Proceedings of the Special Senate Committee on Aging
Issue 3 - Evidence, February 4, 2008
OTTAWA, Monday, February 4, 2008
The Special Senate Committee on Aging met this day at 12:33 p.m. to examine and report upon the implications of an aging society in Canada.
Senator Sharon Carstairs (Chair) in the chair.
[English]
The Chair: Good afternoon. Welcome to our Special Senate Committee on Aging. Before we begin, I wish to do a small piece of business. With your approval, I will move a motion this week in the Senate to ask for an extension for our committee to report from March 31 to September 30, 2008.
Some Hon. Senators: Approved.
The Chair: Today's meeting will focus on aging and services for inmates. To help us understand the issues surrounding this topic, we have before us on behalf of Correctional Service of Canada, Ross Toller, Assistant Commissioner, Correctional Operations and Programs and Leslie MacLean, Assistant Commissioner, Health Services. Appearing from the Office of the Correctional Investigator is Ed McIsaac and Howard Sapers. We also have Kim Pate from the Canadian Association of Elizabeth Fry Societies.
Ross Toller, Assistant Commissioner, Correctional Operations and Programs, Correctional Service of Canada: Thank you for the opportunity to present to this Senate committee. I am Assistant Commissioner, Correctional Operations and Programs for the Correctional Service of Canada. With me is Leslie MacLean, Assistant Commissioner, Health Services. Our presentation today will touch on issues related to how the Correctional Service of Canada manages its elderly offenders. We welcome any questions and comments following our remarks.
CSC, as mandated by the Corrections and Conditional Release Act is responsible for the care and custody of offenders serving sentences of two years or more. This includes providing programming that contributes to their rehabilitation and successful reintegration into the community; preparation for the release into the community; their supervision while on parole; statutory release and long-term supervision orders, with the protection of society as our paramount consideration.
Our policies, program and practices respect gender, ethnic, cultural and linguistic differences and are responsive to the special needs of women and Aboriginal peoples as well as to the needs of other groups of offenders with special requirements including the aging offender population. In order to meet these needs, CSC develops and implements individual correctional plans and interventions that are continually assessed throughout the offender's sentence.
CSC operates 24/7, 365 days a year, and supervises an offender population of 21,617 inmates: 13,170 offenders are in institutions and 8,447 are in the community. We operate 58 institutions, 16 community correctional centres and 71 parole offices across Canada. We have a staff complement of approximately 14,500 employees and a budget of just under $2 billion.
There is and continues to be debate among researchers. I am sure you have heard different perspectives from biologists and epidemiologists about when a person should be considered older or aging. However, the term ``older offender is used to include those aged 50 to 64 and ``elderly'' offenders are aged 65 and over. These terms describe the physical, social and biological changes that people go through with the passage of time that renders them less viable for activities requiring a great deal of physical strength. For our purposes, CSC defines offenders aged 50 years and over as the ``aging offender'' population due to factors related to the determinants of health, including for example, smoking, poor nutrition, lack of health care and lower socio-economic status.
For correctional purposes, there are three distinct differentiations of older offenders: there are those incarcerated while young who grow old in prison; there are those multiple- or serial- incarceration offenders who have made a criminal career part of their lifestyle; and there are older offenders that are serving their first incarceration later in life.
Three factors contribute to the aging offender profile. The average age of new admissions has been increasing. From 2006-07, 10 per cent of new warrant of committal admissions are aging offenders, up from an average of 8 per cent over the last seven years. The accumulation effect of older offenders who have been serving longer sentences — as in life — where the average age of offenders serving life sentences was 44 years of age in April 1998 compared to 48 years of age in April 2007. The average age of readmissions has also been increasing. The average age of revocation was 32 years- old in April 1998 compared to 34 years in April 2007.
As mentioned, over the last 10 years, the average age of the federal offender population has been increasing. For men, it has risen from 37.2 years of age in 1997 to 39.4 years of age in 2006-07. For women, it has risen from 36.9 years of age in 1997-98 to 37.6 years in 2006-07.
On average, the non-Aboriginal offender is older than the Aboriginal offender population. The average age of Aboriginal offenders rose from 33.7 years of age in 1997-98 to 35.7 years in 2006-07. For non-Aboriginal offenders, it rose from 37.8 years of age in 1997-98 to 40.1 years in 2006-07.
Federal offenders aged 50 years and over comprise 20 per cent of the federal population with a total of 4,339 offenders. That is 2,068 or 16 per cent of our prison population and 2,271 or 27 per cent of the community supervision population.
Over the last 10 years, the number of federal inmates 50 years and older has increased by a total of 539 offenders. In the same period, the number of federal offenders 50 years and older under community supervision has increased by 729 offenders.
In general, we are dealing with a different type of older inmate compared with 10 years ago. Close to 80 per cent have a previous criminal history, either adult or youth. There are some increases in mental health problems. Fourteen per cent have current psychiatric diagnosis on admission. Half have reached the age of 50 while serving their current federal sentence. Half were admitted at the age of 50 or above. Forty-six per cent of this group are serving a life sentence and 13 per cent are serving 10 years or more.
Their offence categories range from 43 per cent homicide to 32 per cent sex offences, robbery and drug offences. Some of these may have overlap.
When we look at older types of populations, our considerations must and do range from adjustment to imprisonment, programming, prison environment, infrastructure, peer relationships, family relationships, parole concerns and medical care services including mental health.
When an inmate is admitted to the federal system, the individual undergoes goes a case management process consisting of four phases. In the intake assessment phase, the offender undergoes a systematic and comprehensive process to determine security risk and needs, as well as an initial placement to an institution at the appropriate security level. Upon reaching the penitentiary, the individual undergoes an evaluation to determine the factors that may have led to the criminal behaviour for which he or she has been sentenced. The offender intake assessment process, including those who are aging, results in a multidisciplinary correctional plan for treatment and intervention throughout the sentence.
Age is considered for the following to assure security within the institution: the penitentiary placement; program and employment requirements as outlined in each inmate's correctional plan; inmate counts and security patrols, though exemptions are made for inmates who have medical conditions or an identified physical limitation which excludes them from a stand-to-count requirement; and personal property of inmates. Exemptions can also be made by the institutional head for offenders on a case-by-case basis.
In addition to the intervention phase, we utilize step stools to facilitate entry to and exit from escort vehicles. Correctional Service Canada institutions have cells engineered to accommodate wheelchair entry, as well as plumbing fixtures that accommodate inmates with physical disabilities. Institutions also have cells designed to accommodate oxygen bottles and respirator equipment. Living units, programs, employment and other areas are wheelchair- accessible, utilizing ramps and, where required, lifts. Government budget allocated $1 million so that by the end of this fiscal year all federal institutions will be equipped with defibrillators.
A broad range of correctional programs varying in intensities are available to match offenders' needs. CSC offers reintegration programs for every offender, including those who are aging, mainly in the areas of education employment, job readiness, living skills, mental health, substance abuse prevention, sexual offending prevention, violence prevention and family violence prevention. These have been demonstrated as effective in reducing reoffending. Individual counselling is also offered.
The offender's progress in meeting the requirements of the correctional plan is monitored continually and is of primary consideration in any decision related to the offender. The variety of contemporary health issues requiring appropriate pastoral services includes inmates requiring geriatric and palliative care and persons with chronic illnesses such as hepatitis C, AIDS or cross-addiction to drugs.
The case preparation and release phase includes programming to meet specific needs of aging offenders and providing opportunities to demonstrate progress through transfers to reduced security or conditional release, including temporary absences, work release, parole or statutory release. In any correctional or conditional release decision, the protection of society and safety of the community are the paramount considerations. Release suitability and risk of reoffending are assessed and a strategy to facilitate the offender's transition to the community is developed.
The community supervision phase is the final step. Supervision is carried out by CSC parole officers or contracted agency staff. It is a dynamic process that involves measures of both support and control, working directly with the offender as well as with many resources in the community. All offenders on conditional release are supervised no matter where they reside. The degree of supervision depends on the offender's needs and risks. Parole officers rely on an array of information sources including police, families, professionals and program staff to verify the individual's progress and to develop the appropriate plan of supervision. Parole offers are able to help the offender solve problems and take necessary action when risk is increased. Referrals are made to community services for aging offenders, if necessary.
Programming is required to address criminogenic factors. Therefore, CSC supports all efforts at reducing the disabling effects of aging in order to maximize each inmate's ability to effectively participate in correctional programs. If the aging offender is unable to participate in a program assignment for reasons beyond his or her control, the offender is eligible to a daily allowance of $2.50. Furthermore, under exceptional circumstances, institutional heads may authorize pay for inmates at levels for which they would not otherwise be eligible.
Section 121 of the Corrections and Conditional Release Act allows parole by exception to be granted at any time to an offender who is terminally ill, whose physical and mental health is likely to suffer serious damage if the offender continues to be held in confinement, for whom continued confinement would constitute an excessive hardship that was not reasonably foreseeable at the time the offender was sentenced, or who was the subject of an order of surrender under the Extradition Act and who is to be detained until surrendered.
This parole by exception does not apply to an offender who is serving a life sentence imposed as a minimum punishment, commuted from a sentence of death or serving a penitentiary sentence for an indeterminate period. For this particular group of offenders, CSC considers alternative practices such as increased visits, telephone calls, et cetera.
[Translation]
Leslie MacLean, Assistant Commissioner, Health Services, Correctional Service of Canada: Madam Chair, I am going to speak about our needs and our health care challenges for aging offenders.
[English]
We have a legal obligation at the CSC to provide inmates with essential health care. We have the same challenges as other Canadian communities in terms of sustainability, outcomes and health/human resource professionals.
[Translation]
But I am also going to tell you a little about what is unique in our context. Inmate health care costs are much higher than for the average Canadian due to high-risk lifestyles, substance abuse, high rates of infectious diseases and mental health disorders. In our unique context, the lack of economies of scale is also a challenge.
At the moment, there are three types of health care settings in CSC. Each institution has a small ambulatory health care centre. There are also regional hospitals and five regional psychiatric treatment centres. Unlike Canadian communities, nursing staff are the main deliverers of primary health care in all facilities. CSC employs approximately 750 nurses, as well as other health professionals. For this fiscal year, its health services budget is approximately $155 million.
[English]
I will talk further about unique inmate health needs. Many of you might know that federal offenders have a higher prevalence of HIV/AIDS, hepatitis C and fetal alcohol spectrum disorder. The proportion of offenders who have abused alcohol or drugs prior to their admission is also increasing and we have an increasing proportion with serious mental health disorders. Smoking rates are more than twice that of the Canadian population, and suicide rates, I regret to say, are also three times higher than that of the general Canadian population.
There are a number of chronic diseases that present disproportionately in the inmate population. For example, diabetes, cardiovascular disease and asthma exceed the rates of the Canadian population. Medication rates are also higher.
