Health Committee on April 23rd, 2009

[The Chair, Conservative, Joy Smith]

Order.

Good afternoon, committee members.

To the witnesses, we welcome you. I have just a couple of quick things to deal with before we start with your presentations. But we certainly do welcome you here today from the Canadian Institute for Health Information, Health Council of Canada, Canadian Health Services Research Foundation, and Canadian Institutes of Health Research.

Again, thank you so much for joining us. If you will just bear with me for about five minutes, we will go through a couple of things.

Committee, in front of you is a request for a budget to pay for the witnesses--close your ears, witnesses--and this is what we have to consider: that the proposed budget in the amount of $111,700 for the study on health human resources be adopted, and that the chair present the said budget to the budget subcommittee of the liaison committee.

If you're all agreed, could I have the go-ahead for the committee right now to adopt the budget?

[Some hon. members]

Agreed.

[The Chair, Conservative, Joy Smith]

In terms of the main estimates, the supply period will end on June 23, so on May 12 we will have agencies appear. We'll talk about that next meeting, I think.

We'll go to the witnesses now, and we'll begin with the Canadian Institute for Health Information. Jean-Marie Berthelot is the vice-president of programs and executive director of the Quebec office, and Francine Anne Roy is the director of health resources information.

Jean-Marie, would you please begin? Thank you.

[Jean-Marie Berthelot, Vice-President, Programs, and Executive Director, Quebec Office, Canadian Institute for Health Information]

Merci. Good afternoon.

On behalf of CIHI, the Canadian Institute for Health Information, I would like to thank you for inviting us to participate in this round table on health human resources.

CIHI—that is the English acronym—is an independent, not-for-profit corporation that provides essential information on Canada's health system and the health of Canadians. Established in 1994, we are funded by federal, provincial and territorial governments. We report to an independent board of directors representing government health departments, regional health authorities, hospitals and health sector leaders across the country.

CIHI works in partnership with stakeholders to create and maintain a broad range of data bases, measurement tools and standards on health information. We produce reports on health care services, population health, health spending and health human resources.

While it is not our mandate to make policy recommendations, we hope our impartial information will assist you with your work.

More than one million people in Canada--6% of the total Canadian workforce--are employed directly in the health care sector. Women represent about 80% of this health care workforce.

CIHI has been collecting detailed information on physicians and nurses since its inception. In response to the pan-Canadian health human resources strategy that Kathryn McDade from Health Canada discussed with this committee, CIHI has created new databases that provide detailed demographic and workforce information on occupational therapists, pharmacists, physiotherapists, medical laboratory technologists, and medical radiation technologists. CIHI also collects aggregate data for an additional 17 health occupations, including chiropractors, midwives, and psychologists.

We did distribute to members a copy of the report that includes a profile of those 24 professions. And since our most comprehensive data are on physicians and nurses, the majority of my remarks will focus on these professionals.

In terms of demographics, the number of physicians in Canada has increased slightly faster than the population since 2003. In 2007, the latest year available, there were nearly 64,000 active physicians in Canada. The number of new physicians entering practice has also been increasing since 2003.

The average age of physicians in Canada was nearly 50 in 2007, with one in five physicians aged 60 or older. Their retirement patterns tend to be different from many other workers in Canada. Many studies have revealed that physicians tend to phase slowly into retirement rather than just leave at a precise age.

Younger physicians and female physicians, regardless of age, tend to practise differently from their older peers. They place more emphasis on work-life balance.

While Canada has a smaller ratio of doctors per 1,000 inhabitants than the OECD average, it has a higher ratio of nurses. This is likely due to differences in models of care. Central European countries tend to have more physicians, while the British model, which more closely resembles Canada's, relies more heavily on nurses.

Regulated nurses represent the largest group of regulated health professionals in Canada, with more than 332,000 members. The growth rate of this entire workforce was 7.5% between 2003 and 2007. During this time, the Canadian population grew at a rate just above 4%. The average age of regulated nurses is 45, about 5 years younger than physicians. Almost 22% of them were 55 or older in 2007.

