Health Committee on Nov. 28th, 2011

[The Chair, Conservative, Joy Smith]

Welcome to committee, everyone.

I am Joy Smith, the chair. Welcome to all of our guests today.

I want to say to members that I know a lot of you have flown in today. Members are telling me they wish to have some fruit and so on for our next meeting. I want to let you know that we are going to have some food at our meetings to help you out a little bit. If everyone is in agreement, please raise your hands. Good.

Now we'll start with the orders of the day: Standing Order 108(2), a study of chronic diseases related to aging.

We're very pleased today to welcome our witnesses. From Baycrest, we have William Reichman, president and chief executive officer. Thank you, Dr. Reichman, for being here. It's a pleasure to welcome you.

From the Emergency Medical Services Chiefs of Canada, we have Mr. Michael Nolan, the president. Thank you for joining us today to give us your insightful information.

As individuals, we have Professor François Béland, Department of Health Administration at the University of Montreal. Thank you for being here. And of course Dr. Mark Rosenberg, a professor from the Department of Geography and Department of Community Health and Epidemiology at Queen's University.

We will begin with ten-minute presentations and we'll start with Dr. William Reichman, please.

[Dr. William Reichman, President and Chief Executive Officer, Baycrest]

Thank you so much for inviting me here, on behalf of my organization, Baycrest, to share some thoughts. It's quite an honour for us to be represented here.

Baycrest serves 2,500 Canadians per day across a full continuum of health care services, from home-based services to hospital to nursing home to a wide array of community-based programs, and it's home to the Rotman Research Institute, which is one of the top-rated cognitive neuroscience institutes in the world.

I want to start by commending you for addressing the challenges presented by the aging of our society and the anticipated increase in prevalence of chronic disease that will result as we live longer into older age. As David Crane said in the Toronto Star, in 2007:

Rather than wringing our hands, we should recognize that the changes an aging society will bring are quite manageable if we take the necessary steps now, and celebrate the fact that Canadians are living longer and healthier lives.

What I'm going to say over the next few comments is that with the challenge of an aging population and the burden that chronic disease will present to us also comes a very significant opportunity to make transformative change across Canada in how we keep people well and how we deliver health care services.

I'll commence my brief comments with the following questions, which I would ask everyone sitting around this table to consider.

Number one, must it be inevitable that so many Canadians suffering from chronic diseases such as diabetes, heart disease, musculoskeletal infirmity, chronic obstructive pulmonary disease, hypertension, and dementia end up being treated in an acute-care hospital, coming in through an emergency department because we lack community-based capacity to keep them well and stable with their conditions?

I'll pose another question for us to consider. Why should nearly 40% of seniors, especially the oldest old, have to spend an average of the last two years of their lives in an institutionalized care setting such as a long-term care facility or nursing home, separated from their families and other supports? It's because we lack community-based capacity to keep them in their own homes or in the homes of their family members.

I would ask you to consider this for yourselves. Can a nursing home—even one as special as Baycrest, which is world renowned and which I have the privilege to lead—ever be so great that any of us would choose to live there instead of in our own homes? If the answer to that is no, we would rather live in our own homes, then I would ask that we now take the steps necessary to enable that to happen.

Aging boomers—or, as is said here in Canada, zoomers—expect society to now offer our parents who are living more than what society ever offered our grandparents. And quite frankly, we are a sufficiently self-indulged cohort that we expect society to give us even more than what society will ever give our parents. Certainly we hope that society will offer our children more than we were ever offered in keeping us well and taking the best possible care of us in the best possible place and with the best possible value extracted from that health care dollar.

I think it's important for us together to set some achievable, concrete, tangible, sustainable goals along the lines of the following. If any of us do truly need to be in a nursing home, let's set as a goal that it will be on average for the last two months of our lives, not the last two years of our lives. To achieve this kind of goal, as well as several others that I'm sure we'll discuss today, will require deliberate transformative change—not nibbling around the edges, not small incremental initiatives, but transformative change that can benefit Canadians no matter where across this great nation they happen to live.

In reference to these issues, my comments today will be couched in three principles that will help Canada change the journey of aging for the better and position this nation, if it so desires, to be a global leader in innovations to serve the needs of an aging population.

