Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 38 - Evidence
TORONTO, Tuesday, October 30, 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 Marjory LeBreton (Deputy Chairman) in the Chair.
[English]
The Deputy Chairman: Colleagues, this is the second day of our hearings in Toronto on our health care study. Our first witness today, whom I will now invite to the table, is Michael Decter, chairman of the board of directors of the Canadian Institute of Health Information.
Welcome and good morning, Mr. Decter.
Mr. Michael Decter, Chairman, Board of Directors,Canadian Institute for Health Information: Thank you very much, both for the invitation to be here and for the opportunity to read your very fine Volume 4.
The Deputy Chairman: Did you have a statement that you were going to hand out, Mr. Decter?
Mr. Decter: No, I have a few comments. When I was asked to appear, I was told to bring 25 copies of anything I wanted to leave with you. I was cruel enough to bring 25 copies of a book I wrote.
Senator Morin: You only need 24. I read it.
Mr. Decter: You read it. Well, it is actually not my most recent book, which was on more of an international theme. It is one I wrote shortly after escaping from the job of deputy health minister in Ontario. Some friends saw it as "grief writing."
Anyway, I will leave it with you, because it might give you more insight into my views.
I would like to make a few comments on the report and on CIHI, which I have the privilege of chairing.
I think the report is a very thorough piece of work. It does an excellent job of setting forth the issues, and particularly the available options. I had the benefit, through a lot of conversations with your chairman, of having a good deal of input. I do not praise it just on a surface read. A great deal of effort went into translating the work from the earlier volumes.
It is extraordinarily important. I would have to say that in our last federal election, we seemed incapable of having a real discussion of health care issues. We had, I thought, a very shallow outing, in policy terms. We normally pride ourselves on having greater depth in our political discourse than our American friends. Their last federal election, however, featured a rather thoughtful debate between the two candidates on drug coverage. They each put forward well-articulated plans. One could have chosen how to vote in the United States election purely on that issue. However, in the Canadian election, it would have been a little harder to discern the positions.
Let me leave politics aside and move to my presentation. To my understanding, the CIHI report on health care in Canada has already been circulated to the committee, so I did not bring 25 copies of that.
We put the CIHI report up on our Web site. The first one we produced, in 2000, was downloaded over 120,000 times. For an 80-page report on Canadian health care, that is rather astonishing. My publisher would be delighted if anything I wrote sold 5,000 copies. I think that speaks to the appetite of Canadians well beyond policy circles for quality information about health care. Our reports have had rather fulsome coverage on television and in the print media.
Two budgets ago, the Government of Canada made a big investment in enhancing the work CIHI has been doing, work largely supported by the provinces and hospitals. Your report touches on the point that one of the ways to improve the health care system and make it more accountable is to give Canadians much better information about it. I was delighted when first ministers committed last year to publishing indicators in 14 areas.
I worry that those indicators may not be making the progress they should. I do not really want to say more about that. I will just say that in general, the confidence of Canadians in the health system depends on getting good information, not only about what is working well, but about issues that cause them to lose confidence: Wait times, access issues, quality issues.
We are working very closely with Dr. Bernie Langer and the Royal College of Physicians and Surgeons to help in the initiative that they have taken with respect to the patient safety agenda, which is a remarkably important piece of work. The estimates, driven by rather macro assumptions, are that as many as 10,000 Canadians may lose their lives prematurely because of safety problems in the system.
I want to be very careful here, so I will stick to the ground of "patient safety." There is a tendency, sometimes, to tag this as "medical error," which immediately creates issues with the medical profession, who will be our allies in improving quality if we approach this properly. Many of these errors or problems with patient safety are not the result of one person doing something. They are a result of systems failure, from wrong medications to things as simple as people being fed at the wrong time. They require systems approaches to change them, much as aviation safety has required rather thorough changes in procedure. I think we could save many lives there. CIHI will do what it can to assist with better data.
Another point in your report that CIHI will comment on later this fall is the health human resource area. We devote a lot of time and discourse in Canada to financial issues. We have spent far too little time on the 750,000 people, whom I think of as genuine heroes, who get out of bed every morning and go to work in the health system. Until we stop taking those people for granted and seriously look at the issues that affect them, I do not think we can improve quality. We will be faced with the frustration of those groups, which often shows itself in financial demands: "We do not like the working conditions. The only demand we can really be heard on is wages. Therefore, we will take a very tough position on wages."
I now chair a committee, which is a real adventure, advising the deputy ministers on nursing. I am the only non-nurse out of a 16-person committee. Thankfully, the other 15 are very knowledgeable. There are very difficult issues. Nurses have a higher rate of injury, by a week in lost time, than other Canadian workers. We would find roughly 9,000 new nurses if we could just reduce their absentee rate to the average for the Canadian workforce.
Many, many nurses report physical violence and assaults directed at them. At a time when we want young people to consider nursing and other health care disciplines as careers, we very much need to improve the reality of the work. For a decade, we squeezed them financially. We took it for granted that dedication would keep them there. It did, largely, until the last few years, when a lot of spirits were broken.
I am a little concerned about some of the options for an expanded role for private insurance in your Options report. I understand that these are just options and that you are presently deciding which will be turned into recommendations. There is a comment in your report to the effect: Why are Canadians so concerned when 30 per cent of the system is already "private"?
The reality of the Canadian health care system is that what the private sector pays for and what individuals pay for is quite different from what is paid for from the public purse. We made a decision, rightly or wrongly, not to include dental coverage when we scoped medicare originally. That is a good chunk of what the private sector pays for. When I pay $29 to park my car at a hospital, it is counted through the hospital budget as private spending. I do not think of that as private spending on health care, any more than if I buy a coffee at the Starbucks at Sick Kids.Drug coverage is a patchwork quilt, as your report points out.
I think Canadians are so concerned because they have not seen the need to buy private insurance for what they consider "health care" coverage. They welcome their employer paying supple mental benefits for drug or dental coverage, or for the private costs of a hospital stay. I worry sometimes that we have always had a tendency to say that we have a mixed system of provision. There are some genuine benefits in looking at where we might gain efficiency, where we might gain quality, by greater use of a mixed delivery system. I am very sceptical, however, that an expanded role for private insurance in the Canadian health care system represents a solution. Rather, it would represent some backsliding on the basic principles. Hence, I would urge the committee to tread carefully on that issue. It is great to offer these options. However, when Canadians talk about Canadian medicare, they largely mean the 70 per cent that is paid for from the public purse. The other 30 per cent is not really seen in the same light.
This goes to why the debate can be so divisive and why we do not more carefully consider where the private sector can contribute enormously to an improved health care system. Innovative companies that have improved our health care system with new drugs, new devices and new diagnostics have grown up across the country. They have the potential to make a remarkable contribution.
I was with Dr. Alan Bernstein when he delivered the Juda Volkman lecture on Friday, where there was ample evidence of the interest of Canadians in health research. Four hundred people came out on a Friday night in Toronto and paid $12 to hear a lecture by a leading cancer expert. It was the first time that the Jane Mallett Theatre in Toronto has been full since September 11. Dr. Bernstein, in his comments, asked the audience to guess how much we spend per capita on medical research.
Senator Morin: Sixteen dollars.
Mr. Decter: Yes. He said, "Slightly less than I paid to park at this event tonight."
We have made a brave start in the Canadian Institutes of Health Research, but I think Canadians would be quite prepared to see us spend a little more than $16 per capita on medical health research. Thank you very much.
The Deputy Chairman: As a former deputy minister of health, do you have any thoughts on the issue of home care, its impacts and how we should extend the services?
Mr. Decter: I do. I have been a passionate advocate of an expanded role for home care, and for bringing it fully into the Canada Health Act, for as long as I can remember, and for a couple of reasons. There was a move to shorten lengths of stay in our acute care hospitals. This was an efficiency move that I not only totally supported, but worked very hard to achieve. However, in doing so, we essentially shifted people home who no longer needed a hospital level of care, but still needed nursing care. We shifted some of the burdens of that nursing care onto family members. We shifted some of the cost of that nursing care onto families. I call this "tacit privatization." I do not like that. I think we reneged a little on the deal. When one was in hospital, one's drugs and nursing care were covered, and now one is at home, we say they are partly covered.
That is not true across the country. Some provinces, Alberta notably, fully insure home care. They do not get a lot of credit for it in the rest of the country, but they should. They have laid some good ground. I do not think that expanding home care coverage needs to be a ruinous financial burden for the taxpayer. It is possible to draw some rules around what is legitimate home care related to a medical condition, and what might be a nice social service but not really health related. You have to be tough-minded about managing it.
Seven years ago, when I was deputy minister of health, the total health care budget in Ontario was $18 billion. I think it is $23 billion to $24 billion now. Out of our budget, about $1 billion was for home care. It was probably the best billion dollars we spent. It provided an opportunity to reduce some of the in-hospital stays. Those opportunities are a little more limited now than they once were. We have made great progress there. However, it also represented a great bargain in terms of supporting people strategically during their recovery. It would be a good investment for the country. It is much less tricky than investing in a drug plan. The drug plan option contends with corporate interests and forces, as we witnessed last week. Home care has good support from the public and the health community and does not have as big a price tag. I was disappointed it was not mentioned in the first ministers' communiqué of a year ago.
Senator Morin: Mr. Decter, I want to first of all congratulate you on your career and your work. I read your last book, Four Strong Winds, with great attention. I think it was excellent. The chapters on examples, especially at the end, were very instructive. I also commend you on your work as chair of CIHI. John Millar came before this committee twice and gave excellent advice. I would like to address the question of wait times, in which there is great interest.
As you know, access to health care delivery is currently one of the most important issues in our study. The only list of wait times we have is that of the Fraser Institute. When we were out West, I always asked, "Can you validate the Fraser Institute wait times?" In some cases, people said that they felt they were reasonable; in other cases, that they had little basis in fact.
I think it is an urgent issue. What, in fact, are the waiting lists for hip replacements? We need numbers so that we can compare one province to another. We know that many cancer patients from Canada are treated in the U.S. This means that there is a waiting list problem for those people. I would like your opinion. How soon we can get true waiting times from CIHI?
My other question deals with human resources. Every time one talks to health administrators about this, they say that as soon as there is any extra funding in the system, like the $23 billion of a year ago, there is an immediate rash of illegal strikes around the country. Provincial governments cave in. All the extra resources go immediately into extra funding for the personnel.
The situation now is that non-clinical personnel in the health care system are paid more than those in the private sector. The best place for kitchen workers to work right now is in a hospital, because they are paid more than in any hotel. That is true for plumbers and so forth. There is a problem there. A strike at a hospital, or any other provider, is very difficult for the employer, especially if the employer is government.
I was interested in your comments concerning private insurance. Do you feel that we should have a single payer, which would be the government, and no private insurance? Would you object to multiple providers, including private providers? If so, would that include for-profit providers? How do you explain that nearly every European country, Australia and most of the OECD countries do have private insurance? As you know, Australia is actually promoting private insurance. There are 6 million people in the U.K. who have private insurance and go to private facilities. For them, private insurance is an important part of their health care system.
Mr. Decter: The issue of wait times is actually not with CIHI at the moment. It sits with the committee, led by Alberta, called PIRC. I got myself into rather deep trouble with the health minister recently, commenting on wait times. I will do it again this morning. The health ministers are very close to making a decision not to report wait times. I think this decision would directly renege on the commitment of first ministers. If they do that, they will be walking away from a very good statistical survey that Stats Canada is capable of fielding. Ivan Fellegi, who in my view is a remarkable public servant, has gone to enormous lengths to preserve a window for getting that survey in the field.
If the decision is taken not to do that, then I expect the Fraser Institute will fill the vacuum with what I think is a pretty dubious set of wait times. It is not that there is a conspiracy. It is just that doctors are going to have a very different view of wait times than patients, and both views will differ from the actual clinical wait times.
There are some legitimate objections to simply counting heads on a wait list if it is not priorized clinically, but there is excellent experience. When I was deputy minister in Ontario, I had the wait times for the eight regional centres on my desk every morning, and the wait times from the Cardiac Care Network for cardiac surgery. We made huge improvements because we could measure it. I could tell the minister that wait times were starting to rise beyond where they should be and we would have to do something about it.
Absent those statistics, if wait times are simply gleaned from a newspaper story or the Fraser Institute, then one does not know, with any credibility, what they are. I had great hopes for the Western Canada Waiting List Project, which was given$2.2 million funding from Health Canada. Templates were as far as they got, I think.
Senator Morin: We had them as a witness. You are quite right.
Mr. Decter: This is not a hugely difficult, technical issue. We have too few imaging machines in Canada. We are proposing to add some. It would not be an enormously costly venture to simply find out from each person going through an MRI or a PET or a CAT scanner how long they waited from the time they were diagnosed to the time they were imaged.
It is critical, both from a management point of view and from a public confidence point of view. Virtually every dinner I go to, someone has a story, completely unverifiable, about cousin Matilda who had to go to Buffalo for an MRI.
I have never actually met anyone who went to Buffalo for an MRI. I do not know to what degree it is urban legend and to what degree a reality. However, if people are fearful, it erodes their confidence. You cannot run a short-length-of-stay acute care system without first-class diagnostics and short or no waits in those systems.
It is folly to have people fearful and waiting for a test. The test often removes the reason for the fear. The doctor says: "We see a shadow on your liver." You believe, as a patient, that you have been given a death sentence. That is only removed when the ultrasound or the CAT scan tells you that those marks, which 40 per cent of people have on their livers, are quite normal; or actually confirms that you do have a tumour or something.
I think it is unconscionable what we do to patients in this country. It is easy to say it did not really have an impact on your clinical outcome. You either had a tumour or you did not. However, those waits convince people that the system is not working.
Therefore, we need to measure wait times. I hope some courage prevails among health officials and health ministers, because a year from now, if the public is told that of the 14 indicators, the only one for which there are no data is wait times, they will conclude that elected officials are reluctant to be put those out because they are so long. I do not think they are universally long. My gut feeling is that there are some really bad situations that must be addressed, and others where wait times are not much of an issue. However, it is all tarred with the same brush.
Let me quickly go through the other points. Regarding health human resources: Yes, there is a huge issue when, any time you put money into the system, it is bargained into collective agreements. The CEO in Edmonton had a chat with me last week. She is concerned that a lot of RNs are taking home more than $100,000 a year, much of it by doing excessive overtime.
I worry that we have replicated somewhat the model that we see in some industrial sectors, where people make a very good living, but work an enormous number of hours and pay a price in health and eventual longevity. It is the wrong model for the health sector. We need to be more creative. We need to be more tough-minded about the kind of settlements that we will accept. I do not begrudge anyone who works in the health sector a decent income, but the point of the health system is not to have the maximum number of employees. It is that if an illness can be treated with a pill rather than a scalpel, or with a home visit rather than a week in hospital and get the same result, we would ultimately prefer a smaller, more effective, least-intrusive means of treating illness.
I do not have an answer. I sometimes think that centralized bargaining was the wrong direction to go. Maybe we can do it through regionalization and allow wage rates to be sensitive to local realities. However, that is a difficult issue. In some of the provinces where centralized bargaining is the tradition in the public sector, there may be some trade-offs between current wages and better pension provisions as the labour force ages.
However, I do not have an easy answer. It is a very difficult for the government to face a strike in the health sector. People are genuinely aggrieved. They have had a tough decade and are looking to regain some ground.
You make a good point about private insurance. Many other OECD countries have some form of private tier. Many of them have a very different history from ours and a somewhat different spending pattern. The U.K., in particular, spends about 50 per cent less than we do on the health system. If Canada wanted to spend 6 per cent of GDP rather than 9.3 per cent or 9.4 per cent, then a case could be made for something to fill the gap. I believe we are more in the spirit of the Germans, the Swiss and the French, who used to spend a little less than we did, and now spend a little more because their populations have aged. I do think that if we want to keep a publicly insured system, we will have to gradually raise the share of GDP going to health. We do not have to go to the Americans' level, but will have to grow health expenditures a little faster than we did in the mid-90s, although perhaps not as fast as in the last couple of years.
We have not yet seen all the positive effects on the system of the $23 billion in the first ministers' communiqué. Hospital executives told me a year ago that they did not have the money to hire the staff they needed. Now they are saying they have the money but cannot find the staff to hire, which is a different issue.
There are all sorts of not-for-profit and for-profit providers. We have some for-profit lab companies that do a superb job. I happen to chair the board of St. Elizabeth Health Care, a large, Catholic, not-for-profit agency that provides about $80 million worth of home care in Ontario. I would say Shirlee Sharkey is every bit as dynamic as any corporate CEO in the country. We do a very good job of providing that home care and we compete against for-profit players on a level playing field. St. Elizabeth is under the umbrella of public insurance, so patients do not have to worry about their coverage and can be assured that the home care worker coming through their front door will give them quality service.
I do not think private insurance is an answer. I have no objection to private insurance for services not included under public insurance coverage. However, it is a second-best answer. The best answer is for the public sector to live up to its responsibilities to properly fund the system we have. There is some room for efficiencies, but I take very seriously what your report points out. That is, if I am an advocate of expanded coverage of home care, then I have to be willing to say how that should be paid for. In that case, I would recommend paying for it out of tax revenues.
I do not think that at the end of the day, we can have a European level of social services and an American level of taxation. I am quite willing, as a Canadian, to pay more taxes than the people to the south because I think we get a good deal more out of our public system. That is an unpopular position in Canadian society today. However, back in Tommy Douglas's day, people believed in balanced budgets and in paying for the public services that they were receiving. We got ourselves into a bit of a jam with debts and deficits. As a country, we have shown great courage in working our way out of that, as has our finance minister. I believe, however, that Canadians are willing to pay a little more for medical research and for a properly funded health care system.
Senator Keon: There is not a lot of time left, Madam Chair. I have about 10 things I would like to discuss with Mr. Decter, so you will have to cut me off.
I want to return to the home care situation for your comment. Jeff Lozon appeared before the committee yesterday and we briefly discussed the concept of regionalization, which is back in the pages of the Ottawa Citizen today. That newspaper is parading my name out again because of the brief I wrote.
When the CEOs from Calgary and Edmonton came before us, it struck me that home care works, and I think it works because of regionalization. I am aware of a number of question marks on regionalization. However, Mr. Lozon has had this idea, since he was deputy minister, of a sort of "super board" of bureaucrats that would fundamentally usurp the authority of the deputy minister, but that would have a life. It would be ongoing and there would be continuity, as opposed to a new deputy minister every two years.
I did not have time to debate it with him for very long. However, it has always been my view that that would be too big. I believe the big barrier to the regionalization concept in Ontario was always, how could Toronto be regionalized? Every time the government tries to plan something, Ontario presents this issue. Can you see the concept of regionalization working, for example, in Northern, Eastern and Western Ontario, while not regionalizing Toronto? It is not manageable anyway.
Mr. Decter: Occasionally, I have some regrets about my time in public service. My greatest regret is that we did not push ahead in the early 1990s, after Earl Orser completed his report, with Southwestern Ontario as a region. We did not because there were enormous capital-cost implications. It came just before the downsizing, so it had enormous appeal. The regional population was about 1.2 million, which is at the high end of what is practical for a region. Toronto is too big to work as a region. The price was a huge capital investment to rebuild a lot of facilities that were probably already too big. Therefore, we did not do it. Not only I, but also the premier and the cabinet, just did not support it.
The evidence is overwhelming that some of the really small regions do not work. This is why Saskatchewan has to come down from 30 to maybe a dozen regions. The regions in Alberta, ranging from a population high in Calgary and Edmonton of 750,000, to a low of about 50,000 to 100,000, work really well. You can sense it when you talk to them. There is actually someone who can move money and resources on a daily basis to deal with the problems. For example, the problem of emergency room overcrowding in Edmonton is not dealt with by a lot of ambulances taking sick people from place to place looking for a slot. It is dealt with by the public health doctor who runs a flu immunization campaign. It is dealt with by opening some long-term care beds and expanding home care. Everyone can sit around a table and discuss how to resolve an issue. In Toronto, you would need the Sky Dome to put all the players around a table.
A big place would have been needed in Edmonton before regionalization. There were 14 hospital boards, home care, and all the agencies. It is heretical to say it in Ontario, but many people who served most of their careers here are onside with regionalization. Tom Closson is a good example. He ran Sunnybrook and is now with the University Health Network. He did a stint in Victoria and absolutely supports regionalization. It simply works better. You get your arms around a bigger piece of it.
In Ontario, I think we are getting into quasi-regionalization. I was down in Sudbury one week, where they have one hospital, a district health council and a CCAC for home care. If those groups work together, they can come pretty close to being able to do something regionally. On the other hand, if one of them is not onside, a turf war can start, which is not helpful.
Toronto has to come down to five or six systems. You could never have one region here, but you could have a couple of academic systems and some community systems, maybe one for women and children, as in Vancouver, and maybe a Catholic one. I spent years in the trenches trying to do that and it is not easy. Even if the owners are onside, there are a lot of "antibodies" to regionalization in Ontario. Part of it is history. Part of it is that the hospitals pre-dated medicare. The idea of their being subsumed is very tough to accept. I believe Ontario will get there, but it will be painfully slow and incremental.
It is very hard to do some of the integrated care, where regionalization shows some benefits, as in Edmonton and Calgary.
Senator Keon: Mr. Decter, may I have your comments on the information and communication technology issue as it relates to regionalization? As I have told other witnesses, I have given up on the big, central information-technology concept. I believe it will never happen. I have spent my whole career, either on the scientific end or health care end, working on committees. They all ended in the same place. I believe now that the only way we can do it can be likened to the American army, where Private Jones has his dog tag, which is his health record. All Canadian citizens should have a health card that is their health record. Then there is the question of repositories. A witness before us yesterday from the OMA felt very strongly that the repository had to be in the doctor's office. He said that most of the time, the patients will not carry their health cards and so on; that it would be a struggle to implement.
However, regionalization would simplify the repository con cept. Obtaining relevant data for bodies like CIHI and Health Canada, and for the provinces, which need it for their financial planning, would be simpler. Obtaining this information is a much larger problem as the system works now. We ask people to surrender their privacy to make it possible to create data repositories that we can use for economics.
Could you offer comments on that?
Mr. Decter: I think Canadians are quite willing to share their health care information if they believe there is some benefit to be derived. For example, people are quite willing to give health information to Shoppers because they get back not just a bottle of pills, but a great deal of information about the drugs and about the disease. If there is a tangible payback, people will populate the data record themselves, to the degree they are able. We are seeing that with our hip and joint registry, which I think will be a valuable addition to the Canadian health system that CIHI is developing. The Scandinavians are 20 or 30 years ahead of us on this.
Two types of data need to be considered separately. There is the kind of data that we need to develop policy and manage the system, most of which does not need a personal identifier on it. We are moving to try and do that in real time, instead of with two- and three year-old data. We want hospitals to submit their data within three months. Eventually, I would like to see it in real time. One should be able to hit a button and populate the database. People could benchmark. We have had an enormously positive response to an initiative we took to allow people to benchmark pretty much in real time by submitting their data.
That problem will be solved, although it needs some investment. You raised the much more difficult problem of people's identified health record. There we are into a real tug of war between a number of parties. The privacy commissioners have become very powerful. Historically, the physicians, who remain very powerful, have owned the medical record. People do not understand that, thinking that in this consumer world we live in, they own their own medical record. Hence when the issue is raised, people are surprised: "What do you mean it isn't mine?"
