Proceedings of the Subcommittee on Population Health
Issue 7 - Evidence, June 11, 2008
OTTAWA, Wednesday, June 11, 2008
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:15 p.m. to examine and report on 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: Honourable senators, and witnesses, we have a quorum and we are duly structured so we can proceed, even in the face of some of the break from routine that occurred this afternoon. We are here and ready to go.
We have, first, with us the Honourable Carolyn Bennett, the former Minister of State for Public Health and, indeed, someone whom I have known for a very long time.
From the University of Alberta, Deanna Williamson, Associate Professor, Department of Hyman Ecology, University of Alberta.
Perhaps Dr. Bennett, we could hear from you first.
[Translation]
The Honourable Carolyn Bennett, P.C., M.P., former Minister of State (Public Health, as an individual): Mr. Chairman, it is truly a pleasure to have been invited to come and contribute to the important work of this committee.
[English]
As a family doctor, I experienced what Sir Michael Marmot has so brilliantly described as the worst thing that can happen to a physician: to patch people up and send them straight back into the condition that made them sick in the first place. Whether that was seniors in lace curtain poverty, or whether it was asthmatic children living near a coal- fired generator, or an injured worker with post traumatic stress who is still dealing with the old-fashioned compensation system that deals with an impairment model instead of the modern international classification of function, the social determinants of health were part of my everyday life as a family physician.
I am proud to have come from Women's College Hospital, who with the activists there and the women's health movement have long understood that the role of property, violence, the environment, shelter, equity and education were all part of keeping people well.
[Translation]
In my current role as critic for public health, seniors, disabilities and the social economy, wherever I go people are excited not only about the existence of this committee and its important work, but also about the prospect of the report having a fundamental impact on the future of health and health care in Canada.
[English]
I say health and health care because too often when we say ``health'' people think of the sickness care system. I hope your committee will play an important role in changing the language from health care to systems, to systems for health.
From the beginning of medicare, Tommy Douglas had two goals: That all Canadians would get the care they needed when they needed it, but, secondly, that it would also help people to keep well, not just patch them up when they get sick. Somehow we lost our way through our fascination with the ``repair shop'' side and fell into what the public health community refers to as the ``tyranny of the acute.''
As you and your committee well know, dealing with the social determinants of health will be essential to the ultimate sustainability of our most cherished social program.
In order to keep my remarks brief, I have included my introduction to Denis Raphael's new edition of the Social Determinants of Health that will come out this fall, and also the slide presentation from my presentation at the conference of the International Union for Health Promotion and Education (IUHPE) last June. In both of those presentations you will find my quiz, which I have found quite useful in changing the language.
As we all know, as soon as we talk about social determinants of health the whole room will glaze over. What I found is that, if we use the quiz, and some of the slides you will see in the IUHPE presentation, it can start to change the dynamics of how Canadians can help us with this project by pulling healthy public policy at the same time as we are trying to push it.
The first question is: Do you want a strong fence at the top of the cliff, or do you want a state-of-the-art ambulance and paramedic service at the bottom?
Would you prefer clean air, or would you prefer puffers and respirators for all?
Would you prefer that wait times were reduced by a falls program to reduce preventable hip fractures, or private orthopaedic hospitals and lots more surgeons?
Should we invest in early learning and child care, literacy, the early identification of learning disabilities and bullying programs, or should we increase the budget for the incarceration of young offenders?
Should we assume that the grey tsunami will bankrupt our health care system, or should we include our aging population in the planning of strategies to keep them well?
Is the best approach to food security food banks and vouchers, or income security, affordable housing, community gardens, community kitchens and a national food policy?
Pick the one that is not correct: This was one of my favourites as minister. Pandemic preparedness should focus on Tamiflu for all, or working with the vets to keep avian flu a disease of the birds, or making sure people wash their hands, especially the doctors and nurses, or research on vaccines; community care plans for our most vulnerable?
Governments should boast about how much they spend on the sickness care system, or the health of their citizens, leaving no one behind.
I know all members of the committee just got 100 per cent.
I have also included a speech I gave last year, with the help of the Library of Parliament, to the EU meeting on health in Gastein, Austria, which outlines the economic arguments for investments in health that identified things such as the fact that smog days in Ontario alone cost $1 billion a year.
I have included a presentation that I am having fun with now, on the ``Grey Tsunami? Not,'' which shows how we can do integrated policies to ensure that our aging population stays above the disability line as the WHO has described in its active aging policies.
I believe you have asked me here mainly to discuss the work we had begun when I was minister, and the work that clearly still needs to be done. I remember when Paul Martin called me to ask me to join his cabinet in December 2003, as the first Minister of State for Public Health in the wake of the SARS outbreak. I remember immediately reminding him that this could not be just about infectious disease and that my job would have to include the other epidemics of cancer, diabetes and heart disease.
Early on as minister, I realized that there were divides even within the population health and public health community. One camp focused mainly on getting people to make healthier choices. The other camp pretty well boiled down to the issue that ``it's poverty, stupid.''
In trying to explain that we needed both systems, one day on a boarding pass I scribbled a tree with the root system being the social determinants of health, the trunk being the modifiable risks and the branches being the health outcomes. Everywhere I went as minister; people gave advice to my tree: more root system, more risk factors, more different outcomes, but it was Bill Mussell from the Aboriginal Mental Health Association who helped it come together for me.
If you see on my tree that this ground system here explains so much. It seems that the social determinants of health affect the ground, which means people's resistance, their sense of control and self-esteem, their sense of personal cultural identity. Out of that ground come the choices they make in health, in terms of eating, exercise, and use of alcohol and drugs.
I was grateful to the chief medical officers of health, who asked me to change this from an apple tree whose leaves would come off every fall, to this beautiful Georgian Bay pine tree. As you know, in Georgian Bay the west wind shapes the pine, so we had no branches on the west side for the things we do not want, and we had luscious, big branches on the east side for the things that we do want.
We used an earlier version of this tree, and you will see it, in the workbooks for the health goals for Canada. You can see the evolution of the tree because the one that is in the workbook has a lot less of this and a lot less of this and a lot less of these as we continued to involve citizens in getting this tree just right.
At the first ministers' meeting in September 2004, we were thrilled that the whole of the Tuesday evening discussion was dedicated to public health and prevention. It was really inspiring to hear the first ministers of this country talking about everything from railings for seniors, to poverty, to the kinds of things they knew would make a difference. The communiqué committed all governments.
[Translation]
Governments commit to accelerate work on a pan-Canadian Public Health Strategy. For the first time, governments will set goals and targets for improving the health status of Canadians through a collaborative process with experts. The Strategy will include efforts to address common risk factors, such as physical inactivity, and integrated disease strategies. First Ministers commit to working across sectors through initiatives such as Healthy Schools.
