Proceedings of the Special Senate Committee on Aging
Issue 13 - Evidence, June 5, 2008 - Afternoon meeting
VICTORIA, BRITISH COLUMBIA, Thursday, June 5, 2008
The Special Senate Committee on Aging met this day at 1 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: Honourable senator, as our first witnesses this afternoon, I would invite Carol Pickup, Dale Perkins, Judith Cameron and Elfreda Schneider to the table, please.
Carol Pickup, South Island Health Coalition, as an individual: I am very pleased to appear before you. I must say, however, that your appearance was not well-advertized, so my presentation is very much off-the-cuff.
I currently serve as co-chair of the South Island Health Coalition. Most recently we have been focusing on seniors' health issues, so certainly your panel is of great interest to us. I also serve as a seniors' advocate with the Greater Victoria Seniors.
I totally support the comments made by Lyne England. I work with Ms. England, and she knows firsthand what is happening particularly in residential facilities right now.
I would like to emphasize to the committee the need for much more accountability in the system as a whole and with seniors in particular.
I am sure you have seen the reports of the Health Council of Canada. One of the comments they make in their 2007 report is that they are quite concerned about the issue of accountability and transparency in health care. They make the point, as well, that it is troubling that the first ministers have not reported this year on comparable health indicators as agreed in the 2003 accord and that the federal-provincial-territorial committee that oversees the work has been disbanded. That is regrettable. I wonder if the committee understands that that has happened. I think there was great promise in the Health Council of Canada to establish more accountability and transparency in terms of health issues, particularly vis-à-vis monies that come from the federal government to the provinces and territories. It is disturbing that those bodies did not report in to the Health Council of Canada as to how they spent those monies. They have literally not been accountable.
I would also like to point to the fact that the 2008 report from the Health Council of Canada talks specifically about primary health care and home care renewal. Those are two extremely important topics as far as I am concerned.
You will recall that we had a commission on health in the early 1990s in British Columbia, the theme of which was ``Closer to Home.'' Many more services are needed for seniors closer to home, for example, home care. Seniors need access to dental and eye care, services not covered under the Canada Health Act. Poor dental care in particular can severely impede seniors' ability to achieve health, whether they are at home or wherever, and I am not sure that those services are provided within the institutional setting. It is something we need to think about.
Vis-à-vis Ms. England's remarks, we are very unhappy with the privatization of food services within British Columbia in our residential care facilities. Meals are prepackaged — some come from as far away as Winnipeg — frozen and then reheated. Residents and families are very dissatisfied with the privatization of food services in facilities.
Dr. Patricia Baird from University of British Columbia chaired the Premier's Council on Aging and Seniors' Issues for the province. She was appointed by the premier of the province and reported in November 2006.
I would like to commend and recommend her report as being very insightful. She talks about the positive aspects of seniors in the community as opposed to simply the deficit side of seniors in the community. She points out that seniors are more active than they have ever been, form a large part of the volunteer base that is out there and that many more seniors are contributing than receiving a lot of services. I liked the thrust of her report. Dr. Baird's recommendation is to provide as many services as possible to keep seniors as close to home as possible for as long as possible. I think you will agree with me on that.
In B.C., equal access is not being afforded to seniors — or to anyone right now, in my opinion. The federal minister needs to be looking at the Canada Health Act and enforcing it to a much greater degree. All sorts of infractions of the original principles of the Canada Health Act are occurring, particularly with the issue of equal access, and I would strongly urge that this panel make that point.
You heard from people who are providing health care through independent living. They talked about supportive living and also assisted living. Assisted living, in my opinion, is not accountable. A registrar only acts on complaints. No inspection of the facility is done.
As a seniors' advocate, I am aware that many people in assisted living facilities should not be there at all. They need a higher level of care. Because of the insufficient number of residential care beds in our community, seniors are in assisted living facilities, and some families are sending in caregivers to help them. Unfortunately, assisted living has become the solution to everything, as far as I am concerned and as far as this government is concerned in British Columbia. They closed thousands of residential care beds when they first got in; some of them needed to be closed because they were antiquated. They have replaced them primarily with assisted living and largely for-profit, not non- profit. I think that is a problem too.
In conclusion, I certainly hope that we all support the principles of the Canada Health Act and that we will act to ensure that they are adhered to. The federal government needs to play a larger role in ensuring that there are benchmarks, accountability and access. Thank you.
Judith Cameron, Executive Director, Fairfield Activity Centre, as an individual: This morning we heard with interest the different opinions of how retired persons are living. Some of our seniors are living on very limited incomes, many on an old age pension, OAP, and Guaranteed Income Supplement, GIS, of approximately $1,169 a month.
