports that suggested the provinces feel pressured to approve new drugs that are available in other provinces. A quick review of the approval rates from one province to another would suggest that this is certainly not the case.

Nevertheless, it is interesting that provincial formularies do vary considerably from one province to the other. One might ask "what are the criteria for new product listings?" Does this support a national cost effectiveness strategy, as suggested by the Federal Ministry of Health is another question.

My personal opinion is that our industry would be willing to work with governments on any approach that delivers the best possible individual care to patients using the available health care resources.

Today, however, a grave concern for patients, physicians and health outcomes more generally, is that many provinces seem to want to limit the number of medicines available to patients in each product class. That is a concern to me because it does not make scientific or economic sense. The federal regulations ensure that new products are priced within a range in any given class - even when there are substantial improvements. From a purely cost point of view, it does not really make much difference which you choose.

These incremental improvements, in fact, are what drive research. The history of medicine, pharmaceutical research, and humankind in general is based on these incremental steps and incremental innovations.

Take, for example, the automotive industry. You did not get your first car with ABS brakes, with air bags, seat belts and a whole lot of other whistles and bells. With drugs too, these improvements lead over time to reduced side effects, better or faster healing, more convenient dosage forms, and so forth.

They provide the physicians with more options to respond to a patient's individual needs - no two patients are the same. These medicines, unfortunately, are sometimes dismissed because they are not dramatic breakthroughs.

The committee also suggests that the reference-based pricing should be among those serious policy options the government might consider. Perhaps the committee would want to look again at British Columbia's failed experiment with its reference-based pricing.

As you may know, the current government is now in fact looking at alternatives to this system - which some suggest was really just two-tiered medicine at its worst. For too many people, this scheme meant that they could only get the medicine their doctor prescribed if they had the money.

Indeed, a poll asked B.C. health care professionals about the impact of changing patients' prescriptions to fit the system;90 per cent of pharmacists and 95 per cent of physicians reported that their patients had problems as a result. These percentages did not diminish after the first year of introduction, by the way. It continues to this day, some three years into the program.

In addition, a B.C.-based policy research institute investigated the savings generated by this cost-containment policy and found that drug costs in fact overall grew at a faster rate in B.C. than in any other province in Canada. They continued to grow over an extended period of time. Moreover, it did not calculate any other additional health care costs that were incurred as a result of the policy. I have appended this for your information, thisinformation, to this paper.

This brings me back then to the cost-containment policies implemented without evaluating their impacts. HonourableSenators, we need to build a system that strengthens the patient-physician relationship. Let us look for innovative and cost-effective approaches that start with the patient's needs.

For example, disease management programs are being implemented into several Canadian jurisdictions. Disease management is a systematic and evidence-based approach to utilization of resources to achieve the desired health care outcomes for patients. These programs are bringing the patients, the health care providers, government, industry, information technology and academia into a partnership that assumes that health care and outcomes can be better. It shifts away from the isolated inputs and controls to a systems view that works towards an integration of components and improvement of the health of whole populations.

What is genius about the disease management concept is how it really works. It begins with a baseline measurement, followed by an analysis and then feedback to physicians. The feedback is where the genius comes to life. All physicians want to do the best for their patients. When they get the feedback they are quick to adjust their behaviour patterns. It allows for better interventions. In fact, you continue to raise the bar as new measurements and new improvements come forward. All of these quality improvements for patients are what makes disease management shine against the other alternatives that exist today.

These initiatives are opportunities to demonstrate a health management approach that is a feasible alternative to restrictive formularies and to the silo budgeting. It is the future of health care, in my view, honourable senators.

These programs do not ration care; they expand it. They save money in the process by reducing hospital visits or other more expensive interventions and by simply keeping healthy. That should be the goal of our entire heath system: to keep people healthy.

I thank you for your time and would be pleased to answer any of your questions.

The Chairman: Thank you. Before turning to Senator Keon, I wonder if I could ask Ms Dunlop a couple of questions for clarification.

On page four of your brief, you say:

The approach to home care can be consistent across Canada. However, if "standards" are limited to resource allocation then other factors will influence how successful we will be at developing a national set of standards.

Can you explain what you mean by that?

Ms Dunlop: The Canadian Council of Health Services Accreditation has a standards document that you follow when you go through a national accreditation.

The Chairman: I am sorry to interrupt, but this is for a profession, not for an organization?

Ms Dunlop: No, it is for an organization for their home care accreditation.

The Chairman: I see, okay.

Ms Dunlop: So their approach is consistent. If looking at creating national standards, and the national standards are around allocation of resources, what is appropriate in terms of how many home-making hours someone should have, how many therapy visits someone should have? It becomes more complex because it is no longer about approach; it is about all those things.

Most of the health professions are regulated by the provinces, so that we employ probably 12 different kinds of homemakers across Canada.

The Chairman: Sorry, home care is one thing we have heard very little on, and that is why I am asking you the question.

When you say "different kinds of home care providers," what do you mean?

Ms Dunlop: They have different titles. They have different scopes of practice.

The Chairman: Different skill sets?

Ms Dunlop: Yes, different academic preparations.

The Chairman: Just give me some examples. You would have a nurse? You would have a certified nurse?

Ms Dunlop: Nursing is one of the more consistent, but with the home support staff, we have four levels just in Ontario. We have several levels in British Columbia. There are those who can perform delegated acts and those who cannot. Many of them have different titles. It is very confusing and it is not consistent.

Therefore, when you talk about standards and you are trying to relate the standard to the academic preparation of the individual, then it becomes more complex because the regulations are provincial.

The Chairman: In contrast to the fact that a doctor is licensed nationally and a nurse is effectively licensed nationally.

Ms Dunlop: That is right.

The Chairman: You are licensed provincially. Not only are the licences different, but the job descriptions are different, right?

Ms Dunlop: That is right.

The Chairman: The scope of practice rules are different.

Ms Dunlop: That is right. Most of the standards with which we comply are with the transfer payment agencies of the provinces, and they all have their own.

The Chairman: They are not national standards?

Ms Dunlop: No. The problem with home care is that not that there are no standards; it is that there are so many standards and they are dictated by individual organizations.

The Chairman: Further down on that page, you say that essentially, up until now, you only fund face-to-face visits. Are you really trying to say that some of the things - remote electronics, for example, whereby blood pressure and other things could be monitored from a distance - you could do, but would not receive reimbursement because you did not see somebody face-to-face?

Ms Dunlop: That is right, so there is no incentive and little ability.

The Chairman: Why would you do it?

Ms Dunlop: Well, because I think I am trying to prove the system wrong, that there is a better way to do this within the same resources.

Part of our agenda is to put in a national information system so that at least we could monitor people with the same diagnosis that were having different resource utilization with the same diagnosis. For instance, if Nurse Jones is using four visits to teach a new diabetic and someone else is using eight, then let us find a best practice to make sure that our teaching is consistent and that becomes your standard.

The Chairman: Right. Are you therefore training a lot of your own people?

Ms Dunlop: Oh, absolutely.

The Chairman: So they are not all coming out of formal educational institutions?

Ms Dunlop: Well, actually, everyone comes out of a formal educational institution except a very basic homemaker, the most basic.

The Chairman: The rest you add on the skill set?

Ms Dunlop: Yes, or we fund their participation in a community college program.

Senator Keon: It is interesting to have the three of you here together because, collectively, you represent a problem that exists in the health system now. That is, we have traditionally known how to deal with doctors and hospitals, but we have not done very well when it comes to home care, to technology and, of course, to pharmaceuticals, particularly on the outside. The pharmaceuticals in hospitals are pretty well taken care of, but once the patient is on the outside and needs home care, there is a huge problem.

As well, you get into the tremendously complex problem of physician remuneration, in particular as it relates to home care where there are tremendous gaps and there is really no system for payment in a lot of cases.

You just raised the issue of telehealth, for example. There is no technological barrier to the application of telehealth. It is mostly a personnel barrier because you cannot impose it on the system or the people who are working in the system.

I do not know how to draw the three of you out, but I would like to hear you speak collectively about how home care could be integrated into the hospital system, the institutional sector.

How do you construct a system outside the hospital that would get adequate funding for technology and for drugs? Such a system would have to provide you with the flexibility to change your personnel in a way that you could accommodate the programs and the flexibility to change the remuneration system, particularly as it relates to physicians more than nurses and other healthprofessionals who are usually salaried.

Can all three of you have a go at that and see what you come up with collectively?

Mr. McDole: Well, I could start by suggesting we need to reform how we remunerate the various players in the system, because with the current style of budgeting, it is a real challenge to pull all those things together.

If we were to look at managing the cost of treating a patient and allocating resources to that task, then you would be able to better allocate the appropriate resources - whether it be drugs in one instance or home care in another. By the way, home care and drugs are a tremendous complement because one will enable the other perhaps to take place. It would be a real challenge to do it without eliminating the silo budgeting we have currently.

Senator Keon: Can you think of incentives to change from the silo budgeting?

Mr. McDole: I do not know how you would describe it, but it should be some kind of block funding system for treating a disease as opposed to the individual players in the field.

Right now we have a "divide and conquer" system where each player wants to make sure they get their piece of the pie. It is very difficult in that environment to take either the most economical route or the most appropriate use route.

Senator Keon: So if you had disease-based program funding, it would work fairly well for cancer, and I think it would work for some other areas such as heart disease, maybe diabetes, AIDS, probably arthritis, and then you run out.

Mr. McDole: Well, no, we have an experiment in Quebec now for a respiratory disease, so I think you would include asthma at least and some of the other respiratory diseases. I think a managed care system could apply to a greater number of diseases than the ones we just named.

Mr. Goodhand: I completely agree with Mr. McDole that one of the fundamental issues is silo funding.

Our experience with installing new technology is that inevitably there is a savings somewhere in the system. The closer that saving is to the point of purchase, the easier it is to justify the technology. The further that saving is away from the budget holder, the more difficult it is to introduce that new technology.

I think regionalization of health care is probably a step in the right direction. At least somebody looks at that funding envelope and says, "By spending this here, we save this here, and get people into a home care situation."

One of our members has a product that would get somebody out of a long-term institution and into a supportive home care and probably into a productive living mode as well.

In your report you quoted the 1998 study that discussed the indirect costs of health care, lost productivity and disability being as significant as the direct costs. I think that is one of the challenges we face here. By doing the right thing in the hospital that is integrated into what is happening with home care and that is integrated into the rest of the home care system, you can effect real change that will make people more productive living disease- or disability-free.

To persuade a hospital or an OR that they have to quadruple their spending on a certain product to save money on the home care today will not fly - and that is a huge fragmentation. We do not have a health care system; we have multiple silos standing side by side.

Ms Dunlop: Without drugs and equipment, I could not have probably half my patients at home. Therefore, they are absolutely essential to effective home care.

In terms of integration, the path of least resistance perhaps is to do it through information. If you have an information network, you can begin to follow a patient and at least what they are utilizing from the public purse. I am not sure about whether or not you could do that for the private purse.

I think we can integrate through information. We must determine what patient outcomes are, beginning with the end in mind. We should know from the start what it is that we are trying to achieve; the three of us and our hospital partners should all know this when we begin. We really shouldn't be working ad hoc - which is generally the way we do it.

We are making some progress with care pathways that originate in the hospital, for example. Home care is socially complex. A 50-year-old man who has his first myocardial infarction and is at home and has extended health care and a wife and insurance through his work is going to have a different home care outcome than an 80-year-old woman who lives alone, perhaps in squalor, and she is having her first infarct at 80.

There is no "cookie-cutter" system in home care, because the social context comes into play much more prevalently than it does in an institution. We can certainly do a better job of integrating through information and through all of us starting from the same page.

Senator Keon: Can I bring the three of you back to information technology as it relates to information andcommunication?

Having spent most of my medical career struggling with this subject, I have become convinced of late that we have always approached this from the wrong end. We were trying to do it at the top, at the federal level, at the provincial level, at the big institutional level and then farm it out. I think we are doing it all backwards.

We should be starting at the patient level: provide the patient with a health card containing all of their information as well as the appropriate firewalls. You can have a repository for home care. You can have a repository for the hospitals with which you interface. You can have a regional repository, a provincial repository, a federal repository.

Technologically - as the pundits in the business tell me - it is really quite possible, and in fact, in another life I am kind of working on it.

What do you think of all that? Tell me.

Mr. Goodhand: I completely agree. I have had personal experience with a family member both in a hospital setting and in home care. We actually made the health care system work and ended up with extremely good health care in Canada because of an informed patient and an informed patient advocate. We connected the information that was necessary. Had we been elderly or less able to communicate with physicians, we would have had a terrible experience because the system did not connect and it was not patient-centric.

So just from my personal experience, I think that approach is definitely there.

Methods such as tele-monitoring can play a role in the link between the hospital base and home care; tele-monitoring clearly is patient-centred.

Mr. McDole: Did you mean sort of a health funding account for every individual patient as well then?

Senator Keon: Yes, that could be included. Perhaps now we could just stick to medical information.