With respect to inter and intraprovincial migration, a CIHI study on migration patterns of health professionals in Canada shows that more than 18% of them moved between 1996 and 2001, which is about the same percentage as for the general Canadian workforce during that time. This data is based on the 2001 census.

Our study also found that migration happens primarily within a province. Health professionals tend to relocate to where there is an economic boom—just like the Canadian workforce in general.

What about movement in and out of the country? For the fourth year in a row, the number of physicians who reported returning to Canada in 2007 was greater than the number who reported leaving. When it comes to internationally-educated professionals, our data show the proportion of regulated nurses educated abroad has been relatively stable over the past 30 years, at around 7% of the nursing workforce. The rate of international medical graduates was nearly 23% in 2007—down from 33% in the late 1970s. We have noted, since then, a gradual decline in the number of internationally-educated physicians in the physician workforce in Canada.

As an organization dedicated to improving, standardizing, and providing information on health and health services in Canada, CIHI appreciates your interest in its work on health human resources.

I would be pleased to answer any questions you may have in the official language of your choice.

Thank you. Merci.

[The Chair, Conservative, Joy Smith]

Thank you so very much.

We're going to listen to all of the presenters and then we will go into our first seven-minute round very shortly once we've heard all of those presentations. Thank you for your presentation.

Dr. Jeanne Besner is next, and she is chair of the Health Council of Canada.

Thank you, Dr. Besner.

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

Good afternoon. I am very pleased to be here to represent the Health Council of Canada.

I believe that members of the committee have received our briefing note, so I am just going to speak to a few of the points that were made in there.

In my day job I am a researcher in Calgary and have been for the last eight years, looking at the whole area of health human resources, workforce optimization, service delivery models, and so on. So I will pepper some of the health council comments with some of my own observations and experiences drawn from that research.

We noted in our report that in June 2008 we had commented that ensuring that we had the right number of health care providers in the right place was a central component of both of the health accords. One of the elements of the 2004 accords was the development of a pan-Canadian framework for health human resources planning that all of the members and jurisdictions had agreed on.

I think it is important to note that it was a needs-based health human resources planning framework that was to take us away from a supply-based model of planning for health human resources.

Certainly in my own experience and observation, we have not moved very far in the whole approach to needs-based planning, but in our research, my team and I have certainly tried to develop that. One of the things that has become very clear is that when you begin to look at the needs of the population, and much of our research has been done in acute care, a very high proportion of the bed-days in adult hospitals--about 42% in Calgary--is for individuals over the age of 65, many of whom have multiple chronic diseases. Yet our research has indicated a huge gap of knowledge in the health professionals who are providing service to that population relative to the gerontological risk factor assessment and so on. There is evidence that this lack of understanding of risk factors in particular types of populations, regardless of their specific diseases, in fact leads to avoidable complications of care and less than optimal quality of care. So I think the whole focus on needs-based planning, certainly in my opinion, is very important.

It is also clear to us that while we talk a lot about shortages of nurses, physicians, and so on, the shortages that exist may be worse than we think or not as bad as we think, but there is a lot of evidence, at least in nursing, which has been one of the areas where we've done a lot of work, that the under-utilization of health professionals is really part of the whole supply problem. We have registered nurses in many cases doing work that could be done by licensed practical nurses, health care aides, janitors, housekeepers, and others if the service delivery model were different from what it is.

So we do have to think a lot about how we structure delivery of care as well as look at whether or not the people who are delivering care are actually working to the full extent of their knowledge and skills. While most of our research has been done in acute care, some of it is also currently occurring in primary care networks, family practice networks, and so on. There is evidence there as well of under-utilization of health professionals and the potential to move to a very different place if we think differently about many of the issues we are looking at.

Also, in our “Value for Money” reports, we have talked about whether or not we are using our health human resources to provide cost-effective services. Again I could provide a lot of evidence of the fact that I think we are not. By really focusing on the needs of populations, the risk factors, the management of people versus the management of diseases, we could perhaps prevent a lot of the readmissions, for example, that we see occurring over and over again. So based on my own experience I think there's lots of room there for doing things quite differently.

In our reports we have quoted one of the respondents to our “Value for Money” website who said that “it seems governments and institutions are in a race to cut funding and positions based on today's circumstances”. That is something that we saw in the 1990s. We cut a lot of positions--and nursing was one example--and those were the result of very short-sighted decisions, because those cuts are what has caused the shortage that we have today.

