Health Committee on March 7th, 2017

[The Chair, Liberal, Bill Casey]

Colleagues, I call the meeting to order.

We welcome our presenter.

We look forward to your presentation on palliative care. We appreciate your interest in this issue, because many of us are interested as well. We look forward to this study and all of the presentations, starting with yours. You have 10 minutes. Then we'll go to questions; they'll be brutal.

[Voices]

Oh, oh!

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

That's excellent.

Thank you and good morning.

I thank the committee for the opportunity to appear today and for the unanimous support the bill received at second reading.

I think this bill is timely. Our population is aging and only 30% of Canadians currently have access to any type of palliative care service. The special committee that studied the Carter decision on assisted dying stated that without quality palliative care, a true choice was not possible.

I was surprised to find out that not every location in Canada has the benefits of the integrated palliative care that is offered in my home riding of Sarnia—Lambton, where we have more than five palliative care specialists, palliative beds in hospital and in hospice, and an excellent network of home care, counselling, and crisis response services.

I began to ask about this. I found that an all-parliamentary committee in the 2011 session had studied palliative care and brought forward a report with recommendations. Although a motion was made, not much further action occurred.

With an aging population, the implementation of Bill C-14, and the desire to innovate and to get more out of the health care dollars that we invest in our system, we can see that the time is right for this bill,

Bill C-277 proposes a framework for palliative care in Canada, including a definition of the services to be covered, a definition of the training required at the different levels of service provision, care for those giving palliative care services, collection of appropriate data, and the development of a plan to get consistent access to palliative care for all Canadians.

During debate, amendments were suggested to add first nations to those covered by this framework and to ensure that the language of the bill reflects the proper balance of provincial and federal jurisdictions. I'm very happy to work with the committee should they choose to adopt these or any other changes.

My theme today will be to explain the sections of the bill and recommend to the committee how I see the framework proceeding.

I'll start with services to be covered.

Palliative care can begin more than a year before end-of-life care, and end-of-life care is defined as the last two weeks of life. Pain control, including the cost of the drugs, along with spiritual and emotional counselling, home care, hospice care, and home crisis intervention are the basic services that I would like to see covered. Today some of these are covered in part, and only in some provinces. Others are not covered at all. It's important to note that the costs associated with palliative care in hospital can be $1,200 a day, versus $400 a day in hospice and $200 a day, on average, in home care.

As compared to intensive care, palliative care in a hospital could save our health system between $7,000 and $8,000 per patient. Recent data suggests that, in Ontario, transferring just 10% of end-of-life patients from intensive care to home care could yield $9 million in savings annually. That is a better use of health care dollars in order to get better results for Canadians.

The second part is with regard to training. Different levels of training are required for the various types of care providers. There is currently a shortage of palliative care specialists in Canada. We have 200, versus a need for at least 600.

General practitioners receive two months of palliative care training as part of their medical degree. Registered nurses may not receive any palliative care training at all, but they should take training as offered today by organizations like Pallium Canada or equivalent.

Home care providers and personal support workers, when trained, would provide a cost-savings delivery model that would be effective, especially in remote regions where innovative solutions to delivering service will be needed. More registered nurses, RPNs, and personal support workers will be needed with our aging demographic. As the provinces are introducing training, it would be wise to set a standard terminology, set the training requirements, and have interprovincial recognition of those standards.

We also need measures to support those who are giving palliative care services. As you can appreciate, watching people die and seeing the emotional and physical agony they are in can bring symptoms similar to PTSD, and there is some need to provide support in the care system for those people, as well as for care providers who may be needing respite and rest. It's important to consider them.

Moreover, the lack of data on the need for palliative care, the total average cost, and the breakdown of services should be addressed by collecting data in order to standardize and monitor the provision of palliative care services.

I encourage you to consult the Minister of Health, who already has some ideas on what she would like to see in this regard.

