Evidence of meeting #16 for Health in the 41st Parliament, 2nd session. (The original version is on Parliament’s site, as are the minutes.) The winning word was provincial.
A recording is available from Parliament.
Conservative
The Chair Conservative Ben Lobb
Good morning, ladies and gentlemen. Thank you to everybody for being here today. We're just commencing our study on best practices in a number of different areas. I appreciate your being here. The way it works is you have 10 minutes to present to the committee. Once all the presentations are complete, we allow each side two rounds of questions with seven minutes and then five minutes.
We'll start off first with Colonel MacKay with the Department of National Defence.
Go ahead, sir.
Colonel Hugh MacKay Deputy Surgeon General, Canadian Forces, Department of National Defence
Good morning, everybody.
Mr. Chairman and members of the committee, I'm very pleased to have the opportunity to appear before you today to provide an overview of the provision of health services to Canadian Armed Forces' members and respond to your questions pertaining to the scopes of practice of Canadian Forces Health Services Group clinicians.
The Canadian Forces Health Services Group is Canada's 14th health care system, providing high quality care to Canadian Armed Forces personnel wherever they serve. The system comprises an integrated team of military and civilian health professionals, which offers a patient-focused comprehensive spectrum of care in evidence-based health services.
While making use of provincial and territorial health resources within Canada, it is unique among jurisdictions in its integration under a single command of almost all elements of a comprehensive health system, including: education; training; research; occupational health; public health; professional regulation; clinical services, including medical, dental, pharmaceutical, emergency medical services, etc.; and supportive aids and benefits, such as home aids, return to work programs, and peer and family support. It also must uniquely maintain mobile and medical defensive capabilities to deal with hostile and environmental hazards that are generally not encountered in Canada.
The health needs of Canadian Armed Forces personnel is a top priority for the Department of National Defence as they must be employable and deployable at all times. The Canadian Forces Health Services Group is obligated to provide health services in order for Canadian Armed Forces personnel to maintain and improve their health and mental well-being; to prevent disease; to diagnose and treat illness, injury, or disability; and to facilitate return to operational readiness as quickly as possible. With the closure of our static hospitals in the 1990s, we've become far more dependent on the civilian health sector for domestic in-patient care and now access a significant amount of specialist and hospital care through provincial and territorial health systems.
The Canadian Forces Health Services Group comprises approximately 6,300 regular force, reserve force, and civilian personnel. Our mandate is based on three tenets: one, to deliver health services; two, to provide a deployable health services capability for operations; and three, to provide health advice to the chain of command.
The Canadian Forces Health Services Group provides health services to Canadian Armed Forces personnel in two distinct environments: in garrison and on deployment. In Canada, the primary health services system is based on a standardized approach through the primary care clinic model. The nucleus of this system is the care delivery unit, which consists of a primary health care team comprised of a medical administrative clerk, medical technicians, a physician assistant, a primary care nurse, a nurse practitioner, and a family physician, all operating within established scopes of practice. The CDU team works collaboratively with patients to assess their needs and to provide and coordinate their care.
Additionally, physiotherapists, pharmacists, and a variety of mental health professionals provide care in collaboration with the team or through direct intervention. In support of patient care, the Canadian Forces Health Services Group has implemented a pan-Canadian electronic health record system, a robust quality assurance program, a performance measurement platform, and a comprehensive health promotion and public and occupational health protection system.
We must also provide full-spectrum health services anywhere in the world that the Canadian Armed Forces elements deploy, whether on land, in the air, at sea, or under the sea. We must therefore be able to rapidly deploy and sustain medical, surgical, and preventive health capabilities, including tertiary care hospitals, anywhere for humanitarian or military missions without supporting local infrastructure.
In addition to being broadly clinically skilled, our staff must be trained to survive in hostile environments, deal with diseases, exposures, mass trauma, and other health threats that are generally not encountered in Canada. They must also be able to provide superb care with limited resources and intercontinental medical evacuation and supply chains in extremely dangerous and austere conditions.
