Health Committee on Oct. 5th, 2009

[Dr. Anne Doig, President, Canadian Medical Association]

Thank you.

Good afternoon, Madam Chair.

The Canadian Medical Association is pleased to address the committee as part of its ongoing study of H1N1 planning and response.

In the broad context of pandemic planning, the CMA has focused on developing information and education tools on its website to ensure that Canada's doctors are equipped to provide the best possible care to patients. We have also engaged in discussion with the Assembly of First Nations to address workforce shortages in first nations and Inuit communities during a pandemic. Despite the work of governments and others, there remains much to do.

To provide optimal patient care, individual physicians--primary care providers and specialists alike--require regular updates on the status of H1N1 in their communities; timely and easy access to diagnostic treatment recommendations, with clear messages tailored to their service levels; rapid responses to questions; and adequate supplies of key resources such as masks, medications, diagnostic kits, and vaccines.

The CMA commends federal, provincial, and territorial governments for creating the Canadian pandemic influenza plan for the health care sector. The CMA was pleased to provide feedback on elements of the plan, and we are participating on the antiviral and clinical care task groups.

There are three issues that still must be addressed: the communications gap between public health officials and front-line providers; the lack of adequate resources on the front lines; and variability that exists across the country.

Physicians must be involved in the planning stages and must receive consistent, timely, and practical plain-language information. They should not have to seek out information from various websites or other sources, or through the media. This communication gap also includes a gap between information and action. For example, we are told to keep at least a six-foot distance between an infected patient and other patients and staff. This will not be possible in a doctor's waiting room, nor will disinfecting examining and waiting rooms in between each patient.

Patient volumes may increase dramatically, and there are serious concerns about how to manage supplies if an office is overwhelmed. There is also considerable concern over whether we can keep enough health care professionals healthy to care for patients and whether we have enough respirators and specialty equipment to treat patients.

Intensive care units of hospitals can also expect to be severely strained as a second-wave pandemic hits. This speaks to a general lack of surge capacity within the system. Also, pandemic planning for ICUs and other hospital units must include protocols to determine which patients can benefit most when there are not enough respirators and personnel to provide the required care for all who need it.

Beyond the need for more supplies, however, there is also the concern that there are only so many hours in a day. Doctors will always strive to provide care for those who need it, but if treating H1N1 cases takes all of our time, who will be available to care for patients with other conditions?

The CMA has consulted with provincial and territorial medical associations. Their levels of involvement in government planning and general state of preparedness vary greatly. There is also marked inconsistency from province to province around immunization schedules. We need a clear statement of recommendation to clear up this variability.

In summary, there remains a great deal of uncertainty among physicians about the vaccine, the supply of antivirals, the role of assessment centres and mass immunization clinics, delegated acts, and physicians' medical-legal obligations and protections. The bottom line is that there is still more work to do at all levels before front-line clinicians feel well prepared with the information, tools, and strategies they need.

The CMA was pleased to meet with Dr. Butler-Jones to discuss our concerns last week, and we will continue to work closely with the Public Health Agency of Canada to identify gaps and to prepare user-friendly information for clinicians.

Thank you, and I welcome any questions.

[The Chair, Conservative, Joy Smith]

Thank you very much, Doctor.

We'll now go to Dr. John Maxted, from the College of Family Physicians of Canada.

[Dr. John Maxted, Associate Executive Director, Health and Public Policy, College of Family Physicians of Canada]

Thank you, Madam Chair.

The College of Family Physicians of Canada is pleased to be invited to present again to the Standing Committee on Health about H1N1 pandemic preparations. Having spoken to you on August 12, we'll provide an update on the progress made to address the issues identified at that time.

Specifically to your question about whether the situation has improved and whether family physicians feel more confident now than they did eight weeks ago, our short answer is that much work has been done, but much more remains.

There have been improvements. The Public Health Agency of Canada has invited the College of Family Physicians of Canada to several tables, including those where vaccine sequencing and antiviral therapies have been discussed. During our recent visit to the agency, Dr. Butler-Jones and agency staff demonstrated their continued openness and transparency in listening to our concerns. As a result, we are currently working with the agency and other key stakeholders to develop information resources that will hopefully be more accessible, easier to read, and focused on information of practical value to family physicians and other providers in busy office settings.

Nevertheless, what keeps us awake at night is that all of these good intentions, hard work, and multiple resources will be of minimal benefit to front-line providers unless they are translated for their realities and pushed to them through the channels of communication with which they are most familiar. This must happen at the local level, not solely at national or even provincial or territorial levels of our health care system, for while some regions have been blessed with too much information through a variety of channels, thereby raising the risk of mixed messages, others have not had enough, producing a patchwork of resources for family physicians and other providers across the country.