Mr. McDole: Yes, I agree it is essential that we share the information better than we do today among all of the various players, no question about it.

Senator Keon: Where do you think it should come from? Do you think the federal government should spend $10 billion setting up an information system that will never work? Or do you think we should build health cards that the individual will carry and the individual would have the right to privacy as they release the various firewalls in that system?

Mr. McDole: As a consumer, I would prefer it to be on my health card - a "smart-card" - that knows everything about me and my health needs.

Mr. Goodhand: You could spend $2 billion on one that really did work, and maybe that would be worth it, but $10 million on one that does not work, no.

Ms Dunlop: I agree. I have heard of an individual who was so frustrated with frequent admissions that he put his health history on a CD ROM and would hand it in when he went to the ER and tell them to plug it in.

So I do think it would cut down tremendously on errors and inappropriate use of resources. With home care, our health care professionals are sending paper copy back and forth to physician offices. If we had good, solid information at the local level that we could share easily, we might be able to overcome the physician frustration with home care. Physicians are frustrated because they cannot leave a waiting room full of patients to go out and look after someone who is at home and perhaps we sometimes call them inappropriately.

Electronic health records, a series of pilot projects, and the expansion of those would take us a long way, as long as we are maintaining people's privacy and allowing only the appropriate people access to the information.

My father was a very sick man, and he had this document and he would hand it in at the ER. It was all typewritten. He just refused to go through it one more time. I think patients who have chronic illnesses get frustrated and do not want to go through the whole story again, and then we operate, as health care practitioners, with half the information.

Senator LeBreton: Senator Keon's questions are a perfect entree into what I wanted to raise. Mr. McDole, I would like to talk about the issue of inappropriate use of medications.

A few years ago, I sat on a committee with John Crispo. He talked about health smart-cards then - he used that term. A system like that makes sense. You would have to ensure that the information was properly protected, and I am curious as to how you see the privacy issue resolved.

However, we have people who have been prescribed pharmaceuticals that they are not taking. We have people running from one doctor to the next and having prescriptions filled in different pharmacies. In addition to that, they are buying over-the-counter drugs and probably are causing great damage to themselves in whatever illness for which they are being treated.

In your statement, you refer to "unintended and undesirable results" of studies being done. Have you given some thought from your industry's perspective as to how this particular problem can be addressed and overcome?

Mr. McDole: The reference that we made to the managed care system would be probably the most efficient way of dealing with that. It is much more complex than the inappropriate use. It can be overuse, as you have described. It can also be underuse - patients who do not comply, do not take their medications or seek help in the first place.

It is a case of managing both sides of that coin. We need a more close system that would involve all of the stakeholders and provide more appropriate follow-up and interventions at different levels. It would lead to better outcomes at the end of the day.

Senator LeBreton: So you generally would support a health smart-card?

Mr. McDole: Yes. We need an efficient way to communicate that information - presumably electronically in some fashion - whether it is through the patient's records or through their health card or some other means.

Senator LeBreton: Mr. Goodhand, in your testimony, you talked about the re-use of single-use devices, and I wrote one word on the paragraph, "Scary!" with a big exclamation mark.

How prevalent is this and what kind of savings do the facilities who subscribe to this practice think they are affecting?

Mr. Goodhand: This practice has been around for probably a decade or more because of health care constraints. The only real reason for re-using a single-use device is to save money.

A Health Canada report, which will come out in the next month or so, will show that it is fairly widespread and that most hospitals do not have written procedures for how and when to re-use single-use devices.

Two independent surveys, which will be released next month, indicate that this practice is fairly prevalent. Because of these reports, hospitals have conducted some recent assessments as to whether or not to re-use some of their most sensitive products. "Scary" is a good word.

Senator LeBreton: To say nothing of the potential patients' faith in the system I think that they still have some faith in.

Mr. Goodhand: Right. We have often said that if the patient knew the product had been re-used, they may have a different discussion with their physician.

The Chairman: No kidding. Well, that has certainly shaken up a lot of us who are not in the medical profession.

Senator Callbeck: Did I understand you to say that in some of the hospitals there is no standard regarding using these devices?

Mr. Goodhand: Again, I am cautioning my remarks here because I would like to wait for the reports coming forth from Health Canada and another associated body. I believe they surveyed 700 hospitals and had 400 responses. It shows that in most cases, when they are re-using, there is not a written procedure.

Industry's biggest concern is that Health Canada puts us through enormous and appropriate scrutiny to make sure that the device that we have sold as a single-use, is not only sterile but that it will perform as it is expected to perform, for example, that a balloon catheter will expand at the same rate. If that product is re-sterilized half a dozen times or 25 times, we as a manufacturer can no longer have any control over how it performs.

Industry has said is that there really should be no re-use of a single-use device. However, if that re-use takes place, the hospital should be held to the same standards as industry was when the product was introduced in the first place. That is a good question to ask your physician next time.

Senator Callbeck: Ms Dunlop, did you say that there were six classifications in home care?

Ms Dunlop: In homemaking.

Senator Callbeck: Just in homemaking there are six?

Ms Dunlop: In Ontario, a level 1 homemaker is considered someone that we have recruited with some skills and whom we have trained. Level 2 is a community college program. Now we have a personal support worker, and then there are still categories out there of health care aides that are no longer being trained in Ontario. So there are five right there, just in Ontario. These people are not covered by regulated health professions. They have no legislation overseeing their practice.

Senator Callbeck: For the basic one, who do you hire there or what do you look for?

Ms Dunlop: Well, our work force is still 96 per cent female. The people that are hired just for general housekeeping duties are usually people that have run a household themselves, have experience with elder care or child care, but those are people that are doing light housekeeping, meal preparation and laundry. They are not in a position to assist with personal care, do transfers, feeding and so forth. They have to be trained specifically for that.

Senator Callbeck: So there is no educational level there?

Ms Dunlop: Not specifically. In New Brunswick, in particular, these are minimum wage workers. It is terrible.

Senator Callbeck: I believe you said you are in six provinces?

Ms Dunlop: Yes.

Senator Callbeck: You are in New Brunswick?

Ms Dunlop: Yes.

Senator Callbeck: Are you in any other Atlantic provinces?

Ms Dunlop: Nova Scotia. Nova Scotia provides a little better reimbursement than New Brunswick.

Senator Callbeck: How long have you been in those two provinces?

Ms Dunlop: The organization has been in those two provinces for about 10 or 15 years. I have only been with Comcare for four years. We have been lobbying the province of New Brunswick consistently every year of the four years with no change. We have made significant progress in other provinces.

Senator Callbeck: Mr. McDole, I do not have a question for you, but I was curious about a statement in your brief. I was quite surprised when you mentioned approval rates of new drugs by province and that if one province accepts the drug, there is an extreme pressure on the other one to accept it.

Mr. McDole: The implication - perhaps I misinterpreted what I read - was that they were succumbing to that pressure. I do not see any evidence of that. There is tremendous variation from province to province, so whatever pressure there is, they seem to be managing it quite well from that point of view.

Senator LeBreton: I meant to ask you, Mr. McDole, about that. On the graph that you have provided where you have got the drug approvals for new drugs and you see Quebec obviously, you know, they are quite high and Ontario is at nine, New Brunswick at seven and P.E.I. four.

How does a company like yours deal with that, when you obviously have drugs that are approved in some provinces and then in other provinces - and I specifically look at Quebec and Ontario, because I live in Ottawa, right on the Quebec border. I think people assume, probably incorrectly, that when a drug is approved coming into Canada, that they do not get into this provincial approval.

So how do you deal with that, other than having to pay lobbyists, I guess? That must cause a company like yours significant difficulty?

Mr. McDole: It is a challenge. There is no question about it. You try to circumvent that by doing good research in the first place, to get good products that will meet medical needs and that will become part of those percentages without a lot of debate.

We do a lot of health economic studies and other backup support to prove the benefit and the value-added of our medicines to the system.

It is a constant challenge. Fortunately, as you can see there, the Province of Quebec - which is not a small province - is more favourable to our industry. In some parts of the country you have very little business and in other parts you get a lot of business.

That is one of the reasons it strikes fear in your heart to have a national formulary.

Senator LeBreton: Yes, that is right.

Mr. McDole: National formularies are great if you are going to bring the best medicine to the patient at all times, regardless of his or her ability to pay.

Formularies, by nature of their implementation, tend to become very quickly a measure to prevent the use and restrict the use. They become cost-containment measures as opposed to providing the best possible medicine to the patient at the right time and at the right price.

Senator LeBreton: What would be the ideal vis-à-vis the role of the federal government in dealing with this?

Mr. McDole: If I could believe that we would have a national formulary that would bring the best possible medicine to all patients at all times, I would not object.

In the absence of that, I think we have to look at outcomes and choose the best possible medicine for the patient on an individual basis.

Senator Morin: Mr. Goodhand, does your association represent all companies, for example, Medtronic, Siemens and Phillips? I wanted to address a question to those representing the Canadians. Is there an organization that represents only the Canadian medical device companies?

Mr. Goodhand: No, our membership, and I can provide you with some details on that, is about 50 per cent Canadian,50 per cent multinational.

Senator Morin: As you know, there are several problems, but one of the major problems of our health care delivery system is that we are near the bottom of the OECD countries as far as the medical technology. One reason for this is that our Canadian medical device industry is so poor. There is very little going on.

There has not been a lot of support from the government for that industry. For example, Industry Canada has a technology development program that supports everything, the environment industry and everything, and gives low or interest-free loans to various industries. However, for some reason the medical devices are not part of that list.

If you compare Canada to other countries such as Germany, the U.S., or France, where the medical device industry is very strong, you can see that is not the case in this country.

Maybe we should address this differently. I think we should address just the Canadian situation here. I do not feel that bad about Siemens and Phillips and Medtronic. I do not think they need our support as much as the Canadian industry here. I realize that you will not agree with that because that comprises50 per cent of your membership, but I think that is one of the answers to our problem here.

Mr. McDole, I share your support and your concern about your reference pricing, but one issue that affects all third payers around the world, is the fact that drugs are prescribed by physicians. Consumers do not buy them. That is, of course, an issue.

We know that study after study has shown that physicians are not terribly concerned about the cost of the drugs they prescribe. They are very much influenced by marketing. That is a fact of life. They are also unable to resist their patient's specific request for a given drug. Many studies have shown this.

I will pose this question to you. If two drugs are of equal value in a given situation but one is much cheaper than the other, how can we make sure that the cheaper drug is prescribed?

The Chairman: I will also let Mr. Goodhand comment. I have no doubt he is anxious to comment. Go ahead, Mr. McDole.

Mr. McDole: I think that the mechanism we have for the Patented Medicine Prices Review Board already takes that into account. Drugs in a class, by and large, are almost all the same price. There is a very small range of difference for drugs in the same class.

Where we have the difference is between the brand and the generic. When a drug is off patent, then clearly the choice should be the generic.

The Chairman: If your logic is right or if your facts are right, which is that all drugs in a class are essentially the same, then why would you possibly argue about therapeutic substitutions? If they are all essentially the same and they are all relatively the same medically, what is your problem?

Mr. McDole: They are all the same price, and that was my point. You do not benefit much by limiting yourself to the one choice. By limiting the choice, you put a tremendous disadvantage for the patient and the physician, because they are not all the same in terms of what works for one patient and what works for another. So having the choice within a class gives the physician a wider likelihood of getting the results but without any real economic disadvantage to the payer.

Senator Morin: I do not want to belabour the point, but I can send you drugs in the same class where the price varies by a large factor. I am sure we can find them - ACE inhibitors, for example.

In that situation, let us say it is a hypothetical situation, how can we make sure that the cheaper drug is prescribed?

Mr. McDole: I would like to clarify that we are in a transition mode. Certainly anything post the introduction of the Patented Medicine Prices Review Board, that sets the ceiling, the price and the class.

Since we already have the lowest prices in the world practically, the likelihood of the price spread being much other than being clustered around that maximum price is pretty small. Where you see the greatest spread is where there is a drug that was launched before the controls versus after. There you see a greater spread.

Mr. Goodhand: With respect, senator, I would suggest that it is the other way around. It is not the absence of a strong Canadian medical device technology industry, it is that Canadians do not have access to the best in medical technology. It is an issue of the way we deliver health care that really determines the penetration or the availability of the best in the world of medical technology.

Going one step further, it is the nature of the Canadian marketplace for purchasing health care technology. That is why we do not have a stronger device industry.

Which of these two comes first? I am not sure. You are absolutely right, they are linked. They are clearly linked, and that is why, in my presentation, I was asking for not just a continued investment in health care research, but linking that to an innovative industry.

We have a handful of companies that have proven that they can compete with the very best in the world. Some of our major multinationals have played a significant role in taking products made in Canada, invented in Canada. I presented an award last week to Dr. George Klein, an electrophysiologist from London, a MEDEC award winner. His product had been taken and was commercialized by Medtronic and was made in this country. The question of access to that technology is a totally different issue.

