Health Committee on May 6th, 2008

[The Vice-Chair, Liberal, Lui Temelkovski]

I will now call the meeting to order.

Pursuant to Standing Order 108(2) and section 25.9 of the Federal-Provincial Fiscal Arrangements Act, we are looking at a statutory review of the ten-year plan to strengthen health care.

We have a number of witnesses this morning. We have with us, from the Canadian Institute for Health Information, Glenda Yeates, president and chief executive officer; we also have Kathleen Morris, consultant. From the Health Council of Canada we have Jeanne Besner, chair, Donald Juzwishin, chief executive officer, and Albert Fogarty, councillor. Welcome. Bienvenue.

We will start our debate with the presentation by Madam Yeates, please, for ten minutes or less.

[Glenda Yeates, President and Chief Executive Officer, Canadian Institute for Health Information]

Thank you, and good morning. Thank you for that introduction.

I am Glenda Yeates, the president and CEO of the Canadian Institute for Health Information, or CIHI. Thank you for inviting me to be present before the committee.

As you may be aware, I'm going to focus on the data slides we have presented, which are in front of you. The CIHI is an independent organization that provides accurate, timely, and unbiased health information. It's not our role at CIHI to forecast or to offer recommendations or opinions, and therefore my presentation will focus on data.

What we do at CIHI is collect and process databases and registries. We coordinate and promote the development of data standards across the country, we identify health indicators, and we produce analytical products and reports.

In terms of our relationship to the 2004 health accord, this is an accord that had a series of commitments, one of which was reducing wait times and improving access. CIHI is named specifically in the accord and asked to report on progress on wait times across the jurisdictions.

You'll see that we have produced four reports on wait times since the 2004 accord, between the period of March 2006 and the most recent one this last February 2008.

I'll put some of the information on wait times before you today. I'm going to organize it in two ways. The first is to talk about the volume of activity of procedures in the priority areas and the second is to tell us what we know about wait times, or perhaps changes in wait times.

Slide 6 of our presentation looks at what we know about surgical volumes in the priority areas that are named in the accord. They are listed there.

We look at volumes because our data there is more comprehensive and therefore easier to measure. Also, increasing the volume of activity in these areas has been one of the strategies the provinces have specifically named as they try to move forward to reduce wait times.

Generally speaking, our data indicate that the volume of surgery in priority areas, that is, hip and knee replacement, cataract surgery, bypass surgery and cancer surgery, has increased by 13% in Canada, excluding data from Quebec, over the two years following the accord.

Overall, our numbers show that in the priority areas, the volume of surgeries in those areas named in the accord have increased by 13% across Canada over the two-year period following the accord, and that's excluding the volumes from Quebec.

In terms of reporting what those volume increases mean for wait times, what we know now is that most provinces are regularly reporting on wait times for priority areas. There have been improvements in that reporting, so there are more timely, comprehensive data available, but there are still variations in measurement in reporting, and that means interprovincial comparisons are difficult. And the trend data are not available across the board, but they are beginning to emerge for individual provinces.

There's an example from our February 2008 report for joint replacements--one of the priority areas. You can see there that all ten provinces are reporting in the area of hip and knee replacement. We can see the differences in some of the definitions in the provinces, and we note them there, in terms of what those differences in definitions are. You'll see that the reporting in terms of times is included for those two procedures.

The question that people often want answered is what does that mean in terms of wait times? We see that volumes are up. What does it mean for waiting times for individual Canadians? We've put forward the areas for a number of provinces where we feel the definitions have stayed stable enough over the last three years so that we can actually begin to look at trends. So in the area of joint replacement, those provinces would be Ontario, Alberta, and British Columbia. And for those provinces where we think the data are consistent enough, we can see that they report decreases in the median wait times for hip replacements of at least one month for hips and one month and a half for knees.

If you look at cataract surgeries, the story isn't as clear. We see in four provinces that we find the definitions to be consistent enough over that period where we can look at trends. For those provinces, some of them have reported decreases in wait times, but others have not seen decreases.

