Health Committee on May 13th, 2008

[Russell Williams]

I very much believe that if we protect IP and at the same time ensure that we have proper pricing in this country and ensure good access to innovative medicines, we can in fact be an effective interlocutor, if I could say so, on the 10-year plan. I believe that access to innovative medicine saves lives and helps reduce hospitalization.

This other issue that has been brought to the table, which upsets some of the members, is an issue that has been debated in the industry committee. Unfortunately, the generics are misinterpreting the facts: it is not based on a Supreme Court decision. It does not extend patents; it does not increase prices. In fact, I would challenge the generics by saying it is their pricing regime that is thwarting innovation in this country.

[David Tilson, Conservative, Dufferin—Caledon, ON]

Okay.

Mr. Keon.

[Jim Keon]

We presented our comments today in the context of the 10-year health care plan. The 10-year health care plan has a national pharmaceutical strategy, and an important element of that for the provinces is faster access to generics.

We're trying to save money. We've reached accords with a number of provinces to do just that. If they're delayed in getting access to our products, their costs are going to go up. I think that's an important aspect of the health care system.

[David Tilson, Conservative, Dufferin—Caledon, ON]

Ms. Fralick, I think it was you who talked about the shortages of resources and the prioritizing of funding. We look at all this—the problems with health care—and no matter which country or province you're in, it's called “lack of money”. I'd like you to elaborate on your comment about the prioritization of funding.

[Pamela Fralick]

Thank you.

We can always use more money, but I think there are other things that can be done within the system to promote efficiencies, and specifically around health human resources. Yes, if we had all the money in the world, we would take it and use it, but there are things we can do.

We can get the data. If you don't measure it, you can't manage it. We need to focus on healthy health care work places, so that we can attract people and keep them in the workplace. We need to really focus on interprofessional education and practice, maximizing current scopes and using health professionals as they should be used, within their full scope of practice, and on some advanced practice roles that are emerging as a result of good innovation.

Primary health care was a fantastic investment of funds from the federal government, $780 million, which created numerous models of how to deliver health care differently. These are all things—again, we don't have time, I know, to go on, but we could—that will promote efficiencies within the system. This is why I said earlier that I'm an optimist. I think there are things we can do.

That being said, the HHR issue is heading to a crisis.

[David Tilson, Conservative, Dufferin—Caledon, ON]

Concerning the issue of wait times, Mr. Bellan, how does one prioritize the different categories of wait times? You've given gradings; how do you pick which is more important?

[Dr. Lorne Bellan]

It's a very difficult thing to do. I think you start off by looking at where the problem areas are. The initial five that were selected were picked because it was generally perceived from a political standpoint—basically, I think, from the feedback that you as parliamentarians received—that this was where the pressure was.

We're recommending, if you've looked at our report, another group of six that we've championed and have said are the next areas. The reason we selected those six was that we approached all of the national specialty societies at the meeting we have in conjunction with the Canadian Medical Association and said, “We want to expand our organization. Who here feels that they have critical problems with wait times that need to be addressed and for which you can come up with a benchmark to solve it?”

These were the groups that came forward and said, “These are the problems we have and we think we should go for it.”

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Bellan.

I want to thank the panel. This brings to a close our presentation by our first panel, and I thank you for coming today. I realize we have tight times, but anyone who wants to carry on a conversation can do it outside those doors.

I would ask that the next panel come forward and we'll start our next round right away.

[Russell Williams]

Madam Chair, actually, I would like to respond--really quite quickly--that we have been constantly in conversation with the industry department. We are constantly.... I wanted to clarify that.

[The Chair, Conservative, Joy Smith]

I'm sorry, Mr. Williams, we have a pause. Sorry about that.

[Judy Wasylycia-Leis, NDP, Winnipeg North, MB]

On a point of order, Madam Chair.

[The Chair, Conservative, Joy Smith]

We're coming to the next panel, Ms. Wasylycia-Leis. We're in a pause. There's no committee.

[The Chair, Conservative, Joy Smith]

I would ask that everybody please take their seat. I would like to get on with our next panel.

You're welcome to sit in on the rest of the meeting or carry on your conversations outside, but our committee members are ready to go to our next panel right now.

Ladies and gentlemen, the organizations that will be taking part in the second panel are: the Canadian Labour Congress; the Canadian Union of Public Employees; the Canadian Federation of Nurses Unions; the Canadian Pharmacists Association; and the Canadian Society for Medical Laboratory Science.

