Health Committee on April 3rd, 2014

[The Chair, Conservative, Ben Lobb]

Let's get the meeting started. Good morning, ladies and gentlemen. Welcome. Thank you for appearing this morning.

We're continuing our study. We have four great witnesses here to give us some insight into what we're studying.

I'd like to welcome Mr. Gravelle. He's a new member to our committee.

Welcome, sir. You can give us your perspective from northern Ontario.

We'll start with Ms. Moineau and move right across the table. Once statements have been completed, we'll have two rounds of questions, a seven-minute round and a five-minute round of questions.

I think the clerk or the analyst has probably told you that the length of the presentation should be around 10 minutes. As always, we say just try to pace it so that the interpreters can put it into the language they need to put it into.

Go ahead, Ms. Moineau.

[Dr. Geneviève Moineau, President and Chief Executive Officer, Association of Faculties of Medicine of Canada]

Thank you very much, Mr. Chair. It's a pleasure to be here today.

My name is Geneviève Moineau, and I am here on behalf of the Association of Faculties of Medicine of Canada.

Our Association of Faculties of Medicine of Canada is the representative of academic medicine in Canada. As the association of our 17 faculties of medicine, we support and facilitate collaboration within our 17 faculties relating to their mandates of health research, medical education, and clinical care, always with a focus on social accountability.

We see ourselves as uniquely positioned to help support and facilitate any work that is done at a federal and pan-Canadian level. As the academic partnership of our faculties of medicine, we provide collective leadership, expertise, and advocacy, with the goal of achieving excellence in education, research, and care for the health of all Canadians.

Our strategic goals are thus: to support our faculties, their faculty members, their staff, and our learners, the medical students and residents; to be a leading national advocate for knowledge regarding academic medicine; to support collaborative initiatives that achieve excellence and innovation in academic medicine; and to integrate all of this for the better health of all Canadians.

We feel strongly about the academic mandate as it relates to social accountability. Again, that is a founding principle of our association.

I have the privilege of practising pediatric emergency medicine.

I work in the emergency room at the Children's Hospital of Eastern Ontario, CHEO.

So I have the privilege of working hand in hand, in caring for our most acutely ill children, with all the appropriate health care professionals. The concept of “scope of practice” is something I live day to day in my practice, which I can truly support not only as a leader within the association but as a health care provider as well.

In our work at the association, we really understand, within our mandate to support health research, that our faculties of medicine are the hub of the places where health research is practised and performed. We are a great stimulator of all economic aspects of research as it relates to health. We are the association that oversees accreditation of our medical schools and of continuing medical education with many of the partners who are here at the table with me today as well as with the Canadian Medical Association and

the Collège des médecins du Québec.

It is of note that all of our accreditation work is done at a national level. It is a set of standards and processes that are always done throughout the country. Here is another example in which, although it is supported and funded provincially, we see health truly as a national endeavour.

On the education front, many of you will be aware of the important projects that AFMC has led, our future of medical education in Canada projects. The first is the MD project, in which you will see in the notes provided to you that there were 10 important recommendations that are currently under way.

I would like particularly to note recommendation number 8, to advance inter- and intra-professional practice.

[The Chair, Conservative, Ben Lobb]

On a point of order, Mr. Wilks....

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

The witness said that we have the deck that she's providing, and we don't have that. We have the HESA background, that's it.

[Libby Davies, NDP, Vancouver East, BC]

I have a brief.

[The Chair, Conservative, Ben Lobb]

Okay, just hang tight here for a second, Mr. Wilks.

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

I'm sorry about that.

[The Chair, Conservative, Ben Lobb]

It looks like some people have your presentation and some don't.

Who doesn't have a presentation? Does everybody have one? Okay.

Ms. Fry, do you have one?

[Hedy Fry, Liberal, Vancouver Centre, BC]

I have one, thank you.

[The Chair, Conservative, Ben Lobb]

Okay.

Carry on. That doesn't cut into your time, just so you know. That cuts into Mr. Wilks' time.

Don't worry, I'm just kidding.

[Dr. Geneviève Moineau]

Thank you so much.

I was speaking to our future of medical education in Canada MD project, for which the eighth recommendation is to advance inter- and intra-professional practice. We have been implementing these recommendations—and this is an ongoing endeavour within our association—as they relate to our faculties.