I will turn next to slide eight. This looks at diagnostic imaging. This is the next area, and another area that was named in the accord. What have the trends been there? Again, the data are stronger on volumes, so you'll see in this that we can look at the volumes of both diagnostic imaging equipment in the areas of MRI and CT scans and the number of exams that have occurred. So we can see between the two periods here, 2003-04 and 2006-07, that there are more scanners--27% more MRIs and 12% more CT scans--and the number of actual exams is up even greater. But what we don't know and aren't able to tell you is what that means for the wait for those procedures. We can see that there are increased volumes. What we don't know is what that impact has been on the waiting times for Canadians.

I will turn next to the access to health care professionals. This was another of the areas that was cited in the access portion of the accord. What we can see there is that there is no comparable indicator for access to health care professionals, so we cannot report on that. That hasn't been determined. But what we can see is CIHI does have data about numbers of practitioners. Here I show you the numbers of physicians and nurses. We can see those numbers are up modestly in the 2004 to 2006 period, but those increases are not particularly significant, given the increase in the population that has also occurred in that time. But we do have data there on the increase in the numbers of health professionals in those two professions.

Another question that has been posed to us about the accord from time to time is the question of whether the new federal money that was committed in the accord was in fact spent on health care, and I've included there the table that is appended to the actual 2004 accord. At CIHI we collect and analyze data on health spending at a national level, so that is a question at the broadest level that we can answer. Our data do show that in 2005 the provincial and territorial governments spent almost $91 billion on health care, which was an increase of about $6.1 billion over the 2004 level. And when you compare that to the accord, you would see that the accord put in $3.1 billion of new money in the 2005-06 period. So we can get some sense of that investment flowing to the health care sector, in terms of the expenditures of provinces and territories.

In conclusion, on the progress on wait times reporting--the task given to us in the accord--we do see increased activity in the priority areas. There are increased diagnostic imaging procedures and there are increases in the surgeries in the priority areas.

We do see improvements in the data. There is much more data than there was three years ago. In terms of the interprovincial comparisons, those are still a challenge, because the data is not collected in precisely the same way or using the same definitions across all the provinces. We do see pockets of trends that are beginning to emerge in individual provinces.

In conclusion, what we can say about progress in wait times is that while interprovincial comparisons remain a challenge, we are seeing increased activity in priority areas, improvements overall in wait times data being reported to the public and pockets of trends that are beginning to emerge.

Thank you.

[The Vice-Chair, Liberal, Lui Temelkovski]

Thank you very much. And thank you for staying within the time; it is refreshing to see.

We will now move on to Madame Besner.

[Dr. Jeanne Besner, Chair, Health Council of Canada]

Good morning, and thank you for inviting us here this morning.

My name is Jeanne Besner. I am the chair of the Health Council of Canada. In that role I'm pleased to report to the Standing Committee on Health regarding the progress made toward achieving the reforms set out in the 2003 accord on health care renewal and the 2004 ten-year plan to strengthen health care. I am reporting on that as we have observed it.

For those of you who may not be aware, the Health Council of Canada was created out of the 2003 accord to monitor and report on progress made in achieving health care reform based on the elements that were set out in the accords. In 2004 an additional role was given to us to report on health outcomes. I will take it from there.

These accords have laudable, much needed and ambitious goals. But have they had the broad national impact that government leaders intended? In short, the answer is no.

Undoubtedly the accords have been a catalyst for change in many areas. In particular, the major purchases of medical equipment and various forms of information technology have helped to increase the number of services delivered. Many if not most jurisdictions have improved the way they manage waiting lists. I think Ms. Yeates made reference to that. Most jurisdictions provide wait time information for some procedures on their public websites. As a result, there's no question that many patients now know better than they did in the past when their cataract surgery or hip or knee replacement is likely to occur. In many cases they undergo their surgical procedures with less waiting than they might have five years ago.

Most Canadians have better access to health information and advice through telephone help lines. Some Canadians have better access to publicly insured prescription drugs, to primary health care teams, and to a range of health services at home or in their communities. Albeit slowly but surely, the health care system is adopting electronic health records, which will help to deliver safer, more efficient, and better-informed care.