Following up on the point of who represents the Canadian companies, there are regional associations; in the past, we were not linked. In the last nine months we have made linkages with those associations. We are also working with the Ministry of Energy, Science and Technology in Ontario, with Industry Canada, and we are starting a relationship with industry in Quebec to actually do industry building and working with the National Research Council.

I spend 35 per cent of my time on trying to create that stronger Canadian industry to capture the research that is done here in our universities and not just let that value go off-shore.

We are committed to doing that, but the absence of a strong device industry is not why the technology is missing from Canadian health care.

Senator Cordy: My question is for Ms Dunlop, and it is concerning the unpaid caregiver.

We have heard testimony from witnesses. It is true that most of the unpaid caregivers tend to be women. Also, in many situations, it is not a decision that they planned to take on. No one says, "I or the family will become the unpaid caregivers." In many cases, it is thrust upon them.

I am concerned about the support systems that we have in place for unpaid caregivers - you know, whether or not you get a break. We talked about respite care for the patient but almost a respite type of care for, in fact, the unpaid caregiver.

Also, in your documentation you talked about the tax system, Employment Insurance and employment policies. I wonder if you could expand on that for me just to clarify what you mean by all of those things.

Ms Dunlop: Sure. My thinking was around having a similar dispensation as we have for things like maternity leave or our compassionate leaves.

It is almost always women, although we do certainly have men who are thrown into the position, unprepared as well. However, if people are forced to leave the work force, then I think that we have to somehow support them. It is not always their choice.

We are limited in what we can provide through public programs to support them. People may or may not have additional third-party insurance to help them with some of the costs. They bear equipment costs, pharmaceuticals, the dressings and supplies - they bear those costs once they are home.

On one hand, it is very important to minimize the financial impact for these families. Equally important is to give them respite. One way to do that is, have a worker come into the home. Some families feel too guilty to put their loved one in an institution, even for a two-week respite. So they have to have that choice.

Senator Cordy: Not all family situations are the ideal situations for anybody to be in - let alone somebody who is very ill. Is there any mechanism in place to determine that this is just not a good situation for a patient to be in? Would your organization look at anything like that?

Ms Dunlop: From an organization's risk perspective, I am always saying, I am the first one to send someone somewhere else if that person should not be at home. We also deal with people who believe that they have a right to risk.

We have one case right now in which we disagree that this woman should be in her own home, but she is still competent and she insists that that is her right. So we have put in place a service agreement that states that someone has to be there before we leave and so forth. We have gone outside our current thinking to make sure that we can manage her successfully at home, but it has taken a lot of creative work by a lot of different agencies to do that.

The last thing that I would want for our organization and for our caregivers, is to have someone who is home, who should not be.

The Chairman: May I thank all of you for coming.

Our next panel is Mr. Jeff Lozon, President and CEO of St. Michael's Hospital; Gary O'Connor, the Executive Director of the Association of Ontario Health Centres; and Dr. Ken Sky, the President of the OMA.

Dr. Kenneth Sky, President, Ontario Medical Association: Thank you, Senator Kirby and committee members, for the opportunity to speak this afternoon. I also want to thank the committee for conducting these cross-country hearings and for having the courage to tackle the difficult and complex issues surrounding the future of health care in Canada.

The committee will also hear from my colleagues from our national body, the Canadian Medical Association, in the near future. The OMA shares common concerns with the CMA about the future of health care, and we hope that you benefit from both our presentations.

The Ontario Medical Association has been a leader in advocating frank and open discussion on health care funding for both this province and the country. Our projects are outlined in the packages I have submitted.

Throughout the process, our position on health care funding has been consistent. It is not enough to simply look for better management models for our health care system. We must be open to other funding models that adhere to the principle of universality. Our dialogue will move forward within that framework. Detailed information regarding our work in this area is available on the OMA Web site

Chief among the many issues that are important to this discussion is the current physician human resources crisis and growing evidence that physician shortages will become even more severe in the near future. The implications of these current and projected shortages are clearly critical. The OMA has provided Senator Kirby with useful statistics on this issue. I have also enclosed in our package an article published in this month's Ontario Medical Review entitled "Physician Human Resources in Ontario: The Crisis Continues." I apologize for the late delivery of that, but it was only published last week. I encourage every member of this committee to read it.

Another issue of importance to the current debate is the role in the health care system of registered nurses in the extended class, known as nurse practitioners. The OMA has recently struck a task force to examine the working relationship between physicians and nurse practitioners. We hope to have the final report completed by the spring and we will forward a copy to the committee for your review.

I would briefly like to address the issue of physician remuneration. A lot of debate has ensued surrounding the means by which physicians should be compensated for the medical services they provide. Let me state for the record that the OMA strongly supports the physician choice of remuneration. No one-payment model suits all physicians. The OMA is a leader in exploring alternative payment mechanisms to support physicians in their respective practice environments.

We recognize the challenges governments have as payers in providing care for all of their citizens. To this end, we continue to work with the government to extend access to doctors in all areas. We are negotiating unique contracts to support doctors practising in different sized communities, in remote and under serviced areas.

We also continue to make progress regarding primary care reform in Ontario. The Ontario Medical Association has been actively involved as a pioneer in this initiative, and we currently have six pilot sites around the province in various stages of development and evaluation.

The OMA's governing body will meet on November 10 to review documentation concerning the details of this voluntary expansion. When I say "voluntary," I mean for both patients and physicians. The key component to the success of primary care reform is that it remains voluntary.

While there are many subjects to address today, I would like to take this opportunity to focus on a specific aspect of primary care reform, the role of information technology, IT. The Ontario Medical Association agrees with your committee's assertion that information technology is the most important aspect in the development of a fully integrated health care system. I have special interest in this topic as I currently serve on the Province of Ontario's e-health committee, which is studying the role of information technology in health care. The OMA believes that the development of an information technology system that provides better access to health care information will assist physicians and other health care providers in offering better care to our patients.

I will address three specific aspects in my presentation: the role of the provincial government, the role of the federal government and the role of physicians and, ultimately, the doctor-patient relationship.

We firmly believe that each provincial and territorialgovernment must take the initiative and the financialresponsibility for moving forward on information technology. Their role should be to drive this process. Health care is a provincial jurisdiction. Each provincial government should take a leadership role in developing the necessary technology to move forward toward information sharing. We know that various provincial IT initiatives are at different stages of development.

Currently, in Ontario, the provincial government is developing its own Smart System for Health. This initiative is putting in place the secure IT infrastructure that will enable various stakeholders to develop IT solutions based on connectivity and information technology and sharing.

At the same time, the OMA is working in co-operation with the Ministry of Health and Long-Term Care. We are developing an Internet-based system for the primary care providers, the physicians of this province.

This system will enable physicians to have connectivity by building onto the Smart System for Health. This will create a connected and integrated system that would function with other parts of the health care system. We are calling this initiative the Ontario e-physician project. We will provide more information on this initiative in the near future. We foresee the medical office of the future not only holding important personal health information, but also providing a resource for data sharing for multiple sources, including imaging, labs, hospitals, pharmacies, et cetera.

I have only given you a snapshot of our current provincial IT developments. While we firmly believe the provincial government must take the lead on this initiative, the federal government also has an essential role to play. In our view, the role of the federal government is threefold.

First, the federal government must develop national standards that each province and territory should adhere to when developing their own information technology systems. By establishing these standards, each province and territory is provided with the road map required to ultimately drive their own projects toward producing a national framework.

Second, the government must provide funding to each of the provinces and territories to enable them to proceed with developing the necessary technology. I acknowledge that this is a very costly venture for all levels of government, but in theend, the benefits of a seamless and standardized information technology system will certainly outweigh the high costs associated with it. MRI technology and other diagnosticequipment have always been considered a cost driver in our health care system. We consider the development of information technology as a cost saver in the long run. While there will be significant start-up costs, information technology will ultimately result in greater efficiencies in the system.

Third, and most important, the federal government must have explicit policies and procedures with respect to personal health information that are held and shared electronically.

This leads me to my final point, the role of physicians and the doctor-patient relationship. In our view, the key to the success and, ultimately, the expansion of any IT implementation will be largely determined by the physician-patient relationship. Patients look to their physicians for assurance and direction. If we, as physicians, can assure patients that their identifiable personal health information is safe and secure, the patient will consent to having it released into a shared network. I cannot stress this enough to the committee. Patients must be able to speak openly and freely and feel secure enough that any identifiable personal health information they provide will be safeguarded. If this does not occur, the future of IT in health care delivery will fail.

IT can be as sophisticated and technologically advanced as you wish, but the core component must be the built-in safeguards that will protect the patient's personal health information. The greatest challenge for those of us who want to move forward to a new way of managing health information is to achieve buy in, support and, ultimately, trust from our patients.

Once this IT infrastructure is developed, who should control and manage the medical records of the millions of patients whose information will be electronically recorded and stored? The OMA firmly believes that physicians should act as the gatekeepers for this health care information. Physicians must continue to play a key role in the governance of the storage and distribution of personal health information. In fact, our own internal polling indicates that far more Ontarians want physicians, notgovernment, to control and manage any computerized system of medical records.

The OMA represents 24,000 physicians, but we also advocate on behalf of the people of Ontario. We know that two-thirds of the public has concerns that personal health information will end up in the hands of the government, insurance companies and employers. There is also concern that international pharmaceutical companies could access personal health information. We must ensure that these concerns will be unfounded.

I have raised a number of issues concerning information technology with you today. As you can see, it is essential to the success of any IT implementation that we all work together to create a seamless, standardized and secure system that will ultimately provide better care for our patients.

I again want to thank the committee for the difficult and vitally important work it is doing. I sincerely hope that the debate you are stimulating will be ongoing and that the government will extend your mandate to address future challenges that we, as a nation, have not yet even begun to understand. The OMA looks forward to contributing to the debate on the future of health care on an ongoing basis.

The Chairman: Our next speaker is Jeff Lozon, who is the President and CEO of St. Michael's Hospital. He is also a former Deputy Minister of Health in Ontario and, maybe even more importantly, a terrific golfer.

Mr. Jeffrey Lozon, President and CEO, St. Michael's Hospital: Honourable senators, as some of you may be aware, I have been involved in the health care system in various leadership capacities for more than 20 years. I am currently the President of St. Michael's Hospital. I was fortunate enough to serve the Province of Ontario as Deputy Minister of Health and Long-Term Care from 1999 to 2000. However, I am not here to represent either of those organizations. My comments are based on my combined experience in various roles throughout the system in four provinces and under governments of all stripes.

Let me begin by congratulating you on the work you have done to date. Your report should be required reading for all students and health administration and for health care policy-makers. You provided an excellent history of how we have arrived at this place and time, in health care terms. You have provided an interesting international context from which our system can be viewed. You have also been wise enough, however, to acknowledge that the Swedish, American or Australian systems could not be replicated in Canada Health care systems are endemic to each country and society, and they reflect the values of the society they serve, explicitly and implicitly.

Most importantly, your last volume raises fundamental questions about the financing and organization options that must be considered in shaping the future system. I have no doubt that you raise questions and proposed directions that virtually every elected jurisdiction has considered in the privacy of its own deliberations, but does not speak about openly for fear of losing the next election.

It is one of the real tragedies of this debate that because the current system has reached iconic status, as you point out, we cannot speak openly about the profound changes that are required.

You have created an enormous contribution by opening up room in the policy debate. I note that you join the chorus of others, such as the Conference Board of Canada and the C.D. Howe Institute, in suggesting that profound, deep and perhaps sometimes painful change are required.

You should know that the system is very resilient, and we have seen many reports come and go. The distance you have travelled to get an honest discussion of options is only a fraction of what must be done if the system is to endure and to serve Canadians into the future. A deep and enduring political courage, a clear, thoughtful and wise policy and, finally, focussed and determined execution are necessary into the future.

In the five minutes allotted to me, I cannot comment on the full range of the review that you have undertaken. Suffice it to say, I agree with your directions, quality and ethics. I do, however, want to reflect upon four aspects of your report.

First, I want to present another barrier to the system change that you have proposed. In my view, this particular barrier may be more important than any that you have raised to date, and, based upon my experience, real change would not be possible without addressing this barrier.

Second, I want to provide options on specific matters related to organization of the system, specifically, primary care reform and regionalization. If time permits, I will comment on the federal role as offered in the Interim Report, Volume Four, and comment on certain aspects of the financing option.

My first point is based on the urgent need for predictability and stability in the direction of our health care system, and it is driven by the need to shelter the system from the daily parry and thrust of elected politics. One of the least desirable, most difficult and important jobs in our society is the leadership of the health care system at the provincial level. Without more stability and certainty, the best reform options and best reform policies will fail. Consider the following: in Ontario there have been seven Ministers of Health in the last 10 years and seven Deputy Ministers of Health.

Three months as a Deputy Minister gives you seniority over half your colleagues, and going beyond one year constitutes long service. The job expectancy of a Minister of Health is 15 months, and a Deputy Minister is about the same. Although Ontario may be an extreme example, it is by no means atypical.

