Health Committee on Nov. 18th, 2009

[The Chair, Conservative, Joy Smith]

Order, please.

Good afternoon, ladies and gentlemen, and welcome to the health committee. It's so good to see you.

We have with us some very well-informed guests. We thank you for coming.

Pursuant to Standing Order 108(2), study of health human resources, which is a very important study we've been doing here, we have witnesses from the Canadian Alliance of Community Health Centre Associations. Jack McCarthy is the chairperson. From the College of Family Physicians of Canada we have Dr. John Maxted, associate executive director of health and public policy. Welcome, Dr. Maxted. From the Local Health Integration Network we have Mr. Gary Switzer, chief executive officer, Erie St. Clair.

We will start with Mr. McCarthy, please.

[Jack McCarthy, Chairperson, Canadian Alliance of Community Health Centre Associations]

Thank you, Madam Chair.

My name, as mentioned, is Jack McCarthy. I'm both the chair of the Canadian Alliance of Community Health Centre Associations and an executive director of the Somerset West Community Health Centre here in Ottawa. I've just come from meetings on flu assessment centres, so it's within that kind of busy frame that I appear before the committee.

In my opening remarks, I will be drawing a lot on my experience at the community health centre where I am the executive director. I'm here today to present what, in our experience, is a solution to optimally deploy health human resources across the country, and that's the use of salaried health professionals working in inter-professional teams.

I will advance that CHCs are a solution to the problem of not enough family physicians and an opportunity to shift focus to the recognition of the contribution of other health professionals, such as nurse practitioners, in the delivery of comprehensive primary health care. The solution we seek is not about adding more health human resources necessarily, but currently redeploying and using our existing health human resources in a different way.

I will tell you a bit about what community health centres are. They're non-profit organizations governed by boards of directors or advisory boards and use salaried physicians side by side with other salaried health professionals. They focus on access, removing the structural barriers, whether it be cultural, economic, or social, and provide a range of primary health care, social, recreational, non-institutional services with an emphasis on prevention, health promotion, health education and community development. We work in partnership with organizations in other sectors, such as education, justice, recreation, and economic development, to promote the health of the whole community.

The CHC model has eight specific attributes. It's comprehensive, accessible, client-centred, and community-centred, integrated with other health system partners, community governed, inclusive of the social determinants of health, and grounded in a community development approach. My comments this afternoon are going to focus on one of those attributes, and that's inter-professional teams.

Inter-professional teams allow community health centres to provide the right care by the right provider at the right time. Our team at Somerset West CHC in downtown Ottawa includes doctors, nurse practitioners, dieticians, social workers, kinesiologists, acupuncturists, chiropodists, social service workers, nurses, health promoters, and of course, administrative support staff. This inter-professional team is a dynamic process in which two or more health care professionals with complementary skills or backgrounds, sharing a common vision in health goals, work together to plan, assess, evaluate, and deliver client-centred care.

The key to a successful inter-professional team is communication, collaboration, and consultation. These three conditions result in shared leadership and a positive sense of community, balanced with individual autonomy and, of course, a focus on client care. Unlike a multidisciplinary team, inter-professional teams do not function as independent practitioners but rather weave together tools, methods and procedures to deliver care and overcome common problems and concerns. At Somerset West we are participating in a pilot project that includes physician assistants as a part of our primary health care team. In the future, we would love to add a pharmacist as a part of our comprehensive primary health care team.

Unlike a visit to the traditional family physician, our model does not presume that your care needs to be directed or prescribed solely by the physician. Somerset West, located in downtown Ottawa, as I mentioned, operates a non-appointment based walk-in clinic, staffed by nurse practitioners. We see, on average, 31 clients per day, most of whom suffer from at least one chronic illness, such as a major mental illness, heart disease, chronic obstructive pulmonary disease, COPD, or diabetes. This is I think a key point. In this totally nurse practitioner-staffed clinic, a medical doctor is consulted on only 0.5% of all visits. In other words, for every 200 patient visits, only one involves a physician consultation. With a $52,000 differential in starting salaries between a medical physician--$125,000--and a nurse practitioner--$73,000--I think there's an obvious significant cost advantage in using nurse practitioners.