The next project was on the future of medical education as it relates to postgraduate or residency education. Thanks to the generous support of Health Canada and in collaboration with our colleges, we came up with 10 recommendations, of which the first is to ensure the right mix, distribution, and number of physicians to meet societal needs. We see again within it the important consideration of potential changes in scope of practice, again to meet societal needs. One of the guiding principles of that project was to value, model, and integrate interprofessionalism and intra-professionalism into residency learning and practice. We feel that we are well on our way to integrating these concepts for both MD and residency education.

What is missing here, though, is a strategy for the physician in practice. We are looking to launch our future of medical education as it relates to continuing professional development. I see this as an area in which we can hopefully work together.

AFMC is addressing the scope of practice and skills training of health professionals in many ways. One that I want to highlight is that we have been asked to co-chair the physician resource planning task force, which is a task force that has been established by the committee for health work force at the request of the conference of deputy ministers of health.

The mandate is threefold. One is to develop a process of collaboration and coordination that addresses the imbalance in current physician supply and demand. The next is to lead the development of the pan-Canadian tool to better inform concerning physician supply as well as societal demand. The third is to create some relevant products that will help to provide accurate information to support decision-making by all of those who are considering a career in medicine, those who are in medical school in Canada, and those Canadians who are studying medicine outside of Canada, as well as those who are making decisions regarding residency choice and practice.

The AFMC is actually one of the leaders in the development of a career counselling data set that we hope will help those who have to be making decisions and those who are counselling those making decisions with regard to their future careers in medicine.

The AFMC really has a unique perspective here, because we are those who determine the future of our profession, in that we make decisions on admissions as well as the training of medical students and residents. Also, we are those who retrain members who are currently in practice and perhaps need retraining because of needs of remediation or a change in scope of practice.

Of course, all of this is done with the goal of improving patient care, and thus the recommendation of our association is that we see the federal government is uniquely positioned to take steps to become, in an ongoing manner, the facilitator of the alignment of those professions that are currently regulated, and to attempt to improve the regulation of the scope of practice across the provinces and territories.

We see that the federal government, based on the best evidence—we need to have as much data as we can to help inform our decisions—supports the increase of scope and practice in regulated health professions as appropriate, and again, depending on the practice environment, with the support and supervision of other members of the health care team, including physicians, to provide effective and efficient patient care. By efficient patient care I mean the right care to the right patient by the right regulated practitioner.

The final recommendation is that the federal government support the development of a national consultation on continuing professional development for physicians, with a focus of improved, patient-centred, interprofessional, team-based care.

Again, as a practitioner myself, as someone who has the opportunity of practising...every shift in the emergency occurs in an interprofessional practice mode. The importance of the nurse, of the paramedic, of the social worker, of the pharmacist, and the importance of that work happening in a team-based, patient-centred manner cannot be overemphasized.

As someone who is involved in the care of my elderly mother, who is currently in a long-term care facility, I again appreciate the importance of appropriate scope of practice, and potentially increased scope of practice for health care providers outside of medicine. Our faculties support this completely, and we hope to be a source of information in an ongoing dialogue with you on this matter.

Thank you.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Thank you, on behalf of the committee, for taking time out of your busy day.

Next up we have Ms. Lemire, for 10 minutes, please.

[Dr. Francine Lemire, Executive Director and Chief Executive Officer, College of Family Physicians of Canada]

Thank you very much, Mr. Lobb. Good morning, members of the Standing Committee on Health.

I am a family physician. I practised in Corner Brook, Newfoundland, for almost a quarter of a century and worked for the College of Family Physicians for the last 10 years before becoming executive director and CEO at the beginning of last year.

I am privileged to be with you today, and I want to thank you for the invitation. My remarks will provide an overview of current best practices and the potential for federal government contributions related to scopes of practice of family doctors in Canada.

The College of Family Physicians of Canada, CFPC, is the voice of family medicine in Canada. We represent over 30,000 family doctors. We advocate on behalf of our members to ensure the delivery of high-quality health care. Our mandate in the area of education is to establish standards for the training, certification, and maintenance of certification of family physicians and to accredit the postgraduate family medicine training programs in Canada's 17 medical schools.