It is impossible to take the system forward with that type of turnover, and long range planning is impractical. Moreover, often the greatest expertise in the system does not reside in federal or provincial ministries, and as such, governments cannot effectively carry out the tasks assigned them.

In place of the current arrangements, I urge the committee to consider the recommendation to create independent, provincial-public, non-profit bodies to run the health care system. These bodies would consist of boards of directors appointed by the government with defined terms of service. They would be supported by a staff of experts and compensated commensurate with the challenge, capabilities, and direction of this system. These corporations would be charged with service delivery, financing and organization. They would be accountable for achieving provincial goals such as may be embodied in a "guarantee of care" approach. The development of such goals would continue to be done by the elected officials. In short, the bodies would exist at arm's length from the political process, but would be accountable for the delivery of a first class health care system now and into the future.

Other activities, such as health human resources planning, could continue to reside at the federal or provincial level. However, the bulk of the current departments of health would be replaced by independent expert agencies. In this way, stability and direction could emerge, distanced from the day-to-day pressures of electoral politics, while continuing to try to guarantee high levels of care. Without greater predictability, and insulation from daily headlines, even the best reforms will not be implementable and some of the major changes that you are thinking about will just not come to fruition.

Let me turn my attention now to the matter of organization. I will focus my remarks on two aspects of organization, primary care reform and regionalization.

Primary care reform has been a prominent part of every major system review conducted in the last 20 years. Every health care practitioner that has studied this area knows that as long as the current system remains, real reform will be very hard.

Why then, despite this knowledge, is the system still a cottage industry based on a piecework financing arrangement with little or no characteristics of a modern service industry? The answer to the riddle is complex. In part, it is because such a reform is an insider ball game; considerable interests are at stake. The reform must take place over many years and the public is more likely to support the professionals who may object to this change, as opposed to the planners who propose it. Still, as a health care professional, I can only support active movement toward a reformed primary care system.

The second matter I want to comment on with regard to organization is regionalization. It is absolutely remarkable that so many consider this as an essential element of successful reform, given that it has never been evaluated and there is no evidence to suggest that it works any better than any predecessor arrangement. There is no real health care evidence that patients benefit in a regional system. There is no system benefit as evidenced by lower costs. In an environment where evidence-based medicine is in vogue, this is one of the least studied and most touted changes currently extant.

However, we do know some features of regionalization as practised in this country. It is incomplete as practised anywhere in Canada since no regional system, that I am aware of, includes physician payments in the defined regional envelope.Furthermore, regional systems have not worked in large urban settings where patient mobility is high and consumer choice is at play. I urge caution on the introduction of further regionalization. The jury is still out.

Let me reflect for a moment on the federal role. The committee has described a renewed and expanded role for the federal government in the health care system of this country. In general, I am in agreement with that role. However, health care is not known for its ease of federal-provincial relations, and it is probable that the role will meet with stern opposition.

Did the committee consider either of the two extremes in this regard? One being, having the federal government get completely out of the health care process, transferring its current limited role to the provinces in return for further tax point transfers and abandoning the current Canada Health Act. The other would beto ask the provinces to upload their current health care responsibilities to the federal government and create a truly national system. These options are cleaner, more easily understood and may curtail the endless jurisdictional debates that now characterize our health care system.

While no doubt dramatic, they are no less likely to emerge than the renewed roles proposed by the committee, particularly in the areas of infrastructure, evaluation and population health, all of which I think will cause fairly substantial federal-provincial debate. Your suggestions here would help generate vigorous debate.

In any event, a greater federal role must be supported by amore knowledgeable federal public service and a long-term commitment. One of the greatest fears of provincial health ministries is that the federal government will support the system in a time of surplus, only to remove that support in a time of scarcity. A greater federal role, if it is envisioned, must be negotiated and understood to be permanent.

In addition, the current federal Department of Health needs substantial bolstering in the real world of health care to play the role contemplated in your report.

I look forward to your questions.

Mr. Gary O'Connor, Executive Director, Association of Ontario Health Centres: Thank you, Senator Kirby and committee members.

As a whole, Canadians are proud of our health care system. In comparison with other countries, Canada's commitment to a universal, accessible, portable, comprehensive and publicly managed health care system exemplifies the values of equity, fairness and justice that symbolize Canada.

Its future is an issue of great importance to all Canadians. We commend the Standing Senate Committee on Social Affairs, Science and Technology for taking on this task of examining Canada's health care system. As part of this work, we recommend that the committee also closely examine community health centres. I work for the Association of Ontario Health Centres, and I represent 68 such community health centres in the Province of Ontario.

In commenting on the interim report that the committee has created, I want to comment on four specific issues: first, financing and refocussing of Canada's health care system; second, primary care reform; third, expansion of health care services, and fourth, the population health role.

On financing, we support a comprehensive, publicly funded health care system that is accessible to all Canadians. We do not agree that user fees will enhance health care delivery or control costs. We also believe, as shown in the Australian experience, that user charges or any greater reliance on for-profit insurance systems will end up being more costly.

In Quebec when elderly people and people on welfare had to pay user fees for prescription drugs, they took less medicine, which resulted in sicker patients and more visits to hospital emergency departments. User fees help reduce costs in the short term, but eventually lead to more spending because more people neglect getting treatment earlier.

For-profit organizations, by their nature, are motivated mainly by profit and not necessarily by the best interests of patients. Studies have shown that their administrative costs are higher than those of their not-for-profit counterparts, without necessarily providing better care. In a two-tiered system, waiting lists for public patients become longer, as physicians work more hours in the private sector.

We believe that there are other ways to achieve the objective of a more reasonable use of resources by both providers and users, for example, providing integrated interdisciplinary primary care.

Not all patients must be seen by a doctor. This was shown by a recent review of service events by providers in 20 community health centres in Ontario, where 32 per cent of the services were given by physicians, 43 per cent by nurses or nurse practitioners, 9 per cent by social workers, 4 per cent by chiropodists and 12 per cent by others.

Before considering a two-tiered system, we recommend the committee thoroughly explore the research, showing how two-tiered systems increase waiting times and cost more. Publicly funded health care systems can be made more effective and efficient, and reports such as the Clair Commission and the Fyke committee point the way.

Under refocussing, we commend the Senate committee for recognizing that we must change the focus of our health care system from an illness-based model to a more holistic model of supporting the health of Canadians. The National Forum on Health revealed that Canadians broadly endorse this redefinition and redesign.

Central to this redefinition is the reform of primary health care. We commend the federal government's agreement with the provinces to contribute $800 million to primary health care reform and this committee's support for health care delivered by interdisciplinary teams of professionals.

Community health centres in Ontario have been providing precisely this kind of care for 30 years. We strongly recommend that the federal government promote the community health centre model as described in our paper. I will not go through the list of elements, but they are there for you to read.

Although the community health centre model is mentioned in your interim report, the committee does not appear to have considered that in its discussion of cost-effective options. We suggest the committee should investigate this aspect.

Community health centres are demonstrably more economical than fee-for-service models and practice. In the early 1980s, Saskatchewan Health researched the public cost of 200 fee-for-service urban doctors compared to those at community clinics. Clinics, on average, cost 17 per cent less than the private physicians in terms of lower prescription costs, lower use of services and lower levels of hospitalization of patients.

In Ontario, the Ministry of Health has just completed a strategic review of the community health centre program. Though it is not yet a public document, some details have been released. Key findings presented to the public so far show that community health centres, CHCs, exhibit desired primary care reform features such as alternate payments, interdisciplinary teams, community involvement, 24/7 service and availability, et cetera.

CHCs are accountable through community board governance, service agreements and accreditation. They meet ministry goals and deliver on ministry strategies. They have a strategic role to play in primary health care, particularly in serving thedisadvantaged populations and populations facing access barriers.

Family health networks will not reduce the need for community health centres because family health networks are not designed to improve access for disadvantaged groups. CHCs are one way to meet the needs of under serviced areas.

We strongly recommend that the federal and provincial governments recognize, support and foster the community health centre model as an ideal model for provision of community-based primary care.

On the expansion of health care services, we believe in the need to incorporate home care, palliative care and the cost of prescription drugs under the principles of comprehensiveness in the Canada Health Act. We support the national pharmacare initiative and the national home care program. Both of these programs would reduce costs and pressures on the acute system and on institutional long-term care services.

In the population health role, Ontario's community health centres have devoted their services to community partnerships and to community development as a means of dealing with social determinants of health for the last 30 years. We are strong advocates for communities and many health care services and issues within those communities.

We agree with the Senate committee's assertion that the population health role of the federal government should focus on illness prevention rather than treating people once they are sick. However, we believe that there is a further role for the federal government in population health.

In your report, you reference the determinants of health, but you have not taken the body of work to heart. Canadians enjoy a high standard of health due to many factors that are outside what we traditionally call health care. Over the past century, the most dramatic increases in health and wellness have come from sources other than the curative arts. They have come from safe drinking water, housing, income supports and the use of seat belts, to name a few.

We urge the committee to have the courage to consider its mandate as broader than commenting on things that can be achieved by Health Canada. True health care comes from an integrated approach, which would be achieved by partnerships with other ministries within the government and with other governments.

Canadians need affordable housing, adequate incomes, food security, social supports and education. Attention to these issues on the federal level will help to sustain the health care system by helping to keep people healthier longer.

Finally, our last three recommendations are based on these facts. We recommend that the Senate committee should advocate expansion of the federal government's role in population health to include attention to affordable housing, income security programs, social supports and education. These issues cross ministerial and government boundaries, therefore they require that thegovernment think outside the box.

In addition, we strongly recommend that the federal government re-enter the field of social housing for the general population through strong federal social housing programs. Safe, affordable, sustainable housing is one of the most significant factors contributing to healthy individuals, families and communities.

Finally, we recommend that the Senate committee advocate that the federal government must reaffirm its role in the provision of health services to Aboriginal peoples.

The Chairman: I would like to ask Mr. Lozon one question, partly because he said he might get into the funding issues and then did not, and partly to ask about an option that has been raised with us by various people across the country, which was originally started with the National Forum on Health. That is the question of whether funding ought to follow the patient rather than the institution.

The net effect of that is to separate the payer function from the provider function so that patients would go to any institution they wanted to be treated and the payment would still come from the government. The patient, in that sense, is independent. If you do that, you obviously have to separate the evaluator function as well.

Have you ever thought about that model? What do you think of the idea? You might want to use that as an entree into commenting on some of the other funding options that we outlined as options.

Mr. Lozon: A number of jurisdictions, most notably Great Britain, have moved into a purchaser-provider sort of split, which is the euphemism for what you are talking about, whereby a group of individuals deals with the purchasing of the function and a number of providers provide that function. It has some merit because it introduces a certain amount of accountability into the system and an alignment of incentives that we do not really have.

We are not set up to do that right now. We are not set up in the integrated fashion that we must be set up in, to actually make it work.

I thought you would ask me more questions related to individual participation in the system from a financingperspective. I did have some comments on that, relative to your report.

I actually support greater individual involvement in the financing of the health care system predicated on the assumption that the most vulnerable in our society will continue to receive care and service without financial barriers. Your report could be stronger in this particular regard when you lay out the options.

I support more personal payment into the system because, generally, a free good is seen to have no value. Through a series of technological breakthroughs and successive political promises, we have created a sense of entitlement that the system cannot satisfy.

The purpose of greater personal payment through mechanisms laid out in the report would not only be to provide additional resources but, more important, to create an understanding that the system is not free and should not be treated as a renewable resource.

Senator Morin: Dr. Sky, you feel very strongly about privacy of health information. Would you consider an exception for research?

Dr. Sky: No, Senator. The information belongs to the patient. It does not belong to the greater good of other people.

If you separate that ownership, then you will interfere with the doctor-patient relationship in a very serious way. It is very difficult for me, as a physician, to obtain trust from my patients and to get them to give me all of the details that I need to treat them properly. If, for any reason, they should suspect that identifiable information about themselves was going to be transferred, for whatever good purpose, to a third party without their consent, they might hold back vital information.

Senator Morin: You say the epidemiological research outcome studies for the improvement of the health care delivery system - report cards on given institutions - the outcomes of Dr. Keon's heart surgery as compared to the outcomes of some other hospital, would be impossible.

Dr. Sky: Not at all. Many of the epidemiological studies can be done without identifiable information, and that is the purpose of keeping the health information with the physician. Allow the identifiers to be scrubbed clean so that most of the information can be used without that. If the patient consents to the use of that information, identifiers can be added, but there should never be an implied consent. There should always be an absolute, identified consent.

Senator Morin: Mr. Lozon, as usual, you are very clear and very provocative.

As you know, the Claire Report has suggested a health care agency that would administer the health care program in Quebec, and surprisingly enough, the minister did not put it into application yet, and I doubt very much if he will. This is an idea that has been going around for a little while.

Coming back to the federal role, of course we have a mosaic of health care systems as it is already, and as time goes, each provincial system becomes quite different. That is a fact.

