Health Committee on Nov. 2nd, 2011

[The Chair, Conservative, Joy Smith]

We'll call the meeting to order.

We have a very special guest today. Of course, we have our witnesses, Maureen O'Neil, from the Canadian Health Services Research Foundation, and Elizabeth Badley, as an individual. Elizabeth is a professor from the Dalla Lana School of Public Health, University of Toronto. And you're a senior scientist, I understand. Wonderful. We're so glad you could join us.

Also today we have another guest. Today it's Kids Come to Work Day, where they accompany their parents. We have Michael Norris at the back, who is Sonya's son. There he is. He's going to get firsthand experience of what it's like to come to the health committee. Welcome.

Having said that, we are going to start our presentations. We have a 10-minute presentation from both people, and then following that we'll go into our Qs and As.

We'll begin with Maureen O'Neil, please.

[Maureen O'Neil, President, Canadian Health Services Research Foundation]

Thank you very much.

I'd like to thank the committee for inviting the Canadian Health Services Research Foundation to appear on this very important subject.

The Canadian Health Services Research Foundation is a non-profit agency funded by the federal government. It's mission is to accelerate healthcare improvement and transformation for Canadians.

My presentation will focus on how health systems should be adapted to better meet the needs of patients with chronic conditions. Although provincial and territorial governments have primary responsibility for health care delivery, federal investments through health transfers, research, and spreading innovations are absolutely essential to reform.

To start with some good news, we know a great deal about how to realign health care services to meet the needs of patients. Unfortunately, the reality, the bad news, is that actually making the changes is extraordinarily difficult politically, particularly for provincial governments. However, it is quite possible that the needs of aging boomers and the reality that as we age we experience more chronic illnesses will create sufficient momentum to change the way in which we organize and pay for health services.

On Monday, the U of T's Mowat Centre released a report by Will Falk that explained that we actually don't need new revenues, nor do we need to privatize services to meet our needs. Change can actually happen within the public system.

The fact that chronic disease management has become the main duty of our healthcare systems shows the effectiveness of modern medicine. Illnesses such as heart disease, some forms of cancer and AIDS, which at one time was fatal, are now chronic diseases.

A recent assessment conducted by the Canadian Academy of Health Sciences indicates that there is a considerable gap between how the healthcare system currently functions and the needs of patients with chronic diseases. It isn't just the people with chronic diseases who would benefit from a new organization of healthcare services, it would be good for all of us.

In a report prepared at the request of the CHSRF, Jean-Louis Denis, a full professor and a Canada research chair in governance and transformation of health organizations and systems, is proposing a strategic harmonization of front-line services, the management of chronic diseases and the health of Canadians.

In preparation for a national meeting of health care CEOs next February, we commissioned a health policy expert from Saskatchewan, Steven Lewis, to answer the question, what actually needs to be done to achieve integrated high-quality care for people with complex chronic conditions? He said much the same thing as Professor Denis. He defined integrated care as needs-based, comprehensive and holistic, convenient, seamless, easy to navigate, team-based, oriented toward patient participation and self-management, and, most important, evidence-based and data-driven. He has identified seven barriers to improving performance and seven solutions.

One thing he said was that it's actually rare in Canada to find true team-based shared care models. Non-physician practitioners are generally not practising to their full scope. For example, in the U.K., in England, most chronic care is delivered in the community by nurses.

He also drew our attention to the difficulties that the current payment systems create for modern use of communications. Many high-performing systems in the States allow patients to communicate by e-mail with their physicians. In some places in Canada, physicians cannot be paid for e-mail or telephone communication.

He also points out the exponential danger for patients taking five or more drugs, and some patients with chronic conditions are taking up to 10. If there isn't a comprehensive electronic health record and more integration of pharmacists, that really combines to make the problem more difficult.

To help answer questions about changes to how the healthcare system functions in order to meet the needs of Canada's aging population, we organized round tables in six cities. Over 200 policy-makers, health system leaders, researchers and so on took part. Members of the Senate Special Committee on Aging also participated in these round tables.

