Health Committee on April 28th, 2009

[Dr. Andrew Padmos, Chief Executive Officer, Royal College of Physicians and Surgeons of Canada]

Thank you, Madam Chair, honourable members, and colleagues. It is a pleasure to appear in front of you today. My name is Andrew Padmos. I'm the CEO of the Royal College and a hematologist by training. I continue a small but very important clinical practice in hematology in Halifax, Nova Scotia, where I recently lived before moving to Ottawa.

The Royal College was created by a special act of Parliament in 1929 to ensure the highest standards for the training, evaluation, and practice of medical and surgical specialists. We now supervise the training and certification of 61 specialties and subspecialties and represent a population of 43,000 specialists out of the approximately 70,000 members of the medical workforce in Canada.

I would like to commend the work done by governments, health planners, and policy-makers at the federal level in addressing health human resources shortages. My colleagues have mentioned several specific projects. These have improved our understanding, but they have unfortunately not eliminated the shortages and the misdeployment of health human resources across this country. Many citizens, including members of our families and our circles, have suffered from these shortages on a daily basis.

Our analysis in our brief addresses five areas that the committee has identified as important. The first concerns the supply in the medical workforce. These comments are not confined to physicians, however. They are echoed in literally all of the health professions and consider all of the health care providers that make up our important resource in the health system.

Some particular factors make the issues more concerning for physician members of the workforce. Among them, we're aging at a rapid rate, and the number of our members in the medical workforce who have become age 50 or over is up 9.3% since the year 2000. Probably more important, in terms of the number of services provided, we know that the new members of the medical workforce have commitments to a better work-life balance that limit their productivity, and it is often said that for every retiring physician we need to find and train two replacements.

One of the things that is of particular concern and I think is relevant to today's news, the news that's not related to swine flu virus, is the concern over loss of capital in human health research. Our government has made small, incremental, and augmented changes to the health research funding that pale in comparison to the significant additional investment in other countries, particularly the U.K. and the U.S.A. Even today, President Obama of the United States announced a commitment of 3% or more of gross domestic product to the research and scientific agenda in that country, and this is important in retaining the best and the brightest of our physician workforce, our other health care providers, and our medical scientists.

Our recommendations resonate with those made by colleagues. We commend the federal government and recommend its further investment in training, education, and continuing professional development of medical and other health professionals. We would like to see the Conservative federal election campaign promise to invest additional millions of dollars a year for four years to create additional residency training spots in teaching hospitals. We suggest that commitment should be extended by a further 10 years.

We also recommend that the government expand and sustain Canada's investment in both biomedical and psycho-social research for the health system in order not only to improve health care but to retain leading health, scientific, and biomedical researchers who are otherwise going to follow investments made elsewhere and leave our country.

Anyone who has worked at the front lines of health care knows that it is truly a teamwork-based operation, and our members fully support that.

We commend federal-provincial-territorial initiatives to enhance interprofessional education and collaborative practice. We would also like to acknowledge that other health professionals need support so that their work can ensure that Canadians can access more and better specialty care.

For this, we recommend the federal government support the enhanced supply, deployment, and evaluation of such other health professionals as physician assistants and advanced clinical nurses, including nurse practitioners and clinical nurse specialists.

We follow our colleagues in the Canadian Medical Association in identifying internationally educated health professionals as a crucial component of the medical workforce and the health workforce. We suggest targeted funding to expand medical school capacity and postgraduate medical education positions to develop and augment the incorporation of international medical graduates into our practice.

We also identify that not all Canadians have the luxury of living in urban environments where sophisticated health care services are readily available. For northern, rural, or remote areas, we recommend the federal government study the feasibility of creating a special federal infrastructure fund to provide exceptional relief and assistance to rural and remote communities that lack, or are losing, adequate health services.

