Evidence of meeting #18 for Health in the 44th Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was palliative.

A recording is available from Parliament.

On the agenda

MPs speaking

Also speaking

Geneviève Moineau  President and Chief Executive Officer, Association of Faculties of Medicine of Canada
Ivy Lynn Bourgeault  Director, Canadian Health Workforce Network
Jeffrey Moat  Chief Executive Officer, Pallium Canada
José Pereira  Scientific Officer, Pallium Canada
Fleur-Ange Lefebvre  Executive Director and Chief Executive Officer, Federation of Medical Regulatory Authorities of Canada

4:20 p.m.

Liberal

The Chair Liberal Sean Casey

Good afternoon, everyone. I call this meeting to order.

Welcome to meeting number 18 of the House of Commons Standing Committee on Health. Today, we're meeting for one hour to hear from witnesses on our study of Canada's health workforce, followed by one hour in camera for drafting instructions.

Before I introduce today's witnesses, I have a few reminders for hybrid meetings. Today's meeting is taking place in a hybrid format, pursuant to the House order of November 25, 2021. Per the directive of the Board of Internal Economy of March 10, 2022, all those attending the meeting in person must wear a mask, except for members who are in their places during proceedings.

For the benefit of our witnesses, first of all, thank you for your patience. Once we commence, I would ask that you wait until you're recognized before speaking. You are, of course, participating by video conference. Click on the microphone icon to activate your mike. I would ask you to mute yourself when you're not speaking. At the bottom of your screen, you have something there for interpretation. You have the choice of floor, English or French.

This is a reminder that all comments should be addressed through the chair, and please don't take screenshots. The proceedings of today's meeting will be made available through the House of Commons website. In accordance with our routine motion, I'm informing the committee that all witnesses have completed their required connection tests in advance of the meeting.

We will now welcome our witnesses who have patiently awaited the commencement of today's meeting. We have, from the Association of Faculties of Medicine of Canada, Dr. Geneviève Moineau, president and chief executive officer. From the Canadian Health Workforce Network, we have Ivy Lynn Bourgeault, director. From Pallium Canada, we have Jeffrey Moat, CEO, and Dr. José Pereira, scientific officer. From the Federation of Medical Regulatory Authorities of Canada, we have Fleur-Ange Lefebvre, executive director and CEO.

Thanks to all of you for your patience. Thank you for your presence.

We will begin with opening remarks in the order in which the witnesses appear on the notice of meeting. Even though we've tested your indulgence with our late start, I would ask you to please try to respect the five-minute timeline. There is a possibility that today's meeting is going to be condensed, and we want to make sure that we have time for questions and that everyone has time to get their statements in. Opening statements will be five minutes.

We're going to start with Dr. Moineau. Welcome to the committee. You have the floor.

4:20 p.m.

Dr. Geneviève Moineau President and Chief Executive Officer, Association of Faculties of Medicine of Canada

Thank you, Mr. Chair.

Honourable members of the Standing Committee on Health, thank you for inviting me to speak today on behalf of the Association of Faculties of Medicine of Canada. I'll be speaking in English, but I'd be pleased to respond to any questions in both official languages.

I have the pleasure of joining you today from the beautiful Lake Louise, Alberta, Treaty 7 territory, the traditional and ancestral territories of the Stoney Nakoda Nation, the nations of Blackfoot Confederacy, the Dene people and the Métis Nation of Alberta Region 3. The AFMC is located in Ottawa, the unceded, unsurrendered traditional territory of the Anishinabe Algonquin nation.

My name is Dr. Geneviève Moineau. I am the president and CEO of the AFMC. I also practise pediatric emergency medicine at the Children’s Hospital of Eastern Ontario, and I am a professor in the department of pediatrics and emergency medicine at the University of Ottawa. The AFMC represents Canada’s 17 faculties of medicine, which train and produce the physicians in this country.

The AFMC commends the standing committee for this study on Canada’s health workforce. We recognize that solutions around human health resource planning need to include considerations of all health professions. The ultimate goal is that patients receive the right care by the right care provider at the right time.

