Health Committee on May 13th, 2010

[The Chair, Conservative, Joy Smith]

Does anybody else have comments on this for Ms. Leslie as well?

[A voice]

Everyone nods.

[The Chair, Conservative, Joy Smith]

That's fine. I just interrupted you so that other people can get a chance.

Go ahead, Ms. Hoffman.

[Abby Hoffman, Associate Assistant Deputy Minister, Strategic Policy Branch, Department of Health]

Since you posed your question both to the advisory committee and to Health Canada, I think there's a connection with the concept of having a gathering point for virtually every interest--governmental, non-governmental, professional, public, and so on--to have a huge conversation about the major challenges and issues in this sector.

Your question relates a little bit to Dr. Bennett's question right at the outset about whether there's what I'll call a grand plan whereby progress is being tracked and reported upon, and so on. The nature of the country is such that there can be a grand plan around collaboration, but not necessarily a grand plan that's a strategic, detailed, step-by-step list of what we're going to work on first, and everybody's to get on board and work on the same things at the same time. That's not the reality of the health sector generally, nor is it specifically the reality in the area of health human resources.

I don't want to put words in their mouths, but I think some who are proponents of the observatory concept have a sense that if everybody could gather around the same table, we could get to this grand plan. I'm not sure that's reflective of the political realities of the country or of the health care sector in particular.

Could there be some amendments to the representation at the advisory committee table? Yes, but as Dr. Tepper has pointed out, that is a committee whose principal reporting relationship is to government, and if the non-governmental players want to have their own forum, that's a little bit of a different proposition.

The approach up to this point has been to incorporate stakeholders, professional organizations, and so on at a certain level in the advisory committee, and then as needed in those various subcommittees, working groups, and task groups that work on particular issues that flow from the pan-Canadian framework.

[The Chair, Conservative, Joy Smith]

Please be very brief.

[Megan Leslie, NDP, Halifax, NS]

For what your vision is, would there need to be a formal changing of the mandate of the federal-provincial-territorial committee, or is it something that you envision as organic?

[Dr. Joshua Tepper]

It has been pretty organic. When we added HEAL and when we changed our committees structure to be interprofessional and not siloed, when we changed it to do more modelling and not just data collection, for the most part we've just done that. For a couple of groups we have sought deputies' approval, but for the most part we have the autonomy to do it. Certainly we have the flexibility to receive any group that asks. If the nursing groups or whoever seeks a table, we're very open in our agendas and we don't go higher.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Tepper.

Now we'll go to Ms. McLeod.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Thank you, Madam Chair.

It's good to have you all here in terms of the wrap-up. It has been a bit of a long study. I think we had many important things that happened along the way that stalled us a little bit, but it is an important study, and we're looking forward to getting it completed.

To begin, I'm going to Ms. Woods.

I'm not sure if you've paid careful attention to the testimony of different witnesses who have come forward, but is there anything that you would like to conclude or comment on in terms of some general summary statements?

[Shelagh Jane Woods, Director General, Primary Health Care and Public Health Directorate, First Nations and Inuit Health Branch, Department of Health]

What I would say is that we're a small part of this. We're the aboriginal health human resources initiative, but we are also members of the advisory committee on health delivery and human resources.

I would add to what Dr. Tepper said by saying that we feel there's really good representation of aboriginal interests at that committee. I know this is a bit off topic, but just to try to answer that, several years ago we were able to make the point that we thought it would be useful to have an aboriginal representative, and we have done so. I think that has worked very much in our favour.

I'm sorry; you'll have to remind me exactly what the question was.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

It was just a summary I wanted, but I think we heard that there are gaps in research and data collection in the area of aboriginal HHR. Are we going to make any progress in terms of collecting data, and what are the challenges?

[Shelagh Jane Woods]

I think we are.