[English]
In the following year, we were able to set up the public health network for Canada in which all 13 jurisdictions could plan public health together under the leadership of Dr. Perry Kendal from British Columbia and Dr. David Butler- Jones. We dedicated $300 million in the 2005 budget for an indicated disease strategy and set up six collaborating centres for the challenging areas of the environment, Aboriginal peoples, infectious disease, new tools, how to get healthy public policy for the Province of Quebec, and the Atlantic provinces came together in a collaborating centre on health inequities. Then we moved on to do the process for the public health goals for Canada.
In December 2005, all 10 provincial and three territorial ministers of health approved the health goals for Canada and from there on I have to say I have been pretty sad. I am saddened that there has been very little action on these files since the election of the Conservative government.
In the parliamentary review of the 10-year plan for health, the Liberal supplementary opinion, which will be tabled on Friday, will articulate that even in the communiqué at the 2004 meeting, under prevention, early learning and child care was number one, and that this government immediately cancelled the plan, even though the agreements had been signed with the provinces.
The commitment to further collaboration in terms of coordinated responses has really been carried out by the public health network, by the chief medical officers of health, but we have seen little support from the government itself to be able to move forward on these. Even on the national immunization strategy, that instead of waiting for the cooperation of the interprovincial body that is supposed to determine these, or to renew the four vaccines that that body had committed to, the government went outside the process to fund the vaccine, as important as it is, in terms of cervical cancer. It went outside the collaborative model that had been set up because of David Naylor's very specific instructions to us after SARS on the four Cs of collaboration, cooperation, communication and clarity of who does what when.
Unfortunately, even though we had set up all the foundation to develop a public health strategy, I guess the thing that is saddest for me is that you cannot move forward if you do not know where you are going. Part 2 of the health goals process, and this was committed to in the communiqué in the 2004 first ministers' meeting, was to go on to develop real indicators and real targets. Only with indicators and targets can you develop real strategies of what, by when and how, like Tony Blair did in the first year that he became Prime Minister.
It has been very disappointing that without this collaborative process for indicators and a collaborative process with experts and providers as to what would be meaningful targets — you cannot just pull targets out of the air and expect everyone to get on side, they have to be realistic — the work has completely stopped on this.
I am extraordinarily disappointed that the $300 million that we carved out for an integrated disease strategy that would go to things like healthy schools and things that cross the government departments, went back to the old- fashioned way of disease by disease with one disease getting more than nine tenths of it. It is a bit disappointing that we seem to have slid back a bit.
If I go to the things that I think we could do or that I would like to see you explore in terms of the way forward, I would very much like to see that we could move forward, number one, on measurement.
When I was in Scotland last year and met with the former minister of health there, Andy Kerr, I cannot tell you how jealous I was to see that he had health outcomes down to postal code. I cannot tell you how jealous I was that everyone in Scotland has a family doctor. He was therefore able to have the family doctors in the neighbourhoods with the poorer outcomes write a letter to their patients, ask them to come to a health fair and put in place interventions around blood pressure and lipids, all of these things. And also all the things we have talked about that are more social determinants. He was already, as their government fell, being able to see the incidents of these kinds of interventions going down.
New York State now has haemoglobin A1Cs as a reportable disease. They feel that even though it is not an infectious disease, there is a social contagion to it. So you can provide the interventions as though it was an infectious disease, to be able to turn around this epidemic that means this generation of children will not live as long as their parents.
We have to move to much better epidemiological data and I think we are trying. Maybe it will be a beginning in terms of what we have been studying at the health committee in the House of Commons, to use something like post- market surveillance. If you think of electronic prescribing, consider the different mapping we would get if a doctor just had to type in the diagnosis with the same prescription as on the prescription pad. We would actually start to generally map out things more easily than we are now. Then, again, we have to encourage the physicians to help us get better at epidemiological data than just the billing data that we are dealing with right now.
I see Dr. Cordell Neudorf here, who I was going to boast about anyway. We know that if picture is worth a thousand words, a map is worth a thousand pictures. Because of the core value of Canadians around fairness, if you can take the health outcomes and be able to map the places that are doing well and those that are not doing so well, you can start to justify, as politicians, interventions in those areas. Dr. Neudorf is doing this brilliantly in Saskatoon. You will learn about his plan in terms of a real action plan on improving outcomes and on poverty.
We think it is very important that we go forward on the business of choosing the indicators and targets. I think that Canadians understand, from smog days to the percentage of families spending more than 50 per cent of their income on rent — we know that if you are spending 50 per cent of your income on rent there is probably not much food in the fridge. I think that when you get to pick the targets together, then we go to this brilliant part of our federal system. You articulate the strong common purpose and then respect the local wisdom and get the local knowledge to get it done province by province, territory by territory and community by community.
It is, I think, also very important that we talk about structure. The structure right now in terms of all the silos has got us into trouble and I am sure you have heard that many times. There has always been understanding that interdepartmental committees can work to a certain degree. What we learned the hard way is that unless there are cabinet committees that the department has to prepare the minister for, things do not happen.
Working horizontally is so important, as we have seen in several areas. Take the children's committee in Manitoba, or the poverty committee here in Ontario led by Deb Matthews. Again, Paul Martin chaired the Aboriginal affairs committee of cabinet that all of us had to prepare to go to that actually brought us the Kelowna Accord. Stéphane Dion chaired the sustainable development committee of cabinet where before, Industry Canada, Natural Resources Canada and Environment Canada were all feuding departments with different plans. If you have a cabinet committee where you actually have to thrash out a consensus, I think that is the way you will move forward.
I commend to you the report we did with John Williams on societal indicators for use of parliamentarians. We looked at models like in Alberta and in Newfoundland about whole-of-government measuring and how if governments are responsible for whole-of-government outcomes, as opposed to just ministerial accountability down the silos, we would go a long way to helping Canadians understand that decreasing a smoking rate, like we have over the years from 31 per cent to 19 per cent, is as important an indicator as the GDP.
Based on the work of that committee, I think the role of Parliament in bringing together different departments, and a better role for Parliament in terms of horizontality, would be very important. We found that at the disability committee where we were able to call 13 departments or commissions who were quite surprised they had anything to do with disability in their department. It is therefore also important that if we examine these structures we begin the work on process.
I believe all of us have been heartened by the work of Finland in their ``Health In All Policies.'' Article 54 in Quebec means every bill, every private member's business, every memorandum to cabinet, and every budget submission, must undergo a health impact analysis. Governments may still make the same decision, but at least they were warned that this would actually increase the invoice on the health care side.
I think the last resource is going to be people, and it will be increasingly important that we plan for the human resources that can work together to achieve true systems for health, as opposed to just health care systems. Here in Ottawa, when you see some of the community health centres that have community gardens and community kitchens and people who can run the interference, or if you look to Quebec's l'Économie Sociale, in true economic development approaches to community, we should be better able to support true bottom-up approaches that are about keeping people well.
