Health Committee on May 27th, 2008

[Elisabeth Ballermann]

I think it would be fair to say that to have a specific report from province to province to province is probably not possible. The reality is we still see situations where patients cannot be discharged home because there aren't people to provide the home care. It brings us back to the fundamental question of the human resources in the system.

I think we can all agree that prevention, of course, and social determinants...absolutely, we need to address those. But if there aren't the people, the occupational therapists, the physical therapists, the nurses, and the personal care attendants to provide the care in people's homes, it bottlenecks the whole system. Everything from getting people into emergency, through the wards, through the surgeries and home...if those people aren't getting the services at home, we'll not be able to solve the broader questions.

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

I'm looking at your paper. Unfortunately, time ran out on a couple of items on pages 5 and 6 of your report, Ms. Ballermann, and that has to do with specifically the third item, “Innovation within the public system works”. You give out quite a number of examples of how wait times can be reduced. Can you add to that, because you really did get cut off and didn't have a chance to speak to that?

[Elisabeth Ballermann]

Yes, unfortunately, time being what it is.

There are some tremendous examples. I'll give you one.

The Pan-Am Clinic in Winnipeg used to be a private system where orthopedic surgeries, shoulder and knee arthroscopies, etc., used to be done on a private basis. In other words, the government would fund for it, but there would be profit taken out of that system. The Government of Manitoba has taken that back into the public system.

It is now spending less per procedure than it did when it was a private, for-profit perspective, and the throughputs are amazing. All of the money they are saving on procedures, rather than going into the pockets of the investors.... And Dr. Wayne Hildahl, who is the executive director of that and used to be the owner, has publicly said the difference is he's not putting the profits in his pocket any more. “We're reinvesting that money in services and are able to increase the number of procedures we're doing.” That's only one example.

There are a number of others that are there as well, whether they're in Alberta or in other provinces.

[The Chair, Conservative, Joy Smith]

Thank you, Ms. Ballermann.

We'll now go to Monsieur Malo.

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

Thank you, Madam Chair.

At the various meetings we have had with respect to the 10-year Plan, there has been a lot of discussion of waiting times. Today is no exception in that regard. Dr. Day and a number of witnesses referred to this. It has become popular to assume that the current state of the health care system is directly linked to waiting times.

Ms. Maioni, you seem to be saying that we need to change that paradigm. Could you delve into this a little further and explain to us why we may want to set that aside and focus on something else?

[Dr. Antonia Maioni]

I would not say that it should be set aside, but it does need to be put in context. It is important to understand the reality of health care services. Waiting times for specific types of care depend to a certain extent on the kind of service that is required, the waiting time and the patient's general health status. It is important to know why the service is required in order to understand why those delays occur. It is a little like what happened on the Titanic. We know that there were a number of minor problems on the Titanic, but we cannot say that the ship was not sturdy. Certain things should have been included during construction.

Dr. Day focuses on the number of physicians, which may resolve the problem with waiting times but, as I see it, that is too broad a way of addressing the problem. Waiting times are really a symptom of something else. Why is a particular hospital unable to resolve a situation appropriately? Operating rooms may not be available. But why?

Reference was made to a report in La Presse the other day. It said that one of the reasons why there are not as many day surgeries in such and such a hospital is that there is not enough available equipment. Those problems can be resolved without our seeking to recruit hundreds of thousands of additional physicians. There are other things that can be done within the system.

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

To come back to what Ms. Tremblay said earlier in terms of assessing whether health care agreements have been complied with as far as the Aboriginal people are concerned, you seemed to be saying that you were about to assess all of that.

Can you tell me how you intend to accomplish that? Do you have all the tools you require to carry out such an assessment? What money will you use to pay for it? And, will it be sufficient? Will the Aboriginal population be involved? It's a well known fact that, when Statistics Canada carries out surveys or prepares an analysis involving these populations, there is some reluctance to respond. How can you be sure that monitoring of the agreements—in order to ensure that commitments are met—will be carried out appropriately?

[Paulette Tremblay]

I know from the research we do with the communities that there's a real movement toward community-based approaches whereby communities are involved. We engage the communities in anything we do. It's time-consuming and messy. It takes time to engage people and build capacity as you go, but we are moving in that direction. It's the right way to go.

I think you have to engage populations. Just as Dr. Day was talking about patient-centred treatment, I think it's aboriginal-centred, community-based treatment and involvement. We know that works. Yes, we need more tools. They will engage in assessment if we engage them from a community-based approach that's holistic. Yes, we need money to do it.