I do think the idea of a data bank will develop from the bottom up, not from the top down. Any suggestion that it would be sensible to have a huge data bank in Ottawa has no point and will be fiercely resisted. We saw Bruce Phillips, as privacy commis sioner, fire one shot and the HRDC database was shut down and wiped out, destroying an enormous resource for research, because nobody was willing to defend it.
CIHI has gone to some length to ensure privacy. We have consulted with privacy commissioners. I believe it will have to be a voluntary act, whether through a "dog tag" or on the Internet, whereby people will be willing to give their medical information in an electronic form in the expectation of getting something back. That could be either a bulletin with the latest information on diabetes or asthma or some disease of relevance to them, or genetic screening.
I do not know what the gift will be, but it will have to be part of a new, more informed deal for the patient. I expect a lot of cooperation, but not if it remains a kind of provider/government/ institution issue. We have to engage the public and tell them that we do not want this information to share with their employer so they can be fired. We do not want this information to violate their privacy. We want this information to do a better job of looking after them.
We need to have some courage, go to the public and make them a sensible offer. I too have spent a lot of time in committees and meetings where people design fancy database architectures. Then when they are taken to cabinet, the ministers quite rightly say: "Would not $500 million buy us peace with the nurses and doctors for a couple of years, rather than some computers in a room somewhere?" The deputy ministers acknowledge it would. The cabinet then concludes they are all in favour of the investment, but it can wait until next year. Then it becomes a "next year" kind of project.
I spent some time with Eric Maldoff and learned that there is currently $500 million in an account that could be used to trigger several billion dollars worth of sensible investment across the country. However, the public must support the effort or it will fail. We need some leadership, rather than a fight about who owns the record. Who owns anything in the present world? The information will be there. I do not think that it must be definitely owned by either the doctor or the patient. It could be a shared resource.
I do not have an easy answer, but I believe your instinct is right: It will develop from a bottom-up commitment by individuals into some kind of framework, rather than from something top-down.
Senator Keon: Mr. Decter, given the complexities we are facing, with some services paid for and some being delisted, and with this business of private insurance, I believe we have to separate care provider and evaluator. As far as possible, we should remain with a single payer. There already are, and will be more, private insurance schemes. As long as they can meet the standards of the evaluator, I do not believe it matters who provides. It would be very important to have government or public supervision of the evaluator. Whether that turns out to be the Fraser Institute, CIHI, Stats Can or some of the provincial agencies does not appear to matter, provided it meets a given standard. Would you comment on that concept, please?
Mr. Decter: We have a very good piece of legislation in Ontario, which has been rather uncontroversial compared to that in Alberta, called the Independent Health Facilities Act, which was put into place back in the late 1980s. It is a regulatory statute that provides some important checks on the expansion of independent, private health facilities.
It requires some form of needs assessment. The district health council has to decide that there is actually some need for a facility of that type. It provides for the government to pay the bill.
It is mostly used for radiology clinics. There was a lot of grandfathering, if that is still a politically appropriate term, and a lot of allowing existing facilities into the fold, although some toughness too. To the amusement of some of the staff at the ministry I then headed, one enterprising radiologist X-rayed his mother on a number of vacant parking lots in downtown Toronto and applied for licences under the grandfather provision in case he wanted to build an X-ray facility on any of those lots in the future. The licences were not granted.
However, it is a mechanism for saying there should be a framework and some regulation, because the technology is moving in that direction. Many procedures that used to be hospital based are going to be performed in clinics or may become physician office based. Laser eye clinics, and a whole range of services, are going to be enabled by technology that is less invasive and faster. We may not owe the public insurance to cover the services of a laser eye clinic. I would be willing to debate that. Certainly, however, we have an obligation, as a society, to offer them some safety and efficacy. If one wants to buy a car, it is "caveat emptor." However, if one should require some medical treatment, even if paying for it oneself, it should be ensured not only that the service is being performed by a certified health professional, but that the clinic is operating under some regulatory umbrella.
I think there should be some regulatory expansion of that at the provincial level. This is not because I like red tape, but because the public believes somebody is worrying about the safety and quality issues, and I am not sure that that is always the case. We had a stupendous failure of the blood system. I spent a lot of time with Krever, pre-Krever. It was very clear that we were asleep at the regulatory switch. We licensed blood centres but did not inspect them. We did nothing to ensure that what they were doing was safe. We simply issued licences, a matter of sending a form. That is not what the public expects.
I think we are going to see a raft of new businesses in health. That will only be a terrible thing if we allow a proliferation where they are not needed. Witness the American experience, with an MRI machine on every corner. There are 3,500 MRI machines in the U.S. that were established without a needs assessment. We could make a societal judgment that says: "We do not care. If you want to lose money investing in laser eye clinics, that is your business." However, where there is public concern that it is going to take staff away from the hospitals, there should be some form of needs assessment. American states have a certificate of need for new hospital facilities and some surgery centre facilities. I think we could do something like that.
I share your concern that there continue to be a single payer. There are multiple payers such as Workers' Compensation and auto insurance, but I support the solidarity principle for health services. I am less concerned about having some diversity in the provider base.
We are weak on evaluation in Canada. We have a voluntary accreditation system that is well short of what we need. As we explore the issue of patient safety, we will find that that weakness stems from exactly the same philosophy as in the blood system: The Red Cross are nice people. They are trying to do a socially useful thing. Why should we second-guess them?
Unfortunately, nice people can still do a lot of harm when somebody is not tough-minded enough about applying standards.
Senator Callbeck: Mr. Decter, I have a question about your opening remarks. You mentioned that the public will not have confidence in the system until they get information.
What type of information do you feel the public should be receiving that they are not receiving now? Who should be responsible? How does that information get out?
Mr. Decter: New public expectations are about timely access. The public wants to know how long it takes to get access, not just whether they may have access. They want to know about quality: How does this one compare to that one? Has it been compared to a recognized standard? They want to know about appropriateness. Even if the system does things quickly and well, questions are raised. When ISIS published data showing that seven times as many women in Northern Ontario had hysterectomies as women in Southern Ontario, the question was raised, are too few hysterectomies being done in the south or too many in the north? What is the appropriate standard?
The public wants value for money. People know they pay a lot of money for their health system. They do not know whether that money is well or badly spent. Opinion polls show that people say the only thing they are willing to pay more taxes for is health care, but they are not sure they need to because they are not sure that current dollars are well spent.
It is the obligation of the regional authorities and hospitals delivering care to report as much as they can to the people they serve. Some of the regions are doing a superb job of setting indicators and then reporting progress. It is the role of provincial governments to report at a provincial level. Nationally, it is a shared obligation between CIHI and Statistics Canada that both organizations try to live up to, to report what we can on the performance of the system. There are many levels to it.
Health care is extraordinarily local. To a degree, although we have helped MacLean's publish national reports, what people are really interested in is: How is my hospital doing? Is the hospital in my community doing a good job? How does it compare to the one 20 miles away or the one in the big city? When someone I care about is sick, should I be driving downtown, or will I receive the same quality and timeliness of access where I am?
We make a lot of unproductive efforts because there is a lack of good signalling. When David Dodge arrived at Health Canada, he was completely shocked and appalled at the level of health data. Why? He had spent his life as a labour economist and then as a Finance deputy. The two things we have good information about in this society are labour markets and financial markets. I have a computer on my desk that gives me real-time data on stock markets, interest rates and all sorts of things. We are trying to manage the health system with data that is often two and three years old, and at the same time, to get the public onboard with change. We do not offer them much, just some rhetoric about how this will be good for them. We do not say: "In the last year, we were able to be reduce waiting lists."
Think about the unemployment rate, which is published every month. If you are a provincial premier or member of a provincial government and the unemployment rate starts going the wrong way in your province but not in the adjacent provinces, you have a huge political problem. You have to do something about it. It galvanizes you into action. There is no comparable measure in health care. We mostly deal with the anecdote about Fred waiting in emergency. We deal with the spending, everybody clamouring for more money. We need the middle ground. We need to know how many Freds there are and how long they have waited. We need to do it at every level because it will restore confidence.
People who have used the health care system are much more confident about it than people who have not. This tells me that it is easy to sell newspapers with headlines that say "health crisis." However, the papers are not always wrong. If it is a problem for the system, it is a crisis for Fred if he is in the back of an ambulance being driven from place to place and unable to get care. It is a crisis for his family too. Therefore, the rhetoric comes easily. I think it is a task for every level.
The good news is that we are making good progress on collecting the data because computers are faster, and we are able to do more with them. Some brilliant health researchers across the country, in little groups such as the Manitoba centre, ISIS and so on, are taking what were administrative data sets and teaching us a lot about the policy implications.
Senator Robertson: Mr. Decter, in your earlier remarks, you spoke of two issues that this committee has heard about repeatedly - the need for better home care and a requirement for pharmacare.
You said you felt that home care could probably be absorbed into the system with the current funding methodology, and I agree. There are very beneficial trade-offs. However, you quickly moved away from pharmacare and what this committee could recommend, whether under private-sector insurance or public-sec tor coverage. Pharmacare is, however, one of the most important parts of our health care system and simply is not available to most people. There have been increases in our elderly population and the poverty rates. Today there are as many children living in poverty in Canada as there were 10 years ago.
I should like to know whether you would recommend that a pharmacare program be established in Canada that would be financially feasible for the population without putting too much stress on the tax dollars collected.
Mr. Decter: I have strong views on this. After being an advocate for seven or eight years, however, I am not confident of how we would get from where we are to where I think we ought to be.
We should have a national approach to drug coverage. When I look at the numbers on drug coverage, we do not stack up well compared to the other OECD nations. The ballpark numbers are, the public sector pays about a third of the bills, private employers pay about a third, and individuals pay about a third. If that were evenly distributed across the country, it might be acceptable, but it is not. The situation in Ontario is that seniors now pay a very small percentage of their drug bills, where they used to pay none. Seniors in other parts of the country, Newfoundland, for instance, pay an enormous price for drugs, high enough to keep many of them, I think, from getting the medications they need. Medication is now our number 2 issue. It has passed spending on physicians. New products have rolled out of the pharmaceutical companies, some of them marvellously innovative, others merely expensive.
I think that home care is relatively easy; pharmacare is very difficult for these reasons. The research-based pharmaceutical companies and the generic companies are two very combative industry groups. There is a war on every issue, as we have witnessed in the last few weeks. It is a litigious war that tends to scare people in political life away from getting into that issue. Beyond that, there is the federal/provincial issue. The reality is that a national plan is unlikely to be acceptable to the Province of Quebec. Quebec has gone further than any other province in reforming their own approach and come closest to what I think is the right model for the country - an integrated, single plan with a role for private employers and for the public. Quebec has felt some serious cost pressure since that plan was established.
We do not have good, effective prescribing in the country. We mis-prescribe, over-prescribe and under-prescribe. Why? The answer is complex. A lot of physicians have trouble keeping up with the complexity of the evidence concerning use of medica tions. I am not making a personal judgment here. One of the most remarkable physicians in this province, in my experience, and not including those seated at the table, was the late Dr. Adam Linton, a thoughtful internist and academic physician. I had a call from him when he was very ill from liver cancer. Only Adam would go back through every prescription he had written in the previous year. He decided that 40 per cent of what he had written was not based on the best evidence. He said to me: "I am pretty careful." He was a very careful physician. "If I am wrong that percentage of the time, we really need to change how we do this."
How to pay for prescription drugs equitably is one problem. However, the larger problem is how to improve prescribing on the one hand and utilization on the other. Patients are notorious for not following the drug regime that they are supposed to be on. This wastes drugs and has other consequences. Changing this requires a good deal of cooperation between the levels of government. What arose from the St. John's meeting of health ministers was some agreement to work together on evaluation. That is a good start.
At the end of the day, if we were to bring in a pharmacare plan, it would have to be with premiums, the way we brought in hospital and physician insurance. That would be the right way. Let's have a first-class drug program in Canada. The employers can pay for what they were paying for already. The governments can pay for the elderly and the poor. Those of us who are working and do not have an employer plan, but are capable of paying a monthly premium, can pay it.
I do not like charges at the point of care. They scare off the wrong people. However, there is nothing wrong with individuals and families shouldering some responsibility if they are getting a quality program with good evidence attached and goodprescribing and dispensing.
We will see medications that can effect remarkable changes. I watched slides of Dr. Volkman's work on Friday night. I could not watch children whose massive facial tumours were disappearing without thinking that there is something here. I know there is a lot of controversy around Dr. Volkman's work, but the room was half-filled with people who either had cancer themselves or had children or loved ones who did. In this society, you will not be able to stand between people and those medications. It will be financially ruinous for families if we do not get a proper coverage plan in place.
We betray the spirit of medicare if we accept that we have hospital and physician coverage at the 90-something per cent level, but when it comes to drugs, we are not quite there. We drag our feet on listing new drugs. We do all sorts of things that are not good for patients to try to contain the costs. I do think that we have a lot to learn. The British and the Australians do it nationally. It is difficult to see how the provincial/federal dynamic would work. Why would the federal government want to end up with the most difficult piece of the health sector? However, somehow we have to find a way of properly ensuring and managing access to drugs in the country. It is the only part of our system that really is something of an embarrassment international ly.
Senator Robertson: We recognize the abuse in drug usage. Some people do not take their prescriptions. Some physicians write prescriptions without adequate knowledge. I hope that does not hold us back for too long. How many people fully follow their doctor's directions when they leave the office? The doctors are fully covered. However, although I do not know the percentage, I know some people do not bother to follow their physician's directions.
Mr. Decter: There are problems all the way around. A lot of education is needed. Our seniors are a remarkable group of people. I believe they are very smart. If we give them access to the information, I think that they will do a very good job.
In some parts of this country, some seniors are staring at a crushing financial burden in paying drug bills. I believe that is wrong. It is not wrong to say we are all going to pay $10 a month or $20 a month. It is wrong to force a patient to choose between taking a medication that the doctor says is necessary and going without groceries for a month because the drug has a $300 or $400 price tag.
If the goal of medicare was to remove the financial burden between those receiving care and those providing care, I believe we have done a splendid job on hospitals and doctors. Certainly it is contentious. A lot of things are not perfect. No physician in the country believes the system can be made better without more money. Nevertheless, people are not denied care because they do not have money in their pocket. However, on the drug side, there are such situations.
The Deputy Chairman: On behalf of my colleagues, I thank you very much, Dr. Decter. I can well see why your views on this subject are so sought out. On our part, and I will follow up on this, we must let the Stats Can survey on the waiting lists go ahead. We cannot let people walk away from it, because otherwise, others will fill the vacuum. We may call you again when we are cleaning up issues like pharmacare with witnesses back in Ottawa.
Mr. Decter: It was a privilege. I would be delighted to do anything I can to assist the committee. I wish you well in your work.
The Deputy Chairman: Colleagues, I would like to call our next set of witnesses to the table: David MacKinnon, president and CEO of the Ontario Hospital Association; and Doris Grinspun, executive director of the Registered Nurses Association of Ontario.
Ms Doris Grinspun, Executive Director, Registered Nurses Association of Ontario: Thank you very much for inviting us. I am the executive director of the Registered Nurses Association of Ontario, the professional voice of registered nurses in this province.
We are here today on behalf of registered nurses in Ontario to urge the Senate committee to steer clear of two-tier health care. We are here to oppose the increasing encroachment of private funding, including user fees and private, for-profit delivery, on necessary health services.
We are here also to offer solutions to the real problems that our health care system faces. These are: timely access, inappropriate system utilization, inadequate human resources management and deteriorating public confidence. These problems are the result of a system that is over-reliant on hospitals and underutilizes nurses. Paradoxically, at the same time, it overworks them. It also underutilizes nurse practitioners, social workers, dieticians and others.
We speak about moving health care into our communities, and yet the lion's share of our health care dollars goes to institutions. We have a system in which, if you require medical attention at 8:00 p.m. or on the weekend, you must turn to an emergency room. We have a system in which patients may not be discharged from the hospital because we have not built a solid home care program in this country. We have a system in which hospitals have become "the canary in the coal mine." This is not because people have an insatiable appetite for hospitals, but rather because they have nowhere else to go.
In today's reality, our system offers the wrong incentives. For example, medications are only covered for patients in hospital. Doctors are paid "by the piece." The elderly are housed in institutions rather than supported in their own communities. We hear rhetoric about an ageing population, yet we do not develop services that are in tune with this type of population. At the same time as nurses are underutilized, they are overworked. Almost 45 per cent of nurses in this country are part time or casual, many of them not by choice.
We believe there are solutions to these ailments. We need a recommitment from the federal government that all health care services will be exempted from trade agreements. We believe that should be the case, but know that is not the reality. We also need an urgent and massive move to publicly funded, 24-hour-a-day, 7-days-a-week primary health care provided by interdisciplinary teams of health care providers. We need a clear framework, national standards and adequate funding for home health care services nationwide. We need a national pharmacare program and mechanisms to control the rapid growth in pharmaceutical expenses. We need a national coordinating body for health human resources to address the shortage of nurses and other health care professionals.
Senate members, in today's reality, we know that social disintegration brings the most disastrous results. We see that all over the globe. These are delinquency, violence and insecurity. Our health care system has been a great source of national unity and has provided people with equity. Equity and unity are linked, and social cohesiveness is linked to that. Let us work together to build up our health care system, not tear it down.
Mr. David MacKinnon, President and CEO, Ontario Hospital Association: Thank you very much, Madam Chair, for the opportunity to meet with you today. Since time is brief, I will be brief. I am also tabling a submission that, if time permits, I will take you through. It is a series of charts that describe hospitals and parts of the larger health care system in Ontario.
I should like to compliment the committee on its work. In my view, the executive summary of your report is the best short survey of the issues in Canadian health care that I have seen to date. I think it is a must-read for everybody. It covers almost all the comprehensive issues concisely, and lays them out in a way that is very helpful to decision making.
There are issues that I think the committee could have explored in greater detail. However, overall, as a quick summary that puts the issues before us in a way conducive to decision making, it is a first-class effort. I would like to thank everyone involved, including senators and staff, for the time and energy that obviously went into this document.
I am encouraged by recent statements from Senator Kirby, Roy Romanow, Premier Harris and Tony Clement, that the only option off the table in our health care discussion is the status quo. Your report has certainly demonstrated an ability to think outside the box in a way that all those people have been encouraging us to do.
The Ontario Hospital Association, representing about 150 hospital corporations in Ontario on 200 sites, has recently embarked on a broad-based program to put new ideas into that national debate, so that we can keep the system we have and move it forward. We want to do everything we can, all of us connected with hospitals, to ensure an accountable and sustainable health care system. We have done a lot. We were at the forefront of accountability through hospital report cards and the sharing of best practices. I was interested in a previous question about the kind of information the public needs. We believe we have pushed the boundaries of the possible there with our system report cards. I will come back to that.
We have also developed what we believe is the most cost-efficient system, measured in a whole variety of different ways, compared to the rest of Canada and to the United States. We have established significant working groups to push the system forward. The Ontario e-Health Council has been estab lished to move us into e-health, the delivery of health services on the Internet and in other imaginative ways. We have developed a supply chain management committee that has identified very significant savings in the purchasing of goods and services by hospitals. We are looking at other ways of financing the massive investment needed in hospitals, including a greater role for the private sector in the design, development and operation of hospital facilities. We have commissioned a number of studies on alternative revenue strategies for hospitals, illness prevention, population health and wellness programs, and the effects of the rationing of health care taking place through waiting lists, delays and other problems, to help create a system more in line with consumer expectations and hopes.
We will be releasing the results of all this research over the next few months in our response to the Romanow commission. However, I would like to comment briefly on several of the issues raised in your report.
It is becoming increasingly clear that effective reform of our health care system will require changes to the Canada Health Act. With the exception of the four principles of universality, comprehensiveness, accessibility and portability, all of which are patient-oriented, we believe that the act should be up for discussion. You cannot continue dealing with a business plan that is effectively 35 years old without making every reasonable effort to keep it contemporary. That is what we are doing in Canada. We believe that a new principle could be added to the act on health care delivery flexibility. Provinces and territories should be given greater flexibility to experiment with the delivery of patient care in new and innovative ways.
If we are to ensure cost-effective patient care in the long term, there is a real need for significantly increased investment in up-to-date information technology and medical equipment in Canada. In my own family, a relative was recently treated for a particular form of cancer with X-ray equipment that is16 years old. The treatment was interrupted constantly by equipment breakdowns. Lack of funding to update equipment has huge patient implications.
We think the federal government must always be prepared to fund its share of health care costs. There are problems there, and they are described in our submission. I will not go into them in detail now.
I wish to comment on several features unique to the Ontario health care landscape. In common with the United States, Ontario does not have regional health authorities. In fact, no province in Canada has regional health authorities that integrate all aspects of patient care, including physician services.
However, the absence of regional authorities has certainly not impeded health care in Ontario. Our hospitals are better utilized than elsewhere in the country. They make greater use of day surgery and ambulatory care. We treat sicker patients, and do so with much higher standards of utilization than in other provinces. We also know, in relation to the perceived problems of handing off people from one provider to another, that about 85 per cent of Ontario's patients are highly satisfied with how they are transferred back and forth between providers. That statistic comes from a detailed set of surveys of every hospital in Ontario, with statistically valid samples.
Second, I would point out that we do have a report card system. I am surprised Dr. Decter did not comment on it. It is unique in Canada, and quite possibly in North America. Only in Ontario is there factual information, on the public record and comparable among institutions, that describes clinical outcomes, patient perceptions of the system, and the rapidity and success of major innovations. If you believe, as I do, that the very first requirement in measuring anything is to do so in a comprehensive manner, then we are in real trouble indeed. Report card systems are lacking in all other jurisdictions.
There is a corollary to this. Health care services across Canada would be much better served if the other provinces put similar systems in place so that there could be more points of comparison.
I think my third comment will surprise you. It relates to Ontario's position within the federal fiscal system. Almost imperceptibly, our country has evolved so that virtually all core public services in Ontario are funded much less generously than in all other Canadian jurisdictions. They are held to targets much less consumer friendly than in other provinces. This is true, by every standard, for hospitals. We have measured and studied it in great detail. It is especially true for other public institutions, including colleges and universities. In Ontario, colleges and universities are funded at 80 per cent of the Canadian average. When you consider the extent to which we, because of the size of the province, determine that Canadian average, that disparity of 20 per cent is in fact much greater than it appears. It extends across all types of public institutions in Ontario.
I ask the committee to consider the implications of that. We think the problem urgently needs attention. It is clearly not in the national interest that core public services in the province that is the major funder of the transfer system should be underfunded relative to the rest of the country. It is not in the interests of anybody, whether a donating or receiving province.
I will conclude by saying it is time for the health care debate to move beyond the ideological focus that emerges whenever questions of sustainability and form are raised. For example, the mere suggestion that there is a need for more public-private partnerships provokes accusations about two-tier health care. This is manifestly untrue. The private sector has always had a role in health care in Canada. Instead of erecting barriers to their participation in our national project of improving health care, we should be building bridges to ensure that the private and public sectors help build the system of the future together. Your report outlines some ideas as to how that might be done. In doing so, I think your committee has rendered Canadians a distinguished service.
The Deputy Chairman: I made particular note of the statistics regarding Ontario. As an Ontario senator, I have often said publicly that Ontario people are the last to complain about the inequities of the system across the country.