The mix and complexity of services provided to patients within the scope of family medicine is crucial to Canada's health care system. We are the point of first contact or the backbone of providing primary care and sometimes secondary care to Canadians. Everyone in Canada should have a family doctor to provide continuous, lifelong care in family practices, emergency departments, hospital wards, and patient's homes in every community in Canada.

The federal government has a role in supporting innovative primary care models. It must work with provincial and territorial governments to improve team-based care. Interprofessional teams and the services they deliver must be defined by the needs of the population we serve. To do this, governments can foster collaborative team care through funding structures that support the full scope of practice of all service providers, reward team effectiveness and efficiency, and reinforce organizational accountability in relation to appropriate access and the delivery of population needs-based services.

I would caution us against parcelling out the role of providers. In order to feel cared for—and by that I mean you can think of two experiences: one experience in health care where at the end of the day you really feel that the people who were there really looked after you, and another experience in which probably the right decisions may have been made but in the end you may not necessarily have felt cared for. I want to talk about the first model.

In order to do this the role of all providers must be accepted globally. The federal government must work to ensure health care access for those who live in more remote parts of our country and to aboriginal communities. We have developed a new competency-based education model called the Triple C curriculum in which we ensure that family medicine residents get appropriate experiences to provide comprehensive care, continuity of care, and educational experiences that are centred in family medicine. We prepare our future family doctors to be socially accountable to all populations, including vulnerable populations, and rural and remote populations.

We hope that the federal government can support the CFPC patient medical home vision that by 2022 every person in Canada will not only have their own family doctor but also have a personal family physician whose practice serves as the patient's medical home. This model is a model of team-based, patient-centred model of care where health care providers work to their scope to ensure excellent care and strive for the patient's best outcome.

To me, changing population needs and scopes of practice evolve within different medical specialties and health professions. The implementation of team-based care allows health professionals such as nurse practitioners and physician assistants to work with family doctors and provide a good scope of services. Overlapping scopes of practice provide opportunities for patients to benefit from the distinct strengths of individual health professionals who are part of a team. A clear understanding of scopes of practice among team members can help guide which providers will deliver services to best meet patient needs by providing timely quality care.

We support models of practice that include enhanced roles for other professionals besides physicians to improve access to care for patients. We must ensure, however, that the expansion of scopes of practice does not compromise patient safety and quality of care.

For example, prescribing rights must go hand in hand with the ability to make a diagnosis and take into account a differential diagnosis, the results of investigations, and above all, the patient's perspective regarding management. In most cases, professionals granted the right to prescribe medication should do so only in settings where they are practising as part of collaborative teams, with family physicians as members of that team.

We support collaboration and not competition because we believe that collaboration is what will help in the end to deliver better, timely access to patient care.

I want to provide a few examples that demonstrate this, coming mainly from Ontario.

In London, for example, the family health team reported there an approximate 20% reduction over one year in the proportion of patients with chronic obstructive lung disease who had at least one exacerbation. In 2011, the Petawawa family health team reported a 30% improvement over one year in the proportion of diabetic patients with solid evidence of improved blood sugar control. Also in Ontario, there have been some excellent examples of collaboration between family physicians and psychiatrists in a collaborative model of care, where the psychiatrist actually comes to a family practice to really provide consultation and support to the providers of that practice, thereby enhancing access to care and quality of care in the area of psychiatric health services.

Regarding the ongoing learning of family physicians, we believe the federal government has a role. The college does provide guidance and creates standards for residency programs, so family doctors can begin practice anywhere in Canada. We know that the federal government has actually provided some targeted funding and initiatives in the area of rural and remote training. The government has aimed policies toward loan forgiveness in exchange for practising in rural communities. We would encourage us to measure the impact of those incentives on retention. We do hear of rural communities being able to recruit but having great difficulties with retention.

A pan-Canadian approach is needed to help train physicians not only in hospital settings but also in community settings where so much of that care that we all get is provided.

Once in practice, family physicians need to be supported to maintain the knowledge and skills required to meet the needs of their patients. An emerging issue that you are going to be hearing from all of us is the maintenance and enhancement of physician competence and performance. We believe the federal government can signal the importance of this issue by supporting credentialing bodies, of which we are one, in looking at this more closely, and to adopt policies that best serve the needs of all Canadians.