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

Why did it take four years to realize that we were not equipped to carry out this kind of analysis?

[Paulette Tremblay]

Why did we take four years? We've always needed the tools. We're building capacity in the communities around research, and it's been missing. There's been a gap and now we're beginning to build it. Our organization has been in existence for only eight years, and we're now in the process of getting out there and gathering information. So it's just becoming available now, and there's a lot more to do.

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

Has the $200 million for the Aboriginal Health Transition Fund been allocated? In 2007, the Health Council of Canada's report did not mention it. Now we are in May, 2008; do you know whether that money is available?

[Paulette Tremblay]

I can't answer that question.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Tremblay. We'll try to get that answer for Monsieur Malo.

We'll now go to Ms. Davidson.

[Patricia Davidson, Conservative, Sarnia—Lambton, ON]

Thank you, Madam Chair, and thanks to each of our presenters for being here with us this morning.

It has certainly been an interesting discussion that we've been having to this point. I would just like to bring it back to the focus on the 10-year health care study and try to get an answer, from whoever wishes to give one, about where we can go forward.

I think we've all realized that we have issues that need to be dealt with. We know we're looking at the health human resources issue; we know we're looking at wait time issues; we know we are looking at a lot of other issues, such as jurisdictional issues.

I also know, through another body I belong to.... I have met at different times with the CMA. I have met with the emergency room doctors. I have met with family physicians. I also work with our doctor recruitment group in my own municipality, as does my colleague.

But there are so many issues that have come up that I don't know the direction we need to be taking. We have licensing issues. We've talked about foreign-trained doctors, and in speaking with the other medical groups at different times, I have heard different statements made. The point has been made that we have enough money in the health care system and that it just needs to be expended differently. Statements have been made that our hospitals have enough capacity and they just need to be operating differently. Maybe that speaks to this patient-focused care that Dr. Day was talking about.

But there are so many issues on which we just seem to keep going in circles. Although this is a 10-year federal health accord, we have two provinces who are not part of it. What kind of a challenge does that pose?

Could anybody give me a simple answer on how we should move forward, and how do we coordinate the different jurisdictional issues? Is that where we start?

This is open to anybody.

[Dr. Brian Day]

Okay, I'll start.

I think we have to ask ourselves why we have one of the most expensive health systems in the world and we're not performing. We had a Pollara poll done in December 2007 in which 68% of the Canadian public felt that the health system needed a complete overhaul or rebuild. You may not believe Canada's World Health Organization ranking of 30th, or the OECD ranking of 18 out of 20, or the recent European consumer ranking that put us at 23 alongside 29 European countries and last in terms of value for money.

Canadians are spending a lot of money to get inadequate service, and I think unless we look at the system—which we're not doing—and unless we look at things like the way we fund the system.... The biggest single cost is hospital care, and it is not being done efficiently. It is 30% of the total budget. If we could save a lot of money in that area, we can look after rural and aboriginal health.

The other thing—which no one has really brought up in any detail—is the public-private thing. It doesn't matter whether I would philosophically support the private sector, because Canada does not have any private hospital infrastructure, so we have to solve it within public hospitals, and it can be solved by making them more efficient.

I think our study earlier this year showed that for just four areas in the accord, it costs $15 billion to keep people on wait lists. There is now a study out on the Stats Canada website showing that the costs of mental health to the economy in one year are $51 billion. This is money going down the drain. We're wasting a lot of money in Canada, and we need to fix that.

[The Chair, Conservative, Joy Smith]

If I could just clarify something, all provinces and territories have signed the accord. Two provinces are not in the Health Council.

[Patricia Davidson, Conservative, Sarnia—Lambton, ON]

Okay, thank you.

[Michael McBane]

I think it's important for the federal government to provide leadership, but not in educating doctors. There are some areas that are obviously under provincial management, but at the federal government level we require some oversight and guardianship, some leadership to encourage innovations in the public system to solve problems, and some funding. Those are the areas that we see lacking right now--that kind of commitment to grow the system, to build the system, to expand it. Public insurance works, but we need more of it to cover prescription drugs and home care services. That won't happen without the federal government contributing to cost sharing.

I would like to see the committee get specific in its recommendations, for example, that the federal government share 25% of the costs of pharmaceuticals as a major step forward, as foreseen in the health accord. What's been lacking is the financial commitment to come to the table to build the expansion of a public system. I think everyone here knows, as Elisabeth said, that there are public solutions to questions, and they've been documented by the Health Council of Canada. The question is why everyone else isn't pursuing those successful models. That's where we need the guardian to push and to make sure we get value for our money.

