Health Committee on Feb. 14th, 2013

[Wayne Easter, Liberal, Malpeque, PE]

Before Dr. Ballagh responds, I'll get him to respond to both at once, with regard to the question just asked.

What do either of you see that the federal government, or jointly, federal and provincial, could be doing to overcome, one, the rural doctor shortage, and two...?

I was really intrigued by your video, Dr. Ballagh. I know several people who are having huge problems with Ménière's.

What can we do, from the government's perspective, to enhance better health, in terms of rural health care and some of the technologies you're talking about, to be able to access it within an hour when you need to?

[Dr. Rob Ballagh]

I guess I'm going to frame my answer around medical education. When Brad and I went through medical school, there weren't a lot of options to go into the community and actually have an educational experience. In surgery, I had no option at all to go into any community, outside of Toronto or London or Ottawa, and train with a community surgeon like me.

The rural Ontario medical program that I'm affiliated with, and I also work with the Northern Ontario School of Medicine through my affiliation in Kirkland Lake, have opened up those kinds of opportunities. In the last month, I've had an ear, nose, and throat resident come to work with me in Barrie. I've worked with two family medicine residents in Kirkland Lake.

We have found that in rural educational training and medicine, if you have your formative training, if you have some of those first experiences treating a heart attack or a massive bleed from a laceration in the neck in a small town hospital with very few resources but very experienced and dedicated doctors, those are the experiences that stick with you, and those experiences will often draw you back to that kind of practice.

I was told when I finished my training that I had potential and they wanted me back in the university centre. I'd known nothing else. I was told that if I practised in Barrie, I would be wasting my academic talent. In fact, I would tell you that the opposite is true. I'm able to take the experience I have and hopefully infect some of the doctors who come to work with me with an enthusiasm to work in places like Barrie and Collingwood and Orillia, and even as far north as Kirkland Lake.

[The Chair, Conservative, Joy Smith]

Thank you so much. Those were very insightful comments.

[Dr. Bradley Dibble]

Madam Chair, is there time for me to answer that second question?

[The Chair, Conservative, Joy Smith]

The time is up, and I have to go to Mr. Lizon.

Thank you.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

Thank you very much, Madam Chair.

Thank you, witnesses, for appearing before the committee.

The first question will go to both Dr. Dibble and Dr. Ballagh.

We are talking about innovation in medicine, but mostly what we've heard is related to treatment.

What is occurring on the prevention side? For example, I know of cases where people have had a heart attack and passed away. They were not expecting it. They were in good shape and never would have expected it.

Is there anything that exists today that a person can have, whether it's an electronic device or some other device, that would indicate the person has a problem and should contact their doctor?

[Dr. Bradley Dibble]

If I speak specifically to having a heart attack, or a myocardial infarc, as we call it, having a good general assessment—and it doesn't always have to be with a family physician, it could be with a nurse practitioner or a very skilled nurse even—and going through a complete risk profile.... There are nine classic risk factors that contribute to about 95% of all heart attacks.

If somebody knows what their risks are—and sometimes they know they are out of shape, overweight, or they smoke, but sometimes they don't know what their blood pressure and cholesterol are, and you don't need a specialist like me to be able to determine those risks. If people get access to them, they can have their risks calculated, and then they can access the knowledge they need to make those changes, which are very often commonsense things.

I remember Canada's Food Guide was very helpful in telling people how to eat healthy. I think there should be a Canada health guide for how to live healthy in general, to make sure people are doing the amount of exercise they should and not smoking. Everybody hears that, and it falls on deaf ears a lot of the time because sometimes lifestyles are hard to modify. I think a basic risk assessment will help predict many heart attacks. The real challenge, I would say, is not finding out what the risk is but making people make the necessary changes so they reduce that risk.

I've been dealing with that for 20 years, and it's a struggle.

[Dr. Rob Ballagh]

Whenever I answer a question about prevention in my specialty, I always caution everyone to take this message away from a meeting like this. Tell everybody you meet not to put Q-tips in their ears. Prevention is a very big thing in our area, with regard to injury to the ears.

In terms of prevention in our area, in surgery they have to have good quality primary care. That's what's missing in a lot of communities. In our community, 30% of people didn't have a family doctor 10 years ago. If you don't have a family doctor, then you don't have that initial gatepost into the health care system. You don't have that person to tell you to lose weight or to monitor your cholesterol.

That's what I would say to all levels of government. We have to make sure we have a family doctor for every patient in the country, or the equivalent, in terms of nurse practitioners and primary caregivers.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

As a follow-up question, how far away are we from the technology whereby instead of going to see you, Doctor, I can sit in front of a computer, have a device you can tell me to use, and then you can examine me very well?

[Dr. Rob Ballagh]

I think we have that today in some areas. In Kirkland Lake, some specialists visit via telemedicine. It's hard for me to do so because I have to have somebody with an instrument in the person's ear or a scope in the person's larynx, looking at the vocal cord movement.

Dr. Dibble will answer for his specialty.

Remote access is going on all the time. With the new smart phone technology, I'm able to talk to some of my doctors on my smart phone, and sometimes I can get them to show me the patient. It saves me a run to the emergency department sometimes.

It's not just videotapes and e-mails. It's live patient care, right at the bedside. I see that expanding, particularly with secure video conferencing becoming more and more a staple in technology. We have to have that confidentiality so that those signals can't be abused and used inappropriately.

[Dr. Bradley Dibble]

I would say the technology within cardiology exists today. We just need the dollars to get it out there in those communities. Again, a well-done risk profile, a history, a stress test, and an echocardiogram done remotely by those technologists so I can see them from wherever I'm located will provide a lot of reassuring information to a lot of patients. I think that's one thing.