AFMC is committed to serving the needs of Canadians and has been a long-time advocate for better physician resource planning in Canada. I believe we have valuable information to share with you today in support of this important study.

As you heard from past witnesses, the 2019 Canada community health survey found that approximately 4.6 million Canadians aged 12 and older reported not having a regular health care provider. The pandemic has exacerbated this long-standing deficit. We encourage the federal government to help coordinate change and inspire provincial and territorial leaders to ensure that we have the right number, mix and distribution of physicians to meet societal needs.

There are key considerations that I would like to highlight, based on data the AFMC collects. First, current admissions to medical school are not aligned with population growth in Canada. Second, an increasing number of Canadian medical school graduates have a delay in their entry to residency and, therefore, a delay in providing the care that Canadians need. Third, we are currently not responding to the need for family physicians, particularly in rural settings.

Medical school admissions should align to the population growth to meet societal needs. While the Canadian population has increased by 12% since 2010, admissions to our medical schools have only increased by 6%.

Not only are admissions not increasing at the same rate as the Canadian population, but we continue to see Canadian medical students unable to secure a residency position on their year of graduation. For each medical graduate produced in Canada, public funds are expended. When these graduates go unmatched, there are delays to their entering practice and providing care to Canadians.

Increasing the number of residency positions to ensure, at a minimum, that there's 110 residency positions for each 100 graduates will reduce the number of unmatched Canadian medical graduates. Federal and provincial leaders must work together to ensure that Canada has the right number of residency positions for the system and adequate flexibility to ensure the success of our learners.

Additional family medicine residency positions should focus on the capacity for training in rural communities to further meet the urgent needs of Canadians.

The AFMC recommends that the Government of Canada work with provincial and territorial governments to increase admissions to medical school to match population growth and that all graduates of Canadian medical schools have access to residency positions upon graduation.

Thank you for your time today. I look forward to answering any questions you may have.

Thank you very much.

4:25 p.m.

Liberal

The Chair Liberal Sean Casey

Thank you very much, Dr. Moineau.

Next we're going to hear from the Canadian Health Workforce Network.

Ivy Lynn Bourgeault, you have the floor.

4:25 p.m.

Dr. Ivy Lynn Bourgeault Director, Canadian Health Workforce Network

Thank you, Mr. Chair and committee members, for the invitation to speak on the issue of Canada's health workforce, an issue of critical importance.

I'm coming to you from Ottawa, the traditional, unceded and unsurrendered territory of the Algonquin Anishinabe people, to whom I pay respect.

My name is Ivy Bourgeault. I am speaking on behalf of the Canadian Health Workforce Network, a pan-Canadian knowledge exchange network of researchers and knowledge users—

4:25 p.m.

Liberal

The Chair Liberal Sean Casey

Ms. Bourgeault, I'm sorry. We had a technical issue with the translation, which was resolved in the time it took me to interrupt you.

Please, go ahead.

4:25 p.m.

Director, Canadian Health Workforce Network

Dr. Ivy Lynn Bourgeault

Would you like me to begin again?

4:25 p.m.

Liberal

The Chair Liberal Sean Casey

Is everyone okay with her just picking up where she left off?

Please, go ahead, from the point where I interrupted you, not from the top.

4:25 p.m.

Director, Canadian Health Workforce Network

Dr. Ivy Lynn Bourgeault

My name is Ivy Bourgeault and I'm speaking on behalf of the Canadian Health Workforce Network, a pan-Canadian knowledge-exchange network of researchers and knowledge users dedicated to bringing the best evidence to provide solutions to health workforce challenges.

Let me begin by stating plainly that, if Canada's health workforce were a patient, it would be in critical condition. It needs immediate attention. The committee has heard from many who have provided testimony to date that the pandemic has caused unprecedented burnout, distress and record-level vacancies due to health and safety concerns, unsustainable workloads, cancelled vacations and forced redeployment.

Then there's the violence.

In this committee's 2019 report, you noted that health workers are four times more likely to face workplace violence than those in any other profession, yet most of it goes unreported due to a culture of acceptance. Recognizing that this requires action beyond this committee, we are still waiting for the recommended public awareness campaign and pan-Canadian prevention framework. We are still waiting, also, for the much-needed update to the pan-Canadian health workforce strategy to address staffing shortages, which this committee recognized exacerbates the violence health workers experience.