Several solutions proposed by Mr. Lewis and Professor Denis were explained during these round tables. They also pointed out that we need to think about the issues particular to the very specific population groups. For example, a good number of aboriginals have only limited access to transportation and housing. They also have a higher than average rate of chronic diseases. They have also asked to strengthen partnerships. They have asked organizations like ours to disseminate these innovations because, otherwise, we won't move forward.

Last year we helped in the spreading of innovations in primary health care through a conference called “Picking up the Pace”, where we featured 47 innovations in primary health care delivery, many of which highlighted better ways to care for patients with chronic conditions. For example, the Centre de santé et de services sociaux-institut de gériatrie de Sherbrooke and a research team from the Research Centre on Aging in Sherbrooke, first developed, in 1999, an integrated service model for seniors that was unique in Quebec. They had real success in reducing the number of elderly people who were going into residences, and they also, and this was very important, put the brakes on the deterioration in the health of elderly people during hospitalization because fewer of them were in the hospital.

This was shared in the Province of Quebec, but as in many instances, people cherry-pick, and they pick some things but not others, so it would be interesting to see whether or not the results were quite as sterling as they were in Sherbrooke.

I'd like now to turn to a concrete example of how the Northwest Territories is working with us to develop an integrated chronic disease management strategy.

The NWT estimates that 70% of all deaths, half of all hospital admission days, and costs of over $136 million annually are related to chronic disease.

Working with the territory at the nexus of policy and delivery, our focus has been on mental health, diabetes, and kidney disease. We're bringing together researchers who've spent years studying these topics, together with the territorial policy-makers, health system managers, nurses, and doctors. Drawing on their mutual strengths, they are identifying improvement opportunities and building solutions across their extraordinarily large territory. Closely associated with this work is evaluation to ensure that the ideas and practices spread.

Governments across Canada are working to meet the challenges posed by chronic diseases. We know in recent scans that we've done across the provinces that there are activities everywhere. This is a big concern of all systems.

At the pan-Canadian level, the federal government has supported a number of disease-based frameworks, strategies, and bodies that also are attempting to mobilize support across the country and reduce the burden of specific chronic conditions, whether it's the Mental Health Commission of Canada, the Canadian Partnership Against Cancer, or through the Canadian Institutes of Health Research, the strategy for patient-oriented research.

These federal investments are essential in the reform of health care, so we at CHSRF continue to search for ways to improve health care for Canadians and to share these innovations across the country.

Thank you very much for your invitation to appear.

I'll be happy to answer questions later.

[The Chair, Conservative, Joy Smith]

Thank you.

Could you please give us your presentation, Dr. Badley?

[Dr. Elizabeth Badley, Professor, Dalla Lana School of Public Health, University of Toronto; Senior Scientist, Toronto Western Research Institute, University Health Network, As an Individual]

Thank you very much for giving me the opportunity to come today. I'm going to continue with the theme of chronic disease, and I'll change the tempo a little bit to be a bit more personal.

I'm very delighted that you're interested in chronic diseases related to aging. This is my long-term research interest as an epidemiologist and health services researcher. My particular expertise is in arthritis and other musculoskeletal conditions.

What I want to do today is help put arthritis more firmly on your radar screen and convince you that you must include arthritis in your deliberations on chronic diseases and aging. Of course, this is a huge topic, so I've chosen to focus on a couple of aspects that I think you'll find most relevant.

These are, first, how arthritis and other chronic diseases are related to each other, and second, why this is important to healthy aging.

I should first set arthritis in a Canadian context. It's one of the most common chronic conditions and is by far the most frequent cause of disability in the population. One in six Canadians, about 4.5 million people, report having arthritis, and that is a lot. A great many of these people are aged 65 or older, representing over 1.7 million seniors. That's the same as the populations of Manitoba and Newfoundland and Labrador combined. On top of that, there are a further one million, about the same as the population of Saskatchewan, who already have arthritis and will become seniors during the next 10 years.