Rural and remote practitioners, among others, face a particularly difficult situation. Their patients need them to be knowledgeable and skilled across a very broad scope of practice while building and reinforcing this scope. This can be more difficult if one practises in rural parts of this country. The broad generalist training family doctors receive help to make family medicine one of the most nimble of medical professions. We are trained to care for you from the earliest stages of life to the end of that life.

In conclusion, we're committed to working with you, with the federal government, to ensure that family doctors continue to provide optimal primary care and sometimes secondary care, when appropriate, for everyone in Canada.

Thank you once again for inviting us to speak with you today.

[The Chair, Conservative, Ben Lobb]

Thank you, Ms. Lemire.

Next up, we have Ms. Lefebvre. Go ahead, 10 minutes, please.

[Dr. Fleur-Ange Lefebvre, Executive Director and Chief Executive Officer, Federation of Medical Regulatory Authorities of Canada]

Thank you very much.

Mr. Chair and committee members, I thank you for the opportunity to speak to you today on the issue of scopes of practice and skills training of health care professionals.

The committee is to be congratulated for tackling this complex and difficult issue. Some of us before you today have been at this for 20 years, and we've been having this discussion for 20 years.

My name is Fleur-Ange Lefebvre, and I am the executive director and chief executive officer of the Federation of Medical Regulatory Authorities of Canada, or FMRAC. For the translators, it's one of the few organizations whose name in French is shorter

In French, it's the Fédération des ordres des médecins du Canada.

Unlike Dr. Moineau and Dr. Lemire, I am not a physician.

Our organization represents the 13 provincial and territorial medical regulatory authorities on both the national and international scenes. It's important to note that FMRAC itself has no regulatory authority. I must also point out that medical regulatory authorities exist in legislation. The word “authority” is not used lightly. They exercise their duty in the best interest of the public. Their role is to register and license qualified physicians and to provide oversight to ensure that physicians keep up their qualifications.

On the topic of overlapping scopes of practice, the medical regulatory authorities realize that there are in fact overlapping scopes, not only among the various health care professions but also within medicine itself. There are many different specialties and subspecialties. For example, family physicians, as Dr. Lemire has already pointed out, care for their diabetic patient, but they recognize and are expected to recognize when that patient requires the attention of another specialist.

Overlapping scopes of practice are probably unavoidable, and most likely even desirable, as long as the ultimate goal is to provide quality and timely patient care. Coordination of care is critical to eliminate duplication, and everyone needs to know their own limits. The bottom line is this. Every single health care professional who has undergone the requisite training should work to the limit of their scope of practice based on their knowledge, skill, and judgment.

On the issue of pan-Canadian standards, there are many such standards, all of which contribute to, and in fact underpin, greater interjurisdictional mobility for physicians across Canada. Higher education and professional regulation fall within the mandates of the provincial and territorial governments. Nevertheless, this country has a long and respectable, I might even say enviable, track record of developing, adopting, and implementing national or pan-Canadian standards.

In training and certification, I think we would all agree that flexibility in training warrants more attention at the moment, especially when dealing with multi-year programs like some of those in postgraduate medical education or medical residencies. We are all aware of the rather disconcerting unemployment statistics in the graduating cohort of physicians in recent years.

Others at the table this morning are better positioned to address those issues. The standards for registration and licensure, however, are the purview of the members of the Federation of Medical Regulatory Authorities of Canada. Medical regulatory authorities rely on the rigorous training and/or certification processes of the Association of Faculties of Medicine of Canada, the College of Family Physicians of Canada, the Royal College of Physicians and Surgeons of Canada, and of course we mustn't forget,

the Collège des médecins du Québec.

Medical regulatory authorities also rely on the national specialty societies to develop and promulgate practice standards within their particular medical discipline. Nevertheless, it is the role of medical regulatory authorities to ensure that a physician's licence to practise medicine is based on a demonstrated ability in a given medical discipline. While the physician chooses the discipline in which to train, what a physician can do and with which patient population is tightly controlled.

For instance, as has already been referred to by Dr. Moineau, a physician in practice may not choose to change disciplines without having to demonstrate competence in that new discipline. That often involves retraining. As well, a physician may not re-enter their original discipline after a period of three years away from practice without having to demonstrate competence again. The days of obtaining your licence for life no longer exist. In fact, physicians are now required to provide satisfactory evidence of their commitment to continued competence in their practice.