All members of the team have the ability to refer or consult with other members of the team as determined by the needs of the patient. Sixty-four per cent of all our clients see three more different types of providers. Unlike the vast majority of family physicians in Canada, all our doctors are salaried, enabling the inter-professional planning of care based on client need rather than based on a fee schedule. Many of our clients have one or more chronic medical conditions. Having physicians on salary permits our doctors the necessary time to thoroughly assess and treat, and even prevent, further disability.

Unlike other health care organizations, Somerset West enjoys both a high level of staff satisfaction and very limited turnover in our medical, nursing, and other professional staff. I think this can largely be attributed to the organization, culture, and client-centred care created through the adoption of an inter-professional model of care. The versatility of this model of primary care is designed to respond to the unique needs of specific communities and clients. It is also nimble enough to be able to respond in times of crisis, such as the latest H1N1 pandemic where our community health centre and the other health centres of Ottawa stepped up to be flu assessment centres. We coordinated very well with Ottawa Public Health in providing this service.

I have other comments in my document related to international medical graduates, and we'll deal with that in the question and answer period.

In concluding my opening remarks, I want to say it has been my pleasure and experience that health care professionals, whether nurses or doctors, are motivated to provide the best possible care to their patients, and happy workers provide better care. I think the current crop of medical graduates is largely women, and that's a good thing. I think this new breed of family physician places an equal value on non-work aspects of their lives, such as raising a family. That's why most of our physicians are women. Most work part-time. Most have young children.

Without systemic change in how we structure medical practice in this country, these changing expectations of providers will result in reduced access to primary care for Canadians. In the CHC model where doctors are on salary and part of a collaborative team, we see few, if any, examples of doctors suffering from the pressures of time and long hours that result in burnout and sometimes, as a result, poor-quality care. They can focus on providing services to their patients.

I'll leave it at that, and I'd be pleased to answer any questions.

[The Chair, Conservative, Joy Smith]

Thank you very much.

We'll go on to the College of Family Physicians of Canada.

Dr. Maxted, please.

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

Thank you very much, Madam Chair. I'm pleased to address the standing committee today on health human resources, an issue of ongoing concern to family physicians and the College of Family Physicians of Canada.

With over 22,000 members across the country, the CFPC is the professional organization responsible for establishing standards for the training, certification, and life-long learning of family physicians in this country. As the voice of family medicine, we also advocate for specialty family physicians and, very importantly, their patients.

About half of all doctors in Canada are family doctors, which is one of the strengths of our country's health care system, yet we still have roughly four million people in Canada without a family doctor. For many years we have sought ways to increase the number of Canadians with a family doctor, but the CFPC cannot do this alone. Key stakeholders include government and medical schools.

We believe two issues are central to family physician planning: the balance of supply and demand, and changes in patterns of practice. These two are intertwined.

The number of medical students choosing family medicine as a career is a vital issue affecting supply. We need to have 45% of all graduates enter first-year family medicine residency programs if we are to have enough family physicians to meet present and future workforce requirements.

While we strive to train more family doctors and more young family doctors, we also face the realities of an aging workforce, where 13% of the family physician workforce is older than 65 and looking at retirement. Many young family doctors are also seeking better work balance. Changes in work and scope of practice are having an effect on the number of family physicians we need. Over 50% are women who require time away from active practice during their child-bearing years. Governments must be cognizant of shifting patterns in family practice if they are to plan for sufficient family physicians in the future.