I think as we move into another economic crisis we are going to have to be very careful to think about what we are doing if we consider any cuts.

We also need to match the resources we have to the policy agendas we are talking about. We talk about improving population health, moving to more disease prevention, and so on, yet we're utilizing most of our health care providers in the disease management basket, rather than looking at which of our health care providers really could add and advance the health promotion agenda, the population focus, and so on.

I think it is important that we have a national plan that begins to look at what our real shortages are, where they exist, and so on, but we should do that in light of the policy directives. Where do we want to be ten years from now? Are we educating the right number and types of providers to take us to that place at that time?

We've noted on page three the lack of data on outcomes. It is important to link the health human resource agenda to the kinds of outcomes we're trying to achieve. If we really begin to talk about improving health, well-being, self-care capacity, and so on, that speaks to the need for a different kind of provider mix from what we have when we focus primarily on morbidity or mortality outcomes.

There's no question in my mind that we really need to talk about what collaborative practice models mean for Canada. We've talked a lot about team-based care for a number of years, but the collaborative practice model, using Health Canada's definition, places particular focus on patients and families being part of the decision-making process, being engaged in their care, and ensuring that the services provided to them are very well matched to their needs, goals, and so on. We have a lot of evidence that the system is far more provider-centric than client-family-centred. That's another area where by moving forward with a clear vision of where we want to go, we could make a lot of improvements in the delivery of health care.

I'll stop there. There will be an opportunity for questions later if you have any.

Thank you for giving us the opportunity of presenting.

[The Chair, Conservative, Joy Smith]

Thank you so very much. You certainly brought up some new items there. I'm sure the committee will have a lot of questions.

We'll now go to Maureen O'Neil, president and chief executive officer of the Canadian Health Services Research Foundation. That's a big title.

[Maureen O'Neil, President and Chief Executive Officer, Canadian Health Services Research Foundation]

Good afternoon, Madam Chair.

Thank you for the opportunity to speak with you this afternoon. The committee has a complex and multi-faceted problem to explore. The solutions are equally complex. If the answer was simply "more"—more money, more resources—we wouldn't be talking today, I am sure.

The Canadian Health Services Research Foundation was created in 1997 to support research on health services, and to help decision-makers use existing research better, to the benefit of patients. Today, I would like to share several telling stories that show how our partnerships and research are building solutions in the area of health human resources, and how I think we could make even more of a difference for patients in the future.

A few years ago we partnered with a number of groups, including the Ontario Hospital Association's Change Foundation, to commission research that would address critical health human resource questions. Then the Canadian nursing workforce was a significant issue, and it still is. We've heard that already, both from Jeanne Besner and from CIHI. In fact, the study in 2002 by the Canadian Nurses Association suggested that if we continued with past workforce utilization patterns of registered nurses, Canada would have a significant shortage of RNs by 2011, and of course even more, 113,000, by 2016.

We had to set out to address two questions. First, what was the actual impact of the working environment on the health of the nursing workforce, and hence potentially on patient outcomes? Second, what effective solutions could be implemented to improve the quality of the nursing work environment and patient outcomes as well? It's not only the numbers of people you have in any category, it's also the way in which they're organized, the nature of their workplaces, the way in which they work with one another, that determine whether the number makes any actual sense.

So the researchers commissioned by CHSRF and its partners looked across the published literature and conducted extensive interviews with nurses, health system managers, government employees, and educators. The report that was based on this work, Commitment and Care, identified problems that were familiar, and you're probably going to hear a lot more about them. You've already heard some of this from other witnesses this afternoon--issues of work pressure, job security, support from managers and colleagues, safety in the workplace. Jeanne Besner mentioned the difficult decisions and wrong decisions that were taken during the last period of contraction in the Canadian economy and in public funding. Nurses suffered particularly from that, with lots of them being put on part-time, having benefits reduced. So it was a bad atmosphere for work.

