Health Committee on May 9th, 2022

[Laila Goodridge, Conservative, Fort McMurray—Cold Lake, AB]

Wonderful.

I think my time has elapsed.

[The Chair, Liberal, Sean Casey]

Yes. Thank you, Ms. Goodridge.

Next is Dr. Hanley, please, for five minutes.

[Brendan Hanley, Liberal, Yukon, YT]

Thank you, Mr. Chair.

I would echo the thanks to all the witnesses for re-appearing and for bringing the road map that speaks to solutions. Like my colleagues, I'd like to recognize National Nursing Week and Indigenous Nurses Day.

Dr. Smart, the situation is so critical that we urgently need to find solutions and establish recommendations. In addition to the road map that the three organizations have brought to us, you released a statement just today, I believe, on the need for the federal government to lead, in collaboration with provinces and territories, a drive to increase Canada's supply and availability of family doctors. I think this is critical. What I really liked in that statement was that you talked about reimagining family medicine, which goes back to that concept of reforming primary care.

Maybe you could say a few words on this. What does the modern, happy, useful and efficient 21st century family physician look like? Let's project a few months or a couple of years into the future.

[Dr. Katharine Smart]

I can make some comments, and then, of course, I would love to hear from the two family medicine experts we have here today.

I have really tried to take their approach in this role. The CMA has really tried to take the approach of listening to the people that are experts in family medicine regarding the pebbles in their shoes. What are the things that are preventing them from doing this work?

Every family doctor I have encountered and met through my career has chosen that area of medicine because they really believe in wanting to provide longitudinal continuity of care to families from birth to death. The fact that the system is taking that joy in providing that type of very meaningful care away from them, I think, speaks to the fact that it's fundamentally broken.

Family doctors want to provide that care without having to worry about all of the business aspects of medicine, such as rising inflation, rising costs of providing the primary care infrastructure, rising administrative burdens, inability to spend the time their patients need from them to address complex issues, and not having the team around them to provide comprehensive care.

If we project that to the future, they want to be on a team where their patients have a medical home. That medical home means that the provider that patients need is available to them for the problems they come with, that they are seen as a whole person, that the care is comprehensive around that, and that their job is thinking about patients and what they need. They do not want to think about how to run this small business, how to work through this fee schedule of 18,000 different fee codes and manage all those billings. All of these administrative pieces really detract from the heart of what medicine is, which is a relationship with patients.

If we can get back to that, and really look at addressing the health care issues that Canadians need, we can have a healthier population, a healthier workforce, and a new future for family medicine where it again becomes one of the most desirable areas of practice for new doctors.

[Brendan Hanley, Liberal, Yukon, YT]

Thank you.

Dr. Bouchard, let's flip that around a bit. In this primary care team, anchored by that happy family physician, tell me about the patient and the client in the middle. How are they going to benefit?

[Dr. Brady Bouchard]

Dr. Smart did an excellent job of detailing our vision and how we would like to practise.

The benefits to patients are innumerable. Family physicians are trained in complexity care in a complex health system with complex diagnostic and treatment options. We want to be able to work at that top of scope, and have other providers around us in order not to be focusing on the business. If we're able to do that, patients will absolutely benefit, and certainly in longitudinal care.

I would like to have patients attached to my clinic that I see from birth to death, with whom I have an understanding. I understand their context. I understand their family, their values, what they want out of their care and their goals in life. The evidence is out there that we provide better, and certainly more efficient care, for the dollars invested into that.

That's where the primary health care integration fund comes in if we can transform that. That's why it's a time limited fund. If we can get into these team-based practices, it will be more efficient for the health care system, and patients will benefit.

[Brendan Hanley, Liberal, Yukon, YT]

Thank you.

Back to you, Dr. Smart.

Clearly, there are federal investments committed either in the budget or through the platform commitments; namely, mental health care, primary care, reform, and addressing the backlog. As you have all said, “It's more than just money.”

You spend a lot of time talking with colleagues and associations around the country. How do you see the federal role in igniting change? We're in a federated system. The provinces have control over health care delivery, yet we need a driver. We need to get there.

Dr. Smart, could you comment on how best the federal government can position itself, in 30 seconds or less.

[The Chair, Liberal, Sean Casey]

Actually, he has used 30 more seconds than he's allowed, so when he said 30 seconds or less, he might have been exaggerating.

Go ahead, Dr. Smart, as concisely as possible.

[Dr. Katharine Smart]

I think leadership to define that the integrated team-based care is the gold standard and the future. That needs to be the model. Anything less than that is not going to cut it in 2022, so we need to define ourselves from that benchmark moving forward.

[The Chair, Liberal, Sean Casey]

Well done, thank you.

