Proceedings of the Subcommittee on Population Health
Issue 1 - Evidence, November 28, 2007
OTTAWA, Wednesday, November 28, 2007
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:06 p.m. to examine and report upon the impact of the multiple factors and conditions that contribute to the health of Canada's population — known collectively as the social determinants of health.
Senator Wilbert J. Keon (Chair) in the chair.
[English]
The Chair: We have an interesting meeting this afternoon because we have with us the experts from the first population health program in Canada, implemented in Prince Edward Island.
Of course, one of our committee members was the Premier of Prince Edward Island from 1993 to 1996. We should be able to be educated to a very high degree.
I want to thank the three witnesses for appearing. As I explained to committee members, our witnesses had to prepare themselves quickly; they did not have the lead time that most witnesses have. Therefore, we deeply appreciate you appearing and dealing with this as best you can. We understand fully that you did not have the preparation time you would have wanted.
We have with us Ms. Teresa Hennebery, Assistant Deputy Minister, Health Operations, P.E.I. Department of Health. The Department of Health works with stakeholders to promote health and prevent illness, using several collaborative approaches that focus on health determinants.
We also have with us Ms. Patsy Beattie-Huggan, President, The Quaich Inc., which was founded in 1998 to provide advice and innovation as well as health promotion products. Ms. Beattie-Huggan has served at the senior management level of the P.E.I. health community services systems during the health policy reforms.
Patsy Beattie-Huggan, President, The Quaich Inc.: Honourable senators, I wish to thank you all for the opportunity to share my experience and lessons through the 1993-1996 population health reforms in Prince Edward Island.
Since I received the phone call last week, I have been scrambling to reconnect with my own memories, which is sometimes hard to do when you get to a certain age. It was such an exciting part of my journey and my professional career that it was interesting to go back and reconnect with people who were involved in the health reform days and ask them what they would think in retrospect was the key lesson from that time.
It made sense to me to speak about my lived experience because I think the document your researchers compiled is an excellent record of the time. I could not have done better myself. In going through it, I was thinking that I recognize all of that. I thought I would group it according to the stages in which I had my own involvement and take it from there.
I did this in terms of a planning stage, a change agent stage, and also how I am the beneficiary of having had that experience — what I have been doing currently in the work and how I used those lessons.
In the mid-1980s, I was involved in the Association of Nurses of Prince Edward Island, ANPEI. I chaired a committee that was advocating for baccalaureate education for nurses as entry to practise in Prince Edward Island. In that process, I started to realize that the health system needed to change if these nurses would be using their education to the greatest extent. I began researching health system reforms around the world and what direction they were taking.
There are some profound documents that have made a big impact around the world in a number of different systems. One is the Lalonde report, which is Canadian, along with the declaration of the World Health Organization, which outlined goals for achieving health for all, including guidance and principles for reforming primary health care. We did a lot of research based on that and I was very involved at that point.
In 1989, there was a document that is not recorded in your backgrounder that was pivotal. It was released in P.E.I. and it was called «The Hospital and the Health Care Community,» written by Peter Ramsay, who was in charge of one of the more rural hospitals at that point. That document said that, although good care was being delivered on Prince Edward Island, there was no real system for that care. People who needed care, perhaps for multiple systems, had to knock on several different doors. The systems were not speaking to one another. The hospitals had hospital boards but they were managing just the hospitals. Social services and public health were not attached to that. Aside from that, some of the people using the health system a lot were also using other systems, like the justice and social service systems.
Before I took on my position, we were doing this research. I also found a report written and commissioned by Senator Callbeck, which had a lot of recommendations and identified many of these issues. However, it was that 1989 report that kick-started this need to look at the system and do it differently.
In that next year, there was a call on stakeholders — ANPEI being one of those — to be involved in looking at where to go from here. There was a lot of public consultation around the province. By that point, the association had conducted a literature review, looked at models and put forward a proposal to this transition team in terms of how the system might look.
I feel that was an influence that probably gets overlooked a lot in terms of where some of that material came from. It came from a fair amount of lobbying by that group. It was looking at community health centres in particular as having a big impact on primary health care. It was not talking so much about population health but about organizing care differently around the clients so that they had one point of entry with a number of services built around them — more integrated and holistic care.
Through 1991-92, there was broader consultation. During that time, there were working groups struck that put more detail to the reform of 1993, and contributed to the development of the document, "Partnerships for Better Health.''
During that transition year, I was at the University of Edinburgh studying for my master's degree, where I was receiving all the documents being developed on Prince Edward Island. In my course, I was comparing health systems around the world, looking at the U.K. health system and starting to see that no one system had all the answers. That was freeing because, in coming back to Prince Edward Island, it created that climate and my attitude toward change — which was why can we not do it here?
I was very fortunate. When I came back to the island, my husband had submitted my resumé in response to an ad. Suddenly, I had an interview at the senior management level and became director of community development in the new system. That turned me into a change agent — I think I had been a secret one all my life, but it was nice to do that — and in the fall of 1993-94, the reforms were initiated.
This is where the people part really started. The negotiations with the unions began in earnest, along with the hiring of staff. There was a lot of excitement for those of us involved in initiating this change that had this vision about what health care could look like in a system that would be more responsive and more integrated, with care provided around people.
It was also a painful time for people who had been in the Department of Health. Suddenly, they did not have a job anymore; they had to apply for new jobs in this agency. I have to mention that because the people part is important in what happened and how it unfolded. It is difficult for those of us in that system to be interviewing our colleagues and deciding which one of them would get the job.
The expectations on us were great. We were change agents. We were hired that way. Our resources were few. We had to borrow desks from our previous employers. We had no resources at that time for running simultaneous systems.
However, we were motivated by the values underpinning health reform. If you have a chance to look at the document, "Partnerships for Better Health,'' you will see how laden it was with values. We were working long days and excited by it all. It was a highly educated group of people and it was an amazing experience from that point of view.
There was a lot of interest from outside researchers at McMaster University and the University of Helsinki, along with the European Union. There were a lot of projects going on, and that was exciting.
One of the products we developed on Prince Edward Island was the "Circle of Health,'' and I have circulated that. That tool is still in use, which is amazing, because I thought its shelf life was about five years.
In the end, financial challenges brought a halt to it all. There were problems with cutbacks to federal transfer payments. Provincial creditors were knocking on doors and tough decisions had to be made about rollbacks. People began confusing reform with cutbacks, and we started getting backlash.
Soon, it became billed as a failure for the next election; it meant a change in government. That was 1996. I ended this section of my update here; after the restructuring took place that year, my position was eliminated.
That should be the end of my story, because I left government in 1998 when I decided that was not where I should be. However, it does not end there. I feel I was fortunate to be so motivated by the experience, to be part of something that was so creative and to have a candle of passion lit under me.
I believed there was potential, in the work that came out of that time, to take it forward. I was lucky in that Ms. Hennebery had moved into that position and was supportive.
I started my company, The Quaich Inc., in 1998. By the way, a quaich is a cup of friendship. Normally, one would pass a cup of malt whisky around the table, but I did not bring any with me. However, a quaich is a symbol of friendship and community, which is what I wanted to bring to the company.