Such circumstances require that the military health system be structured in a manner that makes the most efficient use of all health resources and occupations. This is facilitated by the military culture's prioritization of mission first, welfare of subordinates second, and personal interest last, as well as by the surgeon general's control of all clinical matters, including scopes of practice, distribution of occupations, health education and training, allocation of clinical resources, etc. During Afghanistan operations, we would not have achieved history's highest war casualty survival rate without the subordination of individual and professional interests to the mission, nor without expanded training and scopes of practice under physician supervision for certain occupations like physician assistants and medical technicians.
The health team in the Canadian Armed Forces is composed of both military and civilian personnel from over 45 occupations and specialties. Many of these occupations are regulated by professional bodies and have mandated scopes of practice, which, when necessitated by unique military operational exigencies, may be modified by the surgeon general. Health professionals are expected to register with their respective regulatory body. For example, in order for a military physician to practise within the Canadian Armed Forces, like their civilian colleagues, they must be registered with a provincial or territorial professional regulatory authority such as the College of Physicians and Surgeons of Ontario.
Given that we span the country we face challenges with respect to scopes of practice for some regulated professionals as they are not consistent across provincial jurisdictions. There may thus be differences for some occupations in some of our clinics. Additionally, we have an internal credentialing process and a practice review board to address issues with respect to registration and clinical practice. Our professional culture is based on a patient-centred philosophy that strives to provide access to the right care at the right time by competent caregivers. This philosophy is supported by a multi-interdisciplinary collaborative care model hinged on a high availability of caregivers and referral of care, as necessary. The clinicians' achievement of optimal professional practice is supported through a robust maintenance of clinical readiness program, coupled with access to a variety of continuing professional education and recertification opportunities.
At one time, the Canadian Armed Forces were the sole national jurisdiction that trained, educated, and employed two unregulated health occupations: medical technicians and physician assistants. With the rising national demand for allied health professionals to extend physician services, civilian physician assistants are now produced by select Canadian universities and employed in several provinces. The Canadian Forces Health Services Group was instrumental in the establishment of the Canadian Association of Physician Assistants, which certifies physician assistants through an examination and ongoing, annual continuing professional education requirements. Our medical technician training includes certification as a primary care paramedic through external civilian programs, community colleges, and internal guidance for ongoing maintenance of clinical readiness. Canadian Armed Forces medical technicians can also obtain registration from a provincial or territorial regulatory authority. They receive more advanced clinical training to have the skills necessary to deal with the urgent needs of deployed Canadian Armed Forces personnel in austere, hostile, and geographically dispersed environments.
In closing, like many other health jurisdictions, the Canadian Armed Forces are very committed to providing the right care to the right person by the right caregiver to optimize care and resource utilization. The Canadian Forces Health Services Group is broadly engaged with national professional authorities and organizations to contribute to the dialogue and to keep abreast of new initiatives that may benefit the Canadian Armed Forces.
Thank you once again for the opportunity to be with you here today.
Conservative
The Chair Conservative Ben Lobb
Thank you very much.
Next up from CSC are Michele Brenning and Henry de Souza.
Go ahead for 10 minutes, please.
Michele Brenning Assistant Commissioner, Health Services, Correctional Service Canada
Good morning, Mr. Chair and members of the committee. My name is Michele Brenning, Assistant Commissioner, Health Services, Correctional Service of Canada. With me is Henry de Souza, Director General of Clinical Services and Public Health.
I would like to thank the committee for the opportunity to comment and provide input on the federal role in the scopes of practice of Canadian healthcare professionals.
The Correctional Service of Canada, or CSC, is mandated under the Corrections and Conditional Release Act to provide every inmate with essential health care and reasonable access to non-essential mental health care. Moreover, the act stipulates that the provision of health care shall conform to professionally accepted standards.
