Health Committee on May 11th, 2010

[Megan Leslie, NDP, Halifax, NS]

My next question will be for all of you. If there isn't time, don't worry, because I would like to ask that you follow up with a written response if you haven't had a chance to speak here.

I want to open it up to each group for comments specifically about...well, it doesn't specifically have to be this plan, but....

Mr. Kitts, I see you want to jump in.

[Dr. Jack Kitts]

I think strong leadership means setting a goal or vision. The federal government could say: we're interested in investing in collaborative teams, working at the full scope of practice, to ensure that all Canadians have access to quality care in the most appropriate setting as close to home as possible.

I think those three things define a whole different thing. For example, the Ottawa Hospital has a relationship with Nunavut. In the case of providing quality care in the most appropriate setting as close to home as possible, clearly we can't set up a heart transplant program or a major complex surgery program in Nunavut, so the investment in health human resources would be more in transportation and transport workers, to get them to the most appropriate place as close to home as possible.

At the secondary care level, with generalists and consultants, we send providers up there, which I think is more appropriate than trying to staff a rural or northern area that can support one-half or one full-time equivalent. It won't work in those groups, so send providers of care. And on the primary side, use more technology and full scopes of practice to provide primary care.

If you took that model across Canada and looked at urban-rural relationships and urban-northern relationships, the health human resource plan would be very different from what it is today. It takes several years—14 or 15 years—to create a physician. We're talking about providing enough people for a service delivery model that I hope is not based on the status quo 15 years from now.

Putting a stake in the ground saying that we're only supporting collaboration and collaborative teams, that whether remote, urban, or local, we have to start working in teams, is the only way to sustain it. That's what health human resources should be based on.

[Megan Leslie, NDP, Halifax, NS]

Before I turn it over for you to answer the question, you touched on something I forgot to put in my question, which is that making a line between the quick and dirty “this is what we need now” versus.... Yes, we do need long-term planning, and that is probably the most useful way of moving forward, but there are also some things that urgently need to be addressed now.

[Dr. Jack Kitts]

In many respects, at the front-line level the providers are finding ways to provide the service. I think somebody said you're getting a lot of local pockets of innovation and teams and collaboration being forced because of the demands and the shortage. What I'm saying is that it's better to lead it and create it than to respond to it.

[Megan Leslie, NDP, Halifax, NS]

Thank you.

[The Chair, Conservative, Joy Smith]

Would anybody else like to comment? Ms. Gropper?

[Rae Gropper]

Thank you. I can only echo the sentiments that Dr. Kitts has just expressed and tell you that the project I described under the auspices of Health Canada is looking for those pockets of innovation and searching out where they are viable and workable. We will do everything possible to promote them and to share that information for other centres across the system to look at.

The whole issue of education and training, understanding the numbers we need and developing a curriculum that matches it, and most critically, having the graduates go into a system that fits this curriculum.... If we have these integrated teams and we raise expectations for people who choose health as a career, we want the system to be able to adopt them and accept them, instead of hearing from them that it doesn't quite fit. I think I hear an echo around the table of the very same issue.

[The Chair, Conservative, Joy Smith]

Thank you so much.

Now we'll go to Mr. Brown.

[Patrick Brown, Conservative, Barrie, ON]

Thank you, Madam Chair.

Those were interesting comments by Mr. Kitts. You talked about a collaborative health team. I know that in my riding the most successful units we have are the family health networks. I find that they're able to deal with many more patients. It would be great to have more.

What is included in your definition of a collaborative health team? Is it similar to what the Province of Ontario has set up with these family health...?

[Dr. Jack Kitts]

I think the family health teams are a step in the right direction. But I don't think they're based on sitting down and truly looking at the needs of the patient and creating the team around that patient. I think it's more a mixture of family doctors with other health providers. I think I heard that occupational therapists are only now becoming part of the team.

If you actually sat down at every level and looked at the patients you serve and what they need, we would go much further in terms of scopes of practice and collaboration than we do now. But it's not easy. I think health care professionals in general are hard-wired to be independent, autonomous practitioners. We're not oriented around a team, so this goes against our very culture.

