Finance Committee on Oct. 6th, 2014

[Gerald Keddy, Conservative, South Shore—St. Margaret's, NS]

Absolutely.

[The Chair, Conservative, James Rajotte]

Make it very brief, please.

[Dr. Richard Klasa]

Very briefly, I think the problem has been that a lot of these activities have been siloed in different health care jurisdictions. There is no real reason that it can't happen.

[The Chair, Conservative, James Rajotte]

Thank you, Mr. Keddy.

Mr. Caron, you have the floor. You have five minutes.

[Guy Caron, NDP, Rimouski-Neigette—Témiscouata—Les Basques, QC]

Thank you very much, Mr. Chair.

Mr. Klasa, in your presentation you mentioned that at this time there are several gaps in the Canada Health Act that are not being addressed by the federal or provincial governments. Could you give us an example of one of those gaps?

[Dr. Richard Klasa]

There are two different parts to that question.

The gaps in the Canada health accord have to do with the different provincial jurisdictions and the ways in which the funding comes to them currently. At the present time, I'm not an expert but my understanding is that in the current system the funding is based on a head count. Basically provinces with growing populations tend to get more money than do those without that growth.

A simple calculation tells us that in those provinces that perhaps don't have as much growth, where, one might suspect, there may be more vulnerable populations, which is what we're discussing today, the amount of relative funding will be less.

My understanding is that in the previous set of accords, more thought was given to how that money was apportioned.

That's one example of that sort of thing.

[Guy Caron, NDP, Rimouski-Neigette—Témiscouata—Les Basques, QC]

I want to come back to the issue of federal leadership in health care, which my colleague talked about at some length.

We are agreed that health is a matter of provincial jurisdiction. Last week I put the same question to the president of the Canadian Medical Association. How can the federal government play a leadership role in this area, when health is a matter of provincial jurisdiction? How does this work in practice?

I have a second question to ask, which is a corollary to the first.

The provinces do not seem to have adopted many coordination measures. In your brief your refer to one of these measures, that is to say the Pan-Canadian Purchasing Alliance, for the purchase of medication, but there is very little cooperation in that regard.

Should the federal government play a role in helping the provinces share their best practices, and in developing a broader vision when it comes to the administration and delivery of health care?

[Dr. Richard Klasa]

Undoubtedly, the federal government should have a major role in doing this and providing leadership in many initiatives.

The issue again is that provinces are somewhat siloed and separated in terms of how they have traditionally dealt with their health care issues. What one would hope from a federal government in our system is leadership that maintains the actual provisions of both medicare and the Canada Health Act. That does provide, and did solidify to some extent, this idea that access to care would be equivalent across the country and that there would be portability from one province to another. It seems to me that without federal leadership we can't even begin to discuss that, because then we have each province arguing one-on-one with each other about how to proceed.

I don't see that there is any lack of a need for federal leadership in this debate whatsoever. What is necessary is a strong unifying voice that can help the provinces to each see the strengths that may be present in different jurisdictions—and there are strengths, many strengths, that are present in one jurisdiction that are not in another. The federal government could help; the federal policy-makers could help to point that out and to allow the provinces to come together and actually agree upon standards.

[Guy Caron, NDP, Rimouski-Neigette—Témiscouata—Les Basques, QC]

Thank you very much.

That federal leadership could be expressed in certain strategies.

I' m going to put my questions to Mr. Sculthorpe and Mr. McLellan. I will come bact to you, Mr. Klasa, if time permits.

Mr. Sculthorpe and Mr. McLellan, you are in fact the fourth and fifth witnesses to tell us over the past two weeks that it is important for the federal government to take concrete action in developing a strategy to counter dementia. In fact, our colleague Claude Gravelle tabled a private members' bill on that very issue.

What form can federal leadership take to develop a concerted strategy to deal with dementia, do research and implement solutions against dementia, while the provinces are in fact responsible for the implementation of those solutions?

How can the federal government and the provinces work together in a productive way to come up with concrete results in that regard?

[David Sculthorpe]

I think that if they put together an action plan done collaboratively with the provinces, it would go a long way and set the vision for the future.

[Dr. Barry McLellan]

If I could add, an investment in infrastructure, which would help to guide the strategy, which would be a national strategy, bringing together hubs from across the country, would go a long way to building the innovation and the changes we need in order to actually implement the innovation. Innovation is one part. If we don't implement and make the changes, we're not going to see better care for Canadians in the future, whether it's dementia, stroke or depression. I do see that an investment in infrastructure would in fact help us to get to that point.