To accomplish our mandate, CSC relies on approximately 1,250 health staff, as well as contractors, who work in interdisciplinary teams and include nurses, psychologists, social workers, occupational therapists, general practice physicians, psychiatrists, and pharmacists. In addition CSC is looking to diversify our staff mix to include nurse practitioners and physician assistants, as well as non-regulated health professionals such as personal support workers.
On a typical day there are 15,000 offenders in federal institutions across Canada. CSC's institutions are divided into five regions: Atlantic, Quebec, Ontario, prairie, and Pacific.
To support professional competencies, CSC provides ongoing training in a variety of areas within the streams of mental health, public health, and primary health care.
Along with adherence to professional standards of practice as articulated by the relevant professional colleges, CSC's national essential health services framework, the national drug formulary, and active quality improvement processes are key tools used to promote consistent, safe, and effective delivery of health services to our clientele.
Health care is costly, and human resources are a significant cost driver. As a provider of health care to a challenging clientele, understanding the scope of practice of various disciplines and finding the right staff mix are critical in our efforts to maximize effective and efficient service delivery.
Although there is no consensus definition, the key element of scope of practice can be identified in the Canadian Nurses Association definition:
A profession’s scope of practice encompasses the activities its practitioners are educated and authorized to perform. The overall scope of practice for the profession sets the outer limits of practice for all practitioners. The actual scope of practice of individual practitioners is influenced by the settings in which they practice, the requirements of the employer and the needs of their patients or clients.
Achieving the optimal staff mix requires leveraging the flexibility within overlapping scopes of practice, while at the same time valuing and strategically utilizing the specialized expertise. For example, in the field of mental health there is overlap within the professions such that the mental health counselling can be carried out by the disciplines of social work, nursing, psychology, general medicine, psychiatry, or occupational therapy.
On the other hand, there are activities where the expertise resides exclusively or primarily within the discipline. For example, a multidisciplinary team will rely on a psychologist to conduct a psychological assessment. Similarly, general practitioners providing primary mental health care may rely on a psychiatrist for more complex or tertiary level psychiatric interventions.
As a federal government department operating within several provincial jurisdictions, and therefore several provincial colleges, there are barriers to optimizing efficient delivery of health care. For example, there is no automatic interprovincial transfer of licensure for professionals. This significantly limits the mobility of registered professional staff across Canada, thereby limiting matching staff availability to the geographic area of need.
Telemedicine and telehealth are recognized as being both effective by providing access to specialists who might not otherwise be possible, and efficient by reducing travel costs and enhancing the ability to see more patients. However, there is still no consensus on liability with respect to providing treatment across provincial jurisdictions.
Although the scope of practice may allow certain activities by a professional, training may be required to ensure competency in unfamiliar areas of practice.
As a result of these observations, we would offer a few recommendations to improve the ability of health care professionals working with CSC to better respond to our evolving needs. These include a national standardization that allows interprovincial mobility, and flexible scopes of practice that allow, in collaboration with the relevant college, the option to train to an accredited standard beyond the scope of practice in order to address needs in rural and remote areas where recruitment is difficult.
I believe that CSC is well placed to offer an opinion on the practice and training of healthcare professionals on the federal level in direct relevance to this committee study.
Although considerations for time prevent me from providing more specific details. In my opening remarks, I would be pleased to answer any questions this committee may have.
Thank you once again for the opportunity to appear before you today.
Conservative
The Chair Conservative Ben Lobb
Thank you very much.
Next up, from the Department of Health, Debra Gillis.
Go ahead, please.
Debra Gillis Acting Director General, Interprofessional Advisory and Program Support, First Nations and Inuit Health Branch, Department of Health
Thank you, Mr. Chair and members of the committee.
I am here this morning to provide you with an overview of Health Canada's role and work on the subject of scope of practice for health professionals. I'd like to begin by stating that scope of practice is defined in many ways by different players in the health care system, both at the national and provincial levels, including ministries of health and education, regulatory bodies, credentialing bodies, national and provincial professional associations, education bodies, and employers.