We notice more of our inmates are using mechanical aids to help them with mobility or daily activities of living. This is also interesting: All of the offenders in our institutions have higher than average utilization rates of health services. As a result, perhaps we do not see the dramatic escalation that is sometimes seen with aging; our offenders are already accessing health services at a high rate.
As Mr. Toller mentioned, when we look at the demographics of Canada, 16 per cent of the population within the correctional services is now over 50 years of age. There are, due to determinants of health, lifestyle or other risk factors, many common health needs regardless of the age of the inmate. We are seeing that both treatment and intensity of care increases with age.
A real challenge for us is to deliver adequate health care within the resources we have with appropriate health professionals. A couple of initiatives that may be of interest to you in regard to aging offenders, or just offenders in general, are mental health related. This is one of our top priorities. In 2007, one in eight male offenders — a 61 per cent increase in 10 years — and one in four female offenders coming into our system was diagnosed as having a mental disorder. As part of our strategy, we are working to lay a foundation for a continuum of mental health services from intake to parole. Our purpose is to respond to the most pressing needs for assessment for primary services, and to train both our security and health staff in issues of mental health needs.
The proportion of offenders who have abused alcohol and/or drugs is increasing. Our current approach includes keeping drugs out of the institutions and ensuring we support inmates in the institutions through assessment, education, harm reduction and treatment.
We have a number of public health initiatives: access to bleach; clean ranges; harm reduction awareness training, including peer education; and a methadone maintenance program for people who come into the system with serious addictions. We are currently working on a harm reduction strategy based on advice we have received from our independent health care advisory committee, as well as the work that the federal HIV/AIDS strategy supports.
In meeting the health needs of aging inmates, the key for us is the individual health assessment when the inmate enters our system. We have a special assessment tool for those aged 50 and older, or for people who have difficulty with daily living activities. We have palliative care guidelines that we have had in place for several years, which include a multidisciplinary approach. We provide training and support to inmates, as appropriate, so they can work as peer assistants to help other inmates.
We have ongoing issues of mobility. Many of our institutions are quite elderly themselves. We are constantly working, as we retrofit and build new institutions, to comply with accommodation standards. We have a couple of projects under way to look at loss of autonomy and what that means for us in terms of accommodation, health and other health needs. As for new training, next fiscal year we will be providing additional training to our nurses in a number of areas, including geriatrics.
Finally, in terms of the considerations on our plate in managing aging offenders, clearly, as Canada adjusts to the demographics of our current population, our prison population is also adapting. We have to use our resources well to respond to those pressures.
We recognize that we need to be working in an interjurisdictional way. Identifying and managing aging offenders is not something that is unique to CSC. People come from the community and they go back to it. We recognize that many of the levers of change are in areas that affect determinants of health or risk behaviour, such as education, welfare, provincial/territorial health services and, of course, in the communities themselves in terms of support to individuals.
In moving forward, we will continue working with our federal and provincial partners, looking as well at how we can link health and criminal justice information. We will continue to build on best practices so we can adjust our services as required to best meet health, accommodation and security needs of older offenders.
Howard Sapers, Correctional Investigator, Office of the Correctional Investigator: Good afternoon and thank you very much for the opportunity to meet with you on this topic. As correctional investigator for Canada, my job is to be independent ombudsman for federal offenders. It is also my role to review and make recommendations on the policies and procedures of the Correctional Service of Canada, to ensure that these areas of concern are identified and appropriately addressed.
My mandate expresses some important elements of the Canadian criminal justice system. The Office of the Correctional Investigator reflects Canadian values of respect for the law, for human rights and the public expectation that correctional staff and managers are accountable for the administration of law and policy. Good corrections, after all, equal public safety.
Today I am here to discuss my office's concerns with regard to older offenders. Older offenders have been historically defined by the correctional service as those 50 years old and older because the aging process is accelerated by the experience of incarceration. This is due mainly to factors including socio-economic status, accelerated medical care needs and the difficult lifestyle that many offenders had prior to incarceration.
The percentage of older offenders among the inmate population is about 16 per cent, or approximately 2,200 federal inmates, almost 300 of whom are over 65 years of age. The steady increase in the number of older offenders incarcerated in federal corrections is not a new issue. CSC became increasingly aware of the rise in the number of older offenders about 10 years ago. At that time, the Correctional Service of Canada recognized that its capacity to address the needs of older offenders was deficient and that if no action were taken, the problem would get worse as it was anticipated that the number of older offenders was going to continue to increase. That is what happened.
In November 1999, the CSC took decisive action and established a new division. They called it the ``older offender division,'' with the mandate to ``elaborate a sound correctional strategy adapted to the needs of older offenders.'' The Office of the Correctional Investigator supported the correctional service at that time for its proactive steps to address an emerging problem, and was involved in the consultation with it.
CSC elaborated a comprehensive strategy that dealt with the key needs of older offenders. These included: constitutional accommodation planning; community corrections, including supervision and release programs; health care and mental health, including palliative care; staffing and training to address elderly offender needs; and assessment, case management and release planning.
In the 2000-01 annual report of my office, we characterized the CSC's report on elderly offenders as ``a landmark document which, if its recommendations are implemented, will go far in addressing the problems of this group.'' At that time, the correctional service committed to address issues associated with accommodations, palliative care, reintegration options and program development. Unfortunately, shortly after the release of this report, CSC moved away from implementing its numerous recommendations.
Initially, a shift of priorities was cited as the reason for not moving forward, but it later became clear that a lack of resources was also part of the difficulty. The CSC began to distance itself from its report and adopted an approach of providing individualized health care and programming based on an assessment of each inmate's needs, regardless of age.
In March 2004, the Canadian Journal of Public Health published A Health Care Needs Assessment of Federal Inmates in Canada. It noted that there had been a 60 per cent increase in the number of inmates aged 50 and over, with an 87 per cent increase in those 65 years of age and over since 1993. The report urged that specific attention be paid to the health care needs of this growing segment of the inmate population.
The report described the psychosocial concerns with this population as follows: estrangement from, or lack of connection to, other inmates, given the relatively small percentage of older inmates; physical vulnerability to more serious consequences of assault; more difficulty adjusting to a new environment, and a greater length of time to do so; a higher rate of completed suicide, and a greater possibility of dying during incarceration; and a higher incidence of loss of external support systems — for example, spouse, family and friends.
The report went on to highlight a number of planning issues to be addressed, including: mainstreaming older inmates in the general inmate population; the physical plant design, specifically the distances between buildings, stairs, crowding and space for wheelchairs; programs and services, including dietary needs, and adaption of programming to physical, mental and social needs; and staff training, noting the different challenges compared to those concerning younger inmates.
Before I proceed with a more detailed account of the needs and challenges of older offenders, I would like to acknowledge some of the positive initiatives that have been implemented by the correctional service.
The Pacific Institution/ Regional Treatment Centre, has an excellent palliative care program. Inmates taking care of other inmates in need — both elderly and physically challenged — are called ``peer care assistants.'' They are assigned a specific inmate in need of assistance and they help this person throughout the entire day. This is considered a job, so they are paid. I understand that a majority of peer care assistants take this job seriously. They even sometimes call my office on their charges behalf.
To ensure a consistent approach to palliative care services within the correctional service, it is now a requirement to implement the palliative care guidelines when a terminal illness is diagnosed. These guidelines, as well as those related to discharge planning, are currently under review.
Some community residential facilities, CTRs, or halfway houses, have developed expertise in caring for elderly offenders. In spite of those initiatives, there continues to be no comprehensive plan focused on the needs of older offenders, and cases brought to the attention of our office do not suggest that sufficient progress has been made to respond to these growing needs. Let me provide you with a few examples to illustrate the types of situations that we are called upon to review.
Some older offenders are housed in medium and maximum security institutions even though they have serious mobility impairments or illnesses that would negate any public safety concerns. This restricts their access to a range of community supports and correctional programs. Many older offenders, some in their 70s and very sick or disabled have passed their parole eligibility dates, which raises the question as to why they have not been released into the community under some form of conditional release or parole. Recent CSC data show that more than 150 incarcerated offenders over the age of 65 are past their day-parole or full-parole eligibility dates.
Correctional Service of Canada continues its efforts to secure adequate and permanent funding to enhance its capacity to provide mental health services to the growing number of offenders with mental health issues; and we acknowledge that. The percentage of this group of offenders has doubled over the last 10 years. Older offenders with mental health issues and cognitive deficits are vulnerable, and the correctional service's acknowledged lack of capacity to respond to their mental health needs continues to be of great concern for my office. Many offenders with mental health problems end up in segregation for their own protection or are victimized by other offenders. The lack of or delay in accessing programs offered by the correctional service to its inmate population has become a major problem. There are long waiting lists resulting in programs not being provided until very late in an offender's sentence, often well beyond their parole eligibility date. Delayed program participation is directly linked to delayed conditional release. This can result in offenders being ill-prepared to return to the community and, when they are released, it is too often on statutory release with decreased length of supervision by a parole officer.
Few initiatives or accommodation options have been developed to address the physical needs of older offenders. Specific programming and accommodation are alternatives are required. Some older offenders feel isolated. Some withdraw from healthy activities because of a lack of available opportunities. Many choose to stay in their cells because of fear of interacting with the rest of the inmate population or by necessity as the physical environment, programming, or work opportunities are not adequate to respond to their needs and limitations. Access to patient-centred chronic, long-term and palliative care in federal corrections is very limited, and additional resources are required. On occasion, my office has investigated cases involving significant delays in obtaining items critical to an offender's well-being and dignity, such as hearing aids, dentures and adult incontinence products. As well, special diets for older offenders are rarely provided.
Staff are insufficiently trained and ill-equipped to respond to the needs of older offenders, in particular those with significant mental health issues, serious mobility constraints and medical conditions. Additional awareness and sensitivity training for front line staff is needed and the correctional service must recruit staff with expertise and experience in the area of gerontology.
The inmate allowance system and work opportunities are not responsive to the unique situation of older offenders. Some older offenders are unable to work not only because of their own physical limitations but also because the limited work opportunities available in correctional institutions do not accommodate their special needs. Moreover, the institutional setting does not provide productive activities to make use of their time. Many of these offenders spend much of their day alone in their cells. Lack of paid work or program participation also results in limited access to essential canteen items available for purchase.
Clearly, the need to do better is obvious. Lack of resources certainly appears to us as one of the significant barrier that the correctional service faces. The service must also ensure that available financial and human resources are allocated to meet these identified and legally required needs.
In conclusion, I would like to thank the Special Senate Committee on Aging for its interest in reviewing a lesser known reality for some aging Canadians — the challenges of aging with dignity in the federal correctional context. I would like to leave the committee with a few suggestions.