I don't have time to go into a lot of detail about arthritis. If you need to know more, please do ask. An excellent source of information is this report from the Public Health Agency of Canada. It's called Life with Arthritis in Canada, and it gives a very good picture of the personal and public health challenges of arthritis.

Arthritis is a broad family of diseases, and I'm just going to talk about one of them: osteoarthritis, or OA, as we call it. More people have OA than any other kind of arthritis. About one in eight people in Canada have it, and a lot of them are seniors.

OA, like other kinds of arthritis, is linked to other chronic diseases. Take, for example, a friend of mine, a real person, who I'll refer to as Marie. She's a very lively, positive, creative person with a great sense of humour. My husband calls her the one-woman walking cabaret. Marie is only in her late sixties, but she's had OA for about 20 years. She has big problems with mobility. Just walking and climbing stairs is difficult and painful. Over the years I've watched as the pain and stiffness of her OA have made her less and less physically active. That's meant that she's put on weight. The more weight she puts on, the worse her arthritis gets, so she's caught in a vicious circle of arthritis pain, less activity, and more weight gain. Another effect of her weight gain has been that she's developed hypertension and heart problems. And on top of everything else, she's now been told to watch what she eats, because she's on the cusp of getting diabetes.

Marie is not alone in having a combination of other health conditions, as you've already heard. Most seniors have more than one chronic condition. A recent Stats Can survey targeted to healthy aging showed that 90% of seniors with arthritis have at least one other chronic condition.

The interesting thing is that we're now learning that these co-occurrences of arthritis and other conditions likely don't happen by chance.

We all know that lack of physical activity and excess weight are associated with an increased risk of heart disease and diabetes as well as some cancers. So we can speculate that Marie's disability and weight gain brought about by her OA may have contributed to her other health problems.

A well-known side effect of anti-inflammatory medication for arthritis is an increase in blood pressure, and that in turn can increase the risk of a heart attack. In fact, for this reason, Marie's doctor has stopped giving her these meds, which means that she's left with a lot of pain.

It's hardly surprising that the wonderfully positive Marie sometimes get depressed. This is worrying, because depression increases the risk of having a heart attack.

There's yet a further twist to the story. Arthritis is the most common cause of inflammation, and research is beginning to suggest that inflammation itself might be bad for you--bad for your heart, your diabetes, and a number of neurological and other conditions.

This may sound like terrible news, but the good news is that it's opening the door to understanding how and why different chronic conditions can occur together. Knowing what leads to what and why raises the exciting possibility that we might find new ways to prevent chronic diseases. CIHR's initiative focused on inflammation is certainly a step in the right direction.

Let me spend my remaining time focusing on what can be done about arthritis.

There's a powerful myth that influences both people with arthritis and their doctors, that OA is an inevitable part of aging for which nothing can be done. This is not true. Younger people have arthritis, and, for the record, the major treatment strategies for OA are medications for pain and inflammation, maintaining a healthy weight, exercise, and for end-stage arthritis of the hip and knee, joint replacement surgery.

Marie has had both knees replaced, which has helped a lot, but she still has arthritis in her feet, hands, and back. One of her problems is getting access to expertise within the health care system. Many primary care doctors aren't confident in dealing with arthritis, which can probably be traced back to a lack of arthritis training in medical education. Our orthopedic surgeons focus, of course, on surgery, such as total joint replacement, and our rheumatologists are busy dealing with rheumatoid arthritis. This raises the question of where people like Marie can go for expert advice on disease management. And, don't forget, she represents a very large number of Canadians who suffer from arthritis.

This is where we need the kinds of innovations in the health care system you've just heard about. We need innovations in the way we deliver arthritis care to ensure people like Marie can get the help she needs. There are some encouraging beginnings across Canada. CIHR has also funded research looking at new models of delivery of care for arthritis, some of which involve professionals such as advanced practice physiotherapists and nurses. But there's still a long way to go.

