Health Committee on Oct. 17th, 2011

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

My next question is also for the representatives from the Canadian Chiropractic Association.

You talked about progressive public education programs. What exactly do you mean by that? Could you give us examples to get a better idea, please?

[Dr. Eleanor White]

I mentioned three. We have more, but one program that has been very successful has been the falls prevention program. This was developed in conjunction with Canadian Public Health. This is a program on CD and on paper, which is presented by chiropractors to long-term-care facilities, to retirement facilities, or in office, and it is made available through the website to younger, more fit individuals who could take advantage of the material. Again, having that accessibility in a more modern approach is one way to attack it.

Another way is to have in-office groups and speakers. But really, this should be done on a multidisciplinary basis. That is where it is most effective. Again, chiropractors are not accessed through the community care portal, and they could be very well.

[The Chair, Conservative, Joy Smith]

Thank you, Ms. White.

Dr. Carrie.

[Colin Carrie, Conservative, Oshawa, ON]

Thank you very much, Madam Chair.

First of all, I want to thank all the witnesses for being here today for this very important study. One of our earlier witnesses said that the impact in Canada is $190 billion per year. The fact that we are getting this input at this time is very timely.

I would like to talk to the chiropractors, too, seeing as you are here. First, I want to congratulate you. You had a really good write-up in Consumer Reports recently on the profession. I have a couple of questions specifically, if you could answer. One, could you provide us with an example of how chiropractic could be involved with both the prevention and treatment of chronic disease? Also, we hear a lot about collaborative care. There are some good examples out there, and I was wondering if you could give us good examples of that and also some of the hurdles you see.

[Dr. Eleanor White]

If I may draw from personal practice, I will be brief with this. I will give you an example of a 65-year-old woman who came into my office about two years ago with general bone pain. She was also diabetic. She hadn't had a bone density test in almost ten years. We phoned up the physician. She had been lax with her medical care. We got her in, and sure enough we found greatly advanced osteoporosis.

That obviously affects the manner in which one is treated. We got her referred to a good exercise practitioner who could help her develop a safe program and a nutritionist who could help her with a program for bone health.

Down the road, however, she mentioned her granddaughter, who was about 15 at the time and who was having headaches at around eleven most mornings. She brought her granddaughter in, and her granddaughter was moderately obese and was a single child of a single parent. She tended to not eat her breakfast. Of course, by eleven in the morning she was hypoglycemic and would go out and have pop. She drank a lot of pop, maybe five or six cans a day, as an awful lot of kids do. Pop has phosphoric acid, which leaches calcium out of bones. Here you have a child with the red flags in her family of diabetes and osteoporosis. You have a diet low in dairy, high in phosphoric acid, along with lack of activity in the young girl, and she is pre-diabetic and will probably be a candidate for osteoporosis down the road, if not other conditions.

That is a good example of how primary care practitioners—and in particular, chiropractors for musculoskeletal things—will take a look and ask where they can collaborate with other professions and how they can get this person well looked after.

Good access to laboratory and imaging material is essential to all primary care practitioners. That is one hurdle we have. It varies from province to province. These situations allow for education of a patient as well as early intervention and prevention. It allows us to increase activity. It allows for consultation with other practitioners. Again, the message has to be ubiquitous and universal. All practitioners need to be speaking the same way.

You mentioned barriers. Barriers for us are often differences between provincial jurisdictions. Having now worked federally, I see how different it is from province to province for not only coverage of care, but also the access to lab and imaging materials. An easy consultation and referral base with medics in the community is on the whole so much better than it used to be, but still there are some barriers. We've implemented a huge amount of effort into research in the last ten years, and that is helping greatly. But we need more, and we need more interdisciplinary research. Those would be some of the highlights.

[Colin Carrie, Conservative, Oshawa, ON]

Would you be able to provide another example of the prevention and treatment of chronic disease? I know that in my practice, I had a lot of arthritic....

[Dr. Eleanor White]

We have a lot of arthritic patients. I asked my husband, who was a chiropractor before he developed early dementia, if he had noticed that our practice was getting older, and he said “Have you noticed that we are?” We tend to see people our own age and a few family members.

Arthritic conditions, mobility, and capacity-affecting conditions are the most common things we see, and I think it's the best thing we offer.

Structure and function are interlinked always. If people are not able to move well, they don't sleep well. They don't eat well. They become socially isolated, and they may become depressed. The body-mind connection cannot be overstated. Eventually, you end up with chronic illness.

I work as a CPP medical member. I do hearings once a month. I'm about to go into them in the next three days. We see so many fibromyalgia people who are unable to find answers psychologically or from the rheumatologist. The only thing we can offer to date is some management. Early prevention includes what we can offer physically and the use of and referral to all those specialists to prevent some of the early psychological components of fibromyalgia.