In 2000, a parliamentary subcommittee recommended amending the Corrections and Conditional Release Act, CCRA by adding offenders who are young, elderly or who have serious health problems to the list of offender groups with special needs. Should the CCRA come before this committee for review, I would suggest such an amendment. The subcommittee also recommended that the CCRA be amended to make offenders serving life sentences or indeterminate sentences, who are terminally ill, eligible for parole on compassionate grounds, which currently is not the case. Should the CCRA come before this committee for review, I would urge senators to consider such an amendment. Finally, I recommend that the subcommittee encourage the correctional service to develop and implement programs, initiatives and services that will comprehensively address the needs of older offenders.
Kim Pate, Executive Director, Canadian Association of Elizabeth Fry Societies: Thank you, Madam Chair and senators, for inviting us and providing us with the opportunity to address you on this important, and increasingly so, issue of women in prison. I bring regrets from my President, Mâitre Lucie Joncas that she is unable to be here today because she has to attend court.
Some of you know that I have also worked with men and young people in the system but for the last 16 years, my particular focus has been women in prison. This area is of growing concern for our organization of 26 members across the country that provides services in many communities. Some of you may know many of them. They provide numerous different services from early intervention to working with individuals who are senior and ailing in the community as alternatives to incarceration and upon conditional release.
I consulted other people over the last month and a half and we had already the issue of long-term and aging prisoners on our agenda in terms of our organization's social action agenda. However, when the opportunity to appear before this committee arose, we stepped up our consultation with those individuals who are aging in the institutions. Over the last month, I have been in a number of federal institutions. I have spoken to many of the women you have heard about from the previous witnesses.
I propose to provide this committee with the issues that they raised. Certainly, I do not dispute any of the numbers provided by my colleagues at the Correctional Service of Canada or the Office of the Correctional Investigator but I thought it might help to have some of the faces portrayed.
One of the issues was the fact that this has not been a priority issue within the organization. Interestingly enough, the first thing that many aging individuals raised was concern for those coming behind them. Those in the system know they are there and deal with it as best they can. I will talk a bit about that in a minute. Most interesting from all of the individuals and those working with them as life line or in-reach workers — people who have been in prison and return to work with them — is the impact that potential law reform will have on this very issue. The issues expressed were longer sentences, longer mandatory minimum sentences and the proposal to eliminate statutory release. All of these issues were raised by aging and older prisoners as things that will impact not only them but also, and more significantly, those coming behind them.
As you have already heard, an aging individual who wants to exit the prison might not have an opportunity to take age-appropriate or appropriate-at-all programming because they are being asked to take cognitive skills or programming that might be positive for a younger individual. I recall one woman who had just spoken to her case management team, most of whom were younger than her own children and some as young as her grandchildren. They had been encouraging her to think about re-schooling but by the time she finished, she would be in her mid-60s. The idea that she could go back to school at her age was ludicrous, not only to her but also to some of us who heard about the suggestion.
Many of the women are concerned about the same things that the rest of are concerned about as we age — menopause, osteoporosis, diabetes. These are some of the chronic and aging diseases that impact women more profoundly. Although health care is provided, it tends to be predominantly about prescriptions. There is not a lot of opportunity for other interventions such as exercise, diet or other alternative approaches.
Mr. Sapers, from the Office of the Correctional Investigator, discussed some good examples of peer care providers. There are also some not very good examples of individuals being expected to care for each other without any support, recompense or expertise. That is the other side of the issue.
Aging prisoners do not have access to pension benefits. They are expected to work or receive minimal resources while in the institution. A number of individuals were concerned about that kind of proposal coming forward. While they are in the institution, they want the same opportunities that exist in the community. For example, as they are aging and getting older, to have either shorter work weeks or work days and, what I have termed, pension opportunities, so they would not end up with virtually no pay. That leaves them with little ability to buy the extra food or vitamins they may be purchasing to supplement their personal needs. Some women have to use menstrual pads because they do not have access to incontinence products.
There is a perception that there are more services for aging men than for aging women. The example we received was that a man suffering from a heart attack would be assessed quickly; whereas, a woman concerned about a lump in their breast, osteoporosis or some other equally serious medical problem, would be considered a chronic complainer.
We have a number of incidents where women have been diagnosed far too late and had to have radical interventions because breast cancers were not being diagnosed or they were not comfortable questioning those who had made the recommendation following their raising the concern.
The recommendations of the Office of the Correctional Investigator are the sort also supported and proposed by the women in the prisons. However, the women were suggesting there be access to community resources at an earlier stage. The notion that correctional services should provide more services in the prison is not a very helpful one when you know that the aging population is increasing. It would be more appropriate, particularly for individuals who are not a risk to the community or who could be eligible for release, to start work releases that involve going home and providing grandchild care or providing other types of home support. There should be opportunities to be released into familial homes instead of halfway houses that are not equipped to deal with them.
We have a horrible example of an older woman in a wheelchair who could not go to any halfway house in the Prairie region because there was not one which was wheelchair accessible. She ended up in a men's halfway house where she experienced isolation and poor treatment. The woman committed suicide.
Private home placements are allowable within the legislation and women have talked about how these approaches could be used. The section 84 conditional release arrangements that we often think of only in terms of Aboriginal prisoners, could be looked at as an opportunity for individuals to go into senior homes, other age-appropriate residences or palliative care facilities instead of trying to develop those within prisons themselves.
Within prisons, most of the women talked about an interest in units where older prisoners could be housed. One gave an example of the house in which she was first placed in the prison. She was in her 50s and shared with a number of young women in their 20s. They liked to play loud music and often at the time she was sleeping. Conversely, she would be up at early hours wanting to do housework when they were sleeping. These are practical things that many of us accommodate because we have the ability to and the freedom to move around, which are not necessarily available within the prison setting.
Finally, another issue was the notion that there is an opportunity for the women to participate in the development of the options that would be available. They should be permitted to do some of the research to look at what resources may be available within the community. Also, existing provisions in the CCRA allow for prisoners to be taken out of the prison for health reasons at any stage of their sentence. These provisions should be utilized in addition to the recommendations that my colleagues have made around compassionate passes and compassionate parole.
Senator Mercer: This is a fascinating topic, one to which Canadians do not pay enough attention. I am glad we are able to give it some attention.
Mr. Toller, you said that 14 per cent of the offenders aged 50 years and over have a current psychiatric diagnosis. Mr. Sapers you also mentioned mental health. Would either of you assess that perhaps these people would be better served in some mental care facility designed to treat the disorder they may have rather than being incarcerated?
Mr. Sapers: I will provide the first part of the answer. We have made many recommendations concerning this issue.
The Correctional Service of Canada has five regional psychiatric centres, which deal with offenders that have a significant diagnosed mental disorder. They are for all intents and purposes psychiatric hospitals. They represent about 50 per cent of the capacity the service requires to deal with offenders with that degree of mental disorder.
The service has developed a plan that is fairly responsive in meeting with the additional need, but they have not been able to secure ongoing permanent funding for that plan. At the same time, they have not been able to fully staff or implement the parts of the initiative that have received funding.
The challenge continues to grow. There are some offenders who would benefit from permanent hospital placement. However, the service is challenged with having to implement the sentence of the court. When they receive the offender, the issue is how carefully and quickly they can do the assessment, how appropriate is the array of placement options that they have, and what kind of services can they either leverage or partner from the surrounding community to take advantage of available health care services. It is fair to say the problem in that regard has been well identified. Some of the solutions have been well identified but the implementation is lagging behind.
Mr. Toller: I would add that we have seen a significant increase over the last number of years. This is why we have decided in the last couple of years that this is will be one of our priorities. We have branched off the health services into a separate entity within the Correctional Service of Canada to give as much focus and attention on this area as we are able.
As Mr. Sapers pointed out, although a number of inmates are coming in with a mental health diagnosis, they are still convicted of an offence, which we are required to administer. We have do have five regional centres across the country which are centred on the provincial legislation necessary for a full psychiatric diagnosis and/or treatments. We also have memorandums of agreement with other facilities, such as St. Thomas Psychiatric Hospital, with whom we can work in terms of mental health.
I would also point out we are still in a build-up stage. Ms. MacLean will speak to this more eloquently than I. At this time, it is a tough market to recruit people. Great attention is being made in terms of how to recruit people to work in this setting.
I agree we do not have the requisite resources to manage this changing population.
Senator Mercer: That leads me to another question with regards to your staffing difficulties. When you said you had an offender population of 21,617 and 13,170 in institutions, and 8,447 offenders in the community, I was interested in the fact that you went on to say that you have a staff complement of approximately 14,500 people. That is quite a good ratio in terms of the people being administered to and those doing the actual work. Out of those 14,500 people, how many are doing ``chore administrative'' work and do not have contact with prisoners, either in the institutions or in the community?
Mr. Toller: I do not have the exact numbers for you. It depends on where we want to look at that definition. As an administrator, I may be involved with inmates. At other times, I am not. Sometimes I see the products that come in from inmates through direct contact, through agencies. Even the administrators are generally frontline people. The correctional officer group makes up the vast majority of our compliment. We do have a number of program delivery staff that works directly with inmates relative to the provision of programs. Nurses and health care staff work directly with inmates as well and the lion's share of that group is in contact with inmates.
Senator Mercer: That is good news.
However, when you spoke of the intake assessment phase you did not mention the proximity of local relatives to the person entering the institution. Is that a factor that was not mentioned because it was not related directly to aging?
Mr. Toller: It is definitely a consideration in terms of potential, original placement. It is also a consideration during both the sentence and release into the community.
Senator Mercer: Ms. Pate, it seems to me that people commit crimes, they deserve to be punished, they are put in prisons and they serve their time. They come out of the institution, whether on bail or after completion of their full sentence. We have punished them, but in many cases we have not solved the problem. What happens to older prisoners when they come out of institutions? What resources does Canada provide to Canadians who have completed their sentences?
They have no access to pensions; they have not been contributing. Are they eligible for the Canadian Pension Plan? If they have been in prison for a number of years, they have not been contributing. Are they eligible for Old Age Security? Are there programs that need to be redefined or reassessed to ensure people coming out of prisons do not have to look around and say I do not have much choice but to return to my old way of life to survive?
Ms. Pate: I will defer again to my colleagues if they have addition information on this subject. However, in my experience, women cope three general ways once they are released from prison. They may have had a spouse who may have had a pension that they are eligible for, they may be eligible for CPP themselves or they may go and live with their family.
If they are not eligible for anything else, the way most of the women will gain access is through social assistance, which is not always adequate. Often, they try to someone to live with to try to support them.
Senator Mercer: Therefore, the only resource for someone coming out of an institution after, perhaps, many years is to go on welfare and to be put back at the mercy of society. Is that it?
