Health Committee on April 10th, 2014

[The Chair, Conservative, Ben Lobb]

Good morning, ladies and gentlemen.

We're here for committee. I welcome everybody here. It's a beautiful spring morning. It was nice walking in this morning.

We have two witnesses here today from the Canadian Pharmacists Association. We also have Mr. Lopatka, from the Association of Faculties of Pharmacy of Canada, by teleconference. It's not video conference today; it's teleconference.

We'll get started here. We have two meetings inside our two-hour meeting. We'll start off first with the Canadian Pharmacists Association.

You have 10 minutes or less for your presentations. Go ahead, Mr. Emberley or Ms. Cooper.

[Janet Cooper, Senior Director, Professional and Membership Affairs, Canadian Pharmacists Association]

Thank you, Mr. Chair.

I'm Janet Cooper. I'm the senior director of professional and membership affairs at the Canadian Pharmacists Association. With me is Phil Emberley, CPhA's director of pharmacy innovation. We're both pharmacists. CPhA represents the pharmacist profession in Canada. With over 37,000 pharmacists, ours is the third-largest health care profession. CPhA is also Canada's leading publisher of drug and therapeutic information for health care practitioners.

As the most accessible health care professionals in Canada, pharmacists are in a unique position to deliver a range of health-related services to Canadians. We are very pleased to meet with you today and highlight the unprecedented changes in pharmacists' scope of practice over the past several years. In fact, in terms of best practices, other countries look to Canada, as we are leading the way for expanded scope of practice for pharmacists. To support change, CPhA has been leading the blueprint for pharmacy initiative to achieve the vision for pharmacy, “Optimal drug therapy outcomes for Canadians through patient-centred care”.

We'll also discuss with you the significant role the federal government played in some of these changes in pharmacy. For decades our profession has been saying that we need to better use the unique knowledge and skills of pharmacists to improve drug therapy outcomes for Canadians. However, some of the major catalysts for the changes that we see today came from the federal government over a decade ago, working with their provincial/territorial counterparts and health care professional organizations, such as CPhA.

In 2002 both the Romanow commission and the Kirby Senate committee reports recognized the accessibility and underused skills of pharmacists and the need to expand their role. The 2003 health accord also identified pharmacists as a priority profession. The $800-million federal investment in the primary health care transition fund, or PHCTF, helped deliver change. Health Canada's health human resources strategy division played a leading role in engaging with the jurisdictions and health care professionals on primary care reform, health human resources planning, expanded scopes of practice, and supporting interprofessional education and collaboration.

l'll share with you some examples of the federal role that are specific to pharmacy.

The primary health care transition fund funded the IMPACT project in Ontario, which integrated pharmacists into family practice clinics. A focus of this project was to facilitate collaboration between pharmacists, family physicians, nurses, and other team members in this new model of practice. Today there are pharmacists working within such family practice teams across Canada.

PHCTF also funded CPhA for the development of e-Therapeutics, an online resource to provide physicians, pharmacists, and other providers with just-in-time access to evidence-based clinical decision support. Today e-Therapeutics is widely used, but we need to work with Canada Health Infoway and the jurisdictions to take it further. It needs to be integrated at the point of care into electronic medical records to improve prescribing and safe and cost-effective medication use.

Human Resources and Skills Development Canada funded the pharmacy human resources moving forward study, led by CPhA. The research and recommendations from this study were a key driver for the changes that have occurred since. HRSDC also funded further work by pharmacy regulators to support international pharmacy graduates and the introduction of a new health care profession, regulated pharmacy technicians.

Health Canada also funded, in part, the development of CPhA's online ADAPT training program. ADAPT focuses on patient care skills, such as assessment, documentation, evidence-based decision-making, and interprofessional collaboration. ADAPT provides pharmacists with the skills and confidence needed to take on an expanded role and to move from a focus on dispensing prescriptions to a focus on safe and effective outcomes. Not only has ADAPT won a national award, it is so effective in transforming pharmacists' approach to practice that we are now adapting it for use in the United States to support pharmacists there to take on expanded roles, as part of their health care reform.

Without the past support of the federal government, pharmacy in Canada would not be where it is today, and we would not be recognized as the world leader in pharmacy practice change. So where are we today, and what more needs to be done?

I'll turn it over to Phil.