All studies have shown that Canadians support, by a very strong majority, a federal role in the health care delivery system, and they believe in national standards, whatever that means. There is also the matter of the poorer provinces having a presence. Health care for Canadians is not treated equally by the health care system. That is a major issue, and it will be difficult to get around that. The easier way out - and I thought about this - is to just let each province have its own system, as long as we have certain guidelines.

The provinces would be more prepared to go about that if we had stable funding at the national level. That is one element. How we get that is another issue, but if we had the possibility of insuring stable funding to the provinces, it would be easier.

I agree with you on the regionalization of health care. All that does, in my experience, is add an extra layer of bureaucracy. That is about all it does.

You say there is no evidence for that. Do we have evidence for primary care reform? Do we have the same type of questions concerning regionalization?

Mr. O'Connor, I do not know if you listened to the previous witness, Ms Dunlop. I was struck by a good paragraph in her report: "We believe that private for profit organizations are an essential partner in the future of Canadian health care." She goes on to say:

We have proven ourselves as valued stakeholderorganizations providing excellent health care within a context of economic discipline. We do focus on efficiency and effectiveness. Profitability means reinvestment in our health care system...

That is in the form of capital spending.

We were told that capital spending is one of the problems of our system. I notice, in your own report, that recommendation number one is not-for-profit, as though that were something you were very much against.

Mr. O'Connor: I can only speak from my experience. I was not here for Ms Dunlop's presentation. I was only here for questions and answers.

Arguments can be made for profit and not-for-profit. When you compare studies in the United States between for-profit organizations and not-for-profit organizations, the outcomes are not dramatically different.

Senator Morin: I can bring you evidence for the opposite. You have quoted studies that show that, but there is recent evidence showing that for-profit is better. You just quote what you want, really.

Mr. O'Connor: That is fine. We could have an argument on quotations. My point is that when you consider needs, you have to examine what the needs of the patient are. My experience is the needs of patients are better served in a not-for-profit system.

Mr. Lozon: I have a couple of comments to Senator Morin's views.

I understand that Canadians would like a national system. At the same time, my question is, what do the provinces want? The simple reality is that there is a certain amount of federal-provincial wrangling and a debate that goes on. The creation of a national system requires not only that Canadians and the federal government want it, but that the provinces also want it. That would be more likely in an environment of stable federal funding. That has to be knowledgeable and expert funding as well, and not just in selected areas.

I will give you an example. Although we applaud the introduction of $1 billion for health technology, you should be aware that generates additional operating costs that will ultimately be borne by the provinces, or the institutions that are supported by the province.

Senator, I was not aware that the Clair Commission had proposed an independent agency, but I think that addresses the fundamental question. The fundamental question is we have created - and I will use Ontario as an example - a health care system of $23 billion. We asked the system to fund institutions, individuals. We ask it to plan thoughtfully. We ask it to provide effective capital resources. We ask it to conduct research. We ask the system, the Ministry of Health, to do effective human resources planning, and I think you have probably heard enough in your cross-country travels to indicate that that is not well done in any particular jurisdiction. We have simply asked too much of the particular system, particularly in an environment where the turnover of the leadership is so rapid. There is a very big gap between good ideas, helpful intentions and execution. That is the point I was trying to address.

The Chairman: On that score, does your model separate planning from implementation? In other words, would you leave the planning function in the department and the actualimplementation and overseeing management function in the agency, or would you put the planning function into the agency as well?

Mr. Lozon: I would put the planning function into the agency. I would keep certain elements of the current responsibilities within the ministries separate and apart from that. A good case in point would be human resources. Human resource planning at a federal-provincial level is not well done, and in part, it is not well done because it always gets confused with, or does not get the attention that is required, given the enormous operational issues that exist.

I think that your group has considered human resources planning as potentially federal-provincial work. That it would be something that would stay with elected officials, as would the establishment of high level goals: X amount of time for waiting lists for cancer, X number for cardiac surgical wait times, access to primary care physicians, as in the "care guarantee" notion which you have outlined in one of your option papers. Establishment of goals would continue to rest with a government.

The Chairman: The overall system performance measures would rest with the ultimate party responsible, which is the government.

Mr. Lozon: Right.

Senator LeBreton: I was thinking, rather "tongue-in-cheek" when I heard Mr. Lozon talk about keeping this away from elected politics, that we have very much appreciated your indirect support for an unelected Senate.

In any event, my question is for Dr. Kenneth Sky, on the whole notion of information technology. While I certainly concur that it should not be in the hands of government, I would like to know why you think it should be in the hands of the physician and not the individual patient. If I have my own passport and my own Social Insurance Number, is it not something that I, as the patient, should have control over, rather than the physician? I am curious as to why you think a system of having it in the physicians' hands rather than the patients' would be better.

Dr. Sky: Senator, I must point out that I am a real doctor and I actually do take care of patients. In my real life, what I find is that about 20 per cent of patients in Ontario show up, at least in my office, without their health card. When it comes to children, probably 50 per cent who show up, and the other parent has their card.

You made some allusions with the previous presenters to having a "smart card." Our experience with that so far has been that smart cards are really quite dumb. They are very fragile. They are easy to destroy or break or manipulate, and all in all, patients just do not have the wherewithal to keep all of that. You could not store enough information on a card in a strong enough form to keep it portable.

We feel that if you kept information in a central repository, usually with the safeguards that most of the information is actually in the hands of the treating physician, you can perform very much better with the information and in making sure that it flows to the point of service in a timely fashion. That means bringing in all of the rest of the health care information.

In Ontario we have insured with our new system that we will be able to interface with our Community Care Access Centres, CCACs, with hospitals, labs, and even with imaging centres so that everything will be brought together.

Senator LeBreton: Would a patient who, for whatever reason, keeps jumping from one doctor to another or trying different pharmaceuticals and different pharmacies be caught by that system?

Dr. Sky: I would not want to refer to that as "caught," but such an individual would be identified. Certainly that will be part of the savings and the efficiencies that we will have. It will also allow us to prevent duplication of costly diagnostic testing.

Senator LeBreton: Do you means testing, such as blood tests?

Dr. Sky: I refer to imaging tests, in particular, which are expensive.

Senator LeBreton: How does that impact on a patient's right to choice? If you, as a doctor, have a person's file and he or she, for whatever reason, wants to go to a different physician, how are the records transferred out of your system? Is that all on a central system?

Dr. Sky: It will be transferred in the blink of an eye. It certainly can be quickly identified.

We will have a few things in place. For security of the whole system, there will be a 128-bit SSL encryption, which is as good as the banks use, and that should prevent anything short of very sophisticated hackers from getting in.

Certification of the users and of the patients is the next critical step. We think we have the public key infrastructure, PKI, for certification of the users. How to identify patients is still a very critical issue. We have not yet ascertained whether we will use biometrics or some other form of identifier.

Senator Keon: I thoroughly enjoyed all three of your presentations.

I would like to discuss a concept, if I may I will start with you, Jeff, and I ask Dr. Sky and Mr. O'Connor to comment as well.

It is ironic that I wrote a brief when the restructuring commission was struck in Ontario recommending that the hospital system not be touched until we had a concept of regionalization or we would be into a disaster. I am afraid that article, or that brief, will surface tomorrow in the Ottawa Citizen.

I have heard of your ideas about the independent, provincial, non-profit bodies even when you were Deputy Minister, and it is a truly interesting concept. In fact, it is just a much bigger concept of regionalization.

One of the conundrums we have run into is, we are trying to apply models and we are trying to find models that will fit everywhere. Certainly, trying to design a regional model for Toronto would be a nightmare. However, a regional model in Ottawa-Carleton would work very well, but it would not be necessary if you had the independent, provincial, non-profit body fundamentally doing the same thing on a provincial-wide basis.

Let me drill down for a minute. Can you envision this body dealing with the panacea of health on a population health basis; in other words, dealing with the effect of change of the population health of Ontario? To do that, it would have to engage people like Mr. O'Connor. We would have to solve the primary care piece, Dr. Sky, and in my opinion, that cannot be solved until there is an alternate payment plan for primary care physicians. That is just my opinion, but I want to hear you refute that opinion. I think the big barrier to primary care reform is that we do not have a remuneration plan for primary care physicians.

Mr. Lozon: Senator, one of the reasons I made therecommendation that I did was not only because of the issue around stability - which I think is quite real and quite profound - or the lack of stability, but simply that the changes you have even alluded to in your question are difficult to make in the current environment for a Minister of Health, whether he or she is in Regina, Winnipeg, Queen's Park or Halifax. The changes that are required are so profound and so dangerous and they take so long to get through the system. It does take a long time because this is a very major system overhaul - and they often just do not get done.

The notion behind this is not only to create greater stability, but also to create the platform where those types of activities can get done.

Absent a burning platform such as occurred early in the 1990s around provincial finances and federal finances, many of the things that have occurred - perhaps regionalization in other provinces, the Health Services Restructuring Commission in our province - may not have gotten done, in part because the system requires so many trade-offs that the way forward is very difficult to achieve.

I recommended that as a means of separating that out, I often used to wonder, "Is the Minister of Energy responsible for the lights that go on or off in the Royal York Hotel?" The answer to that is no one ever asked the Minister of Health why the lights go off in the Royal York Hotel. However, it is quite possible that the Minister of Health could be asked why a mother was transferred from Taber, Alberta to Montana for service, and for the minister to be able to take either the political credit or the political damage for that particular activity. It is an impractical system that we have set up, in that way.

Senator Keon: Gary, would you comment on what you would think of regionalization as it affects the population of, say, 1 and one-half million people or 2 million people? Would it be a good thing or a bad thing for your concept?

Mr. O'Connor: One of the issues with regionalization is scale. In P.E.I., regionalization makes sense. In Toronto, it does not. It is hard to comment on your question with that overlay.

A lot of planning is now turning to community level planning and examining what makes sense for communities. Community health centres have been doing this for 30 years, helping to create vibrant, strong communities and, through that, vibrant strong regions and provinces and countries.

Regionalization, if it is done in a way that serves patient and community needs, is effective and helpful. If it is done in a way that serves provincial and political needs, it is often done in a way that is not helpful to individuals and communities.

I echo what Jeff said. We have to take the politics out of health care, and we have to find a way to make health care certain of a long-term process, that is longer than the electoral process.

Senator Keon: Ken, would you comment on how you could implement an APP for family physicians?

The Chairman: What is an APP?

Senator Keon: That is an alternate payment plan. Could you comment on a way to put family physicians on salary for a region that would fit with the community resources in the region, the community clinics, the primary care piece and so forth, so they could work as part of these teams? Can you do that without regionalization?

Dr. Sky: Let me first say that as well as being President of the Ontario Medical Association, I am a director on the board of the Canadian Medical Association and I speak frequently to my colleagues right across Canada. It has been their impression that regionalization has been a disaster wherever it has been implemented. It is a system by which governments off-load responsibilities for the shortcomings in the system and tend to just cultivate all the good parts of it. I am not sure that regionalization is necessary for our system, as we have it now.

When it comes to primary care reform, or any other name that goes by - in Ontario it is called the Ontario Family Health Network - let me say, in response first to Senator Morin's question, there is no proof that this works. That is why we have insisted that there be constant evaluation of the system. We have had the first report of that in Ontario. It is an iterative process. We keep changing the model to deal with the shortcomings that we find.

As to the payment model itself, with regard to primary care reform, we are using two or three different models now in our pilot sites. We have a blended form. We have an alternate payment form, which is essentially equivalent to a salary, and we have a reform fee-for-service model. We are using all three systems. We are testing all three of them to determine which one works.

What we have found is that no one system works for everybody, that what patients want and what the doctors want varies from area to area. We must examine them to determine if we can work within three or four models. In fact, that is exactly what the Council of the Ontario Medical Association will contemplate on November 10 when it examines various payment models to determine whether they make sense for the physicians of Ontario.

Senator Keon: Jeff, you were, more than anybody else, successful in getting the $1 billion out of the federal government for changing technology. I recall talking to you when that was coming up.

I am of the impression that if we are to have real change, we must have some real money behind it. I go back to the change that occurred in the 1960s when the health resources money came on stream and medical schools and medical centres such as McMaster got built at tremendous cost. When you think of it, $100 million in 1965 dollars was a huge amount of money.

What do you think of advocating to the federal government - with the same federal-provincial understandings that it had for the health resources money so that provinces can cope with what comes after - that it provide a huge block of funding for change to permit the system to adapt to the times we are in, instead of having everybody limp along from day to day just trying to cope with what they have?

Mr. Lozon: Senator, I use a quote from time to time by Senator Dirksen, who said, "A billion here and a billion there - pretty soon you are starting to talk about real money."

In one of my volunteer capacities, I am President of the Association of Canadian Academic Health Care Organizations, which is the national organization representing teaching hospitals and teaching regions across the country. I ask the committee to consider whether these organizations and the medical schools with which they are affiliated should not be seen as national resources.