What are these principles? For one, we must be willing to take risks through experimentation and innovation in health promotion, health care delivery, and the reimbursement of health care services. We must be willing to take risks, which means that while we will celebrate the successes that result, we must be willing to tolerate the inevitable failures. To truly innovate and transform, there will be failures along the way, and we must tolerate them and learn from them.

We need to understand that to keep people well involves more than just providing good health care. We must provide economic incentives to businesses and organizations that promote healthy lifestyle practices. I'm sure we'll talk about some tangible examples of that this afternoon. We must provide tax incentives, rebates, and credits to individuals who show progress in adopting healthy lifestyles, compliance with medical therapies, and attendance in prevention programs.

I also believe it is critical to financially incentivize families and other informal caregiving networks, such as volunteers. At Baycrest—and perhaps we'll have a chance to talk about this later—we have an active volunteer corps of 2,000 seniors. They spend the bulk of their time caring for other seniors who are more frail and needy. Experimentation and innovation will require that we test new models of integrated care tied to reimbursement methods that can achieve more than cost effectiveness, and take into account outcomes, not just inputs.

The present focus on acute-care emergency department wait times in some of our provinces, such as Ontario, and an alternative level of care is too narrow. We must look more comprehensively. For example, across the nation, from the Maritimes to B.C., there are organizations involved in senior care and chronic disease management that are holding their own against organizations in western Europe and elsewhere in introducing innovations. The difficulty we have is not the creativity that resides within our health care sector and other parts of our community; the difficulty we have is in taking these best practices and translating them across a broader swath of the nation. But with the right structures in place and the right incentives, we can take best practices that are occurring in Saskatchewan, Quebec, and Toronto, learn from them, and scale them up across the nation.

Let me give you some examples of the kinds of innovations that can be successful, and not in a narrow place like north Toronto under the guise of an organization like Baycrest. Baycrest was the first organization in North America to invent senior day care and dementia day care in the 1950s. Baycrest was the first organization in North America to demonstrate that if you spend some dollars on implementing electronic health records and computerized physician order entries, it leads to reduced medication administration errors within a long-term care setting.

Baycrest was the first place to demonstrate that you could develop units in a hospital or nursing home setting to provide diversion from emergency departments in acute-care hospitals. So if a patient is getting sick in the community, the reflex right now is for their primary care doctor to tell them to go to the emergency department. Or if the patient gets sick in a nursing home in the middle of the night, the reflexive response is to call an ambulance. The patient is transferred to an emergency department, which is just about the last place that any of us would want our parents or grandparents to be if they were sick in the middle of the night. Baycrest and others across this nation have developed wonderful programs that are cost-effective, keep seniors away from acute-care hospitals, and get them out faster when they are in acute-care hospitals.

The difficulty is not that we don't have the ideas; it is that we don't have the reimbursement methodologies in enough places across the nation to incent that kind of program delivery. We don't have the methodologies in place to take a best practice in one jurisdiction of the nation and ensure that it can be tested in another jurisdiction.

I mentioned earlier that it goes beyond just thoughtful and innovative health care. We should be providing economic incentives to businesses that can promote healthy lifestyle practices. That's an essential ingredient that could change the way people age. It means healthier food choices on restaurant menus and in food stores, documented gains in workplace wellness programs, better physical education in schools, and healthier lunch programs in workplace and school settings.

When we think about how to mitigate the impact of chronic disease in seniors, we tend to focus on the final destination in life—old age—instead of understanding that how we age is very much determined by the particular journey we're on as adolescents, as young and middle-aged adults, and finally as seniors. So the best way to prevent heart disease in an 80-year-old is to ensure that our children are not obese.

There are other kinds of lifestyle transformative notions that we have to build into this kind of dialogue.

I mentioned before that we can provide, and should provide--

[The Chair, Conservative, Joy Smith]

Can you start thinking about wrapping up, Dr. Reichman? It's extremely interesting, but I know our committee members are anxiously awaiting the time to ask you some questions.

[Dr. William Reichman]

Okay.

I'll mention a few last points and then I will close.

[The Chair, Conservative, Joy Smith]

You have about five seconds.