[Phil Emberley, Director, Pharmacy Innovation, Canadian Pharmacists Association]

Over the past several years, there has been a great deal of change with respect to the scope of practice of pharmacists in Canada, starting with legislative changes in Alberta in 2006. The level of change in practice is unprecedented in the history of the profession. This includes changes in pharmacists' prescribing, such as renewing prescriptions, prescribing in emergency situations, adjusting doses and dosage forms, and discontinuing or starting new medications. Changes also include assessing and prescribing for minor ailments, which can greatly reduce the burden on emergency rooms and walk-in clinics; immunizing and ordering of lab tests to enhance monitoring of drug therapy—

[Libby Davies, NDP, Vancouver East, BC]

Mr. Chair, point of order.

[Phil Emberley]

—for safety—

[The Chair, Conservative, Ben Lobb]

Pardon me, Mr. Emberley. We have a point of order.

Yes, Ms. Davies.

[Libby Davies, NDP, Vancouver East, BC]

Thank you very much, Chairperson, and I'm very sorry to interrupt you, Mr. Emberley, but Chairperson, I would like to move a motion that we invite the Minister of Health to come to the committee at the earliest opportunity to speak about the health accords. So I'd like to move that motion right now.

[The Chair, Conservative, Ben Lobb]

I can provide some clarification. I wanted to confer with the clerk on my thoughts, and it's out of order, Ms. Davies. You don't have the floor right now.

Obviously, you know when you will have the floor, and if that's what you choose to do with your time, that would be the appropriate time to do it. Okay? Great. Thank you.

Mr. Emberley, go ahead, please.

[Phil Emberley]

In addition, we now have regulated pharmacy technicians in several provinces. They do a final check on dispensed prescriptions, freeing up pharmacists to focus on patient education, adherence, and medication-monitoring services.

We have provided the clerk with a one-page summary of the range of expanded scope of practice for pharmacists across Canada, which members should have now in front of them.

Although specific scopes of practice differ across the jurisdictions, the trends have all been the same. Increasingly, governments are recognizing that pharmacists can deliver accessible, high-quality care to Canadians at a lower cost to the health-care system. Research shows that pharmacist services improve patient adherence and outcomes, and reduce hospitalization.

In addition to regulatory changes to scope of practice, provincial governments are also paying pharmacists to provide new services, such as flu shots, treatments for minor ailments, diabetes management, smoking cessation, and meeting with patients to do comprehensive medication reviews and develop annual care plans.

In fact, last summer Canada's premiers at a meeting of the Council of the Federation directed the health care innovation working group to examine opportunities within the team-based model framework to increase the important role that paramedics and pharmacists play in the provision of front-line services. We are pleased that Health Canada, through the FPT committee for health workforce, has recently engaged in this work.

In terms of recommendations and next steps, the pharmacist profession welcomes these developments. However, there are three core areas in which we feel the federal government could play a stronger role.

First, provincial governments have enabled an expanded role for pharmacists not only through legislative changes but also by paying for new medication management services. The same has not happened federally. Although the majority of health care in Canada is delivered by the provinces, the federal government does have populations for which it is responsible for provision of health services. These include groups such as aboriginals, veterans, refugees, and the RCMP. In fact, Health Canada is the fifth-largest health care provider in the country. However, unlike provincial governments, the federal government does not cover the cost of extended pharmacist services. This situation is placing these federal populations at a disadvantage. They are not able to receive the same level or accessibility of services that most other Canadians are receiving. As a result, our first recommendation to the committee is to instruct Health Canada to review the services it insures for its federal populations, particularly pharmacist-provided medication management services so that, at a minimum, coverage policies are aligned with the corresponding provinces' programs.

Second, as we undergo primary care reform and expanded scopes of practice, all health care professionals need support for change, in particular, having the patient care documentation and collaboration skills to practise as part of a team. Our ADAPT skills training program is an excellent example of a best-in-class course to support pharmacists to transform the way in which they practise. But we need more of these types of programs to support intraprofessional and interprofessional collaboration between pharmacists, pharmacy technicians, physicians, nurses, and other health care providers.

Our third recommendation is about the federal government's leadership to support pan-Canadian health human resources—HHR—planning and innovation to achieve better health, better care, and better value.

As we've described, the pharmacist profession is very much in flux. In addition to changes in professional practice, there have been unprecedented changes to the pharmacy business model. With lower generic drug prices in all jurisdictions, the pharmacy business model has been squeezed. Pharmacists are in a situation of being asked to do more with less. As well, we went from an acute shortage of pharmacists a decade ago to a surplus in some cities now. With so much change afoot, it is becoming increasingly difficult to plan and manage the pharmacy labour supply.

The sustainability of the health care system requires that cost-effective models of practice be explored and human resources be deployed effectively. Therefore, we recommend that the federal government assume a greater role in human health resources planning, health care needs assessment, and support for interprofessional collaboration. Specifically for pharmacy, we need to do more research on the supply, workplace challenges, and labour market needs for both pharmacists and regulated pharmacy technicians across Canada. We need to track and forecast pharmacy human resources so that our profession can contribute its drug therapy expertise to ensure that Canadians' medication use is as safe and effective as possible.

