Health Committee on Nov. 25th, 2009

[Michael Brennan, Chief Executive Officer, Canadian Physiotherapy Association]

Thank you very much, Madam Chair.

Good afternoon to all the members.

The Canadian Physiotherapy Association's 11,000 members work and study in all provinces and territories, and we are very pleased to participate in these deliberations.

As noted in the brief we circulated last week, we feel that the answer to the question of sufficient health human resources can be found in the rigorous implementation of inter-professional collaborative care. The efficient use of professional skills in collaborative teams, free from outdated hierarchy, has proven beyond any doubt to improve health outcomes, reduce wait times, and lower costs.

It's not too presumptuous to say that we know already what must be done to meet our health human resource needs. The solution is not to be found in simply increasing the numbers of physicians, or nurses, or physiotherapists, for that matter.

As the Health Council of Canada indicates, in applying what we've learned about team-based, patient-centred care, we can resolve a significant portion of our health human resource needs today. The truth is that bigger is not better: better is better. There's an opportunity today for the Government of Canada to put into practice health human resource management techniques that are proven to yield better patient outcomes at lower costs.

The public service health care plan is by far the largest health services plan in Canada and one of the largest health contracts in Canada. Nearly 1.2 million employees, pensioners, and their families are covered by this plan. Over $700 million in claims were paid last year. On top of that, the government recently awarded Sun Life the contract to administer the plan at a cost of $30.5 million annually. Given the size of this contract, the government's influence as Canada's largest employer and purchaser of benefits is tremendous.

We respectfully submit that members of Parliament have a duty to ensure that this multi-billion-dollar plan incorporates the most efficient use of human resources possible. Within the current plan, physicians serve as gatekeepers. You cannot access physiotherapy, for example, or other health services, without a prescription from a physician. Patient self-referral to a physiotherapist is legal in all provinces and territories; however, under the plan, you will not be reimbursed for a physiotherapist's treatment without proof of a physician's prescription.

This policy is wasteful. Every year, millions of health care dollars are spent on physician referrals that do nothing more than add red tape. This policy is harmful. Bureaucratic delays in accessing physiotherapy services for acute musculoskeletal injuries can result in chronic impairment, costing employers millions in additional staff absence. The sooner a patient receives proper treatment, the better the outcome.

Patient self-referral to physiotherapy services has proven to be less costly, improves outcomes, and decreases employee absence from work. Extensive studies in the United States, the U.K., the Netherlands, and Australia demonstrate beyond any doubt that direct access to physiotherapy results in better outcomes, earlier return to work, and lower costs.

The Government of Canada has the opportunity to put these proven techniques into place. We are asking the members of this committee to share this information with their colleagues in the hope that members of Parliament of all political parties will be able to express the collective will that health human resources be effectively used.

You do not need to wait for a popular uprising to implement this change. As Henry Ford said, “If I'd asked my customers what they wanted, they would have said faster horses.” This is an opportunity for leadership. The 1.2 million Canadians covered under the public service health care plan may not yet appreciate the benefits of this proposal, but once it is implemented, overall health of the public service will improve, employees will return to work faster, physicians will have more time for other priorities, and program costs will go down.

The members of the Canadian Physiotherapy Association are committed to their patients. A thorough examination of our proposal will show that we are not asking for more compensation or any competitive advantage in the market. We are asking simply for the removal of red tape based on outdated thinking. We are simply trying to make it easier for our patients, including the public service, to receive the care they need with fewer administrative hurdles.

If Canada is to enjoy stable and sufficient health human resources, we must apply what we've learned. It is no longer time to study the issue; we are very well informed of the problem and of a number of practical solutions. We urge the members of this committee to help implement a simple yet significant change. In so doing, you will demonstrate both a clear understanding of what needs to be done and the will to do it.

Merci beaucoup.

[The Chair, Conservative, Joy Smith]

Thank you so much. I have to commend you. You have a presentation of 5:01 minutes, so you're a chair's dream, actually.

We'll now go to the Canadian Pharmacists Association, with Dr. Jeff Poston.

[Dr. Jeff Poston, Executive Director, Canadian Pharmacists Association]

Thank you very much.

Thank you for the opportunity to present to you today.

I'm the executive director of the Canadian Pharmacists Association. We are the national voluntary professional association representing Canadian pharmacists. Our members practise in the community, in hospital, in academia, and in industry.