At the same time, the researchers discovered that when they looked closely, they saw a lot of creative solutions within the health care systems in Canada and abroad, local innovations that deserve to be heard about much more broadly. For example, there were the so-called magnet hospitals, hospitals with reputations for being excellent nursing workplaces with stable nurse staffing and high job satisfaction, which could be imitated by others.

The report also highlighted, for example, the B.C. Ministry of Health, which launched a program in 2001 to relieve senior nurses of 20% to 30% of their patient care in return for mentoring the new, inexperienced nurses. Innovative solutions like these and others matter a lot, not just to nurses but to patients, because the research shows us that nurses' job satisfaction is one of the strongest determinants of patients' overall satisfaction with the health care system. If you spent any time in a hospital you'd know that's who's there, that's who's doing the work.

The evidence also shows--and this is a little frightening if you're a patient--that good team relations affect patients, even their levels of mortality. So if you have an unhappy team gathered around your bed you should probably be worrying, because there's evidence that there are far better patient outcomes when there's good collaboration between and among nurses and with physicians.

At the Hamilton Health Sciences Centre they've successfully initiated nursing resource teams that will send in backup as different units in the hospital become overwhelmed, so there's a team there to help out when things get particularly hot in one area or when one area is suffering from staffing shortages.

This sounds very micro, but the fact is that changes in health care do have to happen at a very micro level, at the level between the people providing the care and the patients.

I have another very interesting example, that of the Agence de la santé et des services sociaux de la Montérégie. This agency is using research to understand the needs of the population they serve, and transform the way services are delivered to patients. Through its research efforts, the agency has identified 15 major health and social problems as the determinants of the service offer. It then began by treating the health problems and organized services around these problems.

It then created interdisciplinary teams for each of the problems. These teams mapped out service continuums that would help to prevent the problem, treat it, and provide support to susceptible populations. This approach targets the health and social service requirements of specific populations and engages a wide range of health professionals and services.

The result has been an organization with a strong public health orientation and a determined focus on research evidence as a foundation for all management and clinical decisions.

We've learned about these innovations through the course of our programming and through the partnerships we've had. The research I mentioned on nursing and nurses was funded through a ten-year nursing research fund, a program that ends this year.

I mentioned the region of Montérégie. The leaders in that health region in Quebec are participants in a number of programs. Participants included nine of their senior managers and their CEO. They have been fellows of our executive training for research application program. It is also a ten-year program, funded by Health Canada, and it develops capacity and leadership to optimize the use of research evidence in managing Canadian health care.

These stories should serve as a source of encouragement as well as for any cause for concern. These successful initiatives should be commonplace in Canada's health care system. Sadly, they're not. As a country, we need to devote more resources to supporting the kinds of innovations that are good for health care professionals and also, and more importantly, good for patients.

As we know, the numbers show that we're spending more and more on health care, but we devote minuscule resources to support studying and sharing lessons about how we organize, manage, and deliver care. According to the Canadian Institute for Health Information, we're now spending about $172 billion. We spent that in 2008. By comparison, the combined budgets of the Canadian Health Services Research Foundation and the health services research funding of the Canadian Institutes of Health Research add up to less than $50 million, so the amount of money we're devoting to thinking about and looking at actual health service delivery comes to around $50 million out of a budget of about $172 billion. If you're asking yourselves how quickly we are going to come to the practical improvements that are required to have a more innovative publicly financed health care system, we're going to have to look again at these numbers.

We also need to devote a lot more time and energy to sharing the stories of the innovations, not only with health care professionals but also with policy-makers, politicians, and the public. Everybody has a role to play in advancing systems-level innovation, because we know that's the way we're going to have a much stronger health care system for all Canadians.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you very much. That was a very insightful presentation and very much appreciated.

I will now go to Dr. Beaudet, from the Canadian Institutes of Health Research.

Thank you.

[Alain Beaudet, President, Canadian Institutes of Health Research]

Thank you, Madam Chair.

Hon. members of Parliament, I appreciate the opportunity to bring the perspective of the Canadian Institutes of Health Research to your study of health human resources.

CIHR is the Government of Canada's agency responsible for the funding of health research and training. Our mandate, as defined in our founding act, is to excel according to internationally accepted standards of scientific excellence in the creation of new knowledge and its translation into improved health for Canadians, more effective health services and products, and a strengthened Canadian health care system.