There is no question we have to have a comprehensive food policy in Canada. We need healthy, nutritious food grown close to home that includes agriculture, fishery, industry, food security, food protection, ethical practices in international trade, international development in trade; we have got to get that horizontal piece done right.
Last, I would like to ask the committee to reflect on the role that social determinants play in disasters and pandemic preparedness. I began as minister because of the 44 people that we lost in the SARS outbreak. In that same summer, France lost 14,000 people in their heat wave. France had been named number one by the WHO in both health outcomes and in health system performance. However, we know that they were so focused on doctors and hospitals that they did not really realize that a few years later, all of those elderly women in attics would never get anywhere near a doctor or a hospital.
Therefore I think we have not learned from the work of Eric Klinenberg in 1995, an amazing piece of work called ``Anatomy of a Social Disaster'' after the Chicago heat wave, where there the predictable victims were the predictable victims. They did not have air conditioners, did not have other means and all of those things. However, there was one neighbourhood, the Latino neighbourhood, with a few Polish elders who had not moved out of that neighbourhood yet where there were no deaths. That was because of what Robert Putnam called social capital; what Jane Jacobs called neighbourliness. We should never forget as the federal government that we have to put in place policies that allow the bottom-up community development that is about healthy public policy.
In closing, I would like to underline the Canadian leadership on this file, from Tommy Douglas to the Lalonde report to the Ottawa Charter. I remember the terrific workbook that Prime Minister Chrétien's forum on health had in 1996, with the pie charts explaining to Canadians that poor people do not live as long. We need to redouble our efforts on health literacy. We have to have Canadians pulling healthy public policy and become effective advocates. We need them for the systems for health, not just the sickness care system.
I was there in December 2004 at York University when John Frank and Denis Raphael opened their conference on the social determinants of health. I was there in Santiago as minister when Monique Bégin, Stephen Lewis and Sir Michael Marmot launched the WHO commission on social determinants of health. At that launch it was clear that one of the main jobs of the commission was to stimulate country work so that countries would be preparing the ground to ensure that the commission report would find fertile pastures and so that fundamental change could take root.
[Translation]
I thank you for taking up the challenge and look forward to your report. And now, I look forward to your questions.
[English]
The Chair: Thank you so much. That was a fabulous presentation. I see you have not lost one ounce of your pizzazz. You certainly covered the waterfront. Thank you for putting so much time into your presentation.
We will go to Deanna Williamson before we go to questions.
Deanna Williamson, Associate Professor, Department of Human Ecology, University of Alberta: Thank you very much. I appreciate the opportunity to contribute to your study on the determinants of health and your investigation of the possibilities for a pan-Canadian population health policy.
My comments focus on the question of whether the federal government should develop health goals if a decision is made to initiate a pan-Canadian population health policy that aims to improve the health of Canadians and reduce health disparities.
My response to this particular question is yes, with reservations.
I am basing my comments largely on some work that I did with colleagues at UBC a number of years back, looking at provincial and territorial health goals and what came of them and how they were used.
First, with respect to the yes part of my response about health goals: without a doubt I think that health goals are a necessary component of any kind of population health policy. Well-conceived goals provide a clear indication to policy-makers, practitioners and, I think really importantly, the general public, about what the health-related priorities are and what the outcomes being aimed for by governments are.
Declaring those priorities can subsequently guide resource allocation and provide a foundation for developing specific programs and initiatives that are consistent with the goals that have been set out. Health goals are key to a comprehensive population health policy.
My reservation about health goals is, as I said, based on some of the research I did in the past and also evidence about previous health goals efforts in Canada.
What we have seen from previous efforts at developing health goals is that the articulation of the goals alone does not ensure that effective population health programs and initiatives will be developed.
We have seen that over and over. The provinces and territories all developed health goals throughout the 1990s, and by the end of the 1990s the health goals were not being used in any concrete way to direct population health policies. In particular the health goals did not seem to have much of an influence on re-directing attention or broadening the perspective from health care priorities to non-medical health determinants and health disparities. Despite the fact that most provincial and territorial health goals did include those that focused on social and economic conditions and other non-medical health determinants, most of the action continued to be focused on the health care sector.
Similarly, the federal initiative tried a few years ago, the health goals that were put forward, have not resulted in any concrete actions, for a variety of reasons that Dr. Bennett outlined.
I am not convinced that enough has changed in the policy context from the previous attempts, to start down that path again. I really believe that much more work needs to be done, preliminary work, to take a step back before we start thinking about health goals or taking another stab at that.
As the subcommittee outlined in the conclusion of your first report, a key starting point is that a lot of work needs to be done around the area of generating political and public commitment to the idea of a pan-Canadian population health policy strategy that focuses on non-medical determinants of health and aims to reduce health disparities. I do not think that, generally as a population, we really have our heads around non-medical determinants of health and the idea of health disparities. There is much more work to be done there.
Of course, a key piece that is necessary in all of this is the establishment of adequate and ongoing funding to support this sort of endeavour.
Without significant political will, public commitment and sufficient funding, it is likely that the health goals will fail once again to lay the basis for improving the health of Canadians and reducing health disparities.
I believe when we are talking about the need to develop a broad-based commitment to the idea of a federal population health policy strategy, collaborative partnerships between government and non-government representatives from both inside and outside the health sector are key. I know that is not news to anyone. We have heard that a lot; it is well accepted. We need to work more collaboratively and engage in intersectoral sorts of endeavours.
What is really interesting is that, as was noted in the subcommittee's fourth report, even though intersectoral approaches are required, and I think that is well accepted, for addressing many of the determinants of health and health disparities, the notions and understandings of population health, health disparities, determinants of health really just still belong to the health sector. I do not think those ideas and notions have infiltrated the minds and the work of policy-makers and practitioners in non-health sectors.
I do not know that we will be able to make much progress on addressing the non-medical determinants of health and health disparities until there is a broader acceptance and buy-in and knowledge.
Whether it is a gap in knowledge or the lack of buy-in by non-health sectors, I do not think the solution is for the health sector to take charge and go out and educate and advocate. There are many resistances that could occur. It seems to me, although I do not have a really good idea of what this would look like, that what is more likely to develop into broad-based commitment is an ongoing, mutually educative process by which policy-makers and practitioners from a variety of sectors engage in discussions about their respective interests and their mandates.
The goal of these discussions would be to identify where their interests and mandates conflict, where they work against each other and where they intersect. Ideally, over time, hopefully they can determine opportunities to advance mutually beneficial policies and program initiatives.
Some of those would be collaborative, and in some cases they might be independent kinds of initiatives but we would all be marching in the same direction.