A priority for the CFPC is the training, recruitment, and retention of family physicians who provide a broad range of medical services for their patients. However, one-third of today's family physician workforce has a special interest in practice. While this affects the total number providing comprehensive care, these physicians are meeting health care needs within their communities. Family physicians with special interests or focused practices collaborate with their associates, and they are changing the way comprehensive care is delivered. The CFPC recognizes this, and it is supporting these physicians.

With an aging population, we see an increase in patients with chronic diseases and, in turn, complex co-morbidities. These factors are placing more pressure on the demand for family physician services at the same time as demographic factors affect supply. While Canada has begun to address its past mistakes in physician resource policies, it could take another decade to reach the goal that developed nations have already attained in some areas, and that is every person with a family doctor.

Just as population migration from rural to urban communities leaves many towns and villages with scarce human resources, the shortage of family physicians can often be felt more acutely in rural locations. There is thus a disproportionate shortage of family physicians in remote communities and a dire need for medical services for high-risk populations in first nations, Inuit, and Métis communities. These challenges continue to call for a strategic approach.

I'd like to speak briefly about international medical graduates. IMGs are highly valued contributors to our family physician workforce, but we should not rely solely on IMGs to address our physician shortages. We must consider the ethical implications of luring family doctors from countries that need their services.

Further, for those Canadians who are educated at accredited foreign medical schools, we need to ensure there are enough training spaces available to welcome them home to practise in Canada. For its part, the CFPC is pleased to report that we now have reciprocal agreements to certify and welcome board-certified American physicians and Australian-certified family medicine graduates. And we're working on other countries as well.

It's essential that those responsible for physician resource planning address all of these issues. Our college would welcome an opportunity to meet with the FPT Advisory Committee on Health Delivery and Human Resources to discuss the changing horizons in family medicine.

Finally, we would be remiss not to highlight the growing importance of inter-professional collaboration in primary care teams as an increasing preference for many family physicians. Overwhelmingly, young family doctors now prefer to work in collaborative health care environments. We are thankful for the support our governments have given to this development.

Taking all our concerns into consideration, the CFPC believes all these challenges call for a pan-Canadian coordinated approach to health human resource planning. Physician resource planning, as with all other health human resource planning, is a national issue that affects all of us.

To conclude, the CFPC respectfully encourages the government's support for a pan-Canadian health human resources plan that assesses the health needs of the population in each and every community and ensures that we have enough doctors, nurses, and all other professionals to meet our population's health needs. This plan must address the right number and appropriate mix of health care providers, including the training, recruitment, and retention of family doctors, as well as other medical graduates.

An adequate supply of physicians, including family physicians, continues to be a top priority for Canadians. It should remain a top priority for governments and health planners. To maintain the number of family doctors required to meet the health needs of people in Canada, we require a commitment from our health system and medical schools to have 45% of graduates enter family medicine.

We must also ensure that IMGs, international medical graduates, have appropriate opportunities to be assessed and to be offered further training, when necessary, so that they can enter the physician workforce alongside Canadian medical graduates.

Family physician teachers and other resources required for family medicine academic and distributive learning sites are currently strained and need to be augmented if we are to assess and train more family physicians.

Comprehensive care must be supported through our health care system to encourage family physicians to provide patients with the broad range of front-line medical services they need from cradle to grave. As advocated in our recently released discussion paper, “Patient-Centred Primary Care in Canada: Bring it on Home”, governments should support new or enhanced primary care models through which patients have access to a family doctor and an inter-professional team of providers.

We must maximize the use of electronic information in pulling teams together. This nation is trailing most developed countries in this area, and it should be addressed with urgency.

In closing, the CFPC and family doctors in Canada are confident that by working together with government, we can improve access to high-quality health care for all Canadians. To achieve this, we need a health human resource plan that ensures that every Canadian has a personal family doctor.

[The Chair, Conservative, Joy Smith]

You need to slow down just a little bit so the translator can keep up to you. We got so interested in your topic that we didn't notice. Thanks.

[Dr. John Maxted]

Well, I'm actually finished, Madam Chair.