With respect to research data, there's not really even a baseline of how many people are in need of palliative care or how much palliative care can be expected to cost per person. These are the kinds of numbers we would like to benchmark and monitor.

We also need a plan to develop consistent access for all Canadians. This is one of the most important parts of this framework.

The plan should have several pillars. We've already talked about the trained resources that will be needed. Second, infrastructure will be needed to achieve consistent access for all. There's an opportunity for the government to put money into building hospices and palliative care centres. Canada has about 30 hospices compared to the United States, which has 1,300. Building this infrastructure will create jobs and will address a need.

Finally, in order to service rural and remote communities in Canada, use of innovative ideas will be needed. One such idea is the virtual palliative care centre in Winnipeg, where home care nurses or doctors can call in on a 24-7 basis and get access to palliative care specialists who can guide remote treatment. Web and Skype consults will rely on the government's current infrastructure plan to address Internet in the rural and remote north. Training paramedics, nurses, and home care workers in palliative care and combining this with the fly-in crisis response teams has been shown to work effectively in other parts of Canada, and doing so should be levered as part of the overall plan.

Choosing the mechanism to implement this framework is also important. There are various options. One of them is to add palliative care to the services covered by the Canada Health Act. Another option would be to include palliative care in the new health accord. A final possibility would be to create a government palliative care program to fund the infrastructure, establish training standards, and work with the provinces to implement best practices.

I think any one of these options could work. There are probably other mechanisms I have not thought of, but it is up to the government to provide direction on implementation through the budget.

The $3 billion that is currently promised in the 2016 budget is a good start and I hope to see more in the 2017 budget.

The government should leverage the many national organizations that have supported this bill, each of which has solutions to help deliver the services. These organizations include the Canadian Medical Association, the Canadian Cancer Society, the Canadian Nurses Association, the Canadian Society of Palliative Care Physicians, Pallium Canada, ARPA, the Canadian Hospice Palliative Care Association, and many other member hospices, such as Bruyère Continuing Care, St. Joseph's Hospice, West Island Palliative Care Residence, the Heart and Stroke Foundation, the Kidney Foundation, the ALS Society, and the Canadian Association of Occupational Therapists, as well as the more than 50 member organizations of the Quality End-of-Life Care Coalition of Canada and the many faith organizations across the country, including the Canadian Conference of Catholic Bishops.

In addition, coming up with a standard definition of services to be covered and of the training requirements will be a priority, as provinces are already progressing in their offerings in different ways. Now is the time to act to address this important issue so that Canadians can choose to live as well as they can for as long as they can.

I appreciate your time. I'd be happy to answer any of your questions, and I look forward to our discussion.

Thank you.

[The Chair, Liberal, Bill Casey]

You have 16 seconds left.

Moving to our questions, we're going to start our seven-minute round with Mr. Kang.

Fire away.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Thank you, Mr. Chair.

Thanks, honourable member.

Before you brought Bill C-277, did you do any consultation or did any stakeholders you consulted raise any concerns with respect to the structure or the contents of the bill?

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

That's an excellent question. Actually, when we first started discussing this, it was during the time Bill C-14 came forward. I was made aware of the 2011 committee, the all-parliamentary committee that studied it. I was able to consult with them on the work they had done and their recommendations, and then they put me in touch with people across the country who are working in palliative care, working in a similar way to try to get a consistent service across the country.

I had the opportunity to sit with members of various hospices and talk to palliative care specialists, nurses, people who receive the palliative care, and home care workers to understand what they saw as the biggest need and how—if the federal government was going to act—they'd prefer to see that.

Then when I drafted the bill, I was able to review it with all the various stakeholders so they could see the language in the bill and be able to support it.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Some of the patients are in the hospital. They don't put them in the hospice, but in the hospital, and literally they are getting the palliative care in the hospital. This is costing us lots of money.