In our forthcoming five-year report on health care renewal, which is due for release in June, the Health Council notes many other steps forward on the road to health care renewal.

But in other respects, progress on the accord commitments is not cause for celebration. The Health Council of Canada is particularly concerned about nine areas of health care renewal where action has been slower, less comprehensive and less collaborative than first ministers originally envisioned in the accords of 2003 and 2004.

First, in terms of drug coverage and appropriate prescribing, governments have not made substantial progress, to the best of our knowledge, in creating the national pharmaceutical strategy. Significant gaps in coverage are still evident across Canada, particularly in the Atlantic provinces. Too many Canadians remain vulnerable to personal hardship from needed drugs that cost more than they can afford. Also, Canadians are not always adequately protected from inappropriate prescribing because we don't have the necessary systems in place to keep health providers and consumers informed about drug safety and effectiveness.

With respect to home care, two weeks of publicly-funded home care coverage is not adequate for what many people need, and home care services continue to be poorly integrated with primary medical care in many parts of the country. There are clear disparities in the availability of publicly-funded home care across the country. No matter where people live, home care services that are seamlessly coordinated with other aspects of primary health care should be available.

In terms of aboriginal health, we note that the scope of preventable health problems in many aboriginal communities continues to be of concern across the country. Relatively little funding seems to have flowed from the promising intergovernmental agreements of 2005, the Kelowna communiqué and the blueprint on aboriginal health. Some provinces are working closely with aboriginal communities and the federal government to improve health care and living conditions on a regional basis, but developments are on a much smaller scale than we think were envisioned in those agreements.

Growth in the number of inter-professional teams to deliver primary health care is promising, and some parts of the country are on track to meet the target (set in the 2004 10-year plan) of having 50% of people served by teams by 2011. But nation-wide, progress is uneven and difficult to measure. More concerning, too many Canadians don't have timely access to their regular medical provider and too often primary health care services are not coordinated or comprehensive.

In terms of the health care workforce, ensuring that we have the right number of needed health care providers in the right place at the right time was a central component of both accords. There have been substantial increases in admissions to professional schools, more integration of foreign graduates, and some changes in how various kinds of professionals can practise. However, we still note that there are serious mismatches between need and supply in Canada's health care workforce. On the regional level, some provinces and territories are working together to plan and manage their health human resources more effectively, but the nationwide collaboration, the pan-Canadian framework envisioned in 2003 and 2004, doesn't seem yet to have resulted in coordinated planning.

The sixth area is electronic health records and information technology. Despite recent investments through Canada Health Infoway, Canadian governments have been slow to make progress in the information systems needed to support the delivery of high-quality care. We are not on track to meet Infoway's goal of 50% of Canadians having a secure electronic health record linked to other aspects of health care delivery by 2010—a goal that the Health Council has said was too modest from the start. Public support for these investments is strong, however, and governments must find ways to fund and accelerate this essential part of health care renewal.

In terms of reporting on progress, current and reliable data are fundamental tools to measure and understand what initiatives to improve health and health care are working and what are not. Today, despite the excellent work of a number of national and regional organizations devoted to health information and research, such as CIHI, Canada has a myriad of health databases, but not a comprehensive pan-Canadian health information system. Beginning in 2000, the governments had agreed to develop and use comparable indicators to report to Canadians their progress in health care renewal. A set of 18 indicators has been developed, but some are not as useful as we might like for reporting on the reform priorities of the accord, while those that are of value are not widely used for public reporting.

In 2003, the accord that created the Health Council of Canada also identified the federal/provincial/territorial advisory committee on governance and accountability as a key partner for the Health Council to do its work. However, this intergovernmental committee where governments shared information has been disbanded. Information about how governments spend targeted funds is not easily accessible or, in some cases, not available at all.

In terms of wait times, I think that Ms. Yeates has provided information indicating that a lot of improvements have been made. We note, though, that wait-time benchmarks for diagnostic imaging, which were to have been produced by December 2007, have still not been released.

