Health Committee on April 23rd, 2009

[The Chair, Conservative, Joy Smith]

Excuse me, Monsieur Malo. Before we go to the next question, I notice Dr. Beaudet would like to make a comment.

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

It was a complementary question.

[The Chair, Conservative, Joy Smith]

Okay.

Dr. Beaudet, go ahead.

[Alain Beaudet]

I would simply like to make a brief comment.

You are perfectly right. This is a matter which, when it comes to health care, is clearly under provincial jurisdiction. If we want to conduct effective clinical research in health services, epidemiology in particular, we have no choice but to work closely with the provinces. Moreover, this is why we work closely with the health research organizations in each of the provinces. In Quebec, this would be the Fonds de la recherche en santé du Québec; in Alberta, it is the Alberta Heritage Foundation for Medical Research; in British Columbia, this is the Michael Smith Foundation for Health Research, etc. The purpose is to harmonize our research policies and ensure the effectiveness of health research policies that we are trying to develop.

[The Chair, Conservative, Joy Smith]

Ms. Wasylycia-Leis.

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

Thank you, Madam Chairperson.

Thanks to all of you for actually kick-starting our study, which begs for your input and advice in terms of the macro issues at stake.

I think you've all said, in one way or another, that we have very much a crisis in terms of health human resources, whether it's in terms of shortages, under-utilizations, or difficult working conditions, and that of course leads to long waiting lists, a lack of confidence in our health care system, and could break our medicare model.

We've had studies for twenty years now that I've been around. I think we need to hear from you, as a committee, what do we recommend, where do we start to look, in terms of a strategy that will finally lift itself up off the page and go somewhere?

First of all, do you all agree that we need some sort of a national approach to this issue that has due regard for the uniqueness of Quebec but that coordinates, which is something that I think was supposed to come out of the 2003-2004 ministers meeting? I think that's how the Health Council got its start. Do you agree that we need this kind of a strategy? What are the elements of it? How do we make that happen here in the federal government?

Maybe, Jeanne, you could start.

[Dr. Jeanne Besner]

Yes, obviously, I do think that we would be better off to have a pan-Canadian strategy.

I think the research studies done in Alberta or in Quebec or wherever in many instances have applicability elsewhere. Context is very important when we're talking about professional practice and so on. We need to use what we know works in one area and then try it in other places, in other contexts, and make sure, by replicating or adapting what we know in other contexts, that we get it right eventually.

There's a lot that we know about what we could be trying differently that I don't think is going to be very different in any of our provincial jurisdictions, but we need to bring it to a level of national discussion so that we can work together and make sure that what we apply in fact does work in a number of different contexts, is the right way to go. Then we will have the basis from which to begin to think about our long-range planning, whether we have the right number or the right types, and so on and so forth. Doing it just one little tiny bit at a time, one research project, whatever, is simply not very cost-effective, I don't think.

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

Jean-Marie, Maureen, I'm sure you'd like to comment on this.

[Maureen O'Neil]

Thanks.

Yes, I think there is a need for a national vision, even though I recognize that we have at least 13 health jurisdictions. For one thing, when we're talking about health professionals and service providers, they move around, as we know. They aren't all staying in one spot; in fact it is important to understand where they are.

I think there's something even more profound, in a sense. You expressed the frustration of having seen so many of these discussions on what's going to be done and how we can innovate within a publicly funded health care system so that people are proud of it. I think one of the first hurdles to get over is Canadians thinking that they have the best health care system in the world. They don't, actually. We would like it to be the best, but if we look at international comparisons, we see that there are other publicly funded health care systems that do things differently and that, in some cases, do things better.

I think your committee has a very important role to play in terms of saying that we want to have the best system in the country, and here are the things that will help make it better. I think the Health Council's call for comments on what value for money means is extremely important. I think CIHI's continuing putting out of statistics on how things are working is really important. But we also have to recognize that for provincial governments, doing almost anything in the health area is so toxic politically, I think, people will do a few things, take a deep breath, and hope that they get through to the next election without suffering from doing anything terribly innovative. I think that acts as a brake on actually getting things done.

So the big question is how to create an atmosphere in Canada...recognizing, of course, that it's primarily a provincial jurisdiction. But don't forget that in five years we're going to be renegotiating the Canada health transfer. That's a small amount of the money that flows into health care, but this is coming up.

This next while is an ideal time to be focusing on these questions that are felt across the country. Even though some people may say that these are not national questions--their resolution does not sit completely with the federal government--Canadians across the country are experiencing difficulties nonetheless. They want to have better systems, want to retain the accessibility they have.

The puzzle is how to generate that debate. How do we build out from the issue of health human resources--in other words, the providers? As we know, since the Hall royal commission, which agreed on a payment system but agreed not to touch the organization of services, everybody's been struggling with how to innovate in the organization of services. How do we actually have payment systems that pay for more than doctors in primary health care, or sometimes nurse practitioners, or the doctors and nurses in hospitals, and some of the other professionals, some of whom have been mentioned today?