Senator Keon: My questions will overlap, starting with you, Mr. MacKinnon. I am very interested in the private financing of hospitals themselves. I have been struck over the last few years by how easy it is to raise money on the stock market for a good idea. I had no idea how easy it was until I got into raising money for a few scientific inventions.
It seems to me that we are in a tremendous crisis, or at least redevelopment, of our health system in Canada. We are bogged down in spending all our money on hand-to-mouth and day-to-day activities and have no "change" money. I have raised the question with a number of witnesses as to whether we should try to force the federal government to do what they did in the 1960s. At that time, they threw a lot of money into the pot that the provinces were allowed to spend at their discretion, but they had to go to the federal government for change money, for development money.
You hit on the other option in your presentation. I would like to further pursue the private financing of hospitals with you. It would not seem to be a Herculean task for many hospitals to go public and raise money on the market. If the shareholders had a vested interest in the success of the hospital, they would be involved in its management. I can only see that leading to a lot of good in a lot of ways. Certainly, management would be more interested than volunteers who serve on boards. I am not being critical of those volunteers, by the way.
What are your thoughts on whether private financing of hospitals is possible or not? How close are we to innovative ways to pursue that?
Mr. MacKinnon: I will respond in two parts. First I will describe the extent of the problem of capital investment in hospitals. Second, I will talk about how to go about establishing a private goal that is consistent with the present system.
At the moment, if you took all the directions recommended by the Health Services Restructuring Commission relating to hospitals and added in the ordinary expenditures on equipment and so forth, over the next five years, it would consume the entire capital budget of the Province of Ontario. Clearly, those recommendations have to be implemented over time. No one would contemplate not building the highways or not repairing roads or not worrying about municipal transit systems. We have to stretch those requirements out over time if we are to keep the system in any kind of contemporary shape. We have studied those numbers, and I include many of them in my submission.
One way we have contemplated enlisting the private sector is through various forms of pool lending. We have discussed forms of build-to-lease and to-operate. We have had a committee drawn from the banking industry and the hospitals working aggressively on these. We believe there is much that we can learn from other jurisdictions. At the end of the day, we absolutely have to enlist the private sector if Ontario's nurses and physicians are to work in modern facilities.
We have released a preliminary report describing some of the options. We are now at a much more detailed stage. I am hopeful that over the next year or so, we will see some pilot projects in Ontario. In particular, hospital facilities are to be leased to the hospital boards. Payments will be stretched out over time, and it should be possible to accommodate this in the modern system.
I should comment on one thing you mentioned, the role of community people. I think hospital boards have been exceptional ly skilled at raising money for equipment. We are concerned about the "bulge" that I have referred to for an important reason. If hospitals run charity campaigns of great intensity across the province of Ontario, there is a risk of crowding other people out. We would much prefer that those fundraising efforts continue, but there is a point at which they could become counterproductive. Therefore, it makes sense to talk about build-to-lease, pool lending and all those other measures learned from the practice of other jurisdictions, rather than rely too much on voluntary fundraising. That can have negative consequences for other groups that depend upon public contributions.
Ms Grinspun: If I might comment on the same question. You suggest that shareholders would be more interested in the management of hospitals. It seems to me there is a belief or assumption that the management of hospitals is inefficient. I do not think that is the case. I worked for many years in a hospital as director of nursing. I have visited the entire province in the last six years, and I do not think that that is the case. I would suggest that there are other issues within the hospital sector that need to be addressed. The use of technology is one of them. It is a huge expense. We are not always sufficiently critical of the choice of technology and when to implement it. Another is the utilization of technology. Dr. Decter offered an example with MRIs. I worked in the U.S. for six years. Yes, there was an MRI in every corner in some hospitals. Others went without. I have worked in countries where some of this machinery is working 24 hours a day and people are served at different times of the day and night. We should look at efficient utilization of the equipment we have.
I also believe that hospital services continue to over-rely on providing all health care needs. This over-reliance is at the expense of looking at home care, primary health care, long-term care - and not institutionalized long-term care, but other menus and programs for the elderly. We speak about an increasingly ageing population, but we provide few answers to what we should do about that in the future.
Senator Keon: Ms Grinspun, I agree with you that hospitals really are very well run right across the country and in Ontario. However, we have a problem. We do not have the venture capital necessary to make change. For example, in research, if you make a discovery, you can obtain the venture capital from the private sector and build a lab or a factory, as needed, to proceed with your product. We do not have that flexibility in the health sector. That is the point I was coming to.
Our community access centres, and some of our community clinics, are not working out as well as they should. The reason is that they are starved of development money. I raised something with Dr. Decter that I have raised repeatedly. We have reached the point where we have to separate payer, provider and evaluator. If we maintain the principles of our government to date, we can do that. When we get down to the provider sector, it does not matter who provides the care, as long as it is up to the standard that the evaluators demand. The evaluators have to be government controlled.
Let me take you out to the community. There is no reason in the world why some community access centres or community clinics could not be small corporations, operated by nurses and doctors, physiotherapists and other health professionals who could be shareholders, if they were providing a service up to a given standard. They could also get investment from other people. I am quite aware that this frightens people. They think this means we are "going American." We have not spent a lot of time looking at the American system because we do not want to go American. However, we have to think of improvised ways of improving our Canadian system.
Nursing is front and centre in community care. It has to be. I agree with you that we have to find a different way of remunerating physicians or we will not get anywhere with that one either. What do you think of the concept of some community care access centres and community clinics being publicly owned?
Ms Grinspun: Let me comment on a couple of points you made. First of all, community care access centres are a phenomenon, especially in Ontario. We are creating parallel structures all over the place. We have community care access centres that are supposed to coordinate services. Now we will have family health networks that are supposed to do the same thing. I have discussed these with government officials. I do not think it is to the benefit of the public to have parallel structures. We cannot speak about integration, and at the same time, create isolated, parallel structures.
I fully agree that there are significant problems with commun ity care access centres the way they are today. There are also overlaps between what the community access centre does and what the nurse who provides the care does.
There are no provincial standards on what community care access centres in different areas of the province should be providing. I fully agree we have a problem there.
We do not have a problem with the private provision. When I say "I" or "we," I am referring to nurses, and particularly to nurses in Ontario. What is the incentive? For example, you can have private, not-for-profit institutions where making money is not an incentive, and therefore whatever is being done is in response to the need for quality service to which you refer, and not to make trouble for whoever else. I believe we have a common language there.
We must start to seriously develop those services. Primary health care is the most important one because it will discourage people from going to a hospital in the middle of the night. Home care must be further developed so people with chronic conditions can be treated at home and hospital patients can be discharged earlier when appropriate. Sometimes, we do not discharge because we simply do not have the service. I am involved at least twice a month with clients who wish to leave the hospital. However, they cannot because no nurse is available in the home care sector because of the way we are developing it. Much is needed. However, when we go beyond talk to actual funding, most of it ends up in what I would call "walls" care, that is, institutionalized care.
This also applies to the elderly. We are creating 20,000 new beds in Ontario. We will be institutionalizing everyone. My parents do not want that. They want to stay at home. I do not want that, and I am sure you do not either. We are not developing alternative models of care for the elderly that will allow us to do what we say we want to do, which is to keep people in their homes.
Mr. MacKinnon: Much of that I would disagree with. I will make three comments, if I may. One is that on the management of change, I believe we are doing a little better and there is more room and more local experimentation that is working out wonderfully. For example, our system report card shows that the number of hospitals sharing patient information electronically with positions outside of the hospital doubled from 1999 to 2001; an incredible rate of change. That is the key to any sort of user-friendly retail service.
Let me say that it supports your observation on local initiative. In Sault Ste. Marie, we have a large group practice that has a joint executive committee with the local hospitals. The group practice does many of the things that Ms Grinspun has recommended, and it does so in conjunction with the hospital. A fairly tight relationship exists there. A similar one exists in Parry Sound where a new type of health enterprise has emerged. Regarding the management of change, therefore, and notwithstanding all the pressures, I would be less pessimistic in looking at the system in that respect.
On the fundamental issue of community versus institutional care, I think in Canada we have been very careless. A few years ago we came across about 100 studies worldwide on where care can be delivered most efficiently and effectively. No generaliz ation is possible. Initially, you need to go down into the particular illness or the particular condition, and you might have to do that with respect to several dozen of those illnesses and conditions, and then decide just where it is best to do something.
I do not happen to share Ms Grinspun's view on retirement. My parents have just moved from their family home into a retirement residence, and that was the best thing that had ever happened to them. Their home had become a prison; now they are no longer socially isolated. My three siblings and I are delighted that we have finally got them out of the house. However, one cannot just make that kind of a judgment; one needs to consider the circumstances of the individuals involved.
Finally, I wish to make one plea: In Ontario, for many years we never added up the operating plans of Ontario's hospitals to support provincial budget decisions. We produced no information that was publicly available on what actually happened in hospitals, such as outcomes, readmission rates, complication rates and so on. I believe a large part of our problem in Canadian health care is because provincial governments generally, and the health care system in particular, have not used ordinary business numeracy practices in approaching this problem. If we did that, and basically copied the report card system and the systems that we are now developing, we would see a lot of our problem at least lessen, if not disappear.
It is quite shocking to me that, for 30 long years in Ontario, between $50 billion and $100 billion changed hands. No one ever talks publicly about the output; no one ever adds up the operating plans. All the basic tools of numeracy are not used. I think that is a large part of our problem. We can do a lot better by improving how provinces manage their relationship with health care facilities and how numerate they are while doing it.
Senator Morin: I have been going through your report here. I thank you for your submission. You have very good data there. A large part of your submission deals with stable funding from the federal government. I would like to pose two questions here: Should we also consider stabilizing the funding from the provincial governments? There has been a problem there. Provincial funding has been up and down in many provinces. Second, what are your views on the stability of federal funding in the context where government priorities change? The period since September 11 has been a good example of that. Some other events of the future may change the priorities of the government. The Canadian public follows the government on this, I think. It is very difficult to have stable funding if priorities change. There may be some national crisis where health is no longer the priority, and funding may actually be reduced for health.
I understand the necessity for the stability of funding but, faced with the political reality of changing priorities, what are your views on that? Let us not discuss federal and provincial spending and what the percentages are. That is not part of my question.
Mr. MacKinnon: I would like to make a purely personal comment on what is likely to happen. One has to be respectful of the political process governments have to face on this issue. There is a fundamental mismatch between what people want in health care and what they are willing to pay for through their tax system; there is little doubt about that. I could sit here and say: Would it not be wonderful if we could have stable funding and all the basic percentages could be built in? But I am under no illusions. I think taxpayers are not willing, over time, to carry on in that way.
I believe the system of the future will have three different revenue streams attached to it: The first will be core funding that governments provide for their equity and service goals that they believe are politically appropriate. You have explored the second stream in your report. Some of those ideas are in there, so I wanted to say how much I think that that is an asset.
The second stream would be co-insurance. For one thing, we have to get at the issue of lifestyle causes for many of the problems we are trying to deal with in health care. A portion of the revenue that goes into the system that comes in through some sort of insurance system would be helpful in that sense.
The third stream would come from services that people are willing to pay for on their own, outside the core Health Act. For example, you might have an Internet-based patient record for a person and his or her family. They might pay for that because, wherever they go in the world, information on their health could be as easily accessible as your banking information is when you use a bank card.
In summary, what I think will emerge from the next four or five years, after a national debate of these issues, would be a system based on those three different kinds of streams. There will be somewhat less political pressure on governments to fund everything all the time. There will also be less pressure on providing a complete entitlement system as opposed to a system with some role for personal health management and the consequences thereof.
Ms Grinspun: I would like to offer a comment on that point. We have discussed this subject in the past, and my friend David and I strongly disagree on this issue. I do not speak on a personal but on a nursing basis. I am referring to services that are needed, not to plastic surgery to look better or something like that. What this menu suggests is that some will go without if they cannot pay.
I remind this committee here that Medicare has delivered on its promise, if we look at the GDP. This is despite our need to make changes to it because we now want to move services to the community, as opposed to when we started this initiative. Before Medicare, we spent around 7 per cent of the GDP. We are spending 9.3 per cent in the last three years with this table. The U.S. is spending over 14 per cent. Indeed, they are looking at 17 per cent unless they delist more services for the elderly.
The question is: Is that where we want to go? Some elderly, like Mr. MacKinnon's parents or my parents, can afford a good residential home. However, I have lived and worked in three different countries. I have no doubt that a portion of the elderly will not have the means to pay. Simply, the state will have to pick up on that cost, which will impact on our spending anyway. We cannot just leave those elderly in the street and say: "Who cares?" Those issues need to be taken into consideration when we are proposing different models for payment.
Senator Robertson: In your presentation, Mr. MacKinnon, I note that you are saying on page three of this document that:
According to the Ontario Hospital Association it is becoming increasingly clear that reforming our health care system effectively will require changes to the Canada Health Act.
You go on to say:
With the exception of the four principles of universality, comprehensiveness, accessibility, and portability, all of which are patient-oriented, the rest of the act should be on the table.I believe a lot of people would agree with that statement. I am not sure about accessibility, because accessibility means different things to different people. The devil, as we say, rests in the detail. Interpretations can be terribly detailed, and sometimes offensively wander off in never-intended directions. I would like accessibility to be looked at more clearly.
Then you say that the rest of the act should be on the table. If the rest of the act were on the table, what would that do to the management of the hospitals, for instance, in your province? How would that make it easier?
Mr. MacKinnon: The transformation wrought by technology that we have seen in the hospitals over the last ten years is a shadow of what it is about to become. In the next ten years it is highly probable that health care will become an international industry. At our convention next week we will have a live demonstration of robotic surgery taking place over 200 kilo metres. It could as easily be 2,000 kilometres. We will need online access to physicians and nurses, and online computer systems. We will need telephone triage systems of the most advanced type. We will need a payment system or systems to support all of that.
A much greater transformation of health care is about to happen. It may be much more consumer friendly, but the technological skills needed to develop that system and to give it birth are currently not present in the system. We need alliances with the private sector. We need to plant acorns by making different types of arrangements so that places such as the Shouldice Clinic, the Sault Ste. Marie group practice and others can flower. We need the flexibility to let that happen in a way that is consistent with the fundamental principles of the act.
In summary, I would say, just think of how different the future could be if every part of the country had 24-hour telephone triage with the most advanced computer protocols. You would be better off in the hands of the average experienced nurse and/or nurse-practitioner than with most general practitioners under that system. Imagine online access to physicians and nurses all of the time. If we do not do that, ten years from now we will be buying those services from ABC Health Enterprise Inc. in Denver, Colorado. The need is that serious.
Senator Keon: It is happening now.
Mr. MacKinnon: It is happening now and it is happening very quickly. If we do not develop the flexibility with the private sector to employ their talent in building that system, I think the present system will be almost a distant memory, ten years from now. People will flood to the new possibilities. They should, too, because there are incredible possibilities.
We need the flexibility, therefore, to allow certain forms of private delivery within the current system. We need new strategic partners with those new technology enterprises. We need them very quickly if the present system is to survive at all.
Senator Robertson: Other witnesses have skirted around the edges of that issue but you have enunciated the concerns very well.
I just want to raise something you may wish to think about, and perhaps get back to us. A lot is being said to this committee - and rightly so - about the funding of our health system. That dialogue almost always involves the role of the federal government and of the provinces, and the percentage of funding from one to the other. We know all the changes will make significant differences, national priorities, changes of government, and so on.
Some of us rather think, however, that a stable base of funding would help immensely, especially for smaller provinces. There is little stability in the funding now. Some of us suspect that one of the problems with establishing stable federal funding arises from a practical consideration: taking credit. Here I am not speaking for the committee but for some of the discussions and debates I have had in my own region. All political entities want credit for what they do or what they fund. A group such as this committee and groups like it all across the country understand that there is federal and provincial funding. Federal governments of whatever political persuasion may hesitate with respect to increasing that funding because they are concerned that they will not get credit for it. We all know that politicians like to get credit when they spend money. I have raised this issue before. I would love to have some people put their thinking caps on and see if there are resolutions to that issue.
You cannot have a sign in every waiting room that the federal government is paying for X percentage of a service or for every new building that is built. How could one give credit? Politicians are human. If they make a major contribution, they would like the world to know about it, and not just at the time of the change, which has been forgotten the next day. In the smaller provinces, we find that the governments want to put in blocks of funding in a different way, where there is a sign on the funds. However, that money would not be used for health and higher education.
I have raised this issue to university boards and at home. I feel strongly that if there is a way for federal governments, regardless of their political stripe, to gain credit and to be seen to be doing so by the public, it would be a lot easier to get stable funding.
You may not want to answer that question now. However, I throw it out. If you could think about it and come up with some suggestions, I am one member of this committee that would be most interested.
Ms Grinspun: I believe the issue of stable, proper funding by the federal government is an issue of credit. It is also an issue of ensuring that different provinces meet the same standards. I believe this is the critical "stick." I do not like sticks, but sometimes they are needed. If we are looking, for example, at a national pharmacare program funded exclusively by the federal government, that could be one venue. That is one program that could be spearheaded especially by the federal government, in my opinion. Homecare is somewhat different. It needs to be delivered at the access point, but a national pharmacare program could indeed be led by the federal government.
Returning to the previous question of stable funding, this is also an issue for provincial governments. When we get the money, we will use ours for perhaps something else. I suggest not only a recommitment to stable funding but also to multi-year funding. In this way, we can actually plan not only around issues of technology but human resources, too. This is critical.
Mr. MacKinnon: We have had the same discussion with the Ontario government. One of the solutions is to fund more by formula than by politics. We have done a lot of works in cooperation with the Ontario government, which has been a very willing contributor, to try to shift the funding system over from one that basically relates to history in annual increments to one that relates to funding.
The funding formula that we have developed is one of great sophistication. It says that governments should fund in accordance with community needs, which can be identified statistically. Some sort of formula funding would put a boundary around the scale of political disagreements that otherwise takes place.
I am hopeful that we can make major progress. The federal government may wish to look at the work we have done. I would be happy to return before this committee and provide any additional information on how that shift to formula funding could take place.
There may be much merit in it for the federal government to think along the same lines for whatever funding does take place. In this way, it would be built into the routine of government. Canadian health care is full of public relations flimflam as governments squabble over who gets the credit. It would be far better to have a formula and avoid that squabbling.
I would ask honourable senators to look at page 25 of the submission we have provided to you. Ontario's fiscal relationship with the federal government is a very serious problem. I have described the extent to which public institutions in Ontario are underfunded, relative to every other jurisdiction in Canada. However, there is a growing level of concern in our area and some in the provincial government think that that must be addressed. We have to think about the pressures in Ontario derived from that underfunding relative to the Canadian average. All of the political pressures in Ontario on the issues you have mentioned are related to this issue described on pages 25, 26, and 27. If the developing problem there remains unaddressed, I fear that the interests of all provinces in the medium and long term will be fundamentally affected.
There is an element of intensity. Toronto, for example, is one of the most stressed cities in the countries of the world in terms of hospital services in relation to its population. We really must address that because Toronto is generating so much of the economic growth on which everyone depends.
Senator Callbeck: Mr. MacKinnon, Mr. Decter talked about the importance of drawing out information about the health system that would help build public confidence. You have talked about hospital report cards. I am not familiar with them. What information is there? When were they started? What have the results been from putting these reports out? When you have hospital report cards, does that mean you can compare one hospital against another?
Mr. MacKinnon: I am surprised Mr. Decter did not mention it because CIHI has been a major participant in that scheme. Every year now, we produce both a system report card and a hospital-specific report. The system describes the overall perform ance measures of clinical outcomes for selected illnesses. We are trying to broaden that range. It does that in terms of variables such as readmission rates and complication rates, so people can get a sense of quality.
Second, it measures consumer response. There is a statistically valid sample for each community in Ontario where there is a hospital, and we release that sample. The third product is measurement of the management of change. I have drawn on a couple of those factors in my comments this morning. For example, physician-hospital interaction on the patient record is a really important way in which the system has to develop, so we measure that. Fourth, it measures financial performance.
Those four variables are measured in a way that permits direct comparisons among hospitals. The Ontario government and the Ontario Hospital Association publish a supplement which is published in every major newspaper in the province. That started in July of 2001. The annual supplement will be out there every year from 2001 on.
We are expanding this system to include specialty hospitals, as the present system is not particularly good for complex, continuing care or specialty children's hospitals, for example. We will try to include more and more illnesses.
Basically, however, we have a balanced score card which we believe is one of the best in the world, and leading on the continent. If we did that across Canada, many of our disagree ments, lack of understanding or lack of common belief would be significantly narrowed.
I cannot be critical enough of the way in which most provinces have managed their relationship with health care facilities all over the world. The output of the health care system has never featured prominently in public discussion. As long as that is the case, cost-cutting becomes disproportionately important. Ms Grinspun's members and everyone who works in hospitals pays the price. We have to build a fact base that everyone can rely on and make it publicly available. If we do that, many of our disagreements will be much easier to handle.
Senator Callbeck: Did you start this system in July of this year?
Mr. MacKinnon: No, we started in 1998 with a system report card. In 1999 we produced both a system and a hospital-specific report card. We have produced the hospital-specific and the system report cards for the second time in 2001 so that the trends can be seen. We are expanding the system to include specialty hospitals and complex, continuing care hospitals, for example. We intend to issue a new public report card on emergency room services in the next few months as well.
The system goes back to 1998. Preparation, however, goes back well into the 1990s. We would be willing to make our developmental effort and the materials behind the system available to every other province. I see no reason why it cannot be adopted by every other province. If adapted, however, it would reveal differences among provinces, some of which may cause them great difficulty. Progress will be made, however, if those differences can be illuminated.
Senator Callbeck: How has the public responded to seeing the differences among hospitals?
Mr. MacKinnon: It is hard to measure. First of all, we have had great support in this system. The Ontario government has contributed much of the funding. The OHA developed it but the Ontario government has come in and contributed much of the funding. Public resonance is shown by our press conferences every time we produce the reports. Those are the biggest press conferences we or most people connected with the Ontario government would ever see, with 70 or so reporters and 10 cameras. They dominate the headlines for two or three days.
I think we can do more work to make our products consumer-friendly. We have to think about that. Publishing them in the newspaper every year is certainly better than in previous years, when we did not do that. We will provide a full briefing note and examples for the committee to use in its deliberations so that you can see exactly what we have done, and how we are doing it.
Senator Callbeck: Ms Grinspun, I was looking briefly over your recommendations here. You are recommending a coordinat ing body to deal with the health human resources issue. Would the federal government take the leadership in that?
Ms Grinspun: Yes. We are suggesting the federal government, representatives from provincial governments, employers, and people who work in the system. As you know, and as has been much in the news, we have a very serious situation at present with respect to nursing and to other health care professionals. I strongly commend the OHA on their report card. We need to move to the next steps, however, in relaying what the impact would be of a human resource crisis on patients' clinical outcomes. David spoke about readmission and complications. Many studies show, for example, the linkage between complications like pneumonia and inadequate human resources in nursing, both in numbers and in expertise.
I am not sure if the committee is aware that in 1999, 4,000 hospital beds were occupied by individuals as a result of falls. Those are CIHI numbers. That clearly links to prevention. Instead of focussing only on what is done in our hospitals, we must try to prevent falls, especially in the context of an ageing population. Prevention is an issue of primary health care. The impact of report cards, especially on those sectors, should be brought into play so that we can create a system whereby we can start to utilize the various sectors: primary health care, homecare, hospital care, at the appropriate time of need, and obtain the best outcomes.