Thank you.

[Janet Cooper]

Thanks, Phil.

To quickly summarize, CPhA is submitting three recommendations for your consideration. One, extend coverage of new pharmacist-provided services to federal populations; two, invest in education and training that supports practice change and expands its scope of practice; and three, increase the role and capacity of the federal government in pan-Canadian health human resources planning that includes pharmacy labour market studies and forecasting models.

While we recognize that health care is mostly regulated and delivered at the provincial-territorial level, the federal government does have a key leadership role to play. With our aging population and the challenges of health care costs and chronic diseases, we still have a lot more to do to make sure Canada has the right mix of health care providers with the right skills in the right place and at the right time.

Once again, Mr. Chair, on behalf of the Canadian Pharmacists Association, thank you for undertaking this important study. We look forward to your questions and comments today, and also to working with the federal government and other stakeholders in implementing solutions.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Next up from the Association of Faculties of Pharmacy of Canada, Mr. Lopatka.

Go ahead, sir. You have 10 minutes to deliver your presentation.

[Harold Lopatka, Executive Director, Association of Faculties of Pharmacy of Canada]

Good morning, all.

Thank you to the chair for allowing me to make the presentation on behalf of the Association of Faculties of Pharmacy of Canada. As mentioned, I'm the executive director for the organization. I do have a pharmacy background as one of my first educational credentials.

I've submitted a written copy of my presentation notes and I'll be highlighting some sections of those notes. My presentation is divided into six parts, and I'll just mention each part as I'm going along.

First, some information about AFPC, and I'll use the initials throughout because the name is quite long. AFPC is a national, not-for-profit organization advocating for the interests of pharmacy education and educators in Canada. The AFPC mission is to promote and recognize excellence in pharmacy education and scholarly activities. Canadian pharmacy education is highly rated in international comparisons and new graduates are highly sought after upon completion of their studies. They're approximately 5,000 undergraduate students enrolled at any time, and approximately 1,250 students who graduate from Canadian pharmacy faculties each year.

AFPC has established national education outcomes for educating students to become pharmacists in Canada. The educational outcomes are routinely used in planning, implementation, and evaluation of all university pharmacy degree programs. The current educational outcomes are formatted with the overall goal of graduating medication therapy experts.

Next is some information about post-secondary pharmacist education. There are 10 pharmacy faculties in Canada. Faculties are located at the following universities: British Columbia, Alberta, Saskatchewan, Manitoba, Toronto, Waterloo, Laval, Montreal, Dalhousie, and Memorial. Canadian universities provide a bachelor's; master's; doctor of pharmacy, known as the Pharm.D.; and a doctor of philosophy, known as a Ph.D. They are different.

Until recently, the first professional practice degree in all faculties was the baccalaureate degree. Students in two provinces now—Ontario and Quebec—receive a doctor of pharmacy, or Pharm.D., as their first professional degree. Faculties in other provinces are in the process of transitioning to an entry-level Pharm.D. For example, they're developing proposals, obtaining university and provincial approvals, and then revising their curricula. AFPC has a vision for all pharmacy faculties in Canada to offer the Pharm.D. as their sole professional degree by 2020. The University of Montreal was the first faculty to transition to the entry-level Pharm.D.

The following are a few highlights and elements of this new curriculum provided to Pharm.D. students at the University of Montreal, and it's representative of approaches taken in other provinces.

The curriculum is based on a competency-based framework with generic competencies including professionalism, communication, teamwork, and interprofessional collaboration, scientific method and critical thinking, lifelong learning, and leadership. The program is well adapted for today's students. Students in the program are active learners, with the faculty acting as coaches. For example, students receive faculty guidelines and questions to guide them through the discovery process. Of the curriculum, 44% is what we call experiential learning, which is a mix of skill laboratories, integration activities, and clerkships. The program relies on a pool of over 1,200 trained pharmacist preceptors from all practice settings. It also integrates multiple interprofessional learning modules.

The experience from Quebec suggests that the newly graduated Pharm.D. graduates are very well equipped to practise pharmacy in alignment with the newly defined, expanded scopes of pharmacy practice. All pharmacy programs in Canada meet the AFPC educational outcomes, which I referred to as a requirement for the Canadian Council for Accreditation of Pharmacy Programs.