I think your committee has a real opportunity. The question is how broadly do you cast the question? Do you look at health human resources after defining and recognizing that innovation is required and that the federal government doesn't hold all the levers on it--which, of course, everybody knows? How do you pose your question in a way that generates useful discussion and that doesn't fall into the trap that we see so often at particularly the provincial level when anything happens? Whether it's the Chaoulli decision in Quebec or whether it's B.C. opening up to more private clinics, whenever it comes up, suddenly the camps form in a not particularly helpful way, with “No Two-Tier Up Here” banners over here and “Only What We've Got Now” banners over there.

We never seem to be able to move off the dime. But you have an opportunity to think more broadly about this.

[The Chair, Conservative, Joy Smith]

Thank you, Ms. O'Neil.

Ms. McLeod.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Thank you, Madam Chair.

First of all, I want to compliment all of the presenters today. I think Canada has the benefit of your organizations, which are respected certainly internationally in terms of how we work.

I believe we do have the answers to our more modestly defined HHR issues. In our first presentation, we heard about some things around medical residency and how that's a little bit of a gap. You're right about tinkering around that bottleneck, but I really appreciate the comments that solutions to the HHR issues lie a lot in systems change.

I actually have a couple of quicker questions. The first one is for Dr. Beaudet.

Absolutely, research is incredible in terms of supporting and informing practice, but we have a lot of research out there that is not actually translating into practice. I guess I'd appreciate a few comments in that area.

[Alain Beaudet]

You're right, and as I said at the beginning, it's fully part of our mandate not only to create new knowledge, but to ensure that it is properly translated into better health and better health care. And quite frankly, I think we haven't delivered as well on the second part, and it's more difficult to do that.

That's exactly what we're trying to achieve in our second strategic plan, which is just about to be launched. It has a big focus on what I call patient-oriented research, but it goes more broadly to the patient because it does include primary care and it does include prevention. But we're talking not only about bringing the results from the bench to the bedside, but also about ensuring we have high-level evaluation of new treatments, of new policies, of new practices, of new drugs. And once they're evaluated, we need to ensure that the results of the evaluation are actually properly disseminated, and that this dissemination results in the proper uptake and a change in practice.

This is a continuum where the health professionals play a key role. The thing is, we don't have enough, and the ones we have who have the training do not have the time. So we need to protect their time and we need to train more to do that. I believe it's the only way we'll be able to do it in an efficient manner.

We clearly want to focus on that in the years to come.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Also, if you look at CIHI, I think they bring in 15,000 people through video conferences.

Looking at HHR, we talked briefly about some Canadian statistics. You might not want to share them today, but I think our international comparisons become important in terms of some of those issues. Are we favourably or unfavourably compared? I know every system in every country is different, but do you have any quick comments in terms of that area?

[Jean-Marie Berthelot]

I think that was already in the briefing notes. It depends on the way the care is organized.

In Canada we have a higher number of nurses per 100,000 inhabitants than many of the continental European countries; however, we have fewer doctors. But when we compare ourselves to something a bit more like the British system, or even with the Americans, we're maybe not that far behind. So I think it's very difficult to answer the question of whether we have enough of this or enough of that. It goes beyond physicians and nurses. It depends on how the care is organized. It depends on the scope of practice. The scope of practice of a physician is not the same, depending on the country. The scope of practice of a nurse is not the same. So it's very difficult to make the judgment about whether we are advantaged or disadvantaged compared to other countries.

What we can say is that on average we have fewer physicians than the OECD, but this is because of the model of care. We have more nurses. In terms of the trends over time, there has not been a lot of change in terms of the number of physicians per 100,000 inhabitants in the country. That's relatively stable. In terms of nurses, we saw a relatively significant decrease in the 1990s when the government had a large deficit. We are now seeing an increase. We're not at the level we were before the 1990 reduction.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Certainly I appreciated Maureen O'Neil's comments regarding the political bravery, not just at a provincial-federal level, but even within our professional organizations.

Again, the foundation of our system is within the prevention and the primary health care system, and, yes, our acute care systems.

Does anyone have any more comments in terms of that particular issue, on scope of practice or...? Again, I believe the answers are there. We just need to have the bravery to pull all the threads together.

[The Chair, Conservative, Joy Smith]

Ms. O'Neil.

[Maureen O'Neil]

Thank you.

I think many of the answers are there, and this is also why international comparisons can be so helpful, to look at how other countries actually organize the services, not just at how many positions they have or at how many nurses or how many physiotherapists, but at how they are actually organized and how they are financed.

