Health Committee on May 13th, 2010

[The Chair, Conservative, Joy Smith]

Good morning, ladies and gentlemen.

I would like to welcome you to the health committee. We're doing another study this morning on HHR.

This morning we're not going to have opening remarks. What we're going to do is go directly into the questions and answers.

We've been doing our study on HHR, health human resources. It is very important that we try to get as many people in our committee as we can. Some of you I see here again; you've been here before. We're trying to make sure that we encapsulate all the areas of health human resources.

Today with us, ladies and gentlemen, pursuant to standing order 108(2) on human health resources, we have Dr. Joshua Tepper, from the advisory committee on health delivery and human resources. You're the provincial co-chair. Welcome.

From the Department of Health we have Shelagh Jane Woods, director general of the primary health care and public health directorate, first nations and Inuit health branch. With her we have Debra Gillis, director of the first nations and Inuit health branch in the primary health care and public health directorate, and Abby Hoffman, associate deputy minister, strategic policy branch.

Welcome. We're very glad you're here from the Department of Health.

From Statistics Canada we welcome Jeff Latimer, director. Jeff, welcome. You're from the health statistics division. We're very happy to have you here. We also have Sylvain Tremblay, senior analyst and chief of the Canadian community health survey, health statistics division, and Gary Catlin, director general of the health, justice, and special surveys branch.

We feel very honoured to have you here as witnesses.

I must say at the onset, ladies and gentlemen, that at 10:30 we'll have to go into our business part, so this presentation will last until 10:30.

That said, we will begin straightaway with the questions and answers. Dr. Bennett will begin..

[Carolyn Bennett, Liberal, St. Paul's, ON]

Thank you all for coming.

In some ways we've been operating in the dark as a committee in that we don't really know the strategy, so we're pleased to have the federal co-chair and the provincial co-chair.

I think what we're struggling with is that any strategy should include what, by when, and how. I think we've heard bits and pieces, but I wonder if you would outline what the strategy is in terms of what your targets are, how we get there, how we are going to do this thing in terms of having enough health professionals to do the job, both paid and unpaid, and in terms of the aging demographic. Tell me a little bit more.

We would love it if you would table with the committee anything you have from 2004, when human health resources was a very important part of the accord. How far have you come, where are you going, and what are the provinces and the federal government doing? Could you just lay it out for us?

I think the reason we invited Statistics Canada was that the cost recovery approach seems to be getting in the way of communities being able to plan. We're pleased that the health statistics division and the community health survey are here, but I think we know that the determinants of health--poverty, violence, the environment, shelter, equity, education--are also hugely important for communities to be able to plan. How do communities get the data they need in order to properly plan in terms of the future of health human resources needed for that community, not only on the demographics side, but on the determinants and in terms of the broadest possible definition of health?

Particularly, Josh, I think what we talked about on Tuesday was that in lots of countries statisticians and epidemiologists at the service of individual communities, clinics, or whatever, become very important. If you measure, it gets noticed, and if it gets noticed, it gets done. On the day after Florence Nightingale's birthday we could get to how we incorporate these kinds of epidemiologists and statisticians right on the ground, rather than having somebody do it off the side of their desk.

[The Chair, Conservative, Joy Smith]

Who'd like to start?

Go ahead, Dr. Tepper.

[Dr. Joshua Tepper, Provincial Co-Chair, Advisory Committee on Health Delivery and Human Resources]

Thank you very much for the opportunity to present today and for the opportunity to take what will be a first attempt to answer some of the questions you've laid out.

This is an area that I think is very close to governments provincially and territorially across the country, as well as to the federal government, which is probably the country's sixth-largest employer of health human resources and a very important vested player at the table.

I would say that a lot has changed in the last six to seven years. Where we were in the middle and late 1990s is no longer where we are now. We're in a very different situation in terms of data and in terms of the actions that have been taken across the systems.

Data are only half the story; what you do with the data is the other half, and actions that have been taken have increased the supply in very dramatic ways. There isn't a jurisdiction with educational capacity that hasn't increased that capacity quite dramatically across a large number of health care providers, from technicians to nurses and physicians.