If you overlay this mix with the clinical controversies—about the interaction between seasonal and H1N1 flu vaccines, post-influenza viral spread, who should be prescribed antivirals pre- or post-exposure, and what defines populations in Canada with the greatest potential to be most affected by this pandemic—then we may have the right components for a health system storm.

We respect that protocols and advice will necessarily change as new information comes to light. However, related to vaccine sequencing, we must also not be afraid to answer broader questions such as these. When will the vaccine be available? Why sequenced groups if everyone can get the vaccine? And if there are priority groups, where do people over 65 years of age fit in?

Infection control is a high priority in family practice. SARS and H1N1 have brought greater attention to the way family physicians manage patients with infectious diseases in their offices. Most family practices have not been designed to handle a deluge of pandemic patients, and practical advice is needed to consider patient flow and spacing issues. Family physicians and other members of the health care team also need expedited access to resources for infection control—for example, fitted N95 masks and other personal protection equipment. They need to know where and what the right resources are.

As stated on August 12, it's the unknown potential of an advancing pandemic outbreak that should cause governments and public health authorities to strive for optimal conditions that will provide family physicians and other health care providers with the information resources they require to manage patients who will present first with H1N1 flu symptoms to their family doctor and primary care providers.

To summarize, the CFPC recommends the following. Timely, consistent, easy-to-access, and user-friendly pandemic information must be provided to all family physicians and health care providers included in front-line services. Information must come to family physicians and other providers from public health at the local level. It is imperative that we work together to translate pandemic information into the practical realities that front-line providers experience. And finally, public health resources must be clearly defined and readily available for patients, family physicians, and other health care providers involved in first-contact services.

In closing, the CFPC and family doctors believe that we can respond collaboratively to the H1N1 pandemic outbreak. We are grateful for the significant efforts that have been made and welcome opportunities to address the ongoing challenges.

Once again, thank you very much, Madam Chair.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Maxted.

We'll now go into our first round of questions—seven minutes for the questions and answers—and we'll begin with Dr. Duncan.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

We'll be sharing the time, Madam Chair.

[The Chair, Conservative, Joy Smith]

Okay, Ms. Murray, go ahead.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Thank you.

There are two areas I want to ask about, and one has to do with resources and one has to do with the communication and coordination gap. I've heard from the provincial health agency level that there are concerns about not having federal cost sharing of expenses. That might be things other than vaccines, such as sanitizers, health care worker availability, supplies, respirators, costs of planning, and continuity of care. In asking the Public Health Agency of Canada, we were assured that resources and cost sharing are not and would not be constraints. I want to know from the front-line level whether you see an absence of resources to those non-vaccination expenses as a constraint, or do you predict that it might be? That's the first question.

Second, with respect to the concerns around the Public Health Agency's ability to provide clear leadership concerning public health with this situation, my question is whether you see the concerns being a matter of resources not being adequate to have that clear coordination and leadership at all the levels, or do you see it as a matter of organization, that we don't have the clear lines of responsibility and accountability, starting with the minister probably, so those inter-jurisdictional gaps are still apparent? Is it a matter of resources or organization, in your view?

[The Chair, Conservative, Joy Smith]

Who would like to take that?

Ms. Silas.

[Linda Silas]

I'll take the first, the cost, and then let my colleague speak on the organizational structure. The number one reason we hear on the debate between the respirator and the surgical mask is the cost attached to the compliance because of a lack of education. They all have to be fit-tested, and an education program on how to use them needs to apply, so it's attached to a cost. When we meet health ministers, we encourage them to look at the vaccination program and to lobby the federal government for a 60:40 split in the cost share, similar to what they did with the vaccination.

[Rachel Bard]

If I may add to this in terms of the cost issue, we certainly see it as a shared responsibility. The health and availability of the health professional must be a top priority with the federal government. We really see the federal government as showing leadership and clarifying this issue. It will cost even more if we don't look after making sure the professionals are well protected.

In terms of the communication, there again we see the importance of the federal government leading this initiative. We all know it is important that the proper information is received by the health professionals in a timely, concise, and easily accessible fashion.

I think we're getting a combination of communications, and I think it's important for the federal government to show leadership in trying to get it well organized and making sure it is reaching the professionals.

[The Chair, Conservative, Joy Smith]

Thank you.

Dr. Duncan, you should take your time as well.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

Thank you, Madam Chair, and thank you all for outlining your concerns.

I'm going to put a number of questions out there, and we won't have time for all.

First, what are the key remaining challenges in terms of medical surge and vaccine distribution? Have we looked at the modelling for surge capacity at 15%, 35% of the population affected? In the United States, they've used a higher number to model. What percentage of our provinces could exceed 80% of their capacity or more? I think this is another real issue we have to look at.