I think one of the important questions to try to get at is how the way in which the money flows from a provincial government to hospitals and to health regions either encourages organizing in the way that is most effective for positive outcomes or does not. Does the way the money flows inhibit innovation in the way services get organized or does it not? Does it create barriers? This is going to be different in different places.

In health care, you can't escape getting down to this level of detail to understand where the actual levers for change are. Why is it that we have spent, from the federal level, $800 million over a number of years for primary health care transition, and yet when we look around and ask ourselves in which province primary health care has really been reorganized--and we know primary health care is crucial if we want to grapple with greater efficiencies down the road--it's very hard to do. What are the barriers? Why is it so hard?

The difficulty, I think, is that these things are linked together, but in order to have discussions, you have to pick them apart and say, “Aha. If we wanted to do things differently, then we would not want to be setting a whole bunch of rules for hospitals and how they spend their money. Maybe we would want to give them a block budget, or maybe their budget should be part of a health region.”

These things sound so arcane, and yet if you're looking for ways to change things and looking for ways to answer the question of why things don't get done, you have to get to that level of detail and then, in a sense, step into the shoes of the health minister from the province and ask whether you would really have wanted to take that on, because every time you make a change, it disrupts somebody's day out there. If you find it's less efficient to have an emergency department in a small hospital, you can guarantee that the minister's going to hear a lot about it if you do what might be a more efficient thing.

We all have to keep trying. We always have to keep working on these things. Not coming to grips with the fundamental political economy and the desire to keep on doing things the same way is preventing the actual implementation of research findings around organization of services that have been well known for years.

[The Chair, Conservative, Joy Smith]

Thank you, Ms. O'Neil.

We're now going to go into our second round of five minutes. I wish we had even more time, but your comments are really great, and I thank you for them.

We'll start with Dr. Bennett.

[Carolyn Bennett, Liberal, St. Paul's, ON]

Thank you very much.

Again, I concur that this was a really helpful beginning, but it's also confounding in terms of how we actually do this chicken-and-egg thing of whether we are going to change the way we do things or we are going to decide we need doctor-patient ratios and nurse-patient ratios in the same old way of doing things, regardless of OECD numbers or all of that. If we actually decide to change and work on teams, how could it look different?

I would love to hear from Dr. Beaudet. Is it possible to keep up in medicine or in nursing if you're not teaching? The most important thing that happens to all of us is having some whippersnapper say, “How come you're still doing this, and why aren't you doing that?”

If you were dreaming in technicolor about what this would look like in terms of collaborative care that was truly patient-centred, where we were always doing evidence-based practice or practice-based evidence, what would it look like, and would we still be talking about scopes of practice? Because it's very different in Nunavut from what it is in downtown Toronto. I think the new phrase “core competencies” means that if you're on a team, some people are going to have a little bit better knowledge of this or that or whatever.

From the Alberta bone and joint to some of the community health centres, to some of the things that are really best practices, should we be doing our work based on skating to where the puck's going to be, or do we do the work that also needs to be done but focus on foreign trade in medical drugs, more slots, and more training?

For a comprehensive approach to HHR, I guess I want to know how you would have organized our study if you were actually going to get to write the report.

[The Chair, Conservative, Joy Smith]

Dr. Beaudet, would you like to tackle that one?

[Alain Beaudet]

It is a difficult question, but then I love to dream in technicolor, so I'll have a shot at it.

I would say break the silos. Again, it's very much from the perspective of research-based practice, and to me it's a practice that uses the levers of research. Break the silos between the scientists and the physicians and the nurses and the engineers and the project managers and the bio-statisticians. They're all in their little worlds. We still train them along disciplinary lines. We have to stop that and we have to think in terms of multi-disciplinary teams working together. That would be what--

[Carolyn Bennett, Liberal, St. Paul's, ON]

So that's the first recommendation of the report, that we would have interdisciplinary training in universities?

[Alain Beaudet]

It's very important. I think it's critical if you want to actually bring the research and the practice into practice, because otherwise you'll never have the respect of where the research comes from.

The second point is that everything we do should be in terms of building in mechanisms to monitor what we're doing. I'll give you just a simple example: electronic records. We're getting there, finally.

[Carolyn Bennett, Liberal, St. Paul's, ON]

Google is.

[Alain Beaudet]

Yes; it's about time.

Let's make sure from the start that these will be built in such a way that they will be accessible for research purposes, and that the question of protection of personal information is ensured from the start, so that we're not told in ten years that we can't access those because of the Privacy Act.

Let's build them in such a way that we actually can access part of them for research purposes; that we use them from monitoring what we're doing; that we use them for long-term monitoring of side effects; that we use them not only for research purposes, but that we make sure they ensure a flow so that the practitioner can access the record and have the feedback from the research results, and change the practice through the same vehicle.

In what we're building, think about monitoring and think about the future use of the results of the research.