Thank you very much.

[The Chair, Conservative, Joy Smith]

Thank you. We'll just wait for the translator to finish now.

We'll now go to Gary Switzer of the Local Health Integration Network, please.

[Gary Switzer, Chief Executive Officer, Erie St.Clair, Local Health Integration Network]

Thank you, Madam Chair.

First, let me speak to you today on behalf of the 14 LHINs in Ontario. I represent Lambton County, Chatham-Kent, and Essex County. We refer to it as the gateway to Ontario because of the two major bridges we have as access points.

I'm relatively new to health care. In previous careers I've had the enjoyment of travelling quite a bit around the world. When I travelled, everybody would notice my red Maple Leaf, and they'd come up to me and talk to me about Canada Dry, our ginger ale. But then they'd come up to me and say, “You have good health care.”

If you could look at Canada as a brand, one of our brand attributes is universal health care. It helps to define us as a nation and as a culture. We have plenty to be proud of as Canadians, and I'm especially proud of the health care we deliver across Canada. However, our current health care system was built on fundamentals of the 1950s and 1960s. Since then, our population has aged, chronic diseases are on an increase, and our current cost structure is no longer sustainable.

What I would like to address with you today is what I would call “health care 2020”. Health care 2020 is a call to action to create a vision of transformation for health care in Canada. It is recognition that our current system is antiquated and incapable of meeting 21st century needs. A vision is needed to protect the Canadian brand promise so our children and grandchildren will continue to benefit from our publicly funded system. To do so, I will submit the following three suggestions to the committee: we need to address our human resource issues, both shortages and scopes of practice; we need to transition from episodic care to a comprehensive model of care; and finally, we need to invest in an e-health infrastructure to fully and uniformly transition to the 21st century.

l'II frame this issue with a brief glimpse at our current population health. Our landscape is changing. The prevalence of chronic disease is on a significant increase. This is driving the overutilization of our health care system. This is only compounded by the lack of primary care right across Canada, and especially in Ontario. In Erie St. Clair, we have a shortage of 124 physicians, and that's for a population of 650,000. That leaves approximately 150,000 residents without a family physician. The future doesn't look any better. Over 78% of our physicians are over the age of 50. The bottom line is that our people's health is declining and our system is overburdened.

We need a national health human resource plan that will seek to make the best use of available resources. If we continue as is, we will not have the professionals we need to meet our community needs. We need to redesign the system to work smarter, not harder. To do so, a national plan needs to look at how to maximize the scope of practice of all allied health professionals, such as our nurse practitioners and pharmacists. We also need to look at the barriers we impose across the provinces. A national plan needs to look at a system of redesign to promote the recruitment and retention of our health professionals.

In Erie St. Clair, over 90% of our emergency department visits are for non-life-threatening issues. Most relate to the provision of primary care. However, emergency departments were not designed for that. Collaborative or team-based care is the future of the health care system. It relies on a team of professionals that can look at the individual as a whole and is ideally suited to the provision of chronic disease management. It makes the best use of all allied health care professionals.

As a consumer entering a collaborative family practice, be it a CHC or a family health team, you will not see the sign on the wall saying “One issue only per visit”. They say it takes a village to raise a child. Think of a community health centre or a family health team as a village of care supporting a community. It's all under one roof. The alternative to this system will be an individual going to their family doctor, only to have to go back for another referral, only to have to visit another specialist.

For rural communities, this one-stop shopping experience is a great opportunity to introduce a new level of equality and accessibility in health care, avoiding costly and prohibitive trips to town for these services. In Erie St. Clair we've been working very hard with the local government to expand our community health centres and our family health teams. We've also extended this concept to developing teams for the provision of home care and end-of-life services.

New family practice collaborative models such as family health and community health centres are attractive to new graduates and have been widely successful. We must continue with this success. Collaborative care will depend on access to information technology to unlock its true potential. Health care has been lagging on this front, and so we have not yet seen the benefits of a uniform and functional e-health infrastructure.