[Dr. William Reichman]

Okay. Then I won't mention a few points.

I will ask you to consider whether Canada can really lead globally in this effort. There is no single nation that owns this issue. It's a challenge across the globe. We have sufficient strength in the nation, so let's leverage it.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Reichman.

You have brought us some very compelling documentation. Thank you for that.

We'll now go to the Emergency Medical Services Chiefs of Canada and Mr. Nolan, please.

[Michael Nolan, President, Emergency Medical Services Chiefs of Canada]

Thank you, Madam Chair.

Good afternoon. My name is Michael Nolan and I'm the president of the Emergency Medical Services Chiefs of Canada. I'm here today to talk with you about how paramedics can contribute to the health care system, and specifically how community paramedics can strengthen the resilience of Canadians and support chronic disease self-management.

Good afternoon. My name is Michael Nolan and I am the president of the Emergency Medical Services Chiefs of Canada. I am pleased to be here today to talk to you about how paramedics can contribute more to the Canadian health care system.

Emergency Medical Services Chiefs of Canada represents over 30,000 paramedics and chiefs from coast to coast. Paramedics are the third largest health care provider group in Canada. Paramedics serve on the front line of health care in every community across the country, providing essential health care. We are a reliable and constant force, from the most rural and remote communities to our largest cities.

I appreciate the opportunity, Madam Chair, to inform you and the committee of the important contribution that paramedics make in our communities, and especially to share examples of how paramedics are working today to assist Canadians in becoming more resilient through supporting chronic disease self-management and by providing innovative opportunities to receive care in their homes and in their communities.

Community paramedicine is not a new concept. These programs have been in existence in Canada for many years. However, it is only recently, as a result of the shifting demographics and the move toward de-institutionalizing health care, that community paramedic programs have begun to gain momentum in Canada and around the world. Community paramedics are health professionals who focus their practice on providing prevention and rehabilitation care.

While in some cases this requires an expanded scope of practice applying specialized skills, it is routinely a paramedic who is working with a targeted population, such as with those experiencing a chronic disease, to improve their quality of life and reduce their reliance on our institutional health care system at large.

We know that any frail senior who possesses multiple co-morbidities is receiving care that routinely revolves around interactions with paramedics and acute-care hospitals. Subsequently, their functional status deteriorates during their hospital stay while waiting for permanent placement in long-term care. It has been estimated that 37% of these patients waiting in Ontario hospitals for a long-term care placement have needs no more urgent or complex than those of individuals who are cared for in their homes.

System redesign is identified as essential to transform the health care system to meet the needs of our fragile seniors, the majority of whom want to live in their homes—and should be able to—and be able to rely upon community support to assist with their health and social needs. An excellent example of a community paramedic program that is addressing this need is happening right here in the Ottawa Valley. The Deep River aging-at-home program supports patients with chronic disease in an effort to allow them to remain in their own homes. All of these patients are currently on the waiting list for long-term care with a diagnosis of one or multiple chronic diseases.

With community paramedics acting both as advocates for the patient and as a member of an interprofessional team, this program has achieved an 88% diversion of 911 calls and, equally importantly, a decrease in hospitalization and emergency department visits in excess of 66%. Madam Chair, it is important to note that these gains have been achieved from this client group that is also historically among the highest users of the paramedic service and the hospitals in this community.

The landscape of care within the home and community environment is certainly a challenging one. These hurdles are worsened when trying to access services as an individual with complex and often unresolved needs, invariably resulting in a high need for high-cost resources in the acute-care setting.

While not always a direct result of lack of care in the community, many chronic disease patients experience emergency department visits that often lead to a vicious cycle of readmission. Within Ontario, 15% of all patients discharged from hospital are readmitted within 30 days. That's 15%. An increased focus on effective care transition has been identified as a means to help reduce this burden. The community paramedic is absolutely a means to reduce re-hospitalization.

On Long Island and Brier Island in Nova Scotia, community paramedics collaborate with a nurse practitioner and an off-site physician, and are assisting patients to effectively manage their chronic diseases. As a result of these efforts through community paramedic clinics, there has been a 23% decrease in emergency department visits from islanders to Digby since this delivery model began in 2002.