I'd also like to identify aboriginal peoples and other federal groups as worthy recipients of federal targeted funding. The funding should integrate the framework for aboriginal core competencies developed by the Indigenous Physicians Association of Canada and the Royal College of Physicians and Surgeons into medical curricula in medical schools across Canada. I'd also like to point out that we should have scholarship programs and we should recruit and place first nations, Inuit, and Métis health professionals in practice.

Last, I'd like to return to the recommendation that appears to be common among all groups. At the risk of identifying Madam Silas' concerns in a light fashion, a repetition of the same thing with no discernible result is a definition of insanity. However, I do hope that we're able to see progress on the idea of the federal government working with provinces to establish a pan-Canadian HHR observatory or institute to address the manifest gaps and deficiencies in data research and analysis and to disseminate knowledge about health outcomes, including those outcomes that relate to the amended Agreement on Internal Trade, which we feel will certainly have deleterious results on migration and distribution of health professionals in the short term.

Madam Chair, thank you for the opportunity to present to you today. We commend these recommendations to your committee.

[The Chair, Conservative, Joy Smith]

Thank you, Doctor.

We'll now go to Richard Valade, president of the Canadian Chiropractic Association.

[Dr. Richard Valade, President, Canadian Chiropractic Association]

Thank you.

Good afternoon, everyone, ladies and gentlemen, members of the Standing Committee on Health.

My name is Richard Valade. I am a doctor of chiropractic and the president of the Canadian Chiropractic Association. With me today I have Dr. Deborah Kopansky-Giles. She's a chiropractor on the staff of St. Michael's Hospital in Toronto. We thank you for the opportunity to be here today.

We in the chiropractic profession feel strongly that our services are not being properly utilized for the public good. Chiropractic has been rigorously evaluated by the scientific community so that we now have a solid body of evidence that chiropractic care is effective for neuromusculoskeletal disorders such as back pain, neck pain, and headaches. But it's not being used as much as it should be.

We are well aware that the delivery and administration of health care takes place primarily at the provincial and territorial levels. Provinces make decisions about what services their residents are offered. So we know that it's pointless to ask this committee to comment about decisions that are made provincially and territorially. Instead, we confine our remarks to those cases where federal resources are applied directly to health.

We feel that we can do much more to help people whose health services are paid directly from the federal purse. There are some obvious cases. First, the service provided to members of the Canadian Forces is inconsistent. Did you know that a soldier in Afghanistan cannot get any chiropractic care to relieve back or neck pain, but at the same time, back at home, members of his or her family have access to care for back and neck pain through the public service health care plan? It is regrettable that soldiers in the field do not have the choice of highly effective, non-invasive chiropractic care for their back and neck pain. Chiropractic is well established to provide prevention of injury and to relieve major and minor injury to muscles, nerves, and joints, and it is appropriate to those who serve in rocky, unpleasant, and harsh terrain. We feel there is much that we can do to make reasonable health services available in the places where our soldiers serve their country.

The chiropractic profession is represented by several officers currently serving in the Canadian Forces. Dr. Denis Tondreau and Dr. Lison Gagné both serve as active reservists. They are both fully prepared to offer their skills as doctors of chiropractic while on duty at no charge, and yet there is no precedent to allow them to do that. In the past, they have both used their skills to aid their colleagues in spite of there being no regulation to support their work in the forces. Dr. Tondreau served in Afghanistan in 2008 and was welcomed and supported by the medical chief of staff at the base for his chiropractic skills to treat his injured colleagues. However, he could not get his orders changed to reflect his service as a chiropractor. We think this type of situation needs to be rectified. In fact, we think that chiropractors should be in uniform and actively serving in the forces. However, it would be a step forward if service personnel even had reasonable access to chiropractic care, so they wouldn't be second-class citizens compared to their families in Canada.

Dr. Tondreau most recently was deployed to Sierra Leone in November 2008.