The question was asked a short while ago about what the federal government can do, recognizing that health care is provincial. I think we need to have a federal grants program available so that these rural communities can request funds to be able to purchase these sorts of equipment, so they can access specialists remotely.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

Is there any time left?

[The Chair, Conservative, Joy Smith]

You have about a minute.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

I'm still not clear about the co-ops. Let me ask you a quick question.

In cases like what you described, whereby a clinic you want to keep open is closing somewhere, and instead of a co-op, if a private investor came forward and invested money, bought the equipment, and hired the doctors.... Is this the same idea as a group of people creating a co-op?

[Michaël Béland]

There's some common ground with both. Let me give a really clear example.

If a community would like to have the technology Dr. Dibble was just talking about and the public cannot afford it and cannot get grants for the technology, they can come together, form a co-op, acquire the technology, and offer it to the whole community. This is another way to organize and get access to the technology.

Another example is prevention. We use this Japanese Hans Kai model. We hire people to give educational tools so that people are able to check their own health indicators. This is in addition to the service provided to the public. We don't hire a doctor to come to our office.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

I understand, but those people who come together have to come up with money. They put money together. What do they get back? Is this an investment? Is this a donation? How does it work? What do they get back?

[Michaël Béland]

It's almost a donation to have access to better health services, to have access to better technology, to have access to additional services.

[The Chair, Conservative, Joy Smith]

Okay, thank you. We've run out of time.

We're now going into the five-minute time slots. You have to be aware of your time because we try to get more questions in, five minutes at a time.

I'll begin with Dr. Sellah, please.

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

Thank you, Madam Chair.

I will start by admitting that I had never heard of health care co-operatives prior to an unfortunate incident that happened a few years ago. The Quebec Minister of Health asked RAMQ to investigate some allegations. In fact, 75% of health co-ops were making people pay to get access to a doctor, which is illegal. I would like to hear what you have to say about that situation.

I would also like to know what the real difference is between a group of family doctors—a pilot project that was started in Quebec—and health care co-ops.

[Michaël Béland]

First of all, I fully agree with you, as does the entire co-op movement: restricting access to a doctor, whether you are a member or not, is an illegal practice. And the Fédération des coopératives de services à domicile et de santé du Québec did a lot of work on that to ensure that it does not happen in the network. There were probably some negative perceptions. This is something we try very hard to avoid.

It is important to understand that members do not have privileged access to a doctor when it comes to a provided service. The member has privileged access to additional services. For example, members might be entitled to certain services at a lower price or might have access to additional free prevention services, things like that. But when it is a guaranteed service, it is very clear to us that there must not be privileged access for members or non-members, because everyone pays taxes, which are used to pay the doctor.

Could you please repeat the second question?

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

I would like to know what the difference is between a FMG—a family medicine group—and a health care co-operative.

[Michaël Béland]

Let me give you a concrete example. In my village, we have a health co-op. The doctors are paid by the government and they also belong to the FMG. The health co-op members create a whole environment for doctors. Perhaps the rent for the health clinic is lower, perhaps there is more equipment and perhaps they have better people around. Doctors get a platform for free or that is significantly cheaper for the health care system. That makes it possible for them to move to the village.

For example, Mr. Ballagh said that people did not want to move to Barrie, Kirkland Lake or other remote places. Co-ops are an attractive workplace for doctors. So they will move to work there. They continue to be paid by our health care system. They continue to be part of an FMG and to work as an FMG.

There is another difference. For instance, a co-operative can decide to hire another nurse, in addition to the one paid by the FMG. The FMG nurse will then be able to take on additional work, which will reduce the doctor’s workload and give him or her time to see more patients.

Basically, people in the community come together to add more services. This creates an environment that will attract doctors.

It really complements the public system. There is no competition. This is especially important for places or areas of activity where the private sector would not benefit from investing in low-priced buildings for doctors, and things like that. Perhaps this answers other questions. When the private sector cannot provide those types of services, the community will decide to do so by creating a co-operative.

The same goes for telehealth. In Nova Scotia, one co-op provides a telehealth service. No private investors were interested in that type of service, because there was no profit to be made. So the people in the community decided to form a co-op in order to have access to the public services they were already paying for as taxpayers. By making an additional investment, they improved their access to health care. They took a real good look at what their needs were in terms of having easier access to public services. They decided to put money on the table, because the private sector found that there was no money in it, basically.

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

May I ask you another question?

[The Chair, Conservative, Joy Smith]

No, you really don't have time. You're right on the five minutes. But those were very good questions.

Now we'll go to Mr. Lobb.

[Ben Lobb, Conservative, Huron—Bruce, ON]

Thank you.

I just want to make a comment on the co-ops. I understand maybe why there's confusion, but I'll give you an example from my community.

In Goderich there was really no clinic. Instead of a co-op, they created basically a not-for-profit organization. Basically people from the community donated money, the municipality donated money, and surrounding municipalities donated money so they would have a clinic.

They had a doctor shortage in Goderich. They built a state-of-the-art facility, because there was nothing there before, really, and now they don't have a doctor shortage. People love going there. A lot fewer people in the area don't have doctors.

So one is a not-for-profit corporation. You guys call it a co-op; it's still the same thing. People who didn't donate money can still go to the clinic and receive service. It's just a way of making things happen in a small community. It's not like there's a clinic on one corner and across the street they put up another thing. There's nothing doing; this is why they have to do it.

This is just so we're all on the same page here.