The seniors' activity centres, the New Horizons, received funding to start our programming in the early 1970s. Since then we have received no core funding with the exception of the City of Victoria annual recreation grant for a total of $36,000. Our facilities are city-owned.
We are the frontline workers. We see our members on good days and bad days. We see them before they get to assisted living and land in hospital. We make referrals and advocate for health care services, doctor referrals, home care, housing, and mental health. We offer several programs that promote health and wellness, and by doing this we are able to promote independence. We do promote seniors helping seniors in that we have 160 volunteers at any given seniors' centre. Without them, we would have to employ eight other full-time staff.
As we have a membership-driven organization of 800 to 900 senior adults and only three full-time staff, we are now forced to consider reducing our staff. At the same time our workload has increased significantly.
We are not seen as a health and wellness centre; we are largely seen as a social club, and that could not be further from the truth. It might have been the case 50 years ago, but it is not now.
Most of the staff working at the seniors' activity centre are sophisticated, organized adults trained in gerontology, many of us with nursing backgrounds. We work from the side of our desk helping our members because many of them do not have their families here in Victoria. We have the highest percentage of seniors per capita, and so that really creates a struggle. We see the folks day-to-day whereas their families do not.
Core funding is an issue. Money is available through the New Horizons granting procedure. However, that is very laborious to apply for and is always project-driven. We need core funding. We keep people healthy and well before they go on to that next step.
We are representing over 5,000 seniors in four seniors' centres just in the Greater Victoria area. It really is a shame that as a seven-day-a-week operation, we are reducing staff, not increasing staff. We really would like to see an indication that some value is given to the work done by our seniors' centres. Nothing is mentioned here as a recommendation for them. I find that quite interesting because we are the grassroots.
We keep our folks from being dependent and being pushed into isolation where they may become depressed. We keep them active, well and carrying on with very limited resources. The staff are not adequately paid, and receive no benefits whatsoever. We are there in the field because someone has to do it and because we are seniors aging ourselves, whether we like to think of that or not. If we do not help our loved ones and our seniors, no one will help us.
I really would like some focus on seniors' activity centres, and I would like the senators to have the opportunity to know about the valuable work that we do. Thank you.
Dale Perkins, Minister, United Church of Canada, Victoria Presbytery, as an individual: I am an ordained minister of the United Church of Canada. I come out of the regional organization called Victoria Presbytery. I also sit on the board of the Victoria Multifaith Society, which represents eight different religious organizations in the region.
I have had experience in providing care, support and advocacy as well as counselling to family members with seniors and to seniors themselves since 1988. I have had quite a bit of on-the-ground experience with what is happening for seniors. I am approaching that age myself, having retired a year and a half ago, so I am feeling it at a number of levels.
I am here not to give you statistics or facts but just impressions, anecdotal but also very clearly representative of the facts of the situation.
We are in an alarming situation, and your committee would do us, the public, a great service if you would highlight the alarming deterioration in seniors' care, residential and health care, in this province. In this region in 2002, one of the first acts of the new government after taking power was to bring in five health authorities to replace the 52 that were in place at the time. We have one health authority for the entire Vancouver Island responsible for all the health care services that the public purse is involved in for this region. We have nine directors who are responsible. All appointed, however, not elected, all people who meet the approval of the British Columbia Ministry of Health before they are allowed to become directors of the health authority.
I have seen, particularly in the last five or six years, a phenomenal deterioration in health care and in residential care for seniors in this province. It is alarming. If you visit someone who does not have a family member close at hand, you become their primary hope to try to address or redress some of the terrible situations that they are facing. Staff are no longer available to do basic cleaning in facilities. The rate of homes being quarantined is alarming. At any one time, you may find that you cannot visit a place because it is under quarantine, and that is primarily because of the lack of cleanliness and care of those facilities.
It is not the fault, I might add, of the particular employee who does the cleaning. They are called to handle a phenomenal increase in the number of rooms they look after and the number of people they care for. They are doing the very best they can with what they have. They are not being given the resources, the training or the opportunity to provide the level of services that these people really need.
As Ms. Pickup mentioned, food, we have found out, comes in frozen from, I would guess, as far as Toronto. We are subject to the political whim that decides that they have to contract out food services to a company called Compass Group Canada. Their subsidiaries, Morrison Foods and Crothall Services Group for housekeeping are providing all the services in their facilities. They encourage all of their contracted, independent providers to do the same.
We have found from family members of residents that they are alarmed at the quality of food that is being provided. Diets are being ignored by and large. They systematize it to the point where it is all computerized. If there is someone in that home who has an intolerance for a particular product, the computer does not designate which patients do not receive that product anymore; rather, the whole facility does not receive that product. It standardizes it. Of course, they make more money that way.