Dr. Gagné has been in the Canadian Reserve Force since 2007. During training, Dr. Gagné attempted to alleviate her colleagues' musculoskeletal ailments, an area in which chiropractic excels. However, she was met with hostility from her superior officer and was told not to use chiropractic skills to treat people, regardless of positive results. Most recently, Dr. Gagné trained in Mississippi in January 2009, and she awaits deployment overseas with hopes of utilizing her chiropractic skills for the benefit of her colleagues.

This system in the Department of National Defence is especially concerning when one looks at the RCMP, which has long recognized the value of chiropractic care. For some years, RCMP members have had 2.5 times as many acute care treatments available to them as the Canadian Forces makes available to its members at home here in Canada. The RCMP is currently exploring ways to improve and enhance services and rehabilitation for acute and chronic pain. The RCMP is considerably ahead of the forces in making comprehensive care available to their members.

In terms of Canada's use of chiropractic care, we are significantly behind the United States military. In the United States, the Department of Veterans Affairs calculates that the number one reason veterans seek care when returning from Iran and Afghanistan is lower back pain. In addition, over 20% of U.S. military treatment facilities employ doctors of chiropractic for treatment of military-related injuries.

Let us consider another example: our first nations aboriginal population. Canada's history in dealing with first nations is a blot on our reputation as a dignified and enlightened country. First nations people suffer many health problems, and in many cases their levels of diabetes are higher and their overall levels of health lower than they are in other Canadian populations.

What we see is a highly inconsistent approach to chiropractic services available to the first nations people. Services vary widely, depending on such factors as the province of residence, the particular nation or group they belong to, and the arrangements they have made. This is not the Canada that reflects the values of the Canada Health Act's national principles of portability, accessibility, universality, comprehensiveness, and public administration.

In contrast, as an example of successful first nations care, the Joe Sylvester clinic in Anishnawbe Health Toronto is a pro-service, multidisciplinary clinic that has been offering health care to Toronto urban aboriginal communities since 1996. Health care professionals available at the clinic include chiropractors, physicians, nurses, traditional native healers, and complementary and alternative health care providers.

In this unique setting, comprehensive, traditional, and conventional care is delivered in the spirit of true multidisciplinary cooperation. Dr. Kopansky-Giles has first-hand experience with this clinic.

Building on this example, we would like to see first nations people have equal access to qualified, comprehensive health care services.

Chiropractors are second to none in keeping people healthy and efficient at a very reasonable cost. Essentially, we believe federal populations should have equitable access to chiropractic without gatekeeping. People who have sore necks, sore backs, or headaches should get care right away, get back in action right away, and lose as little time as possible from work and family.

The chiropractic profession prides itself that patients have quick access to practitioners and quick access to treatment. We feel this is a healthier way for the population to stay alive, focused, and engaged. In the long run we feel that not allowing people to become debilitated is a much better way to have a healthy Canada.

We now turn to a very solid example of how care should be offered across the full spectrum of a federally serviced population. It is a wonderful case study of cooperation and efficient service that can serve as a beacon for the best use of health dollars.

St. Michael's Hospital in Toronto offers chiropractic services in one of Canada's first hospital-based chiropractic care clinics. This clinic incorporates the expertise of a health care team of chiropractors, medical doctors, and physiotherapists to deliver comprehensive, appropriate, and high-quality care.

The St. Michael's Hospital department of family and community medicines welcomed the clinic to the hospital in 2004. The initiative was made possible by the Ontario Ministry of Health and Long-Term Care's primary health care transition fund. This successful example of interprofessional collaboration has benefited the hospital, the staff, and, most importantly, the patients.

Because we regard this initiative so highly, we thought it best to send the practitioner who knows most about it to join us here today so that the committee members can explore the working of a program that runs so smoothly and so well.

This finishes my oral comments. Both Dr. Kopansky-Giles and I will be pleased to answer any questions you may have regarding any issue related to our profession's submission.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Valade, for your insightful presentation.