We need to align our systems to ensure interoperability. I'm not talking about a system that's Canada-wide or province-wide; I'm talking about a system within our community. Eight-five per cent of the care our residents receive is in our community. We know our referral patterns, which will take us to 98% of our community.That's where we need interoperability.

Secondly, every Canadian needs an electronic patient record. Until this happens, our system will remain in the dark ages. Physicians should not have to work without access to somebody's medical history. They shouldn't have to order redundant tests and they shouldn't have to worry about reactions to prescriptions.

To change this is like working on a moving train. However, in the 21st century nothing less will suffice. Information technology is at the core of everything we do, and it should be at the core of our health care system.

To summarize, what I've discussed today is the challenges we have in preparing for our resources for 2020 and the need to have a national plan to address these challenges, and secondly, the need to change to a comprehensive model of care. And finally, we must learn to leverage our technology.

The federal government can provide assistance, just as it has shown with the wait-time strategies. Make it a national priority to maximize every health care professional skill for practice. Invest with the provinces to assist in the transformation to collaborative care. Help us build villages of care in all communities, both urban and rural, and provide the incentives that would allow the provinces to make courageous decisions to align our backrooms and our clinical platforms.

In all the places I've visited, health care is a common denominator. Our health care system does indeed help define us, and as a nation we must ensure that our system will live up to the health care brand we are so famous for. Let's continue our promise to Canadians and make the necessary steps to safeguard our universal health care.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you very much.

We'll now go into our seven-minute round with questions and answers. We'll begin with Ms. Murray.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Thank you.

Thanks for being here to help us understand the state of the issue and some possibilities.

In calling for federal leadership, I know that 10 years ago there was a primary care transition fund that was set up for this kind of innovation, so it's not new that we know we need to go in that direction.

In 2004, the health accord led to a FPT human health resource committee that was referred to earlier but I don't believe is active at all. So we seem to have had a golden age of leadership on this kind of innovation. Would it be fair to say that the interest from the federal government has kind of ebbed in terms of taking a leadership role?

[Dr. John Maxted]

I certainly would support that. You pick up on the whole issue around primary care and the fact that there was $800 million given toward a number of primary health care transition fund projects, and there was some really good activity that occurred during that time. I'm afraid that when that time ended, after three to five years, a lot of that went into the library somewhere and into the archives--although there was some good development, and I don't want to ignore that.

I think where the development was probably most prominent was in the development of inter-professional teams, which all three of us have been talking about this afternoon. Nevertheless, the loss of focus on primary care at the federal level probably was a big disappointment to a lot of us.

[Jack McCarthy]

If I might add, I had the good fortune to work at Health Canada at the time when it was rolling out the primary health care transition fund, and I would certainly agree with John. I think there were some incremental changes at making primary care--not primary health care, but primary care--more efficient and effective. I think it was not successful in terms of major reform, because the move to teams, a team-based approach, which is in document after document after document for the last thirty years, has not happened. I think one of the huge barriers to that happening is the remuneration system that's in place. You can't incent one category of health professional--physicians in this case--for doing certain things on a fee-for-service basis and then have other staff on salary. Such a huge challenge, I think, needs a common remuneration system or your teams will not get off the ground.

In my judgment, where the problem stalled out was that a lot of provincial medical agreements were not so much for reforming the system but were more dealing with issues of compensation for physicians.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Thank you.

I was pleased to hear you list acupuncturists in the team.

There are a lot of Canadians who choose as their primary care physician, for example, a naturopathic physician. What's your comment on how a team would be formulated? Would it include...well, clearly acupuncturists, but who decides and how would you see some of the complementary medical practitioners being part of this?