I have been involved in many contracts since then. I will not get into that, but the one I want to highlight, because I see it as a legacy of health reform days, is the Atlantic Summer Institute on Healthy and Safe Communities, which has taken off. It began with an unsolicited proposal that was submitted in 2003, and is now in its fifth year of planning.
Funding is always a struggle but it is Atlantic-Canadian based. The Circle of Health is integral to its curriculum. In what I have distributed here, you can see that the advisory committee is representative of the Atlantic region, with three levels of government, three research centres and also community organizations. That says to me that the legacy of health reform is strong, it does exist, the cooperation is there with the health system, but it is outside the system.
What are the lessons learned? A range of people were interviewed by me in this last week. There was a community partner from health reform days, two former CEOs, and an evaluator who worked with Mr. Eyles as well. They used different words, but the themes remained consistent. In terms of the lessons that were learned, they said that more time is required and that the four-year political cycle followed does not allow that to happen. We need to be planning for 20 to 30 years. Tobacco is one example where we would not be where we are if there had not been long term work on that.
They also said that there needs to be dedicated financial resources for population health. Separation of services was also said to be necessary. As long as acute care and population health are kept within the same budget, the money will go where the crisis is. No matter how much they try to integrate services so that the community would influence the hospital, in reality, it does not work that way because the crisis always takes over.
There needs to be a structure for population health that is an overlay. Perhaps it needs to be a national structure with a national direction. One person said that, if money goes directly to the provinces, which have such a problem with acute care, that that is where the money would go, namely, acute care.
Public support is needed. Most politicians are influenced by public opinion, not necessarily research evidence, whereas public servants are more influenced by research evidence. This presents a dichotomy.
The importance of community involvement was stressed by three different people for different reasons. One, it keeps you real and services should be based on real needs. Two, people know there own experience and it needs to be heard. Three, it is important to have structures for innovation, which do not necessarily occur in bureaucracies but can occur both in community and in regional health authorities or in the private sector. There are different structures that would work for innovation in different ways and bureaucracies tend to stifle that.
I have two strong beliefs of my own that I wish to add. Population health as a concept is difficult for people to grasp and understand. The word "health'' puts up barriers; people immediately think health sector. Even if you talk healthy communities, their eyes glaze over. I have tried to talk to ACOA, the Atlantic Canada Opportunities Agency, about funding for the summer institute, to bring the various sectors together and learn from each other. We know employment is a big factor in health. However, the general response is that the reason you are coming to me is because the health system is running out of money or it is not in our mandate. Hence, education is needed in some of these other sectors to share resources to make a difference in terms of population health.
Interdisciplinary work is a factor across sectors, and we are addressing this in the summer institute. We want to bring people together to develop a common language and understandings, and to build capacity in Atlantic Canada. Work is needed on literacy levels, but this is a complex concept. I have also given you an example of a learning tool developed for the summer institute that is in plain language and illustrates population health through a story.
Change management is also important. We need to value people — and do more than just say we value people. Population health reform was one reform of many, but it is ironic that it is so incongruent in terms of what happened to the people. Workplace wellness research is showing how much being valued is important to people's overall health.
In closing, I am working with many people in the community now. I met a woman last week who is a real leader in Elsipogtog First Nation. She has developed a concept that she describes as population health meets the medicine wheel. However, she struggles with getting her own band council to understand it. The challenge is how to move these concepts forward into a wider community.
Atlantic Canada has issues with changing demographics and we have been doing work in terms of creating a profile; it is a work in progress. The work this committee is doing is very timely.
The Chair: Mr. Eyles is a professor at the School of Geography and Earth Science at McMaster University. His research interests include the evaluation of health care systems and programs, utilization of evidence-based decision- making frameworks in health and environment settings, and, recently, he participated with a group of Canadian researchers in an evaluation paper on the P.E.I. experience.
John Eyles, Professor, School of Geography and Earth Sciences, McMaster University: My work with P.E.I. dates to about five years ago, although my interest and research in population health has continued in different settings. Therefore, I have more to say about population health generally, although it is influenced greatly in a positive way by my P.E.I. experience.
Ms. Beattie-Huggan and I agree, population health and social determinants of health are rich, all-embracing, inclusive concepts. However, there are problems trying to make them operational and meaningful at the policy and practice level. That is a struggle with population health in general. The mandate of health continues to spread outward, across the policy environment, like an octopus. Its relationship to the mandates of other policy areas, particularly in terms of funding, needs serious reflection. Certainly in Ontario, health expenditures have frozen out virtually every other welfare program.
I will address the challenges and successes of the P.E.I. reforms of the 1990s, and then share lessons learned from that experience and from my own growing interests in population health.
First of all, a few strategic comments about P.E.I.'s experience: The reforms were far-sighted and courageous. P.E.I. led Canada for about 10 years in population health matters and in trying to implement population health at the regional level.
The reform that was undertaken was massive, and the relationship between population health and other aspects of the reform did not always sit easily together. In particular, regionalization took a great deal of effort and time to work its way through the system, at the same time that this new agenda of population health was being instigated at the policy level.
The second general strategic point I make is that it was decided in P.E.I. that there would be a separation of powers. There would be the creation of a policy agency, a council to make strategic decisions, as well as the line ministry, the line Department of Health and Social Services. I think that is an excellent idea. It allowed players to focus on different elements required for improving the health of the population. Practically, it was daunting. It could lead to conflict and mistrust and differences of opinion that were perhaps not always helpful.
The final general comment I will make concerns the idea of population health itself. It was accepted, although it is a difficult concept, as we have said, at the policy level. I am less clear that it was accepted at other levels in the P.E.I. system — the decision-maker level, by which I mean the politicians, and the provider level, by which I mean doctors, and citizens. I do not think they fully understood, and that will come back in lessons learned in a short time.
Moving on to some operational comments, I have divided it into challenges and success. There were three or four operational challenges that I see from the P.E.I. experience. The first is the importance of acute care. Of course, it is important, and it stayed important in the minds of politicians, citizens and many providers. At the time of retrenchment, the idea that acute care might be cut was a threat to rural livelihoods, in particular with the closure of hospitals, which meant that population health was dealing again with a very difficult set of circumstances.
The second operational issue concerns trying to change work practices and agreements, particularly among unionized staff, and in that I include the physicians. They have a right to treat and operate in the way they see fit, and for me they are the most powerful union we have in this country.
Third, population health was seen as part of health promotion. My colleagues may disagree. Health promotion is very much at the margins of the health care system, receiving a small portion, only two or three per cent, of the budget. It is perceived to be at the margins of care and is the first thing to be cut or reduced in times of retrenchment. Therefore, population health home in the health system was a difficult challenge because of that connection. Where else would you put it, in some ways, but it is a challenge.
