Health Committee on April 3rd, 2014

[The Chair, Conservative, Ben Lobb]

Yes, sorry. Thank you.

Next up is Ms. Davies.

[Libby Davies, NDP, Vancouver East, BC]

Thank you.

I hope you don't feel that we're all putting you on the spot. You've actually been giving great answers. I think we recognize that, yes, there are turf wars and all of that, and territories, but you're also part of the solution.

I just wanted to pick up on my colleague Mr. Morin's question about nurse practitioners and physician assistants. I don't understand why we don't have more of them in Canada. It's better in Ontario than it is in B.C. In B.C., it's really hard.

I just want to relate a recent experience. I happened to be in the U.S. and I got a bronchial infection. I ended up going to see a doctor and I have to say I was really impressed. I'm not advocating their medical system, but in terms of the doctor's office, first of all I didn't see a doctor, I saw a nurse practitioner. They took all of my medical history and put it into the computer as I sat there with a medical assistant. So I saw two people.

As well, I never got the prescription. It was emailed directly to the pharmacy. So with the issue of abuse, I never held the prescription in my hand. It went straight to the pharmacy, so there was an electronic record. I thought, wow, this is so straightforward.

But it strikes me that in Canada, because most doctors operate in their own practice or with a number of doctors, it's up to them to decide if they want to hire a nurse practitioner, and most people don't. So how do we motivate them to avoid Mr. Young's problem, his great example of people loading up a doctor's office, when really they just need to be treated for the flu? A nurse practitioner would do the job.

It's so incredibly staring us in the face, but it doesn't happen. So how can we help motivate that to happen?

[Danielle Fréchette]

If I could just jump in, we have to understand that there are different types of practice settings, right? For half of the doctors in this country, they often rely on larger infrastructures, like hospitals and so on.

But I know for a fact that the Royal College, much like the College of Family Physicians, is very supportive of physician assistants. But to the point about compensation models, and physicians being in effect self-employed individuals, we talk about the size of their income, but they will often have to pay for the nurse practitioner or the physician assistant out of that income.

[Libby Davies, NDP, Vancouver East, BC]

So how do we change that, then?

[Dr. Francine Lemire]

We just need to scale up some of the innovation that's already existing in this country with some of the new models of care. I think certainly some of the Ontario models of care—

[Libby Davies, NDP, Vancouver East, BC]

That has to get us into the payment model though, because most doctors are choosing not to hire someone because it impacts their own salary. So is it better to have a salaried situation?

[Danielle Fréchette]

Again, for those physicians who are not practising independently, but functioning in a hospital setting.... Some of our very own board members at the Royal College who work in institutional settings would love to work with a physician assistant, but it's not on the books because you have to fit into a larger infrastructure.

[Dr. Geneviève Moineau]

In fact, in organizations where physicians are reimbursed as an alternate funding plan, so it's not a direct fee for service—all of our hospitals in Ottawa function that way, where the physicians working within the hospital settings are on an alternate funding plan—in those environments you do have the opportunity to work with physician assistants and nurse practitioners.

In the pediatric emergency department, I work side by side with a nurse practitioner and they provide fantastic care, at a much lower cost.

[Libby Davies, NDP, Vancouver East, BC]

I think I'm really speaking to what is the traditional model. You go to your individual family physician. They're their own employer, and so really, it's kind of the elephant in the room. We never talk about it.

[Dr. Geneviève Moineau]

There is no financial incentive there.

[Libby Davies, NDP, Vancouver East, BC]

We never talk about it. I can tell you that we talk everything else, but we never talk about the payment method in Canada. It's like people don't want to touch it, at least politically, and I feel that we have to take this on if we're going to deal with this really team-based, patient-centred model that we all talk about.

[Dr. Geneviève Moineau]

The other beauty of what you just described in your personal experience is this. Imagine if I as a patient owned my medical information, and that if I happen to be travelling, I have—maybe not the microchip under the skin—but maybe I have a credit card with all of my medical information on there and any time I access care, that gets put on that card. No matter where I am, no matter who I'm seeing, my entire medical information, my medications, my care providers, all of that would be available to me. That's a complete flip of what currently happens. Right now my personal records are sitting in different people's offices on paper.

[The Chair, Conservative, Ben Lobb]

Thank you.

Mr. Young.

[Terence Young, Conservative, Oakville, ON]

Thank you.

Madame Moineau, we've been talking about that for at least 20 years. They did it in Israel 15 years ago. There were roadblocks to that and part of it is inertia. The medical profession does not want to change. There are privacy issues. We just talk and talk about this stuff.

I want to ask all four of you, if you don't mind, for a one-minute answer to one question. I have five minutes. If you can do it in plain language we will have it as a record here, because you have your own lexicon, and I understand that....

Here's my question, if you can just give a short answer. What are the key roadblocks you can identify in scope of practice to serving patients better? Just a one-minute answer from each would be very helpful. Thank you.

[Dr. Fleur-Ange Lefebvre]

I could start you off by telling you that there's no such thing as a legal definition of a team, the last I heard from the Canadian Medical Protective Association, which means that when you need to hold these professionals accountable for an adverse event, it's complicated. We're beginning work with the National Association of Pharmacy Regulatory Authorities and the Canadian Council of Registered Nurse Regulators to implement something from task force two, which is a framework for interprofessional regulation.

It's just the beginning.

[The Chair, Conservative, Ben Lobb]

That was 30 seconds, really good.

[Danielle Fréchette]

We need to have people understand each other's roles because if you don't know what I'm doing, it's kind of hard for you to work with me. You have to be confident that I'm competent, able to do the things that you think I ought to be doing, no matter where I trained or worked in the country.

[Dr. Francine Lemire]

We need to be able to manage the overlapping scopes of practice at the local level. This is where it works the best, and we have lots of lessons to learn from the rural environments. If you don't do it there, you die.

[Dr. Geneviève Moineau]

I would reiterate the fact that in order to be successful in this endeavour, there needs to be oversight that facilitates all of the players coming into a room, sitting around a table, and you lock the door and you don't let them come out until they have figured it out.

That's the turf. The other piece is that there needs to be financial incentive to move forward. Currently where it is, certain specialties who make a lot of money, family doctors who are specialists in their own right, who are relatively underpaid for that most important work, that is one of the issues. The other financial piece is that, as we described, there's no financial incentive for physicians to even think about bringing in other health professionals to provide perhaps what would be even better care for that particular patient.

[Terence Young, Conservative, Oakville, ON]

Would you say there are perverse incentives in the system to providing better and more efficient care for our patients?

Would you care to identify some, please?

[Dr. Francine Lemire]

That don't support that care?

[Terence Young, Conservative, Oakville, ON]

That undermine that care.

[Dr. Francine Lemire]

Yes.

[Terence Young, Conservative, Oakville, ON]

I think you're the person who could do this best because I don't want anyone picking on the doctors. You are a doctor, so it would be very helpful if it came from you, Dr. Lemire.

[Dr. Francine Lemire]

I've felt quite picked on in the last hour, but that's okay, I can take it.