I'll ask Debra Gillis to give you some more of the detail, but I would say in opening that it's one of the things that we turned our minds to very early. In fact, it's something that bedevilled us for many years when we had our small Indian and Inuit health careers program, before the AHHRI.

We recognized right away that gathering data, as in all aspects of our work, is a very difficult issue, compounded in our case by issues like self-identification. If somebody doesn't want to identify as aboriginal, they don't have to, so it's very hard to get accurate counts, there are different ways of keeping data in different provincial and territorial systems. Those are the kinds of things we deal with all the time.

We have set some work under way, and I'll ask Debra Gillis to give you a little bit more of the detail on that.

[Debra Gillis, Director, Primary Health Care, Primary Health Care and Public Health Directorate, First Nations and Inuit Health Branch, Department of Health]

I'll follow up on what Shelagh Jane was saying. We started off by saying that we really needed to identify the numbers, at least, of the basic health professions--doctors, nurses, etc.--but we also needed to work at developing what would be a minimum data set of information.

We brought together first nations, Inuit, and Métis leaders from across the country. CIHI was involved. The department was involved from a pan-Canadian perspective, because they had been working on some of this.

We did come up with a framework for a minimum data set, but as Shelagh Jane said, the information is held in many different places, such as the Canadian Nurses Association, and you can't really compel people to identify their aboriginal identity.

As a first step, we've been using the Statistics Canada census data. We've done a detailed analysis of that and are using it as a baseline. We've done analysis of the 1996, 2001, and 2006 census data as our initial baseline to identify some trends. That has been incredibly helpful.

We can tell you how many people working in the health field have identified themselves as aboriginal, and whether or not they're first nations, Inuit, or Métis. We know in which province they're working and what the major occupations are. For example, we know that as of 2006, aboriginal people made up 2.1% of the health care workforce in Canada. There were over 21,000 aboriginal people who identified themselves as working in the health system. We know that the number of registered nurses increased by 65% between 2001 and 2006.

It's been a wealth of information, and we're beginning to mine that better with Statistics Canada's help and through working with HRSDC. We're now looking at trying to link those data with education files and are doing much more detailed work.

That will definitely help us as we're planning and going forward. We're also beginning to collect information at the community level on the numbers of people who are working in the community and what their occupations are at the small community level so that we have a better idea of exactly the numbers of people who are working at the community level.

We're really making inroads that we hadn't made before.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

My next question is directed to Joshua. I was interested in your comments, first of all, about physician assistants and nurse practitioners, and also about how your group actually shares best practices with the provinces and all the players.

Could you talk a little bit about the physician assistant role in particular? Where is it rolling out? How are best practices getting shared within your organization? Also, I understand that nurse practitioners in some provinces have real challenges in terms of how their actual role is going to integrate into the system.

[Dr. Joshua Tepper]

To answer your first part, I would say knowledge translation occurs in at least two ways. One is that at every meeting, as I said, we do a round table. It's structured according to a template. One of the areas in the template is new roles and scopes of practices, and each jurisdiction provides an update. The other thing is that when we see a specific area or an emerging trend, we might do a bit more of what you might call a deep dive, or have a specific paper on that area. That would be for new roles or healthy work environments, or for data and modelling. In data and modelling we might hold a specific conference just to bring people together. Two or three times a year we do a crosscut, and when there's an emerging trend, we do a deep dive.

All new roles and all evolutions in health care, whether it's a PA, an NP, or a physiotherapist who can order x-rays, run into challenges from the established group, and it's not always from the doctors. Every group that starts to work in new and different ways faces a challenge. The NPs and PAs are increasingly being looked at or implemented in different jurisdictions across Canada. With PAs, Manitoba was the first. Ontario, B.C., and I think Nova Scotia are now following behind. With NPs, Ontario is leading, but now B.C. and a few others are following. We've got well over 1,000 NPs now in Ontario, and probably closer to 1,400, so we've changed our scopes.