The final challenge that I can point to concerns the centrality of finance funding and budgets. The allocations to the regions were difficult. They were made along historical lines, and there was no attempt, as shown in one of the prime findings from our evaluation, to create a different focus in budget lines. Without a budget line, you are simply nowhere. As times became harder, that was one of the main problems with trying to advance the population health agenda in P.E.I. Circumstances change, as Ms. Hennebery will tell us in a few moments
The successes, and there were many, were largely at the level of integration and cooperation and partnership, the things that Ms. Beattie-Huggan so eloquently emphasized. There was across-department cooperation at the provincial level. Health and Social Services and justice, for a while, were involved. There were across-service partnerships, especially within regions, which was very positive and led to great community involvement in health delivery, broadly defined. There was resource sharing between services, mainly in staff time and infrastructure, which is really important for those on the ground in providing help for those who required it, those in need. Population health as an idea, I think my final success will illustrate, although there are many others, was shared and specifically championed, especially in the service delivery community. I think they got it, and that was a wonderful thing to see.
In closing, I shall talk about three or four lessons learned. The P.E.I. reforms, of which population health was a part, were a massive undertaking. As has been mentioned, it is difficult to move forward on many fronts at the same time. For me, the lesson learned on the way forward would be perhaps to concentrate on specific objectives with targets at specific times. For me, population health is a credible framework for specific conditions. How else can we look at the rise in teen pregnancy? How else can we look at the increase in type 2 diabetes without a population health framework? Who should lead those initiatives is another issue I will come to in a moment. It should not always be physicians, nor should it always be Health Canada policy people who lead them.
Given that we are better at looking at specific objectives, maybe we should reframe what population health is about. We are not very good at health. We are far better at understanding illness. Perhaps we should think about an illness- reduction strategy at a population level.
Population health or illness reduction requires time and money, as Ms. Beattie-Huggan said. Budget lines need adjustment to reflect those priorities that we see as important, and time is required to see if initiatives lead to the desired outcomes and targets. It is important to have those outcomes and targets, and population health in many jurisdictions, not necessarily P.E.I., has been lacking through not having targets. As Ms. Beattie-Huggan also said, those timelines seldom coincide with the electoral cycle. Population health policy, or illness-reduction policy, since I should stick to the term I prefer, requires a reasonable lead time and preparation. We need to inform all constituencies before the specific policy objectives are rolled out to get that buy-in and understanding of what we are trying to do in terms of health improvements or illness reductions for the population. I do not think any jurisdiction that I know has spent sufficient time in that preparatory work because you simply want to get going, which is understandable.
What P.E.I. showed to me and my work since, which has mainly been at the local level, is that it is very important to identify lead agencies, champions and partners in any endeavour to reduce illness or improve health, but then who should it be? Should it be Health? Could it be someone else? What should the relationship between Health and other departments be? Can those partnerships be formalized in terms of agreements? What is the role of politics and the cabinet in this? In other words, who should be the champion for this? What department, what agency, what level, what function? As the program policy moves through, it may be that the champion has to change or there has to be a many- headed champion.
Teresa Hennebery, Assistant Deputy Minister, Health Operations, P.E.I. Department of Health: Thank you for the invitation to speak to this committee today. Senator Keon mentioned earlier that we had a fairly short time frame to prepare for this, and indeed that is correct. I will veer slightly from the notes that I shared with you earlier, not a great deal, but somewhat, if that is acceptable.
It is an honour to be here today to speak to you about population health in our province of Prince Edward Island. In particular, in preparing for this presentation, I was asked by the committee staff to focus comments on health reforms in relation to population health.
I will conclude my comments by highlighting three areas around population health that I believe require national attention. I do not believe that population health is strictly a provincial matter. I believe there are many initiatives that can and should be undertaken by Canada as a country.
Before I begin, I should like to qualify my comments. My comments today reflect my personal experience and observations gained over the span of my career in health care in various provinces and jurisdictions in different capacities and under various organizational structures that I will tell you about.
I am not advocating for any magic bullet or perfect health reform solution to population health. I do not think there is one. Rather, it seems to me that, over the past 15 years in P.E.I., a body of knowledge has developed and various approaches have been tried with lessons learned.
With this in mind, I will relate my experience and observations rather than directly represent any particular policy direction or position of the Government of Prince Edward Island.
Early on in my nursing career, in the mid- to late-1980s, I had the opportunity and privilege to work at outpost nursing stations in small communities in the Northwest Territories for a number of years. In many instances, I was the only nurse and the only health care provider in those communities.
Coming from rural P.E.I., I was nothing short of shocked at the social and health conditions that I met in these communities. There I gained firsthand experience with the stark and harsh realities of health status gradients and also with some of the levers available to lessen health disparities and improve population health.
After working in Southern Alberta as the CEO of a large health unit, I had the opportunity to move back home to P.E.I. in 1995. Since then, I have worked in various roles in our health system, primarily in the areas of home care, health promotion and public health. I was appointed to my current position in September of this year.
Prince Edward Island has had extensive experience with health care restructuring and reform. Our health and social services system has undergone four major changes in the last 15 years. They occurred in 1993-94, again in 1996-97, in 2002 and most recently in 2005. Each change was intended to achieve specific objectives and to improve the services provided to islanders and the overall health of the population.
My colleague, Patsy Beattie-Huggan, addressed the health system restructuring that occurred in 1993-94. I was not working in the province at that time, so I will focus my reflections on last three organizational changes that took place.
In 1996-97, following a change in government, the Health and Community Services Agency, that was alluded to earlier, was amalgamated with Health and Social Services. While the role of the department at that time evolved somewhat, the regional structure remained and, at that time, we had five regional health authorities in the province.
Under this structure, the department was responsible for setting policy direction and for providing advice and assistance to the five boards. Each regional authority had a board with an executive team responsible for delivering a full range of health and social services in their catchment area. The CEO of the region was appointed by the minister but also responsible to his or her respective board.
Under the regionalized structure, a number of gains were made. There certainly were improvements in the integration of health and social services at a community level. The boards provided an effective means for public input into health system planning, policy-making and resource allocation.
Coordination among various sectors, such as education, improved at the local, regional and provincial levels under this structure. Theoretically, the health authorities were well positioned to reallocate resources to support communities-based programs and to address the determinants of health and improve the overall health of the population.
However, the actual experience was quite different. In fact, some would say that the opposite occurred. As was alluded to by my colleagues, during this time, the care system, especially acute care, was experiencing significant financial pressures. These pressures created a drain on other sectors of the health and social services system because there is only so much money to go around.
For example, savings that might have been achieved in the area of financial assistance were not automatically reinvested back into that program or into another social policy area and often were applied to the bottom line to offset expenditures in the overall budget of the health region.
There were also a number of administrative and coordinating challenges associated with the regional structure. For example, it was extremely difficult to clarify roles and responsibilities of the department vis-à-vis the regions. For a small province, our system was very bureaucratic and decision-making processes were cumbersome. Of these challenges, public accountability for service quality and authority for decision making in relation to allocation and reallocation of resources were the most pressing.