People who train at the University of Toronto or the University of Saskatchewan end up practising everywhere in this country, and there has been an enormous commitment by the federal government to the innovation of research agenda through the Canada Research Chairs, the Canadian Foundation for Innovation and the Canadian Institutes of Health Research. That is taxing the resources of teaching organizations and faculties of medicine.

I was reading carefully through your expanded federal role to see whether the committee would consider moving these organizations into more of a national role because, in fact, the activity that we perform, not our service activity, but our education and research activity, really does embrace Canada from coast to coast.

Senator Robertson: Mr. Lozon, it is refreshing to have an ex-senior civil servant speak honestly about the system.

I want to talk for a minute about the independent non-profit boards throughout the system. There have been various references to something like that over the years.

My concern, sir, is that someone has to appoint members to these boards - and never underestimate the ability of politicians to get certain people on boards. Understandably, the public is always suspicious of board appointments by the government of the day, sometimes with good cause and sometimes not with good cause.

If we could figure out a way of having a totally independent, non-profit board, that would be a major step forward. I am suspicious that it would take the good. Lord himself coming down to earth and picking appropriate people to do so without interference by politicians. What keeps running through my mind is how would we get those people there. I believe, regardless of what this board did, that people would say, "Well, that board was appointed by so and so, and they are at fault and out they go," which is often very reasonable.

Have you thought that through? How you would get an independent board?

Mr. Lozon: Senator, I want to make an observation before I comment on your question.

I have enormous and deep respect for the people who are elected and who end up in the positions running our health care system. The colleagues with whom I worked in the Ministry of Health and Long-Term Care were extraordinarily talented, very hard-working and committed. Like most things in life, things do not fail to work because there is human error; they fail to work because we have created a system that does not work.

I have thought a little about the notion of independence and how to achieve independence. One suggestion would be to have the board appointed by an all-party committee of the legislature. I am not sure anyone would ever go for that. We are talking in abstract and theoretical terms, of course. That would be one notion.

I would have to leave that to people who are more knowledgeable about public policy direction. I am more familiar with the health care circumstance. Big change is required, which is tough to make. It takes a long time to work issues through, and we do not have the structures and the processes that allow those things to happen.

Senator Robertson: I agree with you totally in your observations.

Dr. Sky: Senator, we have been suggesting for a long time, at the Ontario Medical Association, that there be an examination of other systems around the world, in particular, those of the OECD countries. We do not believe that all the answers to health care are found here in Canada. There is no one perfect system. There must be consideration of all the others to try to tease out the best parts from each.

If you were to subscribe to Mr. Lozon's theory that what we need is an overseeing matter, I would recommend that you look at the French system. In France the people who run the health care system are at arm's length from the politicians. They still have to report to the politicians, and the politicians still set the policy. There is a way to do that It is difficult to compare our countries because we are a confederation and France is a single country that is run differently. By examining different models around the world, we can come up with ideas that would be appropriate for Canada in the 21st century.

Senator Robertson: Thank you for that. As you probably know, the committee has held video-conferenced meetings with a number of countries to discuss their health systems. Perhaps we should determine if something there might help us with the independent development. However, I am still a little suspicious.

Let me move on, I shall not be too long.

Dr. Sky, on page 1 of your presentation, down toward the bottom of the page, you say:

There are many issues that are important to this discussion. Chief among them is the current physician human resources crisis - and the growing evidence that physician shortages will become even more severe in the near future.

We had a witness this morning, Dr. Rachlis, who does not believe we need more medically trained people and that there is a misuse of those that we have. I do not know whether he is right or wrong or half right. There is a complaint, or a feeling among the medical communities that physicians do not use or encourage the use of other medically trained professionals or paraprofessionals. We have had that reference from time to time. I would like to know how you feel.

Before I ask you to reply, I noted, on page 3, there were three specific aspects to your presentation: the role of the provincial government, the role of the federal government, the role of physicians and, ultimately, the doctor-patient relationship.

I am surprised that what was not added there was the role of 256 physicians with other health providers, the interdisciplinary practices that we have heard so much about that gets the best juice from all the medical professionals or paraprofessionals that we have in the system. Would you comment, please?

Dr. Sky: There seems to be two issues involved there, Senator. The first is the physician shortage itself, whether it is real or imagined, and the second is the issue of other providers in association with physicians. I did allude to the nurse practitioner issue.

Let me deal with the issue of physician shortages. In 1999 Professor McKendry issued a report in Ontario that showed that there was a minimum shortage of 1,000 doctors. The next year Professor George followed that up and said, "No, he was wrong, he is short by about 250 to 300." We now have the government of Ontario agreeing that we have a shortage of at least 1,300 doctors in this province. I would challenge Dr. Rachlis to go to any of the 109 communities across Ontario that are designated as being short of physicians and tell them that they have enough doctors.

That issue has been laid to rest by enough scientific debate that it should not be an issue.

On the issue of physician extenders, nurse practitioners in particular, we have set up a committee. At this point it has not reported on how we will use physician extenders.

From our point of view, the main issue is that there should not be multiple points of entry into the health care system. We consider nurse practitioners as part of a team, working with physicians to see as many patients as possible, but under the supervision of a physician. Most patients in Ontario - by survey, over 90 per cent - wish to see a family practitioner first. We think that need has to be met.

The issue then turns on how to fund nurse practitioners. At the moment, those we have are being funded to a great degree by direct contract with the government, or out of the doctor's resources. Neither of those are very good ways of funding them, and we must consider better ways.

Senator Robertson: Thank you for that. I appreciate your comment on the need for more physicians, especially since you come from a small province, like some of us. My constituents have advised me that they drive 60 kilometres these days to get a family physician. The system is breaking down.

I have a quick observation that applies, Dr. Sky, to what we have been talking about.

Mr. O'Connor, I like health centres. They are good, in my humble opinion. Of course, I say that from the perspective of one who comes from a small province. I think it was you who said that, on prevention, we have to work with the environment, housing and all the factors that impact poverty, and these areas all must work together.

That discourages me somewhat, sir. One problem is that we have silos in the system and nobody speaks to anyone else. We have vertical funding from the Department of Health, up and down, and nobody can see into the other person's silo. This is a wasteful process. I believe that horizontal movement of funding for a particular block of citizens would be better used, but if we cannot get the silos torn down in the health system, how will we get the larger silos torn down for departmental co-operation? I appreciate your comment, but I would like to see the silos first torn down in the health system.

Mr. O'Connor: I will give you a couple of examples. From a community perspective, silos tear down quite easily.

In the South Riverdale Community Health Centre in Toronto, a number of years ago, physicians encountered a high incidence of lead poisoning in their patients. Had this happened in solo practices, physicians would have treated lead poisoning and continued to treat lead poisoning. In this case, the venue was a community organization, which had community outreach workers and a board. The physicians reported the incidence. The outreach workers searched for reasons. The organization lobbied the government to examine sources of pollution in that community. There was a battery factory, which ended up closing down and moving on. The soil is being remediated in the community.

In Windsor, the fire department noticed a great incidence of fire deaths and arsons in the community. It worked with the Sandwich Community Health Centre, which is in a low-income community without much fire prevention or suppression equipment in the homes. They got donations of fire extinguishers and fire detection equipment and put that into the homes. Now there is the lowest incidence of fire deaths in that region, and the fire department credits the community health centre with solving the problem.

There are ways, when you take an integrated approach to care that is more than just the provision of episodic care, to create more wellness, to help the whole community become well.

Senator Robertson: Thank you. I appreciate that. I can give you lots of examples of this in small communities as well.

Chair, we have heard many of the witnesses over the last weeks speak about these silos, where people almost work against each other.

The Chairman: Senators, we have one last panel before we adjourn.

I will begin with Mr. Jeff Wilbee, who is the Executive Director of the Alcohol and Drug Recovery Association of Ontario and the Addiction Intervention Association.

Mr. Jeff Wilbee, Executive Director, Alcohol and Drug Recovery Association of Ontario and Addiction Intervention Association: Mr. Chairman, I would like to express our appreciation to you and the committee for the opportunity to address you today.

Given the limited time for our presentation, I will primarily confine my remarks to Chapter 12 of the "Issues and Options" report, on the population health role, but first, I have just a few comments on the other roles.

On finance, it seems to me, as a citizen of this country, that the most difficult challenge before us is the type of funding mechanisms we develop.

We suggest that a continuing combination of public and private funding must be given in-depth consideration. However, in doing so, full provision for those at the lower strata of the social and economic scale - many of whom are present at our clinic doors - must be ensured.

Another point we strongly wish to make on this role is that the government must maintain, in our view, its current ban on advertising of prescription drugs.

Under research and evaluation, we strongly support enhanced resources for research. However, a large portion of that research should have input and involvement by front line health workers.

Not only should research knowledge be disseminated, there should be greater emphasis and resource allocation to education and training, particularly for health care providers. Health care is about equipment and systems, but it is primarily about people assisting people. The higher the knowledge and skills of both the practitioner and the patient, we suggest, the higher is the effectiveness of all of our efforts.

On infrastructure, we fully support the objectives ofevidence-based decision making and accountability in the system. That can be done, in part, through technology and information systems. Accountability should not just be about costs and administrative efficiencies; it should focus on clinical outcomes. Greater integration of information systems should produce better outcomes, both clinically and administratively. For example, many times the addiction treatment system is in a silo and is not seen as a core service.

Under the service delivery role for Aboriginal health, the report states that programs leading to healthier outcomes are those based on significant input from the members of the involved community. We applaud that statement. We also think it is a principle that should apply right across every community in this great land.

Our major contribution to this discussion is that a larger percentage of our attention and resources must be focussed on health promotion, early intervention and population health measures.

Our client population, substance abusers, costs our health system an enormous amount of time, human resources and dollars. It burdens the health system in a direct way through traumas such as impaired driving, falls, acts of violence, and infectious diseases like AIDS and hepatitis.

Substance abuse is also a contributing factor to other more primary diagnoses, such as kidney and liver ailments, and certainly it does not assist in recovery from cancer and heart pathology. Although I have not referenced this, it might be of interest that a particular study estimated that 20 per cent or30 per cent of general hospital beds are occupied by people with alcohol and drug related problems, and 80 per cent of those patients, according to this report, are not identified as such.

Also of major concern is usage among our youth. Recent, 2001, research on substance abuse among Manitoba high school students reported that the average age of first use of alcohol is a shocking 13.3 years of age. By the fourth year of high school, 33 per cent use alcohol once a week or more. In the survey, 17.8 per cent of the students stated that one of the problems faced as a result of this usage is unwanted pregnancy.

Another concern we have recognized in Ontario is the havoc caused by inebriates arriving at our already overburdened hospital emergency departments, and we are already exploring strategies to divert this client group into other more appropriate interventions.

We contend that these costs to the health care system can be radically reduced by implementing appropriate strategies. An Ontario Auditor General's report stated that there is a $6.00 return for every $1.00 invested in addiction treatment. This estimate is considered conservative. Other reports indicate even higher returns. Therefore, we recommend that substance abuse awareness and treatment be integrated into the mainstream system and that it be adequately funded, which, at the moment, it is not.

As your report indicates, our health care system's contribution to keeping people healthy may only be 25 per cent. It makes eminent sense to concentrate a on the other 75 per cent. To this end, Canada should show world leadership, through a health commissioner, in measuring and improving our population health status.

How do we do that? Experience has shown that just disseminating information may not go far enough. In the addiction field, many millions of dollars have been spent on warning people about the dangers of tobacco and drug use, only to find that we are back to the late 1970s usage rates among youth when it comes to drugs.

We must concentrate on the quality of our programs and our practitioners. For example, the Addiction InterventionAssociation, which markets a certification process for addiction treatment professionals, is about to implement a certification process for prevention specialists.

In closing, the one word that we want to emphasize is "accountability." We must ensure that in spending our limited resources we are achieving the optimal results. We believe that, in general, the suggestions in the report are heading in the right direction. However, we would caution that while we are changing larger sectors of the system we should not overlook the contribution of less visible sectors such as addiction.

We thank you for involving us in this dialogue.

Mr. Denis Morrice, President and CEO, The Arthritis Society: Thank you very much for this opportunity. As citizens, I thank you for all the personal time you have put into this. You are absorbing a large amount of material.

In the report, we examine fairness as really being the issue. Certainly, it is the issue for people with arthritis because, clearly, it is just not fair.

I am speaking on behalf of people with arthritis and my colleague will speak on cancer. My father, brother, mother and older sister all died of cancer and my younger sister has just finished chemo and is starting radiation, yet I am here to speak on arthritis. I cannot help thinking it is time for researchers to stop researching what they want to research and start researching what citizens want to have researched.

I thought Jeffrey Lozon's introduction was beautifully done.

Musculoskeletal arthritis conditions are number one in the nation in terms of doctor visits, and among diseases in terms of disability. Arthritis is the single largest cause of long-term disability, yet we never talk about it. Please just think about the magnitude of that.

We talk about arthritis in terms of aches and pains. Doctors tell arthritis patients, "It is aches and pains. We all get arthritis one day. Go home and live with it," without the appreciation that rheumatoid arthritis, lupus and some other forms are autoimmune diseases and should be treated very seriously.