Ms. Pate: That is certainly the case for some. As I mentioned, some have died shortly after being released from prison; some have committed suicide. Some people have gone on to live with families.
It is part of the reason why I was encouraging you to think about the section 84 types of provisions. While prisoners are serving their sentences, there are some creative opportunities for them to serve their sentence but also transition into a more appropriate community setting, whether a geriatric facility or a senior's home or residence.
There was a woman who talked about wanting to make a human rights complaint because, although there are many staff in the institution, there are not a lot of staff with experience in this area. She said if you wanted to visit, you could see for yourselves the sorts of opportunities that exist in the prisons. Perhaps that is an opportunity also for the community to see what exists. We already know alternatives are sorely lacking for aging inmates.
I am sure your researchers have looked at some of the options in other countries. I noticed when I was looking at options that there have been some interesting options in the European Union and even Japan, which I do not think of as particularly progressive in terms of prison issues. However, they have developed shorter work weeks, early release options into hospitals or senior-focused settings and things of this nature. There are some other options that could be looked at that do not jeopardize or compromise public safety and also ensure that people are still being held accountable by serving their sentence.
The Chair: I think we should put on the record that if the people are over the age of 65, they are allowed to collect Old Age Security and GIS. The ones who are not quite 65 years of age are subject to the problems we are discussing here today.
Senator Keon: This is a truly fascinating group of people. I have a particular interest in population health, and this population health group is of tremendous interest, especially in terms of the subgroup of seniors.
The whole emphasis on population health is to try to identify the high-risk health groups and bring them up to the norm to try to prevent illness and promote health. We do through a series of educational and prevention programs and early detection. I suspect this must be the challenge to end all challenges, in this population health group.
What health services organization do you have for the people who are incarcerated? What organization do you have for the substantial number of people who are on the outside but still under your supervision?
First, for the inmates, what organizations do you have in the way of public health, preventive health and health education? How do you handle the smokers? Can they only smoke out in the yard? Can they smoke in their cells or in the company of their colleagues?
Ms. MacLean: As the new Assistant Commissioner of Health Services, I will attempt to answer your questions, Senator Keon. There is no question that under our legislation, we are obligated to provide essential health care and non-essential mental health care that will assist people in rehabilitation and reintegration into the community.
As I mentioned in my opening remarks, our principal frontline practitioners are nurses, who are in small walk-in clinics. We have physicians and specialists who come on a contract basis and provide service in response.
In terms of population or public health, we had an excellent assessment done by the Canadian Journal of Public Health on prisoners' needs. One of the key areas we need to address as a result of this is thorough data collection. We have a number of proxies; when we try to identify cardiovascular disease to the informed prevention program, for example, we have medication use as the proxy. We still rely on paper, so building an electronic data base to better assess needs and respond to them is a key priority for us.
My colleague, Mr. Toller, alluded to mental health, where we recently received some initiative funding for community mental health to help with discharge. Also, we just received money for institutional mental health to do a better job of primary care services. We have been more reactive probably than we would have wished to have been, but we are working within the resources that we have, which have been focused very much on the primary care level.
In terms of our organizational structure, we have small health teams in each of our institutions, which report to our regional headquarters, which report to me in head office.
Our focus on harm reduction, for example, has been very much in the infectious diseases area. We have peer education programming. When inmates come in the door, as part of that assessment my colleague was talking about, they are given information on how to avoid disease such as blood-borne diseases and sexually transmitted diseases. We have harm-reduction equipment available in the institutions; and we are working to put in place the elements of harm reduction, including methadone for those with substance abuse issues.
There is no question that as we work to better capture the needs, we will be better able to tailor our programming. We are evaluating some of our work in this regard and moving forward.
Senator Keon: I congratulate you for organizing health at a primary care level. On the outside, we have not done that properly at all. We have neglected to do that to our own peril. I commend you to continue along those lines.
The payoff, I would think even for prisoners, would be tremendous if you can provide them with good primary care. That, of course, must include education and prevention, which you have alluded to in your remarks, to prevent some of the complicated diseases.
I think women's health, however, is an issue that could get badly lost when health resources are scarce. Do you have a special women's health program, Ms. Pate?
Ms. Pate: We do not have a special women's health program in our organization, largely because of lack of resources. Mine is a two-woman office. Across the country for every staff member, we have approximately 30 to 40 volunteers.
In the past, we have partnered with the Canadian Mental Health Association and the Canadian Public Health Association to do some initiatives around community-based health initiatives and preventive initiatives. We have tried to put some pressure on the correctional services for that. Although there is the legislative responsibility, the reality is that often, in the prisons themselves, very little of that preventive work is done. It is often done by outside groups.
For women, for instance, the Prisoners with HIV/AIDS Support Action Network goes into the prisons and provides early intervention, preventive work and basic information for people in the institution. They have done a tremendous job in providing education. Linked to that group, are some peer health educators who have taken it upon themselves to get more information, particularly to some of the Aboriginal women, concerning diabetes and other health issues. Generally, there is not much preventive information available. We try to provide it through our network, but it is sorely lacking. Even some of the harm reduction initiatives have not been accepted within the prison setting, even though they were recommended by the Report of the Expert Committee on AIDS and Prisons. Some of the public health recommendations are seen as probably too diverse in terms of meeting the needs of individual prisoners and providing a wide array of services.
Also, some health professionals I have spoken to — and I have been participating in training initiatives — have indicated they do not want to work in a prison environment because of the limitations placed on things like being able to do preventative health care. I have no doubt of the good intentions of anyone working in the area; but when it comes to resources, not surprisingly, keeping people in prison is the first priority in terms of protecting society. From there, the resources to provide additional supports are much more limited, in our experience.
Ms. MacLean: We do not have special programming for women's physical health services. We know, again based on the analysis done for us, that they are accessing health services and medication at a much higher rate.
In the women's mental health area, we have been working for several years to integrate our programming and mental health services. We have the structured living environment for minimum- and medium- security women, where there is a communal living concept with staff on the unit who have mental health training. The staff provides dialectical behaviour therapy. We are looking at it right now to ensure we are implementing it consistently and it meets the women's' needs. I can also speak of adaptation we have done in the area of Aboriginal health programming.
Ms. Pate: Tragically, the individuals with the greatest need are often placed into segregation, not into those units, because they are geared toward minimum and medium security. Those with the greatest mental health issues are the hardest to manage in a prison, so they often end up in the isolation units. We saw that, not with older persons but with a very young one, in the death of Ashley Smith recently.
Senator Keon: Tell me about your connectivity. The health system in Canada is still not organized at the community level the way it should be. I dream about the day that it happens. Where it is reasonably well organized at the community level and where you can identify integrated health and social service programs and facilities, have you a method for connecting to them?
Ms. MacLean: We have been investing new resources over the last while, Senator Keon. One area is mental health, for which we have five-year short-term funding to help us to do a better job of discharge planning and support for people while in the community. We have invested in intensive psychiatric services, training parole workers and providing psychiatric nurses and social workers with information on how to support discharged inmates. We are working to have an integrated discharge-planning model on the health side where, as you say, we need to be working with the community to ensure that when people are discharged, they are not suddenly without a physician to continue prescribing the appropriate medication. We are focusing resources in those two areas. We are quite aware that just as health can contribute to someone's successful reintegration, if we have not helped to build those links then it becomes harder for people to do it themselves.
Mr. Toller: In terms of connectivity in this context, it is important to understand that when an inmate needs medical treatment at a local hospital, there is provision for medical escorted temporary absences, sometimes for long periods of time at any time during a sentence. We have an array of inmates receiving dialysis and other specialized treatments in local hospitals. We have access to all of the specialized services, including the same wait times experienced by other people. We bring the community inside as well as when they come back outside.
Mr. Sapers: The question you asked sent my mind racing in all directions. My office receives between 7,000 and 8,000 complaints or inquiries from the inmate population every year. For at least the last six years, health care concerns have topped the list. The primary complaints deal with access, continuity and quality of health care.
The Correctional Service of Canada tries very hard to deal with those needs but many operational realities occur that confound them. It is not for a lack of trying or a lack of awareness. For example, while there is opportunity to link to outside community-based health care services, operational demands of security might get in the way. Therefore, although an outside visit to a hospital or health care provider may be scheduled, an incident in the institution or staff rotation schedules might preclude the availability of an escort. We receive complaints about delays or cancellations concerning long-standing appointments. As you can imagine, that starts the clock over again in the wait to access specialists in the community.
The connectivity you mentioned makes me think about many of the reports I have read from boards of inquiry called to investigate a significant incident, usually a death, in an institution. The reports talk about the difficulty with paperwork following the inmate, or patient, from place to place. The kind of continuity issues you would experience in a community from hospital to hospital or provincial jurisdiction to provincial jurisdiction also takes place in the correctional setting. Even within the rather closed system of correctional services, just getting the paperwork to follow the inmate to ensure continuity in medication is difficult. Some of the difficulties that we have seen include overmedication, lack of medication and delays in access to psychiatrists so prescriptions can be maintained. Those things happen with an alarming frequency in the correctional setting.
We need to look at corrections on a national level to determine what can be done about those problems. People move from provincial remand centres to federal correctional facilities, sometimes missing some of those connectivity dots you mentioned. People move from one kind of correctional facility to another within the correctional setting. For example, an inmate might move back to a remand centre when going to a new trial based on an appeal. There are many opportunities for the provision of health care to be interrupted. It is a very significant issue that you raise.
Senator Cordy: This is a fascinating topic. I agree with others who have said that the issues related to seniors in the penal system are not addressed often enough.
Mr. Sapers, I was quite interested in your suggestions, in particular the one about allowing those who are terminally ill to be eligible for parole on compassionate grounds. I am thinking of those who have served a lengthy sentence and are elderly and do not present a threat to public safety. That recommendation makes sense to me.
Mr. Toller, you spoke to the issue of short-term medical absences. Is this recommendation or suggestion moving forward?
Ed McIsaac, Executive Director, Office of the Correctional Investigator: The common sense aspect of the recommendation should be attributed to the parliamentary subcommittee that made the recommendation.
Currently, we have provisions within the Corrections and Conditional Release Act, specifically in the areas of parole that limit the decision-makers in terms of the options available to them for offenders suffering from long-term or terminal illness. The result is that they spend time in the institution in a state of either chronic care or under palliative care and are not released until their condition gets to the stage where they are transferred to a hospital and eventually die.
The ability to transfer out of the institution or parole individuals who are in that condition speaks in part to the relationship that the institutional programming has with the programming provided in the communities. There are difficulties in linking the care of offenders internally to their eventual external care. These difficulties were identified by the internal study completed by the CSC more than a decade ago and restated in the report with respect to the health care needs of federal offenders. As it stands, we have a lesser link there than we would like to have. The current legislation has provisions that limit the options of both the Correctional Service of Canada and the National Parole Board to act on what would appear to be very reasonable and compassionate grounds to release offenders.