Other innovative community paramedic programs from Nova Scotia include one in Halifax, where patients living in long-term care facilities now receive care from community paramedics on an as-needed basis. As a result, there has been a 73% treat-and-release rate, meaning that the community paramedic is able to treat them fully in the home. There was also a 27% facilitated transfer rate. This means that the remainder of patients would be seen by community paramedics, who would then schedule their diagnostic treatment and, whenever possible, treat them in the home. They go, for example, straight to the X-ray department and then return to the nursing home. They are not in an alternate level of care beds and not in the emergency department.

This program has helped over 600 patients in Halifax alone since February of this year. Hospitals in both in Parrsboro, Nova Scotia, and in Spirit River, Alberta, are now staffed overnight by paramedics, keeping the emergency departments open in these small communities and preserving limited physician resources for daytime clinics the next day.

In Saskatoon, an innovative program called the Health Bus has paramedics and a nurse practitioner moving from neighbourhood to neighbourhood in an RV-style vehicle. They see over 3,000 patients per year in Saskatoon. One third of the patients they see are children.

In Toronto, the community paramedic program targets patients with a high historic utilization rate for paramedic services, truly our “frequent flyers”. This program has achieved an 81% reduction in demand from this group by ensuring they receive appropriate community support. Of these referrals, 66.4% were for new clients to the community care access centre. So we are finding new people earlier in the system, and it's an advantage for them and an advantage for the health care system at large.

Nationally, approximately 60% of paramedic responses, Madam Chair, are for patients over the age of 60, while patients over the age of 80 represent 27% of all requests for assistance through 911.

Paramedics can and should be used to ease the increased pressure on the health care system. Paramedics perform assessments, post-surgical home care, chronic disease monitoring, health education, administration of antibiotics, and other primary care functions. Paramedics are a valuable service in your communities. Paramedics are important health care providers to meet the growing needs of seniors and other vulnerable populations.

Other benefits of paramedics increasing their role in health care include significant savings based upon a reduction in 911 calls, emergency department visits, hospitalization, and off-load delays; an improvement in the alternate level of care bed availability; a reduction in demand for long-term care beds; and ultimately, an improvement in morbidity and mortality rates in Canada. Paramedics are well positioned to lessen these cascading problems for our health care system overall.

Madam Chair and members of the committee, I sincerely appreciate the opportunity to discuss the role that community paramedics play in strengthening the resilience of Canadians and supporting the principles of chronic disease self-management.

It's important, however, to reinforce that the intent of the community paramedic programs is not to augment existing services but to enhance quality of life. Paramedics continually see chronically ill patients whose needs range from reassurance and advice on self-management to clinical interventions. Community paramedics are here in your communities to serve Canadians.

The Emergency Medical Services Chiefs of Canada ask that this committee recognize the role of the paramedic in the future of chronic disease management.

Thank you for your consideration. I will be happy to answer any questions, Madam Chair.

[The Chair, Conservative, Joy Smith]

Thank you very much. I'm so glad you came today. That was very compelling testimony.

We'll now go to Professor François Béland, from the Department of Health Administration.

[Prof. François Béland, Professor, Department of Health Administration, University of Montreal, As an Individual]

Good afternoon. I will be speaking in French.

I would like to thank the committee for having invited me to appear before it to discuss a topic that has interested me for many years.

In essence, I will try to cover 3 points in 10 minutes, and in each case, I will provide examples that may be the subject of questions afterward. I will first speak very quickly about costs, among others the costs of aging for health care services; second—and on this I agree with Mr. Reichman—I will talk about the need to integrate health care services for seniors, and finally I will present a few guidelines for possible policy, in particular policy that could be developed by the federal government.

You have my notes in your hands. There are tables and figures. The first table is on health care expenditures in Canada. It is important to make a distinction that is not usually made when talking about health care costs: we must absolutely separate what is included in the services covered by the Canada Health Act, that is essentially medical and hospital services, and all other services, at least in terms of funding. Only once this distinction is made do we start to understand what is happening.