So why has progress on so many of the commitments not been achieved? The Health Council of Canada sees several reasons. First, we find that some of the key elements in the accords were not sufficiently well described at the outset to make them measurable. For example, while we talk about inter-professional teamwork, it's not clear what we mean by a multidisciplinary primary health care team. Is it a nurse working alongside a family doctor? Is it more professionals, and so on? Unless we are clear about what we are trying to accomplish, it's difficult to know whether or not we have achieved it.

Second, as a vehicle for financing change and coordinating reform, the accords have their strengths but also some critical weaknesses. All told, the cumulative new funding committed through the 2003 accord and the 2004 10-year plan will amount to well over $230 billion by 2014. While some of the funding is tied to general health care policy goals, much of it comes with no real strings attached, very few requirements for public reporting, and almost no measurable objectives and outcomes.

Third, it is the reality of health care in Canada that we don't have one health care system; we have at least 14, when we consider the care the federal government delivers or directly funds. Unquestionably, this reality presents challenges for coordinating reform on a large scale, but the accord envisioned that governments would collaborate to solve common problems for the benefit of all Canadians, wherever they live. While respecting the rights and responsibilities of the provinces and territories to deliver care, the Health Council believes that we need to revive the idea of a common or pan-Canadian vision of health and health care, and put mechanisms in place to make this vision a reality.

Finally, we are concerned that governments' commitment to the spirit of the accord may be weaning. Many of the commitments have not been honoured or at least not to the degree that Canadians expected. The practical marriage between money and the desire for health care renewal held considerable promise in 2003 and 2004. Governments should either explain what has changed in the interim or signal their recommitment to a clear set of reforms. We encourage governments to renew their vows—to each other and to the citizens.

As we look ahead to the next five years under the ten-year plan to strengthen health care, the Health Council of Canada urges governments to renew their national commitment to system-wide change. We know that Canadians care passionately about their health care system and are eager for reforms that will sustain and improve it. We remain very confident, however, that the public health system can and will deliver more accessible, more equitable, and higher-quality care. We call on governments to rekindle their commitments to health care renewal across Canada.

Thank you.

[The Vice-Chair, Liberal, Lui Temelkovski]

Thank you very much, Madame Besner.

We will start our question and answer period with seven-minute rounds, and Mr. Thibault.

[Robert Thibault, Liberal, West Nova, NS]

Ms. Besner and Ms. Yeates, thank you for your presentations, which were very informative.

Madame Besner, in the accountability section of your presentation you pointed out that the intergovernmental committee, where governments shared information, had been disbanded. As part of the accord, I presume that committee was created for an exchange of information between the provincial governments and the federal government.

[Dr. Jeanne Besner]

Yes.

If I answer incorrectly I will ask Kira to explain, but the intergovernmental committee was formed to help develop indicators and measures that would be used to report on elements of the health care reform. They met for approximately a year, I believe, subsequent to the 2003 accord, and, to the best of our knowledge, they were then disbanded. We don't know why.

[Robert Thibault, Liberal, West Nova, NS]

For what reason were they disbanded?

[Dr. Jeanne Besner]

I don't have that information.

Kira Leeb, one of our staff members, says it was because of lack of funding.

[Robert Thibault, Liberal, West Nova, NS]

Lack of funding?

[Dr. Jeanne Besner]

At least that's what we were told.

[Robert Thibault, Liberal, West Nova, NS]

As to the responsibility for that, who would have told people they were disbanded, or who would have stopped calling this committee? Would it have been the federal partners within the committee who stopped calling the meetings?

[Dr. Jeanne Besner]

It was a federal-provincial-territorial committee. I really don't have the answer to that; I don't know.

[Robert Thibault, Liberal, West Nova, NS]

It would be interesting to know, because the federal government signed on to an agreement, part of which created three agencies for monitoring: the Canadian Institute for Health Information, your agency, and this interprovincial organization.

That it was dropped is interesting.

