Evidence of meeting #33 for Health in the 42nd Parliament, 1st session. (The original version is on Parliament’s site, as are the minutes.) The winning word was need.
A recording is available from Parliament.
Conservative
Len Webber Conservative Calgary Confederation, AB
Okay. It should have stopped here as well. That's my point.
NDP
Don Davies NDP Vancouver Kingsway, BC
Thank you, Mr. Chair.
Thank you to all the witnesses for some very powerful and very trenchant testimony.
Ms. Silas and Mr. Naidoo, I want to start with you. In your view, should we develop a national pharmacare program? Do you believe it should be created as a separate stand-alone program managed collaboratively by the federal, provincial, and territorial governments, or, alternatively, should existing provincial and territorial public health insurance plans instead be expanded to cover out-of-hospital prescription drugs as a requirement under the Canada Health Act?
President, Canadian Federation of Nurses Unions
I think you heard from Professor Perry that it has to be based on the evidence, the evidence, the evidence. It is clear that in our country, because of its size and population, that we need one system to work in collaboration with the federal government, the provinces, and the territories. Right now we have 13 little kingdoms or queendoms around the country deciding on which medication is going to be on a formulary. We need to bring that expertise into one house and save money, but we also have to push the expertise up to make sure that we have the best system in the world.
NDP
Don Davies NDP Vancouver Kingsway, BC
Would it be your suggestion that we create one national formulary, albeit with input from the provinces, territories, and independent experts?
President, Canadian Federation of Nurses Unions
It is, and it's also to take it out of the hands of politicians.
I'll go further than Professor Coyle. In January we had a meeting with the provincial and territorial health ministers. They were all there. The most support we got was when we said we needed an independent committee to accept what was on the formulary.
Take it out of the hands of the politicians. Regardless of their education status, they don't want it to be a political or a commercial decision. It has to be based on the evidence, and we have to make sure it's the experts. It's not the Linda Silases of the world or the Minister Philpotts of the world; it's the experts.
Anil Naidoo Government Relations Officer, Canadian Federation of Nurses Unions
There's also one aspect of this that goes even further and is even more damaging. We have benefits managers in corporations who are asking, “Why am I managing drug programs?” Part of the absurdity of the system we have right now is that a large chunk of it is managed by corporations that have no expertise, and we're price-takers, and beyond that even, it's whatever drug is approved that gets onto the formularies. These are open formularies. They are very damaging financially and also as health benefits.
NDP
Don Davies NDP Vancouver Kingsway, BC
I have one other question to you, Ms. Silas. You mentioned the need to develop a Canadian model based on best practices. You pointed out in your brief that Canada is the only country in the world with a national hospital and physician care system that does not have some form of pharmacare, so we're not reinventing the wheel here.
What specific practices do you think should underpin a Canadian model?
President, Canadian Federation of Nurses Unions
It should be universal for sure, and then it should be based on the evidence. I think if we stick with those two, we will save the money we need to get reinvested in our health care system.
Universality is what our health care system is. Dr. Carrie talked about physiotherapists or chiropractors; those will still exist. We will still have an insurance company system out there in our health care system, but the base of what we need to get better has to be covered under a universal program, and that's where prescription drugs should be.
Government Relations Officer, Canadian Federation of Nurses Unions
I would just add—
NDP
Don Davies NDP Vancouver Kingsway, BC
I'm sorry, Mr. Naidoo. I have a couple of other questions. I only have seven minutes.
Dr. Perry, I need to ask you a question. In fact all witnesses, but you in particular, have highlighted the critical need for independent evidence-based pharmaceutical prescribing and formulary development. If we created a national universal pharmacare system with a national formulary, what specific suggestions would you give us to create that? How do we create that national formulary with independence?
Chair, Education Working Group, University of British Columbia Therapeutics Initiative
We've learned a lot in British Columbia about the value of independence, and we learned that someone who has no stake, who has no conflicts, and is not allowed to hold conflicts will inevitably make a different judgment over the facts than someone who has been compromised.
