Health Committee on May 27th, 2024

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

That's absolutely fascinating to me, and certainly for Canadians listening at home I would suggest to you that this is an absolute travesty to independent practitioners. I guess I would like to implore my physician colleagues on this committee to make comments with respect to this.

That is not to say that mistakes in medicine don't happen, and there is potential for inappropriate prescribing, but I guess what I would suggest is that I would love to hear their comments with respect to the government creating an agency that is then going to potentially monitor physicians in their prescribing of the appropriate medications, and in deprescribing, which is not a new concept—and then there's the suggestion that the government knows best with respect to what your physician should be prescribing or not.

Realistically, that's why doctors go to medical school: to understand the right patient, the right drug and the right diagnosis. Now, for all my physician colleagues out there, that's not always easy. This is an inexact science, and we know that even with long-term relationships with patients and appropriate examination and testing, oftentimes the diagnosis still remains elusive or that, certainly, the specific diagnosis may not be in keeping with what the patient may like it to be or what it actually is, or we may actually lack the ability to access appropriate specialist consultation to come to the appropriate diagnosis.

The wait times, which I mentioned previously, are, sadly, the longest wait times that we have had in Canada in recorded history, since we've been keeping that time in the last 30 years. The wait time from seeing a family physician to seeing a specialist and obtaining specialist care is over six months.

When we begin to hear that now we're going to have a “government knows best” approach, I wish I could interpret it differently. I can't. When I hear those things, I want to take my parliamentarian hat off and put on a doctor hat and say: “Really? I need the Canadian drug agency to talk to me about patient safety, outcomes, system sustainability and appropriate use strategies?”

When we begin to look at this and the incredible difficulty of how you might roll this out, it makes me want to not just add an amendment—as in CPC-12, “respecting the autonomy of Canada's highly trained health care practitioners”—but to get rid of the entire paragraph. This is an affront to the autonomy of physicians, pharmacists, nurse practitioners and, in the future, physicians' assistants, with respect to their training, to suggest that now we are going to have a government agency as the intervenor, saying, “Well, you know, maybe you don't know exactly what you're doing here, and we need the Canadian drug agency to talk to you about patient safety, health outcomes and system sustainability.”

First of all, let's let's talk about patient safety. I can only imagine that, heaven forbid, I'm practising as a physician and my good friend and colleague Mr. Doherty comes into the office and and I have to wait for a memo from the Canadian drug agency to tell me what is appropriate to prescribe to him and what isn't. What did I go to school all those years for?

The interaction between the patient and the physician coming to a mutually agreed-upon diagnosis and treatment plan and follow-up and appropriate prescribing with respect to the contraindications, the indications and the potential side effects are sacrosanct in medicine. That is what Canadians already expect.

Now, if they're not getting that, and if that's the assertion here in this bill, that Canadians are not getting that....

Ms. Boudreau, I want to reassure you that just because I'm looking in your direction, I'm not directing my ire at you. That's not the point here.

I'm directing comments only in your direction. I don't mean to make you feel that way. I direct my ire at the folks who created this ridiculous clause inside a bill to suggest—as I stated earlier, we're talking about patient safety—that a prescriber doesn't have the appropriate abilities to understand patient safety associated with drug X, Y or Z or the ability to appropriately understand the potential drug interactions and monitor potential side effects as required.

That is what prescribers go to school for. That's why physicians go to school. That's why you're there. The biggest tool you have, besides being a good diagnostician as a physician, is related to the things you have in your tool box, which would be related specifically, in the majority of cases, to medications.

When you go to see a physician, oddly enough, historically, when no one else could prescribe medications, guess what you came out of the physician's office with? Does anybody want to guess? Well, it was a prescription, 85% of the time. That is what made physicians unique. It still does.

When you go to see the physician, you would like advice. You would like understanding. You would like explanation. Whether we like it or not, whether we want to admit it or not, we would like someone to fix the dang problem we went in there with. If I go in with a sore big toe, I don't want to come out with a sore big toe and no plan to fix it. I want someone to say, “This is what we're going to do about it. Through all my years of training and practice and experience, and my knowledge of you personally, that's what we're going to do. We have a plan.”