Do you have any studies on how much it's going to save our health care system if we have palliative care? In Alberta, they were calling them bed-blockers.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Yes.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

In the hospital because—

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

It's a real problem. The cost is about $1,200 a day for palliative care in the hospital. Most hospitals are very limited in the number of beds they have. There's a real logjam, and trying to even get a bed is problematic.

The cost depends on when the palliative care begins; it can begin even a year or two in advance of the end of life. The only studies that have been done came out of Ontario, saying that in hospital you could be spending $200,000 to $300,000 on a patient, whereas you could reduce that cost by 80% or 90% by providing home care or hospice care if it was available.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Every time we study something new, we talk about cost savings. Whenever we implement the program, we don't see any cost savings. You're saying it costs $200,000 or $300,000 per patient. If you could put the number on the patients, we'd be talking about lots of money.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

We have to talk about the money, especially when you consider the population is aging. Right now one in six are seniors, and soon we will have one in four.

While I think doing palliative care in one way or another is less expensive and there are cost savings to be had, I wouldn't want you to get the impression that it would be cheap. This is going to be a huge need. The government will have to decide how to pace that effort, especially when you consider the $3 billion originally pledged by the health minister. She sees that home care is a way you can easily start spending that money without having any infrastructure in place. Infrastructure might be the next logical step, and then we'd be branching out from there.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

That's what I was coming at—how much it's going to cost us for the infrastructure. In the end, will we be saving money by instituting a palliative care framework?

Paragraph 2(1)(f) of Bill C-277 requires that the proposed palliative care framework include an evaluation of the advisability of amending the Canada Health Act to include palliative care services provided through home care, long-term care facilities, and residential hospices. Has this possibility been raised with the provinces? If so, did they raise any concerns with respect to amending the Canada Health Act in this manner?

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Certainly this is one of the most controversial parts of this bill. There are those who believe the simplest way to get the provinces to deliver palliative care is to make it clear in the Canada Health Act that it's an included service. There are those who are reluctant to open up the Canada Health Act, because of the many other changes that would be desirable there.

The Minister of Health is leaning towards incorporating this in the health accord because the negotiations with the provinces have indicated the provinces are already starting to move in this direction, and they're obviously looking for governmental support on it. That's a possibility.

When it comes to how best to implement it, there are different parts of the strategy. The government may choose to put a specific palliative care program in place that could be a multi-year program that gets training resources, gets infrastructure in place, starts to work with the provinces to determine what services need to be put in place, and does the rural Internet that will be required as a basis for the north.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Under BillC-277, who would be responsible for funding the additional resources required to give Canadians access to palliative care?

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Today a combination of people are paying.

If you're talking about the hospital, palliative care is already covered in the hospital. You also talked about hospice care; well, in most cases hospices are covered provincially for some of the services that they offer in terms of the pain control meds, but it's only about 43% of their budgets. The rest they are currently raising from charity. Many of the home care organizations, such as the Victorian Order of Nurses, are getting half of their money from charity as well, so I would imagine that in the future as well it won't be just one pot of money. It's not just for the federal government to contribute; it's to encourage the organizations that exist today to continue growing their services through charitable donations and through co-operation with municipalities and the provinces.

[The Chair, Liberal, Bill Casey]

The time is up.

Just as a little plug, my daughter is a VON nurse. She spends an awful lot of her time with people in palliative care situations, even though it isn't a palliative facility.

Dr. Carrie, you're up.

[Colin Carrie, Conservative, Oshawa, ON]

Thank you very much, Mr. Chair.

I want to take this opportunity, MP Gladu, to congratulate you on the great work you've done on this bill and the collaborative approach you've taken. To get all these stakeholders on board was really quite a feat. I've tried this in the past, and to see you succeed in that is wonderful.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Thank you.