You also mentioned examples of good collaborative centres. The one most commonly known is the family health unit at St. Mike's, which has a chiropractic physiotherapy clinic that's working very successfully. There are models in Calgary. There are excellent models in northern Europe, where chiropractors attend university with the medics and split off in fourth year. They're in the hospitals. They're in the state-run clinics. There is just no barrier. We've a lot of lessons to learn from across the water.

[Colin Carrie, Conservative, Oshawa, ON]

Okay, thank you.

One of the things we see is more remote communities and the challenges they have with services. I notice now that a lot more people are having nurse practitioners and nurses as their primary health practitioners. I am wondering what nurses do to ensure that appropriate services are available for seniors with chronic diseases in small or remote communities in Canada. What are your challenges?

[Barb Mildon]

Thank you for the question.

You are certainly right that the number of nurse practitioners is growing across our country, and they are providing primary care services, particularly in remote and rural communities. I would say that the most important thing they do is provide comprehensive assessments and health care plans for individuals.

Where the services are constrained by the lack of other professionals, perhaps, nurse practitioners can draw on other services, such as nurses themselves. Registered nurses can provide an array of services. Generally, in a small clinic, an array of services are available. I would say that there is a considerable amount of ingenuity in our smaller communities. Also, in this era of telehealth, that is probably the greatest use of the ability to reach out to our interprofessional colleagues with the kind of care and guidance that's needed. Telehealth is exploding across the country, and nurse practitioners are certainly the ones on the leading edge.

[The Chair, Conservative, Joy Smith]

Thank you so much.

We'll now go to Dr. Fry.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thank you very much, Madam Chair.

I want to congratulate all of you for the very comprehensive presentations you made.

I think what's important to me is that you didn't talk only about physical health. You brought in mental health, and of course you also brought in the social aspects of chronic diseases and aging, and I think that's really important.

What I hear you all talking about is having a strategy and looking not simply at one disease state but at the whole problem.

Dr. Molnar, you really struck a chord when you talked about the fact that we're backing up beds, not only because we require home care but because people are poor. They're living in residential care facilities because they can't afford to live anywhere else.

I would like to know if you see a strategy, because this is going to be the biggest challenge for us in providing care down the road. It's already starting. Apart from using, as Ms. Mildon said, the integrated, comprehensive primary care model, with all kinds of people working together within the scope of their practice to provide care, how do you see that linking with home care, with community care, and with social services, for instance, so that you can have this broad strategy you're talking about? What form do you see that strategy taking? Do you see that as something we should be looking at in a 2014 accord?

[Dr. Frank Molnar]

Those are enormous questions, the kinds of questions the president of the CMA should be answering, as he's much more experienced than I am. I can only speak to a portion of that, and you might want to pass the question to John, if that's okay.

Several links are not occurring. Speaking for the specialists, the specialists are not responsive to the family physician. So if family physicians or CCAC case nurses have an issue that needs to be dealt with quickly at the specialist level they cannot get in, they cannot get help. The word I kept writing down as I heard it at the different talks is “accountability“: there's no accountability or responsibility on the part of many of the sub-specialties.

We keep waiting lists, we make sure patients flow through, but we have no responsibility to see that particular patient at that particular time. There's a real disconnect between outpatient clinics and in-hospital clinics. There needs to be some way to join these specialists who are in hospital with the specialists who are out of hospital and make sure they are readily accountable to family physicians, CCAC, community care access centres, and that they have rapid access to those areas of expertise.

That's my little piece of the puzzle, but I have to defer on the rest of your question to people who know more about the greater system.

[Dr. John Haggie]

I'll try to take a bite of that one, because I don't think there's a magic bullet there either. But I think if you look at the elderly poor, which was where I took your question started from, they start poor younger. The causes of poverty are interlinked with growing up in poverty and poor education.

I come from a province where there are areas where 40% of children will graduate from high school. Now, in an age of service base and information, knowledge translation, and all those good things, someone who hasn't completed grade 12 is condemned almost from the get-go. There are better experts out there than I am on how you deal with poverty. Poverty and education and the social determinants of health underpin health. There's a crystal-clear link between poverty and poor health, between low education, low housing standards, and poor health. You can't argue those figures. How you choose to deal with that is outside the realm of physical medicine. But if you do not address it, then it could be argued you're tinkering around the edges of the problem.

[Barb Mildon]

If I may just add, what a pleasure it is to hear my colleagues' responses.

One example I would add is we've done it quite well with our community health centres, where it is a fully integrated interprofessional approach, including social workers, who bring their unique expertise to the problems Dr. Haggie has just outlined so well. I believe we need to look more broadly at the fee-for-service model and where it causes barriers, and where a salaried model opens up access and provides some more comprehensive service.

