Health Committee on March 12th, 2015

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Next up is HealthCareCAN, and we have Raj Bhatla and William Tholl.

William Tholl will be first.

Carry on.

[William Tholl, President and Chief Executive Officer, HealthCareCAN]

Thank you, Mr. Chairman, and good afternoon, everybody.

My name is Bill Tholl. I am the President and Chief Executive Officer of HealthCareCAN, which is the national voice of hospitals and other health care organizations in Canada.

We foster informed, continuous, results-based discovery and innovation across the continuum of health care. We act with others to enhance the health of the people of Canada, build capability for high-quality care, and help to ensure value for money in publicly financed health care programs.

You would better know us historically as the Canadian Hospital Association and the Association of Canadian Academic Healthcare Organizations. About a year ago, the two organizations merged.

This afternoon I'm joined by Dr. Raj Bhatla, chief of staff and chief of psychiatry at the Royal Ottawa Health Care Group here in Ottawa, one of our 40 member organizations. I've asked Raj to illustrate for you in some practical ways some of the issues around scope of practice and the area you're studying here today.

Before doing that, though, we're pleased to be here to contribute to your study of best practices and federal barriers related to scope of practice and skills training of health care professionals.

As one of the last groups to present to your study, we're certain you have heard a number of critical issues from individual professions. We would like to think that we bring a collage of those perspectives to this table. Many of the professions you've heard from work in our hospitals, in our academic health care institutions, and the perspective you get from that multi-professional perspective is somewhat different again. We'll try to explain just how that looks from our perspective.

The issue of scopes of practice is one of legislation and involves more innovative approaches to teaching. It is an issue requiring legislators not to look just at eliminating barriers but also at creating bridges, so my remarks today will be split into the two categories of looking at some of the barriers, but also looking at one of the things that the federal government can do. Given this is an area that's principally the responsibility of the provinces and territories—they are the ones that determine scopes of practice, that develop disciplinary legislation, that regulate—there are things the federal government can do to aid and abet, help, or hinder, so I'm going to break my remarks into two categories.

Generally speaking in this context, looking at scopes of practice is a function of time and place. This isn't the first time I've been before this committee talking about scopes of practice, wearing at least four different hats, but it's a different time. The fiscal environment is much different from that of the last 10 or 15 years, so it's not a simple task in the current policy environment of getting it right in terms of scope of practice.

I chair the finance and audit committee at the Royal Ottawa Hospital. We're now into the fourth year of zero means zero in terms of annual budget increases, and it has now become absolutely necessary to look at how we get it right in terms of scope of practice. Dr. Bhatla will share with you some of the things we have been doing at the Royal Ottawa Hospital.

As numerous professional groups have stated already, and I would echo, we need leadership and better leadership at all levels within institutions, within governments or across governments, and in fact, right down to patients. We need leadership such as that being demonstrated, we believe, by Minister Ambrose with the establishment of the Naylor advisory panel on health care innovation.

Health care organizations and personnel seeking innovative solutions find ways to work around things. I don't know whether folks have recommended to you the “From Innovation to Action” report that was prepared for the premiers and released in July 2012, but it identified nine very specific examples of integrated, full scope of practice exemplars across Canada.

One that I remember is the Brier Island, west of Halifax, where they had trouble keeping emergency physicians. They would go in and they would leave. They would shut down the ER department and they would have to open it up again. They came up with a marvellous innovation, which was to have souped-up paramedics to work in the actual community with direct on-call access to emergency physicians as and when necessary. That's the kind of innovation we think we need to have in Canada.

What's missing? What's missing is an ongoing source of support for that innovation. There is no ongoing innovation secretariat. The health care innovation working group doesn't support that. That's an area where we think the federal government has a role to play in establishing an innovation fund that would help promote the Brier Island kinds of innovations in Canada's health care system.

Another potential barrier is the new legislation on temporary foreign workers. You have heard, I think, from others that it has the potential for unintended consequences in terms of impeding our academic health care institutions from going out and recruiting post-residency training professionals or health researchers who are in their fellowship or post-fellowship training programs to spend a couple of years here in Canada. The current law potentially—potentially—creates barriers to our doing that.

I'd be glad to elaborate on any of these.