Senator Callbeck: For this coordinating committee, you see the federal government as having the responsibility to take the leadership on that?
Ms Grinspun: I would suggest that it needs to be championed by somebody. The federal government has a unique interest in championing it. Otherwise, what will happen is that nurses will be stolen, for example, by one province from another. Just moving people around like that does not resolve the national problem that we have.
The Deputy Chairman: May I thank you, Mr. MacKinnon and Ms Grinspun, on behalf of the committee, for your testimony.
Colleagues, our next witnesses are Professor Jeremiah Hurley of McMaster University, Department of Economics, Dr. Cameron Mustard, University of Toronto, Public Health Sciences Depart ment, and Professor Colleen Flood of the University of Toronto.
Dr. Jeremiah Hurley, Professor, Department of Economics, McMaster University: Senators, I wanted to focus my comments on three specific aspects of the report that you tabled. Your committee has done excellent work, for which I congratulate you. In focussing on areas of concern, I will ignore matters that there is not time to comment upon.
The first issue is with respect to the role of user charges. The committee appears to appreciate the large literature on user charges and some of the evidence arising from that. The report appears to favour a system of user charges such as that employed in Sweden. This system does not have the goal of reducing expenditures, but attempts to make individuals aware that a decision to use the health care system costs money, and to increase appropriateness. I am concerned with that proposal. There is consistent evidence that user charges do not increase appropriateness of utilization, which the committee does acknowl edge earlier in the report. Nor is there any reason or evidence that user charges would make people more aware of system costs. Why would paying $10 to see a physician suddenly make the patient aware of how much the physician visit costs?
I would ask you, when you go to the pharmacy to get your prescription and your co-payment is $450, how often would you leave the pharmacy thinking you had better cut your utilization so that your premiums do not rise in the future? That is what we are asking patients to do by imposing user charges as has been proposed in the committee's report.
The evidence is quite strong that demand-side approaches are not the appropriate way to improve utilization. We need to use supply-side instruments to achieve that.
Concerning medical savings accounts, there is virtually a complete lack of evidence regarding their effects, either positive or negative, at this stage. Given this vacuum of evidence, we can say some things based on design and related evidence. First of all, they are unlikely to control expenditures effectively; they are unlikely to increase appropriateness of utilization; they will compromise equity in the system, given their fundamental design and they will likely engender risk selection problems if chosen voluntarily. The committee ends by suggesting that it might be not unreasonable to expect that a plan could be developed to avoid these pitfalls.
I am less sanguine about that when it comes to MSAs. They inescapably embody demand-side approaches, which lead to these problems. In particular, I am concerned about the recommenda tion that we might begin with the long-term care sector, because that is a sector where the pattern and distribution of expenditures is least suited to MSA approaches, certainly in the short term. I have concerns about some of the recommendations or the options put forth in that respect.
Regarding parallel systems of finance, the committee has recognized a number of the problems associated with parallel systems of finance. It ends by suggesting that with appropriate regulations we may be able to avoid some of those negative effects of parallel systems of finance. It identifies three particular regulations upon which you seek comment: that doctors be required to work in both the public and private systems; that there be a guarantee for maximum wait in the public system, with payment in the private system if it is exceeded; and that the public sector be mandated to keep technology as good as the private sector.
In my view, each of these regulations actually will exacerbate the problems of parallel finance, not reduce them. You are creating explicit mechanisms of interaction between the public and private systems. In particular, mandating that physicians who work in the private system to also work in the public system will increase opportunities for gaining across the two systems by providers. This would creating a system in which, if the wait list gets long in the public system, the public system will pay to receive in the private system. Such a system is, of course, the provider's dream because now, with a long enough wait list, they have a long queue of people coming into private practice, paid for by the public system. Hence it will exacerbate all those problems.
Last, linking public sector technology to the private sector does not do anything to ensure appropriate use or acquisition of technology in the public sector in ways that conform to technology assessment standards. It simply links them inextrica bly in a way that does not necessarily advance the public sector interests. In my reading, each of those regulations would exacerbate the problems of public finance, not reduce them.
In summary, I do not think there is a simple case to be made for parallel finance based on advancing the objectives that we have set for our system of finance. The only arguments that appear to stand up include a peer rights-based argument. This says that people have a right to buy the care. In that case, we would ignore the negative consequences. We would be unconcerned about them. It is a consistent argument; some people make it. It means, however, that we have to ignore those consequences, or we could care so much about responding to unusual preferences of a small segment of the population that we were willing to put up with substantial costs to the broader society in order to allow these people to satisfy their preferences for certain kinds of care. It will not advance the interests that we have set out for our system thus far.
I want to comment now on some broader issues. On this public/private question, it is crucial that we separate the issue of public/private finance from public/private delivery. This is not done crisply enough in most debates. The issues and evidence are very different. In the former case, there is clear evidence of the effects; in the latter case, there is no clear evidence that either the public or the private sector is more efficient in delivering services. We need to make that distinction more crisply. Too often we implicitly link the private sector with efficiency. This is false. There is no consistent body of evidence that shows that the private sector is more efficient, nor is there any consistent body of evidence that shows that the private sector generates a higher quality of care.
Third, we implicitly link private with competition. This is false. We have many instances of private sector delivery with no competition, and public sector delivery with competition. When we talk about competition, we need to think about such issues as by whom, in what exemptions, and among whom. This tends to get glossed over. We just talk about competition being good.
Last, we need to be very careful when considering financial incentives. It is right that we need to pay attention to them. It is right that we need to guide incentives so that people are not penalized for doing good things. We need, however, to be very cautious about actively using financial incentives to try and guide behaviour. In the long run, this approach may very well backfire for us as we try to organize our system to meet the health needs of Canadians.
Dr. Cameron Mustard, Professor, University of Toronto, Public Health Science Department: In the interest of being as brief as possible I will summarize the credentials that bring me before you today, then I will offer a few more focussed comments on the issues that I found most challenging among the many issues that your committee's work has laid out.
I am on the board of directors of the Canadian Institute for Health Information, or CIHI. I understand Dr. Decter was here with you this morning. I applaud your emphasis on the federal role in improving the capacity of the Canadian health care system to understand itself and to build an infrastructure to transact this information across the country.
I am on the advisory board of the Institute of Aboriginal Peoples' Health within the Canadian Institutes for Health Research. I, too, endorse your strong recommendation of the federal role in advancing the health of aboriginal peoples in Canada. With Dr. Keon, and Dr. Morin, I was a member of the interim governing council of the Canadian Institutes for Health Research. I endorse your clear statement of a federal responsibil ity in the funding of health research in this country.
I commend you for the range of expression that you have provided in your report. I found myself asking a question of you. It was provoked by chapter 2 of the report. What would your guidance be to Canadians on the most important issue? I would like to offer you a suggestion. On reading your material, I found myself articulating the following priority - and I appreciate that there are many. Here is the one that I feel is the most important.
I do endorse your statement that: "The health human resource problem is more critical than any other problem currently facing the health care system." You say that this is a higher priority among many priorities. I share your view. It is, however, my sense that the resolution of health human resource issues in this country is intimately connected with addressing two other features of the system: One is primary care reform. Related to that is the construction across this country in provincial jurisdictions of integrated health care delivery organizations. Weaving those three priorities together is necessary to see a future with a sustained health care system bearing some significant resemblance to the system we have today. We must solve those three priorities simultaneously.
As you know, some provinces are much farther along in their effort to regionalize services than others. You will appreciate that almost no provincial health care system has succeeded in integrating primary care reform in the effort to regionalize. I would encourage the committee to offer a retrospective examin ation on why that has happened. Why did we move to regionalization, and yet fail to address primary care reform? That is what I view as the most compelling priority over the next decade.
I also found myself very much interested in the questions you were raising: How do we move towards stable, predictable funding for health care? I have been wondering for a long time about what sorts of macro-policy mechanisms we might use to address this issue. There is no answer, from a technical health services/research perspective, to the question: How much money do we need to optimize the health and health care provided to Canadians? It is a political decision. My view is that it would be helpful to consider a federal role in defining a mechanism for building a consensus on what the GDP share is that we as a society are prepared to admit to on an ongoing basis.
The Bank of Canada uses an inflation target. I think we need in this country a GDP share target that signals to providers, to consumers and to institutions what the envelope is within which we will be working. I believe there is a strong federal role for providing us leadership in trying to think about what that consensus mechanism is. Ultimately, it will be a political mechanism, informed by democratic processes.
I am very concerned about the risks to this society of overspending on health, relative to investments in economic growth and social protection. These investments also significantly enhance Canadians' well-being. I am very concerned about seeing GDP share to health rising very much above where it is. This is not because we do not need more resources; we do. It is because of the trade-offs, what we lose in other forms of important social and economic investments.
My final comment is to echo some thoughts, as did Dr. Hurley, on the challenges of blending both public and private funding sources in the delivery and purchase of health care services in this country. I have two primary concerns currently with private funding sources, although I am not opposed to them. The health care systems in this country that draw most heavily on large, private funding shares are the least coherent and most disorgan ized sectors in the delivery system from the perspective of equitable access. They are pharmaceuticals, homecare, and long-term care.
I value the principle of equity. Related to that, I am concerned at the absence of mechanisms which allow us to blend public and private funding sources under a public administration governance. In many European models you may have seen, insurance funds combine public and private revenue sources under public governance. It is an important model for which the Claire commission has recommended some consideration. Medical savings accounts are examples of private funding sources that do not come under a public governance model.
I found the report very provocative. It contains many useful ideas. As a health services researcher, I was disappointed that there was not more anchoring of some of your propositions to what I think the evidence is from the research community.
The Deputy Chairman: Dr. Mustard, I was most interested in the GDP share target. I believe that is something we should make note of and pursue as a committee.
Dr. Colleen Flood, Professor, University of Toronto: I have written a number of background reports for the Senate committee, so I did not take this time to write out further comments. However, I may send in a larger statement about my reactions to this volume 4.
I would like to speak about the issue of two-tier health care.On page 65, the report says:
... a number of benefits can be generated by allowing private insurance... including enhanced patient choice, increased competition, and improved efficiencies in the public sector.
It is that conclusion that I would like to address. Having reviewed this evidence and the international evidence, I firmly believe that it is incorrect.
Two-tier systems already exist in a number of jurisdictions, such as my home country of New Zealand and the United Kingdom, where people who hold private insurance can buy quicker or better care. There is no evidence from those jurisdictions that having that capacity improves either the quality or timeliness of care delivered in the public system. In fact, the evidence is to the contrary. It suggests that waiting lists and waiting times in New Zealand and in the United Kingdom are much longer than they are in Canada. This might seem somewhat counterintuitive, as we normally associate competition with increases in efficiency and service.
However, if we look more closely, we see that competition does not operate between public and private health insurers as it does, for example, between the producers of, say, computer services. If I do not like the quality or price of a computer service that firm A is providing, then I will shift my business to firm B. If enough of us shift our business to firm B then, over time, that sends a very clear signal back to firm A. They must buck up their performance or, at the limit, become insolvent. That is how we expect competition and efficiency to work in the private sector.
That is not how competition works between public and private health insurance. In fact, very different incentives are in place. I agree with Dr. Hurley that incentives are slippery devils. We need to be careful how we think about using them. In a two-tier system, if people can use private insurance to buy care, then there is no clear financial incentive or signal sent back to the public system that the public system has to improve its performance. The public system suffers no hardship as a result of those with the resources being able to buy care in the private system. In fact, because the public sector and public hospitals do not face the risk of insolvency, the movement of dissatisfied individuals into a private insurance system and into private hospitals may actually be quite a good thing. The public sector is getting rid of people who may be complaining about the quality of care being delivered by it.
The way that public institutions are normally held accountable by what the scholar Albert Hirschman would call "voice." Voice means this: We citizens run around lobbying our politicians, like yourselves, at federal and provincial levels to maintain the quality of our health care system. If those of us who could afford it - as we here would be able to - were to purchase private insurance, then our voices would be dissipated in maintaining the quality and timeliness within the public system. The political economy concern about having a two-tier system is that that voice would be lost, and the quality of care in the public system would decline, not improve, as suggested in the report.
I, too, commend the sheer number of issues that have been addressed in the report. It is easy for me to leap on this one and be very concerned about it. However, I believe it is important that we clarify what the incentive structure would be if we allowed a two-tier system. The system of what is known as managed competition has different implications and requires very sophisti cated governance. It occurs in some European jurisdictions. Private insurers are carefully regulated to assure access. A simple two-tier system, however, where you allow people out, as they have in the U.K. and New Zealand, will not improve the quality of the public system.
Concerning user charges, I wish to point out some confusion I sensed in the report between the idea of user charges and two-tier insurance. The goal of user charges is to change consumer behaviour, to make patients more aware of the cost of the health care that they receive. I agree with many of the concerns that Dr. Hurley has raised. However, if we were to move down that path, one important issue to consider would be whether to allow people to hold private insurance to cover the cost of those user charges.
I was talking with Senator Kirby about this. He asked me to speak on that issue particularly. I think if people are allowed to have private insurance to cover the costs of the user charge, the whole point of having the user charge in the first place is completely dissipated. The idea is that if you have to pay out of pocket, you may be sensitive to the costs of the care that you consume. However, if you are able to have private insurance to cover the cost of the care, then clearly you will not be concerned as much about the cost of the care.
That is why, for example, in Australia, where there is a regime of user charges for medical services, you are specifically precluded from holding private insurance to cover the cost of user charges for medical services. That is because if you were not precluded, you would not be controlling utilization. You would, but only for those people who could not afford private insurance.
The Deputy Chairman: When we held a teleconference with Australia, those points were raised vis-à-vis the private insurance and user fees.
Senator Morin: I have some questions for Dr. Hurley. I know you are an economist. We do not have a chance to meet economists very often, although we have one sitting to the right of the Chair here.
I agree with most of your statements concerning user fees. However, would you consider user fees a more efficient procedure, used as an incentive to motivate the patient? Let us say, for example, that we did not have a drug formulary. Could we then consider using user fees for proprietary drugs and no user fees for similar generic drugs?
I share your concerns about the medical savings account. You hit the nail right on the head. One hears so much about this.
You talk about the payer/provider split, but your document is not clear. When talking about private insurance and private providers, I think we have to make a clear distinction. In your statement, you made it, but your document is not clear in that respect. This distinction is very important. I believe there may be a place for private providers. Could you elaborate?
You did mention internal markets. It is not an easy concept. I know some people have been pushing for that. It has been very popular in Britain and Sweden. As you are an economist, could you describe how we could apply the internal markets concept to the Canadian system?
Dr. Hurley: Let me address each question in turn. Do we publicly insure a medically necessary service if an individual desires a more expensive version of it that is of equal quality? You gave the example of a brand-name versus a generic drug. That, I believe, is a different issue than paying $10 to see one's primary care physician. The system is ensuring a medically necessary service. Some people would argue that the brand name drug, when there is a generic equivalent, is not a medically necessary service.
I do not think that contravenes the notion that the system is about insuring medically necessary service. You are saying that we are providing access to the generic drug, which is just as effective as a brand name drug. As an economist, I would say it would be irrational to want to pay more for the brand drug in all but a few cases, when the generic drug is there. The idea that user charges channel people who already have access to medically necessary services is a very different proposition regarding user charges than what I believe was proposed in my document.
Senator Morin: Let us speak of a less expensive drug in a given class.
Dr. Hurley: Certainly.
Senator Morin: The drugs are not entirely the same, but the user fee is applied to bring in the more expensive drug.
Dr. Hurley: This is similar to a reference-based pricing type of approach.
Senator Morin: Yes. The user fee would not be the total cost of the drug.
Dr. Hurley: I do not see as big a problem with that as with the generic notion of a user fee to simply raise revenue or for the purpose put forth in your document.
It is crucial that the user fee be imposed after the person has been able to use the system to determine their problem. Second, access is being provided to what is seen as an effective medical treatment through the public system. In that sense, you have tried to target the user fee to some notion of appropriateness.That is what is missing from generic user fee schemes. Anytime you can tie it to appropriateness, to the person having free access to the appropriate service, certainly that is not as problematic. In such instances, the person is paying for something from which they are deriving satisfaction for whatever reason. A common example is the light cast instead of the heavy cast.
Your second point was about internal markets. I think a couple of clear lessons coming out of internal markets are about how difficult it is to create meaningful competition in the health care sector. It is well understood why that is hard to do. Health care is an extremely complex good. We are not talking about number 5 bolts that are standard across everything.
Outside of areas such as physicians and so forth, how many areas in Ontario could sustain more than one hospital and compete? Outside Toronto and Hamilton, I suggest there are not very many. As well, you need to establish long-run relationships, given the nature of the commodity. You cannot simply say: "We will switch our bypass surgery from this hospital to that hospital." There are many reasons why the classical vision of competition is not relevant in the health care sector, and there are well-understood economic reasons for why that is the case.
In general, the scope for competition is overblown, even in an internal market. Where is it possible in Canada? Certain areas have been exploited outside of health care proper. Hospitals are already outsourcing cafeterias and other sorts of non-healthcare goods and services. However, there is a range of goods related to health care where that is impossible. The regionalization that has taken place in most provinces is a first step towards permitting competition. The regional authority holds a budget and can now engage in some form of rivalry, rather than competition. You want alternative providers to feel that they need to perform or else they might lose their contract. That is not perfect competition in the way that economists use the word, but there is a notion of rivalry, something at risk for the providers. Regionalized health author ities are the first building block towards internal market competition.
"Contracting approach" may be a more appropriate term. Although most people do not realize it, in Canada the physician sector is entirely reliant upon contracting. Almost all physicians are in private practice. We contract with them through a negotiated agreement to pay a certain fee. It is a contract, although not well-written, which is part of the problem.
This notion of contracting is not far from the Canadian system. We need to think much harder about how we can structure contracts and approaches that are advancing the public interest.
Dr. Flood: I would like to comment on the idea of internal markets and contracting out. I have done quite a bit of work in looking at different countries and their experience with contract ing out. I agree with Dr. Hurley to a certain extent, but I believe there is more potential than he does. It is true that experiences from the jurisdictions that have experimented with it have been very mixed. However, I think that has been partly because of our "one-size-fits-all" approach. We try to move the whole system towards contracting out instead of just those health goods and services that are more conducive to contracting out than others.
Where markets are smaller with more competitors, for example, in family doctor services, the GP fundholding model from the U.K. springs to mind. Many small GP groups compete with each other, holding a budget that may cover the drugs and diagnostic services that they prescribe. In this way, they could become more energetic private management teams within the system. That was something that Dr. Hurley did not mention.
However, this also relates to Dr. Mustard's point about primary care reform. Thinking about these kinds of initiatives and engaging in harnessing the private sector to achieve public sector goals is clearly the way to go here.
Senator Morin: I realize what is been done in the U.K. and Sweden. However, is that applicable to our Canadian context? Is it appropriate for a group of family physicians to control the drugs expenditure?
Dr. Flood: This approach would have been no less applicable in New Zealand or the U.K. These elements have been put in place as a reform initiative. There is no reason why it could not happen here. We certainly should learn from the experiences of the U.K. and New Zealand and these other countries.
I wish to emphasize that one thing not thought through very well in those jurisdictions was how to ensure the accountability of these new purchases of the new health authorities and of the new GP fund holders. If you intend to ask health authorities to become active or proactive managers within the system, you must think very carefully about how you can ensure that they do a good job.
Senator Morin: Would you recommend having as part of the primary care reform, in addition to the four points usually given for primary care reform, giving fund holders the power to purchase for the patients to cover drugs, diagnostic and therapeutic services from a number of providers on a contract basis with competition between the providers? This is the British system.
Dr. Hurley: I want to qualify that a little bit. We need to make a decision. Do we want to have geographically-based integration, as represented by the regional health authorities, or do we want some kind of integrated, roster-based, primary care organization?
Dr. Flood: They do not have to be exclusive.
Dr. Hurley: No, but they do have very different implications.
Senator Morin: I understand that, but not everybody is that much in favour of regionalization. A witness here yesterday, Mr. Lozon, said he was absolutely not in favour of regionaliz ation. That is a different matter. However, I am trying to consider another model here, the one Dr. Flood is recommending, which is the British-Swedish-New Zealand model. This is an extension of a primary care reform that is being considered in Canada. Am I right?
Dr. Hurley: The benefits of that system did not arise from demand-side competition, where people are saying: "I am switching my doctor because I want to go to that doctor." We already have that in Canada. Competition in the Canadian system has not increased by doing that. The benefits come, as Dr. Flood has pointed out, from the providers acting as a fund holder who is inducing the suppliers of services to that organization to compete in some fashion. It is a supply-side competition, not a demand-side competition.
Senator Morin: Rather than rivalry, is this true competition with a contract?
Dr. Hurley: It depends.
Dr. Flood: The evidence is mixed about how this would work. The evidence from the U.K. about GP fundholding had a difficulty. It was in the context of numerous other reforms that happened in the system at the same time. It is very difficult to unpack what actually was the impact of GP fund holders. There is some evidence that GP fund holders did make a difference. They were able to negotiate shorter waiting times and shorter lists for their patients. Critics of GP fundholding would respond that that is because they were controlling the marginal revenue of the hospitals. The health authority had to prop the public hospitals up. Therefore the GP fund holders were able to achieve some gains because the hospitals had to respond to them in order to gain their extra marginal revenue.
I am more supportive of GP fundholding. Irrespective of whether you move into purchasing hospital services, in particular when thinking about controlling our drug budget, the evidence is clear that the GP fund holders were much more cost-effective in the drug recommendations that they made. This is because they did have some incentive to think about the costs and benefits of the drug prescriptions they wrote. When you go to a physician, it is pretty easy to get a prescription. It is pretty easy to go get lab. work. You would want your doctor to have some sense of the relative costs of what they are recommending to you.GP fundholding is one way to put in place those incentives without undermining the autonomy of those physicians. You are not telling them what to do but giving them the tools and asking them to do it.
Senator Morin: This is exactly what I wanted to know.
Senator Keon: I would just like to add a comment on the subject of GP fundholding. My daughter and son-in-law are physicians in England. They tell me that the problem with GP fundholding is that when funds start running out, a terrible conflict arises between the physician's desire to do what is best, and his or her financial capability to do what is best. It appears that method has some major problems, too.
Dr. Flood: With all of these competitive models, whether internal market, GP fundholding, or empowering regional health authorities, you need to think about how you structure the budgets, and that you pay them quite carefully. You need to think about the age and sex and risk adjustment factors that go into figuring out how you pay the GP fund holders.
In the U.K., that was not the case. If you came up against a sharp, hard budget but could demonstrate in any particular individual's case that their expenses were beyond a certain point, then you could go to a common pooling fund and collect that money.
There was some risk. One cannot ask family doctors to assume huge amounts of financial risk. However, one has to design the incentives in such a way as to ask them to consider the costs. Clearly, you do not want them sacrificing individual patients at the altar of cost savings. On the other hand, in their day-to-day practice, you do want them to inculcate that idea of thinking about costs into their everyday practice.
Senator Keon: I am aware of the fact that there is an appeal mechanism and so forth, but it is not always very responsive.