There is another very important aspect, and on this matter, I have taken the advice of François Vaillancourt, a colleague who is an economist at the Department of Economics of the University of Montreal. He believes that, for citizens, what is important is not what each level spends, but rather what government spends. What concerns and interests me, therefore, as a citizen, is what government spends on health care services. In Canada, even though health is under provincial jurisdiction, there is federal spending. It is important to take into consideration all government spending, whether it be federal or provincial.

In the first chart, we can see the changes in health care expenditures. Look at the middle line, between 1989 and 2008. It is the proportion of spending on doctors and hospitals by all governments in Canada. It therefore includes the federal budget and provincial budgets. We see that in 1989, spending on doctors and hospitals covered by the system constituted 12% of spending by all governments. In 2007, that proportion was still 12%. There has been absolutely no change in these aspects.

When we look at what is not covered by the Canada Health Act, we see a constant increase over time. In fact, it is precisely in this sector that there are user fees, charges and coverage that are neither public nor universal and that are applied where provincial governments, especially, are investing to make up for what is not covered by the private system. It is precisely this sector that explains the increase in the burden on the provinces, and insofar as the federal government funds health care services, on the federal government. There is therefore an increase in the burden and not in the amounts allocated.

Finally, much is said about health care spending on seniors. Let's look at the second chart. There are at least two elements in all health care spending when we are talking about a population. There is the increase in the population or in different age groups. You see health care spending going up because the Canadian population is increasing, and concurrently, because there are more seniors. That is shown by the bars on the right that you see here. What you see is the increase in health care spending in Canada due to aging and the increase in the population. There is a significant increase between 1989 and 2007 in Quebec.

The curve illustrates the increase in intensity. In Quebec, from 1989 to 2007, the intensity of services provided to the elderly decreased. In this case, you must consider both demographics and the intensity of services which are provided to the elderly. In Quebec and basically everywhere else in Canada, there was an increase in the proportion of seniors in the population. However, the intensity of services which were provided did not increase at the same pace. Further, this intensity increased more for those aged 55 and over, or rather, for people between the ages of 45 and 64, rather than for people aged between 64 to 75.

Let's now look at the overall increase in health care costs. There is the average spending growth for all age groups in Quebec, and there is the spending increase for the various age groups. Surprise! People over the age of 75 saw their health care spending increase over the last 10 years, and at exactly the same pace as for the rest of the population. However, it is rather the baby boom population, those between the ages of 45 and 64, that saw an increase. So when people say that the elderly are responsible for the stunning increase in health care services, they are wrong, because they have not correctly analysed the data. People often make a very opportunistic analysis of the data as a whole.

As Dr. Reichman and Mr. Nolan said, on the one hand, elderly people who need intensive services are relatively few in number, and on the other hand, they really do need these intensive services. We have known for a long time that this was coming. I will quote some words, which I translated into French, from an American observer who said this back in 1975: “[...] about 1 of every 5 people aged 65 and over will eventually need a combination of intensive and extensive social and health care services [...]”. Since 1975 at least, we knew what was coming our way. In fact, we have known this for about 36 years.

[The Chair, Conservative, Joy Smith]

I just want to let you know that you have three minutes left. I know you've covered only one topic. This is just to keep you aware.

[Prof. François Béland]

Let's skip the numbers. At the very least, it is important to understand that there is a tiny proportion of elderly people. You could say that there are between about 5% to 8% of elderly people who live in private homes or in the community, and who need intensive services. These people need an integrated approach to health care.

We know what to do, don't we? There are Canadian examples, such as SIPA. I distributed an article on that subject. Another program could have been a good Canadian example, if the Canadian Department of Veterans Affairs had implemented the report of the Gerontological Advisory Council, a report it had produced for the Department of Veterans Affairs, in 2006. This report recommended the creation of an integrated system which would have allowed the federal government to create a benchmark system integrating health care services for the elderly, in this case, elderly veterans.

In conclusion, I believe that the federal government has three roles to play which are all very important. First, the government must develop a benchmark sector for a certain part of the population, such as veterans, and, of course, first nations, and this sector would fall under federal jurisdiction. In so doing, the government would have the opportunity to test certain things, and to implement policies that may eventually be beneficial to all Canadians.