We are now going to go to our committee for questions. Our first round is seven minutes per person for questions and answers. We'll start with Ms. Murray.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Thank you, Madam Chair.

What a wealth of comments and suggestions. Thank you for that.

I have four questions. I'll try to make them quick, and I'll lay them out first so that there will be time for you to answer.

Dr. Padmos, do you have any assessment or estimate of the impact of cuts to the research granting councils or the absence of funding to Genome Canada? How might that impact human health resources in the coming years?

Dr. Ouellet, you talked about patient-centred care. I took a look at your presentation. What I didn't see was any recommendation around the kind of continuous quality improvement initiatives that I know have been very successful in British Columbia, Deming-based frameworks for quality and process improvement. They've been used by the Vancouver health authority at Vancouver General Hospital. I'm interested in your comment on the role of that kind of initiative in increasing quality and productivity.

Ms. Neufeld, thank you for your list of all the very positive initiatives that have happened in the early years of the 2000s. It's too bad there wasn't much after 2005.

You talked about the health human resources observatory, and I'd like your comment on the possibility of that observatory including complementary and alternative modalities. CIHI leaders told me they don't even collect information about naturopathic physicians and traditional Chinese doctors, and probably chiropractors, because there's no level playing field from a regulatory perspective. How can we address that?

Dr. Valade, this committee will be making recommendations through the study. What would you like to see as a recommendation to the federal government on how we can rapidly increase the number of collaborative clinics and practices and facilities that integrate complementary and alternative modalities?

Thank you.

[The Chair, Conservative, Joy Smith]

We'll start with Dr. Ouellet, and we'll just keep on going as you answer. You have roughly about four minutes for everybody.

Thank you.

[Dr. Robert Ouellet]

Thank you.

This year we're trying to do a blueprint of what the Canadian health system should be. We're looking at every initiative that exists here in Canada and elsewhere to try to improve it. One of them is, of course, quality improvement.

We need to improve efficiency, but quality has to be implemented. The problem is that we have many pockets of very nice initiatives in the country, but we need to put them together and implement it on a larger scale. There are very nice experiences in Canada, but they're not widespread. We need to work on that, and this is part of our project.

[The Chair, Conservative, Joy Smith]

Okay. I think we'll go to Kaaren Neufeld.

[Kaaren Neufeld]

Thank you.

I'm imagining the HHR observatory as an institute that will be a gathering place for people to come together. The CNA really believes in health promotion and illness prevention, and naturopaths and other professionals would have a role to play there. I think it would be important for us to consider the full spectrum of services that Canadians wish to access and, as we set up an observatory and an institute, to involve the full spectrum of individuals to help it grow and develop into something new. Certainly one should consider all the groups that are providing health services to Canadians.

[The Chair, Conservative, Joy Smith]

Dr. Padmos is next.

[Dr. Andrew Padmos]

Thank you for your question about the impact of cuts to research. I think there are several.

One is that because of the poor funding environment, young people, whether physicians, nurses, or other health professionals, are not taking up careers in research, either full time or part time, to augment their practice impact.

Second, research teams are being wound up as we speak, and those individuals quickly move to other locations, most of them outside Canada, where such funding does exist.

Third, over the long term I think we create a negative impression of the value of research, and as a country we do not have the benefit of joining with other partners in collaboration on solving really universal health problems.

[The Chair, Conservative, Joy Smith]

Thank you.

Dr. Valade.

[Dr. Richard Valade]

Madam Chair, I will let Dr. Kopansky-Giles answer that question.

[The Chair, Conservative, Joy Smith]

Thank you.

[Dr. Deborah Kopansky-Giles, Associate Professor, Canadian Memorial Chiropractic College, Canadian Chiropractic Association]

Thank you very much, Vice-Chair, for asking that question, which is a really pertinent question, particularly in today's environment.

