Health Committee on March 4th, 2014

[David Wilks, Conservative, Kootenay—Columbia, BC]

Thanks, Chair. Thanks to the witnesses for coming today.

I think I'll take a little different light at it.

Colonel, my son's in the military, and was deployed over to Afghanistan and has come back. I'm retired from the RCMP so you will have to mind my answer to him when he came back. He came back and complained of some lower back pain. I basically told him to “suck it up, buttercup”, but I recognize it's more than that from the perspective that I don't think we recognize from time to time what our soldiers are doing overseas and the heavy load they do carry.

I wanted to carry on with the questions from Dr. Lunney who had been speaking about the chiropractic care, and it seems like it would be of benefit to the forces to look down that road. It certainly has helped many people.

From the perspective of that, and because you had mentioned in your opening remarks that you follow the primary care clinic model, that would mean to me anyway, coming from a community that follows the primary care model, that there is the potential to enlist those types of medicines that are not normally found within what we'll call the traditional model.

In terms of my question—and I know you can't answer it here today—but I believe there's some opportunity for the armed forces to consider such roles that are not normally found within the health care model. Could you speak to it a little more, especially certainly to those injuries that are not normally looked at from the perspective of chronic pain. When we look at back pain, we look at it from the perspective of a temporary issue as opposed to a long-term issue.

I know that's a difficult way of looking at it, but I guess the way I'm looking at it is from the perspective of primary health care. In my community all of the medical services are provided through one roof, through one funnel, and one of those is chiropractic. If that is the case is there the potential for the armed forces to do that as well?

[Col Hugh MacKay]

As I had indicated earlier, I would like to say there are no barriers to chiropractic care really. We do access chiropractic care. When I was a physician in Shilo, Manitoba, I had a great chiropractor in Brandon I would refer to regularly for low back pain because it worked and I was trying to do what was best for my soldiers. So I know physicians across the country are accessing chiropractic care.

When I spoke about the study, I think it's looking at changing the model somewhat. Right now the model is that we have our CDU, which I had described earlier, and we refer out to chiropractic care. In terms of whether or not there is some better way to integrate the chiropractor into that team, and whether or not that would produce other benefits other than the way we currently access chiropractic care, we are constantly reviewing the medical literature to find out what is the best way to provide care to our soldiers.

We are open to care that is evidence based when that evidence arises. We are engaged in research ourselves to try to develop evidence, in particular through the Canadian Institute for Military and Veteran Health Research, which we helped to set up in order to look at the things that are specific to Canadian armed forces personnel and veterans.

[David Wilks, Conservative, Kootenay—Columbia, BC]

Thank you.

Further down in your opening comments you mentioned a performance measurement platform. Could you speak to that a little bit? I'd just like to understand what that is in the context of what we're talking about today.

[Col Hugh MacKay]

The health services group has a small cell that looks at performance measurement across our organization. It is an evolving program that we currently have. Certainly we are looking at things like wait times, next available appointment, and process-type things right now to evaluate where we are with the provision of health care. We're also doing things like satisfaction surveys to see how our care is being perceived by members of the Canadian Armed Forces.

As we evolve with this performance measurement, we need to start to do more in the way of outcomes measurement. Somebody raised the point here of how you know when you're doing enough. That's part of looking at outcomes. This is where we're trying to evolve our performance measurement platform at this point in time.

[David Wilks, Conservative, Kootenay—Columbia, BC]

Okay. Thank you.

[The Chair, Conservative, Ben Lobb]

Thank you, Mr. Wilks.

Ms. Morin, you have five minutes.

[Isabelle Morin, NDP, Notre-Dame-de-Grâce—Lachine, QC]

Thank you very much.

I am going to change the subject.

Ms. Gillis, I have some questions for you. Just as my colleague Mr. Young asked you some questions about naturopaths, I am going to ask you some about midwives.

I recently met with representatives from the Canadian Association of Midwives and the National Aboriginal Council of Midwives. They told me about the difficulties they are having in practicing with First Nations. We know that the practice of midwifery somewhat matches what First Nations are looking for: it is more natural, there is a lot of supportive care. The profession is more and more popular. A number of Canadian universities offer courses in it. But they told me that they were having difficulty in obtaining the classification they need in order to practice with First Nations.

Have you made recommendations to Treasury Board for new classifications for midwives so that they can practice their profession with First Nations?

[Debra Gillis]

I think midwifery is becoming more and more recognized. In fact Health Canada has been working quite closely, at the first nations and Inuit health branch specifically, with the National Aboriginal Council of Midwives. We have provided them with funding over the years to promote their profession and to start looking at their overall work, which we've been doing.

We've also been working with a variety of different midwifery associations. In fact in the province of Ontario, through some of the work that we've been doing and with the midwives, the role of the traditional midwife is being recognized in first nation communities.

With respect to your last question, the creation of a new classification is one that is quite a complex subject and takes many years of work with Treasury Board. Frankly, we have been focusing much more on a classification for nurse practitioners, more so because there is not a federal classification for nurse practitioners. Although there is a CHIN community health NP, it really doesn't outline a nurse practitioner. So right now our focus is really on nurse practitioners.

[Isabelle Morin, NDP, Notre-Dame-de-Grâce—Lachine, QC]

Has the work begun, given that it needs so much time?

In April 2013, the federal government officially launched—

the student loan forgiveness program.

