Health Committee on March 10th, 2015

[The Chair, Conservative, Ben Lobb]

Good afternoon, ladies and gentlemen. Welcome back and thank you for being here. We're starting our study up again regarding best practices and federal barriers to practice and training of healthcare professionals.

We have two panels this afternoon.

Before we do though, I would ask that at some point in time in the next week or so that the vice-chairs and the chair reconvene. We had agreed on an April 2 date for a meeting and that date will no longer work, so at some point in time if the vice-chairs and the chair could figure out a date that will work, we'll do that. That day is a Thursday, but in the parliamentary calendar, it's a Friday so it's not going to work.

Today, we have the Canadian Chiropractic Association, the Canadian Dental Association, and the Canadian Dental Hygienists Association.

We're going to start on my left and we're going to start with the Canadian Dental Hygienists Association, Ms. Wright and Ms. Leck.

[Ann Wright, Director, Dental Hygiene Practice, Canadian Dental Hygienists Association]

Thank you very much.

I am Ann Wright, director of dental hygiene practice at the Canadian Dental Hygienists Association. With me is Victoria Leck, dental hygienist and manager of professional development.

CDHA is the collective national voice of more than 26,000 dental hygienists in Canada, representing over 17,000 individual members. Dental hygiene is the sixth-largest regulated health care profession, and dental hygienists play a vital role in helping to maintain and improve oral and overall health for Canadians.

Dental hygienists are educated at four universities and 33 colleges across Canada, and practise in a variety of settings, including public health agencies, independent dental hygienist practices, traditional dental practices, hospitals, long-term care facilities, educational institutions, and research centres.

Dental hygiene care is not limited to providing preventive services such as scaling, root planing, tooth sealants, and fluoride applications. We aIso examine clients for signs and symptoms of oral cancer, and are committed to facilitating behavioural change through tobacco cessation and nutritional counselling. ln addition, CDHA has participated in Minister Ambrose's family violence and child abuse prevention round table discussions. Because the physical signs of family violence often occur in the head, neck, and face, dental hygienists are in a key position to identify and report on these signs and symptoms.

We are very pleased to have the opportunity to meet with you today and highlight the areas in which the federal government can provide leadership to better meet the health needs of all Canadians.

Poor oral health can cause pain, diminish workplace productivity and general quality of life, and is now recognized as a risk factor for diabetes, and cardiovascular and lung diseases.

ln its report published in 2014, the Canadian Academy of Health Sciences identified the major issues and inequalities in relation to oral health and access to oral health in Canada. Compared to the rest of the Canadian population, vulnerable groups, including seniors, aboriginal people, and the homeless, are more likely to avoid dental care due to cost and have untreated dental decay, gum disease, and pain.

Although health care in Canada is delivered primarily by the provinces, the federal government does have populations for which it is directly responsible for providing health services. Veterans benefit from programs managed by the Department of Veterans Affairs, and first nations and Inuit communities receive health care through non-insured health benefits, NIHB. Insofar as Canada's indigenous populations are concerned, the first nations and Inuit oral health surveys have shown repeatedly that they experience poorer oral health as compared with Canadians as a whole.

Compared with other OECD countries, Canada ranks among the highest in mean per capita spending on dental care, but the majority is funded by private insurance plans, which are not accessible to Canada's neediest. Canada requires leadership from the federal government to ensure that all Canadians have equitable access to appropriate health care professionals who can provide the highest quality care in the right setting and at the right time, based on their personal needs.

A profession's scope of practice encompasses the activities that practitioners can perform based on educational preparation and legislative authority. ln Canada, a profession's scope of practice is shaped by social, legislative, regulatory, and financial forces, which have often hindered the optimization of resources and the overall improvement of care. Currently, dental hygiene scopes of practice vary considerably across Canada, and these differences become apparent when comparing provincial and territorial legislation.