The last one I'll mention in terms of barriers is kind of a cultural barrier. The recently published report of the Canadian Academy of Health Sciences entitled “Optimizing Scopes of Practice: New Models of Care for a New Health Care System” notes, “Determining the optimal scopes of practice of these health care providers will be an essential element in leading health care transformation for the future.” I remind you that 80% of our health care costs in our hospitals are about people—health human resources—so we have to get that right in terms of striking the right balance. The report goes on to say, “Unfortunately, the systems in place for determining and regulating scopes of practice have done more to preserve the status quo than promote change.” We have to get past that. That's looking to the past to try to create a better future, and that won't work.

Let's get to the more positive stuff. What are the examples of building better bridges that would involve, or could involve, the federal government in a leadership capacity? This is all in support, by the way, of what I've already heard here today, which is the recurrent theme that we need better approaches to needs-based health human resources planning, the emphasis being on needs-based. When all is said and done, we've been more saying things than doing things when it comes to needs-based planning in this country.

I'll give four or five examples. One, the Government of Canada, working with the provinces, could convene a national symposium to bring all stakeholders together to talk about what you're talking about. Health Canada could fill the void left by the health care innovation working group, and in particular the health human resources working group which, to be frank, floundered as the third of the three working groups, and pick up where they left off.

For a very long time we've talked about creating an observatory where we'd look at health human resource needs through the lens of the patient and evaluate those on an ongoing basis, and yet we have not done anything. The closest thing we have come to it, by the way, is to fund a health human resources network on the basis of a CIHR funding grant. Dr. Ivy Bourgeault here at the University of Ottawa is heading that up. Their funding ends at the end of this month. I think that's a tragedy.

Health Canada could continue to work with HealthCareCAN and others to harmonize legislation and regulations across the country. I would put this under the general rubric of aiding, abetting, and supporting the overall intent of the Agreement on Internal Trade. We still have a lot of work to do in terms of harmonizing accreditation and licensing programs across the country.

[The Chair, Conservative, Ben Lobb]

Mr. Tholl—

[William Tholl]

Do I have to wrap up?

[The Chair, Conservative, Ben Lobb]

You're doing quite well. I just wanted to interject for a second, because you mentioned that Mr. Bhatla would have some time to present.

[William Tholl]

Yes, right. How about right now?

[The Chair, Conservative, Ben Lobb]

That's fine. I just wanted to make sure he didn't miss out.

[William Tholl]

Mr. Chair, I've asked Raj to give you some illustrations from one of our local hospitals on some of the challenges.

[The Chair, Conservative, Ben Lobb]

You have a couple of minutes, Mr. Bhatla.

[Dr. Raj Bhatla, Member, Royal Ottawa Mental Health Centre, HealthCareCAN]

Thanks, Mr. Chair. I will keep my comments very brief and it will be mainly a view from the front line.

I'm the chief of psychiatry at the Royal Ottawa, one of the academic health science centres in Ontario and part of HealthCareCAN across Canada.

My work on the ground is in large part telemedicine-based. I work in the operational stress injury clinic, giving support to veterans, RCMP, and members in the forces who are transitioning. What we found at our place is that the field is really ready to adopt some of the newer technologies.

I'll speak specifically about telemedicine where we've been able to get out of our hospital per se and get into all areas of eastern Ontario, providing clinics to people to have access to psychiatry. Not only is there access to psychiatry, but there is also access to nurses, psychologists, social workers, and addictions specialists. I think in many ways the field is really ready to adopt some of the technologies to outreach to patients and families in a collaborative and interdisciplinary way. We have a variety of things we can do not only one-on-one care but group care. Aftercare can be done in groups via telemedicine, a fascinating approach and very well liked by patients. They appreciate the access.

What will be coming, and we're experimenting with it now, is outreaching straight into the patient's home. We know that's happening for other chronic diseases, but mental health will surely follow. I think that will be a huge convenience to patients in the home. We know cardiology can be done pretty much in the home with data transmitted to health science centres and cardiologists. It's the same thing for dermatology. Wait times have decreased substantially.

Last, as a final example, we even do mental health review boards up to Yukon and Nunavut, providing access for people with mental health issues to the care and appropriate judicial safeties that they need, right from Ottawa, as opposed to flying people to the farther reaches of the north.

I think we have a lot of potential and I look forward to any discussion on it.

Thank you.

[The Chair, Conservative, Ben Lobb]

Thank you very much, and thank you for the work that you do with our veterans and Canadian Forces and RCMP, for sure, and other Canadians.

Ms. Moore, you're up.