Since my document is in English, I am going to speak in English. Please forgive my accent.

This permits nurses and nurse practitioners to address the shortage of health professionals working in more than 4,200 rural and remote communities in Canada. Seven universities in Canada offer a four-year health sciences baccalaureate degree in midwifery, and yet midwives have been excluded from this initiative.

Is there any reason for this, and is there any way in which we can include midwives in this program?

[Debra Gillis]

The program is actually managed through Employment and Social Development Canada and not through Health Canada. We would have to check with them to see the scope of health professions that are eligible.

[Isabelle Morin, NDP, Notre-Dame-de-Grâce—Lachine, QC]

Could you make a recommendation to Employment and Social Development Canada to include midwives in that program? Do you support the idea?

[Debra Gillis]

I think right now we would need to take a look to see if they are eligible to begin with. Right now I'm not quite sure if midwives are eligible or not.

[Isabelle Morin, NDP, Notre-Dame-de-Grâce—Lachine, QC]

How can we find out if they are eligible? What is the process? How could I help that group to become eligible?

[Debra Gillis]

What we could do is provide, Mr. Chair, the name of the area within Employment and Social Development Canada that manages this program. That perhaps would then allow someone to get in touch with them.

[The Chair, Conservative, Ben Lobb]

Very good.

[Isabelle Morin, NDP, Notre-Dame-de-Grâce—Lachine, QC]

I would appreciate that very much.

[The Chair, Conservative, Ben Lobb]

Those are good questions, Ms. Morin. I think for all the committee's benefit, a lot of the questions we've heard today are really getting at the whole point of what we're trying to accomplish here, to take that extra step to figure out why these are the barriers and who we have to talk to in order to get it straightened around.

Mr. Allen, you're up. I would normally give you five minutes, but last night you wouldn't let me skate around you and score a goal, so how about four minutes and 45 seconds, sir?

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

At least you didn't go to negative two. Thank you, Mr. Chair. I appreciate that.

Thank you to our witnesses for being here.

Not being a regular member of the health committee and subbing in today, I want to ask a few questions that tweaked me as you were giving your testimony.

Colonel MacKay, you talked about, given the span of the country and the challenges with respect to scopes of practice across, each one of you have regional differences, provincial differences. Which regions and which provinces give you the most flexibility with respect to the capabilities and scopes of practice, and which ones the least?

From all of you, please....

[Col Hugh MacKay]

I'm not sure we've assessed them from a flexibility perspective necessarily. I will say, though, that generally the Province of Ontario provides a fairly well-defined scope of practice that often we're able to look at and use to help formulate where we believe we need to be with our scopes of practice. But that's not to say we don't look at all the other provinces, when necessary, to see whether or not there's something we can learn from with what they've had to say.

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

Ms. Brenning.

[Michele Brenning]

Thank you for the question.

I'm not sure we would have looked at it that way because my sense of it is that it also depends somewhat on the various professions that you're talking about.

One thing we have noticed is that often the regime in the province of Quebec requires us to understand it a little bit more than in other parts of Canada. The example I'll use is that our psychiatric hospital there does not have what you would call listed schedule I beds, so it's slightly different. Their process for certification of inmates under the mental health act is slightly different. All that to say it takes more effort from our part to understand.

I will add that one of the things we do is use generic job descriptions to a fairly large degree. For example, we have generic nurse job descriptions, generic OT job descriptions, generic social work job descriptions. So while the scope of practice across Canada may vary, the work that we require our professionals to do is standardized across, as are our policies that they operate under, our programs, and our processes. That's how we bring standardization across Canada.

[Debra Gillis]

With respect to the work we are doing, like my colleagues, there isn't any one province we can point to. It's with respect to the nurses who are working in an advanced scope of practice that we've been working with provinces. I've been working with first nations and Inuit health branch for many years. We have been working with provinces for many years. Many of them run into exactly the same situation whereby they have to provide services to their remote communities. That's why, for example, in the province of British Columbia, through the work that we've been doing with British Columbia and working with the regulatory bodies and the health professions, they now have a new, advanced certificate that recognizes a broader scope of practice.

Saskatchewan is going there. Each of the provinces are working to ensure means are in place for the broader scope of practice for registered nurses primarily to be recognized. We are not asking nurses to work significantly beyond their scope of practice and putting anything in jeopardy. There isn't one place. We've been working continuously. Each province is dealing and looking at it within their specific area and we're working with them to find a good solution that works for all.

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

I have a quick follow-up.

They talk about attracting and retaining people. In New Brunswick we see some of our nurses choosing to work in Maine. It's not necessarily because of the money but because of the flexibility in training.

What are the key elements that you see as attracting and retaining these people. What specifically is your resource challenge?

[Debra Gillis]

Our primary principal challenge is recruiting nurses in our remote areas. It's not as much of a challenge for nurses who are working in public health. The majority of nurses working in public health are working directly for the first nations. In remote areas the isolation is definitely a factor in recruiting and retaining nurses. The lack of amenities in many of these communities is often an issue. It also offers a lot of other things that attract people in working with a different culture. Working in that expanded role often attracts many nurses. Because of the professional isolation we're trying to look at broadening the interdisciplinary team and having nurse practitioners going in. We have, on average, around a 30% vacancy rate of nurses in remote and isolated communities and then we have to rely on contract agencies to ensure we have the full support of staff.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Ms. Davies.