Ms. Silas, you talked about this. What are the discrepancies we're hearing at the different levels, whether it's the federal, local, or professional organizations?

We want medical professionals to feel safe to come to work. Are we meeting our legal and ethical responsibilities, duty to care?

[The Chair, Conservative, Joy Smith]

Who would like to lead on that?

Dr. Doig.

[Dr. Anne Doig]

If I may, I think I articulated for you what the CMA believes are the three gaps.

To address your specific question about surge capacity, I'm sorry but I don't have absolute numbers for you. I'm sure we can get them for you if you want them.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

I would like that.

[Dr. Anne Doig]

What I would encourage you to think about is that over the last 10 to 15 years we have been driving towards using our facilities at greater than 95% capacity, particularly our in-patient facilities. There is no capacity. So if we're talking about surge capacity in the context of an overburden of illness and a background in which all of us—physicians, nurses, and HHR all together, all of the infrastructure, all of the support services, everything—are running at 95% or 98% capacity, there is no surge capacity. So whether we're talking 10%, 15%, or 20%, it is irrelevant because it isn't there.

With respect to the vaccine issue, I think the most important thing for us to understand is that there needs to be absolute clarity. This is a disease that is sweeping across the country; it is no respecter of provincial boundaries, no respecter of provincial and territorial authorities or the divisions of programmatic responsibility. What needs to happen is that we need to agree on very clear direction that is uniform across Canada and roll it out without the need for people to tweak it a little bit to fit this circumstance or that circumstance. It needs to be said: this, this, this, and please go and do it.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Doig.

We'll now go to Monsieur Malo.

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

Thank you very much, Madam Chair.

I want to welcome our witnesses and thank them for being here this afternoon to help us with our study.

First of all, I want to come back to a discussion this committee had last week and ask the Canadian Medical Association a question.

You put out a postcard for health professionals entitled H1N1 flu virus. Prepare yourself. Prepare your practice. Prepare your patients. Under the “Prepare yourself” column, the first recommendation is “Get a flu shot.” That is a guideline or recommendation for health professionals and doctors. Under the “Prepare your patients” column, the first recommendation is “Ensure your patients get a flu shot.”

Many Canadians are wondering why they need a flu shot, and there is a lot of information on this topic out there, especially on the Internet. Can you tell us why the Canadian Medical Association recommends that Canadians and health professionals get a flu shot?

[Dr. Anne Doig]

The short answer is that is the only method of primary prevention for influenza.

This is a brand new strain of influenza. It is something that people under the age of 65 and their immune systems have not seen; they have not seen anything that closely enough resembles it to have immunity against it. It is going to hit broadly; it is going to hit hard. The only way we have of trying to prevent this is to provide people with immunization.

Fortunately, there is immunization. We've been assured that the supplies will be there and that they will be adequate for every Canadian to receive immunization. So there's no argument about shortages of the vaccine itself; just get out and get one.

There is confusion around some of the timing. There is confusion about the relationship between the pandemic flu immunization and the seasonal flu immunization. That's exactly what my colleagues and I were talking about when we were saying there needs to be clarity of messaging; there needs to be a very clear understanding of the population groups who should get the vaccine; and that if there is prioritization for the purposes of expediency of delivery, it needs to be clearly articulated.

Health professionals should get vaccinated. They are going to be the ones who are most highly exposed to the virus and they have the highest duty to society to protect themselves, both so they can remain at work and so they don't become a reservoir of disease.

[Rachel Bard]

The Canadian Nurses Association agrees with that recommendation. It is very important to ensure that the public is protected, and therefore, we have to be clear about safety precautions. As for the flu shot, it is equally important to make sure that our health professionals have the facts they need to make their decisions. Basically, we must ensure that our professionals can do their jobs with a view to protecting the public.

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

Dr. Doig, earlier you said that you had met with Canada's chief public health officer. Are more meetings planned?

You also mentioned areas where there may be some inconsistencies. Are there other meetings planned? Have nurses had similar meetings? Will there be others?

[Dr. Anne Doig]

Yes, there are meetings planned. There is a commitment to ongoing work, which I understand is proceeding quite quickly, to produce a very simple algorithmic pathway for people to look at to help them with clinical decision-making. And other tools will be made available.

Our association has regular weekly conversations with the Public Health Agency, and I'm sure that is true of others as well.

[Rachel Bard]

The same goes for our association. We met with Dr. Butler-Jones and Dr. Grondin to discuss certain details. There will be other meetings. We also stressed the importance of getting clear and accurate information. That is what we need now so we can work together and ensure that our professionals—nurses—receive that information. So other meetings are planned.

[Linda Silas]

I want to point out that we have been meeting routinely for three years now. There will be more, but there is little to show for it.

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

Dr. Maxted, you are the only one who has not given their opinion on this. Is it the same on your end?