We will begin with Barbara Byers of the Canadian Labour Congress. There are five minutes, as we did before.

[Barbara Byers, Executive Vice-President, Canadian Labour Congress]

Thank you very much.

I'll try to stay within the five minutes. I know you'll keep me to that, but don't start the clock yet.

It's started. Okay.

On behalf of the three million members of the Canadian Labour Congress and their families, I want to thank the committee members for this opportunity to appear today.

In 2004, when the first ministers committed to the 10-year plan to strengthen health care, they recognized the importance of ensuring that Canadians have access to the care they need when they need it. The commitment was made that governments across the country would improve access to care and reduce wait times. They said it was imperative to increase the supply of health care workers and that strategic investments had to be made in community-based services, including home care, a pharmaceutical strategy, and health promotion. They affirmed the principles of the Canada Health Act. They said that timely access to health care should be based on need, not ability to pay, and that all levels of government would work together to meet the needs of Canadians.

Over the past few years, we have seen these commitments cast in terms of the interests of the private health industry. The opponents of medicare are on a major offensive against public health insurance and delivery, and governments are too readily entertaining the argument that privatization equals sustainability. Already, some governments are introducing competitive markets for health care, which is, by definition, damaging to primary care reform and to the seamless delivery of health care between the acute, intermediate, and long-term dimensions of the system.

If the provinces and territories follow Quebec's example, we will have private insurance, two-tier care, and doctors working in both the public and private systems.

Increasingly, governments allow private clinics to take the easiest and most easily billed surgeries from hospitals, so those clinics are operating, for all intents and purposes, as for-profit hospitals.

We object to the way in which employers encourage private clinics to grow by compelling injured workers to receive their surgeries in for-profit clinics. We want to say most emphatically that in no way is this a best practice to be advanced as a broader wait time strategy for medicare.

Due to an exclusion from the Canada Health Act, the federal government is also playing a role in permitting our public workers' compensation systems to be used to create markets for the private delivery of acute care and rehabilitation.

Provincial governments are choosing public-private partnerships for hospitals despite clear evidence that this is the most costly alternative. This course of action is advanced by the federal government, which established a massive new program to promote public-private partnerships.

The privatization of health care services has already resulted in the loss of jobs, inadequate wages and benefits, and reduced community control of our public health care system. Women health care workers, aboriginal women, and immigrant women especially feel the brunt of this degradation of work. Medicare is under threat from privatization, and the attacks are becoming increasingly targeted.

We indeed need sustained action on a national health human resources strategy to address critical shortages of all health care sector workers. As well as focusing on resources for training, we need governments to review what is happening to the quality of health care work. If the quality of work continues to decline, workers will not enter or stay in the health care field.

The government must not meet our health human resources needs by relying on a strategy that encourages internationally trained health care workers to come to Canada only to endure low pay, poor working conditions, and less than full citizenship rights. Immigrant workers deserve to be respected. The federal government must work with provinces to ensure that credential recognition is dealt with in a way that respects the internationally trained workers and contributes to strengthened public health care access across the country. We have to look at the role of Canada as a poaching nation, given that there is no investment in developing countries in their health care systems and health care education.

Furthermore, we would ask members of this committee to call on the government for real action on a national pharmacare plan. The CLC urges members to reflect on the spiralling costs of pharmaceuticals and the pressure this is placing on our health care system. We need a universal, publicly funded, and publicly administered insurance plan to cover prescription drugs. We're not looking only at catastrophic coverage, because that's not able to control the rising costs of pharmaceuticals, which are undermining public health care.

Since the 10-year plan was announced, the CLC continues to hear from our affiliates that medicare is still Canada's most important social program.

[The Chair, Conservative, Joy Smith]

Thank you, Ms. Byers. You're over the five minutes, but you've made some very good points.

[Barbara Byers]

We'll send you our document—

[The Chair, Conservative, Joy Smith]

We also have time for questions.

Mr. Moist.

[Paul Moist, National President, Canadian Union of Public Employees]

Thank you, Madam Chair and members of the committee.

CUPE is privileged to represent over 500,000 Canadians, 170,000 of whom work in all aspects of health care.

Our overarching comment today is under the umbrella of accountability. The 10-year plan, and indeed all medicare dollars, should be spent and accounted for in accordance with the Canada Health Act. Every year the annual report on the Canada Health Act falls short. Provinces don't report. There's page after page of non-accountability. For the Health Council of Canada, created to ensure accountability in the 10-year plan, with two provinces refusing to participate, we're not sure how the accounting or the accountability can hold true.