Compass Groups' bottom line is not service, their bottom line is profit. This United Kingdom corporation, with thousands of facilities in North America and other parts of the world, are in charge of the food. That is all the resources. Family members who see their loved one refusing to eat and getting very sick as a result are forced then to bring in the food that their loved one will eat. That is intolerable.
We need the Senate to sound the alarm that the situation in this province and in this region has deteriorated to the point of almost being at the threshold of being liable for elder abuse. Do you understand what I am saying? It is that serious.
All of my colleagues in the church and in the religious communities are alarmed at what is happening.
I put it to you that someone has to carry the ball on this one to try to awaken those in charge to say, ``This is not good enough. You must do better for a variety of reasons. Just on a plain humanitarian level, you must do better.'' We need you, senators, to do that.
Elfreda Schneider, as an individual: Good afternoon, members of the panel and senators.
I am speaking from my own perspective in terms of being on the cusp of becoming a senior and because of the fact that I have had a chronic illness all my life. I have lived in Victoria for six years and have, on my own lack of access to a physician's care and continuity of care, slowly deteriorated. It shocks me that I am not yet a senior and this is happening to me already. I am afraid for my future health care.
I have lived in four other Canadian provinces. I am a type 1 diabetic. Nowhere, until I moved to B.C., has a physician ever told me that they cannot treat me because of my illness. An endocrinologist wrote a letter to me to say that they have given up on me. This happens at an abhorrent rate.
Senator Carstairs mentioned Martin Luther Kings' quote about people being apt to remain silent, and we are not even aware this is happening.
When I got the letter, I called it being fired by physicians and not being allowed access. It affects patients tremendously whether or not they are seniors in terms of their sense of worthiness of their medical condition. Many of us, if an illness is not looked after immediately, progress to very unstable ill health that leads to a further health care cost for you.
I have been proactive in fighting this. At a provincial level, it is not even on their radar screens. The Minister of Health has not responded to three of my letters, and the College of Physicians and Surgeons of British Columbia will not even answer my concerns and only send a complaint form. I have never undergone the complaint form process through the college. I refuse to do that because I need a physician and do not wish to be black-listed in terms of never getting another physician.
There seems to be no out in terms of a patient advocate, and I call on the Senate to have that established.
A national management strategy meeting for diabetes in general is to take place this week in Ottawa. I do not know what will come of that meeting. The need is extreme for all medical conditions and the continuity of care that is not being provided by our physicians. From what I have read, former Deputy Minister of Health Penny Ballem resigned because there was no physician accountability with respect to standards of practice. This obviously affects seniors now and will continue to affect seniors if nothing is done about it.
Judith Johnson, as an individual: Good afternoon. I am glad to have the opportunity to speak to you about some of my personal and professional experience in the area of caregiving.
I am a past executive director of the Family Caregivers' Network Society in the mid-Island region and in Victoria. I have worked on seniors' issues for approximately the last 20 years.
My experience is probably typical to many caregivers living all across Canada. We start out assisting our parents or relatives in a rather minor way in the beginning; and over time, as their needs continue to increase, we find ourselves spending more of our time offering care and support.
My own experience began when my mother moved here from another province and came to live with me. I was fully employed at the time and found it particularly challenging to care for her and work. When she had a stroke, I had to give up my work to stay home to look after her. I think she lived with me for six years in total.
Eventually, after several years, I was allowed approximately one hour per day of assistance from the government, which meant that someone would come in in the morning and relieve me of my caregiving by assisting her with a bath.
Her situation was stable for a few years, and she eventually developed sepsis and was admitted to hospital. After spending approximately seven months in acute care, she was moved into a long-term care facility, one of which I was told was one of the best on the island. At the time, I thought that if someone else had to share in her care, best it be them.
During the course of her residence in this particular facility, we experienced several models of care changes that brought in different modes of feeding people; one being the contracting out of food services, about which the gentleman just spoke.
It was difficult to watch my mother deteriorate and literally starve to death. I watched a 180-pound woman reduced to 95 pounds. I struggled with the facility to try to get what I felt both professionally and personally was a reasonable amount of care for her condition. We struggled with food, regular medication, trying to get her bathed on a regular schedule, having her baths missed, which meant that someone who has spent their days in a diaper was only bathed at a two- or three-week interval. Personally, having this experience really does not bode well for the future. As my own health continues to deteriorate, I wonder what lies ahead for me.
In a country such as Canada, with the resources that we have, there must be some way that we can ensure that people in the last years of their lives are allowed the dignity that they deserve. They worked to build this country and are being neglected; their human rights are being violated. They are not receiving basic care, again, not because the staff who are employed by these facilities are not doing their very best, but simply because there is not enough resources and quality.