[Guy Caron, NDP, Rimouski-Neigette—Témiscouata—Les Basques, QC]

Mr. Klasa, could you suggest some concrete action that the federal government could take, as a federal entity working in an area of provincial jurisdiction? What strategy could the government adopt to counter dementia or help our seniors?

[Dr. Richard Klasa]

I don't know that I can address the issue of dementia, but there are many experts here on dementia.

Certainly in terms of care for the elderly in general, one of the major issues of our time, and perhaps it's coming into its time now, is that we have to shift from a medicare system designed 40 or 50 years ago to deal with acute illnesses and hospital-based care, when the average age to which people lived was in the sixties, to one now where people born today are, on average, going to live to be 85. Many of the acute diseases are being well taken care of, but we are making out of acute diseases chronic conditions, and those demand care of a different sort. That care is now moving out of hospitals and into communities. One role the federal government could have and should have would be to embrace this and to give funding and to encourage ideas that actually move the model towards one of more in the way of community-based and home-based care.

I don't think that's a surprise to anybody around the table.

[The Chair, Conservative, James Rajotte]

Thank you.

Merci, monsieur Caron.

We'll go to Mr. Allen, please.

[Mike Allen, Conservative, Tobique—Mactaquac, NB]

Thank you to our witnesses for being here.

Ms. O'Neil, I'd like to start with you.

I'm not familiar with your organization, but I read your brief. What is the size of your organization? How do you work? Do you work virtually? Could you briefly tell me how that happens?

[Maureen O'Neil]

Yes, certainly. It's a small organization of 40 professional staff and a board of nine people that includes a couple of deputy ministers, one from Alberta and one from the Northwest Territories, the associate deputy from British Columbia, and the former head of the Ontario Hospital Association—that kind of person, like the person in Nova Scotia who is charged with the incredibly politically delicate task of reorganizing a number of regions there into one. There's a board that is heavily endowed with people who have direct front-line experience in the provinces in managing health care and there are staff who are professionally competent.

We work often through the use of ICT. We run webinars. Our collaborations combine online learning with face-to-face meetings. We back it up. We have a very strong capacity to assist the groups with whom we work to develop indicators and measure their performance so they are able to evaluate whether the interventions they are making are actually making a difference.

The benefit of bringing groups together from across the country, usually those working at a sub-provincial level with health regions and hospitals, is that they have an opportunity to learn what is going on in other jurisdictions, because policy frameworks in each province are slightly different.

I must say that our organization is one of the few that works across the country and that has always had very strong participation from institutions in Quebec, going back 15 years. For some organizations that are participating in programming, this might be the first and maybe the only time that they actually sit down with colleagues from Quebec.

[Mike Allen, Conservative, Tobique—Mactaquac, NB]

Extending on that, you said in your brief that a “recent analysis...demonstrated that if just five of the innovations CFHI supported were implemented across 50% of the healthcare system in Canada, they could generate more than $1 billion in annual savings”.

When I look at that, I'm very intrigued, because even though you said you're not as adventurous as the others, to me getting the best bounce for a buck in health care means the basic blocking and tackling. With that in mind, are some of the five, in those eight that you listed as the most effective, CFHI-supported innovations?

[Maureen O'Neil]

Yes, exactly, and you would be surprised at how simple some of these things are. We were chatting before the meeting about how simple changes can make a big difference. The challenge is that they are shared and that they are taken up.

For example, I talked about the approaches to COPD, which will move care outside of the hospital into the community with proper supports. That alone is a big saving. That keeps people from going to emergency, because by keeping people out of emergency, you are providing care that is good for people but is less costly. There are other things. Doctors' offices using open access and being available for longer hours keeps people out of emergency rooms. It's a whole bundle of things.

Canada has been very slow to organize its emergency differently. We have also been very slow in providing appropriate funding—I'm talking about the provincial level—outside of hospitals. It's really a bit of a mishmash out there at the community level, and that's where we have to go.

It is true, and we've documented it very well, how small interventions can make a surprising difference in expenditures. This money never goes back to anybody. It's shipped somewhere else in the health care system, but hopefully it's shipped to somewhere more appropriate.