For example, Albertans have direct access to a dental hygienist with the broadest scope of practice in Canada. Dental hygienists in that province hold prescribing authority for schedule 1 drugs, can take and interpret radiographs, and provide local anaesthesia to alleviate oral pain during health procedures. ln contrast, federal programs, such as those offered by Veterans Affairs, prohibit dental hygienists from practising to their full scope by permitting only the most basic level of dental hygiene services for veterans. These services are based on the lowest common denominator of dental hygiene scope of practice.

Moreover, first nations communities often have little and/or infrequent access to oral health providers, yet the non-insured health benefits program for first nations does not recognize dental hygienists as direct oral care providers, even if they live on or near first nations communities, except in the province of Alberta.

We urge the federal government to move quickly to ensure that all NIHB program recipients have the same access to oral health services across the country.

In the north, supervisory provisions require dental hygienists to work under the direction of a dentist exclusively, which severely limits public access to oral health care. This requirement has been removed from almost all other provincial legislation, leaving Canada's northern populations decades behind the rest of the country.

The goal of a successful health care system is to deliver safe, effective, and efficient care. The best use of the health professions' scopes of practice embraces innovative solutions to meet the evolving needs of the public. For example, despite current regulatory barriers in the far north, CDHA has partnered with Health Canada and the Government of Nunavut in an innovative oral health project for children between the ages of zero and seven, living in all 19 Nunavut communities.

The government is funding a project where dental hygienists provide preventive services, which include temporary restorations called interim stabilization therapy, or IST, to prevent pain and preserve tooth structure until the child can be seen by a dentist. This project, launched in 2014, has encouraging preliminary results and is a compelling example of the creative and effective use of health human resources to meet the demands of a specific population. We have enclosed a photo collage from this project.

Dental hygienists advocate for a national dental hygiene standard of practice that maximizes scope of practice to ensure that all Canadians, no matter where they reside, can receive equitable oral health care services.

The alignment of optimal scopes of practice with innovative model of care through educational, legal, regulatory, and economic structures will require time and cooperation from all stakeholders. Education is governed provincially, but with dental hygiene programs offered in eight provinces and 37 institutions, there is a federal role for standardized curriculum and accreditation, as well as opportunities to invest in linking education with scope of practice, regardless of jurisdiction.

In addition, the federal government is ideally positioned to take a leadership role in supporting pan-Canadian health human resource planning and innovations and interprofessional models of care to achieve better health, better care, and better value.

The sustainability of the health care system requires cost-effective models of practice. We recommend that the federal government assume a greater role in health human resource planning and in supporting interprofessional collaboration. The ultimate goal of an equitable and sustainable system is for the transformation of scopes of practice and models of care to best meet the needs of Canadians.

To summarize, CDHA is submitting three recommendations for your consideration.

First, the federal government must recognize dental hygienists as service providers and extend oral health services to populations it serves through its federal health care programs.

Second, in order to ensure that all Canadians have equitable access to the right professional providing the highest quality of care in the right setting and at the right time, the federal government must review and amend outdated legislation related to scope of practice, particularly in the far north.

Third, the federal government must invest in education and training that supports comprehensive scopes of practice and must play a greater role in the pan-Canadian health human resource planning.

While we recognize health care as primarily regulated and delivered at the provincial and territorial levels, the federal government does have a key leadership role to play. With oral health disparities experienced by first nations and Inuit populations, and rising health care costs, it is imperative that we work together to ensure that Canadians have access to oral health services. We still have significant work to do to guarantee that Canada has the right mix of health care providers.

Once again, Mr. Chair, on behalf of the Canadian Dental Hygienists Association, we thank you for allowing us to contribute to this discussion. We look forward to working with the federal government and other stakeholders to implement these identified recommendations.

Thank you.

[The Chair, Conservative, Ben Lobb]

Next up, the Canadian Dental Association, Mr. Soucy and Mr. Desjardins.

[Dr. Benoit Soucy, Director, Clinical and Scientific Affairs, Canadian Dental Association]

Thank you, Mr. Chair.

Good afternoon, everyone. I'm Benoit Soucy the director of clinical and scientific affairs at the Canadian Dental Association. Kevin Desjardins is the director of government relations.