And of course we can't forget that arthritis is associated with other health problems. As you know, this is a challenge for our health care system, which typically deals with one condition at a time. Marie spends a lot of time going to medical appointments with different specialists to deal with her various health problems. This issue is not unique to arthritis, and I know you've already heard about the need for a more integrated health care system and patient-centred care. However, the discussions about this, and particularly about chronic disease management, do not always include the needs of people with arthritis. It's vital that this is changed, given the large number of people with this chronic disease.

I'm trying to encourage Marie to take advantage of various community-based treatments such as exercise, physical activity, and weight loss, as well as chronic disease self-management programs. The good news is that these are the same things that are recommended for other chronic conditions, as I'm sure you know. However, we need to keep in mind the needs of people with arthritis. For example, the current Canadian recommendation for physical activity for seniors is at least two and a half hours of moderate to vigorously intense aerobic activity each week. Marie can hardly get out of her house. We need ways to help the Maries of this world deal with the pain and stiffness of arthritis and to be able to gradually ramp up to full physical activity and at the same time reduce their risk of other chronic conditions. Physical therapists and chiropractors can help with physical activity, but, as you've already heard, we need to deal with some of the financial and other barriers that stop seniors and low-income people from taking advantage of their help.

The thing is, exercise works. I have another friend, Jeanette, who has arthritis in her back, hands, and knees. Two years ago, she had to hang onto her husband's arm for support when she was walking outside. This year, she began to meet daily with a personal trainer and started a graduated exercise and walking program. Two weeks ago, she walked 21 kilometres in the Toronto marathon. This, more than all the scientific studies that I've read, convinces me that support for physical exercise for people with arthritis can reduce disability, and may even potentially postpone the need for joint replacement surgery.

In conclusion, I hope I have helped to convince you that when thinking about healthy aging and chronic disease, we cannot and must not neglect the needs of the large number of people with arthritis.

There are three reasons for this. One, arthritis is important in its own right. It is the most frequent cause of pain and disability, especially in older people. Two, having arthritis increases your risk of other chronic conditions, and this knowledge needs to be built into chronic disease prevention and management strategies. Three, we have to recognize that having arthritis pain and disability may prevent many older people from getting the maximum benefit from existing chronic disease strategies.

This is a quick look at some of the most important issues, but there is a lot more. If you'd like to know more about this important disease, I'm sure the Arthritis Society and other members of the Arthritis Alliance of Canada would be more than happy to help you, as would I.

Thank you for your attention. I would be very happy to answer questions.

[The Chair, Conservative, Joy Smith]

Thank you so much, Dr. Badley.

We'll now go into our first round of questions, which will be seven minutes for the question and the answer.

Also, just a reminder that we will suspend at 4:45 for the business portion of our meeting.

We'll begin with Madam Quach.

[Anne Minh-Thu Quach, NDP, Beauharnois—Salaberry, QC]

Thank you, Madam Chair.

I'd like to thank you for your presentations and for giving us information about your organizations.

My first question is for Mrs. O'Neil.

You spoke about a number of interesting things. First, you said that, according to one report, it isn't necessary to privatize healthcare to help patients and that there is still a gap between how things are currently working and the healthcare needs of seniors.

How can the federal government adapt to intervene and improve the healthcare offered, particularly when it comes to chronic diseases?

[Maureen O'Neil]

First of all, I want to underline the research that U of T has just put out, which Will Falk was responsible for. It looked at all of the potential efficiency gains that could be made within our system if we used technology more effectively and if we used different professions to the limit of their capacities. It would mean reordering who does what among doctors, nurses, physiotherapists, etc. It would mean approaching the organization of services differently and approaching the services in a way such that the patient is at the centre. That is an extremely important point to make.

He also noted that, in his view, there is enough money in the system to achieve this. This does not cover, of course, the issues that have been left out so far, which are questions of pharmacare, etc.