The Americans have learned this. The National Academy of Medicine recommended five years ago that guidelines we can trust be developed by people who are not allowed to have conflicts of interest.
Professor Gord Guyatt at McMaster University, an internationally famous Canadian scientist, has been emphasizing the need to revise any Canadian medical guidelines under the same principles so that you have to say to a cardiologist, “You're a wonderful doctor and we know you have a lot of clinical experience, but because you have been a key opinion leader for a pharmaceutical company, you're not going to be allowed on the guideline committee.”
I think Dr. David Juurlink probably explained—he certainly did at the opioid summit—that with an opioid guideline now, people with any possible conflict of interest are being excluded from the guideline. It's somewhat like the best of our court system. It's the only possible way to make the best judgment.
I think the other important answer is we need more evidence. For example, someone amongst us oldsters in this room almost certainly has atrial fibrillation, and if there isn't anyone here yet, there will be one of us within the next five or 10 years. When that happens, we don't know what the best anticoagulant treatment is. There are now five possible oral drug choices in Canada. No one can possibly tell you what the best treatment is—no cardiologist, no matter how expert—and the opinion of the Canadian Cardiovascular Society is that we won't ever know because no one will ever do an experiment to find out.
No, of course, they won't. The drug companies who make product A will not run it against products B and C in an honest trial to find out, but if we wanted to know as Canadians—I am likely to face this, given my family background—what the best treatment is, we need a publicly funded trial on the model of the U.S. veterans administration or the U.S. National Institutes of Health or the British Medical Research Council. Even in Canada we used to have some Medical Research Council trials in the old days. We could find that out, and that would be a critical element of the evidence-gathering for a rational program.
NDP
Don Davies NDP Vancouver Kingsway, BC
Dr. Perry, I want to quickly get a question in on transparency and sunshine laws, because you seem to be highlighting this.
Do you have any suggestions? Maybe you and Dr. Coyle as well could tell us how we can shed more light on this.
Chair, Education Working Group, University of British Columbia Therapeutics Initiative
Yes. Thank you for the question.
We have a desperate need. I was showing one of my medical students an obviously conflicted opinion on opioids from the Mayo Clinic Proceedings journal in 2009, which sounds like a very prestigious journal. It's an article obviously ghostwritten, not written by the professor whose name was on it but written by a medical communications company and paid for by one of the opioid manufacturers. I asked my fourth-year medical student two weeks ago to try to find out how much this man was paid. Within minutes he was back to me by email saying it was $500,000 U.S. during 2015.
The U.S. has cms.gov, the Centers for Medicare & Medicaid Services' sunshine law. We have no ability to know anything in Canada—that is, anything about payments to physicians or to other health care providers, maybe nurses or social workers. With one stroke, if the Parliament of Canada passed a sunshine law, we would suddenly know who the key opinion leaders are and how much they have been paid to give the kind of messages that led, in large part, to the opioid crisis.
Liberal
Liberal
Ramez Ayoub Liberal Thérèse-De Blainville, QC
Thank you, Mr. Chair.
I thank all of the witnesses for being here with us today.
We are going to continue the discussion. My questions are about conflicts of interest.
This seems interesting to me, because the notion of conflicts of interest was present in this regard a few years ago and could continue to be present in the future, but with different parameters, points of view and ways of evaluating these aspects.
I paid close attention to Ms. Silas' testimony concerning the independence of the decisions of a committee or an independent group, in connection with their accountability.
In my opinion, that committee needs to be completely independent, free to act and to make choices. However, the fact remains that there are choices to be made and that a government is always ultimately accountable, either at the provincial or federal level. Governments provide the funding.
Regarding conflicts of interest and accountability, how do you see the relationship between those two concepts? Ms. Silas could answer first, and then I will give the floor to Dr. Coyle and Dr. Perry.
President, Canadian Federation of Nurses Unions
Thank you for the question.
When we talk about conclusive evidence, we are talking about all of the evidence. It is not just a matter of the medical impact the medicines can have, but also their cost.