There's been a huge change in not just the number, but also in who and how these providers are and what they do. We have the introduction of physician assistants in numerous jurisdictions, nurse practitioners, anesthesia assistants, clinical radiation specialists. The range and the roles of the health care providers in the system are fundamentally different from what they were just five or six years ago, as well as the overall supply.

How these people, these larger numbers with an increased scope of practice and a greater role, are working in the health care system is also fundamentally different from what it was before. It's much more team-based, much more patient-centred, much more driven by quality and by evidence, all of which is an opportunity to work to full scope of practice, to increase the quality of care, and to make the best use of the resources that we have in this increasing supply and in this range of numbers.

Compensation models and IT have followed in varying degrees across the jurisdictions as well.

So we have more, we have different, and we have them working in very different ways.

We also have a lot more data than we've ever had before. That data are coming from a variety of different mechanisms locally, regionally, provincially, and nationally. I think what's much more important is how we think about the data, and how we use the data is very different.

I actually did a very short and unsuccessful stint as a data modeller. I wasn't as bright as the folks at the end of the table, but our models used to be remarkably simple. If we have six general surgeons, and they are 50, in 20 years--punch it into Excel--they will be 70. If we have three of them in rural and three of them in urban and one in between, that means we need six more general surgeons. It's just a very strong supply.

One of the most important contributions that ACHDHR has done is to create a needs-based framework for thinking about HHR, which has led almost every jurisdiction in Canada to develop a new way of thinking and modelling. Every jurisdiction now has invested, I would say, often millions of dollars--I know in Ontario alone it's been several million--in developing not data alone, but actually different ways of using those data to do best predictions of what the population is going to need. Rather than driving this through saying, “Okay, we used to have ten plastic surgeons in downtown Toronto or downtown Calgary. Five of them plan on retiring; let's bring five more in”, we're actually looking at the needs of the population and then working back to look at the supply of a variety of health care providers. I think ACHDHR's framework has been absolutely influential in driving that forward.

Again, I would say that every jurisdiction has now driven far forward from where we were at the end of 1990s in terms of resources and in the sophistication of these models. It's also done nationally. I know we have a very robust nurse practitioner modelling. The CMA and others have done very robust physician modelling. There's been good modelling around other rehabilitation specialists as well, so it's a much more robust setting than we had.

I mentioned the framework, which I think was critical, because putting out a common template is very important. I would say that ACHDHR has been able to do two other things. One is it's been able to provide a forum that really brings together researchers, educators, and, as of about a year and a half ago, basically every major national player through an organization called HEAL, which is—

[The Chair, Conservative, Joy Smith]

Dr. Tepper, I've already given you two extra minutes.

[Dr. Joshua Tepper]

I apologize. Somebody just needs to wave me down, and I'll be quiet.

[The Chair, Conservative, Joy Smith]

I am always lenient on time with presenters. Perhaps you could watch for the red button--

[Dr. Joshua Tepper]

Perfect. I apologize for not understanding. There's no need to be lenient.

[The Chair, Conservative, Joy Smith]

--and then just wrap it up.

Thank you.

[Nicolas Dufour, Bloc, Repentigny, QC]

Thank you very much, Madam Chair.

I want to thank our witnesses for being here today.

Since the beginning of this study on human resources, one thing has been of particular interest to the Bloc Québécois, and that is the fact that health falls under provincial jurisdiction exclusively. I understand that the Standing Committee on Health is interested in studying health, but you understand the complexities that this leads to. Which leads me to my question for Mr. Tepper and Ms. Garrison. How did you carry out your consultation, and how do you see the role of the provinces in that consultation?

[Dr. Joshua Tepper]

In all of our activities--and I will watch for the red light diligently--and in all of the work that we produce, we have a very robust consultation process. Often it's web-based, often followed up with opportunities for key stakeholders to come and present and speak to the committee itself. Certainly the framework itself went through numerous iterations of consultations through the web, through paper, and through forums that were pulled together and shared in large stakeholder multi-party groups. We have always had a very consultative approach to this, and that has only increased over time.