So there needs to be a very clear focus. I would argue that most if not all of the associations fiercely defend the turf their professionals work on, and I don't think we're ready to wipe the slate clean and use all of us to the full scope.

[Patrick Brown, Conservative, Barrie, ON]

I hesitate to ask, but what else should be added to the family health teams?

[Dr. Jack Kitts]

I think they're a step towards working as teams, but I suspect that in many cases there could be fewer primary care physicians and more dieticians and nutritionists and others along the prevention line. Physicians are created to diagnose and treat; the prevention comes from all of the others.

I don't know every team in detail, but I suspect that if we were to look at them based on the needs of the patients, the mix would be different.

[Patrick Brown, Conservative, Barrie, ON]

In terms of the academic health care organizations, do you also deal with the teaching hospitals you talk about, with the residency spots available through those teaching hospitals?

[Dr. Jack Kitts]

Yes, the residency spots are dictated by the universities, and we accept the residents.

[Patrick Brown, Conservative, Barrie, ON]

Is there a capacity to have more residency spots in existing infrastructure, if there were the funding?

[Dr. Jack Kitts]

I think in some, but it's getting very tight. Medical school enrollments have more than doubled in the last several years, so I think they're getting tight.

[Patrick Brown, Conservative, Barrie, ON]

I find, when we look at the physician side of the equation, that one of the greatest challenges is the lack of residency spots. Fingers are pointed in different directions, but from what I've heard from foreign-trained doctors and from people looking to be integrated into the health care system, that seems to be the greatest hurdle: finding a residency spot at a teaching university. What steps can we take to open those doors more?

[Dr. Jack Kitts]

I think there are enough residency positions for all Canadian graduates from medical schools. What you're probably hearing is that there aren't enough neurology positions or enough dermatology, so someone may have to graduate medical school and take a specialty that wasn't their first choice; that may be what you're hearing. But there are enough spots for all of the students who graduate.

[Patrick Brown, Conservative, Barrie, ON]

But there aren't for foreign-trained graduates?

[Dr. Jack Kitts]

No, they're created differently. I think the provincial colleges determine how many spots are opened up, and then they deal with specific hospitals. That's getting tighter. At the Ottawa Hospital we have 120 residents from the Middle East, and I think the spots are getting very tight.

But we do not bring in a foreign graduate as a resident at the expense of a Canadian position. The Canadian positions are funded and filled, and the foreign residents are over and above.

[Patrick Brown, Conservative, Barrie, ON]

Are there any additional comments, perhaps from your colleague, about what would be required to open up more residency spots, if we wanted to allot spots for foreign trained graduates as well?

[Glenn Brimacombe]

One of the issues is the issue of funding, both at the undergraduate and the postgraduate level. They go hand in glove. So as much as you're looking at spots within medical schools at the undergraduate level, if you're going to move them into the postgraduate round, it's making sure you have the infrastructure within facilities such as the Ottawa Hospital or the Vancouver General Hospital—pick your institution across the country. There's the notion of twinning the two, as they move from the classroom into the clinical practice environment.

[Patrick Brown, Conservative, Barrie, ON]

In terms of occupational therapists, do you find that there are some areas of the country that have much more acute shortages?

[Elizabeth Steggles]

I can't tell you specifically, but I know that in remote communities there are more shortages of occupational therapists.

If I may also address the field work issues, that is a big problem for us. There are not enough field work placements. Where there are field work placements, there are often difficulties with affiliation agreements or with insurance issues. It is something that we, the Canadian Association of Occupational Therapists, are beginning to look at and do a scan of across the country to try to find out what the issues are related to this. We know that with all the different regulatory bodies there are different requirements, and that becomes a big issue in trying to find placements.

[Patrick Brown, Conservative, Barrie, ON]

What are the consequences for patient care if a hospital or lab or practice doesn't have an occupational therapist? What is the secondary loss because of that? Are there other procedures that can't be done? Does it inhibit patient care?