We know that Health Canada has a strategy to increase collaboration all the way from interprofessional education to interprofessional collaboration. There has been funding dedicated to that. However, there isn't funding dedicated to specifically giving project funding for those innovative projects that are actually producing very creative types of practitioners working together outside of the typical mainstream health providers. We have demonstrated at St. Michael's Hospital very clearly that chiropractic rightly fits in that environment, and we've gotten great feedback from our physicians, who work with us very closely, that we actually helped reduce their workload and improved their quality of work life by reducing the amount of time they spend on musculoskeletal patients where they feel they don't have a significant amount to offer those patients.

I think your question asked what should we do to improve collaboration. To do that you have to actually put in place a significant funding across Canada to help different facilities develop those proposals. The primary health care transition fund was an example of that, but it was the seed funding for pilot projects, which didn't provide any sustainable funding mechanism. We'd really urge the committee to implement, or make recommendations on, sustainable projects that have been successful, such as ours.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you very much.

Now we'll go to Monsieur Malo.

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

Thank you very much, Madam Chair.

First I would like to thank you for being here with us.

I have a comment for Dr. Valade. Thank you for telling us about a number of very specific cases concerning populations that are directly served by the federal government. A little later in our study, we'll come back with workers from those areas and we'll be able to pass on a number of your questions to those people to enhance the study we are conducting.

Madam Chair, last Tuesday and today, we heard witnesses tell us about the situation of nurses. They told us about overwork, changes to ways of doing things and continuing education.

I'm going to ask you the same question I asked the witnesses we heard from last Tuesday. Don't you think that the right forum to state those problems isn't Parliament, but that it would be preferable to speak directly to the stakeholders in Quebec and the provinces, who are the ones who govern education, ways of doing things, health, practices? Have you also made those observations to people who, in everyday life, work or have direct responsibility for the delivery of health services?

[The Chair, Conservative, Joy Smith]

Who are you addressing your question to specifically, Monsieur Malo?

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

Who would like to answer?

[The Chair, Conservative, Joy Smith]

It is open.

Ms. Silas.

[Linda Silas]

I'll start, Mr. Malo.

First, you're completely right: the distribution or delivery of health care is done by the provinces and territories. For our part, we see the federal government in the role of leader and facilitator in introducing new solutions. Before introducing our two projects in Saskatchewan and Nova Scotia, we conducted a study of employers in Canada's health care services. They told us that there were some good ideas, but they lacked funding and researchers. The federal government was thus able to provide that in Cape Breton and Saskatchewan, and those projects have had an impact in the other regions. That's where we see that the federal government can play a role as leader and facilitator.

Of course, it can also contribute financially because employers alone are already limited in what they know and in their budgets. They therefore can't innovate. They also have to work with the entire team.

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

Talking about—

[The Chair, Conservative, Joy Smith]

Mr. Malo, I think Dr. Kopansky wanted to also comment.

Thank you.

[Dr. Deborah Kopansky-Giles]

Thank you very much.

It's an excellent question you've just asked all of us to consider answering, because we are commonly asked the question, “Why don't you just go to the provinces and have the provinces solve those issues?” But we have a perfect example through the primary health care transition fund, where a federal amount of money led to innovative, excellent programs that were distributed provincially and have produced excellent results about collaboration, for example.

Also, we have the example about enhancing the interprofessional or interdisciplinary education initiative. That was a federal initiative that has transcended to provinces. For example, at the University of Toronto they have embarked on a major initiative for interprofessional education. Effective September 2009, every health science student across 10 faculties will have to have 20 credits in interprofessional education to graduate. This was a federal initiative that is actually going to have a local effect.

We've seen the benefits of that. We're engaged actively in these IPE projects. In fact, the team I lead at St. Michael's Hospital, where I actually chair our working group on interprofessional education for our department, has won two awards from the University of Toronto on these initiatives in the last year.

So yes, I think there is a very strong role for you to play in actually guiding provinces to look at issues more broadly that transcend local jurisdictions.

Thank you.

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

I have a question for Dr. Ouellet.