In other words, they must reaffirm in a framework of professional accountability that their competence and performance are maintained in accordance with professional standards. That is our position statement on revalidation.

I want to talk to you about our standards for medical practice and medical registration in Canada. We have developed pan-Canadian standards for full and provisional licensure. Both these licences involve the physician practising as MRP, or most responsible physician. This work was in part done to ensure compliance of our members with the federal-provincial-territorial Agreement on Internal Trade. While the AIT mandates mobility for physicians with full licence, it also mandates consideration of mobility of physicians who work under provisional licence if the receiving jurisdiction can accommodate the same restrictions and the same supervision requirements on that licence. Therefore, it is never possible to discuss standards without talking about the issue of international medical graduates. Most of them, if they come in on a licence, will have a provisional licence.

We define the Canadian standard as the set of academic qualifications that automatically make an applicant eligible for full licensure in every Canadian province and territory. Details are provided in my speaking notes. I only handed these out this morning, but they'll be available. The word “eligible” is used on purpose. There are other issues that come to bear when making a decision to license. For instance, we need to check a certificate of professional conduct and we need to check fitness to practise, and by that we mean physician health issues. We have also defined in great detail the screening criteria and standards for provisional licence. These are also available upon request.

One of the issues that I was told was of interest to this committee was telemedicine. This issue presents its own challenges as not all medical regulatory authorities do the locus of accountability in the same way. Some of them view the locus of accountability as where the physician is when the services are provided. I'm talking about when the services cross jurisdictions. Some of them view the locus of accountability as where the patient is when receiving the services. We have come up with a policy, which is also available in my speaking notes, that we hope addresses these issues, but we understand that one major jurisdiction that was divergent from the others is going to look at changing that, so those are the kinds of discussions we have in the hope that we can eventually come to the same standard.

Just so you know, we define telemedicine as follows: the provision of medical expertise for the purpose of diagnosis and patient care by means of telecommunications and information technology where the patient and the provider are separated by distance. Telemedicine may include, but is not limited to, the provision of pathology, medical imaging, and patient consultative services.

I want to talk to you a little bit about practice-ready assessments. The Medical Council of Canada is not represented here, but through its national assessment collaboration it is developing pan-Canadian standards to assess international medical graduates who may qualify to practise in Canada without further training, for those who are not seeking to enter postgraduate training or residency. As the Agreement on Internal Trade mandates mobility for some physicians with provisional licensure, as I stated before, it is imperative to establish standards so that each jurisdiction may rely on the rigour of assessment elsewhere in the country, because once physicians have obtained a provisional licence in one jurisdiction, they will most likely be eligible to apply for licensure in another.

Another area that may be of interest to the committee is our policy on disclosure of professional information. It's hot off the press. It describes what will be transmitted from one medical regulatory authority to another when a physician moves across to another jurisdiction or even another country, because we're also working on the international scene. The goal is to ensure that the appropriate information is available to the receiving medical regulatory authority to make a sound decision about that physician. Information about a physician's scope of practice is included in the information transmitted.

In follow-up to our work on revalidation—and Dr. Moineau already addressed some of this—we are working with several stakeholders to develop a system of physician performance enhancement. This will be a lifelong quality improvement and assurance system that has a demonstrable, positive impact on the quality of patient care and is feasible and sustainable.

The physician performance enhancement system will help physicians identify their own relevant learning needs, which can be addressed through education and can help improve the quality of patient care and safety. It will encompass all of a physician's roles and competencies—for those who rely on the College of Family Physicians and the Royal College—as well as each dimension of a physician's practice, so clinical, administrative, educational, and research-based.

I'll get to our recommendations. FMRAC believes that at the heart of scope of practice discussion is the issue of health human resources. We need to consider health care professional resources, including physicians, as a national resource. The training and regulatory frameworks for physicians and others support this way of seeing things as they develop, adopt, and apply pan-Canadian standards to these processes.

The role of the federal government should be as a facilitator or convenor of all the various stakeholders as we grapple with the very complex and shifting issue of health human resources planning in Canada and for Canada.