It does no good to raise the daily food allowance for an individual in a care facility with the hope that it will improve their health when they either cannot eat the food, do not have the time to eat the food, the food is not appropriate for them to eat or no one is there to feed them. In the end, the food is wasted; it is just thrown out.
I am not sure what the solution is. However, we need to focus on making these last years of people's lives both comfortable and dignified. The dignity has gone out of care. We have all heard that when you get admitted to hospital, you leave your dignity at the door. When it is supposedly your home and the place that you are spending the very last years of your life, it should feel dignified.
I tried to think of the worst experience that I had with my mother in the facility. I am probably having to choose between the day I came in and found that she had been left out in the rain because, during the change of shift, they forgot she was outside and she was soaking wet; or the day that she told me they had missed her bath and she would have to wait another week; or the day I came in and saw the woman in the bed across from her dressed in her clothes.
Time has to be made to care for people in a reasonable way, and what is happening now is not reasonable.
The Chair: Although we have had walk-ins at every point, we have not had people come forward in the same way that Victoria has sent people forward, and I suspect that that is a reflection of the number of seniors that you have in this community.
I want to thank you very much for coming forward and telling your story because it is important for Canadians to hear that.
Colleagues, this is our last witness for today, and then we will visit Hospice Victoria. You knew that I would not let you out of the study before we had had a visit with a major hospice organization.
Our next witness is Dr. Duncan Robertson. Welcome.
Dr. Duncan Robertson, Geriatrics and Palliative Care, BC Medical Association: I am here in response to the invitation to the British Columbia Medical Association, BCMA. I am a specialist in geriatric medicine, and for the last 15 years until last year, I chaired the British Columbia Medical Association Geriatrics and Palliative Care Committee and was a member of the BCMA Council on Health Promotion. I currently practice full time and divide my time between Victoria and Alberta. I also use telehealth communication between the two sites.
The BCMA Council on Health Promotion has a 30-year record of health advocacy to government, health care organizations and others to improve the health of British Columbians. Initiatives by the council have included influencing air and water quality legislation, promoting mandatory use of car seats for babies and children, and advocating for mandatory cycle helmet use.
One of the committees of that council, the Geriatrics and Palliative Care Committee, has a long history of advocating health promotion, prevention, policy initiatives and anticipating and meeting the needs of an aging population.
Recent initiatives include advocacy for policies and practices related to care of older people, funding for palliative care for individuals dying at home, health, human resources issues, and successful advocacy for a provincial strategy for older individuals with cognitive impairment.
I have provided to the committee the document entitled Building Bridges: A Call for a Coordinated Dementia Strategy for British Columbia, 2004. Members of the BCMA Geriatrics and Palliative Care Committee also promoted and collaborated with a multidisciplinary group to develop a comprehensive strategy for the diagnosis and management of cognitive impairment in older people. This document has also been made available to the committee.
In addition, in May 2008, following along the Building Bridges metaphor, the BCMA produced a policy paper that was referenced in the invitation. I was not a member of the committee that developed that, but I am familiar with its contents and can attempt to speak to some of the issues, if you wish.
I know you have heard a great deal. At this point, perhaps I will turn it back to the committee and ask for any questions that you may have about the initiatives that we undertaken.
I have a few comments to make about some of the recommendations, mostly in strong support for a number of them, particularly with respect to caregivers; education for the public; the issues of capacity assessment, particularly in the context of dementia and frailty; and a number of other issues.
In reading your interim report of March 2008, while dementia is mentioned, I think that the impact of dementia and frailty cannot be underestimated in planning for the future. Any federal initiatives with respect to education, promotion of awareness, and caregiver issues must take full cognizance of the impact of dementia and frailty. While we all would like to age successfully, the reality for most of us is that if we survive into our late eighties, there is a one- or two-out-of-three chance that we will develop significant cognitive impairment or frailty in the months or years before we die.
The Chair: We have heard this afternoon, and we have heard it across the country, about the issue of the lack of adequate resources in terms of gerontologists and the lack of adequate resources in terms of nursing and nursing care staff in personal care homes.
We have heard about the inequities that exist between the payment schedules for a nurse within an Aboriginal reserve vis-à-vis the nurse who works in the hospital that is perhaps 10 minutes away. How do you keep nurses in the reserve community if there may be a 15 or 20 per cent differential in pay in the hospital down the road?
The issue of human resources needs to be addressed. If you have any suggestions along that line, I would appreciate them.
Dr. Robertson: Certainly, it is a major issue. The area with which I am most familiar is the specialists in geriatric medicine. Approximately 200 people in the country have obtained the Certificate of Special Competence from the Royal College of Physicians and Surgeons of Canada, and about 150 people are in active practice in that area. Many of them do other things as well, including general internal medicine. The number of active full-time equivalents, FTEs, is probably fewer than 150. That compares very unfavourably with other countries — Northern Europe, Australasia — and that largely has to do with incentives within the system together with an overall shortfall in the number of physicians that are trained and practising in Canada.