CIHR provides leadership and supports nearly 12,000 health researchers and trainees across Canada. These should be seen as an integral and essential part of the Canadian health workforce.

We in the Canadian Institutes of Health Research are convinced that research is the cornerstone for the well-being of Canadians and for an effective health system tailored to meet our needs and based on solid scientific information.

Your investments in health research lead to improved health for Canadians. Let me give you two examples.

In Canada, the death rate after a heart attack has decreased by more than half in the past decade, due to innovations in treatment and to improvements in health systems to provide timely care. As another example, when the SARS outbreak occurred in 2003, CIHR mobilized a team of 58 Canadian researchers to sequence the genome of the virus behind SARS, studies that would then lead to results in the areas of diagnostics, treatment, and vaccination.

These examples--and there are countless others--depend upon the creation of basic scientific knowledge and equally upon the successful application of that knowledge in the clinical setting. Both aspects are crucial for health improvement. We must have the capacity not only to do the research, but also to translate the results of research into better care and into an efficient, sustainable health care system, as Ms. O'Neil just told us.

This leads me to the issue of human resources, the matter before you today. It is absolutely essential that health researchers, be they scientists or health professionals, be taken into account. And we must recognize that that has not always been the case up until now.

Who are these health researchers? They are, first of all, scientists, holders of a Ph.D. and their students, doctoral and post-doctoral. These people work in the area of basic research or in the more applied sectors of health research: epidemiology, health system organization—as Ms. O'Neil just mentioned—health economics, etc. And don't you think that these researchers are confined to the university ivory towers: too often we forget that more than 80% of health research in Canada, all sectors included, is conducted on hospital campuses. Then we have the health professionals: doctors, nurses, physiotherapists, occupational therapists, psychologists. More often than not, these people split their time between clinical duties and research. They are the key to this transfer of knowledge to clinical practice and health care organization.

But you should be aware that Canada's patient-oriented research capacity is rapidly deteriorating. In the case of physicians—and the situation is even worse for nurses—only a small proportion of them devotes a substantial amount of time to research, and this proportion is not growing.

As you see here on this graph, it is not a map of arms of mass destruction, but it does show you the total number of physicians in Canada—and we're talking about specialists. These are the ones who actually spend less than 5% of their time doing research. Now, the ones who really count, the ones who spend at least 20% of their time actually doing research, are represented by this very dark blue line here at the bottom.

Clinicians' time for research is not protected, and it's not appropriately valued and compensated. How can we compete with the increasing demands of care in the face of insufficient human resources? Time for research is never taken into consideration when staffing the health sector. There are difficulties in attracting and retaining clinician researchers; and insufficient opportunities and unclear career paths discourage the ones who have the talent and taste for it. Yet these clinician researchers are absolutely critical, not only to improving health and health care, but also to ensuring that health care professionals are trained under the scientific backdrop necessary to ensure evidence-based practice.

We need to ensure a system of renewal that prepares new health professionals for research careers. We must ensure that the system appropriately values these promising health researchers, along with creating an environment that is scientifically and intellectually stimulating. And that's what we're trying to do at CIHR. I feel very strongly that as an organization, we need to focus more time and resources on patient-oriented research.

Over the coming years, CIHR will lead a new patient-oriented research strategy to strengthen the culture of knowledge-based care at all levels of the health care system.

Our objective is not only to develop significant human resources in this sector, but also to better exploit our universal health care system. We want to know how to use—and once again, I am repeating what was said by Ms. O'Neil—the resources provided by this system: data banks, medical records that will soon be in electronic form, we hope, to provide better follow-up on patients and improve the viability and cost-effectiveness of the system itself. We have a unique opportunity to develop a niche of excellence at the international level, which will enable us not only to better serve our citizenry, but also to retain and strengthen the health industry. It is up to us to take our health care expenditures and turn them into an investment.

If we make a better effort at this, the result will be internationally recognized clinical research expertise. We will produce groundbreaking Canadian studies and, more importantly, we will improve the delivery of health care to Canadians.

To conclude, CIHR has a responsibility to provide research leadership in building the environment and the people to strengthen Canada's research infrastructure and capacity. We will fulfill our mandate. We need your continued support.