The federal government, most likely through Health Canada, and along with the provincial and territorial governments, of course, should take the lead as follows: (a) in being the convenor, facilitator, and coordinator; (b) collecting the relevant data in a comprehensive and intelligible manner; (c) encouraging all the stakeholders to engage in this process, as, for none of us, is it our main mandate; and (d) identifying success factors and establishing an ongoing evaluation matrix.

I know this is beginning to get repetitive. It wouldn't surprise you that we all knew what each other was saying before we got here this morning.

In closing, on behalf of FMRAC and its members, the 13 provincial and territorial medical regulatory authorities of Canada, I extend our appreciation to the committee and to the Government of Canada for your interest on this issue.

Thank you, and I'll be pleased to answer any questions.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Next up is Ms. Fréchette.

Go ahead, please.

[Danielle Fréchette, Executive Director, Health Systems Innovation and External Relations, Royal College of Physicians and Surgeons of Canada]

Mr. Chair, committee members, thank you for this committee's work on this very important topic, and the opportunity to present today.

The Royal College, as Marc Lalonde called it a number of years ago, is one of the best-kept secrets in the country. We're trying to open our kimono and share our perspectives and the expertise of our more than 40,000 members, where we support their continuing professional development and set the standards for their training in 65 medical and surgical disciplines.

We were founded by an act of Parliament in 1929, and since then we've overseen the certification of medical specialists in Canada. We also support health system innovation nationwide, and we participate in a number of pan-Canadian initiatives, such as being a member of the FMEC PG consortium, which Dr. Moineau described.

Much like the College of Family Physicians, we've also embarked on a major transformation of how we train doctors in this country. Ours is called competence by design, where we're moving away from a time-based educational system, to a more competency-based system set with milestones, which will cover medical education from residency to retirement. We're confident that this will better ensure that our future specialists are nimbler in order to meet patient health care needs, and indeed, adapt to the ever-changing health care environment that this committee is currently trying to tackle.

We know that scopes of practice of health professionals are constantly changing, including those of physicians, in response to numerous factors such as health workforce shortages, increasing patient needs, and scientific and technological discovery. We know that roles are constantly changing. It wasn't until the 1950s that nurses at what was then called the Ottawa Civic Hospital right near here could carry out tasks like taking blood pressure, giving intramuscular injections, or even administering intravenous antibiotics. Only a physician could do those things.

Because health care delivery approaches are in constant evolution, new professions are also emerging, such as physician assistants, as our interprofessional care models. As the scope of health professionals outside medicine expands to encompass a wide range of roles in varying levels of clinical judgment in the diagnosis and treatment of patients, the Royal College supports and believes they are playing an important role in patient care and helping to improve access.

While we all benefit from these new ways of doing things, we also recognize that precautions have to be in place to ensure the safety and well-being of patients, as everyone has mentioned so far. This is particularly important because there are so many different definitions in the scope, admission, educational requirements, and regulatory oversight among health care professionals in Canada.

While there are many pan-Canadian standards for medicine, as described by my colleagues today, such is not the case for many other health professions. For example, pharmacists can order and interpret lab tests in Alberta and Manitoba, but not in British Columbia and Saskatchewan. They can initiate drug therapy in Ontario and New Brunswick, but not in B.C., Prince Edward Island, and Newfoundland.

Even with the emerging physician assistant profession where there are honest efforts to establish pan-Canadian standards, the University of Manitoba offers a graduate degree, but McMaster University offers an undergraduate degree. Physician assistants are a regulated profession in Manitoba, but not in Ontario.

Better coordinated approaches to the regulation of health professions not only helps assure pan-Canadian standards for education and practice, and hopefully safer, high-quality care. The very act of regulating a profession also supports data collection that can inform quality improvement and planning.

The scope of practice of every health professional should always be consistent with quality skills training and education throughout the continuum of practice. So we have to be mindful of evaluating the quality of the educational programs that lead to entry to practice and throughout their continuing professional development.

The scopes of practice of all health professionals should be the subject of not only high standards of education, but we also have to have the regulatory oversight, because this is all the more important because of the mobility of the workforce across the country. We don't want a health professional trained in one jurisdiction to arrive in another jurisdiction with slightly different skill sets. It's not in the interests of patients and it just makes the system so much simpler to control.