What's the evidence of our concerns on accountability?

One, since the 10-year plan was signed, the number of private, for-profit clinics delivering medically necessary services has doubled.

Two, in terms of illegal fees, some provinces—notably British Columbia and Quebec—are allowing private clinics to charge privately for diagnostic and surgical services, which are clearly necessary hospital services within the definition of your Canada Health Act.

Three, queue jumping. Some doctors get around the ban on user fees and extra billing by charging patients for uninsured services, which leads to queue jumping and potential conflicts of interest.

Four, commercialization is linked to the wait times guarantee debate. The 10-year plan approach to wait times in the federal government's model of care guarantees has hastened commercialization of medicare. Almost two years ago, the federal wait times adviser, Dr. Postl, issued his report. In our view, it has been all but ignored on the issue of wait times.

Five, public-private partnerships. There are 38 P3 hospitals under way in four Canadian provinces. Through this government's initiative, PPP Canada Inc., the federal government is actually pushing the P3 model in all sectors, including health care. We believe that P3 hospitals deserve immediate investigation and action by this health committee, the Auditor General, and the current Parliament.

Our recommendations, to close, are to enforce the Canada Health Act, a requirement of Parliament; establish a national long-term care program; implement a wait time strategy that guarantees public sector improvements, or, in short, follow Dr. Postl's advice; establish a national pharmacare program; create a national infrastructure fund to build and redevelop hospitals and long-term care facilities; follow through on the commitments made in the Kelowna accord and the “Blueprint on Aboriginal Health”; establish a national strategy to combat health-care-acquired infections; and finally, develop and implement a pan-Canadian human resources strategy to achieve better working conditions, training, upgrading programs, and wage parity to improve retention and recruitment across health care, which is another recommendation of Dr. Postl.

Thank you, Madam Chair.

[The Chair, Conservative, Joy Smith]

Thank you very much, Mr. Moist.

Next is Linda Silas, who is the president of the Canadian Federation of Nurses Unions.

[Linda Silas, President, Canadian Federation of Nurses Unions]

Bonjour.

The Canadian Federation of Nurses Unions represents 138,000 nurses in nine provinces, plus 20,000 associate members who are part of the Canadian Nursing Students’ Association. Our members work in hospitals, in long-term care facilities, in communities, and in our homes.

We thank the Standing Committee on Health for the opportunity to share our views. We will bring 10 renewed calls for action. These are nothing new; they are renewed calls for action, and we believe they are essential to fulfill the next step for the vision set by the first ministers in 2003 and 2004. We're focusing on health human resources and accountability.

Regarding health resources, the first ministers said that “access to timely care across Canada is our biggest concern and a national priority”. They also linked it to health human resources. The concern resonates all the louder in light of the Canadian Medical Association's estimate of 4 million to 5 million Canadians not having a family physician or access to primary health care. The nursing sector does not fare any better. It is estimated today that we are short over 20,000 nurses if we only take into account the overtime and the vacancy rates.

Canada is home to over 250,000 nurses, of which over 80% are unionized, but working conditions are far from satisfactory. For example, just overtime and illness in Ontario are estimated to cost $1 billion. For every nurse under 35, there are two nurses over 50. We know we're an aging workforce, if not the oldest workforce. To keep up with this demand, we need to graduate about 12,000 nurses per year, and we only graduate about 8,400 now.

Here are our suggestions.

We believe the government needs to coordinate health human resources at a national level. For example, Saskatchewan, P.E.I., and Newfoundland and Labrador lose 30% of their new graduates to other provinces. The first recommendation is, of course, a pan-Canadian health human resource strategy.

The second recommendation is that we believe research in nursing needs to continue. We had $25 million over 10 years, and it is finishing this year. We're asking to renew this funding.

On the third recommendation, we all know we have to work together to implement healthy workplace initiatives to retain and recruit all staff.

Fourth, through the 10-year plan to strengthen health care, the federal government committed to reducing the financial burden on students in specific health education programs. We urge the federal government to honour this commitment as soon as possible.

The fifth recommendation is to have explicit targets for enrolments, funding and other support, new faculty, and appropriate technology.

In the home care sector, nurses echo the plea of VON Canada to call the federal government to create and support an expert advisory panel on family caregiving.

Accountability, as this government has emphasized, is vital to all areas of government, and health care is no exception. The Canadian Federation of Nurses Union, partnered with CUPE, launched the campaign called “Your Medicare Rights”. We are talking to the public about extra billing, user fees, commingling, queue jumping, etc., but what we really need is the federal government to act on this.