On paper, the boards were responsible and accountable for the quality of services within their area and had the authority to make resource allocation decisions. In reality, and in the public mind, the minister was ultimately accountable for service delivery. On P.E.I., this level of accountability is very personal. Islanders like to have ready access to politicians, including the minister responsible for health and social services. In practice, this meant that boards were not accountable for budget deficits and, conversely, if the boards had a surplus, they were not able to retain that to reinvest back into their programs.
In addition to local efforts associated with regional authorities, there was a number of fruitful system-level initiatives. I will speak briefly about one success story, the Healthy Living Strategy. In 2003, the province launched this strategy. It focuses on common risk factors that contribute to chronic disease — namely, tobacco use, diet and physical activity.
The strategy featured a truly collaborative approach involving various levels of government, a wide variety of government departments including Health and Social Services, Education, Communities, Cultural Affairs and Labour, as well as justice. It also involves a number of community-based organizations and actual municipalities within our province.
This strategy provides a mechanism to facilitate a multi-pronged and multi-partner approach to reduce risk factors for chronic disease in our province. To illustrate how a multi-pronged approach worked, I will discuss briefly the tobacco reduction component of the strategy.
The approach to tobacco reduction included broad-based public education, social marketing efforts, smoking cessation support programs, legislation focused on creating smoke-free places, blocking tobacco sales to minors, as well as very strong point of sale display bans for tobacco and restrictions on where tobacco can be sold.
Efforts were coordinated under the Prince Edward Island Tobacco Reduction Alliance. Similar to the overall strategy, the Tobacco Reduction Alliance took a partnership approach that included government, regional health authorities and communities. These results speak for themselves. On P.E.I., smoking rates have declined from 26 per cent in 2000 to 20 per cent in 2005. Even more impressive, the rates of teen smoking have declined from 17 per cent in 2004 to 13 per cent in 2005.
Certainly, provinces will be challenged to make further reductions in the area of tobacco. I understand the Federal Tobacco Control Strategy is aiming to reduce smoking prevalence in Canada to 10 per cent.
Still along the lines of tobacco, I think it is very important to note as well that within our province there has been a change in the culture. There is certainly less public acceptance of tobacco use, especially in places, both public and private, where Prince Edward Islanders may be affected negatively by second-hand smoke.
In 2002, our health and social services system underwent another restructuring. Under this structure, the two provincial hospitals and some specialty services were amalgamated under the provincial health services authority. The two health regions in eastern P.E.I. were amalgamated into the Kings Health Region. As well, minor structural changes were made to the Department of Health and Social Services. These changes were intended to focus planning for the delivery of acute care and related specialty services within a provincial framework in order to enhance efficiency and effectiveness, thereby allowing health regions to focus on integration of community services at a community level.
Again, there were successes and challenges associated with this structure. For instance, the two provincial acute care hospitals each held their own long-established identity, culture, norms and their own ways of doing business. However, over time, integration and coordination did occur and there were cross-facility quality teams formed.
Front-line service providers did begin to see the benefits of inter-facility integration and collaboration between these two hospitals. Regional health authorities were freed from the responsibility of managing provincial acute care and specialized service and were able to place more of their time and effort on integrating community services, moving forward on implementing family health centres as an important aspect of primary health and emphasizing overall wellness and population health.
While a number of benefits was associated with this structure, there remained the problem of bureaucracy. We continue to have essentially five regional health authorities and a department. Role clarity continued to be a challenge; as well, we were challenged by the issue of financial pressure and cost containment.
In 2005, the most recent major restructuring at the health and social services system was announced. This restructuring resulted in central administration of all health and social services. The four regions and the governing authority for the two hospitals, the provincial health services authority, were collapsed, and the Department of Health and Social Services was separated into a Department of Health and a Department of Social Services and Seniors. The role of the department changed fairly drastically to include direct responsibility for service delivery.
While the regional health authorities were eliminated, community-based boards were established for each of our five community hospitals, in accordance with legislation entitled the Community Hospitals Authorities Act. These changes were intended to improve efficiency and reduce duplication and public expenditures, while having minimal impact on front-line service delivery for islanders. During this process, approximately 140 administrative management positions were eliminated from our system, resulting in savings of approximately $9 million.
While it is very early days in our new structure — and I do need to stress that we are only two years into this structure — I would like to make a few observations. The structure certainly has streamlined decision making and has clarified that accountability for the quality of health services does rest with the Minister of Health. Our system is very lean in terms of management and administration in all areas, especially in some of our corporate service areas.
The current structure has limited opportunities to link with communities, and programs and service integration continues to be a challenge. There is a need to establish and improve mechanisms that support linkages between the systems in the communities — and this need has been identified.
From a social services perspective, each structure has had challenges and successes as well. The regional structure created and supported opportunities for enhanced integration and collaboration. However, this was to some degree offset by the urgency and resource intensity demands of acute care. Under the new structure, the social service system is a separate entity and can focus on social programs and social policy.
Another issue is the fact that emphasis on population health strategies, such as those focused on children, youth or seniors, cannot be framed solely within departmental scopes of responsibility. As a result, mechanisms are being established to enhance intersectoral collaboration. For example, in our province we have a deputy minister level committee that focuses solely on the area of social policy. We are in the process of developing a youth addiction strategy that is intersectoral in its planning.
Although we have had various types of structures in place in the province to govern and manage our health system, I think that most people who work in our system would suggest that there is no perfect structure. In fact, the most important ingredient for success appears to be good relationships among people and a willingness to work together across organizational and sector boundaries for the right reasons and to achieve the right results.
The ongoing search for the right structure has been costly. Repeated health system restructuring in our province has created some lack of consistency. It has affected staff, as we have heard earlier. It has impeded progress in some areas and we have lost some corporate memory and knowledge.
As a result of the ongoing changes in our system and the tendency to focus attention on the provision of acute care services and the recruitment and retention of health care professionals, it has been difficult for us to create a foundation for population health interventions and health promotion strategies. In the area of health promotion, we have tended to take a universal approach as opposed to a targeted approach to programs.
In terms of health status in P.E.I., we are doing really well in some areas and not so well in others. For example, life expectancy continues to rise. Low birth weights are well below the Canadian average in our province and we have had huge success in the area of smoking rates. However, obesity, use of alcohol and physical activity rates are above the Canadian average and are continuing to rise. As well, principal chronic conditions are above the Canadian average. As well, 25 per cent of our population have less than high school education; and average income in P.E.I. is lower than the Canadian average.
However, the good news there is that we have much more equitable income distribution than in some other provinces, and we have a very high level of social cohesion.
I would like to make some comments about areas where I believe we need national leadership in the area of population health. All of my suggestions focus on strategies aimed at children.
First, the area of childhood poverty requires a national solution. Recent Statistics Canada data indicate that approximately 800,000, or almost 12 per cent of Canadian children, live in poverty. I would encourage this committee to examine the success we have had in Canada in reducing poverty among seniors, and explore if any of the same strategies can be applied to alleviate poverty among Canadian children. It is known that adequate family income for children, especially in the early years, is a contributing factor to positive outcomes.