It's our pleasure as the national representatives of Canada's dental profession to participate in your study of best practices and federal barriers related to the scope of practice and skill training of health professionals. There are more than 18,000 dentists in Canada. All are licensed by a provincial or territorial authority. Thanks to the work done in relation to chapter 7 of the Agreement on Internal Trade, all can move between Canadian jurisdictions without any need to have their professional competencies retested.

The majority of dentists work in private offices, either as solo practitioners or with one partner. The largest practices in the country can involve as many as as 30 to 40 dentists. Independently of their practice setting, all dentists involved in the delivery of oral health care in Canada share an important characteristic. They could not provide services to their patients at the same level of quality and as efficiently without the support of a dental team where each individual has a clearly defined role to fulfill.

Some members of the dental team, such as receptionists and practice managers, are completely unregulated because they are not directly involved in patient care. Others, such as assistants and dental hygienists, are regulated under models that vary from province to province and that in many cases provide for independent self-regulation, placing these occupations outside the purview of dental regulators.

In addition to these members of the dental team, three other occupations are involved in the delivery of oral health care in Canada: dental technicians, who are mainly involved in the fabrication of devices used by dentists in the treatment of their patients; denturists, whose scope of practice is related to the independent delivery of removable prostheses to those who are partially or completely missing teeth; and dental therapists, who are trained to deliver limited restorative and surgical services under the direct supervision of dentists.

Of these occupations, dental therapy is likely the one that has the most relevance to the work of the committee. Outside of Ontario and Quebec, where they are not allowed to practice, dental therapists have been used to improve access to care for children and for remote populations. In many cases they have been employees of the federal government working for the first nations and Inuit branch of Health Canada.

The National School of Dental Therapy, NSDT, was created in 1972 operated with funding from Health Canada until 2011 when the funding was discontinued. This was done because, in spite of its ongoing funding of the NSDT, Health Canada had chronic difficulties filling the positions it had available to serve first nations and Inuit living in remote areas, as the graduates of the program preferred working in urban dental offices in Saskatchewan and Manitoba, the two provinces where they could get licensed to practice.

The failure of the NSDT program to provide access to care in areas where it was intended does not mean that such results cannot be accomplished through actions related to scopes of practice. As mentioned above, dentists rely on the presence of dental assistants and dental hygienists in their offices to deliver quality care efficiently. Changes to provincial regulations, such as the introduction of scaling modules that allow an assistant to provide that service in provinces experiencing a shortage of dental hygienists, continue to improve the dentist’s ability to do so.

The presence of dental therapists in Saskatchewan improved access to care for children while economic evaluations of the federal program have demonstrated that dental therapy is a cost-effective means of providing care to children under specific circumstances. Outside of Canada, the use of dental therapists in New Zealand and Australia has been a success while preliminary evaluation of the impact of their use in Minnesota showed benefits that included direct costs savings, increased dental team productivity and improved patient satisfaction.

To achieve those positive results, these programs had to limit the new providers' ability to perform independently in the private system. Evidence has shown that, in many cases, the availability of additional types of providers will not reduce care prices or improve access to remote regions. They had to find ways to address the fact that dental fees in public programs do not meet the minimum amounts that are required to keep practices solvent, especially in remote locations with low population density. This was done by defining scopes for new providers in a fashion that allowed for reduced training times and reduced cost to the system, and by making the new providers salaried employees restricted to work in certain health settings to ensure they went where they were needed most.

In addition, successful programs provided sufficient, stable funding and managed to maintain the cost savings related to the reduced training time through careful management of the new providers' scope of practice over time.

Based on the experience of the programs discussed above, the Canadian Dental Association sees the following as best practices in relation to the scope of practice and the training of health care providers.

Only regulate occupations where the risk to patients justifies the cost of regulation.

Support regulation at the provincial levels with national systems of accreditation of educational programs and of certification of individuals to promote labour mobility.

Design scopes of practices for each of the involved occupations so they fulfill a real need and contribute to the safe and efficient delivery of care.

Identify all of the factors that could impact the success of new models for the delivery of care before they are implemented and put in place strategies to mitigate them. Such strategies will usually include reducing training time and costs to the system, preventing changes of scopes of practice that erode these savings, limiting the practice settings available to the new provider groups, and hiring them on a salaried basis to ensure they practice where they are needed.