Then you can look at the other end. We don't talk a lot about it, but there is traditional Chinese medicine. Ontario and B.C. have both regulated and have really started to put that profession forward. In an increasingly multicultural country, it's very important. Quebec and Alberta have regulated acupuncturists, though not the full traditional TCM model.

Again, it depends on how you look at this. I'd be happy if you had some specific questions around PAs or NPs or one other area, and I'd do a bit of a deep dive for you.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Tepper.

We'll now go to five-minute rounds. I've been extremely generous with the time in order to get in as many questions as possible.

It will be a five-minute question and answer now, and we'll begin with Dr. Bennett.

[Carolyn Bennett, Liberal, St. Paul's, ON]

I want to explore some of the concerns that were expressed in the last round table about psychologists and the difference across the country in terms of their scope of practice. I thought 10 years ago that scope of practice was an outmoded view, and that we were supposed to be moving to core competencies based not only on the letters after your name, but also on your geography, IT backup, and all of those things. Certain people have a core competency that can be augmented in various ways.

How far are we from being able to have that conversation across the country, and being able to move in a way that isn't hard lines on scope of practice toward a much more flexible approach of letting people do what they're good at and what they've had extra training in?

[Dr. Joshua Tepper]

Having the conversation is easy; creating the change is hard.

We've changed the name around scope of practice, but we have not done nearly enough in moving to the core competency model. It's a ping-pong game between the health education system, which says it's willing to train to a competency model if the regulatory bodies will approve their licences afterwards, and the regulatory bodies, which say they'll approve on a competency model if the education system starts to produce them. There are a lot of turf and silo aspects, so it has not moved nearly as far or as fast as it should.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Thank you for being here to help us complete our study.

I have two questions. One is related to what Dr. Tepper was just talking about. We heard last session that change is necessary and has to be based on collaborative teams. We also heard that data are essential. I think I wasn't hearing collaborative teams as being the core of what your organization is addressing; the collaborative team model is very different from the model of identifying the needs for certain specific practitioners individually.

The other question I have is about international doctors. I've been briefed about the transitional licensing law in Ontario for international doctors, with the view that it could be a way to engage those doctors before they are fully qualified to work in Canada by having them assist physicians. The physicians get paid for the supervision. The international doctors get employment in their field at a pay rate that makes it affordable to go through the hoops. It is an important way to address the international medical graduate system. I would like somebody to talk to me about that as well.

[Dr. Joshua Tepper]

I will be brief, Madam Chair.

I have three quick points. One, I was unfair to point out only the education and the regulatory bodies as culpable in my last comments. Government owns a lot of it too, in our legislative and regulatory frameworks, as do many parts of the system, so to move to a competency model will take major efforts by all parties, and a real intent has not been seen.

On the issue of teamwork, it is absolutely a big focus for our group. We actually have a specific committee, called the interprofessional committee, that has now been created to replace the physician committee and the nursing committee and the allied; however, the actual on-the-ground issues of how you compensate different people in different models and which areas of the health care system get picked for funding, whether it's primary care or specialist care, become jurisdictional issues.

In Ontario we did family health teams and anesthesia care teams. Other jurisdictions might pick cardiovascular surgery or emergency departments to focus their initiatives. As a framework it's data collection, principles, and sharing best practices; where there is a pan-Canadian approach, we do have a specific interprofessional committee.

The IMG transitional licence is something that I'm quite familiar with as a proposal. I don't know if time will allow me to fully go into it. There's a lot of complexity and patient safety issues, but we're finding a lot of other options for international medical graduates.

I would also say that international medical graduates in Ontario—you mentioned Ontario specifically—have gone from roughly 75 a year in training to over 200 new ones in training a year, and currently there are almost 1,000 international medical graduates in training a year. We've actually seen a decrease in the number of IMGs who need to be assessed for training. We used to process 1,000 a year; we're down to about 550 a year, so we're catching up.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Tepper.

We'll now go to Ms. Davidson.