This point was reinforced as well by the CMA in its own briefs, that a public system, reorganized with the same amount of money—or the amount of money that rises depending on population—can cover this without any particular need to privatize payment of services.

That doesn't mean you can't have different organizations actually providing services, but the research seems to suggest that there are enough inefficiencies in the way in which we do things now that, with a reorganization of those services, the needs could be met.

Can you repeat your second question? I'm not actually sure if I answered all your questions.

[Anne Minh-Thu Quach, NDP, Beauharnois—Salaberry, QC]

Yes, you did, but with respect to the Toronto research, would it be possible to have the results of the research sent to the clerk?

[Maureen O'Neil]

I think they are on the site of the Mowat Centre for Policy Innovation at the University of Toronto. I think it was posted on Monday of this week, so two days ago.

[Anne Minh-Thu Quach, NDP, Beauharnois—Salaberry, QC]

You also talked about partnerships with aboriginals and the fact that they have specific problems. You mentioned the problem of access to transportation and social housing. You also said that we need to work in partnership to improve the conditions and prevent an exaggerated rate of chronic diseases in that group in particular.

Do you have any ideas about strategies that can be implemented so that the federal government can get involved in this?

[Maureen O'Neil]

Yes, but as you know, the federal government has a lot of responsibilities related to aboriginal health. But they are often shared with the provinces.

I think Manitoba has implemented an initiative. Two weeks ago, it was announced that government airplanes instead of ambulances were going to be used to transport patients. Ambulances can't be used in many communities anyway. A study was done establishing that using the small government airplanes costs almost the same as using ambulances in the cases of patients in regions that are very far from Winnipeg.

It was a recommendation that came out of our round tables on aging. I should mention that we always need to think about specific populations, rather than think only generally, because the situations are very different.

[Anne Minh-Thu Quach, NDP, Beauharnois—Salaberry, QC]

I have a question that perhaps you both might answer. You both spoke about grouping teams of professionals to help seniors. We know that there are only 200 geriatricians in Canada to treat seniors. We know that the number of people 65 years and older is going to increase exponentially in the coming years.

Do you know whether the research under way is providing enough information about the need for healthcare professionals to adapt to demographic changes? Is there enough training? Should there be more?

[Maureen O'Neil]

I can answer, but I think Dr. Badley will have something to say as well.

It's well known that there is a shortage of people trained in gerontology. You will probably invite the scientific director of the Canadian Institutes of Health Research's Institute of Aging. He is really the leader when it comes to the research and organization of services in Canada.

We can say there's a shortage. It takes nearly 10 years to train a specialist. This shortage is serious.

[The Chair, Conservative, Joy Smith]

Dr. Badley, would you like to make some comments on that as well?

[Dr. Elizabeth Badley]

Thank you. I'd just like to add to and echo what you said earlier about using other health professionals.

A lot of health care for older people in the community and people as they age can be delivered by physical therapists, particularly for musculoskeletal disorders, by nurses, and we can use chiropractors, occupational therapists. For some of the needs not directly related to health care but to well-being we can use social workers. There is a whole range of professionals out of there. There are exercise therapists, who can be used to help people remain active and to deal with physical activity and the consequences of obesity. And pharmacists have been increasingly used to advise people around drugs, for example.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Badley.

We'll now go to Mr. Brown.

[Patrick Brown, Conservative, Barrie, ON]

Thank you, Madam Chair, and thank you, witnesses, for your comments so far.

I want to get your perspectives on the CIHR's Institute of Aging. We were previously told that there has been a funding allocation of $122 million and that it's one of the strategic priorities of the CIHR.

Do you have any impressions of this Institute of Aging? Is it accessible for research? Is it helpful to have CIHR put a focus particularly on the theme of aging?

[Dr. Elizabeth Badley]

In a word, yes. They're doing a great job. They have e-mailed researchers who are interested in the field regularly to keep them up to date about their calls. I'm very grateful to them, because I've just gotten a grant from them to investigate whether baby boomers are in fact going to be less or more healthy than their older counterparts, because we don't know the answer to the question, whether it's going to be better or worse than we feared.