Mr. Toller: We are talking about parole by exception that would include inmates not in the two categories we have mentioned who would not yet be eligible for parole by exception.
As Mr. McIsaac pointed out, lifers are exempted. Within that group, as you mentioned it could be short term. A lifer at any time in the sentence could be subjected to long-term medical escorted temporary absences. In some cases, it could be during a terminally ill situation. That means they are in a hospital and under escort. In such situations, we look to expanded visits from family members in this particular environment, but it is unlimited for medical escorted absences. There will come a time when lifers and all others in those categories will be eligible for parole. There are other options depending on where it sits in their sentence for consideration for release. The parole by exception deals with those who have not yet attained their parole eligibility dates. That is an important point for your deliberations.
Senator Cordy: I also read there are a lot of older inmates eligible for parole that are being overlooked and not being paroled.
Mr. Sapers: I think the point you are making is that there are offenders who are being released later and later in their sentence. Increasingly, offenders are being released through statutory release, that is, after two-thirds of their sentence has been served. Therefore, they are not getting the benefit of earlier conditional release through day parole or full parole. There are many reasons of that. They may be considered too high-risk. They may have had a hearing and the parole board does not consider them to be a manageable risk in the community. Increasingly, we are seeing parole hearings waived, postponed or not even applied for. This concerns me. Many of those are coming from offenders who have also had delayed participation in programs. They are not getting the support from their institutional team or their institutional parole officer to apply for parole. Many of these offenders may have substance abuse problems or mental health problems and they are aging.
This becomes troubling because these offenders who may have greater needs are the ones who are not getting the benefit of early access to programs. It is a vicious cycle: they do not get into the program, parole is delayed and they get out into the community without the benefit of good correctional intervention. However, they also have shorter periods of supervision once in the community. You layer on top of that either chronic health issues or mental health issues and you do not have a good recipe for success.
I think the number right now in the correction service is about 150 older offenders who are past their parole eligibility dates. We would have to look at each one cases and determine why that is. Some of them may not be considered manageable. For the majority of them, their parole may never have been considered.
Senator Cordy: Offenders who are paroled and sent out into the community after they have been in the system for a long period of time always have an adjustment period. You provided statistics about the number of inmates who have mental health issues within the system.
When they are paroled, are programs set up to help them within the community or are they on their own?
Mr. Toller: To a great extent, the preparation for return to the community begins on the day of sentencing. When an individual comes into the system, we look at their individual needs and causative factors that may have led them to become involved in a criminal lifestyle. Is it impulsivity, anger management, education or lack of employment skills?
Within the institutions, we look at those areas and furnish programs to improve in those areas to reduce crime. There are provisions in the earlier stages of a sentence for escorted temporary absences, work release programs and unescorted temporary absences. With day parole eligibility, we would look to support from agencies such as the Elizabeth Fry Society, the John Howard Society plus an array of volunteers that come in to see what can be done through supportive communities. Community assessments are done with family on the outside and other agencies or groups that may need some level of support.
As Mr. Sapers points out, there are inmates, despite eligibility for parole that pose such a significant risk to public safety that they would not be released and stay until the last day of their sentence. However, there is a continuum to provide support right through all the stages.
Ms. Pate: It is important to point out that continuum exists in some respects more on paper than in reality. Aside from the good intentions of people around this table and many in CSC, I know of one work release in the last three prisons I have visited.
Mr. Sapers talked about passes to receive health care outside the institution being cancelled. That has been an issue in every institution I have visited in the last six months. In two prisons I visited over the past two weeks, women were coming to me asking for help to intervene. There was the perception there would be labour unrest, therefore passes were cancelled and appointments missed. We succeeding in negotiating to get one woman sent back out and upon arriving at the hospital, they said, what are you doing sending the woman here, the appointment was yesterday.
A lot of this exists on paper. The reality, too often, is the practical follow through is not there despite all the best intentions. That is why our organization and others, such as the Disabled Women's Network Canada, are pushing for resources to be developed in the community. As Senator Keon pointed out, they are not necessarily available in the community now, but it is better to shore up what is available in the community and use the resources that already exist to get prisoners into those community-based services than in trying to replicate them in a less than satisfactory way in the prison system.
[Translation]
Senator Chaput: Thank you, Madam Chair. What is the annual cost of all correctional services in Canada? And what is the average cost per inmate?
Mr. Toller: For health care only?
Senator Chaput: No, for correctional services.
Ms. MacLean: Federal and provincial?
Senator Chaput: Yes.
Ms. MacLean: We will have to provide you with that information later. The details are in the report we have tabled, but we could send you a written reply.
For the Correctional Service of Canada, it is $1.9 billion. And with the figures that we have given you today, we can do the math. Of course, because of economies of scale, it is also different for male and female offenders. We can break it all down and provide you with the provincial portion.
Senator Chaput: Given that budgets are tight — we are all in the same situation — do you consider training your staff in aging as a priority? After all, in your institutions, you are also dealing with an aging population of offenders. Someone mentioned the Peer Care Assistance and Review Program. Have you considered training those people? It is excellent that younger people are providing help to those who need it.
Ms. MacLean: I can begin the answer and my colleague can continue it. First, staff training is fundamental to how we operate as a correctional service. We have national standards and, each year, employees must complete the annual training required for their type of work. For example, right now, we are improving our training in mental health, not just for health care professionals but also for correctional officers. We really must create an integrated, multidisciplinary team.
As to offender training, as Mr. Sapers mentioned, we have established a program in which offenders help other offenders. In health care, we prefer that the training is also provided by peers. For example, Aboriginals have their own program.
Senator Chaput: But you do not have a specific program for women's health, if I understand correctly?
Ms. MacLean: Our program for women deals rather with mental health. Given the factors I mentioned earlier and the higher demand from women compared to men, we are in fact presently studying whether we should also be addressing physical requirements.
[English]
The Chair: On average, how many people die in our federal institutions in a given year?
Mr. Toller: Are asking based on age, by suicide or on the average?
The Chair: No, I am simply asking how many die in prison each year.
Mr. Toller: Fifty or 60 a year, on average, die in prison.
Mr. Sapers: It is about one per week on average. Suicides account for roughly a dozen of those deaths. We also know that the highest-risk period is immediately post-incarceration; that first initial period after release is high risk. As I said, I think there is a relationship between the deaths by natural causes and some of the health care concerns raised in my office.
The Chair: We talked about the need for resources. We are interested in this particular issue because, although we know the problems of aging are municipal, provincial and federal, federally-incarcerated inmates are entirely the responsibility of the federal government. This is, after all, a federal committee. When we talk about resources, clearly we are saying we need more money, more expertise, et cetera, from the federal budget. However, in listening to all of you, it seemed to me that you had a significant area where you could find resources from within. Why are these elderly, disabled people still living in medium and maximum-security institutions? Clearly they are not a danger to anybody except perhaps themselves since they are so incapacitated. Why are they not living in minimum security facilities?
Mr. Toller: I know that a comment was made and there may be some specifics that need to be looked at. The mobility capacity of any inmate is a factor but not the overarching factor of the capacity to live in minimum security. We ask ourselves questions such as: Is it possible for a person with some mobility impairment to leave that facility? Is it possible, with some external help? We look at escape risk factor, institutional adjustment, potential public safety concerns and other things. Mobility is only one factor considered in terms of transfer.
Again, without having some kind of level of specific example, it is hard to really comment. Nowhere could we ever say that by the mere nature of this, that that would translate into a minimum security until all the factors are considered.
Ms. Pate: There is only one minimum-security institution for women in this country. CSC is attempting to close that facility and the woman inmates, most of whom are older, are trying to keep it open.
Often the way women are classified to maximum security is via institutional adjustment. That is often hidden in the issue of institutional adjustment and is not addressed. People with mental health issues or issues like suicide or self- harm, often end up in those institutions because they are not adjusting well. In my experience, it is important they are crucially linked to that kind of access.
I do not know of any aging women that CSC would say are an ongoing risk to the community. If I am wrong, I will stand corrected but I do not know of any aging woman who would fit in that category who could not, as you have identified, fit into an alternate setting.
It is something of an issue with cost. Currently, the cost is $185,000 per year, on average, to keep a woman behind the walls of a medium security setting. That cost rises to $250,000 and higher if they are in a maximum security or segregation institution. Currently, minimum security is also that costly because they have not allowed the women to transfer there while they are trying to close it. The numbers are quite high.
The Chair: In British Columbia, there was an inmate who applied for parole for health reasons and was denied. He died shortly thereafter because he had significant health problems. Are those the types of things you are trying to address in your recommendation that the CCRA be amended?
Mr. Sapers: Without speaking to that specific case, the answer is ``yes.'' What we are trying to ensure is that parole by exception be applied in the most meaningful and helpful way. The Correctional Service of Canada is going through a number of reviews of the tools and the procedures that it uses in terms of placement and assessment, risk prediction, et cetera. Without getting really weighed down by the details, they need to ensure that the assessment procedures, tools and techniques used are culturally specific, age specific, gender specific, et cetera. In some instances, they have proven not to be.
The kind of release question you were talking about, namely why is an aging offender who is increasingly incapacitated housed in a higher security level is a very complex question. To begin to disassemble it, you have to look at the way the person was originally placed, the kinds of program prescription done and the correctional plan, the kinds of opportunities that were provided to make progress against that correctional plan and a whole host of other operational realities within the correctional setting.
Conversely, what we are seeing is the parole board coming into institutions and releasing individuals from, for example, medium security institutions. Most offenders are housed at medium and most of the conditional releases are from medium security. Some of these same offenders being housed in medium security have been judged to be too high an institutional risk by the Correctional Service of Canada to be moved from a medium to minimum security prison. The Correctional Service of Canada states they are too much of a risk to be managed in a medium security prison, but then the parole board comes in and says they think they are an acceptable risk to be managed in the community. Clearly, there is a disconnect between the two.
The Chair: Honourable senators, I am delighted to welcome our second panel.
Appearing on behalf of the Insurance Bureau of Canada is Mark Yakabuski, and from the Federation of Medical Regulatory Authorities of Canada, Fleur-Ange Lefebvre. Welcome to you both.
Mark Yakabuski, President and Chief Executive Officer, Insurance Bureau of Canada: Thank you very much, Madam Chair. I am delighted to appear before this committee to address the matter of aging drivers in Canada. I commend you and your colleagues for undertaking the study of this very challenging issue.
The Insurance Bureau of Canada is the national industry association representing Canada's private home care and business insurers. Our member companies represent nearly 95 per cent of the property and casualty insurance market in Canada, an industry that employs over 104,000 Canadians, pays more than $6 billion in taxes to the federal and provincial governments annually and has a total premium base of $35 billion, approximately half of which is derived from automobile insurance.