Second, a truly national early childhood education and care program would pay big dividends in the area of population health. Experts agree that there are three characteristics of quality child care: low child-to-adult ratios, highly educated staff with specialized training, and age-appropriate equipment and facilities. It follows that children from low-income households benefit the most from quality child care. Currently, each province and territory has its own approach to early childhood education, and the approach varies considerably from province to province.
Finally, I would encourage the committee to consider making observations on strategies that are known to reduce childhood obesity, such as increasing breast feeding, regular physical activity in schools and comprehensive school health programs.
Thank you for allowing me this opportunity and I will be pleased to answer any questions.
The Chair: I want to turn to Senator Callbeck to have the first go, but the tradition is that the chairman asks the first question, so I will ask one that all three of you can answer, if you wish.
Have you seen any evidence of reduction in the health inequity since 1993 on the island? You must have rich and poor on that little island; you must have unhealthy and healthy. Are you able to put your finger on any evidence of reduction of health inequities?
Ms. Hennebery: We know that there are areas in which health status is improving generally. We know that in other areas the indicators are going the wrong way.
We do not have a lot of data in Prince Edward Island that segregates our population, for example, by income level. We rely heavily on Statistics Canada. They are, in my opinion, a wonderful asset to this country. StatsCan has wonderful data-collection mechanisms and high credibility with the Canadian public. In part because of our small size, we have not historically examined health data by various determinants, whether that is education, income or social status.
The Chair: In addition to Statistics Canada, are you using CIHI at this point in time?
Ms. Hennebery: Yes, absolutely. Much of the information that is provided to us by CIHI is based on information that is given to them. They do not do a lot of population level surveys. For the most part, that is the purview of Statistics Canada. I would be remiss if I did not suggest that we rely heavily on CIHI, another wonderful asset.
The Chair: It is refreshing to hear about some of your accomplishments at the community level. At the community level, have you been able to provide any connectivity between the health resources and the other major determinants of health? The health care system is one — and we can say there are 12 or 15. Let us say there are 12 major ones. Have you been able to provide any connectivity between the health system and the other determinants at the community level?
Ms. Beattie-Huggan: Some particular projects have done that, and have some mapping techniques. Understanding the Early Years, UEY, is one of them; they looked at children. In terms of inequities in health in relationship to income and health status, UEY found that our sense of social cohesion on the island overrode what might have in other cases been thought of as poverty. People whose incomes were lower were still healthier because of social cohesion. That came out of that project. They have been able to link some of the determinants when they were looking at children in relation to that.
There are initiatives in Atlantic Canada looking at creating what they call community accounts. Newfoundland has it, and Nova Scotia is in the process of developing them and will invest more energy into it. It is something that seems to be extremely valuable in going right down to the very community level and looking at the determinants.
One of the problems we have in Atlantic Canada is that national research often does not give us what we need at the local level because the sample sizes are too small. We get these generalized pictures. My husband, who works in physical education, gets irate because it says our physical activity levels are lower than the rest of the country; however, local research tells us that they are not necessarily lower. It shows up that way because of where we fit on a national survey. We have to look at it in a more particular way.
The profile that I distributed related to Atlantic Canada. The group out of Newfoundland is working to create a set of Atlantic Canada accounts. They have them set up. They just need the resources to get the data in there. Where the provinces make that decision or have more resources, it is happening. The National Crime Prevention Centre was providing some resources to gather data on youth crime, for the youth who are staying in Atlantic Canada. In P.E.I., and this is why we are into some of the problems with youth, our educated youth are leaving because the jobs are not there to keep them. Many of the youth who are staying are disfranchised. They may not have the trades to go west to Alberta. The jobs just are not there to hold them. We are seeing some rise in small crime because of that, especially related to prescription drug use, in all the Atlantic Canadian provinces.
Our colleague in Newfoundland at Memorial University keeps raising the flag, that we have to start looking at the community and getting that information. We have to understand the shifting demographic and what is happening in Atlantic Canada. For me, it is a matter of awareness more than anything else. There is a link with safety, where mapping is done. In looking at high levels of chronic illness, you will find that poverty is high, levels of injury are high and levels of crime are high. We cannot just talk about health in terms of illness. We have to look at health as being broader than that and all the determinants. We have a lot of work to do on P.E.I. because we are the smallest of the Atlantic provinces, and having the resources to create those accounts will take some investment.
Mr. Eyles: I would add something that is not a P.E.I. answer, unfortunately. There have been attempts to link the social determinants. We have tried to do that amongst different communities, within Hamilton, for example — which, I know, is not the topic before this panel today. However, it does depend on data availability. It also depends on the health outcome you are interested in. This gets back to my earlier point about how to specify the objectives carefully. When we get a measure of emotional distress, we get different social determinants being important. When you get a measure of the absence or presence of chronic condition, you get different determinants being important, as you would expect.
Senator Callbeck: This has been an interesting panel. We have learned a great deal about health reform on Prince Edward Island. We have had some successes and challenges.
My first question is about the federal government's role in population health — or, as the doctor said, illness reduction might be a more understandable term. What we have now is a patchwork of programs across Canada. Every province is out there doing its own thing. Population health, as you say, is really not that well understood. Health, to many people, is still doctors and hospitals. Even within the system, you have people with a great difference in thinking about the importance of population health.
It takes a long time to change attitudes and to change thinking. You mentioned the smoking campaign, which has taken 20 or 30 years. If you think back 30 years, it probably would have been unthinkable then that we would come to a time where smoking in a public place was not permitted. However, it has happened. When the federal government stepped in, the smoking campaign really took off. The campaign educated people that not only were they killing themselves, but they were affecting other people.
Ms. Hennebery, you mentioned the campaign on Prince Edward Island. I congratulate you for the results you have obtained. I think if the federal government had not been involved, we would not be seeing the results we see now in relation to non-smoking efforts.
I believe the federal government has a big role to play in population health. I think it is very difficult for each province to go out on its own. The provinces need leadership and assistance from the federal government.
Ms. Hennebery, you suggested in your brief that there needs to be national leadership in some areas of population health. Are these suggestions for priorities, or do you believe there should be an overall population health strategy by the federal government? You can start it off, and then we can hear comments from the others.
Ms. Hennebery: I support your comments with respect to tobacco. There was federal leadership in that area. I can certainly speak for our province. We benefitted from that leadership. Our tobacco-reduction strategy was modelled on the National Tobacco Strategy.
There is more that can be done at a national level. I identified areas that I personally feel should be addressed — for example, the area of childhood poverty. We have had tremendous success in reducing poverty among seniors. We have not had that success in reducing poverty among children. We have a model that can be followed in this country to improve the health of Canadian children and their families.
I expect that if we had someone on the panel from Health Canada or from the Public Health Agency he or she might say it is not their role to lead the development of a national population health strategy, and that may well be accurate. However, I do not believe that should preclude the federal government from taking a lead role in certain areas where they do have the policy levers available to them.
Senator Callbeck: I should like to hear from the others as well.