Of the 4 million people who have arthritis, 2 million take medications every single day to relieve pain and inflammation. Right now in Canada, we are talking about 38,000 hip and knee replacements. Considering 9.8 million baby boomers started turning 50 just a few years ago, we can foresee what is to come.

I will just address a few points that were in your report.

I ask you to recognize arthritis in terms of its magnitude and the impact that it has on the health care system and on society.

In terms of research, those of us with disease want to get rid of the damned disease. We can only do that through research, and that is why we fully support the Canadian Institutes for Health Research, CIHR. It is not just a matter of doubling that budget. It has to be more than doubled because the mandate has been broadened so much. How many real dollars are there now available for the kind of research that was being done?

We are very fortunate in the area of arthritis to have the Institute of Musculoskeletal Health and Arthritis, which is one of 13 institutes. The nice thing about that was we were able to bring together dentists, osteoporosis people, orthopaedic surgeons, rheumatologists and skin people to, finally, begin to truly break down those silos. We made them come together.

On network centres of excellence, we are very fortunate to have the first disease-specific network centres of excellence, the Canadian Arthritis Network. Attached to that is a consumer advisory board of citizens with arthritis who help to set that agenda. We know the system can work when you involve the citizens.

By interfacing with one another, researchers have come to appreciate who we are and to appreciate our problems, as we have come to appreciate the research that scientists are doing. They became the ambassadors. We feel that the silos can be broken down.

I would like to touch on specialist training. We heard it in the last discussion about the shortage of doctors and so on. This is not calculus, this is arithmetic that we are talking about. We do not even have a rheumatologist, which is an arthritis specialist, in P.E.I. There is not one. In Kitchener there are three, but two will retire this year, which will leave one to treat people. There are 4 million people who have arthritis.

One of the things that we are considering, along with the nurse practitioners, is physiotherapist practitioners. I guess this comes back to the community care concept, where the answers really lie in the community. We are now talking about new biologics in terms of infusions and needles that have to be taken. The nurse practitioner is there. What about the physiotherapist practitioner? These are the kinds of things that we are considering and trying to introduce.

The Arthritis Society is a little not-for-profit organization. We fund clinical fellows and doctors who want to become specialists in rheumatology. We literally pay for half of that, and we match the Ministry of Health. We should not have to do that, but in fact, that is what we are doing because there is an unbelievable shortage.

In terms of drug approvals with which you have been dealing, I know you have heard many discussions on it with Therapeutic Products Directorate. Health Canada cannot handle all the new drugs and the biologics. Why are we not using our network centres of excellence? Why are we not using our institutes? Health Canada still plays a major role and has the final say, but let us take our brightest minds and people and put them to work. We are funding them anyway.

On provincial formularies, we all know it is nonsense. How can we have a drug fully approved in one province and the province right next door has a restricted listing and, in the province next to that, it is not even listed? We are all Canadians. This is just not fair.

People with arthritis really suffer in that respect. For the first time there are new medications that do not cause the same kinds of side effects. Better stuff has happened in the last couple of years than in the last hundred years. Side effects are the major issue. Non-steroidal anti-inflammatories cause side effects.

To get down to statistics, more people die from the side effects of arthritis medications than from AIDS in this country. Considering the magnitude and the numbers, something should happen here. That is why we support a national pharmacare program.

Another thing that we support and that has to be introduced, is not just post-marketing but also post-approval surveillance. We have enough medical schools. We have 16 medical schools in this country. Why not use them, with all the doctors that they have, to do the studies and reporting and have that kind of surveillance? We do not have it right now. We can debate for hours about clinical trials. Having surveillance is really the answer for all the people that I have talked to.

I will leave primary care reform because many other people addressed it well.

Citizens and patients must be involved to help set agendas. When doctors, scientists, researchers and patients get together, we come up with the proper kinds of solutions.

Concerning the Health Charities Council, certainly, we are trying to play our part. We run arthritis self-management programs. We have patient partners in 12 of the 16 medical schools, and so on. We have the peer review system. We have citizens involved. Use us to listen to the patients and we will all be better off.

Dr. Barbara Whylie, Director, Cancer Control Policy, Canadian Cancer Society: Thank you very much indeed for allowing the Cancer Society to participate in these consultations.

I guess we are all going to quote statistics to you. Cancer is the leading cause of premature death among Canadians, and the statistics tell us that cancer will affect one in three Canadians in his or her lifetime. It is a major health risk for Canadians.

It is a growing health risk because cancer is largely a disease of the elderly. We project that the number of new cases each year will double over the next 15 or 20 years.

The Canadian Cancer Society is a volunteer-based organization. It has been around for over 50 years. We raise funds for cancer research. We give information to Canadians and people living with cancer about cancer and about its risk factors. We provide direct support services to people living with cancer, and we undertake public policy advocacy to support cancer control.

We are very much concerned about the increasing burden and the increasing challenge that cancer brings to our health care system, and as such, we are one of the key partners in an effort that has been going on for the last couple of years to develop a Canadian strategy for cancer control. That strategy development involved about 200 experts and consumers from all parts of the country to review our current knowledge in all aspects of cancer control. These individuals developed a set of 94 recommendations, which we will not table for your consideration, but these have been refined through a series of consultations into five action priorities.

The five action priorities are: development of standards; development of a research strategy; rebalancing the focus in our system to ensure attention to the less developed aspects of care; in particular, support of rehabilitative and palliative care; human resources planning, which is an issue in the cancer system as well as in the health care system at large; and attention to prevention. Our comments, with respect to your work, are grounded in this strategy. If people are interested in having more information about the strategy, I can give you a reference. There are reams of material available through the Internet.

We recognize and support all of the federal government roles and objectives that you have identified in your "Issues and Options" report, but we particularly would like to focus on two areas. Those are the areas of population health and reform of primary care.

With respect to population health, we know from research, or it has been estimated from research studies, that up to 70 per cent of cancer cases can be avoided by people avoiding exposure to known risk factors, which include tobacco use, diet, physical activity, exposure to the sun and occupational and environmental carcinogens.

One of the interesting things is that many of these major modifiable risk factors for cancer prevention, in particular, tobacco use, healthy diet and physical activity, are also important prevention measures for other chronic diseases, such as diabetes and cardiovascular diseases, both also major health concerns for Canadians. Therefore, an integrated chronic disease prevention strategy for the country should be developed and implemented. Work in this area has recently begun collaboratively through the NGOs related to cancer, diabetes and cardiovascular diseases in collaboration with Health Canada.

The Canadian Cancer Society recommends the development and support of a nation-wide health promotion and disease prevention strategy, and that the federal role in health promotion should be strengthened to enable the achievement of this goal.

Studies that have shown that for every $1.00 spent in prevention, we can save $3.00 in treatment costs, so shifting more financial resources to health promotion and chronic disease prevention will defer illness until later in life. That, obviously, will not eliminate those illnesses altogether, but it can be anticipated that it will generate substantial long-term benefits both by reducing costs to the system and - more important maybe - by improving the quality of life for Canadians.

More research into risk factors and into how to modify risk factors is needed. The Canadian Cancer Society urges your committee to recommend that a specific percentage of health research dollars be dedicated for research into risk factors and into socio-behavioural research.

On primary care, more services are being delivered in the home by health professionals, including doctors. Under the Canada Health Act, we would like to see the definition of "insured health services" to be expanded to include services in the home and in the community, particularly for drugs, rehabilitation and palliative care.

Canadians need access to excellent quality care, both in and out of the hospital setting, so the Canadian Cancer Society therefore endorses the suggestion of the National Forum on Health that public coverage should be refocused to cover the care, and not the site.

There is also a need for a nationwide, coordinated system for hospital, home and community care so that all patients in Canada can receive an equitable level of treatment and care regardless of place of residence, and so that the transition between levels of care is invisible. In our case, we are particularly concerned about individuals who are experiencing cancer. A seamless access to cancer treatment and care is essential to reducing the suffering that goes with the cancer experience.

Equally, as much as possible, treatment and care must be evidence-based. Many current treatments for illness are not grounded in research and do not reflect best practices. We would like to see the establishment of interprovincial mechanisms to develop evidence-based standards and guidelines for the full spectrum of cancer treatment and care.

Finally, our current system of primary care lacks incentives for physicians to practice health promotion and health maintenance, whether by themselves or in collaboration with other health providers. We would like primary care reform to specifically address these aspects of health services.

As a member of the voluntary sector representing Canadians at the grass roots level, the Canadian Cancer Society looks forward to working in partnership with governments and other key partners to ensure that health care reform occurs in a timely way and benefits all Canadians.

Health care is a major challenge to our systems. It is not feasible for any one organization or any one jurisdiction to effect change on its own, so we believe very strongly in a collaborative approach to health care reform.

Dr. Robert Conn, President and CEO, SMARTRISK: Good afternoon to all the members of the standing committee. I would like to join the other members of the panel in applauding the important work that you are doing on behalf of Canadians.

I am here this afternoon, on behalf of SMARTRISK, to amplify an issue that was touched on briefly in your September 2001 "Issues and Options" report and what really is a silent epidemic in our country, the issue of unintentional injury.

What I would like to do in the few minutes that have been allotted is to give you a sense of the magnitude of the problem and to talk a little bit about why this is a silent epidemic.

My training is far removed from injury prevention. I am actually trained as a cardiac surgeon. I had the opportunity to do some of my training with one of the fathers of modern day heart surgery, a fellow by the name of Dr. John Kirklin at the University of Alabama in Birmingham.

His program was a little different in terms of transplantation work in that he insisted that we spend the first three months of our program, even though we were very keen to do transplantation work, on what is called the "harvest team," which is the team that actually procures the donor hearts.

It is very embarrassing in retrospect, but I had never stopped to think where donors come from. I had always focussed on the miracle of transplantation. In doing that work, day in and day out for three months, what I quickly began to appreciate was that our donors are like the majority of people in this room, in fact, the majority of people that have testified to you, people who are very healthy one moment, with very active and challenging lives and then, as a result of being hurt, are brain dead the next. That made a huge impression on me.

When I returned to Canada and began my training in children's heart surgery at the Hospital for Sick Children in Toronto, I began to examine the whole issue of unintentional injury. What I found absolutely astounded me.

If you were to ask most Canadians what the number one cause of death was for Canadians in their prime, they would probably say cancer. If you told them they were wrong, they would probably tell you heart disease. If you told them they were wrong, they would tell you other things that they had heard of. In fact, the number one cause of death for Canadians up to age 44, is injury.

If we consider children between the ages of 1 and 20, you can consider every cause of death that you have ever heard of, AIDS, meningitis, leukemia, cystic fibrosis, name them, add them all together, and we have more children in this country dying of injury than everything else combined. In fact, in Canada, last year 7 out of every 10 teenage deaths were a result of a predictable, preventable injury.

About 10 years ago, the Head of Cardiac Surgery at Sick Kids was tired of me bringing in these statistics every day, and he grabbed my arm and said, "If you feel very strongly about this, do something about it." I have come to appreciate in retrospect, now that I am a little older and a little wiser, what he was actually saying to me was "Shut up!" The challenge then became: what can you do? Upon examining the world of safety, I began to realize that traditionally we talk about safety in the form of rules. We talk about safety in the form of "don't" messages. What we have failed to recognize is that life is about taking risks. The challenge is getting people to appreciate and understand those risks in a way that they can then manage them and benefit from that.

In terms of the magnitude of the problem, the numbers are astounding. Every hour, of every day, 220 Canadians go to hospital as a result of being injured. In fact, 21 Canadians die, on average, every day from injury and about 47,000 people are disabled every year.

In situations where people do not die, the most serious injuries are to the brain and the spinal cord. It is estimated that we spend about $3 million on each serious head injury in lifetime costs. Just in the province of Ontario, we average about four serious head injuries a day. We spend about $12 million a day to treat the four people in Ontario who are seriously head-injured.

We commissioned a study in partnership with Health Canada two years ago to examine the economic burden of unintentional injury in this country. We thought the numbers would be large, but we had no idea how large. It is the third highest economic burden in our entire health care system. We are spending about$8.7 billion a year to treat people who are seriously injured. What is most compelling about injury prevention is that over 90 per cent of all of the injuries that come into the hospital are preventable. They are predictable and preventable.

Other countries have recognized the magnitude of the problem. In the United States, the Centre for Disease Control has actually created an institute for injury prevention and control. Great Britain has identified four major health priorities for its population: cancer, heart disease, mental health and injuries. In Canada, we do not have a national strategy or a national plan for tackling the issue of injury prevention.

In terms of research, less than 1 per cent of all of our research dollars in health care are spent on injury prevention research. It is crucial, if we are going to have good programming, that we have evidence upon which that programming can be based.

In your "Issues and Options" report, in Chapter 12, you said that disease issues are complex, but many chronic and infectious diseases and most injuries can be prevented. However, there has been a tendency to focus on curing diseases rather than on preventing them, largely because of a lack of political will.