They sponsor a number of targeted competitions, which are very important for the research community, that enable the research community to look at aging more broadly—not only looking at diseases, but also at health.

[Maureen O'Neil]

They were excellent partners when we were doing these six round tables across the country on aging. They were extremely good partners in terms of sharing the basic research they have accumulated over the years and in making extraordinarily useful interventions in round tables that included, as I mentioned, a real mix of people, from researchers to people at the community level to providers of health services.

[Patrick Brown, Conservative, Barrie, ON]

It was my hope to hear that. It's certainly nice to see the CIHR have that focus.

When I think of the $122 million, I also imagine that there are grants available through the cancer research funds and through neurosciences that would also have many links to aging.

One thing this committee has taken an interest in is the neurosciences. Concerning the population study that is also being funded, what do you hope from Minister Aglukkaq's funding of $15 million for the neurological charities to figure out the exact prevalence of neurological disorders in Canada? I know we've taken estimates, but what are your hopes concerning what this will help establish?

[Dr. Elizabeth Badley]

Neurological disorders, I think, have been largely neglected. They are perhaps one of the most common causes of very severe disability and of course occur more frequently with aging and also in conjunction with other conditions. It will be very good to get prevalence estimates and also to learn more about their consequences for individuals.

I would also say that the Public Health Agency of Canada has recently focused on living with chronic diseases and has had other looks at hypertension and arthritis and related conditions. We commend the agency for commissioning research to look in depth at a number of different chronic conditions, because the general population health service, while extremely useful, often does not give those in-depth insights that we really need. So I think the work on neurological disorders and other disorders is an extremely welcome thing.

[Patrick Brown, Conservative, Barrie, ON]

Has the Canadian Health Services Research Foundation, which you, Ms. O'Neil, head up, done any research in the area of neurosciences, in terms of Alzheimer's and dementia?

[Maureen O'Neil]

No. We're a very small agency. You talk about the $122 million in the institute and the agency; our total budget is just over $10 million. We work much more at the nexus of policy and delivery with the provinces, with the health institutions, regions, etc., working on the way in which they organize services rather than being a financing agency for primary research. Canadian Institutes for Health Research do that. Also, many of the health charities focus on primary research.

In many areas, such as the work on neurological conditions, it's primary research that we need as much as—I would say even more than—we need research on how to organize services for people. In fact, we simply don't have good answers to many of the questions they're dealing with.

[Patrick Brown, Conservative, Barrie, ON]

I think you highlight that very well. One thing I'm always perplexed by is how little we know when it comes to neurological disorders. I hear positive reviews of government programs, such as the New Horizons program, which has programs for seniors' homes, such as arts programs and physical activities, to stimulate and delay the onset of neurological disorders.

At the same time, you can look at individuals such as Ronald Reagan and Margaret Thatcher, who fell ill with neurological disorders, and I couldn't imagine individuals who have busier days. It really leaves you perplexed, wondering what we can do to delay onset or prevent some of these horrible diseases. Do you have any policy advice on programs that the government should look at and that would be helpful in this field?

[Maureen O'Neil]

I would say obviously research, but I think something else. I think that as we become much better at using electronic health records and become better at engaging clinicians who are seeing people every day—one of the CIHR programs is attempting to get physicians who are actually in contact with patients every day to use the data on their own patients and share that evidence—we're also going to have a much better way of building up knowledge of the people who are coming to see their doctors now. Even if we don't actually know what the cause is, we'll get a much better sense of how people's disease progresses.

In other words, without electronic health records, we are working with one hand tied behind our back. We're not able to accumulate the information. If you imagine how companies who want to sell us things and companies who are able to use our credit card information, let's say, to develop a profile as a consumer.... They're way ahead, in their capacity to understand us, of where our physician is.