At the Insurance Bureau of Canada, we strongly prefer to refer to medically-at-risk drivers, since the issue at hand is not the age of drivers, per se, but the limitations they may face as a result of the onset of medically identifiable conditions.
We understand that there is a correlation between aging and the growing incidence of medical conditions that can undermine one's ability to drive safely. We know, for example that visual acuity diminishes with age and that medical conditions such as dementia or Alzheimer's are more prominent among older populations and significantly impair the cognitive abilities that are essential for the safe operation of a motor vehicle. As well, older drivers are more likely to be on medications and the interaction of various prescriptions can impair cognitive and psychomotor skills.
Because Canada's population is aging, we have to look at the issue of medically-at-risk drivers more closely than ever. As we know, the population of people who are 55 years of age and over is growing faster than any other age group in Canada. In 2005, 12 per cent of our population was 55 year of age or older and this will grow to 25 per cent by 2031.
[Translation]
Even more challenging, the fastest growth in the senior population is among those who are 85 years and older. In 2001, there were 430,000 Canadians in this group, twice the number there were 20 years ago.
Fortunately, many of these Canadians, who have contributed so much to their country, can now live very independent lives, thanks to healthier lifestyles and important advances in medicine.
[English]
It is important to recognize that older drivers, in general, are among the safest drivers on our roads. In fact, the collision rate for drivers between 55 years and 70 years is the lowest of any age group in Canada, bar none. What the data does seem to indicate, however, is that the incidence of medically limiting conditions rises substantially above 75 years of age; in general, drivers of this age or older have a much higher collision rate — one that is very similar to that of young novice drivers. However, we have to be careful not to base our analysis strictly on averages. While the incidence of medically limiting conditions may increase with age, the aging process does not affect all individuals in the same way. Some seniors at 80 years of age are distinctly better drivers than someone who may be only half their age.
We must also recognize that in our society, driving is more than just a privilege; it is a powerful symbol of freedom and independence. The loss of driving privileges can have serious psychological consequences for those affected and increase dramatically the social isolation experienced by many. That is why we must take a very thoughtful, yet determined look at the issue of medically-at-risk drivers.
Today I would like to focus on three areas around which potential solutions need to be built: the identification of at- risk drivers; licensing procedures; and the provision of alternative transportation.
Since the issue at hand is really that of medically identifiable conditions that impair one's ability to drive safely, the paramount challenge is to properly identify those who are affected. One option that has been advocated by many, and is in place in a number of jurisdictions, is mandatory testing of drivers after a certain age. It remains to be seen whether such an approach has had any positive results in diminishing the collision rates of older drivers.
One of the problems with mandatory testing is that the test itself represents only a snapshot in time and does not assist in identifying the onset of medical conditions that could affect one's driving ability. Moreover, mandatory testing perpetuates the myth that all older drivers are bad drivers, and that is simply not the case.
[Translation]
Instead, we believe that an important part of addressing the issue of declining abilities to drive lies with clarifying the role of physicians — and I am well aware that we have physicians with us here today — in reporting medical conditions which can have a debilitating effect on driving abilities.
[English]
In many jurisdictions, medical doctors are required to report to licensing authorities when they are of either the opinion that their patient is temporarily or permanently suffering from a condition that does not allow the patient to drive safely. This regime places physicians in an almost impossible situation. They are asked to deprive a patient of the freedom and independence associated with driving.
In my opinion a much more objective approach would be to define in legislation those specific medical conditions that are known to impair one's driving, either immediately or in time, and to ask doctors simply to report the presence of these conditions to the appropriate licensing authorities. It should be up to these licensing authorities, not physicians, to decide whether the individual reported to be suffering from one or more of these defined conditions should be tested for their fitness to drive.
In addition, police, social service agencies and families need to have a continuing role in identifying drivers whose abilities to drive have declined significantly. Police officers, for example, need to pay greater attention to erratic drivers on our roads. The police are on the front lines of witnessing the performance of drivers who might be suffering from a medical condition that impairs their ability to drive. Equally, social service agencies have an opportunity to help to ensure safer roads as they are regularly interacting with clients who require home support services for impairments that might affect the ability to drive as well. Finally, families have a difficult but an essential role to play in making sure that when their loved ones develop impairing conditions, they not threaten their own safety and that of others on our roads.
[Translation]
There are no perfect mechanisms for the early identification of problem cases. Nevertheless, we believe, with this clarified and concerted effort among physicians, police, social service agencies and families, along with provincial licensing authorities, that we will dramatically improve our ability to identify medically-at-risk drivers. In that way, we can prevent their behaviour from having tragic consequences.
[English]
Once a medically-at-risk driver has been identified, it is not necessarily the case that all driving privileges need to be withdrawn. This is especially the case if identification occurs in the onset of impairing conditions. A number of research institutes in Canada and elsewhere have developed objective testing methodologies that identify the particular driver limitations that medically-at-risk drivers might face.
On the basis of this kind of information, they can determine what specific restrictions need to be imposed on those drivers in order to ensure their safe operation of a vehicle. Examples of such restrictions might include a prohibition on night driving or driving at rush hour or on freeways.
At the Insurance Bureau of Canada, we recommend that specific driver restrictions be given serious consideration by this committee and by provincial licensing authorities in the case of medically-at-risk drivers. However, this approach needs to be supported by following those drivers on a regular basis to determine whether their medical condition is improving, remaining stable or deteriorating. If a person's condition improves, some or all of the driving restrictions could be lifted. If a person's condition deteriorates, however, further driving restrictions would be appropriate and the complete loss of driving privileges would be possible if a person's impairment became serious enough to compromise both the individual's safety and that of the motoring public.
The idea is to encourage early action in identifying the onset of medical conditions as opposed to waiting until the conditions become debilitating and necessitate the sudden removal of driving privileges, which can cause very negative psychological and social consequences for those affected.
In cases where a medically-at-risk driver eventually faces the complete loss of driving privileges, we need to find innovative ways of offering support and alternative transportation to them and to their families. The easy answer would be to promote the use of public transit, for example. However, the reality is much more complex than this. Adequate public transit simply does not exist in many rural and suburban areas of this country. Currently, medically- at-risk drivers who have lost their licenses have to rely almost exclusively on the generosity of neighbours, family and friends to help them get around. For families who play this critical role in providing transportation, it can sometimes represent a major financial burden. I believe that consideration needs to be given by our governments to providing fiscal incentives to those who assist in providing alternative transportation to medically-at-risk drivers.
[Translation]
Honourable senators, I have tried today to present some elements in the challenge of medically-at-risk drivers in Canada. This is not the entire solution, but I still wanted to describe the key elements. I have suggested that early identification is critical and requires a team approach involving medical professionals, police forces, social service agencies and family members.
[English]
Early identification would allow us to introduce a system of supervised driver restrictions for those suffering from medical impairments. We need to provide greater support to those who bear the burden of providing alternative transportation to medically-at-risk drivers who have lost their driving privileges.
Madam Chair, these issues need to be addressed resolutely as Canada faces profound demographic changes that will become all the more acute in the years to come. The Insurance Bureau of Canada is determined to work with all key stakeholders to ensure the safety of our nation's roads and to encourage the development of proper supports for medically-at-risk drivers.
Fleur-Ange Lefebvre, Executive Director and Chief Executive Officer, Federation of Medical Regulatory Authorities of Canada: Madam chair, committee members, I thank you for the opportunity to speak to you this afternoon. I am the Executive Director and Chief Executive Officer of the Federation of Medical Regulatory Authorities of Canada, FMRAC.
I address you today on behalf of FMRAC and its 13 members, which are the provincial and territorial medical and regulatory authorities. You might be more familiar with our members in each of the provinces under the name, College of Physicians and Surgeons of . . . and just tack on the name of the province. We thank and applaud the Senate and this committee for addressing the important issue of aging in Canada and, in particular, the aging workforce. I will address two aspects of this issue. Note that I will not address the role of physicians in safe driving as the Canadian Medical Association had an opportunity to present on that topic one week ago today.
I will address physicians in practice and health care concerns. Under physicians in practice, I will address two issues: audits and questionnaires, and revalidation. I will begin with audits and questionnaires.
Self-regulation of the medical profession is a privilege granted in the public interest and for the public good. Our members have been granted this privilege to serve the public through the regulation of medical practice by licensed medical practitioners and through that mandate to establish and endorse standards for the profession and to monitor, evaluate and where necessary, bring its members to discipline.
All physicians, regardless of age, are held to the same standard of practice. Traditionally, for the most part, mandatory retirement has not applied to practicing physicians. Thus, our members, the Colleges of Physicians and Surgeons, have some experience in dealing with older physicians who continue to provide care to patients. Their approaches can vary from doing nothing special compared to what is done for other physicians, to very specific policies. I will provide several examples.
Most medical regulatory authorities have a peer review process which involves random practice audits and/or surveys of a physician's stakeholder group which normally includes patients, colleagues, team members and others as needed or as pertains to a specific practice environment.
The College of Physicians and Surgeons of Manitoba, through its standards department, has for many years reviewed the practices of older physicians. Until recently, this review was conducted on all physicians who reached the age of 70. If the audit was acceptable, the physician was once again reviewed each five years.
This college did a review of the literature fairly recently and determined through the literature that the appropriate age of initial audit for older physicians, all things being equal, is 75 years. It is generally accepted that most physicians can practice safely until that age.
The College of Physicians and Surgeons of British Columbia performs random audits. In addition, their Committee on Office Medical Practice Assessment has reviewed the office practices of all physicians over the age of 60. I often say when you visit one medical regulatory authority you have visited one medical regulatory authority; we have great variation across the country. The CPSBC continues to do these audits as physicians reach that age. However, at this moment, has no specific schedule to revisit the practice of those physicians who had a favourable audit at the age of 60. CPSBC has other quality assurance activities in place such as prescription reviews. Unlike random audits which are very resource intensive, these other forms of quality assurance can be employed to a greater number of practices on a more frequent basis.
In Ontario, the CPSO carries out peer assessments on all physicians at the age of 70 with follow-ups every five years after that. Nova Scotia, the Yukon and Prince Edward Island have no specific policies pertaining to the competency of physicians over a specific age. While Alberta also does not specifically target physicians for a peer review or closer look at the practice based on age, it has established a program that has garnered a lot of attention called the Physician Achievement Review or PAR Program. PAR uses questionnaires to review all physicians every five years. These questionnaires are completed by patients, colleagues and co-workers. In this, and in other jurisdictions, the medical regulatory authority is sometimes alerted to possible competency issues through the Triplicate Prescription Program, which tracks the prescribing and dispensing of a set of drugs, primarily narcotics and others, that have the potential for abuse. Here again, this applies to all physicians, not only physicians over a certain age.