COVID-19 has traumatized Canada's health workforce, but most of these challenges predate the pandemic. The pandemic has sharply exposed the lack of clear answers to the most basic questions about Canada's health workforce. For example, we know little about how many health providers work in critical sectors such as home care, long-term care and mental health care.

Canada lags well behind comparable OECD countries in terms of health workforce data and decision-making tools. Health workforce research receives less than 3% of health services and policy research funds, and less than 1% of all national health research funds. Other OECD countries provide nationwide support for evidence-based decisions, but here in Canada we are left to make critical decisions in the dark.

This lack of very basic human resources knowledge is particularly egregious because health workers account for more than 10% of all employed Canadians and over two-thirds of health care spending in Canada, which amounted to $175 billion in 2019 or nearly 8% of Canada's total GDP. Recognizing these facts, all levels of government, including the federal government, play an essential role in sound policy development, strategic health workforce planning and health system stewardship.

To date, more than 65 health care organizations and 300 health workforce experts and organizational leaders have signed on to a call to action for the federal government to take a lead in supporting provinces, territories, regions, hospitals, health authorities and training programs in investing in better health workforce data and decision-making tools.

In our brief to the committee we put forward a set of promising evidence-informed solutions for consideration. Our preferred option, based on existing Canadian models and leading international practices, is for the federal government to create a dedicated coordinating health workforce agency with a mandate to enhance existing data infrastructure and decision-support tools for strategic planning, policy and management across Canada. This would be done in a similar fashion to the way the Public Health Agency of Canada was created after our last SARS crisis—a crisis dwarfed by COVID-19.

In addition to addressing needed data and decision-making infrastructure, an agency could address the immediate challenges by gathering and sharing leading evidence-informed practices to retain health workers and foster the return of those who recently left, while also informing Canadian-focused recruitment strategies—the new three Rs of health workforce management—retain, return and recruit.

Those working in health care today need to know that a better future lies ahead. They are tired, and a great resignation looms large. Patients in critical condition require follow-up care, ongoing monitoring and support as well as measures to prevent critical illness from happening again. This is exactly what we need for the health workforce.

The public understands this. Overall, nine out of 10 Canadians in a public opinion poll from this past March said they were concerned about the mental health of health care workers. Eight out of 10 were also concerned about what this meant for their access to and the quality of health care.

Action is needed now. The status quo must be seen for what it is—the most expensive and the least tenable option going forward.

I'd be pleased to address any of these or other points of the committee. Thank you again for this opportunity.

4:30 p.m.

Liberal

The Chair Liberal Sean Casey

Thank you, Ms. Bourgeault.

Next we're going to hear from Pallium Canada, Jeffrey Moat, CEO.

Mr. Moat, you have the floor.

4:30 p.m.

Jeffrey Moat Chief Executive Officer, Pallium Canada

Thank you, Mr. Chair and to this committee, for this opportunity to speak with you today. I will be joined by Dr. José Pereira in sharing our remarks with you. I am the chief executive officer of Pallium Canada.

I want to take this opportunity to acknowledge that the land from which I am presenting, the city of Ottawa, is the traditional, unceded and unsurrendered territory of the Algonquin Anishinabe people.

For over 20 years, Pallium Canada, a national non-profit organization that was established in Alberta and now has its head office in Ottawa, has been equipping frontline health care workers with the essential skills needed to provide palliative care to Canadians. The ability to provide a palliative care approach when and where it is needed is essential for all health human resources in a modern, agile and increasingly diverse workforce, yet most health care professionals receive little to no training in palliative care during their formal health education.

Pallium's flexible and adaptable interprofessional training solutions meet both the team and individual learning needs of all health care professionals, including physicians, nurses, social workers, personal support workers, paramedics and others. Pallium has developed training specifically targeted to health care leaders so that they have the knowledge necessary to support the success of the health care teams they lead.