Whether you're a primary care provider or a specialist, it doesn't matter. If you don't care enough as a Canadian-trained and internationally trained physician or as a prescriber to know that there's a person behind what you're doing, and that they have to be safe and receive trustworthy advice and intervention and prescribing from you, then, my goodness, the last thing we need is a darn government agency trying to say, “Hey, you'd better reconsider what it is you're doing and what you're prescribing.” My goodness, think of how cumbersome that will be: “Just a minute, Mr. Doherty, I have to get the Canadian drug agency on the phone. I'll call the 1-800-WHO-CARES phone number, and they'll get back to me in six months.”

Of course, I'm being facetious.... I'm sorry; I trust I'm being facetious; there's no plan within this pamphlet to suggest that I'm not.

That being said, on the ridiculous nature of saying that we need an agency, I'll come to the other points and talk first and foremost about patient safety.

If you have a prescriber in your life who's not primarily concerned about your safety, then you're in deep trouble. You will not be safe. It doesn't matter if we have a Canadian drug agency or a CDA or an LMNOPQRSTUVWXY and Z agency who's there to protect your safety; you're in deep trouble.

Next, health outcomes are incredibly important, but it all comes down to not necessarily just nationwide or countrywide health outcomes. It also comes down to your personal health outcomes. Again, if we're going to make an agency of the Government of Canada, which is the most inefficient agency, one that can't....

In this government, sadly, they can't issue passports. They can't pay their bills on time. They certainly can't manage inflation. They can't build houses, even though we all know that this is not within the purview of the federal government. There's an inability to provide primary health care, as we've already talked about, to seven million to 10 million Canadians. There is an inability—

[Peter Julian, NDP, New Westminster—Burnaby, BC]

I have a point of order.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

—here we go—to provide lab tests in a timely fashion.

[Peter Julian, NDP, New Westminster—Burnaby, BC]

I have a point of order, Chair.

[The Chair, Liberal, Sean Casey]

You have a point of order, Mr. Julian.

[Peter Julian, NDP, New Westminster—Burnaby, BC]

We've now had votes on three amendments after four hours. I would question the relevance again of Dr. Ellis' comments.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Are you kidding me? This is ridiculous.

[The Chair, Liberal, Sean Casey]

Dr. Ellis, please go ahead. We're talking about the autonomy of physicians, and that's what the amendment relates to.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Amen.

[The Chair, Liberal, Sean Casey]

I don't think we're very far off that, so go ahead, Dr. Ellis.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Through you, Chair, this is talking about a significant change in how medical care is delivered in this country, and Mr. Julian thinks this is a joke. I am unsure of what his antics are to attempt to interrupt what we're talking about here. Maybe it's because he doesn't understand what it is to provide medical care. I don't think he needs to understand that. I think he needs to understand what it is to actually receive medical care. If he doesn't understand that, I'm quite happy to provide him with a diatribe with respect to that, but if he does not believe....

Ms. Kayabaga, if you want to wave your hands, and you don't think it's important either—

[Arielle Kayabaga, Liberal, London West, ON]

You're just going on.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

This is ridiculous.

[The Chair, Liberal, Sean Casey]

Please, Dr. Ellis and everyone else, direct your comments through the chair. The back-and-forth shots are uncalled for.

Ms. Kayabaga, you don't have the floor. If you want to have the floor, you should put your hand up.

Dr. Ellis, please go ahead.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Chair, I do apologize because this is something.... No, I don't apologize for calling out Ms. Kayabaga. What I do apologize for is the passion with which I have approached this. It is incredibly important on behalf of Canadians and it's not humorous. It's incredibly important. For anybody who doesn't want to choose to believe it, that's their own prerogative

Chair, I would suggest to you that those who do not have the floor really should keep their peace.

That being said, Chair, it's having a government agency that wants to be responsible for health outcomes on “behalf of Canadians”, when—as I mentioned previously—we know that the relationship between a primary care provider and the patient is sacrosanct in Canada.

That's something that Canadians are absolutely starving for. When we ask them what they would like to see in a health care system, what do we hear? They'd like to have a primary care provider. That's because they trust that the training that the primary care provider has had will best represent their interests, will create a relationship and, hopefully, over the long term, the primary care provider will understand what the patient's goals are with respect to health outcomes.