For more than 10 years now, the Collège des médicins du Québec or CMQ has been conducting site visits for physicians who have been in practice for more than 40 years, with follow-up visits every three to four years if there are no problems.
We have often talked about the Top 40 Under 40 for young achievers. Quebec has now reached 80 over 80; they have 86 physicians practicing who are over the age of 80.
When audits are conducted and deficiencies of concern are recognized, recommendations for improvement or change are made to the physician. Follow-up audits are scheduled appropriately. Conversely, when the audits indicate all is well, the physicians are congratulated and commended.
It is important to remember that medical regulatory authorities have extensive discretionary powers and will often meet with the physician to discuss a particular situation before it becomes a problem. Through this and other mechanisms, older physicians may be encouraged to limit or leave practice as appropriate under the circumstances.
It is also important to note that there are other mechanisms in place that also address this issue that are beyond the purview of the medical regulatory authority such as hospital privileges that are granted to physicians by each health care institution. These institutions have their own policies.
I now want to shift to revalidation, which is recent in the world of medical regulation. Recently, FMRAC and its members have embraced the concept of revalidation of licensure in Canada, not re-licensure and not recertification. Revalidation is a quality assurance process in which members of a provincial or territorial medical regulatory authority are required to provide satisfactory evidence of their commitment to continued competence in their practice. The word ``required'' is important.
The purpose is to reaffirm in a framework of professional accountability that physicians' competence and performance are maintained in accordance with professional standards. It is also staged to assess and confirm that over time, our learning changes, medical knowledge increases, and it is up to the physicians to show that they have kept up.
FMRAC's position statement on this issue is that the stage of endorsement by each of the provincial and territorial medical regulatory authorities, and the feedback received is positive, revalidation will apply to every practicing physician and will help all medical practitioners make practice-relevant decisions and improvements.
The position statement states that all licensed physicians in Canada must participate in a recognized revalidation process in which they demonstrate their commitment to continued competent performance in a framework that is fair, relevant, inclusive, transferable and formative.
By ``fair,'' we mean the process is transparent to the physician, uses fair and standardized tools and is considerate of cost and administrative burden to the physician. We are in a time of physician shortages and do not want to give physicians something too burdensome to do.
The second principle is ``relevant.'' The process of revalidation is designed to confirm a physician's competence within the scope of his or her practice. This will apply to aging physicians. As they get older, physicians often realize that their entire scope of practice is no longer possible. We can ask Senator Keon what happens to surgeons when their fine motor skills begin to degenerate. They will usually self-identify to the regulatory authority and to the institution where they practice. This for the most part is something that is done well and in advance of a problem occurring. It also means that a family physician who does not do intrapartum obstetrics is not asked to revalidate in that area which he or she does not practice. It must be relevant to what they do.
By ``inclusive,'' we mean that revalidation applies to all licensed physicians, even if their practice is mostly of an administrative nature. They must engage in revalidation.
``Transferable'' means that participation in the process of revalidation will be mutually recognized by each Canadian jurisdiction and will not inhibit mobility in Canada.
Finally, ``formative'' refers to the process of revalidation as a constructive, educational, quality assurance process, independent and distinct from the disciplinary processes of the regulatory authorities.
I want to end on the health care requirements of the aging population with a plea to the federal government to pay attention to the growing health care needs of all Canadians as we grow older and particularly to those of an aging work force. With a significant number of people remaining on the job for longer, there will be different and possibly more health care requirements. In times of physician shortages, more physicians will remain on the job as they grow older. With an aging population, these physicians will deal with more complex cases. They and other health care providers must also have access to services for themselves so they can remain as healthy as possible. On behalf of FMRAC and its members, I thank the committee for this opportunity.
Senator Mercer: I thank you both for being here.
Mr. Yakabuski, you have described graduated licences, something that is used in some provinces for licensing younger drivers. Perhaps we can call the revoking of driving privileges to be diminished licensing.
How do you see graduated or diminished licences for people whose ability to drive has worsened being policed, and how do we identify them? Will we require people to put identification on their car as they do in some places for people learning to drive?
Mr. Yakabuski: Some people talk about graduated de-licensing. I have not quite presented that today. I think there are important distinctions.
I think it is very important to avoid saying that after 75 years of age, everyone must go into the same process. I think the reason why some people have declining driving abilities is due to the onset of some identifiable medical condition. Let us deal with the medical condition, whether it happens at 45 years or 85 years rather than ``hurting'' people at a given age.
If we say, for example, that everyone at 80 years of age must go for a test, we may not capture half the people we need to capture because at that particular point in time, they have not had the onset of their condition, they are in remission or something of that sort. Therefore, we need to be more calibrated in what we are doing. We suggest that we can administer testing through a combination of objectively identifying medical conditions that may have a debilitating effect. We can simply ask physicians to record these conditions, not make a subjective judgment as to whether or not this person is fit to drive. We can work with police forces. I think it will be a distinctly smaller subset of people as opposed to specifying a particular age where everyone must go for a test of some sort.
I think it will be more efficient and accurate. It will certainly be less costly. At the Insurance Bureau of Canada, we like to start that kind of dialogue amongst people in Canada rather than taking the ``certain age'' approach.
Senator Mercer: One of my concerns with that is that someone must make a decision. Your suggestion is conditions must be identified as ones we need to be concerned with, someone would make a decision and then someone in the licensing agency in the provinces or the police would do something. I do not have as much trouble with the police as I do with the bureaucrats sitting in a licensing agency in a registry of motor vehicles or in Services Nova Scotia and Municipal Relations.
Mr. Yakabuski: I see the point you are raising. I think it is very legitimate to decide who should make a final determination. It is important to move that subjective decision away from physicians because it compromises the patient-client relationship.
Senator Mercer: We have heard that comment from physicians.
Mr. Yakabuski: It is not working. We have to find something that does work.
Senator Mercer: Early medical identification requires either self-identification by the driver, the family, the physician or someone else who reacts with the person. Self-identification of a problem is a difficult thing to do.
Mr. Yakabuski: Yes, it is. What I have sketched out today does not rely as heavily on self-identification. Physicians have a role, but it is not a subjective role. They should not bear the burden of determining who can drive. That is a major pillar. Cooperate with the police. Let our police forces, as part of their mandates, pay more attention to drivers on the road who do present symptoms of erratic driving, et cetera. That is another avenue of pointing out people who should be tested.
Senator Mercer: This is difficult to measure, but it seems to me that a number of older Canadians self-regulate. Drivers regulate themselves by deciding that they will not drive on highways anymore or on downtown roads, but will continue to drive to the drugstore, to the grocery store, to the doctor or to visit family.
Mr. Yakabuski: There are many Canadians who do that and it is laudable. I think this kind of regime gives that situation greater support and legitimacy. I think the two can be married well together if we all get together to work out the technicalities.
Senator Mercer: What you see as restrictions that might be put on a driver would vary from driver to driver and on condition to condition. I do not necessarily dislike that idea; I find it rather attractive. However, from an administrative point of view, I cannot see how to administer it in situations where my 88-year-old grandmother has this restriction on her but her 79-year-old neighbour has a different restriction.
Mr. Yakabuski: It may be a matter of adjusting to that paradigm. I do not think there will be an infinite number of restrictions. I think we can manage this. Many people have indicated on their driver's licence that they need to wear glasses while driving. That is a restriction placed on many people's licence already. We can expand those restrictions in a productive way. I think we need to have a dialogue around a new approach towards people facing medically-limiting conditions.
Senator Mercer: Ms. Lefebvre, I am from Nova Scotia where we have no policy for physicians to be audited at any age. What is the feedback from physicians themselves as they go through this? As you have referred, many physicians self-identify and realize that their skills are not as sharp as they were a few years ago. Therefore, they will move away from practicing certain aspects of medicine.
What about the doctors who have not done that but, after going through the audit, some restrictions are imposed? What is the feedback from them?
Second, what is the feedback from the communities they serve? In many cases there are small communities in rural Canada. If you have restricted a doctor's ability to practice medicine, you have not only affected the doctor but everyone in the community.
Ms. Lefebvre: I am not sure about the feedback from the community. I certainly know of a few instances where a doctor has been removed as a result of a discipline committee decision, but not necessarily due to an age-related audit.
If the audit shows there are some areas for improvement, they are given an educational prescription. Once they have completed that, they are re-audited. If there is no improvement, the decision of the regulatory authority must be more serious.
I cannot imagine those physicians would like it. Again, I do not have hard data to give you concerning the feedback.
Coming back to the jurisdiction that you are interested in, while Nova Scotia does not have this it does have NSPAR, which will also be lead into revalidation. NSPAR is based on the PAR program in Alberta. Through that process, we think the best way to address this issue is to have physician's self-identify the areas that are either getting so complex that they need to abandon them from their practice, or where they need to have ongoing education to keep up to speed.
We have great hopes that will show physicians and the communities that a standard is a standard is a standard; and that if you are not practicing to standard, you have to at least come to the attention of someone. You may be able to remain in practice, but someone must be watching you more closely.
Senator Mercer: I think the advantage physicians have over the rest of the population is when we talk about peer review. It is a standard term used by physicians and people supporting physicians in research, et cetera. It is something that goes on all the time. It is terminology and discipline that they are used to and I guess the rest of us need to learn a little from the College of Physicians and Surgeons on that subject.
Senator Stratton: The approach of the Insurance Bureau of Canada is interesting. I address this question to both of you, but I address it to you first, Mr. Yakabuski. It is a matter of independence.
If people want to work longer, they should be encouraged to do so. It is so important as we grow older — this independence to keep working and to keep active — because that makes us healthier. I am all for that.
Recognizing the safety issues, I am curious as to why we have mandatory testing at certain ages. I think in Ontario it is between 75 and 80 years and every two years thereafter. A professor last week said they did studies in two Scandinavian countries. One had mandatory testing and the other did not, and there was no difference between the incidences of accidents. That is an argument for the side that encourages independence.
In determining whether or not someone is capable, I think they also said last week that Saskatchewan has a list of medical conditions on the licence form that folks fill out annually; the person would tick any that apply and answer questions on them. To a degree, it is a questionnaire that informs the regulators as to whether or not the person needed to have conditions imposed. I do not disagree with that. If someone is relatively honest — and I think most people are by a long shot — that would be a good step.
I worry about the physicians in the sense that they're dammed if they do and damned if they don't. If they realize someone has a problem, they have to do something in most provinces — at least in Manitoba and I know others. There was a list from the CAA as to the conditions under which people can drive. For example, someone who lives in the same condo I do has macular degeneration and can only drive during the day. There are those kinds of conditions that happen all the time.