Pallium's LEAP programs—LEAP is an acronym, by the way, for learning essential approaches to palliative care—have been proven to increase palliative care knowledge and skills and empower health care providers to make changes in their practice and improve the palliative care they provide to patients. The interprofessional design of LEAP courses also creates a common understanding and culture among health care teams and has been shown to increase job satisfaction and enjoyment.

As a national, evidence-based, accredited training program, LEAP supports health human resource labour mobility and responds to identified workforce mental health needs. This is something that was recently highlighted in Ontario's long-term care staffing study, which identifies the ability to provide palliative care as a key challenge for long-term care staff that negatively impacts their mental health and well-being.

This lack of palliative care skills among health human resources in Canada has too often led to unnecessary pain and suffering for Canadians and grief for the families and loved ones who can't access the palliative care they need. If the pandemic hasn't made a strong enough case for the need for better skills training in palliative care, then I'm not sure what will. Past calls to improve these essential skills have been too often ignored.

The good news is that solutions, such as LEAP programming, have already been paid for by Canadian taxpayers. There needs to be a commitment to spread and scale such solutions so that health human resources have the competencies and confidence to provide better palliative care to more Canadians.

Dr. Pereira.

4:30 p.m.

Dr. José Pereira Scientific Officer, Pallium Canada

Thank you very much.

Honourable members, good afternoon, and thank you for the opportunity to make the case for health workforce preparedness in palliative and end-of-life care.

I'm Dr. José Pereira and I've been a palliative care physician, educator and researcher in Canada for over 25 years. I'm currently professor and director of the division of palliative care in the department of family medicine at McMaster University. I'm also scientific officer and co-founder of Pallium Canada.

Advanced progressive cancer and non-cancer illnesses continue to exact a very high toll on Canadians in terms of quality of life, suffering and health care costs. A large body of evidence shows that palliative care can reduce this burden by improving quality of life, reducing hospital admissions and emergency room visits, and reducing health care costs.

While there have been noteworthy improvements over the last two decades with respect to access to palliative care services and the integration of palliative care in the curricula of health professionals, many gaps remain. Despite what some may say, not all Canadians have access to timely, high-quality palliative care when they need it. One of the main reasons for this is the lack of health workforce preparedness to provide palliative care.

These workforce issues relate to both specialist-level palliative care and primary-level—also known as generalist-level—palliative care. If equipped with core palliative care competencies, clinicians and other professionals across many fields, such as primary care, long-term care, cancer care, cardiology and nephrology, to name just a few, are also able to initiate a palliative care approach.

There are currently not enough palliative care specialists and funded positions for palliative care clinicians in many Canadian jurisdictions. Moreover, many palliative care clinicians, including me, are nearing or contemplating retirement. In a study that I co-authored in 2015, we found only 265 physicians in Ontario who practised mainly palliative care. Emerging standards call for at least double that number.

There are not enough funded training positions for palliative care physicians. In my own division of palliative care at McMaster University, for example, we have the capacity to train up to six or eight new palliative care specialists every year but receive funding for only one trainee a year.

In my clinical work, I often see palliative care being activated only in the last days or even hours of life, when it's too late. This is demoralizing when there are evidence and experience to support early palliative care initiated many months before that, alongside treatments to control the diseases. Again, a root cause is lack of core palliative care knowledge and competencies across the health workforce.

In a large 2015 study involving primary care professionals across several OECD countries, only 42% of Canadian primary care doctors said that their practices were prepared to provide primary palliative care to their own patients, largely related to lack of education or experience. This was one of the lowest rates across the 10 countries studied, and it's not only in primary care. We see similar findings across studies and different speciality areas.

In a recent Canadian study, palliative care clinical rotations were mandatory in only two medical schools, not offered at all in two and only optional in 13. At the postgraduate level, only 60% of family medicine trainees and only 31% of internal medicine residents completed such rotations.

The good news is that there is evidence that core training can make a difference. In a large study that we did involving over 4,000 doctors, nurses, social workers and pharmacists who completed Pallium Canada's LEAP courses, we found that these courses improved advance care planning and goals of care discussions, improved pain and symptom management, improved opioid use and improved teamwork for up to four months after the courses.