Earlier presentations to this committee have advocated the need for a pan-Canadian health human resource strategy and have introduced the concept of the need for a national HHR institute or observatory. We, as the Canadian Pharmacists Association, would certainly support those proposals. However, in this presentation, I want to highlight three things from our submission that are innovations required to promote recruitment and retention of pharmacists in health care.

First, pharmacists want satisfying, meaningful jobs, and this means an expanded role for pharmacists in the health care system. Second, to develop these, we need investment in training places in the practice setting. Third, we have to move to become more self-sufficient and reduce our dependence on pharmacists who have been trained outside of Canada.

Pharmacists are experts in ensuring medications are used safely and rationally. It's clear that patients need help getting the best from their medications and that the health care system would gain through improvements in the safety and quality of drug use. There's also increasing evidence that pharmacists, particularly in collaborative practice models, can improve outcomes from drug therapy.

Supporting collaborative inter-professional models of health care delivery is critical to system sustainability and this will increase the need for pharmacists with the specific skills and expertise for expanded practice. The development of these skills requires experiential inter-professional training and practice, and universities require additional funding to increase the number of such training opportunities.

Best practices in recruitment and retention must also consider the proportion of internationally trained pharmacists in the workforce. International recruiting, while a potential solution to workforce shortages, must be done in an ethical manner. In the longer term, Canada should work towards becoming more self-sufficient in meeting its health care workforce needs.

The Association of Faculties of Pharmacy of Canada reports a pharmacy school applicant acceptance rate of one in six, yet in Canada last year the national examining board for pharmacy registered more than 1,200 pharmacists who were eligible for licensure, and 40% of these pharmacists were trained outside the country. More than 50% of pharmacists licensed in Ontario last year were trained outside Canada.

Despite these numbers, pharmacist shortages in both community and hospital settings continue to be a challenge, although somewhat less so than in the past. This leads to significant dissatisfaction as pharmacists continue to report heavy or increased workloads as their biggest challenge, while owners and managers report finding and keeping qualified staff as their challenge. Overwork and burnout are common complaints, resulting in lack of time to meaningfully interact with patients.

Achieving optimal drug therapy outcomes needs an approach that requires time. To meet some of these challenges, we've seen employers introduce innovative HR practices, such as flexible work hours and compensation packages with incentives. such as signing bonuses and subsidizing continuing education.

On a more pragmatic side, pharmacists currently spend too much time on drug plan administration. Simpler drug plans would be a good first step to better manage the use of Canada's available pharmacy workforce.

We also need innovation in the use of trained pharmacy technicians to support the optimal use of Canada's pharmacy human resources. We now have accreditation standards for pharmacy technician education programs and approved entry-to-practice competencies, and many provinces have put in the legislative and practice requirements to allow for the registration and eventual regulation of pharmacy technicians.

In conclusion, to make better use of pharmacists in the health care system, we need innovation to develop expanded roles for pharmacists that will lead to increased satisfaction; we need investment in inter-professional education and training in practice settings; we need to develop the role of pharmacy technicians in relation to drug distribution; and last, we need new practice models with new methods of compensation.

With support from the federal government, and indeed many provinces, we are beginning to develop innovative practice models. At the national level, we're supporting a major “Blueprint for Pharmacy” initiative to lead and direct change in the profession.

Thank you very much.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Poston.

We'll now go to our seven-minute question-and-answer round, starting with Ms. Murray.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Thank you.

Thanks for being here to help us understand the shortage of health human resources and what we need to do about it.

We've heard from a number of witnesses before today about the benefits of inter-professional collaborative care. We're hearing more support for that. We've also heard about barriers to implementing the model in pilot projects that's been shown to work.

I'd like to hear from the representatives of the naturopathic physicians. This is about barriers to this kind of practice. We've heard about such barriers from other members of the medical profession. I'm hearing that there's more bias and there are additional barriers to those generally in place through...well, the other kinds of changes to the system that would be needed to foster inter-collaborative care.

I have two questions.

First, can you tell me what kind of research supports the cost-effectiveness of naturopathic treatment?

Second, perhaps you could tell us a bit more about your problems with or barriers to access to substances that you use in treating patients, and how restrictions on the full scope of practice for which you're trained also create a barrier to your contributing to the health human resource solutions.

I'll be sharing my time with Dr. Martin as well.

[Dr. Paul Saunders]

I'm going to answer the first part of your question and let Dr. Lescheid answer the second part.