I want to bring both of you back to your concern about us moving into a two-tiered system. The fact is that we are in a two-tiered system. How do we get out of it? I would like to hear your comments on that. About 25 services have been delisted in the last ten years: A number of drugs are not paid for; homecare is not fully paid for, nor is chronic care. How, then, do we get out of the two-tiered system that we have?
Dr. Flood: That is a good question. I am not convinced by the argument that a two-tiered system exists to some degree already, which therefore can be made even more two-tiered by hospital and physician services.
Senator Keon: That was not my argument at all. I did not raise an argument. I asked you a question. How do we get out of what we are in?
Dr. Flood: My response is along the lines of what Dr. Mustard was saying: We need to embrace primary care reform. We need to move to integrated delivery systems. We need to get more efficiency out of our present system. We need to try and wrap these other services into that primary care model. That is why I am talking about physicians holding drug budgets, perhaps even homecare budgets. That is one way to move forward.
How do we expand into family care and homecare? I think there is not a lot of provincial willingness to embrace another Canada Health Act model. That is going to happen any time soon. We need to think about other ways to get there.
My feeling is that we should be examining European models of managed competition, and as has been experienced in Quebec. We should consider regulating private insurers across the country in order to try to improve access to drugs and homecare.
Senator Keon: Would you go back to listing all of the delisted services?
Dr. Flood: I think that listing and delisting is a process that has to go on. We have to make decisions about what services should be publicly funded and what services should not be publicly funded. I am not happy with our current processes for that kind of decision-making. We need better processes for deciding what is in and what is out. After we look at how we fund drugs on the basis of cost-effectiveness, we can apply some of those lessons to physician services, for example.
A part of the problem here is that the way in which we decide what is medically necessary in physician services is also part and parcel of how we decide to remunerate physician services. This makes it difficult to take services out. You said we took 25 services out. We probably should have delisted more and listed more. How do we do that? The problem in the system is all about how we fund physicians. If we could think about how to pay physicians separately from a decision-making process about how we decide what is in and what is out of the publicly funded basket, we would be moving closer to where we should be.
Senator Keon: I agree with that. Do you want to respond, Dr. Hurley?
Dr. Hurley: I share a couple of Colleen's thoughts. We need a reorganization of primary care in the system. It has to happen. Changing different funding models that blend capitation with other forms, such as program funding, is the way to go. The fundholding idea is retained but does not carry some of the risks that you spoke of with a peer perspective kind of system. It also de-links coverage decisions from funding.
Funding may receive too much attention. Most of the evidence on funding is not funding, per se, but funding differences with associated changes in management of practices and organizations. We cannot isolate the specific effect of funding. I think we place almost too much emphasis on funding compared to other non-financial ways to try and improve practice and provide incentives for people who do good things.
On the financing side, we currently spend close to a $1 billion subsidizing private insurance. That is the least efficient way we know to expand coverage for services. If we get rid of the tax subsidy to the wealthy to purchase private insurance, that will raise close to a billion dollars. That money can be used far more directly to provide needed services to people. It has been well established that subsidization of insurance is an inefficient way to increase coverage for services.
Canadians are somewhat leery about tax increases. They have, however, experienced large cuts recently. Creative things can be done to link increased contributions to something that they value - health care, and health care systems. Whether we call them premiums or not, I would not advocate a flat head-tax kind of approach, meaning the same premium for everyone. There are dangers with an integrated tax system when you start earmarking specific funds. However, Canadians would probably support it as a way to increase revenues and get value for those increased expenditures.
On the issue of coverage, Canada is only now starting to grapple with the fact that, historically, we have not needed elaborate, rigorous processes for deciding what is covered. Thirty years ago, almost anything a doctor did was medically necessary. We know that this issue will only get worse as new products come out on the boundaries of what we think is medically necessary.
Not everything doctors and hospitals do are medically necessary, or need to be publicly financed. We need to invest a lot of thought into creating processes for addressing this issue. Canadians will have to learn to distinguish why some things are publicly financed from one provider, when other things from the same provider are not. Canada is starting to have consumer goods as part of what it delivers, unlike 30 or 40 years ago. We need to come to terms with that evolution of the health care sector.
Senator Keon: You appear to be keeping the definition of "medically necessary" as it relates to public funding. Is that correct?
Dr. Hurley: We have left the principle out of pharmacare and homecare. However, it is vital that we maintain and expand the principle that, in Canada, access to medically necessary services is not impeded by financial barriers. We know that from an ethical point of view it is important, and from a pure efficiency point of view it is important to do that.
Senator Morin: What is this billion-dollar subsidy we have paid for insurance?
Dr. Hurley: My compensation from my employer in the form of a supplemental insurance plan is tax-deductible.
Senator Keon: Dr. Mustard suggested that he did not have time in this presentation to cover some of the areas in our report where we did not dig deep enough for evidence. I wonder if you could highlight those for us?
Dr. Mustard: The discussion here with my colleagues Dr. Flood and Dr. Hurley is certainly referring to a research base that I am familiar with and have some confidence in. The research base asks the question: What is the role of economic incentives in influencing the behaviour of patients, providers, and organiz ations? That evidence base, as I have come to understand it, is actually quite informative. With familiarity, it tempers our ideological comfort. By "ideological comfort" I mean our comfort with certain ways of thinking about how the world works. These ways may be anchored in ideologies. For example, there is a belief that private markets are inherently more effective at producing goods efficiently than are public markets.
Health care does not work that way. You do not get the efficiencies. Sadly, more aggregate costs are incurred when you choose to use private market models to deliver something as complex as health care.
There was some important literature that the committee did not appear to have.
Senator Morin: I have an objection to that. What literature did we not see? Let me go one step further: Your presentation, although not your answering of our questions, has been totally negative. There has not been one single proposal. Dr. Hurley, you told us that user fees are not good. Private care is not good. In your case, Dr. Flood, it was the two-tiered system. In your case, Dr. Mustard, you were disappointed. Luckily, we obtained from you some positive recommendations as if there were no problems with the health care system. All you offered was negatives.
You seem, Dr. Flood, to be in favour of internal markets. Why did you not come out with it? Apparently we had a paper of yours, which you did not bring.
Dr. Flood: Actually, I have put several reports before the Senate recommending that.
Senator Morin: Your three presentations were totally negative and slightly insulting. You were disappointed.
Dr. Mustard: May I apologize, if that was the committee's perception of our presentations?
Senator Morin: Now it appears we did not review the literature.
The Deputy Chairman: Let Dr. Mustard respond, please.
Dr. Mustard: Senator Morin and I have argued many times, and always to a good outcome.
The Deputy Chairman: After all, our paper was Issues and Options.
Dr. Mustard: It is. I apologize if you take offence at my closing comment. I do believe I brought forward what I was attempting to do: A number of constructive observations provoked by your very thoughtful, wide-ranging sets of issues.
In the next stage of your deliberations, it would be helpful if you guided Canadians to what you thought were the most important priorities. That was offered in a constructive way to build upon the work that you have done. I made a proposal around system reform, integrating health human resource issues, primary care reform, and integrated service delivery, which is, in my view, the key.
As a constructive contribution also, I offered you a suggestion of a way of thinking about this very important issue you have raised. That is: How do we move towards a framework of stability and funding? The idea of a consensus process, however it may happen, with federal leadership around thinking about a GDP target share that we are trying to hit on a sustained basis was meant constructively, not critically. The idea was provoked by reading through the challenging set of issues you have brought forward.
You asked the question about a research base. I apologize if it sounded critical in my writing to you. Through the research attempting to compare different models for the organization and delivery of services being influenced by different finance mechanisms, we do see some significant differences in the performance of health care systems. It was that reflection that I felt we could contribute as a research community towards your thinking. Maybe it is our obligation to summarize that for you.
The Deputy Chairman: Do you have any more questions, Dr. Keon?
Senator Keon: I think not. We have given these gentlemen a pretty hard time, I think. Thank you very much for coming and presenting to us.
The Deputy Chairman: On that note, then, may I, on behalf of the committee, thank the three of you for the enlightening and lively debate.
The committee suspended its proceedings.
Upon resuming.
Senator Michael Kirby (Chairman) in the Chair.
The Chairman: Our first witnesses this afternoon, honourable senators, are Mr. Geoffrey Mitchinson, Vice-President, Public Affairs, GlaxoSmithKline Inc.; Mr. Ron Elliott, President, Canadian Pharmacists Association; amd Mr. Larry Latowksy, President and CEO, Drug Trading Company Limited.
Please proceed.
Mr. Geoffrey Mitchinson, Vice-President, Public Affairs, GlaxoSmithKline Inc.: Mr. Chairman, thank you very much for the opportunity to address the Standing Senate Committee on Social Affairs, Science and Technology as you review the role of the federal government in the health care system.
GlaxoSmithKline is a research-based pharmaceutical company that has been in business in Canada for over 100 years. We employ 1,800 Canadians and every year we invest over$100 million in research and development in Canada. This makes us among the top 20 R&D providers in this country.
As a company, as an industry, we share the concern of many Canadians about the rising costs and declining state of health care in the country, but we believe that neither pharmaceuticals nor the companies that develop them contribute to our health care systems problems. Drugs are not the problem, but they are certainly part of the solution. Let me state the case even more plainly: We believe that medicines represent the single best investment in the health of Canadians and the sustainability of the health care system in this country.
Pharmaceutical expenditures are frequently described as being uncontrolled and unsustainable. There is no disputing the fact that drug expenditures are rising. Recent Canadian data, and the evidence cited by this committee in its own report, show that drug costs are increasing and out-pacing growth in other parts of the health care sector.
Faced with this fact, policymakers have jumped to the conclusion that controlling drug costs is a sure cure for an ailing part of the health care system. However, as any medical practitioner can tell you, the prescription will not work if you have made the wrong diagnosis.
This Senate committee's first report identifies a number of myths and realities about the rising costs of health care. The first one is that increases in health care expenditures can be attributed to the needs of older Canadians. The reality you offer is that there are other drivers influencing spending increases such as, first, the use of new technology; second, the cost of new drugs; and third, changing consumer expectations and needs.
The Conference Board of Canada has also looked at what is driving health care costs and they put inflation at the top of the list followed by an aging population and the rising cost of services. Nowhere do they cite the cost of new drugs. We concur with the Conference Board's diagnosis. From our point of view, the rise in health care expenditures is and will continue to be driven by two relentless realities. The first is an aging population and the second, a by-product of the first, is higher consumption of health care services for treating age-related diseases. The fact that drug costs are growing more rapidly than other health care budgets is the inevitable result of these two realities.
Let me offer a few other realities about the cost of drugs and put these in perspective. It is the demand for new drugs, not the cost of new drugs themselves, that is rising. The latest report from the government's National Patent and Medicines Review Board confirms that in 2000, the prices for patented medicines increased by only 0.4 per cent on average, well below 1 per cent, while the quantities sold increased by 16.2 per cent. The volume shot up dramatically, but the prices were basically static. The issue here is not rising costs, it is rising need.
The higher volume is a result of Canadians needing and wanting access to more services, new drugs and medical procedures. Canadians are justified in wanting the most innova tive and effective treatments available. Perhaps the question we should be asking is not how to make these life-enhancing and life-saving innovations cost less, but how to make them more available. It really boils down to a question of access, not cost.
Another reality is that we are spending more on drugs because so many treatments are extremely effective. New medicines are doing a remarkable job of preventing, treating and curing diseases, improving quality of life, controlling pain and suffering, and saving lives. It is hardly surprising that we spend more and more on drugs.
The pharmaceutical industry introduced 331 new drugs in Canada over the past twelve years. Many of these drug therapies have proven to be a most effective way of treating such diseases as cancer, diabetes and HIV/AIDS. In fact, since 1995, new drug therapies have played a key role in reducing the number of deaths from HIV/AIDS by 75 per cent. They have also had a profound impact on other areas of the health care system including hospitalizations. We believe the results justify the expense. This is the kind of investment in health care that pays dividends. We should encourage more of it, not less.
The price of medicine is one factor but not the only factor that accounts for total spending on drugs. Drug spending is also affected by the prescribing habits of physicians, by the increasing use of drug therapy to replace other treatments such as surgery, and by the shift from in-patient hospital procedures to outpatient and community-based drug therapy.
This leads me to my next point. Drug therapies can help people stay out of hospitals or long-term care facilities and offer substantial savings to the health care system.
In 1978, surgery for ulcers was common and surgical treatment for a serious ulcer problem could cost as much as $28,000. When was the last time you heard of people having ulcer surgery? You probably have not because, 20 years later, pharmaceutical innovation has made ulcer therapy virtually obsolete. It now costs less than $200 per year in prescription drug costs to treat a condition that used to cost tens of thousands of dollars to treat with surgery. Anyone who thinks drugs are expensive should remember the alternatives are often more expensive.
Let us recognize that, even at current rates of double digit growth, drug expenditures represent a fraction of spending in the health care system overall. Drugs represent only 15 per cent of overall health care expenditures of $95 billion and the $4.9 billion in prescription drugs paid for by governments accounts for just over 5 per cent of total health care expenditures.
Compared to other industrialized nations, drug spending in Canada is among the lowest. Canadian drug spending as a proportion of overall health care spending is among the lowest for G7 countries. Canadian prices are also below average compared to those in other industrialized nations. Drug prices here have increased at a rate of less than 1 per cent annually since 1988.
In 1999, the PMPRB price indices show that American prices for patented drugs were 62 per cent higher than Canadian brand name pharmaceutical products. Interestingly, a study comparing the prices of top selling generic drugs in Canada to American prices in 2000 found that generic drug prices in Canada were 33 per cent higher on average. I leave it to this committee to determine why that should be the case.
There is a perception among policymakers that me-too drugs are more expensive and not necessarily more effective than the innovative drugs they are copying. We can look at three major categories of drugs: Antidepressants, antihypertensives and cholesterol lowering medications. In all three categories, which are the primary drivers of drug plan costs, the next entries into the market were actually cheaper than the first product and provided significantly more, or in some cases, additional clinical benefit.
As such, increasingly restrictive drug plan policies will not necessarily win the war on costs. Papers have clearly demon strated that by restrictions on drug plans, we see a shift in other health care costs. Those include physician services, hospitals and emergency room visits.
In fact, in many countries drug policies have changed dramatically based on the German experience where they introduced restrictive limits on drug costs. The initial feedback was a savings of 25 per cent, however, extra hospital admissions and doctor referrals negated most of that saving. Norway did away with reference-based pricing in January 2001 as it cost more than the anticipated saving.
Innovative drug plan strategies can provide greater benefit, greater efficiency to the health care system than restrictive drug policies. As this committee's own research has observed, the number of hospital beds in Canada has been reduced over the years. Information on Saskatchewan and Manitoba is cited. This is because those people who would have occupied those beds simply did not disappear, they were able to be treated in the community with drug therapies.
Our own company, since 1994, has taken a leading role in establishing community asthma centres in hospitals across Canada. This has resulted in decreased hospital utilization for asthma, improved asthma treatment supporting the physician's ability to coach and manage the patient and including other health care professionals in managing patients. The net effect is that they are working. The Canadian Institute for Health Information has released data showing that the number of asthma hospitalizations for all age groups has dropped by 30 per cent over the last five years.
Drugs are not the problem. They are part of the solution. They represent one of the most efficient means of delivering health, wellness and improved quality of life to Canadians. We urge this committee, the government and the policymakers to use the advances in drug treatments constructively, to help reform the system, to achieve greater efficiency and manage costs by reducing reliance on acute care services.
Mr. Ron Elliott, President, Canadian Pharmacists Associ ation: Mr. Chairman, thank you for the opportunity to make this presentation to this committee.
I am a community pharmacist from St. Thomas, Ontario. The Canadian Pharmacists Association is the national, professional, voluntary association providing leadership to pharmacists in all areas of practice. Our members are active in community and hospital pharmacies, long-term care facilities, home care, acade mia and industry.
CPhA welcomes the opportunity to comment on your volume 4, the "Issues and Options" report. We applaud the breadth and scope of the analysis of the report and note that the committee has raised a myriad of important issues that generate questions, foster debate and challenge us all to think outside of the box.
For today's discussion I will limit my remarks to a few of the issues that are directly within the knowledge and experience of the CPhA and pharmacists.
We support the report's analysis on the roles and responsibi lities of primary health care providers, and the need to change the current system. We also support and applaud the degree of detail undertaken on the issues surrounding prescription drugs. As the experts on prescription drugs in the health care system, I will devote the majority of my time to that issue.
CPhA strongly supports the need for reform of the current hierarchy of health care professionals. We believe that scopes of practice need to change in order to improve effectiveness and efficiency. This in turn will provide better access to health care services for Canadians and increase cost effectiveness for the system.
As the committee noted in the "Issues and Options" report, you believe that primary care reform is one of the most critical steps that needs to be taken in order to modernize Canada's Health Care System. Honourable senators, we concur.
As you know, the system has built-in barriers to change that discourage innovation and discourage the best use of health care professionals' time. As a pharmacist, I have the skills and the abilities to do a lot more, but I cannot. You note that physicians are the gatekeepers of the system, and that is true. The perpetuation of that problem is partly to do with the manner in which physicians are paid and not physicians themselves.
Physicians are the key to the health care system now, and they must continue to be the key if we are to change the system, both for the sustainability of the system and because it makes sense. Focusing on incentives to bring about change is critical. However, beyond remuneration schemes, rationalizing the roles and responsibilities of health care providers according to their skills and abilities and to the needs of Canadians is paramount if the system is to evolve.
From a pharmacist's perspective, let me tell you who pharmacists are and some of the things that we can bring about to save physicians' time, improve patient access and ultimately bring about cost savings. Pharmacists are recognized as the drug experts of the health care system. We are extremely accessible from coast-to-coast, well respected and trusted by Canadians. Increased drug costs weigh heavily on the health care system, and logic would dictate that pharmacists should be able to expand their scopes of practice to help improve things. An example would be to permit pharmacists to initiate and modify drug therapies in collaboration with physicians and according to established protocols. Another example would be to allow pharmacists to take blood and give vaccinations.
Senators, do you not find it strange, when I am teaching someone how to use a blood-glucose meter in my store, I cannot draw blood from their fingers to show them how to use the meter correctly? However, that same person can go down the street and have their ears pierced or get a tattoo. It does not make sense. Pharmacists can do so much more to promote wellness and illness prevention through smoking cessation counselling, asthma and diabetes education and monitoring, to name just a few.
We need more in your final report on the expanded role of pharmacy practice. In order to expand this role in the health care system, we recommend that Health Canada fund pilot projects on primary health care reform that feature new practice models for pharmacists with new methods of reimbursement.
Another issue related to primary health care reform and pharmacists wanting to do more is the problem of human resources. Pharmacists, like physicians, nurses and other health care professionals, are facing a shortage. We estimate that we are short 1,500 full-time pharmacists in our country. The problem is particularly acute in hospital and rural settings. We recognize and applaud the announcement by HRDC on studies relating to physicians and nurses.
We reiterate that the federal role is crucial in supporting human resource planning and policy initiatives. We would particularly encourage the development of mechanisms to support changes to scopes of practice of health care providers to ensure the skills possessed can be used to the benefit of both the public and the health care profession.
Before going directly to the issues in chapter 8 of your "Issues and Options" report, let me state that CPhA shares the committee's concerns about escalating costs and the need to get better value for money in the store. There is enormous waste. There is also an enormous set of problems that we must deal with, and I will give you just a few examples.
Some of the newly introduced drugs allow patients to stay out of hospital and offer them improved living conditions, but those drugs are not covered by the drug plans across the country. Since many people cannot afford them, they decide not to go with them.
There is extraordinary waste in the system because of inappropriate prescribing, poor compliance and failure to monitor outcomes. Every day in my pharmacy I see the over-prescribing of antibiotics and limited or no follow-up to determine how well the medication worked.
We all recognize that smoking cessation is a credible goal within the country. Last night in my pharmacy a fellow walked away from the prescription counter because he said he could not afford the smoking cessation program. How he makes his own decisions is his business, but I cannot help him go through the smoking cessation program if he cannot afford to buy the products.
A burden is placed on pharmacists and physicians who administer cost-saving measures such as therapeutic substitution for which they get no reimbursement.
The Chairman: Mr. Elliott, rather than have you read the next three pages, would you make a brief comment on each of the items? In that way we will be able to move on to questions.
Mr. Elliott: We should like to introduce the concept of a national drug use management centre to develop policy and implement programs.
We urge caution on the issue of bulk buying of drugs. I visited New Zealand just a few weeks ago where they are experiencing bulk buying of drugs nationally. In their practice settings, patients' medications are changed routinely because of the availability of a particular contract. It is not focused on patient care. It is focused on what is available. If the product is no longer available, pharmacists have no option to use another product.
As to the advertising of prescription drugs, the CPhA is a long-time proponent of the consumer's right to comprehensive, unbiased and accessible information. However, we are concerned about direct consumer advertising. We have anecdotal information that suggests that patients assimilate information from advertise ments, make their own diagnoses and then go to the physician demanding a particular drug.
Mr. Chairman, it is important to look at the number of Canadians covered under drug plans. We dispute the figures presented in "Issues and Options" that indicate that 97 per cent of Canadians enjoy some form of prescription drug coverage. Our numbers through CIHI would suggest it is closer to 74 per cent. However, our experience indicates that, although a person may be covered by a plan, the plan may not cover a specific drug and is needed to treat a particular illness.
I will leave with the committee our detailed study on pharmacare. If honourable senators do not have copies, we will provide those for you.
We see four cornerstones for a national pharmacare program and we would emphasize that, to succeed, all four cornerstones need to be in place. Those are: establishing guiding goals and principles; involving key stakeholders; without question there must be government leadership; and funding and implementing the plan in phases so that we can provide health care to Canadians at a reasonable cost.
I would thank the committee for the leadership you have shown in your work in health care and in particular, with "Issues and Options." Tough issues are raised by committee members, and you have a right to raise those issues. As costs rise, we know that important decisions must be taken. We would like, as pharmacists and the CphA, to be part of the solution. I will be delighted to answer your questions later, Mr. Chairman.
The Chairman: Ms Jane Farnham will be speaking for Mr. Larry Latowsky who is the president of the Drug Trading Company Limited. Ms Farnham is Vice-President, Pharmacy. Since Larry has laryngitis, Jane will make the presentation.
Ms Jane Farnham, Vice-President, Pharmacy, DrugTrading Company Limited: Mr. Chairman and honourable senators, we appreciate the opportunity to make a presentation to you today.
Drug Trading is a 100 per cent Canadian-owned retail pharmacy services organization that provides value-added buying, merchandising, marketing and logistics solutions to more than 1,450 independent pharmacies across Canada. Many of our member pharmacies are located in small towns and rural communities where they are the only pharmacy.
Our company operates the familiar IDA, Guardian, RX Central. and Community Drug Mart retail pharmacy banners. One in six Canadians fills a prescription at a Drug Trading network pharmacy. In 1999, DT members filled over 41 million prescriptions, more than any other drugstore organization in Canada, totalling approximately $3 billion in retail sales.
Through our subsidiary, ProPharm Limited, Drug Trading is also the largest supplier of computerized pharmacy systems in Canada with installations at more than 1,000 participating pharmacies.
We directly employ more than 180 men and women with expertise in pharmacy, customer service, retail marketing and operations, technology and software development. Approximately 20,000 men and women work in our member pharmacies across the country.
In December 2000, Drug Trading was named one of the 50 best-managed private companies in Canada.