Second, funding is important, as well. There are other figures in the articles I have given you, and which I talked about. Regarding the elderly, it is impossible to separate health care services and social services. The elderly are in a unique situation. Therefore, funding must reflect that particular model. It is important that funding be appropriate for a category of people, and that it support all health care services. But to achieve this, we must think beyond the Canada Health Act.

Lastly, as Dr. Reichman said, innovation, innovation, innovation. The federal government will have to invest in innovation. It has done so in the past, but it seems to have forgotten about it along the way, and it is time that it reinvest in innovation.

[The Chair, Conservative, Joy Smith]

Thank you very much.

We'll now go to Dr. Mark Rosenberg, please.

[Dr. Mark Rosenberg, Professor, Department of Geography and Department of Community Health and Epidemiology, Queen's University, As an Individual]

Thank you. Madam Chair, honourable members, thank you for the opportunity to speak to you today about the older population of Canada and chronic diseases.

Some of you might be asking yourselves why a professor of geography, who's also cross-appointed as a professor in community health and epidemiology, should be speaking to you at all.

[The Chair, Conservative, Joy Smith]

I asked myself that.

[Dr. Mark Rosenberg]

I'm going to answer it.

In 1989 my colleagues from Queen's and I produced the first atlas of the elderly population, funded by Health and Welfare Canada's review of demography and its implications for economic and social policy, better known to some of you as the Demographic Review.

What that atlas did was open the eyes of policy-makers and academics to the fact that the older population of Canada needs to be understood, not just at the national level or the provincial level, but at the local level, when we try to think through the services required to treat chronic diseases and the access to those services required by older people to manage their chronic health problems. Having read through many of the presentations that you've already received, I feel this point deserves as much emphasis today as it did in 1989.

Canada is a complex geography of communities, where the needs of those with chronic diseases and the services required have to be thought about in their local context, whether we're discussing the older population of your riding, Madam Chair, or of the ridings of each of the honourable members of this committee.

My graduate students and I are now in the final stages of a project funded by the Social Sciences and Humanities Research Council of Canada. Our project asks how close did we come in our forecast in 1989 to how the older population would look in the first decade of the 21st century.

Our forecasts from 1989 turned out to be fairly accurate in terms of the local geographies of the older population. What we did not, however, foresee—and indeed I have seen very little in previous testimony that takes this into account—is that the older population of Canada today is a much more ethnically diverse older population than it was in 1989.

Why is this critically important to take into account? Coupled with my first point, ethnic diversity of the older population is very much a phenomenon of our largest cities, but not so much in small towns and rural Canada. Although there have been a very small number of studies published on the challenges that older Chinese Canadians and South Asian Canadians face in accessing services for their chronic health issues, we only have a rudimentary understanding of how older people's life experiences affect how they understand and manage their chronic diseases. I might add that we have few examples of culturally sensitive models of service delivery that actually work.

You might also note that I draw a distinction between Canada's largest cities and small towns in rural Canada. In other research my group and others are doing, we find there are unique challenges in living with chronic diseases in small towns and rural areas in Canada. The research shows that small towns and rural areas already have amongst the highest percentage of older populations in Canada. Many already have populations where the older population is well above 25% of the total, and will have even higher percentages in the future.

In other words, when we talk about 25% of the population being over 65 some time between 2031 and 2036, this misses the point that in many small towns and rural areas, the percentage of the population that is 65 and over will be much higher. In absolute terms, the numbers are and will be small, and the distances that either older people or service providers have to travel in rural areas are far and on average will be far greater than in urban areas. The implications for providing services, either for treatment or management of chronic diseases, are that models that might work in larger urban areas, predicated on large numbers of older people and, relatively speaking, short travel distances and times, might not be relevant in small towns and rural areas of Canada.

Parenthetically, I might add that there's already indirect evidence that the private sector is not prepared or is unwilling to provide services in small towns and rural areas for these very same reasons. Even the voluntary sector is challenged by these issues in small towns and rural areas.

There are two issues raised by previous witnesses to your committee, to which I'd like to add some comments and perhaps provide some additional insights.

What research there has been on the particular challenges of providing services to treat and manage chronic diseases in small towns and rural areas generally emphasized, as I have done, the small numbers of older people and the distances that need to be travelled by older people and service providers alike. This research emphasizes the demand side of the equation.