This leads me very clearly to understand here that there's no mention in this pharmacare bill of what the patients may want. This is, again, a pharmacare pamphlet brought forward by the costly coalition, and it does not mention that.

There are two more points that we have to discuss here.

One is on system sustainability. Once again, the best stewards of the health care system are those people who are working in it, not another government agency. I don't believe for one second that there are groups of primary care providers out there who, when they make a decision.... It may be a pharmacoeconomic decision around understanding, for example, the best ACE inhibitor to prescribe, the pharmacoeconomic advantages among ACE inhibitors, the studies that have been released over the last 30 years that encompass all of them, and whether to choose to use generic medications, which is the choice, naturally, in this day and age, made by a prescriber. These appear, at the current time, to be reasonably good pharmacoeconomic decisions.

Those are often made outside of the purview of the prescriber, but certainly we know that when there are untoward effects, there's a significant ability to allow a primary care provider to advocate on behalf of their patient to have the best health outcomes related to the best medications with the fewest side effects available at the current time. That's something that primary care providers have done from time immemorial. The system itself is part of the overall ecosystem in which primary care providers and specialists alike practise.

Are there people out there who are ordering MRIs, CAT scans and unnecessary lab work willy-nilly? There are a few. I'm not going to sit here and tell you that there are not.

Do I believe in any way, shape or form that another government agency from this costly coalition government—the most inefficient government and the government with the greatest inability to provide basic services to its citizens—should be the one that is now in charge of system sustainability, believing that primary care providers and specialists alike have absolutely no idea what is going on or no responsibility to the system? That's a fallacy. Quite frankly, it's an affront to prescribers out there everywhere. More importantly, it's a big fat lie.

Finally, on appropriate use strategy, for the edification of those watching—and I hope not for my colleagues—physicians out there have to maintain a continuing medical education every year to ensure that they are able to continue to practise medicine in the most forward-looking fashion available. It's another slap in the face to physicians, pharmacists and nurse practitioners to talk about an appropriate use strategy, whether it is for medications, hospital beds, MRIs, CTs, ultrasounds or specialist consultation, etc.

The practice of medicine is not some cookbook kind of thing that you do on your days off, when you say, “Well, suddenly I think I'm just going to be a doctor. Maybe I could whip out this book and look up the fact that maybe somebody has syphilis” or something like that, and say, “Hey, this is the test I need to do, and knowing that syphilis is now rampant in this country and perhaps multi-drug-resistant, now we need to talk about an appropriate use strategy.”

I just don't believe that's true. If our primary care providers out there don't have a desire to understand the environment in which they practise and continue to get better. We have those governing bodies in existence now. We don't need another legislative body to come out and say, “This is what we need. Surely the Canadian drug agency will make sure that everything is going to be used appropriately. Surely the Canadian federal government will be the best arbiter of that.”

I will close by saying again that this is a slap in the face to every highly trained health care practitioner out there, and it needs to be amended.

Thank you.

[The Chair, Liberal, Sean Casey]

Go ahead, Mr. Naqvi, please.

[Yasir Naqvi, Liberal, Ottawa Centre, ON]

Thank you very much, Mr. Chair.

I think what this clause is doing is ensuring that we put the well-being of patients front and centre. That's really what is central to this clause.

That sort of goes to the essence of the principle of appropriate use. I don't think that this clause challenges the concept of physician autonomy in any way. It says that at the centre of everything we do, we need to make sure that patient well-being is front and centre. That primacy of patients, by using language like “health and well-being of Canadians”, is really at the core of this provision.

Of course, we heard from Dr. Ellis, and I'd love to hear from colleagues from the Liberal side as well who are medical practitioners and have more experience than I do in this particular area.

This is what my understanding is. It looks at ensuring that in the Canadian health care system, the most important feature is the well-being of a patient and having a system that is patient-focused and patient-centric. This is what this clause is trying to do. In no way is it trying to take away from the autonomy of a physician. It makes sure that Canadians' well-being remains central. That's why this provision is drafted in this way.

I suggest that we vote against the amendment, because it dilutes the patient-centric aspect of it, which I think is critical.