[Patricia Davidson, Conservative, Sarnia—Lambton, ON]

Thanks very much, Madam Chair, and thank you to our panel here this morning.

I'm sure you've all been following the presentations we've had so far on this study, and as my colleague has said, it has been a long study and it has been rather drawn out. It's a challenge for all of us here now, I think, to try to draw it all together and put together the many things we've heard.

I'd like to ask Ms. Woods the first questions, if I could.

We heard a lot from the first nations and the Inuit health organizations about special challenges they face, and definitely data collection was one. We've heard a bit of information about that, but I have a question on the data collection first. Do we need a lot more data collection, and is there a timeframe involved with putting that together? Do we have enough at this point to make any recommendations or to try to develop a strategy? That's my first question.

We also heard that there were challenges in the Inuit and first nation communities about pay scales and the high levels of burnout because of a lot of different circumstances. We heard there were extreme challenges with the education portion, especially with the math and sciences, and that those challenges were a deterrent to those who wished to get into the field.

In terms of the education issues, is anything being done through your department to coordinate efforts to improve that situation?

[Shelagh Jane Woods]

Let me start with the last part and, as always, I'll turn it over to Debra for specific details.

Let me say that none of these things are surprises to us. We have been working all these issues all the way through and, as I said earlier, even before we had the aboriginal health human resources initiative, we had begun to turn our minds to all of these things. We have begun to address all of them.

The educational barriers are one of those areas where we could easily have spent all the money that we had by going into the schools and trying to get kids to take maths and sciences. That's not our responsibility. We really are looking at the workforce.

As a result, we've collaborated with the Department of Indian Affairs. We've tried to make available to them, and with them, materials promoting the value of taking maths and sciences if you want to take health careers. We have an arrangement with that National Aboriginal Achievement Foundation. They do extremely well-attended career fairs on reserves, in communities, and in large cities that draw in aboriginal high school students and show them the joys and the beauties of health careers.

Those are really good opportunities to emphasize the importance of continuing in your math and science studies, so I think we've begun to address that. The fact that we're seeing more and more people signing up for health careers is evidence that we're beginning to get somewhere on that one.

The challenges on the pay scales are very complex. Those are very difficult, particularly as they relate to people who are employed by the first nations. We hold no sway over what the first nations can pay. We can't tell them what they must pay this professional or that professional.

Where possible, we pass on any increases that we get, such as the increases that we get every year on our contribution agreements, which is how we fund the first nations. We pass those along, and they can then top up the pay of their health care workers. In the last year we asked the Assembly of First Nations to begin to do some more detailed work on pay scales. We'll maintain a keen interest in that as it goes forward.

Maybe I'll ask Debra if she could answer some of the specific challenges on data collection, although I think she did provide quite a bit of information at the beginning.

[Debra Gillis]

I'll add one point about the data collection. I think you're really asking if we have the information now to plan and say how many of these we will need. That becomes very difficult when you're looking at a smaller population, and we're also working within a provincial health system.

In many communities, even if we could take some of the modelling methods to establish how many nurses you need, when you translate that down to a very small community of, let's say, 600 and use traditional needs-based modelling, you may actually end up with one-quarter or one-half of a nurse, depending. Then it becomes very difficult, because you can't hire half a nurse or a quarter of a nurse in a remote or isolated area.

So sometimes the traditional methods don't work. That's why we're starting to work with the communities and first nations nationwide and region-wide in developing a health human resource planning tool they could use in the community--a tool that's based on the pan-Canadian framework and based on needs-based planning--so that they can start taking a look at the resources they have within their communities and ask what the best mix is of the resources that they have for their needs. Do the people have the right education? We have this many nurses and this many of these other paraprofessionals; maybe we need more of this or more of that. This is to help them plan at the community level, because traditional data modelling methods just don't work in those small areas.

[The Chair, Conservative, Joy Smith]

Thank you very much.

Now we'll go to Monsieur Dufour.