We look forward to a future where these workforce training needs are addressed and long-term investments are made in palliative care training to increase specialist-level and generalist-level palliative care in Canada, and to spread and scale up across all care settings existing, proven, Canadian-made education programs.

Thank you very much.

4:35 p.m.

Liberal

The Chair Liberal Sean Casey

Thank you, Dr. Pereira and Mr. Moat.

Next, we're going to go to Ms. Lefebvre, please.

4:35 p.m.

Dr. Fleur-Ange Lefebvre Executive Director and Chief Executive Officer, Federation of Medical Regulatory Authorities of Canada

Good afternoon, Mr. Chair and committee members. I thank you for the opportunity to appear before you today. I also have the privilege of speaking to you from the same indigenous lands as those who spoke before me this afternoon.

I want to highlight a few things before I start. First, I am not a physician. Second, members of the Federation of Medical Regulatory Authorities of Canada have delegated statutory authority to regulate physicians to serve the public interest, and, third, as a voluntary, member-based organization representing all 13 provincial and territorial medical regulatory authorities, or MRAs, FMRAC facilitates discussion and collaborative efforts of its members towards the goal of improved regulation.

HESA has undertaken this study in recognition of the exhaustion and burnout among health care professionals, including physicians. Over the past few years, the MRAs have seen an increase in the number of physicians who have come to their attention because of burnout, mental health and substance abuse disorders. MRAs are mandated to protect the public, and their responsibilities rarely if ever include advocacy for the profession. However, they do include administration of a quality assurance program for identified physicians. While this is hard to quantify, FMRAC believes that the exhaustion and burnout of physicians across Canada are significant enough that they are having a negative impact on the quality of care that Canadians are receiving. In other words, physician health is a patient safety issue.

Your study intends to examine how the federal government can facilitate the recruitment and retention of health care professionals. The only way to do this is to approach the situation by putting the patient smack in the middle of this discussion.

I'm going to address four issues.

First is virtual care. FMRAC defines virtual care as the provision of care by means of electronic communication in which the patient and the physician are at different locations. MRAs believe virtual care may enable more access to care across Canada. However, physicians are expected to provide all elements of good medical care. The standard of care expected is the same whether the patient is seen in person or by virtual means. Importantly, meeting the standard of care inevitably requires access to in-person care for many conditions. This means that virtual care can be leveraged only so far.

Second is international medical graduates or IMGs. IMGs seek to come to Canada from many countries with very many different training programs. Supporting pathways to licensure for IMGs represents a meaningful opportunity to help address health human resource shortages, provided the right review and assessment protocols are established and/or maintained

Graduates of Canadian medical schools, as Dr. Moineau can very well describe, go through thorough accredited undergraduate and postgraduate training, with regular assessments along the way before being promoted to the next level of education. They also must pass national certification exams before being issued a licence to practise in any part of Canada. These are all steps along the way to ensuring the public that the physicians who treat them are qualified to do so.

MRAs also have mechanisms in place to assess the international graduates. There are limited resources available, and scaling these programs up to a broader national level would require a lot more resources, but doing that could have a significant impact on the challenges Canada is facing today. It would, in our opinion, be unconscionable to bypass the appropriate review and assessment of each IMG candidate on the route to licensure simply to increase the number of physicians available, because even a handful of incompetent physicians could have a dramatically negative impact on the health and safety of tens of thousands of Canadians

Third is a national registry of physicians and other health care providers. The MRAs are the single source of truth when it comes to data about physicians who are licensed to practise in this country. Their data are held in each province and territory.

Having a national registry or list of all the physicians could be a very useful tool for the regulators themselves—as many health care workers are licensed in more than one jurisdiction—but also for health human resources planning, especially if it includes information about a practitioner's scope of activities.

Such a registry requires significant developmental resources and an ongoing commitment to keeping the database up to date and relevant to governments, regulators, researchers and policy-makers. Two important tools are already available for medicine—a unique identifier for universal data collection, and a common portal for licensure applications.

In addition to a national registry, the federal government may wish to look at the U.S. National Practitioner Data Bank. There's more information about that in the document I submitted.