I do want to emphasize that I am not arguing against the proposition that the federal government should pursue a population health policy strategy or health goals. In fact, I think it will be impossible to reduce health disparities in Canada if we do not have some sort of comprehensive policy approach, which includes health goals.
However, I do think that the time horizon is very long. When I was reading the overviews of what is happening in different developed countries, some of them seem much further ahead. They started a long time ago and have been working for decades on this.
I think the time horizon is long term, and although the articulation of health goals will likely need to be part of the process at some point, I do think that it is just too soon right now.
What would be more fruitful in the long run is to focus on the establishment of strategies and processes for developing a strong foundation of commitment and funding.
Those are my comments, in brief, and I look forward to speaking about this more.
The Chair: Thank you very much, indeed.
Of course, this is such a huge subject that it is difficult for anyone to get their arms around it. I will go to you first, Dr. Bennett, with a question, and then to you, Ms. Williamson, with another question.
The senators all have questions, so I will try not to take too long, but I do want to exploit your knowledge while you are here.
We have done four reports. The fifth is coming out in December, barring some change in things over there, in other words, an election or something like that. Right now our plan is to recommend very strongly a whole-of-government approach to population health. Most of the links are in place, and I am very encouraged. I spoke with Ontario Health Minister George Smitherman at some length about this. He will do it; he has put some people to work on it already. This is very encouraging.
Quebec is into it. If we could get the provinces to go for it, get the federal government to go for it and try to be partners rather than someone preaching the gospel from the top down.
I think a huge missing link is community organization. We went down to Cuba. There is a special report in there on Cuba. I wanted to look at the polyclinics. They were integrating health, sport, education and virtually all of the determinants of health through the polyclinics in Cuba. Like Scotland, every Cuban citizen has a doctor, and that doctor is in a polyclinic. That is integrated with public health and so on.
I want to ask you specifically, Dr. Bennett, did you look at Tony Blair's organization with his people down below, the whole-of-government approach?
Dr. Bennett: It was the deputy chief officer of health, Fiona Adshead who invited me to Gastein last year. Tony Blair took someone who had actually turned around one of the worst neighbourhoods as the medical officer of health and put her in charge. She had such a huge reputation in terms of being a turn-around person that she set an example for the country in this whole-of-government approach. She knew even as a physician that poverty, violence, the environment, all of these things mattered. Even though people felt the Wanless report, in terms of ``choose health'', had been skewed towards the causes.
Sir Michael Marmot, as you know, talks about the causes and the causes of the causes. The causes of the smoking exercise are that if everyone would stop smoking, eat nicely and exercise, everyone would be fine. Fiona took that report and put it on a base like Dr. Neudorf has in Saskatoon, saying, ``If you cannot afford the running shoes —'' We have to take a much more community-development approach but also the self-esteem approach and whatever.
I remember being in Ireland as an international observer shortly after and looking at these hard targets, the take-in on reducing diabetes or heart disease or whatever right straight out of the gate. My feeling is you need to have included people as you choose those targets, but then it is this strong common purpose, local wisdom, local knowledge too.
I would highly recommend, in terms of this weird, complex federal system, that you think of Brenda Zimmerman's report to Romanow, research paper No. 8, where she talks about complexity theory. She looks at the difference between Africa and Brazil on HIV/AIDS. Brazil took the hit because the World Bank had come in and said you will have to let a generation die off. You have no drugs, your people are illiterate and the priests and the nuns are in charge.
The communities said, ``We will not let that happen.'' The self-organizing that happened there meant they got the drugs. The nurses started drawing circles on pieces of paper telling illiterate people what time of day to take the drugs. The nuns and priests started handing out condoms.
If you look at the measurements of what happened with HIV/AIDS in Brazil, it did this, virtually plateaued, and Africa did this.
Setting some goals as a country and then setting some targets is important. Then you have to have the respect for the local wisdom and knowledge to do what communities know need to be done and to be able to set some priorities.
This idea of Brenda Zimmerman's book Getting to Maybe is about respect. The people can do what they can do, but you need the targets.
I have to say, I do not think Canada needs to go and get new goals. We have goals. We need the indicators, we need the targets and we need the strategies of what, by when, by how.
I would love to see our Aboriginal peoples lead us. When we wrote the goals, we wrote with them in mind, the people who were here first, who had so much of this right. So the overarching goal as a nation is that we aspire to a Canada in which every person is as healthy as they can be, physically, mentally, emotionally and spiritually, is the medicine wheel.
From the attachment to the land to thinking seven generations out to walking a mile in someone's moccasin, which is the inclusions piece, this is a place where we could turn victims into leaders because the teachings of the Aboriginal peoples are really what population health is. It is what sustainability is.
My dream would be that we would be like New Zealand where the identity of every New Zealander is the Maori teachers and Maori culture.
We will not build these inequities unless we allow this kind of work to happen as well.
The Chair: Before I leave you, at Senator Cook's urging, we went down and had a very close look at the Community Accounts program in Newfoundland.
They are measuring indicators and determinants now. They are modifying them, and they have measurable red dots going to yellow, which is very encouraging. Of course, that is why we want Professor Neudorf here after you, to tell us about that, because I know he has tremendous knowledge about this.
I have talked to the whole hierarchy of information technology. They are convinced that they can wire the system in Canada now.
Dr. Bennett: When Dr. Neudorf comes, maybe you would ask him a question. Even though we set up the map generator project at the Public Health Agency of Canada where any community in the country can log in to the map generator and build a map for their community, I am worried also that there are certain places where they still have to pay Statistics Canada to get the data. I would like you, as your committee, to figure out whether or not communities should be paying on a cost-recovery basis for the information that they need to keep people well.
The Chair: Senator Cook will not stand for anything less, so do not worry about that. That will be in the report.
Ms. Williamson, you raised the question of leadership in this great Canadian mosaic. It is relatively simple for someone like Tony Blair to put out a system in England. I know that system well; my daughter and my son-in-law both work in it as physicians. Compare that to the complexities of Canada, with our federal, provincial and territory arrangements, the arrangements into larger cities, and the lack of community arrangements in most places. They have grown by serendipity and some of them are good. Then there are our native peoples. We just spent time looking at some of our native communities.
We are committed to strongly recommending a whole-of-government approach and fundamentally saying to governments: Forget about the politics here; get together and work this out. We are going to nail health disparities as a driver, and what we are going to say will not be nice. We feel that we need that kind of initiative to get things rolling. You talked about this terrible problem we have in Canada of leadership, and whether in fact health should lead. When we talked to people through video conference from Scandinavia, they said health cannot lead because health is eating too much of the pie already and people do not want to fall in line. However, you talk to other people and they say the only driver you will get is health because they are the only ones that will get the huge benefit of this — the salvation in Canada of our health care delivery system financially. Perhaps health has to drive it.