My message to you today is that research in the hospital setting is not a luxury, but the key to improved health care. One cannot plan for health human resources without integrating research at every level; it is essential to the quality and outcomes of health care.

Merci beaucoup.

[The Chair, Conservative, Joy Smith]

Thank you very much.

I need to tell you that this committee is very involved in this particular study, and we find it extremely important. What you say is taken under very careful consideration.

We're going to go into two rounds of questioning, and the first round is going to be seven minutes per person for the question and answer.

We'll start with Ms. Murray.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

It's very humbling to be a committee member and part of a team responsible to add value in the whole area of human health resources, and to be able to hear from people like you who are leaders in the field and who have spent their careers knowing about some piece of it. It's hugely complex. My first career was in growing the health of forests, not an area associated with health care. So it's a humbling experience.

I'm going to focus in on the area of prevention, because in my view that's an area in which we can do far more than we do, and I think the amount of funds that go into health repair and the amount that go into prevention of health problems are out of balance.

I have one more personal biographical detail. I have three grown children, and I have never been in a hospital other than to visit someone else, so I have the good fortune of being very healthy. Prevention is the key, from my experience and my thinking, and that's what I wanted to ask about.

In terms of the comments that were made on research, can somebody comment on whether you believe there is adequate research into complementary and alternative professionals like naturopathic physicians and the care they provide and the modalities they use?

[The Chair, Conservative, Joy Smith]

Who would like to start off with that question?

[Alain Beaudet]

I'm happy to take it.

Your question is a very interesting one. I think it reflects the huge changes in society. You remember that until 1999, our agency was called the Medical Research Council. It is now called the Canadian Institutes of Health Research. I think this shift in focus from medical to health is a very important one. I think it's a reflection of what's happening in society. We're starting to realize that health is much more than patients in hospitals. Health is also promotion of health. It's also prevention of disease.

Is there enough research in that area? No. Are we putting more money in that area? Yes. What is the problem, and why aren't we doing more faster and building capacity? It is new. It is not difficult to find biochemists out there who will apply for research grants for biomedical research, but it's more difficult to find the people who have the talent and the know-how to do the type of evaluation research that's needed in these sectors.

We really have to take it upstream and train the researchers of tomorrow. We're very aware of the importance of these issues, and particularly, I would say, with an aging population and in the realm of chronic diseases. If we don't do something about preventing chronic diseases--

[Joyce Murray, Liberal, Vancouver Quadra, BC]

I have a couple of other topics, but thank you very much for that. I know that the practitioners and the associations are very interested in seeing more government-supported research, and I'm sure they would be happy to bring some of the capacity forward should the funds be available.

I have another question. The word “patient” was used a lot--patient-centred care, patient-centred outcomes, and so on. There is the issue of complementary and alternative practitioners being part of the continuity of care so that we don't have to be patients. I think a huge percentage of people use those services and stay away from being patients and stay out of hospitals, and that's not recognized as being an important preventative. From a health human resources perspective, what is being done, and is enough being done? I'd like your comment on bringing naturopathic physicians, traditional Chinese doctors, acupuncturists, homeopaths, and so on into primary care as part of the health human resources team. Do you see that being a priority? Do you think that's being adequately supported?

[The Chair, Conservative, Joy Smith]

Who would like to take that question?

Dr. Besner.

[Dr. Jeanne Besner]

Is it a priority? I can't answer that. Where the needs of patients' families determine they should be members of the team, there should be more opportunity than what we have. But we also need to use the opportunities we have to do more prevention.

All members of the team working to full scope and focusing on what they ought to be focusing on perhaps is an example. If you look at depression among women of childbearing age, in one of the family practices in which I was doing some work it tended to be the number-one billable code in that age group. When we introduced nurses into the family practice, we really started focusing on the importance of having them assess the extent to which the depression was interfering with parenting in women who were depressed. It can put children at risk of neglect, abuse, and so on if the depression is severe enough.