Finally, on other health care providers, FMRAC and the MRAs welcome other regulated health care professionals, such as physician assistants, nurse practitioners, anaesthesia assistants, associate physicians and others, into the system, as they can assist in meeting the health care needs of the people of Canada.

For all health care professionals, the main tenets will be the identification of the required competencies, the appropriate training to achieve those competencies and, finally, the relevant assessments in the right settings to ensure that those competencies have indeed been achieved.

In closing, thank you for allowing me to present to the health committee today. I am happy to answer your questions and listen to your comments in both English and French.

Thank you.

4:40 p.m.

Liberal

The Chair Liberal Sean Casey

Thank you very much, Ms. Lefebvre.

We're now going to begin with questions, starting with the Conservatives and Mr. Barrett.

4:45 p.m.

Conservative

Michael Barrett Conservative Leeds—Grenville—Thousand Islands and Rideau Lakes, ON

Thank you very much, Chair.

I thank the witnesses for joining us today.

Chair, I have one item of business that I'd like to do before handing my time over to Dr. Ellis.

I'm seeking the unanimous consent of the committee, through you, that the following motion be adopted. I move:

That the Standing Committee on Health report to the House that it supports the full participation of Taiwan in the World Health Assembly (WHA) and the World Health Organization (WHO).

As the 48 hours' notice wasn't provided, Mr. Chair, it requires the unanimous consent of the committee.

4:45 p.m.

Liberal

The Chair Liberal Sean Casey

Thank you very much, Mr. Barrett.

As you pointed out, the requisite notice wasn't provided, but that can be waived with the unanimous consent of the committee.

I think we have two questions. First of all, is the committee prepared to entertain the motion absent the required 48 hours' notice? Do we have agreement on that?

4:45 p.m.

Some hon. members

Agreed.

4:45 p.m.

Liberal

The Chair Liberal Sean Casey

We have agreement.

Now that you've heard the motion, is it the will of the committee to adopt the motion, or will there be debate?

(Motion agreed to)

Go ahead, Mr. Barrett.

4:45 p.m.

Conservative

Michael Barrett Conservative Leeds—Grenville—Thousand Islands and Rideau Lakes, ON

Thank you, Chair.

With a minute and 12 seconds used, I'd like to turn my time over to Dr. Ellis.

4:45 p.m.

Liberal

The Chair Liberal Sean Casey

Dr. Ellis.

April 27th, 2022 / 4:45 p.m.

Conservative

Stephen Ellis Conservative Cumberland—Colchester, NS

Thank you, Mr. Chair.

Thank you, Mr. Barrett. You're very kind.

I'll jump right in it, since we're already running significantly behind. I think that's the most germane thing.

I would like to start with Dr. Moineau, if I could.

We talked about pairing admissions to medical school and residency spots in trying to keep up with the growth in the Canadian population. We know that we've fallen significantly behind. Does your association have, in real numbers, any idea of how many extra medical students we would need at the current time to make up the difference, and what that might look like going forward?

4:45 p.m.

President and Chief Executive Officer, Association of Faculties of Medicine of Canada

Dr. Geneviève Moineau

Thank you for the question.

We are in the process of confirming what those numbers are, as well as what the capacity of our 17 medical schools is at the present time. We would certainly be able to provide you with this information in very short order.

4:45 p.m.

Conservative

Stephen Ellis Conservative Cumberland—Colchester, NS

Thanks, Dr. Moineau.

With regard to “short order”, I come from the medical field where that might mean five minutes, but in the federal government it might mean 15 years. What does it mean in your world, if I could push you on that a bit?

4:45 p.m.

President and Chief Executive Officer, Association of Faculties of Medicine of Canada

Dr. Geneviève Moineau

It means within the very next few weeks.

4:45 p.m.

Conservative

Stephen Ellis Conservative Cumberland—Colchester, NS

Okay, that's terrific. Thanks for propriating it to the committee here.

As a follow-on question to that, will that include data on matching medical schools with residencies? Can you speak to what that gap is at the current time? That seems to be a significant problem.