Mine is a bit of a ramble here, but I believe that the independence and the self-identification on the part of both physicians and individuals as to their health concerns can go a long way to eliminating the driving condition. Family and friends must play a part in this. I have had relatives where you simply have to sit them down and tell them it is time. I know my kids will have to say the same thing to their old man one day because he will fight it every inch of the way. There is no way I want to quit driving.
With that independence and with self-identification, what further steps do you think have to take place? We want to do this in a way to encourage that independence. Do you agree with that, or do you think there needs to be something more?
Mr. Yakabuski: I agree with just about everything you have said. I think it is a matter of bringing these various tangential things together in a way that makes sense. There is no doubt that we have to encourage the independence of people as long as we can; that is in the interests of everyone. We have to recognize these are men and women who have made great contributions to their society, and we should respect that.
At the same time, we also have to ensure that they are not a safety risk to themselves and to others on our roads. We have to balance those objectives in the most sensitive and sensible way possible.
You talk about the Saskatchewan approach. I think these approaches need a bit more support. First, regarding your point with respect to mandatory testing, I could not agree more. I made that point tangentially at the beginning by saying there is no evidence that mandatory testing reduces collision rates. That is what most of the literature seems to be saying. That does not seem to be a fruitful effort. By the same token, if you rely solely on self-identification, it is quite possible, speaking realistically, that some people who are a safety risk to themselves and others may well not comply. This is a way of providing the right supports.
We need to provide social and institutional support to those people affected by driving restrictions. We should be looking at the possibility of financially compensating those who are taking on the additional task of driving people, sometimes at great lengths, because they have been deprived of their driving privileges. However, we have to get away from this idea that it is an all or nothing game. As you have pointed out, there are conditions that properly might require restrictions on one's driving privileges but not a full taking away of those privileges. Therefore, if we encourage the understanding that this is not an all or nothing game, perhaps people might also be more willing to comply with the system. They might say, well, I might have some restrictions placed on my ability to drive, but they will not take my licence away entirely. I think that is the fear of many people today. We need to address that. The questions you raise are obviously very good ones.
Senator Stratton: Ms. Lefebvre, with respect to the independence of doctors, I know my physician has hit the magic age of 65 and is stepping back, but he is still practicing and he has a wealth of experience. We want doctors to continue to work and practice for as long as they are willing and able. Do you believe there should be mandatory testing after a certain age in the medical profession or do you think this should be a voluntary thing?
You see people at age 85 who are still operating at a very high level compared to others at the age of 65. I look at that and say, as long as a doctor is capable of working and wants to work, he or she should be encouraged to do so, as long as he or she maintains a standard. Would that be fundamental to what you want to get at? Is that a good question or does it put you in trouble?
Ms. Lefebvre: It does not put me in trouble. You might think that there is not a lot in common between regulating the medical profession and according people the right to drive. However, our colleague in Yukon both regulates physicians and hands out motor vehicle licences; the staff has to multi-task.
The practice of medicine is based on a one-time award of a licence, once the appropriate credentials have been achieved. An annual license renewal process is based on the honour system. Physicians are asked about criminal records and some provinces are moving to mandatory criminal record checks on a regular basis. Physicians are asked if there is anything at all that could impede their right to practice the full scope for which they are licensed. More and more jurisdictions are moving to no longer giving physicians a blanket licence in that the licence will define what they have the right to do when they are interacting with patients, other health care professionals and the system.
The honour system works well if it is in a non-punitive environment. At the same time, we have the expectations of the practicing physicians that they will be given the independence to make decisions or that they will be surrounded in a way that allows them to make the right decision in a non-punitive environment, and then we have the expectations of the public. When there is an adverse event, often the consequences are dire and affect many people.
We know that physicians and the public expect that physicians will keep up. When we ask physicians and the public whether they expect physicians to account for keeping current on a regular basis, we see divergent opinions. Physicians would like to continue on the honour system but the public expect something more tangible.
We still have faith in the revalidation system, although it is still in its infancy. When a physician is targeted for an audit, it is simply a peer review audit. For example, if it is found that a physician is prescribing too much of any given narcotic, peers perform an audit to determine why that is happening. It might be because of a specific patient population or there might be no justification for it at all. The regulatory authority has no choice but to intervene in a way that will bring that physician's practice in line with the standards or do something to limit or prevent that physician from practicing.
Senator Stratton: All things being equal, you would want them to continue to practice as long as they are capable.
Ms. Lefebvre: Yes.
Senator Stratton: The independence factor is so important to me in all aspects of life as we get older. The more we encourage that, the healthier we will be as a society.
Ms. Lefebvre: The increasing number of physicians over a certain age in most jurisdictions who are continuing to practice is an indication that there is no barrier to continue, other than how they succeed at the various steps where they need to demonstrate that they still have the competence to do so.
Senator Cordy: Do any jurisdictions have limitations on licences for those with medical conditions? You mentioned earlier about the need to wear eyeglasses. Are there any such jurisdictions in Canada?
Mr. Yakabuski: As a standard procedure, not that I am aware of, senator.
Senator Cordy: I am interested in your comment about consideration to provide fiscal incentives. Theoretically, that is a wonderful idea. Most people take their neighbour to see a doctor or to buy their groceries because they are good, kind people. Providing financial assistance, even just for gas for the vehicle used would be wonderful. However, with all the things that happen in government, it would become so complicated that you would have to fill out a 10-page document or more to get your $15.98 back for gas. I also wonder about a motive behind your suggestion because you are in the insurance business. If some kind-hearted person drives someone to doctor's appointments and to the grocery store every week, will their insurance rates go up? I think it is a great idea but how can it be accomplished simply?
Mr. Yakabuski: Senator, we have not worked out all the technicalities, as I have said, but it is a way of giving expression to the saying ``put your money where your mouth is.'' If you want to encourage independence, as I think we should, then we have to give support to those people taking on that extra burden. Obviously, we would want to make this as administratively streamlined as possible. Surely, where there is a will, there is a way. It would be a way of building and maintaining communities, and surely that is what our tax dollars should be doing. Obviously, much would have to be worked out but the idea should be explored because independence is so important.
Senator Cordy: It is a good idea but I am not sure how we can keep it simple with government involved.
Ms. Lefebvre, you spoke to self-regulation and the fact that the provinces work independently. Do the provincial colleges of physicians and surgeons get together to talk about these things? Has there been any discussion about developing national standards so that eventually a review in Nova Scotia would be the same as a review in Saskatchewan?
Ms. Lefebvre: We are planning our first meeting under the review of the mutual recognition agreements, through money funded by HRSDC. Two members did not sign in 2001, before Nunavut became an independent regulatory authority. We are reviewing that with a compliance deadline of April 1, 2009. One of the issues we are looking at deals with labour mobility and chapter 7.
If you open up that whole issue, you might as well open up the whole thing. We have national standards for the gold standard licence in Canada, which states that you must graduate from a medical school, preferably in Canada or one of the accredited schools in the United States with whom there is a reciprocal arrangement; hold a licentiate of the Medical Council of Canada; and hold a certificate from a college of physicians and surgeons in Canada in family medicine or a certificate in a medical specialty or surgical specialty from the Royal College of Physicians and Surgeons of Canada. That is the gold standard that is national at several levels.
We are moving toward national approaches to revalidation, although we realize that Prince Edward Island cannot mount the same kind of revalidation process as Ontario. Prince Edward Island licenses about 200 physicians while Ontario has about 30,000. However, we have that ``rob and duplicate'' approach. When we get together on a regular basis at our annual general meeting, our registration people talk about how they can standardize registration processes and questions, et cetera. We have put in place a Physician Credentials Registry of Canada, which means that if you are a physician in Ontario and you want to consider practicing in Quebec, Nova Scotia or British Columbia, you can have a central repository of your credentials from which the regulatory authorities can obtain that information, thus eliminating a repetitive process. Other than in the Atlantic provinces, we do not have a standardized process for peer review. Currently, we are putting all of our efforts on revalidation. There was the Atlantic system for a while but Nova Scotia has since pulled out of that to put its Nova Scotia Physician Achievement Review, NSPAR, program in place. We do not despair of national approaches and instead work on them quite hard. I do not despair that in my lifetime we will not even broach the topic of national licensure.
Senator Cordy: If I hear of a doctor in Nova Scotia being looked at by the College of Physicians and Surgeons, I immediately think they have done something wrong. If such a peer review becomes a regular part of being an accredited physician, would you need some public relations funding built in so that people can be made aware that this is standard procedure?
Ms. Lefebvre: Yes, I could not agree more. Once we get endorsement from our members on revalidation, the issue of public relations is most important.
Senator Keon: I congratulate both of you on your presentation. You have very objective remarks and you are making a great deal of progress in both areas.
Many times during my life, I dealt with the dilemma of whether people should drive after receiving a pacemaker. You are wise and you should try to find a way — and perhaps we should try to help you — to define high-risk drivers because this is an issue of public safety. We want to be good to seniors and encourage them in every way, but we also have an obligation to protect the public.
On the question of transportation, I am aware of and I also used voluntary agencies which provide drivers for people who are incapacitated. Ninety per cent of these voluntary drivers were seniors. I have often thought that as a resource it has never been encouraged or exploited fully. I have to agree with Senator Cordy that your idea of a financial incentive to those drivers would get so complicated with bureaucracy, it would be unworkable.
Ms. Lefebvre, for 16 years of my life, I had to deal with competency on an annual basis. I think there is nothing more difficult than calling in a surgeon who has turned 66 years-old and discussing with whether he or she should continue to practice. When the mandatory retirement at age 65 came into our institution, it became easy. It was easier to extend someone for another year, but before that trying to restrict someone who is on the borderline was an extremely difficult subject.
We must be extremely careful in the medical profession. When things go wrong, they go terribly wrong. We are all seeing this in the press right now where things went wrong with an individual. We must be careful about what doctors are allowed to continue after their skills are starting to fade or after their vision has faded. The window is long. Vision begins to fade at about age 40 and it keeps fading.
A tremendous change takes place with fine motor movements in people over 50. For someone who looks the same when they are 70 years-old as they did at 50 does not mean they are the same. We must be careful because we have an obligation to protect the public.
I have no questions for Ms. Lefebvre because I am aware of what you do and I congratulate you for that.
The Chair: Mr. Yakabuski, what would you think of a licence that could be limited on the basis of visual impairment, medication impairment, dementia impairment, seizure impairment or other medical impairment and one that restricted total driving — for example from night hours, roads greater than four lanes or rush hour from 9:30 a.m. to 3:30 p.m.?
Mr. Yakabuski: That is very creative and with your permission, I would like to take that back to the people we have been talking with today.
The Chair: You may. You may find it in our report. I want to thank you both. You have clarified a number of issues for us.
Honourable senators, next week we are discussing pensions, both private and public. Hopefully, that will be the end of our witnesses for the next while as we have an interim report to produce.
The committee adjourned.