Broadly speaking, “scope of practice” refers to the roles, functions, tasks and activities, professional competencies, and standards of practice that licensed health care professionals are authorized to perform in a specific field. By this I mean that each regulated health profession has a scope of practice statement that describes in a general way what the profession does and the methods that it uses.
The scope of practice statement is not protected in the sense that it does not prevent others from performing the same activities. Rather, it acknowledges the overlapping scope of practice of the health professions, and therein is the challenge, because health professions often practise as a team. The result is that the scope of practice for each health professional is enacted according to the needs of the patient and the practice environment in which he or she works. Consequently, the actual scope of practice—that is, what happens in day-to-day practice—may vary substantially across health care settings and sectors as well as according to the patient population being served.
The provinces and territories play a major role in scopes of practice. They make the decisions about how best to optimize the scopes of practice of health professionals working within their jurisdictions. They are responsible for health professional legislation and regulation, payment mechanisms, education, and health human resources planning, all of which impact scopes of practice.
The federal government plays a supportive role in this area through research, health human resources programming, related regulatory responsibilities, and working within established scopes of practice for the delivery of care to federal populations. The federal government is committed to ensuring a health system that is responsive to the needs of Canadians and that Canadians have access to the care they need. To this end, we support efforts in health human resources management that allow professions to work to their optimal scopes of practice in a number of ways.
Firstly, the federal government is responsible for national enabling legislation such as the Controlled Drugs and Substances Act, which supports health professions to practice to their full scopes as set out in provincial or territorial legislation. Specifically, Health Canada introduced the new classes of practitioners' regulations that came into force on November 1, 2012. These regulations authorize midwives, nurse practitioners, and podiatrists to prescribe, administer, and provide controlled substances, with some exceptions, provided they are already authorized to do so under provincial or territorial legislation.
Secondly, Health Canada facilitates the advancement of optimal scopes of practice in collaboration with provinces, territories, and key stakeholders in various ways including, for example, by providing $24 million in funding to advance the adoption of team-based care through initiatives such as the Canadian Interprofessional Health Collaborative; by providing $6.5 million in funding to McMaster University to evaluate team-based approaches to health care delivery; by providing advice to deputy ministers of health on the planning, organization, and delivery of health services through the federal-provincial-territorial committee on health workforce; and by partnering with the Canadian Institutes of Health Research to support a best brains exchange on March 14 of this year on optimal scopes of practice.
Thirdly, as a provider of services to federal populations, including to first nations and Inuit, federal inmates, and the Canadian Forces—as you have heard—the federal government has a direct role to play in championing novel approaches to health care delivery, including with respect to scopes of practice. Given this, I will now turn specifically to Health Canada's role in first nation communities.
Working to improve the health outcomes of aboriginal peoples is a shared undertaking among federal, provincial, territorial governments, and aboriginal partners. Health Canada's role involves supplementing and supporting provincial and territorial health services to provide culturally appropriate health programs and services that work to improve the health status of first nations and Inuit communities. To fulfill this role, Health Canada funds or directly provides public health, health promotion and disease prevention, addiction and mental health, and home and community care on all first nation communities, and primary care services in 85 remote and isolated communities.
Regulated health professionals and unregulated health workers make up the almost 10,000 strong workforce. Regulated professionals include registered nurses, nurse practitioners, licensed practical nurses, dentists, dental hygienists, dental therapists, nutritionists, pharmacists, physicians, and environmental health officers. Health Canada requires its health professionals who provide direct services in first nation communities to be licensed in the province or territory in which they work and to maintain good standing with the regulatory body.
However, in remote and isolated first nation communities with limited direct access to physician or even nurse practitioner support, registered nurses delivering direct primary care services often provide a broader range of health services and functions than would be authorized by provincial legislation on scope of practice .