To your specific question around provincial role and autonomy, I think it's something we're quite conscious of. Quebec sits at our table but does not necessarily contribute financially; however, they are a very active player, and we learn a tremendous amount from their observer status, to be honest. They're leaders in numerous ways in health human resources. We're very careful, in the types of activities we pick for ACHDHR, to be respectful of individual jurisdictional roles and responsibilities. The types of things we select for the pan-Canadian activities are carefully selected, and every jurisdiction always has an opportunity to participate in different levels or ways. Often Quebec takes more of an observer role in these, but their comments are always welcomed and documented, and their valuable insights are always incorporated into the final documents if they so wish.

I apologize if I didn't answer the question.

[Nicolas Dufour, Bloc, Repentigny, QC]

Yes, that's fine. I have to tell you that I understand very well.

Of course, as you say, people do want to discuss the good things that Quebec has done so as to give a hand up to the rest of Canada regarding human resources. We know that because of federal cuts in the 1990s, Quebec had to make some difficult choices but was able to manage anyway given its very strong public health care system. We heard it said a few times that certain parties may have wanted to establish a national strategy or to broaden federal powers somewhat regarding human resources. Aren't you afraid that this might cause a direct conflict, since it is an exclusively provincial jurisdiction? Quebec's role for the moment, if I understand correctly, is more that of an observer, an advisor if you will, at the table. Are you not scared that this could cause friction with the Government of Quebec?

[Dr. Joshua Tepper]

I would say no more so with Quebec than with any other jurisdiction. I would argue that when we get into these conversations, because the field of health and health education is a provincial jurisdiction, the reality is that on almost all topics there is a large degree of provincial and territorial divergence.

The number of opportunities to truly get everybody on the same page in a seamless way is extremely small, because we increasingly have very different systems, health needs, and structures in each jurisdiction, but I would say that there is surprisingly little conflict. It's much more of a sharing of best practices, to be honest. I would actually argue that the real enrichment comes from the table.

The most important part of the meeting, in my humble view, is that we set out about probably a third of our meeting to go around and have every party, including the health professional representatives and associations, talk about the pressing issues. We have it broken down and reported on a specific template in a consistent manner so that we're all reporting in similar ways on similar things.

Knowledge translation and examples of best practices are a huge focus for what we do; that still allows us to respect the individual jurisdictions and what they do. I know B.C., for example, just decided to take an action on Canadians studying abroad that is very different from what the rest of Canada is doing, and now they're having some fun experiences with that. Each jurisdiction is going to play a little bit differently, and there's certainly an opportunity and respect for that.

[Nicolas Dufour, Bloc, Repentigny, QC]

The problems in the health care sector are extremely different from coast to coast, as some like to say.

My question is for the Statistics Canada representative. Do you have any data on the number of physicians and nurses from 2000 on? Has there been a decline in the number of physicians and nurses? Could you break this data down by province so that we can see which province had the greatest increase in the number of doctors and nurses, or the greatest decrease?

[The Chair, Conservative, Joy Smith]

Would you like to take that, Mr. Latimer?

[Jeff Latimer, Director, Health Statistics Division, Statistics Canada]

We're just discussing, actually, who would be best to answer the question. Thank you very much.

[The Chair, Conservative, Joy Smith]

Talk among yourselves and let us know.

[Nicolas Dufour, Bloc, Repentigny, QC]

That was a good question.

[Sylvain Tremblay, Senior Analyst, Chief, Canadian Community Health Survey, Health Statistics Division, Statistics Canada]

Currently, there are no Statistics Canada surveys on that. The Canadian Institute for Health Information covers the whole area of human resources. So this is more akin to a shared responsibility. The tracking of human resources in the health care sector is done by the CIHI.

[Nicolas Dufour, Bloc, Repentigny, QC]

Thank you very much.