On the first part of your question, I'll use an example. We worked with Canada Post in doing a research study in which patients received standard naturopathic care, including all of the things we do, or physiotherapy care, or just the usual sort of care. What we showed in that particular study was that for the postal workers who received naturopathic care, there were savings of more than $1,000 per person in health care costs, and individuals returned to work sooner, were much healthier, and were able to do their work much better. There have been similar studies in the United States.

That's an example of research that actually shows naturopathic care is effective and cost-effective.

[Dr. David Lescheid]

Just to give you some examples of barriers for us, we have a lot of training in different kinds of natural health products, and one of the barriers is access to the substances that we have training in.

I'll give you three examples. The first two examples are about access to the doses that we know are safe and effective. One of them is for vitamin D, which is really the Michael Phelps of the vitamin world. We've learned a lot about vitamin D in the last little while. Currently, the upper limits are 2,000 international units. The science is suggesting that you need to go higher in order to have a therapeutic effect, but you need to go higher with a person who's well trained and knows the dosing. Yes, we could have our patients take handfuls of 2,000 international units or less, but really, it's best to be able to have access to a larger dose.

Something that goes along with this is that we're now starting to learn that vitamin D is related to vitamins A and K, and we're also restricted as to the amount of vitamin K we can use. So even though we do understand the interaction and vitamin K has really been shown to be a very, very important vitamin, we just can't get access to it with Health Canada.

So that's the dosing. Something such as L-carnitine is an example of one that is safe, but we don't have access to it because it's on schedule F. I'll just give you an example of the barriers and how frustrating they are, I work in a medical building that's owned by a medical doctor. We share patients. A patient went to him to ask about L-carnitine. The medical doctor said that he really didn't know much about L-carnitine, but he told the patient to see the naturopathic doctor downstairs. The patient came to see me and I was able to tell him about L-carnitine, the doses, the side effects, and what he needed to look for. Then, at the end of the conversation, I had to tell him that it was on schedule F and I couldn't do anything about it, that he'd have to go back upstairs to see the medical doctor to get a prescription for it. So here's a way that—

[The Chair, Conservative, Joy Smith]

I'm sorry, but Dr. Martin is going to run out of time completely unless he asks his questions now.

Or do you want to continue with this, Dr. Martin?

[Keith Martin, Liberal, Esquimalt—Juan de Fuca, BC]

Will there be another chance? Is there time?

[The Chair, Conservative, Joy Smith]

No, probably not.

[Keith Martin, Liberal, Esquimalt—Juan de Fuca, BC]

Then I'll quickly submit my questions, if I may.

[The Chair, Conservative, Joy Smith]

Go ahead.

[Keith Martin, Liberal, Esquimalt—Juan de Fuca, BC]

Thanks to all of you for being here.

Briefly, Dr. Busing, could the AFMC submit a couple of things to this committee?

Number one, you've done some excellent work in showing the demographic changes within the physician and the nursing populations. If that could be submitted, it would be appreciated, because it shows the graphic change taking place within the profession.

Secondly, if it isn't in your submission, could you also submit the plan for the 3,000 spots at the undergrad level, and also the plan for the 250 spots at a cost of $86 million in order to dramatically increase the post-graduate training positions the AFMC has?

Thank you.

[Dr. Nick Busing]

Thank you.

A couple of the asks are embedded in the slides, but I will be happy to formalize them in the way that Dr. Martin has suggested.

[The Chair, Conservative, Joy Smith]

That would be wonderful. If you submit it to the clerk, we'll ensure that each member gets a copy, including Dr. Martin.

[Dr. Nick Busing]

That's fine.

[The Chair, Conservative, Joy Smith]

By the way, welcome, Dr. Martin.

He's not a regular member of our committee but is a very valued member when he comes to our meetings.

[Keith Martin, Liberal, Esquimalt—Juan de Fuca, BC]

Thank you, Chair.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Do we have additional time left, Chair?

[The Chair, Conservative, Joy Smith]

Of course you do.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Thank you.

It seemed as though you weren't complete with your response, and we still have a bit of additional time in this section.

[Dr. David Lescheid]

I was almost wrapping up. It just seems like a very inefficient use of health care dollars to have essentially three different visits in order to be able to answer the question for this person about how to safely and effectively use L-carnitine.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Are you suggesting that the federal government ought in some way to work with the provinces to update the scope of practice for naturopathic physicians?

[Dr. David Lescheid]

Absolutely: to include the substances that we're trained to use safely and effectively.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Lastly, have you studied the B.C. scope of practice that's just been formalized in regulation? Does that fit what you're requesting?