Our seventh recommendation talks about the Health Council of Canada having the authority to ask the provinces and territories to report on matters concerning the Canada Health Act. Health Canada should make use of their powers to enforce the principles and conditions under the CHA.

We've also asked the Auditor General to perform an audit on federal moneys transferred to the provinces in health care delivery.

Regarding pharmacare, we know the cost of prescription drugs rose 77% between 1996 and 2006. We spend more on drugs in this country than we spend on doctors. We know that New Zealand achieved a 50% saving using its coordinated bargaining methods for bulk buying. Nurses recommend that the federal government develop a national pharmaceutical program. We had progress in 2004, but since the national pharmaceuticals strategy, not much has happened.

Lastly, we have the structure in place, so let's use it. Each province and territory should prepare a yearly report to the Advisory Committee on Health Delivery and Human Resources on the 10-year plan, taking into account its objective and proposed funding. The advisory committee can in turn report to the federal health minister as well as to key health stakeholders.

Health care is the business of taking care of people, and we need people to do it.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you so much, Ms. Silas.

We'll now go to Mr. Jeff Poston.

[Dr. Jeff Poston, Executive Director, Canadian Pharmacists Association]

Thank you very much, Madam Chair.

The Canadian Pharmacists Association very much welcomes this opportunity to present to you today during your review of the 10-year plan to strengthen health care.

While medication use is an integral component of Canadian health care, adverse drug events and medication misuse remain a serious issue. In a recent Canadian study, 24% of patients were admitted to a hospital's internal medicine service for drug-related causes, and over 70% of these admissions were deemed preventable. Similarly, another recent study in Vancouver found that one out of every nine emergency department visits was due to a drug-related cause, and over two-thirds of these were preventable. It's against this background and concerns about appropriate use and access to care that we want to base some of our remarks to you today.

Since the announcement of the 10-year plan in 2004, some progress has been made; however, there are many challenges that remain unmet. I'm going to focus on four areas.

First is the national pharmaceutical strategy. Progress has been slow to date. There's been a relative lack of progress in overall strategy. The process has not been very transparent, consultation with stakeholders took place relatively late in the day, and we still don't know what's happening in many of the key areas, if indeed any progress has been made on issues such as expensive drugs for rare diseases or the development of a common national formulary. We're concerned that many of the issues identified as priorities in the NPS are being addressed in isolation, and we see the need for more focus on a comprehensive strategy to address the issues.

Appropriate use of pharmaceuticals needs to be a key focus of the national pharmaceutical strategy. In September 2006, over 20 months ago, the progress report on the national pharmaceutical strategy identified further work to be done. We've seen little activity, and the process seems stalled.

There have been a few initiatives in the NPS that have resulted in meaningful benefits for Canadians: some provinces have announced catastrophic drug coverage programs; the recently announced Bill C-51 should modernize the drug approval process; the Patented Medicine Prices Review Board has been analyzing non-patented drug prices; and some provinces have announced new regulations and policies concerning pharmaceuticals. There needs to be a sustained effort by federal, provincial, and territorial governments to continue to develop and implement a truly national pharmaceutical strategy.

With respect to health human resources, the 10-year plan recognized the need to increase the supply of health care professionals in Canada, including doctors, nurses, and pharmacists. There has been progress in health human resources planning. Health Canada has invested in interprofessional education and collaboration, support for integration of internationally educated health care professionals, and generation of data for the seven priority health care providers identified in the 10-year plan.

The approval of an FPT framework for pan-Canadian planning and progress in provincial plans to manage health human resources have been positive developments; however, there is much more that remains to be done. Areas of focus need to include planning based on population needs; addressing shortages, particularly of doctors, nurses, and pharmacists, and of other health care professionals; and healthy workplace issues. We also still need better data collection.

Thirdly, I want to comment on primary health care reform. This is critical to the sustainability of the health care system as we move forward. Much more work is needed to address issues of timely access to care, interprofessional collaboration, and optimizing the scopes of practice of health care professionals. As medication experts and the most accessible health care providers, pharmacists need to be further integrated into primary health care and primary health care teams.

Finally, I want to comment on electronic health records. EHR and telehealth are key technologies to enable health system renewal. Adoption of computer technology and electronic health records by clinicians remains a challenge. Progress has been slow. Most provinces are developing a drug information system that will include a complete drug profile and enable e-prescribing applications. We believe the electronic health record will enable primary health care reform and allow health care practitioners to better care for their patients.