[Dr. Jeanne Besner]

As I said in the report, there were 18 indicators developed, and they may have found their work was done. The problem is that not all of them have subsequently used the indicators for reporting, and therefore the comparability of data collected across the country has been rather difficult to establish.

So my assumption would be that they felt the work was done.

[Robert Thibault, Liberal, West Nova, NS]

I don't know who to pose the question to, but I will start with Madame Besner again.

When we look at wait times, there have been some significant improvements, especially in certain areas, in empirical terms. What is difficult to tell is whether the overall wait-time scenario has improved in the nation, because we see that not all provinces have had to respond to the five critical areas. So some provinces can have a great increase in one area and no change in others. I think it was pointed out in the CIHI report on eye surgery, for example.

The other thing we hear from health professionals on an anecdotal basis is that in order to respond positively on the wait-time report card, there may be other areas of intervention that suffer within the medical system. Has either of you in your research been able to identify any of these?

[Glenda Yeates]

In February 2007 we took a look at the question of crowding out, as it's sometimes called. We were able to tell that at that time, when we looked at the volume of surgeries in the priority areas, which represent about 20% of surgical procedures overall, they had gone up in relation to the population by about 7% for that grouping, and the rest of surgeries, the other 80% of surgeries, had gone up slightly or had basically stayed about the same. There was about a 2% increase, but for all intents and purposes, they had stayed about the same. That was at a national level.

So there are two things I would caution about that. One, I think we could answer that question at the national level. That doesn't mean that in particular provinces or in a particular facility there weren't issues. We looked at the broader level where our numbers supported the analysis. We will be redoing that analysis and putting that out in the months to come, because we want to make sure of the situation now. But we did take a look at that one year ago, and we will be continuing to monitor that question.

[Robert Thibault, Liberal, West Nova, NS]

On the pharmaceutical strategy, one of the areas of great promise was the National Pharmaceutical Strategy. There was the creation of a federal-provincial working group. I understand that group hasn't been very active or hasn't been meeting. Is that your understanding, Madame Besner?

[Dr. Jeanne Besner]

I am aware that they have been meeting. I don't know what the outcome of their meetings has been.

[Robert Thibault, Liberal, West Nova, NS]

Have there been changes or improvements in the availability of pharmaceuticals to Canadians following the ten-year agreement or as part of this agreement?

[Dr. Jeanne Besner]

Go ahead.

[Dr. Donald Juzwishin, Chief Executive Officer, Health Council of Canada]

In respect to access to pharmaceuticals, there are still challenges ahead of us, but significant progress has been made on a couple of fronts, which I think deserve mention. One is that the Common Drug Review, which was established to provide some form of coordination on behalf of the provinces to deal with those questions about pharmaceuticals that are emerging and that are to be introduced within the provincial context, has provided a valuable service to advance that particular effort.

Another initiative, which is concerned about something we're still concerned about--and I've indicated that in our brief--and which has challenges yet is the optimal prescribing practices of the health care community. Our evidence would suggest that there are still gaps that exist in that area. However, a program called COMPUS, run by the Canadian Agency for Drugs and Technology in Health, is beginning to work with health care professionals across the country to provide best practices in terms of optimizing. So although there's still much work to be done, and access to pharmaceuticals is somewhat fragmented across the country, there is some progress.

[Robert Thibault, Liberal, West Nova, NS]

But the CDR process you're talking about is about recommending that drugs be put on the provincial formulary and not about financing pharmaceuticals for low-income people or people who can't afford certain drugs. Some of its critics will tell you that the CDR has been a lot more effective at keeping pharmaceuticals off the formulary than at including them on it.

[Dr. Donald Juzwishin]

Disinvestment is always a challenge, and it continues to be. However, the kinds of analyses and health technology assessments that have been conducted by CADTH, which are shared with the provincial jurisdictions, provide the jurisdictions with some effectiveness studies they can base their policy decisions on. So it's a beginning, and it's a way to start using better evidence to inform decisions around what should be on the formulary and what should come off.

[The Vice-Chair, Liberal, Lui Temelkovski]

Thank you very much, Mr. Thibault.

Madame Gagnon.