Ms. Beattie-Huggan: I think it is very important. My reason for saying that is that we have had programs funded throughout Canada on a project-by-project basis. The organizations need to apply for funding maybe every three years. The funding descriptions change. It could be the Population Health Fund one year. I will provide an example of this.
There is a family resource centre in Charlottetown that was initially funded by Health Canada. It had a different name at that time. Its purpose was to promote the health of young children. Subsequently, that same program was funded by the National Crime Prevention Centre, because the root causes of crime and the determinants of health are actually the same. Therefore, by investing in crime prevention through social development, it was the same centre, but their funding source changed just because that is where the money was.
There are organizations and infrastructure out in the communities that can be delivering programs, but I would say they are spending at least 50 per cent of their time scrambling to find the money to keep their programs operating. It depends on where the funding will come from and where it is changing.
The National Crime Prevention Centre is now no longer funding those programs because a shift has taken place and they are looking at youth at risk. There is currently a big fear with respect to the CAPC — Community Action Program for Children — which are national and are funded across the country through the Public Health Agency of Canada, that the Population Health Fund will not be renewed and there will be no funding for those early intervention programs.
Therefore, if we believe our youth are valuable and that they are our future, leadership must come from somewhere. I agree with Ms. Hennebery on this one. We have to find some way of supporting people who are trying to deliver programs and help them continue to operate.
In terms of a national scope, I do not know any other way. Right now, given the way the health systems are set up — you have heard the scramble that happens within the systems for the acute care dollar. I do not think it is any different in P.E.I. than in other provinces.
Mr. Eyles: I agree with you. There is a role for federal leadership. I think there is federal leadership already. It takes various forms. Ms. Hennebery alluded to Health Canada and the Public Health Agency's work on social determinants and population health.
I think there is a place to bring the federal leadership together, but it is in different areas. It gives us more bang for our buck. There is a diabetes strategy being developed.
Maybe the role of federal leaders is to diffuse the best practices between the provinces. In Ontario, there is a marvellous document, which is now 10 or 12 years old, about the primary prevention of cancer. There are wonderful tools that can be used to help us attack specific outcomes or reductions, if you like, that the federal government can link together, but you need the strategy over here to do it in this way and over here to do it in that way. There is a tremendous role for leadership.
Ms. Hennebery: From a provincial perspective, it is important that any commitment from the federal government be ongoing and that it not be two or three years of funding and then the province is left to continue. We are certainly seeing that in the area of immunization. There has been excellent federal leadership in that area. Unfortunately, it is time limited. At that point, the provinces are left in the very difficult position of having to find the money to continue those programs that were initially set up as a federal commitment.
Ms. Beattie-Huggan: In relation to federal leadership, Canada is seen around the world as a leader in health promotion. The Ottawa Charter for Health Promotion is quoted in just about every health promotion document you can find. Population health is a great goal and approach, but we also have the strategies mapped out throughout the Ottawa Charter that can guide the development of a national initiative.
Think of tobacco. When there was just health education and the targeting of individuals, the impact was negligible. However, when multiple strategies such as addressing community action, creating healthy public policy and creating supportive environments were employed, we started to see change.
We have the knowledge. We are seen as leaders, but people are questioning why Canada is not following through. It is time to put some of that knowledge to work.
Senator Callbeck: As we have said, population health certainly takes a number of years to implement. We just talked about the anti-smoking campaign, which took 20 to 30 years. As you know, governments are focused on the four-year cycle. Therefore, it is very difficult to see the results of population reform within a four-year period.
How do you persuade people, not just the public, but people within the system that a healthy population is better for everyone in the long run? How do you do it in a relatively short period of time? As I mentioned, governments are on a four-year cycle, and it takes so long to see any results from the population health perspective. Do you have any advice on that?
Mr. Eyles: It is not advice, just a comment.
For me, there are three major players in shaping health policy: There is government; there is the public; and there are the providers. When it is two against one, you have a win.
Extra billing in Ontario was struck down in the 1980s because the public was on the side of the government on that issue. Using that as an example of this three-pronged system, I think it is essentially an education or requirement, especially with the public.
We talked before about how difficult it is for the social determinants to be gotten across in a meaningful way. Maybe it is education via bite-sized chunks. I am not sure, but I think the answer is to get the public on side to realize health could be better and their wellness could be better. It is also important to get the providers on side to understand that there is more to health care than just care.
Senator Callbeck: It takes so long to change those attitudes.
Mr. Eyles: You are exactly right; it is a long-haul job. Your example of smoking was spot on. I think the Canadian Diabetes Strategy will take the same — it will be 20 or 30 years before we see a turnaround in those figures.
Ms. Beattie-Huggan: In Ireland, an interesting thing happened when the peace initiative was being developed. The Public Health Institute of Ireland was developed, looking at both north and south. It is bringing together two countries to say we need to look at the health of the population of Ireland. It is not just a research institute. They have a mandate to reduce health inequities in the country, advise on policy and be a watchdog on programs. It is separate from the political process and they have funding in the long term to exist.
To have something outside the four-year political cycle that does not get burned every time there is an election, or the flavour-of-the-day changes, how do you create a vehicle to take that leadership over the 20 to 30 years? As I thought of that question, the Ireland model came to mind — what they have been able to construct there.
I am thinking outside the box here. Maybe it needs to be an existing organization. The Senate is here. They are not going to make you go away at the end of an election. How do you have an organization that somehow has credibility and life and can provide leadership over that period of time? Those are just two thoughts.
Ms. Hennebery: You have asked a million-dollar question to which many people would love to have the answer. I do not think there is one answer.
I have often wondered what our health system would be like if we had national health goals that really meant something, that were not so broad that you could drive a truck through them and that the federal government as well as each jurisdiction signed on to.
I think a reasonable person would conclude that the health system, as we know it, will be difficult to sustain in the future from a financial perspective as well as from a supply of providers. I do not know when and I do not know what form it will take, but something will give at some point in the future. There will be a tipping point that will help shift some of the focus back to the root cause of illness.
The Chair: I could not agree more. I agree with you totally, and I do think we will arrive at health goals. I do not know how long it will take, but it will be on a population health basis.
Once we have established the framework for population health information, established the inequities and are able to measure the correction of inequities, government has no choice. It is game over. You have to have health equity. The social conscience of our country will demand it.
Senator Eggleton: Thank you for being here and for your role as change agents in P.E.I. That should go to Senator Callbeck as well, because she was a former minister and premier on the Island that helped bring about these changes.
The topic is population health. What I have heard more than anything though are comments about the health care system. When it comes to population health, there are many other factors, and there has been some mention made of them.
Toward the end of your presentation, Ms. Hennebery, you talked about children living in poverty, early childhood education and childhood obesity. Social determinants of health are wide-ranging — education, poverty, decent housing, employment. Is the Island into those things as part of its population health strategy or do they stand alone and separate? Is there coordination of all these social determinants of health that are part of population health, or is this something the Island is still working its way to getting into?
Ms. Hennebery: We do not have a population health strategy per se. Is there recognition of the determinants of health and the importance of those? Yes, we are connecting the programs and services in many areas, but we have not yet got to a comprehensive population health strategy.