We share the concerns of Canadians, their governments, and this committee around access to quality health care services, the sustainability of our health care system and health promotion and wellness. We believe that we are an important part of the solution in keeping our health care system affordable and capable of delivering effective, quality care to Canadians.
The basis of our submission is that the professional expertise of pharmacists is dramatically under-utilized in the delivery of health care services in Canada. This has been recognized for many years. For example, the Lowy pharmaceutical inquiry of Ontario in 1990 noted that: Pharmacists are not meeting their full potential of members of the health team whose objective it is to ensure optimum drug therapy. We believe that ways must be found for pharmacists to provide more comprehensive patient-oriented services.
As small business owner-operators, Drug Trading Company member pharmacists lead the way in developing innovative approaches to patient care. We are both willing and eager to participate with governments in exploring ways to improve patient care and control systemic costs.
Our submission outlines a number of significant opportunities for action by Canadian governments to improve the health of Canadians and the effectiveness of health care service delivery. These opportunities are real and immediate, and they represent little or no new cost to government. At the same time, they will reduce inefficiencies and remove duplication and other forms of waste from the system. In fact, these initiatives offer federal and provincial governments unprecedented opportunities to drive costs from the health care system, dollars that can used to offset increases in drug costs that arise from new health care technologies and an aging population.
Our recommendation is to focus on better use of the professional expertise of pharmacists. They are a roadmap to a stronger, better and more efficient system of delivering patient care and improving health outcomes across our society.
Drug Trading is excited by the opportunities represented by these initiatives. They are supported by the experience of our member pharmacists and by independent studies. We are frustrated at the slow pace at which federal and provincial governments are moving to consider their results and applicability to a large number of Canadian health care consumers.
Recent discussions among first ministers have focused on institutional rearrangements like a national formulary, a national drug-purchasing agency, and so on. While these are important, our submission goes behind existing practice relationships and recommends changes that will alter existing cost structures and, by better utilizing the professional expertise of pharmacists, make our health system more effective and more sustainable.
Our submission recommends immediate action by Canadian federal and provincial governments in six areas: We recommend that there be limited prescribing authority to remove duplication and waste and relieve workload pressures on over-burdened physicians. We recommend that pharmacists be given authority to authorize drug refills within established protocols, to prescribe, manage and treat patients for self-limiting conditions and to prescribe supplies for people with diabetes.
With respect to lowest-cost therapeutic alternative policies, to ensure that patients receive the most cost-effective drug product within the same therapeutic class, we believe an important driver of drug costs is preference-switching by prescribers from an established drug to a newer drug within the same therapeutic class that may be more expensive but not necessarily better. Canadian hospitals have engaged in these practice for many years, effectively controlling costs without adversely impacting patient outcomes. We recommend that Canadian governments implement prescribing guidelines, based on protocols established collabora tively by pharmacists and physicians.
We believe it is important to counter waste with initiatives such as medication reviews conducted by pharmacists and trial prescription programs. We recommend adoption of these pro grams, many with demonstrated effectiveness, in all Canadian jurisdictions.
With respect to academic detailing to educate physicians so they can make better-informed choices about medication and select cost-effective options for patient drug therapy, we recom mend the adoption of academic detailing programs to educate physicians in all Canadian jurisdictions.
As to disease management and wellness programs, to reduce system pressures on our health care system and improve health, well-being and productivity, we recommend that Canadian governments invest in disease management and wellness pilot programs that use pharmacists to effect better patient outcomes.
Finally, I will deal with patient medication compliance programs to reduce waste and unnecessary public and private insurance costs and improve patient outcomes. Seniors and people living with chronic disease conditions such as asthma represent a tremendous opportunity for pharmacists to positively impact quality of life and outcomes and dramatically reduce system costs, costs that were estimated at $7 billion to $9 billion in Canada in 1995. We recommend that Canadian governments implement pharmacist-based medication compliance programs.
Details on each of these recommendations are provided in our submission, which also contains information on a number of important independent studies that support our recommendations.
Mr. Chairman and honourable senators, it is clear that Canadians are concerned about the sustainability of our health care system and eager for leadership that will preserve what is best in it while improving its ability to provide quality, affordable services to citizens when they need them. We thank the committee for the leadership it has shown in advancing discussion on the "Issues and Options" report.
We believe that we are part of the solution to the problems evident in the health care system in Canada. Our member pharmacists are willing and eager to work with governments to build on the knowledge we have gained. As this committee and the governments of Canada continue the task of identifying necessary changes, we urge you and them to work with us to seize these opportunities.
The Chairman: Mr. Mitchinson, my question to you is asked partly tongue in cheek. I notice that you commented on all of our proposals. You say that you do not like the idea of a national formulary. You do not like the concept of therapeutic substitution. However, since you did not comment negatively on our proposed continuation on the advertising ban, is it reasonable to assume that you are in favour of that?
Mr. Mitchinson: By way of correction, we commented negatively on therapeutic substitution because we do not believe it will work, and our submission goes into why. We did not comment specifically on the idea of a national formulary. Our criteria around any formulary, national or inter-provincial, are three-fold: One, that it create ready access to new technology; two, that physicians shall be the primary deciders of what patients will get; and three, that the selection of drugs must be relevant to the community it is trying to serve. The Quebec formulary may be an interesting model for this committee to consider because it meets all of those criteria. It has full access.
As for direct consumer advertising, the truth of the matter is, most Canadians can get access to reams of information on drugs of any nature or type, approved, unapproved, through the Internet. They see it on TV. They see it in magazines. We take no issue with allowing our industry to advertise our products in a responsible, regulated way.
The Chairman: Since they can get the information in all kinds of other ways, does it follow that, equally, you do not care whether they are allowed to advertise?
Mr. Mitchinson: No. We would like to be able to advertise.
The Chairman: I thought you would say that. I just wanted to be clear.
Mr. Elliott, you talked about a patient who came into your store last night who decided that he could not afford to start a smoking cessation program.
Ms Farnham, you talked about a 1995 study, which found that 50 per cent of prescription drug users are non-compliant by either not filling the prescription or by not taking their medicine as prescribed.
It would be helpful to the committee if you could give us, first, the number of people in Canada who are prescribed drugs and then do not take them because they cannot afford to; and secondly, the number of people who are prescribed drugs, buy them, and do not take them. Is the 1995 study to which you referred the best information that you have?
The committee is more than a little concerned about the fact that, clearly, medically necessary drugs are not available to a number of Canadians because of costs. I am not blaming the drug companies for that. Some people just do not have some form of paying for them. This committee wants to find some way of dealing with that problem.
To the extent that you have data on how serious the problem is, and to the extent that you have better data on the percentage of people who are covered by adequate drug plans, by province, if you could provide us with that material, that would be most helpful to the committee. Does that data exist?
Mr. Elliott: Mr. Chairman, yes, it does, but I do not have it at my fingertips. A number of studies have been done over the last few years. We will try to provide the committee with the data contained in those studies.
Ms Farnham: We have done a lot of work on medication compliance within our member pharmacies. I can provide the committee some information on some of the outcomes of these very recent programs.
The Chairman: That would be helpful. My guess is that the people who cannot afford these medications are older. However, I may be wrong because, in some provinces, once a person reaches the age of 65 prescription drugs are accessible. Perhaps this applies to the working poor.
I would also guess that the problem is more evident in rural and remote areas than it is in urban areas. However, I may be wrong in that.
Whatever information you have in that regard that you could provide to our committee would be helpful.
Senator Morin: Mr. Mitchinson, how do we fair in relation to other G7 countries in terms of drug costs as a proportion of health care costs? If you have that information, you could send it to the clerk or to myself. People have the impression that we spend a lot on prescription costs. I do not think they realize how little we do spend on drugs in this country, but that amount is increasing. In relation to total spending, I believe that, compared to other G7 countries we are spending less.
In The Globe and Mail this morning I read that you spend $100 million in research in this country. Could you tell us what type of research you are supporting and the place you occupy? I think you are in seventh place in private sector spending in Canada.
Mr. Mitchinson: First, we will provide you with that information you requested.
Second, as a company, we are in the top 20 research companies in the country. As an industry, about $1 billion in R&D has come into Canada. The governments over the past twelve years are to be complemented for striking a very good deal, from a public policy point of view, with the pharmaceutical industry. There are price controls through the PMPRB. There is a guarantee that a percentage of our sales will go into research. That has created a $1 billion research facility in Canada in our R&D companies alone.
These same companies have been the basis for venture capital in many cases around new start-ups in Canada's robust and growing technology community.
There has been a superb growing relationship where I think all parties have had access to new products.
Our research has started, typically, at the clinical trial level. A tremendous expertise has been developed in Canada. We are now backing up, and putting our research into pharmaceutical development. We hope to go into discovery research here in Canada. One of our colleague companies, Merck, has already made that shift. It does discovery research in Montreal.
It is a tremendous success story in terms of R&D in Canada and the relationship between government policy and encouraging that kind of development.
Senator Morin: Ms Farnham, I support most of your recommendations. Many of them are already in place in several provinces. Your recommendation is that they be extended throughout the country.
Your fourth recommendation surprises me somewhat. You recommend that all Canadian governments adopt therapeutic interchange policies in order that pharmacists can dispense the most cost-effective drug, particularly if a new drug is more expensive.
I understood that there was a PMPRB regulation prohibiting a company from introducing a drug in a given class that would be higher in price than the existing drugs. What you are alleging cannot exist in Canada, although it may exist in other countries. We can check on that.
As I understand it, a new drug in a particular class cannot demand a higher price than the other drugs in that class or cluster of drugs. The new drug must fit into a different class.
Ms Farnham: I apologize. I do not have them with me today, but we could follow up and provide you with some specific examples of interchanges that can be made, with the specific associated cost savings.
Senator LeBreton: I also have a question with regard to the presentation by the Drug Trading Company Limited. You recommend that all Canadian governments implement pharma cist-based compliance programs, and you give some examples of that. Many witnesses have testified before this committee about the improper use of medication, over-medication, having two different doctors prescribe different drugs and the problems that causes.
In committee we have tossed around ideas of health smart cards. We have debated whether those should be held by the patient or by the physician. Do you anticipate monitoring or controlling medications by some form of a health smart card? Dr. Keon used the U.S. army example of people actually having a dog tag with their medical information. How would you see that recommendation being implemented?
Ms Farnham: We obviously support the use of this kind of technology. Inevitably we will be required to address some of these issues. We also recognize, however, that some of these things are some distance away because of concerns around privacy regulation and restriction.
Our member pharmacies, using pharmacists, have done a lot of work to directly influence and impact on patient compliance by having the pharmacist engage in programs such as calling a patient to find out how they are doing with their medication; to determine if they discontinued usage because of an adverse drug reaction; and following up to ensure that they fill their refills as scheduled and as appropriate. We have been able to demonstrate that pharmacists can have a direct and positive impact on ensuring that patients do take their medication properly and take it for a sustained period of time as appropriately prescribed. We are focusing on direct pharmacist intervention within the context of our remarks.
Senator LeBreton: I go to an IDA pharmacy in the town that I live in. They have all my records and all my husband's heart records. He is a patient of Dr. Keon at the Heart Institute. The pharmacy provides good printout information about what the drug does. The pharmacist is very helpful. I am quite sure that if my husband went to another doctor - although I can hardly get him to go to the one he is supposed to go to - brought in a prescription, the pharmacist would notice that. What would happen if he went to another pharmacy?
Ms Farnham: The smart card technology would be required to address that issue. The pharmacy-patient care systems are not linked today. What we are focusing on is that pharmacists as health professionals have more interactions with the patient than virtually any other health professional. The average Canadian family has a minimum of 28 prescriptions per year filled at a pharmacy. The pharmacist is extremely accessible and has many points of contact. The pharmacist is also the health care professional who understands what happens to that prescription once it leaves the doctor's office.
The physician may write a prescription and then see the patient in three, six or nine months. It is the pharmacist who notices whether that patient comes back when he should and whether he is taking the medication as prescribed. That is where our recommendations are focused, although we recognize the import ance of technology and of managing the system.
Senator LeBreton: If they notice that someone has not refilled a prescription in a specified amount of time, pharmacists are rather powerless to do anything about it. Is that correct?
Ms Farnham: There are some things that pharmacists can do, but the system of rewarding and providing incentives for pharmacists does not support that kind of interaction. Many of our member pharmacists are involved in this sort of activity, but as Mr. Elliott mentioned, we feel certain changes are required in the pharmacists' scope of practice to help us function effectively and to deliver quality health care.
Senator LeBreton: Mr. Elliott, I was struck by your story about the gentleman coming in to fill a prescription for smoking cessation and making the decision that he could not afford it. Is there anything you can do other than try to encourage him to find the money to pay for it? Can you report it to the doctor or recommend some other less expensive product? I know the smoking cessation aids are a limited product. It must be very frustrating because there is not much you can do.
Mr. Elliott: Thank you for your question. Yes, it can be a bit frustrating, but pharmacists do have some options. Patients elect not to take their medication because they cannot afford it, or they do not have coverage, or there are ancillary products they need to do that. We routinely work closely with the physician community in offering alternatives that may fold into the particular drug plan coverage. We offer less expensive alternatives.
With the consent of the physician, we often provide therapeutic substitution. We find a product or a means to achieve the goal the physician has determined.
Apart from the compliance issue of people being able to afford the product, there is also the issue of people being able to use the product. If a three-year-old child is supposed to use, say, a Ventolin inhaler, that child or the parent may not be able to cope with the device because it is intricate. Another device may be required but, in most cases, that particular product will not be covered as part of their benefits. The child wants to be compliant. The parent wants to be compliant, but he or she cannot afford the device.
They will return to the physician who may recommend a different type of treatment which requires respiratory technology to be involved in the home or home visits. A second visit to the physician is required. You end up with a large circle of activity to meet the additional needs of the patient in order to comply with the physician's directions. Compliance is more than the ability to follow directions, there is also an inability to use the product for whatever reason.
Senator Keon: Mr. Mitchinson, I want to acknowledge the tremendous contribution that your industry is making to research in Canada as well as your desire to work cooperatively with CIHI and other granting bodies in providing matching funding for scientists and so forth.
In your discussion with Senator Morin you used the term, "discovery research." I believe that there is a tremendous opportunity in the Canadian research sector for better utilization of the funding that the pharmaceutical industry is providing. I appreciate the problems with patents and so on. I think what is needed is more of an effort to locate scientists in the basic science medium, in the institutes or university institutions of various kinds, in cooperation with granting bodies to truly make a commitment in personnel and career support to some of our top Canadian scientists. This is a tremendous problem for them, as you know. There is nothing quite as fragile in the whole health sector as the scientist who has to repeatedly apply and be peer-reviewed in order to get personnel support.
I have talked to some of your colleagues about this idea of jointly funding research personnel in research institutions and creating chairs and so on that have a long-standing commitment.
Would you care to comment on that? Perhaps I am trying to sensitize you to this issue.
Mr. Mitchinson: I am not only sensitized to the issue, but I am also pleased to say that, in the past year, we have put 14 chairs into universities across Canada at an average cost of about $1 million per chair. Those are run by the university; in agreement with the university. Our claim on any research is merely at an intellectual property level. As you indicated, this does provide a scientist with solid funding. The university can commit to that individual, and they can then draw in other experts around them, and draw on other funding.
We undertook with the Ontario government to take a group from the University of Toronto, from the Ministry of Science and Technology, and from our own company to research Triangle Park in North Carolina where our company's U.S. head office is located. They have managed to create a cluster where they have linked together the universities, the local industries, and the government and created an office through which the coordination of those three sectors could come together to try to direct some of this research money. Currently, universities have their research agenda; the government has its agenda; and we have ours. You may want to consider what they have done when dealing with the research segment of your report. How do you create clusters whereby the research monies can come together in a collaborative approach dealing with the kind of issues you have described?
Senator Keon: Ms Farnham, I want to bring you back to a remark you made about your computer programs as they may relate to the privacy of health records. This is quite a barrier at the present time. Health information is very carelessly stored right now. Hard copy is probably more of an interest than a computer program.
If a patient has a prescription filled in one outlet, can somebody in another outlet draw up that information without the patient's consent?
Ms Farnham: No. Current privacy legislation prohibits us from making that accessible and available. Technically it can be done, but legally we cannot do that.
Senator Keon: If someone gets a prescription filled in Vancouver and he comes to Toronto and gets another prescription, when your pharmacist goes to the computer, what comes up?
Ms Farnham: If the patient's record was in Vancouver, we would have no record of that patient in Toronto. If the pharmacist in Toronto required information on that patient, he would be obligated to call the pharmacy in Vancouver to obtain the required information.
Senator Keon: Supposing the patient had a previous prescrip tion filled in Hamilton, what would come up on the computer?
Ms Farnham: Again, if the patient had not visited that particular retail pharmacy outlet in Toronto, that pharmacist would have no information on what had occurred in Hamilton.
Senator Keon: I appreciate your answers and what you are trying to do. Hopefully, some day it will all come together.
Mr. Elliott, you raised a subject that virtually everyone raises with us and that is the manner of payment of primary care physicians, which is a tremendous barrier to the integration of the health professional work force in Canada. Do you have a solution to suggest to us?
Mr. Elliott: I am not sure we can add more clarity to that discussion than the others who have struggled with that question.
We are concerned that payment on a fee-for-service basis encourages the treatment of illness but does not encourage wellness. It encourages over-utilizations rather than under-utiliz ation.
We all have to work together. Pharmacists can offer team approach opportunities to manage patient medications and reduce the number of visits to hospitals and to physicians by some of the methods Ms Farnham referred to with respect to monitoring for compliance and for drug use.
Pharmacists are paid on a fee-for-service basis as well. That raises its own challenges because the pharmacist's ability to deliver different types of care and programs is not remunerated.
A number of studies have been done both in U.S. and Canada where remunerative programs have been put in place by private insurers. In some cases these have been done by governments. I think the U.K. has programs under which pharmacists are paid to do an intervention. I might cite an example in Quebec where, for a number of years, pharmacists were paid to not fill a prescription. They would provide a written pharmaceutical opinion where the patient was believed to be at risk by taking the medication, and they would be reimbursed for not filling the prescription. Those are examples of schedules and other types of programs that could be put in place.
There is probably a balance between a fee for service, a salary and a capitation process. However, we may not have the exact answer to that.
Senator Callbeck: Mr. Elliott, do you not agree with bulk purchasing?
Mr. Elliott: There is nothing wrong with bulk purchasing, and my learned friend to the left will probably have some discussion with me about that, so long as the contracts are set in such a way that delivery to the ultimate user, to the patient, is consistent and dependable.
Our concern is that, when you move all the decision making on a particular product into one brand, one product, one selection, if there are supply problems with that particular product, availability problems, an unexpected increased demand or a contract change, then there is risk presented to the patient because there is a subsequent change of product to the patient or unavailability of the product.
Our colleagues in New Zealand reported a number of instances where they had to ration products being delivered to patients. A prescription may have been for 100 tablets but the patient was given 10, 15 or 20 tablets to tide him over until the problem with supply was solved.
Senator Callbeck: Do you agree with that?
Mr. Mitchinson: I do not profess to be an expert on bulk buying. We do know that occurs in the generic market or that market where products are off patent. Saskatchewan did have a fair bit of success in having standing-order contracts. They would put out a tender for a product, the price would be set and, in the case of Saskatchewan, they would go with one manufacturer. Tendering for products in the generic market and setting the base price is not an issue, because all-comers can match that price if they wish.
Ms Farnham: When contemplating bulk buying to the degree at which you would be on a national level, you could, potentially, introduce a number of issues or problems into the system. On the scale at which the federal government might contemplate bulk buying, there actually is the opportunity to decide the fate of a manufacturer - whether that manufacturer continues to exist or not. It raises issues of restraining competition. You can become very dependent on one supplier, and although in the short-term you may find some economies and efficiencies, in the long-term you may end up with an outcome whereby you are paying higher prices and becoming very dependent on one primary supplier. You must be very careful with bulk buying. All of us, as retailers, must be very sensitive to the competitive nature of the marketplace. Certainly on the scale of what the federal government might be doing, you could introduce some real issues and problems into the marketplace. We would urge caution.
Senator LeBreton: My other question concerned direct consumer advertising. Are you against that for prescription drugs or for all drugs?
Mr. Elliott: We have hesitation about the advertising of prescription drugs because we are concerned that it will drive up demand for prescription drugs that may not be necessary. We are concerned that, in the very busy offices that most physicians occupy, a patient will present with a preconceived diagnosis made on their own and a preconceived need for a particular product and perhaps, directly or indirectly, bring pressure upon the physician to make that decision on his or her behalf.
We are concerned that patients may not have all of the information in the text and the presentation of the commercial itself. We have concerns about whether it should fully describe the side effects, the adverse effects and the interactions with other medication. Those decisions on prescription drugs should be made with a patient and a physician meeting together and comparing information, rather than through public advertising.
Public advertising of non-prescription drugs is ongoing and it is not a problem. I could keep you fairly busy for the next couple of hours with anecdotes as to why it is a problem within the pharmacy, but it does not affect this discussion. There are concerns about name recognition in advertised over-the-counter products where a multiple number of components contained in those products have a consistent brand name. We called them "line extensions," for want of a better term. Patients are confused and often select the wrong product. We encourage them to talk to their pharmacists before they buy certain over-the-counter products to make sure they are getting the right product, or at least the product they think they are buying.
Senator Robertson: I note in one of your documents you deal with the cost drivers of health care. You say that Canadian drug spending as a proportion of overall health care spending is among the lowest of the G7 countries. We are below the average of other industrial nations. Of these countries, who has the highest costs for patent drugs?
Mr. Mitchinson: The highest-cost country for pharmaceuticals is the United States.
Senator Robertson: Are there countries where the costs are lower than in Canada? Why is there a difference?
Mr. Mitchinson: A number of factors come into play. We think the PMPRB has done a superb job in striking a good balance: a medium price between European countries and the United States and, at the same time, encouraging innovation. While we may have certain disagreements with interpretation from time to time, the net effect of their activity is that Canada has either the average price in a given drug or one of the lower prices.
An additional element in Canada is that each province sets up a cost effectiveness barrier, which we do need to meet. If we want access to the provincial formularies, we have to provide a value argument, which again has an impact on the real price of product.
Senator Robertson: If we had a national drug plan, would costs be reduced further in Canada?
Mr. Mitchinson: Currently, the PMPRB is an effective drug agency. There are two components to what a national plan could do. Would it ensure broader access for Canadians? The Quebec drug plan is, perhaps, one option the committee could consider in that regard. Would it create timely access to new technologies? It may or may not. We find incredible variance across Canada. It depends on the philosophy.
With regard to pricing, there may be an opportunity in the generic market to drive prices lower. However, the kind of national review that would be done would be similar to what is being done in each province, which is related to what the product is displacing.
It is unlikely that bulk buying or a similar approach would create price competition.
Senator Robertson: If I understand you correctly, that would not have a great impact on the price of one item.
Mr. Mitchinson: I would ask the committee to consider again the Saskatchewan example. The used a standing, not-for-profit type of contract approach with one of the smaller pharmaceutical markets in Canada, and they still managed to extract the lowest prices.
Senator LeBreton: We recognize the massive amounts of research required in the development of a new drug. What percentage of the total budget of, say, GlaxoSmithKline would be spent on research? Are you permitted to discuss that?
Mr. Mitchinson: It varies year to year. There is more than one definition of research. There is the PMPRB definition and there are others. Approximately 13 per cent of our revenues go into research.