This has to do with, as I am sure you are aware, the fact that Canada was already in the lower half of the numbers of physicians per capita in 1992 when a 10 per cent cut was made in medical school enrolment across the country. These things take a long time to work through the system.
Another big issue has been the decline in the number of family physicians and the changing practice of family physicians in Canada. This made access to a primary care physician less easy for a lot of people.
In British Columbia, for example, in the last year, recognizing this, substantial changes have been made to the fee schedule that make it less disadvantageous for family physicians and others to provide care in long-term care facilities — a small example of how changes within the provincial systems can help. However, when you have a constrained resource, that comes at a price somewhere else in the system.
With respect to physicians, most provinces recognize a significant shortfall in most specialties but particularly primary care and in specialties such as geriatric medicine, psychiatry and others. I believe the only country in the world that is overproducing physicians for its needs is Cuba. Similarly for nurses, the only country that seems to be overproducing nurses for its needs is the Philippines.
We have physicians in this country who have trained elsewhere and are not able to be licensed. Even for Canadians who are trained overseas, they have difficulty with licensure. There are huge issues there.
With respect to nursing, the problems are probably more acute. Many physicians continue to work, as I do, well into their sixties; but many nurses are leaving the profession in their fifties, and that has exacerbated the nursing shortage. I do not have any immediate solutions for that other than to underline the concern and anxieties that other people have.
The Chair: We have been told that at the present time only 10 physicians are in residency in gerontology across the country, so the numbers in gerontology will not increase in any significant way.
I had heard the same with respect to palliative care physicians when I began my work in the field of palliative medicine. We were able to fund the development of core curriculum initiatives so that, as of this year, no one graduated from medical school without training in palliative medicine.
Do we need to do the same in terms of young physicians being trained in gerontology if we are to hope that some of them will choose to become gerontologists?
Dr. Robertson: The dilemma is the point at which physicians-in-training need to make decisions about their career.
Two types of physicians essentially practice mostly with older people and particularly frail older people: family physicians who have done a two- or a three-year program after graduation with six months or a year in geriatrics; and individuals who have gone the Royal College of Physicians and Surgeons of Canada route, which is a minimum of five years of training to become a specialist in geriatric medicine. It is the latter group that we have somewhere between six and ten per year entering the program, so a total of ten in training in Canada.
In 1981, we did a study for the Royal College of Physicians and Surgeons of Canada, which was published, and we anticipated that by the year 2000, Canada would need about 550 specialists in geriatric medicine to barely meet needs.
Specialists in geriatric medicine do not provide primary care. They are there as a resource to primary care physicians, health care teams in the community, in hospitals and in long-term care facilities to give advice. Their involvement would typically be fairly short term and relies very heavily on a strong primary care system in order for it to work. This is in contrast to the United States where many geriatricians are in primary care practice and have an ongoing, continuing relationship with patients over a long period of time and are de facto both the primary care physician and the specialist together.
To answer the question, in most medical schools now, both the teachers and the students would say that they are exposed to large numbers of old people because the reality in most hospitals is that the majority of patients are older patients mostly with acute care illnesses.
A systematic approach to dealing with the broader issues of frailty, dementia, and particularly — and I bring this up because a brief reference to it is in the report from the BCMA — post-acute care is missing and has been missing, and we have tried in various parts of the country to initiate it. While your report and the report from the BCMA identify declining hospital utilization in terms of numbers over the last few years, caused primarily by the reduction in the number of acute care beds in relation to population, it is frail older people who stay for long periods of time in acute care hospitals.
The reason they stay, some people would say, is because there are no long-term facilities for them to go to. I would say that that is part of the issue. Our system is missing post-acute, step-down care for those individuals who may take a month or more in a properly structured environment in order to recover from an episode of delirium that they had in hospital or a fall and fracture.
In the absence of those resources in sufficient numbers, decisions are made prematurely and inappropriately, often to bypass the option of potentially returning home and going into permanent facility care. That is a major part of it as well.
Returning to the question, yes, I think it would be very helpful. There have been some initiatives. For example, for the last 15 years, the Canadian Society of Geriatric Medicine, now called Canadian Geriatric Society, has sponsored a summer institute that brings together young medical students, often in their first year, from across the country and gives them an intensive one-week program in all aspects of care of older people right from the community to palliative care. Many of those individuals are among the 10 people training in geriatric medicine. That initiative has been extremely successful in identifying interested individuals.