[The Chair, Liberal, Sean Casey]

Thank you.

Go ahead, Dr. Kitchen, please.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you, Mr. Chair. Thank you for the opportunity to speak.

It's interesting to hear the conversations we've had today. I recall that on Friday, when Canadians were sitting and listening to what was going on and the short list of witnesses we had, many of the witnesses put forward recommendations that they would have liked to see addressed and looked at.

We were aware, at that time, that the time when amendments had to be in was four o'clock, so a lot of them were not there. People and Canadians who are watching this expect this committee to look at those amendments and make some changes. I said at the time that there's no way that this NDP-Liberal government would ever accept any of the recommendations put forward, and they're just going to push through with what they're doing.

When we look at this amendment being put forward here, I was a little shocked when I heard what you said about appropriate use, Ms. Boudreau. I'm wondering if you can clarify for me the meaning of what you said at that point in time on the issue of appropriate use by practitioners, suggesting that practitioners are providing medications inappropriately or providing medications without keeping track of them, etc. Could you clarify that, please?

[Michelle Boudreau]

The idea of appropriate use in the simplest terms is the right medication for the right patient at the right time.

Typically, for example, even now, physicians will often look at practice guidelines to decide which would be the best treatment. There is certainly the discussion—and the patient and physician relationship—but the statistics are fairly consistent that in fact a good deal of over-prescribing occurs.

For example, with seniors in particular, there are statistics showing that as many as two million seniors report that they are taking medication inappropriately. When that happens, there are often severe and serious side effects, and as a result, patients end up using health system resources, going to hospitals, etc.

“Appropriate use” is really intended to be a tool used by the physician to, as has been noted here, work towards the best possible outcome for the patient. It's another tool that would help physicians do that.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you for that clarification.

I find that shocking, given my years of practice and all the professionals I've practised with. Your suggestion that they aren't trained and that they aren't practising appropriate use is mind-boggling, because these practitioners, whether they be pharmacists, doctors, nurse practitioners or nurses, are providing those medications. Your statement suggests that this legislation was written to give the minister the ability to regulate what that appropriate use is. I find it extremely shocking that we're sitting here with a piece of legislation that basically tells practitioners, who should be paying attention to what's being done here, that once again this government is coming after them for what they're doing and is putting the power into the hands of the minister to do that.

You know, this government came after practitioners who incorporated with the capital gains tax that it's now proposing changes to. Again it is trying to attack professionals along those avenues. Here we see another attack against them. You know, the great Paul Harvey said that self-government won't work without self-discipline. Self-government is what practitioners do, and they govern themselves. That's what regulatory bodies are there for. Each one of them has those bodies there to regulate and govern their professionals. They have steps and procedures to deal with that, and you're saying that this legislation now is suggesting that you're going to take away that autonomous ability of those practitioners and put it in the hands of the minister to deal with this aspect. I find that just appalling.

My riding is Souris—Moose Mountains, and the great city of Weyburn is in my riding. The great city of Weyburn was home to Tommy Douglas, and many of his family are still in the community and the area. Does anyone remember what happened right after that legislation came out in Saskatchewan in 1962? There was, across the board, a doctors strike. Why? It was because people were attacking the professionals.

The dental plan being put forward by this government suggests that we're going to provide all this help for Canadians. Don't get me wrong—we need to have that health care, and I'm 100% behind providing that dental care, but of the practitioners the government and this Liberal-NDP government keep talking about, hardly any—less than 1% to 2%—are dentists. They're dental hygienists, but not dentists. When you try to find a dentist, you can't find one. When you try to find a dentist in a rural community, it's almost impossible.

With respect to the statements you're making here and clarification of what this piece of legislation says, paragraph 4(c) in particular is suggesting that if this goes through, the professionals will be regulated by the Government of Canada, by the Minister of Health, and that's appalling. I think Canadians who are watching this, as well as doctors and health care professionals, need to be aware that they're losing their ability to self-govern.

I find it just appalling that we wouldn't look at this simple amendment so it could ensure that autonomy was there for the trained health care practitioners who provide that service. I find it just shocking that people would not support this amendment.

[The Chair, Liberal, Sean Casey]

Dr. Hanley is next.