Senator Robertson: Does that include the research chairs to which Dr. Keon referred?
Mr. Mitchinson: Yes.
Senator Robertson: Do you do most of your research in-house?
Mr. Mitchinson: No. Typically, we have collaborated. One interesting collaboration was with BioChem in Montreal which developed the product 3TC, a staple of AIDS therapy. That was a case where we contracted with them. They created the innovation. We worked with them to bring that product to market.
We have also found it productive to work with university researchers in Canada. Canada has world-class researchers in various elements of disease research, and we have created a number of collaborations on that front. It is a combination, senator.
Senator Robertson: What is your biggest expense?
Mr. Mitchinson: It would be our commercial expenses.
Senator Robertson: Does that mean advertising?
Mr. Mitchinson: It would be the cost for us to promote our products, to educate physicians and patients on our products, and to work with pharmacy.
Senator Robertson: Is there a better way to educate physicians than the way we do it now? Could it be done better under a national program? It seems that many general practitioners are not familiar with the benefits of certain drugs, and that they often call the patient after a consultation and change the prescription.
I think the best source of information is my local pharmacist. If I am at all suspicious about something my doctor has prescribed, or even if I am not suspicious, I always check it out to make sure there will be no counter-effects with any other medication I might be taking. I think pharmacists are greatly underutilized.
Years ago, if we had a cold or measles or whatever, we would go to the pharmacist for advice. Nobody seems to do that any more. Is there a better way of educating the pharmacists and, in particular, general practitioners? It is very difficult for them to keep up with it all. I have every sympathy with them. However, the consuming public is also frustrated because they recognize that they are not getting enough information about new drugs. Would this be handled better under a national pharmacare program? Is there a better way of doing it?
Mr. Elliott: If I may be so bold as to comment, senator. Pharmacists in Canada are highly educated and, in all provinces, they have to comply with a number of ongoing competency requirements. Pharmacists are more often asked for advice rather than less often.
In many provinces, pharmacists self-fund their own pharmacy drug information centres which have access to unbiased world information on virtually all medications we use in Canada. Often we find good references on drugs from European or other sources. Pharmacists have instant access to the information a patient needs. We routinely contact that service. We routinely prepare printouts, handouts and literature for patients on unusual drugs and on new drugs.
The new drug information that our colleagues in the industry provide is often available in the research form before the public has access to it. Pharmacists do have access to that and make it available. Our colleagues do coach and help us with the materials from the industry.
Senator Robertson: Do you in turn pass the information along to the medical profession?
Mr. Elliott: Absolutely. We share with the professions. We have education programs in the form of conferences, and we provide written material. The Canadian Pharmacists Association produces updated texts, both electronic and print. The information is available. An interesting driver of the production of information is the patient who asks questions. They often raise questions that no one else has asked.
Senator Robertson: New developments are happening so fast that I do not know how everyone keeps track of all the information. It must be very difficult for physicians, pharmacists and everyone.
Ms Farnham: One of the recommendations in our submission specifically relates to academic detailing of physicians by pharmacists. Some work on this has been done in Australia, and some preliminary work is being done in Ontario now. We would encourage a recommendation that we engage in more pilot projects of this nature to see if we can effect the kind of outcome you are looking for.
Senator Callbeck: You said that 13 per cent of your budget was spent on research. Then you talked about the commercial expenses for promoting the drug and educating the public. What percentage of the budget would that be?
Mr. Mitchinson: Our commercial expenses are dedicated to bringing our products from the point of about two years prior to regulatory approval. Those expenses include health economic studies, setting up education programs, getting guidelines in place, and compiling other materials for the promotion of our products. In any given year, the total cost can range from 15 to 22 per cent.
The Chairman: I wish to thank the witnesses for attending here today.
Senator Marjory LeBreton (Deputy Chairman) in the Chair.
The Deputy Chairman: Colleagues, we will get started on our last panel of witnesses. We have with us Donald Hurley, President of Medtronic; Bill Gleberzon, Associate Executive Director, Canada's Association for the Fifty-Plus. I see my friend Lillian Morgenthau.
Ms Lillian Morgenthau, President, CARP: We changed our name to Canada's Association for the Fifty-Plus. We felt that "retired" did not really reflect the 50 year-olds. While they would love to be retired, they are not old enough.
The Deputy Chairman: We also have with us Cheryl Gulliver, who is with the Canadian Association Of Community Living; we have Cameron Crawford, President of the Roeher Institute; and we have Dr. Ed Brown, Director, New Network Telehealth.
I should like to extend a welcome to all the witnesses.
I shall use the chairman's prerogative and start with you, Mr. Crawford.
Mr. Cameron Crawford, President, Roeher Institute: Thank you for the opportunity to present to the committee. I apologize for distributing my written paper at the last moment, but there was no time to get it to you before now.
I will just run through the main points of the paper. They speak specifically to ideas that are presented in "Issues and Options." I wanted to keep the discussion focussed around that paper.
The work that has gone into "Issues and Options" is impressive. There is a lot in there. It is virtually impossible in a couple of minutes to address the depth and range of thought that has gone into it. Hence, I apologize in advance for whatever shortcomings my presentation leaves you with.
The Roeher Institute does public policy research on issues affecting people with disabilities in Canada. We look at income security issues, health issues, health planning, labour market issues, and so on. Our research agenda is quite broad. We have looked at issues of health and health planning in the past.
Our written paper provides some context. It lays out that there are about 4 million Canadians with disabilities in Canada. The proportion among those who are senior citizens with disabilities increases quite rapidly after the retirement years. After age 70, approximately half the retirement age population has some level of disability.
Our paper then provides a snapshot of the general health of people with disabilities. We at the institute do not subscribe to or use the medical model when we talk about disability. The medical model speaks of disability as if that in itself were an illness. We do not subscribe to that notion. Nevertheless, it must be said that the overall self-reported levels of general health among people with disabilities are quite a bit lower than for the Canadian population as a whole. Approximately less than half of those with disabilities will report excellent or good general health, as compared to the approximately 75 per cent of those who do not have disabilities.
The paper goes on to look at the reliance of people with disabilities on the health care system. The basic picture is that they are more likely to have contact with physicians, more likely to be doing overnight stays in hospital and more likely to be using emergency services. Where hospital stays are necessary, they are more likely to be in hospital for longer periods of time.
People with disabilities also have proportionately greater difficulty accessing health care services perceived as necessary. The national population health care survey asks the question in this past year: Have you felt that health care services were needed and not received? A very large share of those with disabilities answered yes to that. A very small share of those without disabilities answered yes to that. The paper gives some leading reasons for why that is the case. Cost is a key reason why people are not accessing the services they require.
With diminished health status comes lower levels of personal income and other social and economic disadvantages. These have been recognized by the Supreme Court. There is an excerpt from a Supreme Court decision in our paper to support this. There is also a supporting reference to a recent publication by the federal, provincial and territorial ministers responsible for social services. The point here is that as disadvantages accumulate, so too do adverse health effects. Also, where people's health is poorer, they tend to be poorer economically as well.
As people's health diminishes, the likelihood of having any form of health insurance or insurance for prescription medications also decreases significantly. Overall, in excess of 25 per cent of persons with disabilities do not have prescription medication insurance. The level of severity of disability increases the likelihood that people will be paying out of pocket for a whole range of goods and services needed because of disability.
Given the foregoing - lower levels of health, poorer socio-economic situation, lesser capacity to pay for necessary health care services - what sense do we make of the issues and options? Does a right to health care exist, or is that just a perception? If one looks at the Health Act, the Constitution Act and rulings from the Supreme Court, one could argue that there is a right here. If that right were eroded, it would be eroded on top of rights already severely eroded for people with disabilities on the education front, the labour front, the civil justice front, the criminal justice front, and other fronts. It is really problematic to be talking about an optional right here.
In terms of the federal government's role, the paper examines the financing roles laid out in "Issues and Options." We foresee no appetite in the immediate future for any kind of cost-sharing between the federal and provincial governments. Cost-sharing was repudiated in the mid-1990s by provincial governments; it was abandoned with the CHST. By the same token, the present system of block funding is largely unaccountable. We do not know what kind of health outcomes are being achieved with federal dollars. We do not know what labour market outcomes are being achieved with federal dollars. Those are in the context of agreements that talk about the need to have reporting. It is not working.
Your report talks about improvements to the CHST, which make a lot of sense. If a proportion of the CHST were dedicated to health care service, ramp up those transfers to the provinces by some kind of an escalator, arguably one based not only on the prevalence of senior citizens in a provinces but also on the less-than-retirement aged people and people with disabilities, the fiscal basis for the escalator approach would be more meaningful. We are talking about a large share of the non-senior population having disabilities in any given province in a particular year. On page 8 of our paper is a chart that shows that.
Our paper then talks about medical savings accounts, MSAs. These are potentially good on many fronts. For example, they would offer a share of control, which many people applaud. However, they could be absolutely catastrophic for people with heavy health-related needs. The paper illustrates some examples of how MSAs would work in an adverse way for some groups of people.
The conversion of CHST cash transfers into tax points would result in no further federal-provincial discussion on health issues. It would mean federal-government withdrawal completely, in terms of their commitment. Our paper also emphasizes the importance to the health and well-being of Canadians of the federal government continuing to play an active role in research, health promotion, and so on. It is very unlikely that the provinces will have the capacity to move in where the federal government will withdraw.
Your committee laid our options for raising new revenue for health care. However, people with disabilities have less income and, therefore, are less able to pay, either through the tax system or cash. If we were to go to a system of co-payments, preferably, a low, flat-rate scheme, one not based on the value of the services consumed, it would lessen the adverse impact on people with high, health-related costs and probably would be perceived as more fair.
A pharmacare plan would be well received by people who have disabilities. However, I would urge that you target it to people other than those who are on welfare. For low-income people with disabilities, there is a disincentive to remain in the labour market because often they do not have drug coverage, as compared to people on social assistance. Many people with disabilities would welcome a pharmacare program; it would enable them to seek independence from social assistance and thereby be more involved in the social and economic life of the community.
Ms Cheryl Gulliver, President, Canadian Association for Community Living: Honourable senators, the Canadian Associ ation for Community Living believes all people should live in dignity in this country regardless of vulnerability or no vulnerability. With me today is my daughter Margot. I will not tell you my age, but I will tell you that she is 30. Obviously, we have hung out together for 30 years and have fought the good fight, and are proud of ourselves and what we do around human rights and equality. On the other side of me is Connie Laurin-Bowie, a policy analyst. She always helps me make sense of what I do.
I will ask Ms Laurin-Bowie to speak next.
Ms Connie Laurin-Bowie, Executive Director, Canadian Association for Community Living: Thank you for the opportunity to speak to the committee today.
The Canadian Association for Community Living is a national federation of 13 provincial and territorial associations across the country. We have over 400 local associations. We advocate for people who have an intellectual disability and for their families.
Our central mandate is to support families in building communities that are inclusive. For people who have a disability, that means that we create systems in our communities that allow them to participate in school, in work and throughout their lives in different capacities.
We have worked for many years to distinguish the issues of disability from health, and I think only recently have understood the significance of the need to continue to deal with the issues of access to health. For people who have a disability, I think that there is a sense in this country, and particularly for people who live outside of this country, that disability is an issue that is dealt with through our health care system and therefore is well treated in Canada.
In fact, the stories from families and from individuals who themselves have a disability is very different. You will have received a copy of Our Lives, Our Voices, a document that is a series of stories from families across the country. I do not have a copy in my hands, but it is red and has a picture of families on the front of it. The stories that families tell are quite complex, and not all of them focus on particular health care needs. However, if you take a quick glance through those stories, it will become very apparent that the issues of health in their lives are intricately connected to every other aspect of their lives. It means that if your health care needs are not met, then, in fact, you cannot work. If you have a family member who has a disability, likely one or both heads of the household have left the work environment to care for that person. The document details some of the impacts and the statistical information about those impacts on the economic well-being and the health status of people who have a family member with a disability, and on and on.
We looked through the committee report and were quite alarmed, probably by two things. The first is the complete absence in the report of the issue of disabilities, and so we particularly appreciate an opportunity to bring our perspective today. The second involves the implications of many of the directions the report seems to be considering, for people who are vulnerable and particularly for people who have a disability, because of their vulnerability. Take for example the notion of user fees for those who have a disability or for families who have a member with a disability; those are really problematic directions, given the income potential in those families.
Having said that, we go back to the motivation for examining some of those options and understand very clearly that the committee is concerned about the sustainability of the health care system in this country. With that in mind, we have something to contribute in our own experience, which is the experience of people who lived in institutions for many years in this country. Because disability was seen for many years as a medical issue, the treatment and care of those people tended to take place in institutions. Our view is that in order to truly address the needs of people with a disability, and therefore all others in Canada, we need to develop health care systems that are integrated in our lives. That means taking responsibility from institutional health care into community in a whole number of ways. It may mean being quite revolutionary in the way we look at health in our communities.
For example, families who have children with disabilities may benefit more from having some health care support in a school than they would by having to leave the school to go to a hospital or a consultation in a doctor's office. There are many ways we have not even begun to explore that we might be able to integrate our health needs and health issues in our communities.
Our report does not detail many of those recommendations but it does detail the vulnerability of people. Before I hand it over to Cheryl and Margot to detail in a more personal and concrete way the implications of our current health care system and of future proposals for health are, I would say that our experience in many policy discussions has been that disability is often forgotten in the initial discussions of reform of any particular system. The tendency when the realization occurs that without any intention those people have been excluded is to create a separate kind of answer for those issues affecting people with a disability. That simply does not serve the purposes of people with a disability nor our systems as a whole. We need to consider those who are vulnerable in the design and basic philosophy of anything we do in this country, and particularly in health care.
With that, I will let Cheryl and Margot give you a little more precision.
Ms Gulliver: I want to talk to you about our experience 30 years ago when Margot was born. My father and mother, who were small-business people, taught me that we take care of our own in Canada. We did not complain about our taxes. We whined a little bit, but we did not look for any large loopholes because we believed we were a very fortunate family living in Canada. We were very proud of who we were and what we stood for. With that in mind, I got married, and I taught my children the same things because I really do believe that.
Thirty years ago, Margot was born at six o'clock in the morning and was operated on before noon. She was born with spina bifida. That was the first of 14 operations we have faced over the years. You have to understand that Margot is not sickly. She has never had the measles; she has never had the mumps. She gets the odd cold, but that is about it. She has also spent a total of six years in hospital, whether that is right or wrong.
I have always felt a personal obligation to be with my children. When we got married, my husband decided that my role was to be with my children. Therefore, I want to thank you for the $45.63 per month I receive from CPP, at 65. I have not worked outside the home, but I have enjoyed doing what I have done. It has not been an obligation. I love what I have done with my children and husband and others.
I am now a member of the sandwich generation. My father has had a stroke. He lives with my sister, who has cancer. We have Margot, plus all this extended family. I am only one of two. It never dawns on us that you owe us anything, either the federal government or the provincial government. What I feel very strongly about is what I referred to at the beginning - I want a safety net. I want a hand up. I want a level playing field. After 30 years of marriage, I have no income other than support payments, and I have no future for a job. I have diabetes; I also have a disability because I have lost my toe. I also have a very pretty stick that I can hit you with.
All I want to do is be a good Canadian, contribute where I can and have you do the same.
There were days when Margot went to school, but there was no way I could work because the school might call me for attendant care, medication, anything of that nature. I have no rewards, other than beautiful children. That was enough until I turned 60; it does not look quite so exciting at $45.63 a month.
Margot is a delightful young woman, who can speak well for herself. If she wanted to be independent of me, she would have to live next door; we would have to spend $1,500 a month on a mortgage or rent. We do not see that as being feasible at this point in time.
I want her to share with you her feelings of vulnerability. Give my daughter and me a safety net so that when I die it is okay.
I am a good Canadian, and I love Mr. Kirby. He shared morning breakfasts with me for I do not know how many years on Thursdays, he and the boys.
Margot?
Ms Margot Easton: In looking to the future, it is actually quite scary, because I have my mom and I have some friends. Basically, however, my supports come from my mother, and if something ever happened to her, where would I be?
Ms Gulliver: Do you want me to help you, hon?
Ms Easton: No.
Ms Gulliver: Okay. I have been told.
Ms Easton: I have some family and friends. Mom and I have gone through 30 years of pain.
Ms Gulliver: Sometimes.
Ms Easton: There is some good. Understand, now, that I am going to live until I am at least 100, so you cannot go until you are 150.
Ms Gulliver: We just added 30 years to my father's life, because he is not going without me.
Ms Easton: It scares me that our health care system is somewhat falling apart. We used to be comfortable going into hospitals. We always felt comfortable and safe and that people would be listening to us and understand our needs.
It just does not seem to be there anymore. I am scared because I am my own best advocate sometimes, but when we go into doctors' offices it is like I draw a blank, and mom is there to say to me: "You need to talk to him about whatever." I would say, "Oh, yes."
Where are we going to go? I can speak for myself, but there are other people who do not have speech such as I do. They do not have an advocate who can speak for them and look after them and be there to tell them that everything is going to be okay.
Ms Gulliver: You have to understand that Margot and I have hung out together for a long time, and it is not a hardship for me in any way. We fought the good fight. We are comfortable with one another. In the hospital file, it says: "Delightful young woman. Beware of killer mother." That will be there time and time again.
If you are vulnerable, call me, because I will not let you face the hospital alone.
Ms Easton: I just want to add one more thing. I have never had problems before in health because we were comfortable. I look back now. My nephew, who is not even two yet - I look at what he will have to face as he gets older. I am scared for him because if we do not put a good system in place now, it will hurt our future generations. Where will they be?
Ms Gulliver: My nephew's name is Connor, but we call him "Roo." If Connor was with us today, he would be right here. He is 19 months old, and he sits behind Margot and looks at the world and is taken places, because I cannot handle, obviously, a stroller and a chair. He just sits up there like: "Okay, world, here I am."
Ms Easton: And he is the boss.
Ms Gulliver: Unfortunately. Can you tell?
Thank you for your time. We appreciated you listening. If we did not have it dead on, at least you know how we feel about what is happening in our lives and the impact you are having. Thank you from us all.
The Deputy Chairman: Thank you, Cheryl and Margot. That was compelling evidence. I would say you hit it dead on.
We will turn now to Mr. Hurley, who is the President of Medtronic.
Mr. Donald A. Hurley, President, Medtronic: Thank you very much for allowing me to speak to this committee. Just a few words about Medtronic. Medtronic is the world's leading technology company. We sell to 120 countries in the world, and our sales amount of $6 billion. We spend more than 11 per cent of that in research and development.
We employ 200 people in Canada. We have a state-of-the-art facility that manufactures pacemakers and, more recently, a new product called "Reveal," an implantable loop recorder, invented by a Canadian doctor. We now manufacture that in Canada for the world, so we are on the global scene.
Our sales in Canada exceed $150 million annually, including $20 million worldwide. We are one of the few Canadian manufacturers of implantable medical device, and we are exporting on a worldwide basis.
I should like to comment on the options in your report.
Because of underfunding issues, Canada needs a form of two-tier health care system, especially for those who can afford to pay for it, so that we can afford to have health care for both those who can and cannot.
At Medtronic, I am responsible for 55 countries. I can tell you that waiting lists in Canada are a lot longer than they are anywhere else in the world. An individual has to wait anywhere from three to six months or longer for open-heart surgery, and up to 24 months for hip replacement. That is not state of the art in terms of health care.
We can compare Canada to other countries in terms of procedures per million population. I do not intend to go through them all; I shall just give you one example. There are further details available in the information I have left with you. When we compare ourselves to the top 12 developed countries in the world as to procedures per million, we are lower than most of them. Let's take implantable defibrillators as an example. We do 46 of these procedures per million population in Canada; the U.S. does 212 per million population; and Germany does 80 per million population.
Lack of funding is not the only factor involved. At issue as well is the fact that the technology being used in Canada is not the latest technology in the world, given the regulatory hurdles in Canada.
We have waiting lists. Our procedures per million are getting lower. The provinces are spending in excess of 40 per cent of their budgets on health. There has to be some form of two-tier health care systems.
As outlined in your report, Canada is at the bottom third of OECD countries in terms of availability of health care technology. For example, we are number 17 in the world for MRIs per million population, right behind Turkey, and that is not the latest state of the art.
Our industry faces regulatory constraints that do not allow us to introduce products that are introduced everywhere else in the world. That, of course, leads to a lot of things. We are a high-tech company where we prove that our products are efficacious and more cost-saving than the existing technologies. The difficulty is that you cannot get the new technology reimbursed in the system the way it is today. We are falling behind other countries.
We are the only country in the top 12 developed countries of the world that does not have a form of two-tier health care system in the hospital part of our economy. Of the $100 billion spent on health care, yes, $35 billion dollars of that is for two-tier health care systems, but the part that is in the hospitals is 100 per cent one-tier socialized medical system. The rest of the world is a combination of both. My question to the committee is this: Are we right and the other 11 countries wrong, or is there something in between that we should be doing to sustain the health care system?
As you know, there are many doctors leaving this country because of the underfunding. I will give you just one example. Canada has 60 electrophysiologists, people specialized in dealing with the electronics of the heart. There are 60 electrophysiologists in Philadelphia alone, as an example.
The Deputy Chairman: And how many did you say there are in Canada?
Mr. Hurley: Sixty in the whole country.
Ms Gulliver: Sixty in Philadelphia.
Mr. Hurley: Hence, Canada faces underfunding and a very slow regulatory environment, - both of which lead to cost-recov ery problems. It will cost our company at least $500,000 this year to get products released, and at a slower pace than they were before. We have been in Canada for almost 35 years. We have invested a lot in R&D. We export products; we create jobs in Canada. Canada needs a form of two-tier health care. The Canada Health Act fosters this dilemma even further. Under the act, all Canadians are supposed to get access to all these new technologies. However, because of underfunding, people are not able to get these new technologies.
The problem compounds itself because under the Canada Health Act one is not able to pay for these on one's own.
There are 2,000 people in Canada waiting for deep-brain stimulation for Parkinson's. One hundred and sixty are receiving this technology. This device will cost the health care system $50,000 over five years. On the other hand, not to implant one will cost the system $500,000 over that five years.
Hence, even though we prove from an industry point of view that it is more cost-effective to implant one of these devices, it is not happening. And it is not happening because there are three silos. One is the hospital budget, one is the home health care budget, and one is the pharmacy budget. They never talk to each other. Therefore, people are not getting the more cost-effective technology.
Canada needs to harmonize with other countries. Other countries are getting approval of medical technology well in advance of us. Conversely, we are becoming more restrictive, which is affecting our industry and affecting the latest technology available for this country, technology that is cheaper and more cost-effective, not technology else that going to be more costly to the health care system.
In a society where there is a lack of funding or unwillingness to assume access to the latest diagnostic and therapeutic technol ogies, the patients must be allowed to choose. There has to be a form of two-tier health care system to make this happen.
In summary, we as an industry see the future of Canada's health care system as dependent on the willingness of governments and individuals to face the truth that medicare as it currently exists is underfunded and is not sustainable over the long term. New policies are needed to introduce more money and to facilitate more efficient service delivery. In so doing, we will enhance, not decrease, patient access to treatment and improve overall quality of care.
Thank you very much for the opportunity to talk with this committee. I would encourage the committee to come and visit our facilities, one of the latest state-of-the-art robotic assembly manufacturing facilities in the world.