I hope this short review of the experience of oral health care, with attempts to improve access to care through the introduction of new occupations and the broadening of the scopes of practice of others, will be useful to your work.

I thank you for your attention and will gladly answer any questions you may have.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Next up is the Canadian Chiropractic Association, Mr. David and Mr. MacDonald.

Go ahead, please.

[Dr. Ward MacDonald, Member, Canadian Chiropractic Association]

Thank you very much, Mr. Chairman, for the invitation to present to the committee.

Good afternoon, honourable members. On behalf of the Canadian Chiropractic Association, or the CCA, the profession and its patients, it is my pleasure to be here today along with my colleague Dr. Robert David, chair of the CCA, and a chiropractor in Montreal, Quebec. My name is Dr. Ward MacDonald, and I'm a chiropractor in beautiful Wolfville, Nova Scotia.

The CCA is the national professional association representing 8,400 trained and regulated doctors of chiropractic. Doctors of chiropractic must complete a minimum of seven years of post-secondary education, including a four-year, full-time program at an accredited chiropractic college. The intensive training prepares chiropractors to serve as Canada's musculoskeletal experts, providing evidence-based, drug-free, and non-surgical conservative care.

As one of three chiropractors in Wolfville, I am often required to practice as a primary contact provider within my full scope of practice. My patients will commonly seek care for a variety of musculoskeletal conditions, and even non-musculoskeletal complaints. Because of my training and the shortage of practitioners in my community, I am asked to evaluate, diagnose, and help patients find appropriate care. I work closely with other health care providers to ensure that my treatment enhances the care that my patients are receiving from their MDs and others. I feel privileged to have this opportunity.

Musculoskeletal conditions are a much bigger pressure on the health care system than most people are aware. Eleven million Canadians each year are affected by back pain and other musculoskeletal issues. lt is the second leading reason for a doctor visit, and the number one cause of disability in overall health costs. This burden has increased by 45% over the past two decades and is expected to continue to grow, in part due to the aging population.

As doctors of chiropractic, we have the clinical skills and expertise to not only assess patients but aIso diagnose musculoskeletal conditions. These conditions are some of the most debilitating and taxing to Canadian society. Our goal is to return patients to their activities of daily living as quickly as possible.

The evidence in support of manual therapy and other chiropractic approaches has made chiropractors an increasingly valuable part of the collaborative care team. This allows teams to use health dollars more effectively in managing patients with musculoskeletal conditions. For example, a number of provinces are using chiropractors and advanced practice physiotherapists to assess and triage patients with chronic low back pain, awaiting referrals to specialists. Among these, 90% are not candidates for surgery, but they can crowd wait-lists with unnecessary diagnostic imaging, such as MRIs and CTs. The outcomes include higher patient satisfaction, improved outcomes, and reduced system costs.

Musculoskeletal conditions are not only a provincial problem, but aIso of direct significance to the federal government. As the fifth-largest purchaser and provider of health care in Canada, the federal government has a direct and vital role to play in musculoskeletal health. Federal populations have a significantly higher incidence of back pain and other musculoskeletal conditions compared to the general population.

Most importantly, we need to talk about our Canadian Forces and veterans. Low back pain in the Canadian Forces is double that of the general population. These are young and fit men and women, yet musculoskeletal conditions are the reason for 53% of medical releases. Being a soldier is one of the most physically demanding careers. Without quick access to care, the result of that injury becomes chronic and can lead to medical release.

As musculoskeletal experts, our profession would like to do more. Currently, our soldiers have less access to chiropractic care than other federal employees. These injured soldiers go on to become veterans, and over half of the health claims made by veterans have a relationship to musculoskeletal conditions. Chronic pain from musculoskeletal conditions may not have the same profile as some other health conditions, but for those who suffer the impact can be profound. For example, musculoskeletal conditions can complicate treatments for mental health conditions if opiates are required for pain relief. As well, undue reliance on opiates can create dependency, with many related consequences.