Again, I will advise all members that we are up against the clock. We will try to keep it very close, if we can, to seven minutes.

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

Thank you, Mr. Chair.

My questions are for the President of the Canadian Federation of Medical Students.

During the previous hour, I spoke with a physician. I told him that when I did my schooling, the emphasis was placed on the clinical assessment of patients, and we were told that questions made up 70% of the assessment, the physical and visual examination made up 20%, and the remaining 10% was made up of additional tests such as blood tests and X-rays. Dr. Cline replied that he had noted among many young doctors a lack of skill or competence in physical examination. This comment was also echoed by other experienced physicians who said that they had often observed this shortcoming among young physicians.

On the other hand, it is difficult to fill positions in remote areas. Young physicians and nurses are asked to go and work in remote areas, where practitioners should have excellent skills in clinical and physical assessment and questioning patients, because there are fewer possibilities to get complementary tests done.

According to you, does medical training focus sufficiently on the fundamentals, that is to say skill in asking questions, relationship skills and the physical examination, so that that training is adapted to work in remote areas—for instance in aboriginal communities or areas under federal jurisdiction—where young physicians often have to practise when they finish their training?

[Bryce Durafourt]

Thank you for your question.

When we're talking about the physical exam, it still remains the basis of our training, I would say almost certainly. Of course our curricula do keep up with the times.

The curriculum at McGill, for example, has recently changed. The new curriculum does include ultrasound, which was not even included in my curriculum. There has been a lot of talk that these technological advances will replace instruments like the stethoscope, and we'll be more reliant on ultrasound.

I think training will always continue to have the basis of the physical exam, and we'll always learn to use the traditional ways, but we need to keep up with the times, for sure.

I think what we could do better is to promote campaigns such as Choosing Wisely Canada, which is a program that aims to reduce physicians' prescribing or requesting unnecessary tests. It saves money by reducing these tests. It also leads to better outcomes for patients if we don't have incidental findings that we need to investigate if there was no indication to do such a test.

By promoting these initiatives, we'll continue to focus on the important basics of the physical exam and the history taking, which has been and I think will remain the focus of our training.

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

If I understand correctly, even if new technological elements are being integrated into the training of doctors or nurses, it is essential that this never be done to the detriment of the fundamentals, such as the physical examination and the health questions designed to gather the patient's history.

[Bryce Durafourt]

That is correct.

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

Thank you very much.

Are young medical students made aware of the importance of prescribing fewer tests that are not necessarily useful and slow down the functioning of the health care system?

[Bryce Durafourt]

Not enough, and I think more should be done to raise their awareness.

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

Fine.

Sometimes, one has the impression that physicians order tests to protect themselves from being accused of not having done the test. Sometimes, they order tests just for reassurance, when they are already 99% sure of the diagnosis. But the test is done anyway, just in case.

[Bryce Durafourt]

That is certain. Ordering tests for self-protection is a part of the legal aspect of things.

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

Fine.

So this is a barrier in the way of good health care practices.

[Bryce Durafourt]

Yes.

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

Very well.

Mr. Bhatla and Mr. Tholl, do you have anything to add?

[Dr. Raj Bhatla]

Being a psychiatrist, obviously I think talking to people is really important. Tests will only tell you so much. You won't even know what to test if people don't actually come forward with some comfort in telling you what's troubling them and don't have the confidence that you will do things the right way.

The other thing is that health care is turning into a team game, so even if you talk about physicians, it's how physicians interact with nurses, psychologists, an others to make sure we bring out the qualities in other professions and work as a team to help an individual. I think we'll have much less one-on-one care, but understanding and caring about patients and speaking to them, I hope, is going to remain front and centre in the art of health care.

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

As a psychiatrist, do you often see that people have not received optimal treatment, simply because the examination was done too quickly? Do you sometimes hear patients say that they consulted a physician who saw them for two minutes and prescribed something that did not help?

[Dr. Raj Bhatla]

That happens a fair amount, and I wouldn't fault anyone other than the system on that one. In psychiatry we're blessed—or unlucky, depending—that we're time-based in terms of the remuneration to psychiatrists in a fee-for-service system. You get paid for the amount of time you spend, and we don't overspend because of a lot of demand. In family medicine at times—and not in all the models, but it's fee-for-service—you really have to get through a lot of people, so I really feel bad for the primary care physicians who sometimes cannot spend the time they would like. That's where you can get into very good shared care models that could help both sides.