The need to address the legislated scope of practice of registered nurses working in these remote communities, while ensuring safe care and protecting the licences of nurses, is addressed in various ways across Health Canada's regions. For example, the Province of British Columbia has introduced a certified RN designation that defines additional education requirements and broadens the scope of practice for isolated and remote communities, and we require nurses to obtain that certification.
Saskatchewan has introduced new nursing standards specifically addressing primary care service delivery in northern communities that will authorize RNs to take on additional functions.
In Alberta first nation communities, a collaborative and consultative practice model, accessed on site or via telehealth, between nurse practitioners and registered nurses has permitted the safe, timely, and high-quality delivery of primary care services that align with provincial nursing scope of practice legislation.
In Quebec, provincial legislation has been introduced to delegate or transfer authority for RNs to provide primary care. Working with provincial partners, Health Canada has introduced practice directives or ordonnances collectives that align with the legislation.
In Manitoba and Ontario, a provincially recognized delegation process permits the alignment of Health Canada's employment functions of RNs with the provincially defined scope of practice.
To mitigate the risk of nurses working outside their scope of practice, Health Canada has recently reviewed its nursing delegation tools, specifically the first nations and Inuit health branch's clinical guidelines for nurses in primary care and the nursing station formulary and drug classification system. This review identified a need to revisit and update these tools to ensure alignment with provincial frameworks, and we are in the process of doing so.
Further, Health Canada provides education and training to all nurses working in primary care to ensure they have the skills and necessary certifications to provide safe care. All nurses are required to take, within a period of time after joining the federal government, a primary skills training course covering the expanded care needs. Health Canada also makes sure that nursing staff in remote and isolated locations have direct phone or video access to a physician at all times to discuss diagnosis and treatment, and to authorize treatment such as prescription medications.
We are also implementing the recommendations from an internal study on health service delivery models in remote and isolated first nation communities, which will further support an alignment with the provincial scope of practice legislation for health care providers in primary care services. The measures being implemented include the introduction of collaborative and interdisciplinary teams; the introduction of providers not currently included in primary teams, such as X-ray technicians and pharmacy technicians; the increased presence of nurse practitioners; and the increased use of e-health services.
In closing, Health Canada will continue to undertake activities to address scope of practice issues to support improved health care in first nation communities. In terms of Health Canada's broader role, I would emphasize that we will continue to collaborate with the provinces and territories and to facilitate the sharing of knowledge and best practices in support of their efforts to optimize the scopes of practice of health care professionals.
Thank you very much.
Conservative
The Chair Conservative Ben Lobb
Thank you very much, Ms. Gillis. That's good, we know you're committed because you're the first witness that's got choked up doing their presentation. We know you're definitely passionate about what you're talking about there. Thank you. You got through it.
First up, Ms. Davies, you have seven minutes. Go ahead, please.
NDP
Libby Davies NDP Vancouver East, BC
Thank you very much, Chairperson, and welcome to our presenters today.
As you've heard, we're just beginning our study about best practices, scopes of practice, health human resources, and so on. It's a bit of a mouthful, and we're just beginning to get familiar with the topic and how we need to address it. So maybe our questions will be a bit general today.
Listening to what you each had to say, I have two questions. First of all, I have to say I was a bit surprised that none of you mentioned Health Canada's pan-Canadian health human resources strategy, which we understand from the background work that we had prepared is sort of the document or strategy that's overseeing a commitment that was made—I think it was made in 2005. That strategy outlines five areas, one of which is health human resource planning and forecasting, so that takes us directly into the issue of where there are shortages, how they're regionally based or within remote communities.
I guess my question is this. Who's doing that? Who's overseeing the planning and the forecasting? I can tell you that when we, and I assume this is for all members of the committee, meet with various professional associations, whether it's the nurses, or psychologists, or occupational therapists, or whoever it might be, this issue of disparity and shortages, depending on where you are, but particularly in remote communities, northern communities, comes up again and again. It certainly was a major issue identified in the 2004 health accord. My first question is whether the various departments that you work in federally are aware of this strategy. Does your department collaborate with other departments? It's meant to also be a provincial and territorial thing, not just a federal role. I'd just like to know, do you know who's responsible for it? Do you work with those people? That's one question that you could all address.