As politicians, when recommendations are submitted to you, as is being done today, you try to find a balance. Firm recommendations will be made. Of course, the cost aspect must also be included in any decisions.
However, the conflict of interest issue must be of prime importance in how the evidence is collected for those who will ultimately make the decisions.
Liberal
Ramez Ayoub Liberal Thérèse-De Blainville, QC
I believe I understood that you want us to exclude the political aspect from our decision making.
President, Canadian Federation of Nurses Unions
Yes, and that is what the majority of Health ministers would like to see happen. Currently, neither the medical evidence nor the evidence related to costs is preeminent. Political lobbying seems to have precedence, and I acknowledge that reality. I also do lobbying, but in favour of a general system.
As for politicians who must determine what is most effective, only scientific medical proof and the cost aspect should be considered. In this way, politicians would be in a position to make a decision.
Professor and Interim Director, University of Ottawa, School of Epidemiology, Public Health and Preventive Medicine, As an Individual
Thank you very much for your question.
I'll answer in English, because French with a Scottish accent is an experience you don't want to hear.
I think the idea of independence is crucial, but transparency is equally crucial. We need a system put in place that the policy-makers and politicians have agreed on, that represents Canadian values, that is transparent, and that represents what's best for society in general. Then you leave independent people to make the individual decisions about what interventions are covered and what are not covered. You appoint another body, an overseer body, to make sure the independent body is adhering to the principles that Parliament or decision-makers have agreed to. That works well. It creates a system that the legislative decision-makers have bought into and have created.
You find the experts who have no conflict of interest to take part in that. Don't believe the argument from the pharmaceutical industry that those who have pharmaceutical money are therefore obviously the experts. The pharmaceutical industry creates experts and creates key opinion leaders. There's a great German saying, “Whose bread I eat, their song I sing.” That is very common across the physician world these days. We need to keep independence, but transparency is the key.
At the end of the day, it comes up to the decision-makers to develop the process that represents Canadian values and then let those independent people run with it.
Liberal
Ramez Ayoub Liberal Thérèse-De Blainville, QC
Thank you.
I am going to continue on the issue of ethics and conflicts of interest, but more specifically as concerns professional ethics.
The topic is not new. We have already heard physicians and pharmacists tell us that pharmaceutical companies exert daily pressure on them. I would even add that some of them are given training by these companies. It is a fact where surgeons are concerned, and we have examples. Some pharmacists are solicited regularly to promote certain medications, or asked to offer replacement medications rather than filling physicians' prescriptions.
It's useful to have a committee that recommends a list of available medications that may be reimbursed by insurance companies, but afterwards you have to make sure you choose the right medications among thousands of possible options, while being subjected to influence and pressure by the pharmaceutical industry.
How do you see this situation?
Professor and Interim Director, University of Ottawa, School of Epidemiology, Public Health and Preventive Medicine, As an Individual
That's an excellent question. As I said, I sit on the Ontario Committee to Evaluate Drugs and make funding recommendations. We're supposed to have the leverage to ask for physician education as part of our decisions. There is no funding available for independent physician education relating to pharmaceuticals.
We can make a decision to fund a drug that might cost an extra $8 million or $10 million a year to the Ontario public drug plan. It would not take a fraction of that to be able to put out some documentation to do some insight in terms of training of physicians to know what the implications of these new drugs are.
If we're to go ahead with a national pharmacare strategy, the decision has to be that physician education is a key component to that as we allow new pharmaceuticals to go into the formulary.
Chair, Education Working Group, University of British Columbia Therapeutics Initiative
I appreciate the question, but it might be better if I answered in English.
I'm a recovering politician, as Mike Harcourt would say, so I've been on both sides of this issue, and I'm proud to be a good specialist physician. Doctors are trained and socialized, as nurses will know only too well, to think that we are special and we are better human beings than other people. Nurses have an element of that as well. It's very difficult for us as a species to come up with the idea that we might be bought or conflicted or influenced by conflict.