Other witnesses who represent professional associations and consumer organizations have talked to you about increasing the supply of geriatric and gerontological professionals. No provincial government has found an effective way to solve this problem, to address the lack of geriatric and gerontological professionals in small towns and rural areas. In fact, the supply issue in small towns and rural areas is far more profound and critical than in the areas of primary, secondary, tertiary, chronic, and home care. Without first addressing the supply issue, we are likely to fail to find ways to encourage professionals in the care and management of chronic diseases. We failed to do this in the past, and we are currently failing Canadians living in small towns and rural areas.

Coming from the university sector, I'd like to suggest that to address the supply issues I've raised, the federal and provincial governments will need to work together on structural issues found in Canadian universities and colleges, which train young people for jobs that focus on the young instead of jobs that focus on the older population. I'd like to give you one example.

In Ontario alone there are 13 faculties of education graduating thousands of students each year as qualified teachers. According to one national website approved by the Ontario College of Teachers, there were only 26 teaching jobs available in all of Canada last week. With all respect to my colleagues in the faculties of education, I do not question the quality of their work, the training they provide, or their commitment. But we cannot address the supply issue for geriatric and gerontological professionals if we continue to train young people for jobs that do not exist today and will not exist in the future, while we claim a shortage of resources to train young Canadians in areas of demand such as services and management of chronic diseases in the older population.

The other issue I'd like to address is the need to take into account the older aboriginal populations. It is still the case that most health researchers that focus on aboriginal populations are working on critical health issues of young aboriginal populations. There's only a small group of researchers focused on the older aboriginal populations. Yet the older-age cohorts of the aboriginal population are the fastest growing. By the middle of the century, the older aboriginal population will be in double digits as a percentage of the aboriginal populations. The older aboriginal populations will have many of the same service and management issues as the non-aboriginal population. In addition, they will have many service and management problems related to chronic diseases unique to their particular life courses and geographies. We need to prepare now and not make the mistake of waiting and then trying to catch up, which has brought us all here today to discuss the aging population and chronic diseases.

As someone who has spent more than 30 years carrying out research on access to health services, much of it related to Canada's older population, I'd like to comment on two issues that need much more attention than they currently receive. First, much of our research is constrained by our inability to designate levels of severity and to design service delivery models that differentiate between those living in the community with chronic diseases and those who need more intensive modes of treatment and management of their chronic diseases.

Second, we have at best a poor understanding of the transitions from living in the community with chronic diseases to moving into residential care settings. In other words, when is the optimal time to leave home and move to a residential care setting? To answer this question, CIHR in general, and the CIHR Institute of Aging in particular, needs more resources as well as assurances that long-term research investment such as the Canadian longitudinal study on aging will be supported now and sustained over the next 20 years.

To sum up, I respectfully urge the committee to emphasize in its final report the importance of complex local geographies of Canada, the diversity of the older population, and the growing older aboriginal population. Leadership in changing the structure of Canadian universities and colleges is required to shift resources to train young people in the fields required to address the needs of the older population who live with chronic diseases. Support for research on the older population with chronic diseases needs to be increased and then sustained.

Thank you for the opportunity to speak to you today.

[The Chair, Conservative, Joy Smith]

Well, that was perfect timing. My goodness, that was a compelling presentation. All of you have had extremely compelling presentations today.

We're going to go into our Q and A section now.

We'll begin with Madam Quach.

[Anne Minh-Thu Quach, NDP, Beauharnois—Salaberry, QC]

Thank you, Madam Chair.

Thank you to all of the witnesses for coming here and providing us with information. Despite the fact that we have already held a dozen meetings, we always seem to learn something new. It is very interesting.

My first question is for Mr. François Béland.

You briefly mentioned the fact that services provided to the elderly decreased between 1989 and 2007. What explains this decrease? The demand is still there, and I presume it is growing. What explains the fact that health care services decreased?

[Prof. François Béland]

No, the services did not decrease. What happened is that the growth in intensity decreased. The growth rate decreased, not the health care.

When we make forecasts, we use growth rates. Take the hypothesis that care for the elderly is generally more intense, given that some say that this care sometimes includes therapeutic obstinacy, and one hears other such arguments. This seems to indicate that the intensity of care given to the elderly increases systematically.