I would now like to turn our presentation over to Dr. Robert David to outline opportunities that exist and the action the federal government can take to improve care of musculoskeletal conditions.

[Robert David, Chair, Canadian Chiropractic Association]

Thank you, Mr. MacDonald.

The federal government has been playing an instrumental role in innovation for many years. Such federal leadership contributed to the creation of St. Michael's Hospital Family Health Team. This hospital's project is an example of a collaborative care model based on nine provider groups, including medical doctors, nurses and chiropractors.

This model has grown and continues to operate successfully to meet the needs of patients and the community at large. As chiropractors, our role in this model has focused on better assessment and treatment of musculoskeletal, or MSK, conditions. St. Michael's Hospital Family Health Team was recognized as one of Canada's four centres of excellence in health.

There are a number of international models where MSK sufferers aIso have direct access to team-based care, including chiropractic care. The U.S. Department of Defense and Veterans Health Administration are two key examples. In Canada, Ontario and Saskatchewan have launched similar initiatives. These models of care can serve as benchmarks in assessing how team-based care could effectively serve federal populations.

ln December 2013, our association made a submission to the Standing Committee on National Defence and suggested the need to invest in the development of a comprehensive MSK strategy, emulating their efforts to develop a Mental Health Strategy.

A robust MSK strategy could address the significant burden of MSK conditions on the operational readiness and well-being of Canadian Forces members. We further recommended that both the Department of National Defence and Veterans Affairs Canada work collaboratively to reduce medical releases for MSK conditions.

Any recommendations from your committee should take into account this issue of need among federal populations and how best to utilize the practitioners already working in communities across Canada. We believe that advancements in the way we care for federal populations could also further benefit Canadians as a whole. Our association recommends that the federal government's approach seek to break down the silos between the various departments and better coordinate delivery of healthcare services by community-based providers.

Fortunately, the Canadian Chiropractic Association, or CCA, has observed first-hand how collaborative partnerships can help implement best practices to better serve federal populations. Notably, the Canadian Forces have taken important steps to better address the burden of MSK conditions for soldiers.

I would like to highlight the Canadian Forces' leadership for the support we have received during preliminary discussions on the merits of partnerships between the Canadian Forces and allied health providers to help support the care of soldiers. The CCA has committed to providing significant funding for a project designed to assess whether our soldiers could also benefit from the kind of access to chiropractic care that is in place for the U.S. military.

For the chiropractic profession, we already have a strong national scope of practice that establishes us as doctors delivering primary care for MSK conditions. We would welcome the chance to work with federal departments on developing new approaches that would not just improve health outcomes, but also use federal healthcare dollars more effectively.

We would be happy to further discuss any recommendations made, as well as provide more details on how MSK conditions are affecting Canadians. We can also share examples illustrating how we can use financial and human resources more efficiently.

Thank you very much for your time and attention. We will be happy to take your questions.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

The first round of questions is going to come from Ms. Moore.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

Before asking my questions, I would like to move a motion that we do not need to bring to a vote now. It reads as follows:

That the Standing Committee on Health include in its study of Best Practices and Federal Barriers: Practice and Training of Healthcare Professionals the witness testimony from Meeting 47 (January 27, 2015) from its consideration of Bill C-608, An Act respecting a National Day of the Midwife.

I will now ask my questions.

In your three respective professions, not everyone has coverage. Often it is private insurers that pay, but people who are not covered by such insurance have to pay out of their own pockets.

In terms of access, it is not the mechanism that interests me. I would like to know what health problems could be prevented if the entire public had access to your health services.

I would also like to know whether you think that your skills are sometimes underutlilized.

In what specific areas could they be better utilized?

If we had better and more efficient access to your services, what would be the benefits to our health systems in terms of costs?

When it comes to affordable care, other ways of doing things sometimes cost more. In regard to chronic conditions and complications of health problems, I would like to know how much costs could be reduced if you could intervene at an earlier stage to help people's health.

I will let each association take a turn to answer this series of questions.

[Robert David]

There are indeed many of them.