Ms. Beattie-Huggan: When the regions were actually functioning as regions, even though there were problems with budgets and acute care demands, if you took the Circle of Health — which was really developed on P.E.I. from P.E.I. experience — and looked at that blue ring and at what they were trying to achieve in addressing those, they would look around the table to ensure when there was an issue to be discussed that there was someone present from each of those sectors. Those sectors were working together when it was at the regional level. That was one of the successes of being regional.
On the blue ring, they were working with individuals, families, communities, all those populations, and they were trying to achieve balance in people's lives. There was more effort on addressing not just the physical health — because social programs were integrated — but also they were addressing the emotional health.
Structure makes it more possible to bring people together, to integrate services around the clients and the people who are at the centre. That is where community health centres do such a great job. You were saying that it is problematic now that the structure has been changed, that it is harder to keep that integration and to address the determinants.
Although the strategy does not say that this is the population health strategy per se, it was happening with the structures that were there and the legacy of the health report time. It is a problem now.
Senator Eggleton: You said at the community level, not necessarily at the political or government level.
Ms. Beattie-Huggan: The Circle of Health was working well at the community level. However, if my memory is right, because people at their local levels were getting together more, it had an influence upwards too; you had people working more on projects across sectors.
Right now, I would not say it is working as well. You cannot see it as visibly. Back then, if you gave that Circle of Health to someone at the regional level, they would see themselves in that. Right now, I am not sure that everyone would necessarily see themselves in it.
On the other hand, the Circle of Health is something that could be used as a planning framework if we were to go forward. Because I am doing more Atlantic work now, I am seeing it being used by wellness coalitions in Newfoundland and Labrador, where they have their social strategic plan and are trying to work at bringing those determinants together.
Senator Eggleton: Do you have any way of measuring the success of integrating these various social determinants? If you go to a population health strategy, per se, ultimately, how will you determine your success in those areas? How will you measure it?
Mr. Eyles: I am not quite sure I fully understand the question. Success in terms of building from the bottom up?
Senator Eggleton: Population health.
Mr. Eyles: Across the various determinants?
Senator Eggleton: Yes.
Mr. Eyles: If it is from the bottom up, I can tell you that first. You look at your capacity, and there are ways of measuring capacity that exist which would also help measure social cohesion and social integration and efficacy of a community to help itself, which is far stronger in smaller than larger provinces.
On measuring success across the determinants, we have been talking about it in answer to some of the other questions. You set targets and goals for the various determinants and see if you meet them on a national level, and you would hope the provinces would do the same to fit into national targets.
There are now 12 determinants, according to the Public Health Agency of Canada, and some of those will be pretty heard to measure. Perhaps we need strategies that target the ones that are easier to measure to begin with. If you do not measure it, it does not mean anything.
Ms. Hennebery: Certainly the Canadian Institute of Health Information has a very comprehensive framework for indicators that do include some population health indicators. At a national level, that would be a very good starting point, and they are being monitored to some extent now.
You raise a very good point. So much of the health care discussion focuses on the health care system, and yet the research would tell us that, in terms of the impact of the health care system on the health of individuals and families, it is anywhere from 17 to 25 per cent.
Senator Eggleton: In the case of P.E.I., the reorganization came essentially in the health care system, the health care people, so it has come from that paradigm or perspective as opposed to all the social determinants.
Mr. Eyles: Yes and no. I think who is around the table obviously shapes what gets talked about, but some of the determinants are really within the bailiwick of other departments. That is the problem you have. Does the mandate of health keep on stretching outwards? How do you engage those other departments?
Senator Eggleton: You need horizontal links and commitment from the top.
Mr. Eyles: Especially around income changes.
Ms. Beattie-Huggan: When I talked with the person who was the first CEO of the agency, he said maybe it was because we went too broad, but that first umbrella of health pulled in housing and corrections and social care and all the things that might have otherwise been out there. They were pulled under that one umbrella called health, so during that health reform time, it just expanded the definition of health. It could have done it another way. I remember him saying at one time that the only one we really left out was education. He did not think it would go over very well if we pulled them in under health.
The Chair: It is one the major determinants of health.
Ms. Beattie-Huggan: I used to ask myself about the role of the health system in this, because I wore the hat of health promotion and community development. We were to develop that philosophy of health promotion within the system, so what was our role? Part of this was delivering services, and the other, because we have this hat called health, was to be an advocate for population health and to try to work with other sectors to make that happen. Then all the responsibility falls on the health system rather than on something that is outside of it that is looking at the overall population.
Senator Fairbairn: I have been listening with great joy to some of the things that you have been saying. Not so very long ago, back in the early 1990s, I was dispatched to Charlottetown to hitch up with the premier — and the premier is my friend sitting down the table here. I was working in the area of literacy. We were to get together and jointly launch a province-wide literacy program, particularly for families and children. I am looking at your statement on the second- last page that a truly national early childhood education and care program would pay dividends in the area of population health, and then you go on about the quality that each child should have a chance at.
A wonderful thing happened in Prince Edward Island at that time, and terrific people were just so keen to go out in every part of that island and enable adults to themselves get a lift with this but, at the same time, be able to turn with great enthusiasm to this new set of programs on the children, the little ones and young people. It worked.
Times have changed. In the area of literacy, we had a scary event a year ago, and this committee had some lively and overwhelming hearings about what was in fact going on now and how much more was needed.
Is the basis that the senator as premier started back then still there? Is it still growing? Is it still doing the kinds of things that you want to lift up the opportunities in your province? Is it still out there with good roots?
Ms. Hennebery: Yes, it is. Literacy is still a very high priority in our province. You can only address so many issues in a few minutes. I could have spoken much more about literacy. It certainly is lead by the Department of Education. There is a fairly comprehensive strategy that is intersectoral, and it does take a population health approach. Some interesting work is going on with adults in the area of workplace literacy, where employers will actually invest in employees who wish to improve their literacy skills. There are some wonderful stories of what it has meant to people who were not able to read to be able to learn to read as adults with the assistance of their employer. A lot of work is going on with adults, and the Department of Education is increasing its focus with children also, because we do continue to have a fairly high percentage of our population who read at a grade six level or less. There is a lot of activity going on and many services and programs available. It has not resolved all of the problems, but it will not.
Senator Fairbairn: That is good to hear.
Ms. Beattie-Huggan: The partnerships around literacy have mobilized. The theme for this year's summer institute is «literacy.» It is reading between the lines of health, safety and literacy. That was put forward by some of our francophone advisory committee members because literacy is a huge issue with the francophone population, the Aboriginal population and a number of seniors that we have heard from. The early intervention programs are good. Our new immigrants are getting a lot of support now as well, but there are still issues in the province.
Senator Brown: I have a question for Ms. Hennebery. You said in your notes that you had five regional boards at one time. Could you tell us what the percentage of the health care dollar, not in terms of dollars but in terms of percentage, was used up by this bureaucracy? Since they have all collapsed, is there a significant difference in the amount of dollars used by the bureaucracy as opposed to the knowledge that actually goes into health care?