Next is a brief history on national pharmacist human resource activities. In the period 2006-08, the initiative named Moving Forward: Pharmacy Human Resources for the Future was conducted, involving a multipronged research and analysis program to gather qualitative and quantitative information on Canada's short-term and long-term challenges in the area of pharmacy human resources. My colleagues from the Canadian Pharmacists Association have explained this activity briefly.

Meaningful workforce planning can only be conducted based on available data. Since the moving forward initiative, the Canadian pharmacists database has been further developed and refined. The database is administered through the Canadian Institute for Health Information, known as CIHI. The database has collected information about pharmacist manpower since 2006, with six years of data currently available. The database contains information on the supply and distribution, demographics, geography, education, and employment of pharmacists in selected provinces and territories.

The Canadian pharmacy practice and business environment were stable for many years. However, the environment for the pharmacy profession has changed dramatically. These changes have been summarized by my colleagues from the Canadian Pharmacists Association. There have not been any recent national reviews of pharmacist manpower. Given the recent changes in pharmacies, there is a need to review pharmacist workforce planning, including pharmacist supply and demand.

Next, from the perspective of AFPC, are some words about the pharmacist workforce balance.

In the late 1990s and early 2000s, there was a pharmacist shortage in Canada. The shortage was addressed through increases in the numbers of international pharmacy graduates, abbreviated as IPGs. Immigration policies were adjusted to allow foreign-trained pharmacists to gain entry into Canada. Annual quotas were established for IPGs, and formal IPG training programs were established to assist foreign-trained pharmacists adjust to the Canadian pharmacy practice environment.

According to the most recent 2012 CIHI pharmacist workforce report, 24.5% of the Canadian pharmacist workforce is made up of IPGs. While these pharmacists are qualified pharmacy practitioners, their skills and abilities to address the expanding scope of practice of pharmacy in Canada are often limited by their educational background, which usually has focused on drug distribution and not on the new clinical services pharmacists can offer.

In addition, the capacity of the Canadian pharmacy faculties to produce Canadian pharmacy graduates was increased, including the addition of one faculty at the University of Waterloo. In the 10-year period of 2003-2012, the size of Canada's pharmacy faculty graduating classes increased by 42.8%. Based on current enrolment figures, the number of new graduates projected for the year 2018 is 1,398.

A coalition of national pharmacy organizations, including the Canadian Pharmacists Association and AFPC, met with representatives from Health Canada and Citizenship and Immigration Canada to discuss the concerns about changes in pharmacist supply and about the quotas of internationally trained pharmacists. The meetings resulted in Citizenship and Immigration Canada making a minor adjustment in immigration quotas for internationally trained pharmacists.

AFPC believes the Canadian pharmacist manpower balance has changed from a shortage to a surplus. The deans of pharmacy and pharmacy faculty members began receiving anecdotal feedback from new graduates about changing employment conditions; for example, being unable to secure pharmacist positions. In response, AFPC has instituted a graduate employment survey to track the employment situations for newly graduated pharmacists. The results from the survey indicate that 17% to 19% of new graduates were unemployed at the time the survey was administered after the completion of their winter term classes in their last year.

CIHI data shows that the percentage of unemployed pharmacists increased from 6.2% to 7.7% over a four-year period.

Next are some recommendations from AFPC.

It is recommended, first, that Health Canada, through the health human resources strategy division, and Citizenship and Immigration Canada reset immigration quotas for internationally trained pharmacists until a comprehensive assessment of current and future pharmacist manpower is completed.

The second recommendation is that Health Canada, through the health human resources strategy division, establish a multi-stakeholder pharmacist workforce planning initiative to conduct a comprehensive assessment of current and future pharmacist manpower, focusing on the supply and demand for pharmacists. My colleagues in the Canadian Pharmacists Association have identified this as their third recommendation.

In summary, I've presented AFPC observations, reflections, and suggestions about the pharmacist manpower situation in Canada. AFPC is submitting two recommendations for your consideration: one being resetting immigration quotas for internationally trained pharmacists; and two, conducting a national multi-stakeholder pharmacist workforce planning initiative.

Thank you on behalf of the Association of Faculties of Pharmacy of Canada for the opportunity to present our views and suggestions on this important topic for pharmacy educators, students, and other pharmacy organizations. I look forward to your questions and look forward to working with the federal government and other stakeholders in addressing this topic.

[The Chair, Conservative, Ben Lobb]

Thank you very much, Mr. Lopatka.

We're now entering the question portion of our meeting.

First up for the first seven minutes is Ms. Davies.

[Libby Davies, NDP, Vancouver East, BC]

Thank you very much, Chairperson.

Thank you to the witnesses for being here today, in person and also on the phone.

I do think that looking at the scope of practice for pharmacists is probably one of the best examples of where some really practical things could be done that would improve health care and, as you have pointed out, where pharmacists could become much more part of a community-based team approach.