[Colin Carrie, Conservative, Oshawa, ON]

I've been hearing concerns about getting the money flowing. The Prime Minister campaigned on an immediate investment of $3 billion directly into palliative care. Disappointedly, 18 months later we're not seeing that promise being executed. One of the concerns I've heard is that that the Prime Minister or the health minister seem to be using palliative home care as a bargaining tool in the health accord, and again, the two most-populated provinces, Ontario and Quebec, still haven't signed on. We're seeing delay after delay. They were supposed to be using the collaborative approach, and we're seeing more of an adversarial thing.

My question is simple. What are your thoughts on the immediate $3 billion investment into palliative care that's no longer on the table, while instead, the government has announced, I believe, an investment of $5 billion over 10 years into home care?

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

To start out with, the Minister of Health was clear that there was $3 billion set aside in budget 2016 for home and palliative care. She made that comment at least five times in the House of Commons and certainly many times in the public sphere. While I didn't see a specific line item in the budget that talked about that, I don't know that it's off the table. I think the $5 billion that's being talked about is a combination of home care and some of the other services that the provinces are looking at. The negotiation of the health accord needs to have palliative care if that's the mechanism—which I believe it is—that the health minister favours.

I would say we need to see more action. Certainly if there is work going on, I'm not aware of what it is. That's part of the reason for my bringing the bill forward: to try to actually come with a plan and start moving down the path. You can't press a button and instantly have consistent access to palliative care everywhere in Canada, because it's a huge feat, but taking action and starting with that $3 billion would be great.

[Colin Carrie, Conservative, Oshawa, ON]

That is the comment: it takes time. I know the budget's coming up and I'm really interested to see what is in there. Your bill specifically requires the Minister of Health to develop and implement the palliative care access framework, but the government is now using different language. Language is extremely important. I remember the issues when we were looking at Bill C-14, and the language. There was more “palliative”. It was the same during the election. Now we're hearing different language, and they seem to be referring to it as “home care”.

I was wondering if you could explain your interpretation or the difference, if any, between palliative care and home care, and what your concerns would be, if any, about the new terms being used by the government instead of the specific term that they were using before.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Home care is a subset of palliative care. It's one of the many things that are involved in delivering it. Not everybody wants to be at home. Some people need to be in the hospital because they are in such an acute situation. Some people don't really want to be at home; they prefer to be in hospice. There's a continuum of palliative care services, and home care is just one part of that.

In terms of the government coming forward with a framework quickly, there has been a lot of work done by numerous organizations. There was a paper put forward in 2015 by the quality coalition, these 50 organizations that are doing palliative care in Canada. It was called “The Way Forward”, and it recommends a framework. That was done with government support and funding, I believe. In terms of a framework, there are a number of examples out there, and the government may decide to adopt them, which will then really hurry along the beginning of the implementation of those plans.

[Colin Carrie, Conservative, Oshawa, ON]

You mentioned how important innovation will be because of the demographic wave that's moving into this area. Palliative care and home care will be required. You mentioned the Internet, Skype, and things along these lines. Have you talked to any stakeholders who are worried about red-tape obstacles for that type of innovation? I've heard, for example, that if a doctor does a Skype interview in certain provinces, or people provide different consultations, it even gets down to the billing. How do people bill for that type of thing?

As well, has any work been done on that for rural and remote areas? If a Canadian is a Canadian is a Canadian, what about first nations, indigenous communities, and remote and northern communities in terms of how this will work?

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

I think while there's always an opportunity for bureaucracy to creep into everything, if you look at the places today that have no palliative care services and are in desperate circumstances, you see that these are the locations that have come up with innovations. In some places they only had paramedics, so they had their paramedics trained in palliative care so that they could start to deliver that and were phone-calling into the Winnipeg centre. There are fly-in resource teams for some of these very remote communities, where they can do crisis intervention. There's training the only nurse on the reservation or the only nurse in a northern community in palliative care to be able to provide it and to be able to call a palliative care specialist to walk her through what needs to be done to administer it. In an area where there is nothing else and they are without palliative care, people will hugely suffer.