Musculoskeletal problems are very significant and have a serious impact on Canadians' health, quality of life and productivity. These problems account for over a third of missed work days and half of all visits to doctors. This situation has become almost epidemic.

There is indeed a very high need for care. That is also why we are suggesting that a comprehensive MSK strategy be developed. This would first helps us analyze the people's needs and the reasons why there are so many musculoskeletal problems.

Then we should see what can be done to prevent these problems. Naturally, it would be necessary to have access to appropriate care. For example, it may happen that in a military base a person has access to spinal surgery for a problem that can be easily treated by conventional treatments that are not available. In this case, care is accessible, but it is not necessarily the right care in that situation. Accessibility is very important.

That is the first part of my answer.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

If you do not have some data on hand today, you may send it in writing to the committee chair.

[Robert David]

That is a good suggestion. We will certainly send you a document with our answers to the other questions.

[Dr. Benoit Soucy]

In regard to dentistry, over the last five years, Statistics Canada conducted a very thorough study on the needs of Canadians. The study showed that the vast majority of Canadians were receiving the care they needed.

Due to the lack of public coverage for these services, a segment of the population—about 20%—does not have access to the necessary care. We must therefore target this population through public programs. The association certainly recommends programs specifically intended for these people, who are also those with the highest levels of dental disease.

We know that 80% of all cavities are found in the poorest segment of the population, which represents 20% of all Canadians. This is a major problem because it is entirely possible to prevent cavities. There is no problem preventing them, provided the necessary resources are there.

One of these resources is, unfortunately, education, while one of the factors that predict the occurrence of tooth decay and periodontal disease is socioeconomic level. If we were able to provide assistance in these areas, it would be very useful.

Dentists already have a relatively broad scope of practice, which allows them to diagnose, do surgery and use nearly all the approaches needed for the treatment of maxillofacial structures. Dentists can prescribe appropriate medication to treat these conditions. Therefore, we do not really have huge problems in terms of our scope of practice. We are able to deal with whatever problems we have with little difficulty.

When we do nothing and allow problems to go unchecked, we end up facing problems that are much more complicated and much more expensive. For example, it is well known that the main cause of surgery under general anesthesia in children is tooth decay. All these surgeries are easily predictable if the children are properly monitored in care. This is one reason why we propose that children be seen from the age of one at the latest, within six months of the eruption of the first tooth, so that we can intervene, predict and assess the risk of cavities, and act appropriately.

The use of hospital emergency services is another area where there are very high costs. There are not many reasons why a patient with dental problems should have to use a hospital's emergency department. Dentists can provide all the treatments needed. Many dental societies organize emergency services to deliver care around the clock. That is not available everywhere, but it is very common.

Therefore, there is no reason to go to a hospital. In most cases, people who go there do so for financial reasons, and treating them in a dental clinic would be much more efficient and less costly for the system.

[The Chair, Conservative, Ben Lobb]

Okay, Ms. Wright, a brief response, then time is up.

[Ann Wright]

Thank you.

I'll ask my colleague Victoria to answer that.

[Victoria Leck, Manager, Professional Development, Canadian Dental Hygienists Association]

I agree with much of what has been said by the Canadian Dental Association. There are targeted populations who, even though they have financial access to programs through first nations and Inuit health, still do not have access to the providers who can give them the care that they require.

It's not just a financial need or a need to expand access to programs, it's a need to have the right providers available to the populations that are most at risk. Social and economic situations are definitely impactful in oral health care. As the CDA said, many of the conditions are preventable. Early interventions by a prevention specialist, a dental hygienist, could have a positive impact in providing education to the families and to establishing good oral health care habits early in life.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Mr. Lunney, sir.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

Thank you very much, Mr. Chair.

Welcome to all of our witnesses today. I wanted to pick up where Ms. Moore was in talking about cost savings. She had directed that at the Canadian Chiropractic Association.

We're all concerned about sustainability of health care services and the accelerating costs. You mentioned a third of absentee-from-work situations involve MSK, musculoskeletal conditions, and half of medical visits, and you mentioned a global strategy for managing the costs of MSK.