It's a way of beginning to look at the many opportunities to introduce primary prevention. The woman's depression needs to be treated, but the children's well-being also needs to be attended to. So you begin to look at more than one member of the health care team working in a particular context, and shift your focus away from just managing the disease--depression--to look at the issues that surround the needs of that patient's family. Then there are more opportunities to look at all the other health care providers who could become part of the care team and manage people far better, so we don't have people constantly on the treadmill of treatment, illness, and so on.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Besner.

Monsieur Malo.

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

Thank you very much, Madam Chair.

I would also like to thank the witnesses for coming here this afternoon. I would like to make a few points with respect to your presentations.

Ms. Besner, you told us that, in your opinion, we were not using our resources well, that nurses should have more responsibilities and that we needed to change the way we do things in order to take into account the fact that patients now want to be more involved in their health care.

Ms. O'Neil, you told us that the working environment of nurses needed to be examined to create greater job satisfaction. You talked about stress and the fact that relations with superiors were sometimes difficult.

You have made all of these statements before a federal health committee. But do you not find that you are speaking to the wrong people, because the stakeholders most able to effect changes in this sector are to be found in other parliaments? The way I see it, your observations are based on rigorous, serious studies that were carried out using certain scientific research models. Have you apprised these stakeholders who, in my opinion, would be more appropriate, of these findings?

[Dr. Jeanne Besner]

As far as I'm concerned, I can say yes. However, that has not changed much to date. We try to bring up these issues in every possible forum.

There is a lack of vision with respect to what we call the scope of practice, whether it be for nurses, doctors or others, throughout Canada. We can effect change little by little, and that is what I am trying to do in my own sector, in Calgary. I do this one day at a time, one unit at a time. The fact remains, however, that at this rate bringing about change at the national level will take centuries.

I feel we need to adopt a Canada-wide vision and start discussing the roles of our health care providers. We have to envision changes that can be made on a broad scale, so that this happens earlier rather than later. In my opinion, this is very important.

[The Chair, Conservative, Joy Smith]

Ms. O'Neil, please go ahead.

[Maureen O'Neil]

Thank you very much for your question. We are here at the committee because you invited us, and not to lobby about our research findings. I mentioned that we had worked with the Ontario Hospital Association and that we were very involved with the British Columbia Ministry of Health.

It is true that, in Canada, we are often afraid to make comparisons between the provinces. This is what CIHI does, but that makes everybody very nervous. However, this is what we need to do. Canadians need to know how things would unfold, depending on whether they lived in Ontario, in Montreal, or in Alberta, if they were diagnosed with a certain type of cancer. Provinces are not all that interested in doing these types of comparisons. However, with respect to innovation, we know that the OECD countries are quite prepared to draw comparisons among themselves.

If we want to progress, we really need to know what is happening. You are right in saying that we have 13 different health systems in Canada. As Dr. Besner said, it would take a very long time to change things. We do, however, have to make changes in each health system. For this reason, research is very important, because it enables us to compare the various systems.

I do not know whether or not Canadians living in Ontario are aware of what's going on in primary health care in Quebec, and vice versa. As citizens, our taxes pay half of the health care expenditures in each province. So we really need to know what is happening elsewhere and whether we have the health system we need.

[The Chair, Conservative, Joy Smith]

Thank you, Ms. O'Neil.

I think Monsieur Berthelot would like to make a comment.

[Jean-Marie Berthelot]

Thank you for inviting us to the committee.

You touched on the very essence of our CIHI mandate, which is to provide a mechanism enabling the various provincial governments to compare themselves with each other. The CIHI mandate is to work in cooperation with the provinces. To do this, we have a bilateral agreement that governs our relationship with each provincial government.

You asked us how we make sure that the information gets to the provincial governments. The institute is not necessarily invited to the National Assembly or to the legislative assemblies, but it does ensure that every Ministry of Health, or, for instance, the Institut national de santé publique du Québec, receives information produced by CIHI and can use it in its political system in order to further its causes.

The objective is to produce data enabling us to note the differences between the systems, and not to say that one system is better than the other. Each system may prove to be better or worse than another one when it comes to certain issues. We want to enable people who develop provincial or local health policies, whether it be at the CLSC level or within a regional district, to have access to this information.

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

That somewhat answers the question raised by Ms. O'Neil, who appears to say that—