I ask those questions because I wonder, in the end, how you would judge that population health would factor in. I assume that chronic and emergency care always takes first priority on the health care dollar. I am trying to get an idea of how fast that can change — how, if you receive benefits from cessation of smoking, childhood diseases, childhood poverty, diabetes and those kinds of things, that percentage would change.
Hopefully, if the ideal world were to happen — utopia — where everyone is healthy because they practise a healthy lifestyle, then 100 per cent of the health care dollar would go to maintaining personal health rather than, as Mr. Eyles said, dealing with illness.
Have you some thoughts on that? Could you give us any percentages?
Ms. Hennebery: I could not give you specific percentages. I can tell you that, with the last restructuring, there was between $8 million and $9 million taken out of our system, and that was mostly at the senior- and mid-management levels.
I have worked in health care for 26 years, and I have come to stop talking about trying to save money because I think we need to think about ways to reduce the amount that the health care system budget increases.
A former CEO in one of our health regions came to that same conclusion, but a number of years before I did. He said that we cannot afford to save any more money in health. You take steps to try and reduce in one area and then another area grows.
However, if the committee wished, I could try to get a very specific percentage of the health care budget that is spent on administration and management.
Senator Brown: That is part of the equation. I am not trying to save money, either. I feel that health care will cost more and more every year regardless of what we do just because we have a large boomer population becoming seniors now, so that will affect health care dollars across the country.
I was trying to learn what you thought might be the return and the ability to transfer the health care dollar from chronic and emergency care to this program of maintaining personal health. How could that percentage change over a generation? Getting people to quit smoking after 30 years of doing so does not necessarily mean they will not become ill because of previous habits.
Ms. Hennebery: The payoffs for some of those interventions are way down the road. There is research available that would suggest that for every dollar spent on prevention the payback is somewhere in the area of approximately $6 to $10, depending on the study. Maybe Mr. Eyles can comment on that.
Mr. Eyles: I do not have the exact figures, but if you spend money on virtually any determinant, you can save money on the acute care system. For example, in terms of environmental expenditures to try to reduce bad air, the same affect applies. You can reduce it theoretically, but it is still there.
Ms. Hennebery: The difficulty is that the savings are not tangible money in your pocket. The amount decreases as the expenditures grow.
Senator Brown: In other words, the money goes towards something that did not happen.
Ms. Beattie-Huggan: Before I came here, I pulled out of my files a report on a site visit to Finland. We visited their system in 1995.
One interesting thing they had done — again, this is paying more attention to health promotion but also to primary care services — is they made a policy decision in 1972 to move 5 per cent a year of their health budget to the primary level. They have a national system, so they can do this. They gradually built up their primary level, and by the time we got there, they had good research to show that they had decreased the demand on the acute care system. In fact, they were able to demonstrate that, not just by the number of admissions but by the number of re-admissions. All their statistics showed there was actually a reduction in demand.
I have not looked at any of the studies that have come out of Finland since then, and I do not know if they are in the same situation we are, but at that time they were demonstrating that their policy to invest at that primary level was paying off.
Senator Brown: Thank you. That is the answer I was looking for.
Senator Callbeck: What was the time frame on that?
Ms. Beattie-Huggan: They started that process in 1972. It was around the same time we were setting up our own system in Canada. They made a decision to try to build up their primary care system, separate from their acute care system.
Their structure of government is different, so they had local authorities looking after education and all the determinants of health and would manage health care for their area. They gradually closed down all of their small rural hospitals and made them into primary care centres. They had good emergency transport to this more centralized acute care system.
Therefore, the two systems were managed separately and they gradually moved money over. We do have this report. I think it is on file with Ms. Hennebery. It provides a lot of information from that time frame as to what Finland was doing.
The Chair: I will impose on you for a copy of it. We teleconferenced with Sweden a few days ago, so I am aware of the Finland situation. I look forward to reading your report.
Senator Pépin: I will have to ask you to plug yourself into translation. My question was the same as Senator Brown asked, but with the nuance, I cannot ask it correctly in English.
[Translation]
Senator Pépin: It was said that the province was divided into five regional health authorities. Were there major discrepencies between the results of each region? Were such discrepencies taken into account when allocating the total budget for these five regions? On what basis were budgets allocated? Was it mainly on the basis of each region's population figures or specific needs?
[English]
Ms. Hennebery: I just caught the last part of the question. The regional health authority budgets were allocated based primarily on population, because there would be significant complexities in allocating budgets based on need.
Senator Pépin: Someone said that they are doing all kinds of studies and they are giving money, and when you look at the result, there is no specific region. That is why I said, if you did something similar in P.E.I., was the money given especially for the needs of the regional population or for the number of people?
Ms. Beattie-Huggan: The intent was that it would be given by need. Early on, the regions conducted needs assessments that were based on determinants of health.
It was complex; there were surveys and interviews. They gathered information and then they profiled what was rated by the public as being the top needs, so there was the public's perception. They also looked at what the data they could gather was telling them and compared it.
The idea was that this would help to determine priorities and then funding would go that way, but it did not really materialize in the way that it was planned. Trying to find a formula to make it work was very complex — at least, in the days that I was there it did not happen.
However, the needs-assessment process itself was extremely important in mobilizing the community, and that area. They started looking at ways, not of getting more money from the province, but of using resources that they already had to address the needs. There became more resource sharing.
One of the needs that was identified as a top priority was unemployment. In some of those regions, they actually got the people together that were working on job creation at the provincial level, working with the federal department of HRSDC or whatever it was that time — you lose count of the initials after a bit — to co-locate their offices to try to deal with unemployment. There was good cooperation based on those needs assessments, so it served that purpose, but it did not really have the time to translate into the kind of formula that that would get to a budget allocation.
Ms. Hennebery: Further, once the budgets were set initially, they were renewed based on history, so there was some historical element.
Senator Pépin: Were municipalities involved in the reorganization of services at the regional level?
Ms. Hennebery: In a small way. In Prince Edward Island, municipalities do not play a large role in delivering formal health services, like you would find in other provinces.
Senator Pépin: It was mentioned that it is important to work at the local level and identify the leader in the community, so I thought maybe the municipal level could have been involved.
Ms. Hennebery: At a regional board level, the municipalities would have had input, but they would not have had a role in funding.
The Chair: Honourable senators and witnesses, I am afraid we will have to wrap up. There is another meeting in this room at 6:15 p.m. and we need a short in-camera session.
Again, I want to thank the witnesses very much. Regardless of where you think you are, you are out front with what you have done in Prince Edward Island. There are tremendous lessons to be learned from the normal cycles of success and failure and frustration and all of that.
We deeply appreciate your coming here on short notice and sharing your strengths and weaknesses with us. It will be tremendously useful to us. We are hopeful that, when our report is out, it will show you what is available. There are close to 100 initiatives in Canada to overcome health inequities, but they are all disjointed. Hopefully, our report will help people like you learn which ones are useful and which are not useful. I have a feeling I will be back to some of you. Thank you very much indeed.
The committee continued in camera.