[Jack McCarthy]

The beauty of the community health centre model is that it's responsive to the local community. For example, in the CHC where I'm the director, there is a large Asian community, so it was a no-brainer for us to have an acupuncturist as a part of our comprehensive team. To understand the needs of a particular community is to know what kinds of interventions fit best with that particular community. That's one of the advantages of this model.

Who decides? I think it should be a group of residents on a board, working with staff, assessing community needs and resource requirements. Is there a high concentration of people with type 2 diabetes? Do we need to help people deal with COPD? It's an iterative process, a community engagement process. I wear my bias with pride. That's why the CHC model has this kind of community engagement focus.

[Gary Switzer]

One of the exciting changes in Ontario is that we have the LHIN, which stands for Local Health Integration Network. And we work with our CHCs all the time. I'd like to highlight Grand Bend, which is the centre of excellence. We have a senior population. They identify their needs through their board, they come to us through their admin staff, and we invest in them. We have the ability to allocate funding according to their needs, and we can turn this around very quickly. It's based on local needs and local decision-making.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

In the long term, do you see this model reducing health care costs for Canada? Do you see this as being an additional cost for better service and better access to a physician, or do you see it as a cost reduction over time?

[Dr. John Maxted]

We have to be careful about how we approach the topic of cost reduction in primary care. The research, both in this country and throughout the world, has shown that if you strengthen your primary care system—and I would quote some of the research from Barbara Starfield—you can save your health care system money and improve the quality of care. We want to deliver the message that we need a strong primary care system if we are to improve the whole health system in Canada.

[Jack McCarthy]

If we don't invest in our primary care system, we're going to bankrupt the system, because acute care is just too expensive. It's very expensive. We need to focus on keeping people healthy before they get to emergency. We need programs that engage people in managing their diabetes and chronic diseases through exercise, good dietary practices, and so forth. If we don't invest there, as countless federal reports have said we should, then we're going to bankrupt the health system. If this happens, the health care portion of overall spending will rise.

[The Chair, Conservative, Joy Smith]

Thank you, Mr. McCarthy. I'm sorry, you're going over the time.

Monsieur Dufour.

[Nicolas Dufour, Bloc, Repentigny, QC]

Thank you, Madam Chair.

I wish to thank the witnesses for being here today.

My first question is for Mr. McCarthy. In the case of the community health centres which, in Quebec, include the CLSCs and the CHSLDs, might the situation be different, depending on where the community health centre is situated?

[Jack McCarthy]

Within the CLSCs? I'm sorry, but I caught only the tail end of your question.

[Nicolas Dufour, Bloc, Repentigny, QC]

In Canada, are you seeing different situations depending on where the community health centre is situated, and this would include the CLSCs and the CHSLDs in Quebec?

[Jack McCarthy]

The CLSCs in Quebec have been the leader across this country in the provision of comprehensive community-based services. The beauty of the CLSCs, which is comparable to the CHCs in other provinces, is that they're responsive to local communities. What you have in downtown Montreal may be very different from what you'd find in rural Quebec. That's the beauty of the model. Quebec has the advantage of covering the whole geography of the province with CLSCs. As the chair of our national association, I'd like to say that other provinces need to follow Quebec's lead in having CHCs that cover the whole geography.

I'm not sure I'm responding to your question.

[Nicolas Dufour, Bloc, Repentigny, QC]

You have indeed responded to my question. We can see that the situation is really different, between the rest of Canada and Quebec, with regard to the community health centres. That is what I understand from your statements.

[Jack McCarthy]

I would also say that I think from discussion with my colleagues in Quebec, now that the CLSCs are in a broader group called the CSSSs, Centres de santé et de services sociaux, there has been a real focus on helping the individual access seamless care. While I would submit that is important, it is not sufficient. You have to make sure that you can still have the grassroots community input into deciding the kind of care.

It's not all about helping an individual get faster medical care. It's about making sure that we keep and build healthy communities. I think the history of the CLSCs has to be strengthened in terms of its community-based approach and not simply helping individuals navigate a seamless health system.