What I would like to suggest this afternoon is that it is actually more than a lack of political will, and here I would like to share some insight as to why this issue, even though it is so large, is totally unrecognized in our society.

We know that a lot of our thinking in life, a lot of the way in which we behave as humans, is shaped by the language we use. There is a particular word that we use to describe all of these things that I wish we could eradicate from the human vocabulary, and that is the word "accident."

In the dictionary "accident" is defined as "an unavoidable act of fate." We know from human behaviour studies that if we believe something is fate, most people respond by coping with that through denial.

For example, if I were to suggest that three people around this table were going to die in the next hour as a result of fate, in the next hour we would observe a variety of coping mechanisms. Some people might be very angry with me for having suggested that, some people might get agitated, some people might actually feel physically unwell and the more sophisticated "copers" would spend the next hour looking around the room and picking out the three people that they thought were going to die - and you can bet that they would not be among them. Denial is a very sophisticated coping mechanism.

We live in a society where, if tonight in any city - Charlottetown, Kitimat, British Columbia, or Red Deer - six children were to die in a car crash, we would call it a terrible tragic accident and not much more would happen. Yet, if anywhere in this country six children were to die of meningitis, it would be a national story and there would be an outpouring of resources into the community unlike any that have been seen.

We believe that in order to move forward on this issue, there are three concrete things that can happen which can be led by the federal government.

The first is in the area of surveillance. We know very little about how people actually get hurt, and in fact, it is very interesting to find, when you start examining the data we have, that we do not even have a uniform way of coding deaths related to injury in this country. If you die of a heart attack anywhere in this county, you will be counted once. If you die of pneumonia anywhere in this country, you will be counted once. If you are from Ontario and you are visiting British Columbia and you are killed in a car crash, you will not be counted. If you are from Alberta and you are visiting Saskatchewan, you will be counted twice. This is such an unrecognized issue that even at the level of coding our injuries we do not have a uniform system.

We know that, in the economic burden of $8.7 billion, 28 per cent of the injuries that account for that $8.7 billion are coded as "other" and we cannot tell you anything beyond that. We do not have a good surveillance system, and that is certainly a role that the federal government can play. A good surveillance system is akin to turning on the lights. If we do not know who is getting hurt and how they are getting hurt, it is impossible to design programming.

The second thing that we need is comprehensive research, and I think all of the other members of the panel would echo that. We need good evidence upon which we can base our programming.

The third component is comprehensive programming of a multidisciplinary nature. There is probably no other health care issue that can bring in as many different disciplines into the research of an issue as can injury.

I would like to conclude by thanking the members of the Standing Senate committee. I applaud you for the work that you are doing.

The Chairman: I thank all of you for your comments

Dr. Conn, thank you for explaining that to me. Other people have used the term "unintentional injury," which implies there must be something called an "intentional injury," and, that, I always had great difficulty with. I wondered why we did not use the word "accident" and now I know why we do not use it.

Dr. Conn: Actually, the World Health Organization has defined "injury prevention" as encompassing three areas: unintentional injuries, suicide and violence. We encourage Health Canada to ultimately take a similar approach and to consider those three areas in unison. We, at SMARTRISK, believe that the unifying link is really the appreciation of risk.

The Chairman: That makes sense.

Senator Cordy: Mr. Wilbee, you talked about the millions of dollars that have been spent warning people about the dangers of tobacco and drug use. In my other life, I was an elementary school teacher, so I am aware of the numbers of programs that were put out by provincial and federal departments to discourage such behaviour in young children. You told us that starts at a very young age.

What did we do wrong? Are the tobacco companies spending more money than we are spending?

Mr. Wilbee: The answer to the last one is yes. At least in the area that we are concerned with, and despite that we spend millions of dollars, my view would be that we do not take prevention seriously enough. I take it I have agreement of the panellists.

We have not done anything wrong; we have gone far enough, and it is not that the "don't" messages do not work. My 10 year old granddaughter has decided that she is neither going to take drugs nor get a tattoo, the former pleasing her grandmother a great deal. However, that does not guarantee that she will not experiment three or four years from now.

In terms of prevention we are saying, "we need to involve." I think we have talked a lot about involvement, about involving the community in planning and implementing our system, but, gosh, we must involve the children themselves.

The late Dr. Paul Steinhauer, who was an expert in child development, talked about resiliency and how to develop that kind of resiliency.

I would like comment on the quality of the prevention practitioner. For example, many times, in elementary school or high school, we bring in either a former addict, or maybe an athlete to tell horrible stories. That affects me for a short while. It does not involve me, but it affects me.

The best example I can give is that I tend to slow down when I see a car accident for maybe the next 20 kilometres. Then I find I am speeding up again because it has not really involved me.

The answer is that this is complex, but we can do a better job. Part of that is training, and is evidence-based. What really works? What are the outcomes?

I just would suggest - and research would back me up - that if you advise, "Just say no," a kid will respond, "But how do I say no?" How do we build that resiliency in?

There must be more research, which cannot be done without resources. That goes to your first question. If the "competing people" are out there, not only for tobacco, but for the lifestyle advertising that is hanging around the pool about having a cold one, there must be a counter to that which involves people really thinking that through. It is complex.

Senator Cordy: Children will all nod appropriately and say all the things that the teacher or whoever happens to be in the room says, but we have to develop decision-making skills within the students as well.

Mr. Wilbee: I am not sure, Mr. Chair, if I have enough time to share a very quick story.

Last year we went into a school in Kitchener that is known as a "problem school." It has two combined classes of young ladies in grades 9 and 10. We did a kind of four-point process with them. We did the traditional bringing in of a person who is a clinician, who was very highly regarded among the youth, to do the story and give the information on the dangers and the risks.

We have developed a journal, in which we asked those 28 young ladies over a 30-day period to record their thoughts. We were involving them. We came back in a month or so later and four of those 28 came forward and said, "I have a problem. Can you help me?"

The real value in the exercise is that we had a clinician who could assist them and get them into the right programs. One of the greatest dangers is to open somebody up and then not have the solutions.

We, like everybody else, would argue that we get what we pay for. It would be interesting to see the data - I am sure it is there, or if it is not, we should get it - on injuries, particularly among youth where substance abuse may be a contributing factor there as well.

Senator Cordy: You have made an excellent point. The resources have to be there for follow-up. I remember also doing a program, "Feeling Yes, Feeling No" many years ago about sexual abuse, and children were disclosing to the teacher or to a trusted adult and then being told, "You have to wait six months to get help." So much for trusting the adult, right?

Mr. Wilbee: What are those kinds of messages? That is when you get into the suicide or continued increased drug use because you think there is no answer.

We have to have those kinds of resources and programs.

Senator Cordy: My next question is for Mr. Morrice. You said that people were frustrated by the lack of standards, and I was just a bit confused. Do you mean, in terms of drugs that are available, there are disparities among the provinces? Is that what you meant, or is there more to it?

Mr. Morrice: There is a lot more to it, in terms of overall standards, but I was referring to what is happening with drugs concerning the federal approval process and also the provincial formularies. Why should we wait for over two years in Canada? Remicade, a biologic for people with arthritis, was just approved a couple of weeks ago, despite that it was approved in the United States and Europe two years ago. Why are we sitting back? Why are people still in wheelchairs when other people who were in wheelchairs are out walking around and playing with their children? It is like a game. This is just not fair.

Senator Callbeck: Thank you all very much for your presentations.

I just have one question, and it is for Mr. Morrice.

Regarding drugs for arthritis, I was struck when you said that more people die from the side effects of taking drugs from arthritis than from AIDS. Is that statistic for Canada?

Mr. Morrice: Yes.

Senator Callbeck: You spoke about the clinical trials and that there is no surveillance. How are these trials conducted?

Mr. Morrice: Dr. Whylie could answer the clinical trial part and I will answer the last part of the question.

Dr. Whylie: How are the clinical trials organized?

Senator Callbeck: Yes, are there clinical trials before a drug is approved by Health Canada?

Dr. Whylie: Yes. Clinical trials are basically large-scale experiments to identify which new medications are effective and which are not.

Basically, people with a certain condition are recruited by their physicians into these trials, and there are different levels of trials depending on what you are actually trying to find out. In the simplest form, you give patients either a new drug or the old drug and they are monitored to identify which one is more effective than the other.

That type of very technical and very detailed information has to be provided to Health Canada or any other regulating body to determine whether drugs will be approved.

One consideration is what and how dangerous the side effects are, and whether new drugs are more dangerous or less dangerous than the other drugs that may be almost as effective, which we currently have in place. It is complex.

Senator Callbeck: How many people are on these trials? Does it vary with the drug?

Dr. Whylie: I do not know how to answer that question. In the cancer field, we would like almost everybody being treated for cancer to have access to clinical trials. In fact, in Canada just now, approximately 4 to 5 per cent of cancer patients have access to clinical trials.

Senator Callbeck: Would that drug be free to the patient?

Dr. Whylie: Yes.

Mr. Morrice: Once a drug is approved it is not free any longer. Then you are relying on the provincial formularies.

Clinical trials involve a kind of a "bandwidth." Once medicine is approved for an indication, it is available to the broader public, and later on we hear of more side effects and so on. That is why I say surveillance is really the issue here. If we can get on top of the surveillance on a regular basis, we will solve all of that. It really shakes itself out. We need good surveillance, which we do not have right now. That would solve many other problems.

We are part of the Cochrane Collaboration, where citizens are involved. The Cochrane Collaboration was really for specialists doing world studies on what is best evidence in terms of therapies and their medication.

The Cochrane Collaboration in Canada was given the area of musculoskeletal and arthritis. We said, "We will partner with you if you promise to put all the medical stuff, the gobbledy-gook, into lay language and that we have citizens right at the table who have arthritis to help write it."

I have a very quick story. I know, Senator Kirby, you are in a rush here. Citizens were sitting around a table with doctors and researchers, who were from Australia and so forth. I watched a woman with arthritis write something down, fold it up and put it in her purse. That was interesting, but I did not comment. Three months later we were at another Cochrane meeting, and I said to her, "I saw you at the last meeting. I am not challenging you, but I am just wondering, what did you do with that note?" She said, "It had the names of the international researchers at the bottom. I gave it to my doctor and asked why I was not on that drug." She said that he read it and said, "Why not?" Now it is in lay language, with documentation on who did the research. She said, "We then sat and talked for over 20 minutes about my disease. We are now partners in my disease."

If there is anything more telling than that, I do not know what it is, in terms of partnership and people understanding.

Senator Callbeck: You talked about surveillance. I was surprised that there is not any. I am on a new drug, Enbrel, and I have to report for tests all the time. I have to see my rheumatologist at certain times. I thought that was what was happening.

Mr. Morrice: Enbrel is one of the newest biologics, as is Remicade, for people with arthritis. It is heavy-duty, and I am sure you will benefit tremendously.

The Chairman: Last question.

Senator Morin: I have a short question for Dr. Whylie. I share your support for research on the risk factors of cancer. Your organization, of course, represents Canadians who suffer from cancer.

What is your position on waiting times for cancer treatment? Especially with the recent evidence in the Canadian Medical Association Journal that waiting times adversely affect various forms of cancer, especially cancer of the breast, what is the position of your society concerning the fact that we are still sending Canadians to be treated for cancer in the U.S.?

Dr. Whylie: Our position is very simple. We would like to see all Canadians with cancer have access to expert cancer care within the appropriate time frame.

Senator Morin: If you had additional resources to put into the system, would you put them into research on the risk factors or into reducing the waiting lines and having efficient treatment in our country - if you had a choice here?

Dr. Whylie: We have been thinking about these issues for some time. Our answer was to approach the Canadian Association of Provincial Cancer Agencies, which is responsible for providing treatment to cancer patients across the country, the federal government and other major partners to suggest that we all come together to examine the total challenge around cancer in this country and develop a strategy that would solve both of those problems. That is the objective.

Senator Morin: You are not answering my question.

Dr. Whylie: No, I know that I am not. I do not really have an answer to your question. My answer is that I think it is not simple. We believe, for example, that there are options within the cancer treatment system that perhaps can make the system more efficient. We also believe, in the long term, if we pay enough attention to prevention that will relieve some of the pressure on the system.

I am sorry, I do not have an either/or answer to that particular question.

Mr. Morrice: That gets back to citizens and patients being involved. We did a bill of rights, which involved patients, all the professionals, rheumatologists, orthopaedic surgeons, chiropractors, occupational therapists, physiotherapists and so on. It was the patients who said they wanted a bill of rights and responsibilities. I will happily give you a copy of that.

It was a pleasure to watch that kind of thing happen. That is how you can start to address those choices and very hard issues.

The Chairman: Thank you. Could you leave us a copy of the bill of rights?

Mr. Morrice: Certainly.

The Chairman: May I thank all of you for coming. We really appreciate it. Senators, we are adjourned until 9:00 tomorrow morning.

The committee adjourned.

Social Affairs, Science and Technology

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

Issue 37 - Evidence

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