[The Chair, Conservative, Joy Smith]

Thank you, Mr. McBane.

We'll now go to Ms. Wasylycia-Leis.

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

Thank you very much.

You've raised some very important issues here today. I think they will be helpful in our report.

One of them, as Antonia, Michael, and others have raised, is the issue of funding. For such a long period of time, every time we talked about a greater financial role by the federal government, we were dismissed as tax-and-spend individuals, when all the system really needed was innovation and reform, but that didn't mean more money. It seems to me that we have a situation in which federal transfers to the provinces still haven't got us up to a 25% partnership. As long as that's the case, it's pretty hard to advance a reform agenda.

Nowhere I think is that more apparent than when it comes to aboriginal, first nations, and Inuit peoples. I know that along with this main accord there was a separate accord signed on September 13, 2004. It committed to substantially increase the resources from the federal government to Inuit and first nations communities. I haven't been able to find out where that money is, other than in the last budget. The only significant health care announcement--and it's not even significant--was $147 million over two years for something about integration between health systems.

I need to know what is really happening and what we should be recommending, since we are talking about one of the most neglected areas, and seeing the most in terms of costs to the system, whether it's for mental health issues, suicide, addictions, you name it.

Why don't you start?

[Onalee Randell]

Thank you.

A lot of the money from 2004 is flowing, but one of the challenges is that just as it's starting to flow, it is almost done, because the last year is 2009-10. For example, for the aboriginal health transition fund, which was $200,000--and I'll tell you about the Inuit share of it--the first part of that money, a significant portion of it, flowed March 12. We have less than three years to spend five years' worth of funding. There's been some effect, but people are already starting to worry about what they're going to do with it in the future.

As far as the number of resources dedicated to mental health goes--$65 million over five years for suicide prevention for first nations and Inuit--that doesn't address anywhere near the need for suicide prevention, mental health counselling, and mental health supports.

The jurisdictional issues that people have been talking about between provinces and the federal government tend to be escalated in the Inuit communities. That's why in my presentation I talked about one of the benefits we have being improved relationships, but there's still a long way to go.

Someone asked previously what we can do and what kind of recommendations we should focus on. Other people around the table have mentioned that health promotion and disease prevention are of the utmost importance. If 85% of a population is hungry and malnourished or has nutritional deficits, then it's very difficult for them to be healthy. For Inuit populations specifically, they are the only group we can find for which life expectancy is decreasing. Canadian life expectancy is increasing, but the Inuit population across Canada has the same life expectancy Canadians had in 1940.

We need urgent and emergent recognition of this issue. It's difficult for people to contribute to health human resources if they're not healthy enough to make it through school or to be contributing as they could be.

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

Thank you very much. I'm glad you're both here to raise these issues with us.

I wanted to touch on one more issue if I have time. That is the role of the federal government, generally, on health care.

Marlene, you touched on it with respect to both accountability and the national pharmaceutical strategy. When I tried to suggest to the minister the other day that he really ought to follow through on a long-awaited promise for national home care, he basically said to me that I was raising issues that were provincial and I should go back to provincial politics.

Are we past the point of ever being able to hope for expanding medicare into areas of pharmaceuticals and home care and prevention, so that we can actually do the next step in medicare that we all dreamed of and still do?

[Dr. Marlene Smadu]

My own personal belief, and I guess it's my professional belief, is that we have to have a pan-Canadian federal approach in health care. I live and work in Saskatchewan. Anybody from there has that in their blood. They know that the medicare that we experienced was only phase 1, and that if we don't deal with prevention, promotion, and the holistic approach to health, we're never going to be able to deal with the challenges that our impoverished population, our aboriginal, first nations, and Inuit population experience.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Smadu.

Mr. Vellacott.

[Maurice Vellacott, Conservative, Saskatoon—Wanuskewin, SK]

Thank you.

I'm not exactly sure who would be the best to answer this question; I know there are a few who might want to jump in on it. It's on the issue of midwives. There has been the suggestion by numbers of people that more of an endorsement and support and encouragement for midwives would be a great help in terms of reducing costs.

I know there are turf protection issues involved there as well. I'm well aware that professional bodies have their own vested interests, if you will, sometimes. But I would appreciate a response on that, maybe from the Canadian Nurses Association, and possibly from Dr. Day or Dr. Tholl. I know Saskatchewan is moving that way. There have been other provinces ahead of us. I see it as a good thing. Birth is a natural, normal kind of thing; it's not a disease. For most normal deliveries it can be a good thing and reduce costs significantly.

I would appreciate your comments with respect to that.