I really like that you've put out this spreadsheet that shows the different aspects of expanded practice across the country. It's very helpful. Looking at Alberta where everything is ticked off, I think Alberta and Nova Scotia are the best.

How aware is the general public? I'll give you an example. We've been using a lot of our personal experience in scope of practice. In B.C., I did not realize that pharmacists could provide emergency prescription refills or extend or renew. How does that happen? Who activates that? I have prescriptions; most people do. I didn't know that. How is this public knowledge and how does one activate it?

[Janet Cooper]

That's an excellent question because one of our top priorities is awareness and supporting a national public relations campaign. I think many Canadian patients have already accessed these services, but most Canadians don't even know. When they do experience it, they like it. It's fast; it's accessible. You can go out on your lunch break, get your flu shot, and be back and still have time for lunch. A lot of Canadians are aware of flu shots, but the ability to have an appointment to sit down with your pharmacist and spend 15, 20, or 30 minutes to review your medications, most of them don't know about that and all these other services. Some of it will be word of mouth but I think we need to be putting more effort into it.

For example, when the Ontario government introduced the MedsCheck program they had TV ads.

[Libby Davies, NDP, Vancouver East, BC]

If I could get specific, I think most people do know about the flu shots because the pharmacies advertise. And most people know, certainly in B.C., if you get a prescription they automatically sit down with you and go over it.

I think what is not so well known is that they can provide an emergency refill and renew and extend and change the formulation. Who activates that? Is it the patient who says she thinks she needs a change in dosage, or is that the pharmacist? Do they check with the doctor? How does it happen?

[Janet Cooper]

It depends on the province. Alberta is the most advanced. They have something called additional prescribing authority, and the pharmacists can start new drugs and stop. It has to be within a collaborative practice model. The community pharmacist has to communicate with the family doctor, because they have to know of any changes. You can't just go and do these things and not tell anybody. If you have electronic health records, it certainly enables that kind of communication in a better way.

A lot of times it's very simple things, like a prescription for amox antibiotic suspension and the mother says her child won't swallow that. The pharmacist can change it to two tabs: very simple, practical things. Or somebody can't get in for the refills for their hypertension medication because their doctor's away, so the pharmacist can extend those refills, check the patient's blood pressure while they're in the pharmacy, and make sure things are okay.

Awareness will increase with time. We would like the awareness to be much greater, of course, and we're working toward that.

[Libby Davies, NDP, Vancouver East, BC]

Do I have some more time?

[The Chair, Conservative, Ben Lobb]

You have, yes, two and a half minutes.

[Libby Davies, NDP, Vancouver East, BC]

I have a couple other questions, then.

Changing the scope of practice goes through provincial legislation, does it not? In all of the provinces in which it has happened, it has been through specific legislation.

Is there a negotiation process, say, with you and the College of Physicians and Surgeons or some regulatory body in coming to agreement when a scope of practice is seen to infringe on somebody else's scope of practice?

How does this happen? Or do you just wait for a provincial government to say, this is a good idea; we're going to do it?

[Janet Cooper]

I think Alberta was first. It really was driven in a big way by the pharmacy regulatory body, and by their volunteer association as well. There was a lot of angst within the physician community, and we had many discussions with the Canadian Medical Association and others. But once it rolled out, it was not an issue. Everybody figures out a way to work together. New Brunswick was next. The health minister said: we like what Alberta did; make it happen here.

So it has happened in various ways; sometimes it has been pharmacy pushing it, sometimes governments.

What we've seen over the years is that the level of angst and concern, with physicians in particular, has decreased so much. Over the last few years, the provinces that have rolled out—Saskatchewan, Nova Scotia—have worked very closely with the medical regulatory organization and the advocacy organization to talk through it. As long as everybody understands what it means—and the word “prescribing” means different things to different people—it will work out in the end.

[Libby Davies, NDP, Vancouver East, BC]

Here is one last quick question to Mr. Lopatka.

In your recommendation you say that you want to “reset” immigration quotas. Could you explain what you mean by that? Do you mean reset it up or reset it down? Who would decide what the number is? I'm just not quite clear what you're saying in your recommendation.

[Harold Lopatka]

Thank you.

Our understanding is that the immigration quota is determined by CIC or the immigration group within the federal government. The last we understood, in the neighbourhood of 1,000-plus individuals were being allowed to immigrate into Canada. We would like to see the number lowered until the manpower situation is completely studied.

[Libby Davies, NDP, Vancouver East, BC]

All right, thank you. So you want to see it lowered.

[Harold Lopatka]

That's correct.