The second question, if I could just be quick about it, is this. Ms. Brenning, I really appreciated your presentation. There was one paragraph that you actually didn't read out, and I don't know whether you skipped over it or whether you didn't want to say it, but I thought it was good. It said health care needs to exist on a broad continuum ranging from addressing activities of daily living and emotional support to more complex medical interventions. It's at the top of page 6. We've heard previously that 80% of inmates have substance use issues. That's obviously a major concern. I wanted to ask you whether or not Corrections Canada uses a harm reduction approach—for example, needle exchanges, methadone—in looking at the issue of substance use from a multidisciplinary perspective and actually reducing the risk and the harm of inmates who may be involved, particularly with drug use. If you could address that, it would be very helpful.
Those are my two questions. Sorry to take so long.
Acting Director General, Interprofessional Advisory and Program Support, First Nations and Inuit Health Branch, Department of Health
Mr. Chair, I'd like to address perhaps the first question on the pan-Canadian health human resources strategy. Yes, Health Canada is very aware of this strategy and very proud of the work that we have done with the provinces and territories over the years on the development of this strategy.
Perhaps it was garbled in the time that I was having a choking attack and getting over my cold, but one of the pieces of work that Health Canada leads, and in fact we are the co-chair with the Province of Manitoba, is with the federal-provincial-territorial advisory committee on health delivery and human resources. That is a committee that reports directly to the conference of deputy ministers of health. Their work is guided by the health human resources strategy. The provinces work very closely together with the federal government in areas such as planning, identifying health service needs, sharing information.
NDP
Libby Davies NDP Vancouver East, BC
Ms. Gillis, is there a report that we could look at? This has been going on since 2005. Are there any sort of monitoring reports, evaluation reports, that we could get our hands on? It would really help us address what has happened or where the gaps still are. If you could point us to anything....
Acting Director General, Interprofessional Advisory and Program Support, First Nations and Inuit Health Branch, Department of Health
Absolutely. I'd be happy to ensure that any reports the group has provided, public reports and things like that, are provided to the committee.
You also talked about planning. As part of the work of this committee, they do a lot of work in modelling in health care, such as the number of nurses. The other piece is that a lot of work is also done in terms of health planning, workforce planning, and looking at the distribution of the health workforce across Canada. The Canadian Institute for Health Information produces reports on a regular basis around health workforce planning. It released a report a couple of years ago that I think you will find very interesting.
Assistant Commissioner, Health Services, Correctional Service Canada
I'll start with your first question, which Health Canada also answered. Certainly we rely on the leadership of Health Canada, but from a very operational perspective, we're a fairly small employer of about 2,400 health professionals.
We do very detailed operational planning. Each of our five regions has an operational plan for where the hiring needs to happen. We know that we have a continuous need for intake of nurses in the prairie region. We have an open process where we're always evaluating nurses who would be willing to come and work for Correctional Service of Canada. The prairies is one area where we do see a shortage of nurses.
We do have some needs, depending on how remote some of our institutions are. For example, Grande Cache is an area where we typically have challenges recruiting health professionals. There are some gaps with psychologists, but overall we have fairly good success in recruiting health professionals.
To answer your second question, yes, thank you for pointing that out. That really was a paragraph that talked about the overlapping scopes of practice. We did address that earlier, but to answer your question very specifically, we do have harm reduction programs. It includes the use of bleach kits and other types of measures such as that. We do not do needle exchange.
With regard to a methadone program, we have a very rigorous methadone program. It's an interdisciplinary team approach. Essentially you have an aspect where the physician, the nurse, and counselling will be provided, and there's ongoing, very regular routine monitoring of that particular program.
So yes, we do have that program in place.
Conservative
The Chair Conservative Ben Lobb
Thank you very much.