Better information will lead to better health care decisions, and DIS applications will lead to enhanced drug safety. To this end, funding for Canada Health Infoway needs to be increased in order to realize the vision of the electronic health record.

In conclusion, while progress has been made on some elements of the 10-year plan, significant challenges and opportunities remain. More funding and more work will be required to address the issues that were identified by the first ministers four years ago.

Thank you very much.

[The Chair, Conservative, Joy Smith]

Thank you, Mr. Poston.

Mr. Kurt Davis.

[Kurt Davis, Executive Director, Canadian Society for Medical Laboratory Science]

Thank you, Madam Chairman.

I'd like to share with you some concerns today in a key area of health human resources in the area of clinical education.

The medical laboratory has been referred to as the diagnostic engine of the health care system. With over 85% of physician decisions being based on medical lab results, you can be pretty well assured that you need to have a good motor in this engine. I think you would all agree that we need to keep this as a priority, and I hate to inform you, but the “service engine” light has been on for some time.

Canada is facing a nation-wide shortage of medical laboratory technologists. We predict that by 2015, half of Canada's MLTs will be eligible to retire. Since 1998, we've been alerting decision-makers that the number of seats in MLT education programs is not sufficient to produce enough new graduates to replace those who will leave the workforce. Currently there are 27 education programs across Canada, with an estimated 762 students enrolled in those programs.

Provincial governments across Canada have responded to our promptings about the shortages by opening new programs and expanding existing programs. This is a positive development; however, we're still short 120 seats of the recommendations contained in our 2002 HR report.

But there's a bigger problem.

Funding for new and expanding programs has been provided for the classroom portion only of those institutions. Unfortunately, little thought has been given to support for clinical training.

As with most health professions, clinical training is a vital component of medical laboratory science education. Completion of a clinical placement is a mandatory component of a Canadian accredited training program.

In 2002, our organization started to hear anecdotal reports that clinical sites, the vast majority of which are in hospitals, were finding it increasingly difficult to devote resources to educating students. Technologists on the bench simply didn't have the time to educate students, because of staffing shortages. Their first priorities—which they should have been—were patient results.

Our 2004 research study, Clinical Placements for Canadian Medical Laboratory Technologists: Costs, Benefits, and Alternatives, revealed several issues that compromise the ability to deliver the clinical component of MLT programs in the future. Significant issues identified in the study included inadequate funding for clinical education, student training resources seriously impacted by clinical staffing shortages, and a lack of research on best practices in clinical education.

Some people have suggested that clinical simulation would be cheaper, faster, and would relieve the burden on clinical sites. We wanted to put those assumptions to the test, and earlier this year we published the results of a study that found that simulation-based training to be resource intensive in terms of both personnel and equipment. Programs adopting simulation required the very expensive high-tech laboratory equipment that is used in today's hospitals, with very high start-up costs and operational costs—clearly a wasteful duplication of resources. Two colleges that participated in our study indicated that they had already been forced to terminate their simulation programs because of the lack of ongoing government funding.

Our study also revealed that there is a lack of research evidence to support the use of simulation in medical lab technology programs.

And we're not alone. Other health professions are facing similar problems. The pan-Canadian health human resources plan explicitly recognizes the importance of clinical education and sets a specific goal of increasing access to clinical training and clinical education.

Herein lies the rub. UBC's Dr. John Gilbert notes that the responsibility for funding of clinical education at the provincial level lies “in the purgatory of clinical education”, somewhere between the ministries of health and education. Specific funding for clinical education is pretty well non-existent. How can we increase access to clinical training if no one is willing to claim responsibility for providing the necessary resources to support it?

So where are we today? We're in a situation where clinical sites, primary hospital labs, are refusing to accept students because of staffing shortages. It has become a vicious cycle. They can't take students because they're too busy due to staffing shortages, and they're short of staff because there aren't enough new graduates.

We need to break this cycle now. CSMLS is recommending that provincial and federal governments target funds to support on-site clinical education for medical laboratory technologists. Across Canada, we need funding for 140 dedicated clinical preceptors in our labs who can devote the necessary time and attention to support students.

We further recommend that funding also be made available to conduct additional research into the value and effectiveness of clinical simulation. A reinvestment today may help ease the future impact of a shortage of medical laboratory professionals.

[The Chair, Conservative, Joy Smith]

Thank you so much, Mr. Davis.

We'll now go into our five-minute first round of the second panel presentation, and we'll start with Mr. Temelkovski.