The reality for all of us in the health profession, except for pediatrics and obstetrics, is that the people we see are an aging population, and in some areas a very aged population, whether it is orthopedics or urology or general medicine. We also need to ensure that the curriculum content is enhanced for all students and not just didactic, that it is a mandatory clinical experience that involves working with older people in the community, the hospital and the long- term care facility, in all aspects of care.
The Chair: You talked about change in the funding model for family physicians to now go into personal long-term care facilities, but there is an overall funding problem. The pie has to be divided, and it is a limited pie. The pie cannot grow from an 8-inch pie to a 9-inch pie. You have to fit everybody in.
We know that if a physician, whose specialty may be internal medicine, practices palliative care, he or she is paid less to practice palliative care than to practice internal medicine. The incentives for people choosing areas of expertise, such as gerontology, tend to be limited. I would be the first to say that money is not the only thing that doctors pursue. However, I also know that it is pretty hard to come home and say to your spouse, ``If I practice this type of medicine, I can make $250,000 a year, and if I practice this type of medicine, I can make $175,000 a year, or I can make $50,000 a year.'' The reality is that it is not just the physician who makes choices; there is a whole family dynamic.
Dr. Robertson: Huge disparities exist within medical incomes, and it is true that anything that involves cognitive processes and time is less well-rewarded than other activities. This is one of the disincentives for individuals going into geriatric medicine.
This has been solved to some extent by many of the physicians that are practising either having university appointments with partial salaries that enable them to teach as well as have some protected time, or for individuals who work on a blended model of payment rather than a pure fee-for-service model. That is the way that the system and the individuals within it have adapted to it.
For example, a consultation of a new patient referred to a specialist in geriatric medicine is at least an hour and a half, which includes getting collateral histories: history from the family and the patient, mental status examination, full physical examination, functional evaluation, and then putting it all together and talking to people.
We hear constantly about very short medical encounters of 10 minutes and 15 minutes. The reality is that it does take a long time to do it properly. This is attractive only to some individuals.
However, I should point out that in research studies done in both Canada and the United States, paradoxically, the highest levels of professional satisfaction are found among specialists in geriatric medicine.
Senator Mercer: Dr. Robertson, you said that you were involved in a study in 1981, where the projection was that we would require 550 specialists by 2000. Where are we now?
Dr. Robertson: The number of individuals who have obtained the Certificate of Special Competence from the Royal College of Physicians and Surgeons of Canada is now around 200.
In 1981, when I obtained my certificate, there were six of us. Those were the first six individuals. From one perspective, it has been fantastic. We have grown enormously.
Within that group, some individuals are heavily engaged in research, some people are outside the country, and some people are not doing geriatric medicine full time. The actual FTEs are difficult to ascertain, but there are probably in the order of 150 full-time equivalents doing geriatric medicine in the country. We are at least a third away from where we should be.
Senator Mercer: We are at a crisis level. You are 400 doctors short, using your number of 150, which is probably quite reasonable under the circumstances, eliminating the people you did in your assessment. When governments cut medical school enrolments, I have no idea what they were thinking. It is the old saying: You cut off your nose to spite your face. You said that you thought it was probably worse in the nursing field.
How do we get more people into medical school, and then to study geriatrics? If they are not in medical school first, we will not get them to specialize in anything. In addition, how do we solve the nursing problem?
Creative thinking is needed on how to attract young people into the profession of nursing. It is an honourable profession, a wonderful profession and, as we all agree, vital to a healthy society. There has to be some answers. How do we go into high schools and into community colleges and say, ``Think of a career in medicine either as a doctor or as a nurse''?
A young man in this city, a friend of mine who has achieved excellent marks from the University of Victoria, has gone back and upgraded and then applied to medical schools across this country time and time again. He is a wonderful young man, and I think he would make a terrific doctor from the personality side; I cannot assess his academics — he gets no interviews. People want to go into the profession. How do we fix this?
Dr. Robertson: I am not sure that there is an easy fix to this one. I spend a lot of time hanging around universities, and I am not as close as I used to be to the current thinking around this. However, if we look at the number of physicians per capita from Canada and other Organisation for Economic Co-operation and Development, OECD, countries, we are less than halfway down the list in terms of numbers.
Certain functions that physicians are performing in practice, in a well-organized system, could be done by other individuals within the system, but then we are talking about a shortage of nurses as well.
Clearly it involves, as you said, going back to the high schools, getting people to understand that these are interesting, valuable professions to follow. A short-term fix would be to encourage and incentive the nurses and physicians who are currently in practice to stay in practice until new individuals are trained and recruited within the system. As a longer-term fix, a person moving into a profession such as this where there is a long training period has to have some sense of the career plan that they may follow.
In the last couple of decades, we have seen instances of dramatic cuts, particularly to nurses in other provinces, that have resulted in a wholesale migration of well-trained nurses to other countries. It seems we have to take a longer view to understand that we are training individuals who will be required for a 30- or 40-year period within the health care profession.