However, if the intensity of care is increasing, it is not increasing as quickly as health care given to other age groups. In other words, the rate of increase in the future will go up much more quickly for people between the ages of 45 and 64 than for people aged 65 and over.

So just because the rate of increase is not as high does not mean that fewer health care services are being provided. The rate of increase is not as fast, but it does not mean there are fewer services.

[Anne Minh-Thu Quach, NDP, Beauharnois—Salaberry, QC]

You also referred to the 2006 program for veterans, which was not implemented, but which could have been a positive program, in your opinion. Why did it not work, and what could have been done to improve it?

[Prof. François Béland]

You have the document I distributed. It was produced by the Gerontological Advisory Council, which was set up by Veterans Affairs Canada, but does not exist any more. I believe it ceased to exist about two years ago. I was a member of that council from start to finish, that is, for about 10 years. The council worked closely with the Department of Veterans Affairs. The follow-up given to the committee's advice was very interesting. In fact, every member of the council, in particular academics, all had a very positive experience in working with the department to improve all services provided to veterans.

In 2005 or thereabouts, we thought it would be interesting to review all of the services provided to veterans, especially because there were two other projects in Quebec, namely SIPA and the PRISMA research project, which provided integrated services to the elderly. So we suggested to the representatives of Veterans Affairs Canada that they emulate that model.

There were three major components. First, health promotion. At the time, the idea was to help veterans who were still in terrific health to stay healthy. Most of the elderly were in fact in very good health.

The second component involved what we called guides. Some people called them navigators. These were people who helped individuals who were beginning to develop functional disabilities and one or two chronic illnesses, but who were still in a stable situation. They were given the appropriate services. This group represented between 25% and 30% of the elderly.

Lastly, there was the largest group amongst the veterans. In the elderly population in general, this group represents about 8%, 10% or 12%. But the last component was a truly integrated system which was based on the PRISMA and SIPA models. It meant that veterans with very complex needs had access to all the services they needed, both social and health services, to help them maintain the best possible quality of life at the end of their lives. But this model was not adopted by the Department of Veterans Affairs. In fact, it was the only measure which the advisory council recommended which was not adopted by the Department of Veterans Affairs.

[Anne Minh-Thu Quach, NDP, Beauharnois—Salaberry, QC]

At the beginning of your presentation, you talked about the costs related to treatments which were not covered. You said that these costs have increased significantly and that this has increased the burden on the provinces.

Can you explain this cost increase? Given the demographic trends, should we integrate some treatments into the current system?

[Prof. François Béland]

There are several ways of looking at this. You are asking a difficult question. When I was younger, we talked about the $64,000 question, but today, it is probably the $64 million or $64 billion question. It is very difficult to give a clear answer regarding that aspect. I would say that the Canada Health Act is extremely restrictive, because it only covers medical, hospital and diagnostic services.

However, the more people age, the more they need hospital and medical services, but that is not really where things play out. In fact, the increase in medical and hospital services is much more due to treating people during the last years of their life—one or two years—meaning that the increase in the health, medical and hospital services is not due to aging, but to the time leading up to a person's death. In fact, if you die at the age of 65, you will usually cost much more to the system in terms of hospital and medical services, than if you died at age 85.

However, as far as the other services are concerned, and in particular what we call long-term care services, these go up with age. Integrating these two types of funding is important.

[The Chair, Conservative, Joy Smith]

Thank you very much, Mr. Béland.

We'll now go to Dr. Carrie, please.

[Colin Carrie, Conservative, Oshawa, ON]

Thank you very much, Madam Chair.

I want to thank all the witnesses for being here today. It is an excellent panel. I don't know where to start because I have so many questions, but perhaps I could start with Mr. Nolan.

I like your idea about the community model of keeping people in their homes. I think Great Britain has been experimenting with this for people who are discharged from hospitals. They will send people out.

As you said, there is a huge readmission, 15%, within less than a month. I was wondering, when you talk about this model, what are the cost savings? When you diverted 88%—you said the diversions from the emergency or the hospital—and there was a 23% decrease in emergency visits, have you calculated what the cost savings to the system are?