[Mike Allen, Conservative, Tobique—Mactaquac, NB]

Is this because of the silos, I guess, the barriers to implement making it difficult to work together, so you have this spread initiative...? I'd just like to understand those barriers to implementing. It just seems like a no-brainer. It's a billion dollars. Why don't we go after it? If that's the case, does your organization receive any funding from the provinces? They're a major benefactor of this, too, because our provincial tax dollars are going into this. Are they a partner in the funding of your organization?

[Maureen O'Neil]

Yes, they are a partner inasmuch as it is teams within their provinces who are working on these innovations and working to share them; hence it's the labour of the people in these institutions who are making the changes. In that way the provinces are indeed assisting greatly. Where I don't feel we are where we ought to be is in ensuring an understanding of how you move from, say, across the country 52 long-term care homes doing this and then the work that we have to do as a kind of intermediary, which is really to do the convincing work to put that information before provincial people to say, “Look how this has spread”.

That happened in Manitoba. After the first personal care home used a different approach to dealing with long-term care residents with dementia who had been over-prescribed antipsychotics, the province, looking at that, said, “Okay, now we're going to spread it all across Winnipeg, and now we're going to work on spreading it across the province”. Similarly in B.C., in another very interesting project that reduced the time for a patient between seeing a GP and seeing a specialist, they are now working on spreading that across the province.

Provinces are key in taking up the innovations in health care delivery. Our challenge in what we do, in working with people across the country, is then also working with them in their provinces and moving things along. Why doesn't it happen? People get used to doing things a certain way, and they continue doing them a certain way. The economists call it path dependency, and that's what we see operating all the time.

[The Chair, Conservative, James Rajotte]

Thank you, Mr. Allen.

We'll go to Mr. Rankin, please.

[Murray Rankin, NDP, Victoria, BC]

Thank you to all the witnesses for coming today.

I'd like to start with Dr. Klasa of Canadian Doctors for Medicare.

First of all, I'd like to thank your organization for its passionate support of publicly funded health care in Canada.

You had three points, I think, in your very short presentation. The first was the desire that we uphold the Canada Health Act. The second was that we renew the health accord that has expired. Third, you talked about a national pharmacare program. I'd like to talk about each of them.

You mentioned in your remarks what you called “legislative loopholes” that violate the spirit of the act. Then you talked about new fears of privatization. I can't help thinking that you may be referring to the federal government's apparently lacklustre support of the medicare program in the Cambie Street clinic case, Dr. Day's clinic in Vancouver. Is that what you had in mind? Is the federal government there aggressively supporting our medicare system?

[Dr. Richard Klasa]

The case that's before the B.C. Supreme Court now involves a suit and then a countersuit that basically involves the provincial health care authority. The main protagonists here are Cambie Surgeries Corporation, the provincial government PHSA in terms of the Ministry of Health, and then there are intervenors, such as Canadian Doctors for Medicare and the BC Health Coalition, which have that status to inform the discussion.

The federal presence in that particular argument has been less than obviously all the other players. It is, at this point, as far as I can tell, a provincial jurisdictional matter. The crux of the matter is there needs to be some sort of enforcement of the Canada Health Act if indeed we have a Canada Health Act. The issue has been there are providers of private for-profit care across the country that have, it would appear, or it is alleged, abused the system and inappropriately billed. That is in the public record. There was an audit done of the Cambie Surgeries clinic.

The question is, what is the power, and what is the power that will be used by the federal government in response to this? Supposedly the Canada Health Act says that if a jurisdiction is improperly using the resource, then those tax dollars that were spent...let's say in overbilling or double billing or extra billing. If any of that came out of billing on top of what the province was paying, of which a proportion was coming from the federal government, then we have a right to reclaim that money. There has been no attempt made federally or provincially to actually enforce those provisions.

[Murray Rankin, NDP, Victoria, BC]

It's a lack of enforcement by the federal government that has led your organization to appear as an intervenor in that lawsuit, to defend the medicare system.

[Dr. Richard Klasa]

It certainly is one of the things. We are there because we believe that the medicare system deserves to be protected, but also deserves to be changed and reformed as is required by the times. It's not as though we're for a static medicare system of all things going on as before, forever—that's not true. What we do want here is to not throw the baby out with the bathwater.

The majority of what the Canadian health care system can deliver, it delivers very well. There are other things that need to be dealt with, but a solution is not to have more in the way of private care, and the brief details why.

To cut to the chase, you withdraw much more in the way of resources from the public system when you set up a private system parallel—