That is a very unsatisfactory answer, I am afraid.
Senator Mercer: It is not unsatisfactory. It is a good assessment of the situation. One of the ways I have always looked at it is getting new people into the profession, expanding medical schools and opening new nursing schools, or, more importantly, opening old nursing schools that have been closed. Your suggestion of trying to keep doctors and nurses working is a very good one, and I am not sure that we have the answer to the incentives that are needed.
As we know, geriatrics can be physically demanding for nurses because of the frailty of the patients. We are talking about keeping people in the profession who are probably toward the end of their careers, so they themselves have aged and have the bangs and bruises that we all get as we age — people the same as me with artificial knees and so on. If we keep them in the profession, then it frees up other nurses that could do the geriatric side of the profession.
Dr. Robertson: Some technical fixes can be done. For example, heavy lifting is a problem for nurses. Many facilities now are installing ceiling-mounted lifts that will assist them with that.
We could take it a step further and look at the potential for technology to create safe living environments for individuals that could be monitored from a distance. Ideally, we will have more human interaction, but if we cannot get that, we should look at the possibilities of smart houses or smart living units in which monitoring is carried out, for example, to detect whether the patient falls. Now we wait for them to be able to find their alert button, press it, and summon help. If we have a seismic detector in the floor, one could detect a change in the pattern that would enable people to send a responder if someone has fallen. There are a number of examples such as that, where, if we were imaginative, we could probably identify ways to deliver care better and perhaps more effectively.
Senator Cordy: Friends of mine who are nurses in their fifties are asking to get out of there. They are short-staffed in the hospitals. People who are in the hospitals are now sicker than they used to be because as soon as they start to feel better, they are discharged. These nurses are being phoned on their days off to go in to work, and they are counting down to retirement, which is truly unfortunate, but we certainly understand why.
In answering a question of Senator Carstairs you talked about post-acute care. You went over it quickly, and I was scrambling. You talked about assessments sometimes being made a little too quickly, you thought, so that people are perhaps put in assisted living when maybe they could go home. Would you mind repeating that?
Dr. Robertson: One of the features of many other countries' systems is the provision of a range of post-acute care that recognizes that a hospital is actually a good place to be if one needs all of the things that a hospital does. However, it is not a particularly good place to be if one requires long-term care, or palliative care for that matter. Specialized units are there to focus on what it is that they need to do.
For example, in the United States, many of the nursing homes are not entirely long-term care facilities. At least half of their beds are for individuals who come in and go home. These are often linked in what is called vertical integration with acute care hospitals in order that a patient may go in for surgery, may go in for an acute illness, and stay a very short period of time. Only when they are physiologically quite unstable and actually need the intensive medical and nursing care that can only be provided easily in an acute care hospital, then, as rapidly as possible, they are transferred to nursing homes. However, we might not recognize them as nursing homes because many of them will provide five or six hours of nursing care per person per day as opposed to the two hours or three hours that might be provided in our nursing homes for long-term care.
The intent of admitting those people to those facilities is that they are restored to health and function and discharged home as soon as is practical.
This would include convalescence, which is basically that people are just given time to improve; it may include what we call geriatric rehabilitation, which is a little different from standard rehabilitation. The reality is, if you are providing rehabilitative services for people over the age of 85, at least a third will have significant cognitive impairment and many more will have some mild cognitive impairment. Many of those individuals are not seen as prime candidates for rehabilitative services, which are focused more on younger, fitter people with shorter lengths of stay.
A unit that accepted that a person with multiple chronic illnesses is medically a bit unstable, could in two months improve their function to the point that they could return to either their home or to a lesser level of care than they might require, would put that person into a geriatric rehabilitation unit. A few of these resources are available in Canada, but fewer than are needed at the moment and will be needed in the future to meet the needs of this population.
Indeed, in the BCMA report entitled Bridging the Islands: Re-Building BC's Home and Community Care System, this group of services were excluded simply because they were different from the standard home and community care. The focus is not on maintenance but more on improvement. It is somewhere between acute care and long-term care.
Senator Cordy: Are you saying that they are not funded by our public health care system?
Dr. Robertson: They are simply not there.
Senator Cordy: They are not in Canada.
Dr. Robertson: Toronto has some geriatric rehabilitation units around the city, and there are some beds in Calgary, Edmonton and a few in Vancouver. Their numbers are very few in relation to the need. Most of them are not in long- term care facilities, they are either in rehabilitation hospitals or in sub-acute areas of acute care hospitals.
Senator Cordy: We are still doing the hospital-doctor model. We are not veering away from that at all under Canada's health plan.