[The Chair, Conservative, Joy Smith]

You have about four more minutes.

Dr. Molnar is first and then Dr. Haggie.

[Dr. Frank Molnar]

I would be very careful about a full-salaried model. I know our geriatrics groups have been on full salary for dozens of years, and what you see over time is a loss of incentives to do more clinical work. What the Province of Ontario is now looking at is a blended model where you have a base salary so people are attracted to the field, but then you have to do fee for service to move yourself up. So full salary I think has real drawbacks. Fee for service has perhaps even bigger drawbacks. So a blended model would be preferable.

[Dr. John Haggie]

I just spent two days in Fraser Valley Health Authority at a meeting on medical makeover. The whole issue of payments boils down to two things: what you want to pay for and how you want to get it. The second thing is there is no perfect system. What you have to do is pick the system that gives you the problems you can live with, not the ones you can't live with. Because there isn't going to be a perfect system, and there isn't the Harry Potter spell that's going to make it all work. You have to pick so that you mix and match, so the deficiencies of one system are covered by the advantages of another. To try to legislate one size fits all, it ain't going to work in Nain or Hopedale or Moose Factory. It might work in downtown Toronto and vice versa. So I think you're going to have to look at geography as well.

First, you have to decide what kinds of services you want and then the best payment model to deliver those, and what can you live with as a problem from it.

[The Chair, Conservative, Joy Smith]

I'm concerned about that Harry Potter aspect. I'm glad you chaired it.

Your time is pretty well up, but you go right ahead. We'll give you a little more time.

[Hedy Fry, Liberal, Vancouver Centre, BC]

I don't really want to take up somebody else's time, but I want to have one quick follow-up on what you were saying.

I think you talked a bit about accountability. How do you see that being built into such an integrated system? It would seem to me that accountability from the part of the caregiver, or even from the part of the public administrator, which is government, is to look at outcomes. Should accountability not be based on outcomes?

If you talk about, as Ms. Mildon talked about, decreasing hospital admissions by 25%—I don't know if it was you who talked about it—and then the length of stays and bringing them down by 51%, that is a clear accountability measure, isn't it?

[The Chair, Conservative, Joy Smith]

Very briefly, Dr. Haggie.

[Dr. John Haggie]

It is. In one sentence, I think the system has to be responsible and accountable to the person who funds it, which is the Canadian patient, the Canadian taxpayer, and there are various ways you could do that. But yes, I agree.

[The Chair, Conservative, Joy Smith]

Mrs. Block.

[Kelly Block, Conservative, Saskatoon—Rosetown—Biggar, SK]

Thank you very much, Madam Chair.

Thank you, to all of you, for being here today.

My questions are going to be for Dr. Molnar.

I used to sit on a health board—the largest health region in Saskatchewan. I haven't been there for about three years, but I know that the lion's share of a provincial budget typically is going to health and that the lion's share of the health budget is typically going to acute care.

Back in the day, I recall we had something called a “one-way valve”. We moved into the health district model and then the region. We could take acute care dollars and put them into community services, but we couldn't take from community and put into acute care, and that's probably for obvious reasons.

I want to ask you about the slide in your presentation under “Community Care: The real cause of Hospital ALC crisis and Bed Gridlock”. We've talked about primary care models, encouraging collaborative effort on the part of health care providers. In the last point, it says that hospitals are the most expensive site of care and they've become the default care system. You say that this needs to change. What would you do to change that reality? What has to happen?

[Dr. Frank Molnar]

Number one, we have to strengthen community care.

My area of expertise is in the realm of dementia. Many people with dementia get sick with minor illnesses—a bladder infection—that just brew and stew until they explode into a septic episode where they end up in hospital for a long stay, for months and months.

What you really need is a community care system that allows people—CCAC nurses, home care workers—to identify symptoms early, allows the patient to get to the family doctor quickly, or that has home visits.

Toronto has been experimenting with home visits. There are many seniors who cannot get to the out-patient clinics; they can get to the emergency department by an ambulance, and that's it. We need a system that gets them to family doctors, or that gets family doctors or nurse practitioners to them very quickly, that deals with the acute problems quickly, and that has immediate access to specialists in areas where they don't feel they can manage. Those specialists should have some ties to the hospital, and they should have the ability to have some elective admissions—this is language we don't like to use in acute care—maybe a one-week admission, to pre-empt or prevent a three-month admission.

We really need to look at systems in other countries, to see how we can get to patients quicker, how we can get help to them quicker, how we get to the specialists, and how we can do controlled, short admissions rather than long ones. That's what I see is missing in the system right now.

[Kelly Block, Conservative, Saskatoon—Rosetown—Biggar, SK]

Again, we've talked about primary care models, health care providers working together at the local level. What are the different associations you represent doing at a provincial or national level to address the need to change that focus and address community care?