By the way, it is only because of the robotics that we are in Canada. The efficiencies of manufacturing and doing research in this country are not there like they are in most countries. We have found a way to be more cost-effective because of robotics. That is why we have manufacturing and research in this country. Thank you very much.
The Deputy Chairman: Thank you very much, Mr. Hurley, and thank you for the invitation. I would urge some of my colleagues to take you up on it.
We will now hear from the Canadian Association for Fifty-Plus.
Ms Morgenthau: I am the President and founder of CARP.
The Deputy Chairman: I was on a committee several years ago when you presented. You impressed me then and I am sure you will do the same now.
Ms Morgenthau: CARP is a non-profit organization with over 400,000 members aged 50 and older. We have a magazine that goes to over a million Canadians. We have a far-reaching association, one that does many good things.
We do not carp; we recommend. We have a very definite way of helping government do the things that people over 50, and even children, need.
I would ask the committee to review the materials we have left with you. There is a lot to go through, so take your time.
Before I begin my presentation, I wish to ask the following questions: What is the relationship between this committee and the Romanow commission? We will be presenting to them also. I presume you will cooperate with each other, so as not to have different attitudes when you each report your findings and recommendations.
Our presentation will limit itself to some of the issues raised in the committee's interim report. We support the committee's request for a non-ideological discussion on health care. The discussion should focus on what is in the best interest of the Canadian public.
The first time my economy professor walked into our classroom, he said, "Ladies and gentlemen, everything, but everything, is based on economics." We cannot do that here. Health care is not a matter of economics. Economics is part of it, but we also have to look at health care as a moral issue.
The debate over any changes in our health care system should not be driven solely by financial and legalistic consideration. Fairness, what is morally and ethically correct, and the impact on the overall health and economic competitive nature of the nation should also be taken into consideration.
We are pleased that the committee acknowledged the myth of age as a major cost-driving factor in health care. Indeed, ageing will not have a truly great impact on increasing the cost of health care until 50 or 60 years from now, when the baby-boomers start to die. As we know, the greatest increase in health care costs are during the last six months of life. By then, new cures, techniques and technology will undoubtedly change the nature of health care.
More than 100,000 North Americans are 100-plus years of age. This is good, and this is bad - good because we are going to get up there; bad because we are going to cost the system. What the committee does today will affect tomorrow. Therefore, no precipitous or irreversible action needs to be taken immediately in order to maintain the long-term sustainability of health care.
CARP endorses the committee's observations that health is not just another commodity, rather that health care is different from other goods and services for reasons the committee has already identified.
CARP agrees with the committee that the current publicly funded single-tiered health care system shapes Canadians' definition of themselves. In particular, in contrast to our southern neighbour, Canadians have created a unique, made-in-Canada health system based on a collective sense of community rather than on individualism. If this system and the philosophy it is based on are eroded, destroyed or replaced by a system based on another type of philosophy, it could cause irreparable damage to our nation's self-identity. Canadians are different than Americans. They have an entirely different philosophy, and we want to keep it that way.
We are pleased that the committee has endorsed the first four principles of the Canada Health Act. However, the committee asserted that the fifth principle, public administration, required reassessment. CARP is concerned that if one of the principles of Canada Health Act undergoes revision then the other principles will not be far behind. If you change one, beware of the other changes that will come with that.
CARP notes that the public funding for private health care services or facilities is a contradiction in terms and in principle. How can a privatized health care service make money for the owners? This is, after all, the main purpose of a privately owned service or facility. If through better management publicly administered agencies can learn and apply these lessons, why cannot we? If we lower the wages for staff, then the principle of "you get what you pay for" may apply.
Any surplus profit made by publicly funded agencies is either reinvested back into the entity or taken back by the government that is providing the funding.
What are the non-ideological advantages of privatized health care? They are not less expensive for governments, if govern ments are still paying for them at the same rate that they are paying for their public counterparts. Further, administrative health care costs in Canada are lower than those in the U.S. That is why they like to bring their people here and do their operations here, if possible.
Privatization represents the thin edge of the wedge that could undo the current single-tiered health care system that generally characterizes at least part of the Canadian health care system, hospitals and doctors. The homecare system is heavily privatized. Studies demonstrate that where a privatized system co-exists with a public health care system, the public system suffers from neglect, as the experience in the United Kingdom has showed us. Prime Minister Blair has pledged to invest £90 million, or three times the dollars, into the public system in an effort to raise its long neglected effectiveness.
User fees - the dreaded expression. Senator Kirby has been quoted as saying: "A major reconstruction is needed and new sources of financing, either from taxes or from patient patients, will be required." Of course, the same patient may pay both simultaneously.
There may be a third option, however, which is to identify ways to use the current amount of funding more effectively and prudently. User fees, in fact, are a form of taxation that is imposed on people on an individual basis as well as a collective basis. Moreover, they penalize people for being ill or seeking to prevent illness.
User fees can reduce frivolous and wasteful usage of the system; they can pump more money into the health care system - without raising income taxes; and they can enable those with money to get more timely service.
How do you know use is frivolous and wasteful until it has recurred? What does the research tell us about how many people actually misuse or abuse the system? Do all have to suffer for the small minority? Does the request for a second opinion constitute an abuse of the system? There has been much talk about allowing only one visit. I do not think we can go with that. Sometimes, one visit might not be just right and the patient will want a second opinion. Are we going to refuse second opinions? I think we have to look at that very closely before we go with that.
The Swedes, whom the committee noted, charge user fees. The cost to administer their program is equal to the amount raised. Hence, before we go down the user fees road, we have to look carefully at what we will get if we implement it.
How much should be charged, either to increase the amount of new money into the system or to reduce abuse of the system, to provide a surplus beyond cost of administration? If hospitals or doctors made a profit, what impact would that have on funding? Would public funding be reduced in correlation to the amount of the surplus? How much should be charged without penalizing those unable to pay for health care? Those people may put off a service until their condition becomes unbearable, thereby increas ing the cost for their treatment.
Timely service certainly needs improvement, although, as many have noted, Canadians with money can purchase medical services in the United States. Why should they go to the United States and take Canadian dollars and spend them over there? They should be able to get those services here.
Medical accounts, which have been suggested, have had very limited practical applications other than in Singapore.
Let me move to the issue of human resources policy for health care. During the 1990s, health care institutions and facilities were forced by cuts in government spending to engage in a yo-yo human resources policy and practice. They would let staff go in times of downsizing, during the first half of the decade, and rehire them during the second part of the decade. Nurses and non-medical staff were particularly vulnerable.
Because of this instability, staff shortages have spread to homecare as well. We hear constantly about the shortage of nurses, the shortage of doctors, the shortage, the shortage, the shortage. We created that shortage by firing them all; now we have to rehire them. The same thing happened with the teachers - they fired them all. Now they want them back. Why fire them in the first place? Let's keep what we have. Let's keep our quality.
There is a serious lack of geriatricians in our country. Very few medical students are entering the field. As the population grows older, we will need more geriatricians.
In the 1990s, health care shifted from institutional care to homecare. We have given you our booklet, which contains 32 recommendations. If you look at that book, you will find out what we should be doing about homecare.
With respect to homecare, we had Queen's University do a survey for us. We hired them again a year later to report on what things looked like a year later. I am sorry to say that the situation is dreadful. Homecare is becoming even more important, as we know from listening to this young lady, but we are not doing anything about it. The committee should look carefully at this issue; it is what awaits us in the future.
Let me conclude. CARP endorses the committee's appeal for a factual and non-ideological approach to examining the health care system within the context of Canadian values. The issue of what can society, governments and individuals afford must be balanced by what is in the best interest of the majority of Canadians, who, regardless of age, will at some point come into contact with the health care system. That contact will be made either as a patient or a caregiver, and they will pay for their health care one way, indirectly through taxes, or another, directly out of the pocket, and indeed, often both ways at the same time.
In conclusion, let me say that I appreciate the opportunity to have attended here; however, the fact that the full committee was not present was not fair to any of us. It was neither polite nor right.
The Deputy Chairman: Thank you very much.
Ms Morgenthau: You know me. I say it the way it is.
The Deputy Chairman: I appreciate your presentation particularly, and I think my colleagues will agree with me. We are very seriously looking at this whole issue of homecare and how it can be incorporated within our health system.
Senator Robertson: Mr. Hurley, I have a question or two for you that will help me to understand some of these issues. You spoke of the restrictions, the time that it takes for approval when you are trying to introduce new technologies. The same complaints exist in trying to get approval for new drugs as well. It goes on and on.
From your experience, sir, do you find that these restrictions on approval are related to understaffing in the Health Department or staffing that is not fully qualified, or do you get a sense that the tedious process that we hear from so many of trying to get approvals is there to save costs for the system?
Mr. Hurley: It is a combination of all of those. The bottom line is that the staff keep moving around. By the way, companies like ours have to train them. After we have trained them, they tend to move to other jobs. The system is complex, and based on seniority.
New medical devices are getting more complicated, but the point is that the FDA is now approving faster than Canada. It used to be the other way around. Of course, European countries are approving new technologies even faster. Hence, it is a combina tion of staff constantly changing and less efficiency.
We are now being charged, where once we were not. Our company will pay $500,000 this year to get products delivered a lot later than they were in the past. The charges are there to make the system more efficient, to cover their costs. Nevertheless, it is less efficient than it was before.
Senator Robertson: Interesting. We also hear this from frustrated constituents who just cannot seem to get through the system. It is interesting that you are training people. I do not understand why the system cannot be more efficient. Why do they not put in place an experienced group of people, to make the system more efficient?
Mr. Hurley: Especially when they are charging us.
Senator Robertson: Yes. They could involve the private sector or join hands with other countries. Our processes are obviously not very good.
Mr. Hurley: All the European countries are harmonized. If something is approved in the United States, or in Canada, a company should not have to go through the same loops to get approval in the next country. We should have harmonization.
Senator Robertson: This is absolutely disgraceful. I am very pleased that you raised this issue.
The Deputy Chairman: What about interprovincially, across Canada? Do you run into the same problem, Mr. Hurley?
Mr. Hurley: There is no approval provincially.
The problem we have is lack of funding for new technologies, when we can prove that they are more cost effective than the existing technologies. That is the most frustrating thing for the high-tech industry.
The Deputy Chairman: It is not like pharmaceuticals. You do not have to worry about interprovincial issues.
Ms Morgenthau: May I make the point that what he is saying is true about the standard. CARP has been working toward a health standard across the country. We are also working toward approval of drugs at the federal level, so as not to have to go through 13 or 14 territories and provinces to get a drug through. In England, it takes 120 days to get approval. Here, it can take five years off the patent. It is ridiculous. If a drug is approved at the federal level, it should be passed automatically by the provinces. The cost of that drug would come down dramatically. I am advocating the same thing as this young man said.
Senator Robertson: It is one of the very frustrating aspects of our system. It certainly would not be difficult to correct. It is a deterrent in our efforts to attract companies into our country. Canada needs to attract corporations that are developing not only drugs but new technologies, but they will not locate here if this continues. The situation is very bad.
The Deputy Chairman: Do you experience any similar difficulties, Mr. Crawford, in your work?
Mr. Crawford: The problem of accessing medications at the provincial level is endemic to the Canadian way of life. There have been repeated requests for attention to that issue. The lack of timely access to fully or even partially reimbursed medications has major impacts on the health status of people. It keeps them locked out of the labour force, because they have to be on the welfare program to get the provincial government to pay for what is needed.
There have been complaints, certainly, that the listing approach to medications and technologies that would be publicly financed, the kind of approaches we use in Canada, typically do not keep pace with fast-breaking developments on the pharmaceutical and technological fronts. By the time governments even get around to considering whether a medication or technology should be funded, another mediation or technology supersedes it. The list just gets longer and longer, but increasingly irrelevant.
There has been talk about the need to have an approach that is more principle-driven, one that allows for faster acknowledge ment that a given device or medication is needed in a given circumstance, to get away from the listing approach. The approach would use discretionary judgment.
The Deputy Chairman: I have a question for you,Ms Gulliver, and your daughter, Margot. Your testimony was very compelling.
The committee will certainly pursue this particular topic with a lot more vigour, but is there anything currently within our health care system that has potential for you and people in your situation that could be expanded upon? Are there any good-news areas that we should be pursuing and pushing the system along towards?
Ms Gulliver: Yes. We should be pushing for physicians like Dr. David Clarkson, who we have hung out with for 28 years. When Margot left the Sick Kids hospital, he hooked us up with all of the things she needed, the neurologist, the urologist, and all of the orthopaedic people. He totally coordinates us. When things are bad, when I need answers or Margot does, we head for Dr. Clarkson. He is our coordinator and our rock, and the one who advises us the most when we talk about second opinions.
The thing that has been absolutely wonderful for us is homecare. We use the St. Elizabeth Visiting Nurses Association. We will not use a private, for-profit homecare agency. I resent people making money off my back when I am vulnerable. I appreciate that that has to be part of it, but sometimes people forget why they are there. There have been occasions when people have wanted my daughter and me to fit into their system, as opposed to looking at how they can make their wage with dignity by providing for us. If we were not around, they would not have jobs - and you know when I say "we" I mean not just my daughter and me but a whole lot of people like us.
The other thing is how people are made to feel dehumanized in the hospital. I just had a toe removed. It had gangrene. There was an occasion when I was in the hospital and hooked up to an intravenous that I had to get to the washroom but nobody was around to help me. I don't have to tell you what happened. All I got from the nurse was, "Oh dear, I'm so sorry." I blame the system for not having enough people to provide us with the respect, dignity and understanding we deserve, for not recogniz ing that the hospital or the health care system would not exist without patients. I feel that what Margot and I are experiencing, any one of you could have. I do not care whether you are 25 or 95. We are all vulnerable, and we should not separate disability fromvulnerability.
The Deputy Chairman: You talked about Dr. Clarkson. The point you are making is that there should be some coordination, a central point, correct?
Did you want to make a point on this, Mr. Gleberzon?
Mr. William Gleberzon, Associate Executive Director, Canada's Association for the Fifty-Plus: Yes, I did. The material we handed out to you consists of three reports. The most recent one is a report entitled "Homecare in Canada." I just wanted to bring that to the attention of the committee.
A lot of the testimony you have heard here is replayed in this report from hundreds of people, maybe more. We have done extensive studies on homecare. If the committee is interested in knowing how a two-tiered system, privatized, will work, I suggest you take a look at the homecare system in Ontario; it is exactly that type of system.
You are hearing about the results of that kind of system, where the backbone of the system is the informal caregivers, 80 per cent of whom are women. Many woman, about 12 per cent, I am told, have to give up their jobs in order to work full-time at providing care, with minimal support - in some cases, in some provinces, with no support and no compensation. At the end of the day, as Ms Gulliver has said, they go without any kind of support, other than, if they are lucky, a guaranteed income supplement. They can look at an income of around $12,000 a year when they get to be older, 65. Of course, because of mandatory requirement and age and things like that, they are not able to get jobs.
Therefore, we are looking at a system that needs to be reviewed from top to bottom in a very comprehensive way. Someone used the term silos. We should not review it just in terms of the silos we have now. The whole health care issue goes far beyond health care. There are all these determinants of health. What we have seen develop over the past 10 years is a system that has put the onus, really, the full burden, on people like Cheryl Gulliver. They become the backbone of the system. I think if the committee is looking at homecare, that is the way you have to begin.
The Deputy Chairman: We have heard in other testimony what it does to the health of the caregiver, intended or unintended.
Ms Gulliver: We have enjoyed an excellent family physician who is not afraid of anybody in his hospital and who always makes sure we get what we need. When Margot is in the hospital, I go at nine o'clock in the morning and leave at 11. I take drinks and sandwiches. I do all of that, but it still costs me $20 a day. The last time she was in the hospital, she was there for four months. Add up $20 a day, not counting the cost of the TV and the phone - her father paid those. But do you understand?
The Deputy Chairman: Yes.
Ms Gulliver: I want to be home and drink my coffee out of my own mug. I had never thought of it that way, sir, about the homecare system. I just am so happy they come to us as opposed to us running around the world.
The Deputy Chairman: That is a very good point.
Ms Gulliver: His point is excellent. Can you see my halo? You are right. I should be real proud of myself. Margot has something left to say.
Ms Easton: Mother and I have been very fortunate. Dr. Clark son has been very helpful to us and does not seem to be scared of me because I have a disability. He will always say to me: "This is what we need to do," or "This is who we need to go see."
I can remember going to have my wisdom teeth out. Most people go to the dentist's office to have them out, and then it is all over. I went into the hospital to have my wisdom teeth taken out because the surgeon who did it did not feel comfortable with me in his office and because of my medical condition and things like that.
It is nice to have Dr. Clarkson, who, as mum said, is not afraid of anybody. He especially is not afraid of me and my disability and the things that go with it.
Ms Gulliver: Other than when she gets a certain look in her eye, and then we all run.
The Deputy Chairman: You had a point you wanted to make, Mr. Crawford?
Mr. Crawford: The Dr. Clarksons of the world are very much the exception rather than the rule. If we look at the state of medical training in Canada, there is very little systemic attention to issues of disability. A huge proportion of the Canadian population will suffer some kind of disability; it is almost inevitable, as people get older. Nevertheless, medical students are given virtually no instruction on what disability means to the individuals themselves and to their families, nor the implications on the labour market, et cetera.
Medical students may get a course here and there on neurology and gastroenterology, courses that focus on the biomedical aspects, but the social aspects, the ones that people have to live with on a long-term basis, are ones about which physicians typically know little and therefore are not in a position to play a coordinator role.
If the government were to be involved, therefore, in helping to mount a broadly based human resources development strategy for the health care sector, which I think makes a lot of sense as laid out in Issues and Options, I would argue that some attention in medical schools to these issues ought to be required of physicians. After all, probably 10 to 15 per cent of the base of people physicians will see in a given year will have some level of disability.
Mr. Gleberzon: When the committee really focuses on homecare we would be very pleased to work with you, because we have done a tremendous amount of work in this area.
The Deputy Chairman: Thank you. When our committee finishes hearing testimony across the country, we will be spending some time doing follow-up and clean-up testimony, before we start writing our reports. It may well be that we will be inviting some of you people back. I really do feel very badly about jamming so many people into this last session and then running against the clock.
Senator Robertson: I want to tell the witnesses how important it is for this committee to spend a considerable amount of time on the issues they have brought to our attention, not the least of which is to persuade the government to put in place standards so that financial concerns, which can be so very severe, can be met. Even applying for a disability pension takes ages. It requires visits back and forth between doctors' offices and government officers to fill out form after form and to get file after file. We would be negligent if we did not do something about this in a substantive manner.
It is not that we have not previously thought about the issues you have brought to us today; we have.
I look forward to reading the material you have left with us today. Some of us have worked a long time, many years, in trying to be helpful with these matters. I really believe this committee can make some very appropriate recommendations.
The Deputy Chairman: I agree with that. Senator Robertson speaks with great knowledge because she was a former minister of health in the province of New Brunswick.
Ms Gulliver: I am concerned that we may have projected ourselves in a pathetic and negative way. I want you to know that Margot Easton and Cheryl Gulliver have a really good life. Sometimes we meet people and they talk about their illnesses, and we feel so sorry for them.
I did not want to give you that impression.
The Deputy Chairman: You did not leave that impression at all.
I should like to thank all the witnesses for their attendance here. I think a few of you will be getting another call from us, because we will be seeking a little more information on this. I do apologize for the way we ran against clock.
Senator Robertson, before you and I leave, as this committee travels across the country, we have had people from the public request that they make a statement. We have two gentlemen in the room today who have requested to put on the record a statement. They understand that there is a maximum of five minutes per person and that there will be no questions.
I will invite Mr. Robert Campbell and Mr. Clement Edwin Babb to the table to make their statements.
Mr. Campbell, I know you have sat through a lot of the proceedings. I appreciate that very much. I understand you have a statement you wish to put on the record. As you know, you will be given a maximum of five minutes. There will be no questions, but your statement will be duly recorded and put on the record of the committee hearing.
Mr. Robert S.W. Campbell: Thank you, Madam Chair and honourable senators. I am not in the category of most of the presenters that you have listened to. They are very well qualified in the health care field. I am not. I am a member of the public. I am a retired lawyer; I retired from active practice a number of years ago in Toronto.
I am, however, interested in the matter of health care. In a general sense, I have done as much reading as ordinarily can be done by the individual by way of publications and the press.
I have one or two initial comments. You may think I am out of order; I plead understanding in this respect.
I have been rather unsettled by comments principally from the minister of health and the chairperson of this committee, and also from the Prime Minister. They seem to conclude that the present health care system is unsustainable, which may or may not be true. In addition, they seem to conclude that the solutions seem to be either user fees or increased privatization of the system, that is to say, a two-tier system.
The other remark I want to make, which may seem equally negative in its direction, is that it is extraordinary that, in a matter of such importance as the present question before the committee, the committee is time-restricted in such a narrow fashion. This two-day hearing has been held in such an obscure location. I only heard yesterday of the existence of this committee and the hearing today.
If the trend of my remarks is out of order it is principally because I have not had time to read the report of the committee.
I would have hoped that a hearing of this sort would be in a larger and more important forum. I think an appropriate one would have been Massey Hall, where the general population could have sat and listened to what the experts say about the health care system, what is wrong with it, and hear some voices that might offer some different directions.
Having said that, my impression is that the costs with respect to the health care system have been relatively stable over a considerable number of years. Over roughly 25 years, as I recall, there have been no substantial changes in the relative cost of the health care system with respect to the GDP. There is an exception, however, and that has been with respect to specific aspects of the system.
The Deputy Chairman: You have two more minutes, Mr. Campbell.
Mr. Campbell: Thank you. Those aspects include drugs and certain aspects of clinics, that kind of thing. In other words, the privatized part of the system is the one that is pushing the costs of the system up.
In capsule form, my position would be that we reject the for-profit type of health care system - at least, not expand it more than it presently exists. We should take steps to introduce solutions that would improve the system, at least beyond its recent decline. One would be to concentrate on long-term care, a pharmacare system, a drug plan, and at all costs attempt to re-establish uniform aspects of health care in all the provinces or all across Canada. In doing this, we would maintain public control and particularly the administration, which I gather is one of the thrusts of this committee's study.
The Deputy Chairman: Thank you, Mr. Campbell. I will make sure that you are sent the reports we have released thus far and the ones we are about to release. We will be releasing two volumes in the next few weeks. We have released volumes 1 and volume 4, and we will make sure that you get volumes 2 and 3. I will ask the clerk of the committee to make a note of that so that you receive these things in the mail.
I would now ask Mr. Babb to come to the table.
Mr. Clement Edwin Babb: I will decline to come to the table, Madam Chair. I would be very pleased to withdraw and not go ahead. My world is not going to come to an end if I do not make a presentation, and I suspect that your world is not going to come to an end if you do not hear what I have to say.
The Deputy Chairman: But you have been so patient sitting here today.
Mr. Babb: No, I am okay. I have learned a great deal the last two days, so I am quite satisfied. To be practical about it, much of the impact of my terrific presentation was going to rest on being asked questions and then responding. On that basis, if you do not mind, I will withdraw.
The Deputy Chairman: Likewise, if there is any information you would like from the committee, we would be very happy to provide it. Thank you very much, Mr. Babb.
The committee adjourned.