I'm going to flip back the calendar a bit to...I think it was 1993. I believe it was the Ontario government that commissioned a report from a health care economist right here in Ottawa, Pran Manga, who studied chiropractic efficiency in managing low back pain alone, I believe, at that time. It was called the Manga report. I think his conclusion was that in Ontario alone they'd save hundreds of millions of dollars by employing an MSK strategy that would have chiropractors be primary contact practitioners that would engage first, just on low back pain.

I wondered if you could comment on the outcomes of that report. Was it a missed opportunity?

[Dr. Ward MacDonald]

Even just speaking back to earlier interventions and their success, the largest part of the burden represents about 30% of the patients who become chronic with musculoskeletal conditions.

Many models are built right now on getting early access so that conditions can be treated effectively before they become chronic. There are many models that have shown the cost effectiveness of having that early intervention. Many models exist right now where that is the primary focus. Anything that eliminates the barriers for patients to be able to get appropriate care at the right time has shown in many models to be cost effective. We're happy to provide more information with regard to those models.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

You mentioned a couple of examples of integrative care successes. I think it was St. Michael's Hospital. There are some very promising studies. You were talking about the United States model with the military. You said that the U.S. Department of Defense and Veterans Health Administration are two key examples, and that studies demonstrated that integration of chiropractic care to standard medical care improved pain and function without increasing costs, due to a strengthened team.

Could you tell us a little bit more about the U.S. experience with the military?

[Robert David]

Actually there are models even closer than that. Here in Ontario there have been some projects by the province to integrate the chiropractor as a secondary adviser for musculoskeletal conditions within a medical setting. It was a great success and the patient satisfaction.... The medical doctor appreciated the suggestions made by the chiropractor in order to orient the patient towards the kind of conservative care that he needed.

Again, this is a process of triage. People who desperately needed medical attention from a specialist got it faster. When you look at it from the patient's point of view, who's on a waiting to see an orthopaedic surgeon and knows that the list is two years in front of them, to have somebody come to them, assess them, and say that they really do need medical attention, then they're going to get it sooner because we've cleared the waiting time of a year and a half. It's terrific news. For the patient it's wonderful to have collaborative care like this.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

You can have some long wait times for a specialist, and that's a missed opportunity if your problem is degenerating in the meantime.

Can you give me an idea of the study that you said was here in Ontario? Where did it happen? How long did it run? Was it a pilot program? Is it still ongoing?

[Robert David]

I don't have that information right here but I'll make sure that it's forwarded to the committee within a few weeks.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

Okay, we thank you for that.

You mentioned practising in Wolfville earlier—I think it was Dr. MacDonald. You mentioned quite a percentage that was musculoskeletal—I've forgotten what percentage—but also another range of conditions that you have to get involved in.

For full disclosure, one of my colleagues suggested that I declare my conflict of interest here as a chiropractor for 24 years. We're called the House of Commons and we represent a lot of different backgrounds here.

I think people are surprised that chiropractors study the wide range of subject matter that we do, including obstetrics and gynecology, the medical doctor at here at the table with us as well. It's not that we're going to be delivering babies, but if you're practising up in Nunavut or in the boondocks somewhere and you're it—we've had the midwives here—and it's up to you to be the primary birth assistant, it's very helpful to know something about the process.

Could you just comment on chiropractors as primary care practitioners—I think you mentioned 8,400—and integration? You gave a couple of examples, but I see examples across the country of integrative care that includes dieticians, physiotherapists, and psychologists sometimes, but there is no chiropractor on that health care team. Are there missed opportunities in integration? Is there an opportunity to better integrate chiropractic services?

[Robert David]

You are right, for sure. St. Michael's again is a great example of where chiropractic is integrated. It's a multidisciplinary setting with nine professions within a hospital in downtown Toronto addressing the needs of musculoskeletal conditions for a low socio-economic community. It has had wonderful results. This is a program that has been going on for at least 10 years, but I'm not sure about the length of time. It's also giving care to the patient who couldn't afford it in this particular instance. It's a total success.

We would be happy to forward you some more information on that one.