Ms. Williamson, tell us what we have to say.
Ms. Williamson: I cannot even say anything because it is a huge challenge and it is a huge problem. Part of my reason for saying that I do not know that it can work if health is leading is exactly what you talked about in terms of the potential for resistances. On my sabbatical several years ago I spent time at the policy research initiative and it was fascinating to me how they were working on social policy and horizontal policies, but health was not in there. That was one of the things I worked on when I was there. I was very conscious that health was not part of that; the rationale being, if health already gets so much money and if they cannot figure out how to fix things, then we are not going to go into that area.
I saw from some in the non-health sector that the resistance is there. If you are interested in reducing health disparities, the non-health sector needs to be involved. As an example, at the federal level, you can be interested in childhood development and early intervention and having kids prepared for school, but at the provincial levels in the ministries responsible for social assistance, you have kids living on incomes that are so low that that will have negative life-long effects starting with their school readiness and for the rest of their lives and their health.
If health is wanting that outcome, they somehow must work with other ministries to figure out what it is that they want, what their interests are, what their mandates are, and how they can work together to move their agendas forward. That is just one example where it is a conflict.
My hesitancy in that this is a health initiative is that the fundamental bases of health disparities are rooted in causes outside the health sector. Some processes to work together are the only way to move it forward.
The Chair: I heard the Minister of Health from British Columbia speak a year ago. He has a slide of doomsday with rising health care costs, education as a straight line, everything else going down. In fact he is saying that the health care delivery system is a threat to health because it is robbing all of the 11 or more determinants of the money they should have to provide what they need for a healthy population. Do you think that is incentive enough to bring the other people into the fold?
Ms. Williamson: I do not know. That is a good question. Perhaps it could be.
Another key problem is that as Canadians we have an incredible commitment to our public health care system and are proud of it, and that is well founded. We are stuck there and do not have a good understanding of what it is that will enhance our quality of life beyond the times when we are sick and need that health care system. It is not just what is needed from leadership; trying to change the values and understandings of the public is a really important piece of it.
The Chair: I usurped a lot of time from the other senators here and I am sorry, honourable senators, but I will give you more time. We will run a little overtime here.
Senator Callbeck: Dr. Bennett, I want to go back to 2005. The provincial, federal and territorial ministers agreed on health goals to improve the status of Canadians. The provinces were to implement these goals. What was the federal government's role going to be?
Dr. Bennett: We felt it was important that it be first ministers doing this if we were going to get these things done that are really none of your business as a health minister. The health ministers approved the goals but the next step was to continue the collaborative process that we had begun in terms of cris-crossing the country and listening to people as to what should be in the goals. Then, what it says in the communiqué, to collaborate with experts and all governments to pick the indicators and the targets. It was still felt that there needed to be a federal role on the indicators and targets. The thing I left out a little bit was that my picture of the teepee of the Big Brother federal government and all the little provinces reporting to the federal government is very old fashioned. It went from the teepee to the dream catcher, where the dream catcher was a horizontal thing. The federal government would still have to bring up its challenges with Aboriginal people, with the Armed Forces, military and RCMP. We had the same struggles, and we should be at the same table sharing best practices and choosing indicators. We have moral authority as the federal government when the people for whom we have the direct responsibility have the worst outcomes. We need to work together on this. It is a shared responsibility.
We need to pick good indicators and health goals. Youth suicide is a harsh indicator, but it tells a lot, just as do finishing high school or smog or boil water orders, obesity, injury, lifelong learning. There were various indicators that we could have chosen and then to pick real targets that were doable. The health ministers felt that was a collaborative thing and that the federal government had to have a role. So did communities. We knew that things like the Vancouver agreement had really worked in terms of people coming together from all three jurisdictions, saying we will not spend one more penny but could we take all the money we are already spending and spend it differently? We had done that under Judge McMurtry in Toronto on community safety where officials from all levels of government came together to discuss what to do about this issue. It needed to be collaborative, particularly since we had just come through SARS where clearly the lack of communication and cooperation had killed people.
Senator Callbeck: You spoke about a cabinet committee. Comments have been made and we had witnesses who said that it should be headed by the Department of Finance, and some said by Health Canada. How do you feel about that?
Dr. Bennett: A truly collaborative cabinet committee should be headed by the person who can get it done. I would not put Finance there, in that Finance officials' job is to put enough sticker shock on everything so that you cannot do anything. Finance officials would not be the people I would have preparing the meeting. You need to have someone who really wants to get it done. Obviously, with the Aboriginal Affairs committee of cabinet, Paul Martin chaired it. My co-chair on the health goals process in Manitoba chaired the children's cabinet subcommittee. I do not think the chair is as important as the direction from the Prime Minister or the first minister that they want results from this committee and in what, by when, and how, and that they put in place whoever has the time to bring everybody else together so that this cabinet committee becomes a priority, not running their ministry or whatever.
Senator Callbeck: Ms. Williamson, you talked about generating public and political commitment, in other words, getting broad-based support, and I agree with you 100 per cent. The question is how you do it. You said that the health sector should be out there on the front lines, but who should take the initiative here?
Ms. Williamson: I do not know. A group of people. The health sector can take the initiative, but it has to be willing at an early stage to be working with those who are not in the health sector so that there is the commitment within governments. When I was thinking about this, I thought maybe there are other initiatives that we can look at where Canadians' understandings and values have changed significantly over time. An example would be smoking. That is a drastic change. What are the kinds of things that were done to change the public's perceptions of smoking and their understanding of the dangers of it? It has taken decades, but it came from a variety of different places, from the school systems and projects that kids do early on in school, to broad advertising, to the cigarette packages. There are many of them. Over time, that shifted thinking. There may be something to be learned from looking at other initiatives that have been successful, and that has been a huge success.
Senator Callbeck: It has been a tremendous success, but the federal government took the leading role there, did they not?
Ms. Williamson: Probably.
Senator Callbeck: Thank you.
[Translation]
Senator Pépin: Earlier, Dr. Bennett, you talked about a department where everyone collaborates. Should aims and targets not be entrenched in legislation, as is the case in Sweden? Should we not adopt a new act or propose amendments to the existing one to include necessary aims and targets? Is there a better way of achieving our objective than resorting to legislation, so that departments and agencies are able to work together and have a major impact by focusing on health targets?
Dr. Bennett: I have dreamed of a true public health act where the focus would be on the need for clear program analysis, not on the need for a public health agency. It would be something like section 54 in Quebec. We would have a first minister, like the one appointed once by Mr. Trudeau. There would be an emphasis on gender-based health studies. Sometimes, this is determined by legislation, other times, by culture and tradition. A leader would implement the provisions of a health memorandum, taking into account cabinet considerations.