Dr. Robertson: It is rehabilitative in the sense that it involves rehabilitation therapists, social workers, nurses, doctors and psychologists — a whole group of people. They could occur in acute care hospitals, but in terms of a more appropriate location, if you are planning discharge home, it might be in a community setting such as a long-term care facility with these additional resources added to it.
We had some experience of this in this city many years ago, and it continues to some extent. It is taking individuals usually after a serious acute illness, very often an episode of delirium or when they have had a sudden decline in their functional abilities or their ability to ambulate, and identifying within that group those individuals who have the potential to improve with time.
Senator Cordy: We talked about education in medical and nursing schools in terms of geriatrics. However, I believe it goes farther than just educating doctors, nurses and seniors and anyone working in the health care field. It requires educating the public as a whole because seniors are living in communities not in isolation. That is something that could be a federal impetus, that could come from the federal government. We have had the smoking cessation programs, which worked very effectively.
We have heard from seniors who may be abused financially, but also physically and sexually and in other ways. Seniors are very embarrassed to tell people about it because they think that they are doing something wrong or that they will be isolated from a family member or caregiver.
How would such a program work nationally, and who should be the targets?
Dr. Robertson: I am not certain how it would work nationally. However, education should include future planning but not just future care planning.
Many of us approach old age perhaps with a rosy view or an inappropriately pessimistic view, and to give people information about what might reasonably be expected as we age could well be part of one of your recommendations with respect to educating people about ageism. Changes occur as we age that we should know about that will ultimately, if we live long enough, affect our functional abilities. Thinking ahead and making arrangements with respect to financial management and health care decisions are ways of protecting oneself against the issues of financial abuse of elders that you heard about yesterday. Failure to make those advanced planning decisions renders people vulnerable.
Would getting information ensure that everyone would follow that? I doubt it. Tools could be developed to help people work through the advance planning decisions they need to make. That is something that could be a federal initiative as well.
I would like to speak to the issue of planning, which is in your interim report. In the BCMA report, although the BCMA is a strong advocate for a strong public health care system, the recommendation for a tax advantage savings system for chronic illness in old age is included — and I see that you have that as one of the potential recommendations in your report. I would tie that to this as well. You deal with ageism, which is pervasive; we all know that. One deals with the advance planning that needs to be made in anticipation of living a full human lifespan, what one might reasonably expect in the later years of life and how one prepares for that. It is preparation in terms of one's personal and financial decisions. That could be put together as a positive way of giving people the information and tools needed to proactively think about where they will live.
I deal with this frequently when individuals are at a point where they can no longer safely drive. If they are living in a location that is remote from public transport, if they have not anticipated that sometime in their late eighties or nineties they may have to stop driving and are living in a location that they are reluctant to move from, that places them in a very difficult situation.
We should all recognize that at some point all of us will have to face a decision about our continued ability to drive. The location in which we live is an important part of that decision. We can recognize that in advance and take the steps that are required to anticipate that.
The Chair: I will end with an interesting concept, and I would like to have your views on it.
It was health economists who told us, in 1991, that we were training too many physicians. It was people other than physicians who told us this. We all bought that and cut enrolment in medical schools across the country. We certainly have lots of people applying for medical schools, but we are not taking nearly as many in as we could.
It has been suggested that maybe we are overeducating physicians. In Britain, you can go to medical school after your A-levels, so you are about 19 years of age. In Quebec you can go after two years of Cégep, which means you are also 19 years of age. In the rest of Canada, we are, for the most part, not taking people until after their bachelor of science and, in some cases, their masters of science.
Do we need to do that? Is there something wrong with the Canadian English-speaking student that we could not start training them in medical school at the age of 19?
Dr. Robertson: As someone that entered medical school at 18 and came to Canada in 1966, yes, it is possible to do that.
Some would argue that there has been a change in the educational system as well. I know Britain, while you can technically enter medical school at the age of 19, many more individuals are entering now than used to be the case with at least one degree. In Britain, medical schools are a five-year program, or six years in some places, as opposed to the four and, in some places, three years in Canada.
It rather depends on what people expect from their physicians. The amount of knowledge that is required to demonstrate basic competence continues to increase. The amount of knowledge that one has to replace in order to maintain continued competence is significant, and certainly life-long learning and knowledge transfer can be valuable.
The University of Calgary and McMaster University have three-year programs, as you well know, and their graduates do not seem to be at any significant disadvantage having done shorter programs.
In a competitive, restricted market, where it is very difficult to judge personal attributes in an interview, grade point average and degrees are less subjective measures that are used, at least in part, to make decisions about entry into medical school.
The Chair: I know there were 24,000 applications for the first-year class at McMaster University this year. All of the applicants had degrees. It was not a lack of ability, simply a lack of places.
Thank you very much for being with us this afternoon.
The committee adjourned.