I have no further questions, Madam Chair.

[Dr. Joshua Tepper]

Madam Chair, I can probably arrange to get those data to you by end of day. If you get me an email, I'll provide you a jurisdiction-by-jurisdiction multi-year trend line for physicians across the country. I'll just grab your email on the way out. I should be able to get it to you by the end of the day at five o'clock.

[Nicolas Dufour, Bloc, Repentigny, QC]

That's fine.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Tepper. We really appreciate it.

Mr. Dufour, is that the end of your questions, then?

Go ahead, Ms. Leslie.

[Megan Leslie, NDP, Halifax, NS]

Thank you, Madam Chair.

Welcome. This question is to the advisory committee, but perhaps also to Health Canada.

If you have a look at the transcripts, you'll see that witnesses have said the provincial-territorial advisory committee hasn't been as inclusive as it could be, in particular when it comes to health care professions and tapping into their knowledge to have more of a vision of interprofessional dialogue and collaboration.

A lot of other witnesses have also said that what we really need is a new mechanism, a new body perhaps, to bring together health professionals, government, workers, unions, etc., to work a bit more collaboratively on this. I'm wondering what your perspective is on this idea, and if you see barriers or pitfalls to that approach. It sounds like a good idea at face value.

[Dr. Joshua Tepper]

This idea is far from new. This was something I worked on back in my days working for Health Canada as part of Task Force Two, the body that initially put forward this idea under Tom Ward, the deputy minister from out east. He championed this idea. This has been around for a long time.

You made two separate points, one about inclusivity and how ACHDHR functions, and the second about the observatory idea.

I'll say that ACHDHR has worked very hard in the last year and a half to completely restructure itself. We used to have a nursing committee and a physician committee, for example. We got rid of that and we now have an interprofessional committee. We used to have a variety of individual groups, but it wasn't representative of all the health care groups, so we changed our membership to allow HEAL, which represents basically every major organization you could think about, to have a full role at the table. We meet with their co-chairs. They represent about 34 groups, but it goes up every day. I can give you the list of members of HEAL, but they're a very inclusive group. They have full members. They send out minutes. We get full reports back, so we've really changed that.

We also open up each of our meetings to outside groups—whether it's the oncologists who came in one time or somebody else—who feel they need to be heard, or have a presentation, or have an idea. They often get time on our agenda very easily, so we're quite inclusive of that. Then all our products are developed with the input of HEAL, which sits at our table, and then they go out for broader consultation. Often we use HEAL, but not just HEAL, to circulate it. We go to the Canadian Medical Forum, for example. Everybody in the Canadian Medical Forum is also part of HEAL, but we'll channel it in multiple ways. Most of our nursing organizations, unions, etc., are all part of HEAL, but we'll go straight to them as well. We try to capture it not just through HEAL, but in different ways. We have the researchers sitting at the table; CIHI is an example.

In terms of the observatory idea, again it's been around for a while. I think it certainly can have merit. There was a brief effort by a group called CPRN to revive it about two and a quarter years ago. I think the large challenge that's been addressed in the past is the jurisdictional and territorial issue and the large and increasing differences among the different jurisdictions, as well as what the interface would be with the large number of players, such as the Health Council of Canada, which was in some ways the answer to the observatory idea when it was created, if you go back in history. Their first two or three reports were predominantly focused on HHR at the time, because that was a bit of their impetus. You have CIHR and CHSR. If you have a lot of groups already at play here, that doesn't mean there can't be a value added from an additional field.

I think one of the things that stakeholders and organizations probably have said, and that I'm very sensitive to and respectful of, is that ultimately we are a table that reports to the deputy ministers of health federal, provincially, territorially. Ultimately we take a lot of our direction from the table, so it is ultimately the federal government and provincial or territorial governments. What I think you're hearing from other groups is that they would like an arm's-length body, with either no or very limited participation of the federal government and the provincial and territorial governments. I've had some email exchanges with Nick Busing and people. The goal is to have something outside of government, and there are pros and cons to that.