We need a public health care system and the best way to develop one may be through legislation.
Senator Pépin: We need a public health system, but should we not be focussing more on disparities, rather than on determinants? That would make it easier to see where action is needed. Every bill is focussed on health, but we need to focus attention on health disparities. People could then focus their efforts on these areas and tackle the problems that need to be addressed.
Dr. Bennett: Indicators are important. To achieve our goal of horizontal government, we need to institute some changes. Ministerial accountability is not enough. Indicators must apply to the whole of government, through the efforts of the Auditor General.
In New Zealand, a commissioner is responsible for measuring health outcomes.
[English]
The Chair: I thank you both for the magnificent presentations.
Dr. Bennett: We cannot thank you enough for these deliberations.
The Chair: Mr. Neudorf, please proceed.
Dr. Cordell Neudorf, Chief Medical Health Officer, Public Health Services, Saskatoon Health Region: On behalf of Saskatoon Health Region and the intersectoral partners that have taken part in our Comprehensive Community Information System, I would like to thank the members of the Senate Subcommittee on Population Health for the opportunity to speak today. I will focus my comments on the surveillance, research and advocacy that is being led by our Saskatoon health region through the population public health observatory we established in Saskatoon in partnership with the members of our regional intersectoral committee. I have given you a description of the types of stakeholders gathered around that table.
The group has been supportive in getting us to where we are at, and I will give you details about the efforts in building the CCIS. I will also give some examples of how population health data has led to program and policy change at the local level.
If I were to step back 10 or 15 years and look at what we were charged to do within the public health system in Saskatoon, I would find that the human service providers — the sector that we deal with in terms of determinants of health — were needing to gather together more to look for joint solutions if they wanted to get at the root causes, or causes of the causes, behind some of the population health problems facing our community.
There was a group was mandated to come together at a regional level, comprising representatives from health, social services, education, justice, municipal government, and a few different non-government organizations and associations. Its mandate was to find issues of common concern and to find common solutions.
Many of the sectors had individual programs aimed at certain problems, but many of them felt that these were band-aid solutions. They were looking for more complex and elegant solutions to weave together in order to improve population health outcomes and deal with the root causes. I learned early on that the term ``population health'' or ``community health'' did not resonate with this group. They were looking for more inclusive wording and getting away from the health imperialism.
In Saskatoon, the Medical Health Officer is charged with producing a health status report on an annual basis. This used to be aimed primarily at the health region level, setting out the kinds of things that the health system should be doing differently to improve health status. As we were developing plans, I found increasingly that more and more of the data I needed to get a picture of the health status of our community resided outside the health system. Much of that data was not available to me in a format that I could analyze easily and link with our health data to give a coherent picture.
However, I found that presenting the data only was not enough; interpreting the data was very important and giving recommendations for change was necessary. We started giving recommendations for changes within the health sector, but other sectors as well. With this in mind, I met with the Regional Intersectoral Committee in the late 1990s to talk about the need for data sharing between our groups at a much more detailed level. In the past, we would receive annual reports from these various groups. They would be at their own geographic boundaries for their systems. So we could not make one-to-one comparisons.
The argument was made that we could give data sharing a priority at a low level of aggregation and work at determining the underlying tools for housing, maintaining and analyzing it, as well as maintaining privacy on the data. The plan was to see whether, by sharing data at that level, we could start using each other's data in a more layered way for more comprehensive planning within our sectors and for looking at joint problems and solutions. From this, the concept of the CCIS was born. You will notice that the word ``health'' is not in the term because they decided this was more than a focus on the health system.
Since then, we have developed several versions of the system as a proof of a concept. Increasingly data users have been engaging with the data and starting to give us feedback as to what makes it more useful for them. We have made improvements on it and now we have a penultimate conceptual and logical design for the definitive system that we started to build this year.
The key component is that this information system is a linkable relational database from these various sectors. It assembles data from multiple sources and is supported by appropriate tools for analysis, including display through mapping software. It enables users to choose a variety of breakdowns by different types of geography within our region, by different age groups, risk factors, et cetera. The data can then be integrated and analyzed according to individual user need.
We are forming a network of databases across agencies and sectors instead of creating a centralized mega database so that we can pull data from different sectors as needed at a population level.
As people analyze the information and analysis is produced in terms of layered maps, reports, new surveys or research, it is added to that website so that people can continue to access and receive the benefit of the researchers' studies and the perspectives of the various groups. In that way, we do not have duplication of research.
Some of those reports are pre-analyzed, such as health status reports in my case or neighbourhood profiles that the municipality will do using census data. These might include charts, maps and some text analysis at various geography levels.
Another level of access is that a limited amount of querying can be done. I provided a CD with some screen shots indicating what the system looks like and the type of output it provides. Essentially, it allows more educated users, let us say epidemiologists or analysts, to be able to query the database and get a customized output of what they need for producing their own reports, and also allows a more detailed level of access to data for researchers.
An important aspect for me was the public concept. We wanted to have a certain level of data available to anyone who could log on to obtain access to this. We get requests for all kinds of population health data from students, from community groups and associations. We want this data available for these groups to use free of charge.
While this system is being built in its definitive form, we have been trying out the tool as a prototype. We worked on the concept and tested it within the region. I want to provide you with a brief example of how we did that.
We used the census and health data together to focus in on neighbourhood analysis within the city and now in the rural part of our region as well. We wanted to try to categorize neighbourhoods by an index of deprivation, and also, using only income, to categorize it into quintiles, so we can see where the most deprived versus least deprived areas of the city are. Then, using those geographic boundaries, we have gone back to the health data from hospitalization, mortality, primary care use, pharmacy use, vital statistics information, health status indicators and usage of certain preventative services. Across that whole continuum, we have looked at what the health disparity is in our city.
This has been done in other countries. It was intended to be done at a small geographic level in Saskatoon. The biggest difference with what we have done here is when this type of study was previously done in Canada, it was mostly done at a census boundary, a census track level or a postal code level. What you are after there is an academic exercise determining what degree of poverty or lack of education is associated with health disparity. I found that in trying to translate that information to decision-makers, it loses impact. I found what was needed was to put it into a local context.
We use natural neighbourhoods in our city, which have a population of between 1,000 and 5,000 people, that everyone recognizes. They know what neighbourhood they belong to. We cluster those neighbourhoods according to deprivation and present data in that way.
The extent of the deprivation is a bit diluted when you do it that way, but it is far more recognizable and it connects with people at a visceral level. The study that came out showed for many of these conditions there were health disparities of hundreds, sometimes thousands, of percentage points of difference.
Just before we released the data, we did a public survey to see what the extent to which the public already knew this existed. The important issue we found here was that although most people knew that social determinants of health, or income and education, et cetera, were associated with poor health outcomes, they vastly underestimated the extent of how many health conditions were associated with that as well as the magnitude of the problem.