Next up is Mr. Lunney for seven minutes, please.
Conservative
James Lunney Conservative Nanaimo—Alberni, BC
Thank you, Mr. Chair.
Thanks to the witnesses for being here today as we get started on this important study on scope of practice. We're wanting to get an update on where Health Canada is at in terms of managing the processes in evaluating human health resources for federal institutions and so on.
Colonel MacKay, you described the primary care model that DND uses. You described the primary health care team as being regulated and non-regulated persons, and others at the table here described a very comprehensive list of professionals. It strikes me a little odd, if I come back to the military first, that our third-largest primary contact profession is not represented in any of your teams that you discussed today. I'm curious about that.
We have about 75,000 medical doctors in Canada. There are about 19,000 dentists who are primary contact. There are 8,400 chiropractors in Canada; that's a very large and regulated profession across the country. It strikes me odd, when we're talking about human resource shortages, that the third-largest primary contact profession is not represented.
Colonel MacKay, I know that chiropractors made a presentation not too long ago to the Standing Committee on National Defence about representation in the military. We know that amongst their areas of expertise for low back pain it's well established that chiropractors give far more cost-effective and effective care delivery. Chiropractors are working with the U.S. on 51 bases as part of the integrated health care team.
Is there a barrier to chiropractors participating in the primary care delivery, at least as part of the integrated team, to manage musculoskeletal issues on bases? I understand that 53% of your medical releases are actually related to musculoskeletal problems.
Could you respond to that?
Col Hugh MacKay
Thank you very much for the question.
We didn't mention a chiropractor specifically as part of our team within our clinic model, but we do access chiropractic care through the civilian community on a regular basis for personnel suffering from musculoskeletal pain.
You're absolutely right about the issue with respect to low back pain, and we actually, recently, just held a week-long task group to look at development of a clinical pathway for low back pain, because it is such an important issue to us. We did invite the Canadian Chiropractic Association to participate in that week-long working group with us. As a result of that meeting, we are right now pursuing opportunities for a clinical trial to integrate chiropractic care more fulsomely into our clinic model. I don't believe there are specific barriers to doing this right now. We're in the process of looking at building in an evidence base in order to be able to continue to support further work with chiropractors.
Conservative
James Lunney Conservative Nanaimo—Alberni, BC
I appreciate that. Probably it's the integrated model and working together that you'd be having trouble with, because the clinical effectiveness of chiropractic in low back pain is well established. I could point you all the way back to the Manga report here in 1993 in this province. That report was done by an economist here at the University of Ottawa. He studied the issue and at that time recommended that Ontario could save $100 million in this province alone by selectively making use of chiropractic, because the evidence was there from the Cochrane Collaboration and others.
I appreciate that you're willing to experiment with those models. I notice that a chiropractor who made a presentation to DND offered to provide services on five bases. They'd make them available for those studies to go on on to see how they could integrate these services. I'm glad you're looking at that.
I might apply the same question to Corrections Canada. For full disclosure, I practised as a chiropractor for 24 years in two provinces, and one of our other colleagues across the aisle is also a chiropractor. Obviously we carry a bias in that regard, but having delivered those services for 24 years, I have no doubt in my mind of their clinical effectiveness, and it surprises me that others haven't benefited from or expanded on that opportunity in the north. In Corrections Canada, I made a house call to one of our local prisons, a provincially regulated one, and there were lots of people who would have liked my service beyond the patient of mine who happened to be spending some time there.
I just wonder, Corrections Canada, when you have all kinds of regulated professions and Health Canada is sending unregulated professions and even training medical technicians and physician assistants, why you wouldn't take someone from an area that is highly regulated, someone who is well educated—it takes up to seven years of post-secondary education—and look at using those resources for Corrections Canada. Do you have any models you've been working with there?