Understanding the nature of scopes of practice will not only help us assure patient safety, but it will also help us better understand the impact on care, health outcomes, and how we plan our workforce in our health system. We've conducted some research that showed that interprofessional practice models and changing scopes of practice are having a direct impact, not only on health care delivery but the number of physicians we need in this country. Conversely, there's likely that ripple effect across other health professions. More disconcertingly, as we have seen the evolution of different health care roles, we are now seeing—and are continuing to see because our research is ongoing—that there is an increase in the unemployment and underemployment of physicians. This is not necessarily a bad thing if we can better assure that we're training the right people to do the right things.

I'll give you an example. With the introduction of anesthesia assistants, who are increasingly in demand by anesthesiologists, we can see that the number of anesthesiologists we need in the country could be reduced by half. There was a study carried out in 2010 of physician assistants working with orthopedic surgeons in an arthroplasty or joint replacement or repair clinic in Winnipeg, and PAs helped reduce wait times and increased the number of surgeries that an orthopedic surgeon could do. But we haven't translated that into a more cohesive approach to planning our services and the number of workers we need.

New roles have also been emerging among advanced practice nurses, which substitute or complement the work of physicians. Nurse practitioners not only play various roles in primary care, they're also practising in acute care settings in hospitals and they assume a wide range of roles such as providing care for acutely critically ill patients with complex conditions. Advanced practice nurses can also specialize their focus within a particular disease or medical subspecialty, such as neonatology, cardiology, psychiatry, and palliative care, among others.

Evaluation of scopes of practice should be built into appropriate territorial and provincial regulation to ensure that these changes are actually having the intended impact, such as improving care, more efficient cost-effective delivery of service, and positive patient health outcomes. But we don't know that. Sharing of knowledge and research on these and other performance measures among all of us is crucial to continued advancement of quality in Canada's health care system and the judicious use of our human and financial resources, and here, the federal government could play a role.

Building on its research about physician employment challenges, the Royal College has begun planning with other health professional organizations and researchers further research about scopes of practice in medicine and in other health professions, notably nursing. This is a large-scale endeavour and its contribution to building a body of evidence and information to inform public policy and health system planning will only accrue with proper financial support.

When we think of the way forward, I see unemployment among physicians, as we recently observed through our research, as symptomatic of ongoing inadequacies in health workforce planning in this country, including planning and properly educating who does what. Although there are many constructive efforts to improve our approaches to plan and regulate the workforce in Canada, gaps remain. Our research and that of others has shown that planning at the profession-specific level will only perpetuate current problems that hinder timely access of Canadians to high-quality and safe care. This also impedes, as I said earlier, letting workers work to their fullest potential.

We must not only look at the number of health care professionals and population health needs, which are usually the predominant elements in how we plan health services in the health workforce in this country. We've learned that, when planning health care delivery and its workforce, it's equally important to understand and consider the effects of interprofessional health care delivery models and the availability of resources such as OR time, but also the changing scopes of practice, and how they're educated and regulated throughout their professional life cycle.

We have a number of pockets of excellence, such as those emerging from the physician resource planning task force. We have a growing body of data and evidence and a keen interest by many to collaborate, but there's no locus to bring us together. The Royal College and so many others, if you go back to all of the submissions to this and other committees, have long hoped for a national human resources for health strategy and federal leadership to convene, facilitate, and support the gathering and analysis of data and to help with knowledge translation at a pan-Canadian level to support provincial and territorial endeavours in health and workforce planning and development. The long-standing call for a pan-Canadian or a national human resources for health institute or agency would serve to garner the benefits and strengths of the learnings, evidence, and experiences from provinces, territories, professional agencies, and researchers.

The interest of the Standing Committee on Health in scopes of practice of health professionals is heartening. We truly appreciate the opportunity to share our research findings and our recommendations on the way forward.

Merci beaucoup.

[The Chair, Conservative, Ben Lobb]

Thank you, Ms. Fréchette.

This is the first round of questions for seven minutes.

Ms. Davies, go ahead, please.

[Libby Davies, NDP, Vancouver East, BC]

Thank you very much, Chairperson.

First of all, thank you to our presenters for coming today. We've only just started this study, so this panel is actually the first non-governmental officials that we've heard. We're kind of just getting into it and—well, I'll speak for myself—wrapping my head around it.

First of all, it's just wonderful to see such an esteemed panel of women from major organizations in the country. Thank you so much for your presentations.