[Brendan Hanley, Liberal, Yukon, YT]

Thank you.

I'm really happy to speak on this, especially at the invitation of my friend and colleague, Dr. Ellis.

Look, I haven't been intervening a lot in today's clause-by-clause debate because my constituents are asking me to support pharmacare and get this critical legislation passed.

I do think, with all respect, that there's a little bit of a “Trust me—I'm a doctor” tone to what Dr. Ellis and colleagues have been saying. Of course physicians practise with patients' best interests in mind. That's a given. We're all trained to do the best we can, as do the vast majority of health professionals in general, whether we're talking about OTs, nurses, pharmacists, lab techs, all the providers in the system.

However, we all contribute to a system where errors and over-prescribing occur. I was thinking, when my colleague quoted a great Dr. Harvey, that there's another, Dr. William Harvey, who said:

As art is a habit with reference to things to be done, so is science a habit in respect to things to be known.

I think we just have to look at a little bit of what the science is telling us. For instance, nearly 70% of Canadians over 65 take five or more medications, and about 10% take 15 or more. That's a recipe for a higher risk of harm, hospitalizations, other reactions, injuries, potentially avoidable hospitalizations, and even deaths. There are many, many studies and much evidence to document polypharmacy, over-prescribing and inappropriate use. It doesn't mean that physicians aren't working hard or prescribing diligently, but mistakes do occur. I think of this as a kind of a system error or a way of errors, and we need system approaches.

For example, there was a U of T program to provide tools to practitioners to recognize inappropriate medication use as a result of prescribing cascades. In other words, you participate in a system where more and more medications potentially get added on to a patient's prescribing risk, and no one really has the tools, the time or maybe even the knowledge to really take a look at de-risking and having that holistic approach to reducing the risk of adverse effects by re-examining the whole list of medications.

Alberta even has an appropriate prescribing and medication use strategy for older Albertans. Most physicians in practice know—and I'm sure Dr Ellis knows very well—the Choosing Wisely program, with which the Canadian Medical Association is a strong partner. Really, it's looking at increasing physician knowledge in recognizing where there are common pitfalls, whether in the way we use diagnostic strategies or in prescribing.

Further to all that body of evidence, I just don't see where it says that the minister, the CDA or the government is going to tell physicians what to do. What I see are principles. Really, what the clause says is that “The Minister is to consider the following principles”. I won't read the whole thing—it's before all of you—but it specifically says that the minister will:

(c) support the appropriate use of pharmaceutical products — namely, in a manner that prioritizes patient safety, optimizes health outcomes and reinforces health system sustainability — in order to improve the physical and mental health and well-being of Canadians

I don't know a physician who is not going to support that principle and who does not want to participate in a system that helps improve patient safety through rational and appropriate prescribing. That's why I will not be supporting this amendment.

Thank you.

[The Chair, Liberal, Sean Casey]

Dr. Powlowski is next.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

In keeping with much of what Dr. Hanley said, I support the section as presently worded. I don't think it needs to be amended.

I certainly do not think the purpose of this section is to establish a federal bureaucracy to decide on what is and isn't the appropriate prescribing of medications and pharmaceutical products. That kind of decision or judgment is rightly left to institutions like the college of physicians and surgeons of the individual provinces, medical advisory committees, chiefs of staff and chiefs of department. Again, I don't see this as an attempt to encroach on that jurisdiction or make those kinds of decisions, which are appropriately left to doctors. There is appropriate oversight within the medical community.

Again, as Dr. Hanley suggested, these are things for a minister to consider when working towards implementing national universal pharmacare. Certainly, the minister and the whole system would want to consider what is and isn't an appropriate use of medications when setting up such a system, along with safety.

I would put the emphasis on sustainability. Those of us who have been practising medicine for a long time all learned, when we were clerks and interns, that we should always take the cheaper option when available. Similarly, in setting up a national pharmacare system, if there's a choice between drug A and drug B, and both of them work just as well, we want to be able to use the cheaper medication when it has equal outcomes, in order to make a more affordable system—which I think all Canadians want, as we don't want to be paying all our money in taxes.

Again, although I understand where the concern is coming from in the Conservative party, I do not see that as the intention of this clause.

Thanks.