Assistant Commissioner, Health Services, Correctional Service Canada
I'll just go back to what our mandate is under the Corrections and Conditional Release Act, and that is to provide every inmate with essential health care. Our essential health care framework defines what essential health services are for federal inmates. We work on a referral system. In other words, if a medical doctor determines that there's a need, for example, for speech therapy or physiotherapy, we would bring in the appropriate specialized expertise. I didn't mention speech therapy or physiotherapy, but I do know that we do referrals as needed.
Conservative
James Lunney Conservative Nanaimo—Alberni, BC
I noticed one of your recommendations was for flexible scopes of practice that allow the option to train to an accredited standard beyond the scope of practice. Again, when you're dealing with northern communities, where you have trouble getting people up there and you take a nurse practitioner, that's very good, but if you had a nurse up there, along with a chiropractor who has a broad range of experience to help with those issues.... First nation communities, by and large, are a little bit less oriented towards medications, and they handle them, perhaps, less well than do other populations. Would it be possible to make use of these resources in remote and northern communities where it's hard to get physicians to go?
Acting Director General, Interprofessional Advisory and Program Support, First Nations and Inuit Health Branch, Department of Health
That's an interesting question, Mr. Chair.
Right now, I think as you can imagine, staffing remote and isolated communities is very complex and very difficult. Although, as I described, in the first nation communities for the most part throughout Canada our mandate is public community health care, first nations people who live on reserve or in Inuit communities access the provincial health system for physician, dental, and even chiropractic care.
It is through our non-insured health benefits program that we either provide medical transportation to these services or pay for the services, such as dental services specifically. In the remote communities, occasionally we are able to have and find physicians and other health professions beyond nursing who are willing to come into the communities on a rotating basis based on the need of a community. I can't speak to the fact if ever a chiropractor has been brought in, but I know physicians come in on an occasional basis. We pay for their travel in and they bill the provincial health system because of the universal nature of physician services in the health system.
If there are other more specialty services or dental services, sometimes they're brought in, but more specifically people are transported out of their communities to the provincial health system. Sometimes we've also used the mid-level dental technician, dental therapist, to provide some services in the remote communities under the guidance of a dentist. There are a variety of different ways to do that.
Conservative
Liberal
Francis Scarpaleggia Liberal Lac-Saint-Louis, QC
Thank you, Chair. It's a pleasure to be back here, if only on a one-off basis.
I find this to be a very interesting discussion.
Colonel MacKay, I'm trying to understand how your health system, which is essentially internal to National Defence, is laid out. You would have doctors on bases or around military bases. In an emergency, or if we're talking about a complicated case, the military personnel would be transferred to a provincial hospital. There are no national defence hospitals or even veterans hospitals left, so you're working in close collaboration, but you might have a doctor who would see the officer or the military person first, and then basically refer them—or even maybe you have to airlift them if the base is far from a hospital. Is that correct?
Col Hugh MacKay
Yes.
The situation is that we don't have any static hospitals in Canada at this point in time. If a patient becomes emergently ill they may be seen by one of our clinicians, initially on the base. That could be a physician, a nurse practitioner, or a physician assistant, who would assess the patient and make a determination as to whether or not a higher level of care is required, in which case they may be referred to a local civilian hospital. We work very closely on the local level with those health care facilities in order to make sure that we have all of the transfer smoothed out and that it can happen as easily as possible. There may also be occasions, though, where a military member is at home on a weekend, has an accident, and may call 911, and a civilian ambulance service may come and pick them up and transfer them automatically to a civilian hospital.
Liberal
Francis Scarpaleggia Liberal Lac-Saint-Louis, QC
That was actually my follow-up question, what happens if the individual worked at DND headquarters but did not live in Ottawa or around DND; they could live in Montreal, for example, or wherever.
In terms of PTSD, in the case of personnel suffering from PTSD, how is that situation managed? I know in my riding we have the Ste. Anne's Hospital and there is a PTSD unit. I don't imagine it's only for veterans. It could be for DND personnel who have not left the forces yet. Is that correct?