We asked them specifically things such as: What amount of health disparity is acceptable to you? Do you think it is inevitable? Fifty per cent said none was acceptable to them, and only 4 per cent thought that something greater than 100 per cent was acceptable in Canada. As I said, the vast majority of our results showed much higher than 100 per cent differences.
We knew this would connect with people locally in a powerful way, and it certainly did.
We also asked them if they would support policy changes, if they could be made to reverse this. I will not get into the details. We looked at over 30 policy options, and there was a lot of public support for many of the proposed policy solutions. Interestingly, where there was average support, when we added some restrictions such as for families with children, the support often went up by 15 to 20 per cent.
We used the results of the health disparities study, the public opinion survey and then subsequent CIHR research studies we had done in school health. We brought it together collectively to our regional intersectoral committee that sponsored this data sharing initiative and suggested to them that now we had some concrete evidence and some measure of public support. What should we do with it? We did not want this to be just a negative story.
We engaged in dozens of community consultations with various affected agencies, groups and individuals to give them the data ahead of time and see how they reacted to it and what kind of proposed solutions they would have. Then the data was released publicly, but at the same time, we announced a few local solutions that some of the agencies were planning to enact immediately. We worked with the media so their focus would be more on the community coming together on what we can do about this and not just another bad news story about the inner city.
We then asked this committee to endorse our going back and doing an evidence-based policy review, looking at the international best practice of what types of policies showed promise for increasing health equity. We are in the final stages of obtaining their endorsement of that report. We should have it to you within a month, if you are interested. We will be able to give you that literature review and a list of the policy recommendations that this intersectoral group has endorsed.
That is just one example. Other examples have been shorter term, with agencies such as the health region, for example, reallocating 10 per cent of the public health budget to inner city programming and changing the way we have done targeted interventions in neighbourhoods.
Pediatricians in our city came together and decided to start some clinics within the inner city schools. Both provincial and municipal governments have announced in the last few months over $40 million in funds for low- income housing and other neighbourhood revitalization projects in these neighbourhoods.
Our United Way has decided to focus its interventions for the next few years on initiatives that will affect health disparity in these neighbourhoods. The list goes on as you look at the individual agencies and how they have decided to respond in the short term.
This is a prototype of our system and, as I say, we are working on the more definitive system. The intent is to have indicators set up to monitor our success. We have said we will not put this data out just once. We will look at what interventions have been put in place, monitor their impact and keep the community informed.
In summary, CCIS is a good example of how population health data can be combined with a population health approach to intersectoral planning and policy-making, to highlight shared challenges, initiate solutions and monitor the impact at a local level.
We have certainly shared this research and our local process of intersectoral engagement with my MHO counterparts across the country through the Urban Public Health Network, which are the MHOs of the 18 larger cities in Canada. We are now working with the Canadian Population Health Initiative to duplicate the health disparity study in all 18 cities. We hope to have a report released showing that combined pan-Canadian look at this issue in November of this year.
We are also developing through this urban public health network a common set of indicators that will be used by our members for health status reporting across Canada. This calls to mind some earlier comments that what we are lacking to do appropriate analysis is low-level, consistent health status and health determinant indicators on a smaller geographical basis, free of charge and in an easily accessible, downloadable form.
That process has begun. There is a lot of desire among these groups to agree on these indicators and to be able to provide them in a way that those of us who have capacity to do the analysis can add to it, while for those smaller regions that do not, it should be there in a very easily accessible, downloadable way.
I think the translation of these complex population health concepts to a local level using recognizable local geography has been quite key in getting intersectoral and community support for program and policy change in Saskatoon.
The Chair: Thank you very much. You have accomplished a tremendous amount. I was anxious to hear you, and I think I mentioned it to you the other day, was because I wanted to get your comments on your initiative as it compares to the Community Accounts program in Newfoundland. I think these are the two key initiatives in Canada. We would like to use those frameworks in our report to advocate something on the ground.
I mentioned to the previous witnesses that we have a commitment from the information technology community to put the necessary people together to design a system from top to bottom and, of course, to eliminate the charges at StatsCan. I do not know who the leader of this will be, but there is a very strong commitment to get this done for us for the report.
Your system really has both the afferent and efferent loop, right? You have completed the circle. You are getting the data in; you are getting the data out. You are analyzing the data. You are effecting change and measuring it again.
The Community Accounts is doing the same thing in Newfoundland. As I said, they are changing the colour of the dots. This is really very encouraging stuff. If we could have every Canadian citizen benefit from what you two groups are doing, it would be a tremendous step forward.
Tell me what the strengths and weaknesses of your system are compared to the Community Accounts system in Newfoundland.
Dr. Neudorf: I would like to preface that by saying that there are a number of places in Canada trying to do this, though the Community Accounts and our region may be farthest along. Technology is changing so fast that the types of solutions that one thought were the limitations to setting up a system 10 years ago are no longer barriers.
Over the last 10 years, I would suggest we have taken a slower, more deliberative process of trying to build a definitive system. Community Accounts has said, ``We need to get something started and off the ground and available to everyone quickly,'' but keeping in mind something more definitive as they build. From what I have been able to gather, we are going at the same goal, but we have chosen slightly different development paths.
My suggestion has been for some time that we need to find the key places in Canada where some of this innovation is going on and bring those groups together and look at a melded approach, taking the best of each of the examples that we see and use that to build some kind of a Canadian system.
What we are trying to do with ours is less a gleaning of data from a central source and building into it a ``data mart'' or a central repository although there is some of that in our prototypes. Our conceptual design is more meant to act as a way to have each user who contributes data maintain their own system, because they are the ones using it, but agree on which data elements will be shared and in what format. Our system is designed to go and pull that data as needed so that the maintenance of the system is not one where you are continually updating old data but going and accessing data as it is cleaned at the source and is maintained at the source.
There are some central data elements, like census data, for example for ours, that would be maintained centrally, and I think that is common in the way that is done with Community Accounts.
The other difference I would see right now is our building block. Where possible, it is at the individual level but often at a postal code or a neighbourhood level depending on what detail the providers have and then building in the flexible geographic interface for all of the data. So that instead of choosing your geographic municipality and then seeing what data is available there — because whatever was provided at that level is what you have — we are asking everyone to share their data at a slightly lower level. So if you want to look at health data by a social service planning boundary, that is there for you; if you want to look at education data by a health boundary, that will be there for you. We are trying to build that flexibility within the system and ensure that with the linkages we establish you will get the most real-time, up-to-date data.
I think that is probably the same vision that Community Accounts would like to have. That is just not quite where they are built to yet. I do think it is possible, in fact preferable, to bring the groups together as they have designed these various systems and work together with information technology experts to decide what the best approach for a Canadian system would be.