I'm actually going play a little bit of a devil's advocate today. I find that some of what you say, maybe a lot of what you say, is difficult to translate into everyday reality from a patient's point of view. So that's what I really want of kind of put out there.

We have this huge issue of scope of practice, team-based practice, and patient-centred care, and I don't really get why it's not happening at a much faster pace. You represent four major bodies that are right in the centre of this discussion. You've talked about the need to have the federal role, which I absolutely support, as a catalyst, collaborator, convenor, and all of that. But describe for us, what would an ideal team-based approach look like, say in an urban community? What would it look like in a remote community? Could you describe it to us? Describe it to us in terms of a family practice, or how it is connected, then, back to an acute-care facility.

I just feel like we're not getting the picture of what it actually should look like. You've given some examples, but if we had an ideal patient-centred care, team-based approach, say here in Ottawa, what actually would it look like if I walked into that as a patient? I often feel that people get bounced around. You go to your family doctor or you go to a specialist, and they can only deal with this bit. You go to someone else, and they can deal with that bit. Then, your GP feels like they don't have the expertise, so who's taking care of you overall? I do feel like there is a gap.

I'm being a bit negative, and I'm really kind of putting it to you. I just feel like it should be better than it is, because everybody's talking about the same thing, but it's not happening, or it's happening in a very patchy way. So if you can respond to that and give us some concrete examples, it would be really helpful.

[Dr. Francine Lemire]

You're asking us to try to tell you in three minutes or less how we can fix the health care system. I won't pretend to try to do that, and I don't want to sound negative either, but certainly as a family doctor I observed an incredible increase in the complexity of the patients I looked after over a 30-year career. No longer did we see patients with one diagnosis. We'd often see people with two or three different illnesses going on at the same time, all requiring a range of services, and certainly a consequence of that complexity has been for me to say I cannot look after all this person's problems by myself. That has been one factor.

A second factor has been—and I may get tomatoes on this, not necessarily in this room—the mode of payment for physicians. In primarily a fee-for-service system, which I think over time has not favoured collaborative approaches, we're seeing some innovation in looking at alternate payments, capitation, enabling us to say the person we're seeing in front of us is important. But the population of this practice—my colleagues and I, the nurses, the social worker who comes in to help us, the pharmacist—we all have a responsibility to know who we are looking after and to look at what's happening from a population-based perspective.

The third factor has been a very slow introduction of the electronic medical record, and you cannot work effectively with other providers unless you have an electronic medical record. Paper works, but I can tell you that in this environment we need to have effective information systems that enable that practice to be connected with the hospital and other resources. That's not to say we're not responsible, but to try to explain why this is not happening at the pace you and I would like to see it happen.

[Libby Davies, NDP, Vancouver East, BC]

That's very helpful.

[Dr. Francine Lemire]

That diabetic patient who comes to see me probably has not only diabetes but hypertension and may be at risk for coronary heart disease, heart attack, or may already have a history of such. So the patient already presents complex needs and takes probably 10 medications. We're talking about pharmacy, drug interactions, ability of that person to pay for all those drugs, so I need the social worker because I can't deal with all that in a 15-minute visit. Those are some of the realities, and those are some of the things that make that seamlessness difficult to implement.

We have some examples of very important innovations. I didn't mention the family health teams. They're not the best things since sliced bread, but they are an attempt to really try to get at this and to say we need to be able to provide access to our patients, if not the next day by that family doctor or at least by a nurse practitioner, at least by the day after that, and if not by that person, at least by someone from that practice. There are some very good examples of innovation that we need to scale up. If we have those tools that I've just talked about, then all those providers need to be able to work together to help that diabetic person with those three chronic diseases and to try to coordinate those needs from a societal and a pharmaceutical point of view.

I'll stop here since I'm not the only one here, but those are some of the factors.

[The Chair, Conservative, Ben Lobb]

Okay, thank you. That's a great explanation. Unfortunately we are out of time, so perhaps next time round we can expand on that.

Mr. Young, you have seven minutes.

[Terence Young, Conservative, Oakville, ON]

Thank you, Chair.

Thank you, everyone, for being here.

Dr. Lemire, why in this day and age, after talking about this for decades, do we still have doctor shortages in many parts of Canada?

[Dr. Francine Lemire]

Once again you're asking me to solve this problem—