The challenge we found is many of these systems are different from province to province. Once you get beyond the CIHI and Statistics Canada data, it is different provincial systems and in some cases regional data sources, so it becomes a little more complex to flesh out the entire system. Even starting with those data elements available nationally would be possible.
The Chair: What could we do to help people like yourself who are pretty well along in this? Do you have a framework to meet with the vertical system as well as your horizontal peers, or would it be useful for us, for example, to have a round table and have StatsCan and the gurus from Infoway, the CIHI and Canadian Population Health Initiative and the other people involved and so forth? We would have to bring the provincial data banks. It is interesting that the information technology people have already gone there. They are pretty well organized.
Would it be useful for us to ask Infoway and StatsCan and CIHI, for example, to bring people like you, some of the provincial people, around the table? Would it be a positive step or should we just recommend that this be done? They will design a framework for us anyway to put in the report, but should we get more practical right off the bat?
Dr. Neudorf: Prioritization is the issue. Where this sits on the relative priority list of each of those individual groups is perhaps one of the impediments. Having a recommendation that this is a priority and needs to be done for a variety of ministries and for a variety of levels of government would probably go a long way to pushing this up in that priority list.
Currently, I am in the fortunate position of being involved with many of those organizations in an advisory capacity. I sit on the board of CIHI. I am the chair of the Canadian Population Health Initiative Advisory Council and chair elect of CPHA, the Canadian Public Health Association. I am on the advisory council for the population health surveys for Statistics Canada. I am connecting with these people individually and we are talking about these ideas.
However, in terms of a mandate and making it a priority or a focal point, I think that would certainly be useful.
The Chair: I have taken too much of your time. I will move on to some of the other senators.
Senator Cook I know is just dying to ask you some questions. She convinced us we had to go to Newfoundland. We went to Newfoundland and we really liked what we discovered.
Senator Cochrane: I sit here and balance off what I know about my own province. Listening to you, there are many similarities. As I understand it, the Newfoundland and Labrador Statistics Agency is a repository and they have a board that sits and sees the relevant information.
One thing I came away from in Newfoundland was someone who said, ``There is a fine line here, that you could move this'' — whatever name you want to put on it — this IT system or whatever; that it would become redundant and not manageable. I would like your opinion on that. I hear you say that your users feed into a central point from a number of sources. Then I thought of the word ``clutter.''
It must be relevant, clean, pure and whatever.
I know you know the background of why the Community Accounts became a living document in Newfoundland. We found ourselves at a crossroad after the collapse of the fisheries and the exodus of 30,000 people. What do we do with what we have?
It is working well. However, the more I hear in different parts of this great country of ours — what the provinces are doing — I think we would be remiss if we did not bring them all together.
I know you do it on a regular basis with your peers. However, someone like me who only understands it at a very small level, would get a better picture if I saw all of you around a table where I could listen to you share your knowledge. A prototype is what we desire to use as need be from Nunavut to our urban parts.
I think a prototype would be like building a sky scraper, will it not? It would be like using whatever you need that is peculiar to your region. I would like you to comment on that.
Dr. Neudorf: The potential for clutter is a huge challenge. When we first started approaching the various agencies to ask if they would be interested in sharing their data, the first response was silence in the sense of them wondering what we could possibly want with this data. They knew they had reams of data within each of their departments, but they had no idea what another sector would find interesting.
We spent an awfully long time examining with each of the agencies what their data sources are, how reliable they are, how clean they are, what they use them for and what their limitations are. We designed from that a subset of the data that has reliability and that others would be interested in. We started from that smaller subset.
The reality is, you do not know exactly what it is you will find useful until you start trying to use it. In many cases, the data does not get cleaner until you start trying to use it and find that it has limitations. We found that in health data within our hospitalization records, in mortality statistics and the things that we think are very high quality. It is true in the other sectors, as well.
We found the very act of approaching people and getting them to talk about sharing data, focuses on the quality of the data, its reliability and what small set of indicators would be useful for us to monitor in a shared way. It gets down to a very small subset that way. It has taken a long time to get to that level.
One of the drivers behind this is that most of those sectors did not have a dedicated analyst department to do this kind of proactive analysis of their individual data sets. They would use it for administrative purposes, but not for planning. We found that by focusing on a shared need, we could actually talk about something that might be sustainable in terms of the data cleaning, data maintenance and help with how to use the data.
What I am finding wasteful is that, if this is happening in multiple places across the country now, it is probably time for us to come together and share the knowledge we have gained. We need to find out where the dead ends are in this process and where the most promising solutions are and then see if there is something we can develop with a common interest, which would only make sense from an efficiency perspective.
We have already found out in our province that all the other regions in our province would like to have access to the system that we have built already. There is a certain amount of provincial support moving into a feasibility study for making it a provincial system in our province, as well. I think the same is happening in many provinces.
Senator Cochrane: How accessible is your system?
Dr. Neudorf: Right now, it is accessible to the individual contributing agencies because it is in the prototype stage for them. Their analysts and decision-makers can use it, but we have not made the public side active yet. That will be launched in January, 2009.
Senator Cochrane: Newfoundland is on the web.
Dr. Neudorf: Yes, it is.
Senator Cochrane: It is free for all.
Dr. Neudorf: That is certainly our intent.
I have always erred more on the side that this data will be more useful in the hands of more people and we should ensure it is designed in such a way that people can understand it and use it in a ``data liberation'' sort of way.
Senator Cochrane: If we will move to the well-being of our people, surely we have to open up this wealth of information because NGOs do so much with so little. We heard it at home. They can have access to this for planning. It does not cost them one cent. Surely that will benefit our people.
They have moved from using the word ``wellness'' to ``well-being,'' and I kind of like that. From school lunch programs to economic planning, every one is in and excited about it. With crime and justice, the RCMP is using this Community Accounts, and they are contributing to it. They have a board, maybe 15 or 20 people, who feed data. However, the instrument is the Newfoundland and Labrador Statistics Agency. The Premier has put a lot of money into this and I think that is why we are moving as well as we are.
The Chair: Unfortunately, the clock will not stop ticking and we are about to be evicted from the room.
I think the message is very clear. We will enlist your help together with some people from StatsCan and Infoway and CIHI, all of whom you know. We will do a round table so we can get this right for our report.
Thank you for what you have done out there. It is fantastic.
The thing that really interested me about you from way back, as we were looking at witnesses, is the fact that you are from the Saskatoon Health Region. We need to find a way to the ground, as Dr. Bennett said. Thirty thousand feet will not do it. We need the people up at the top but we need to get to the ground to effect change. You are there. That is very gratifying. Thank you.
Dr. Neudorf: Thank you.
The committee adjourned.