Mr. Lake, you have five minutes.

[Mike Lake, Conservative, Edmonton—Wetaskiwin, AB]

Thank you. This is a great study.

I want to say, first of all that I've had some experience, unfortunately, with the health care system for people close to me and for myself, but it's always been a great experience when we've had something urgent.

I had encephalitis when I was 31. I'll tell you, it was taken very seriously and I was very happy to have the support that I had.

I have a son with autism. I know, Dr. Smart, that's something close to the work that you do. When we've needed help with him, trying to figure out what's going on because he's non-speaking, we've always had fantastic support.

However, in those interactions, I've noticed things that seem inefficient, and we probably all have at different times.

In the times when I didn't have a serious injury—playing hockey, for example—and had to go into the emergency department because I don't know where else to go, I waited for hours because there were more important case. That seems inefficient in the general scheme of things. It doesn't feel like I need to be there, but it's the only place that works. Going to my family doctor, who is fantastic, I see him do a lot of administrative stuff as he's working with me. He's taking notes and things like that. It seems very inefficient.

It seems that a big part of the challenge is people doing things, largely, that someone with different training or less training than the experts—the expert training people have—whether it's doctors, nurses, or others.... They're doing things that they don't need to do.

When you think about those really expensive inefficiencies in the system, such as someone going to emergency who doesn't need to be there, having a doctor taking notes or, as Mr. Guest talked about, nurses doing cleaning, they all seem to be very expensive inefficiencies.

What are the ones that are the easiest for us to address as we think about action coming out of this set of meetings?

[Dr. Katharine Smart]

Is that question for me?

[Mike Lake, Conservative, Edmonton—Wetaskiwin, AB]

It's for anybody who wants to answer it. It's such a great group.

[Dr. Katharine Smart]

I'll let someone else talk, because I've talked lots.

[Mike Lake, Conservative, Edmonton—Wetaskiwin, AB]

Dr. Bouchard's unmuted.

[Dr. Brady Bouchard]

Sure. I'll take a stab at that.

The most essential component of building efficiencies into our system is moving to what the CFPC puts forward as a patient's medical home. That patient's medical home, that team-based care, will vary across the country based on community demands. We're not prescriptive so much about how each clinic is set up and which team members are involved but, exactly as you mentioned, focused on what the community needs are. Getting everybody in that team to work the top of the scope, so that we've using our resources efficiently is where we want to go.

The 10 pillars of the patient's medical home and the resources of the primary care integration fund will get us there.

[Mike Lake, Conservative, Edmonton—Wetaskiwin, AB]

When I think about my own doctor and family doctors, they seem to be running small businesses of a sort. Individually, it's their own small business. My observation is that there's something....

I come from a business background. If I was running a business of a similar size and nature, I would have support staff doing some of the things, and you would think that it would enable me to see more people. The money, the compensation, comes from that and it would almost pay for itself in a sense, if you get the right people doing the right supportive work. It's an observation from the outside.

What gets in the way of that?

[Dr. Brady Bouchard]

We're on the record as saying that alternative payment models—specifically not running your own business in a fee-for-service practice—is where to go, and I would say a couple of things get in the way of that.

Family physicians are not trained to run a business. We're not trained to hire staff, manage staff, sign contracts and deal with remuneration. We don't want to be doing that. Unfortunately, that ends up, depending on the practice, being a significant portion of your day, when you could be focused on clinical care. It's contributing to burn-out, especially in our urban areas right now, with inflation and increasing commercial overhead costs, medical supply costs and everything else.

I think alternate payment models in a team-based practice are one way to make substantial change to get away from some of the areas that are in the way of providing best care.

The other one is our IT solutions, our electronic medical records software. If we were able to integrate those systems between referral centres, primary care clinics and even hospitals, it would save a huge amount of time for every team member and it would be a sustained win into the future.

[Mike Lake, Conservative, Edmonton—Wetaskiwin, AB]

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Lake and Dr. Bouchard.

Next is Mr. van Koeverden, please, for five minutes.

[Adam van Koeverden, Liberal, Milton, ON]

Thank you very much, Mr. Chair.

Through you, Mr. Chair, I have a question that might be a little bit technical. It doesn't require a specific answer or a really technical answer, but I'm really curious if anybody has any reflections on the potential proportions of the contribution that could come to the Canadian health care workforce, whether through nursing, physicians or any level or layer of the workforce, that could come from the various.... I was looking specifically at points 5 and 6 of the joint submission by the CMA, CNA and CFPC, dealing with new training and education infrastructure and also new licensing.

I'm also reflecting on the fact that if there isn't the capacity currently in Canada to educate new nurses and physicians at this time, perhaps creating simpler pathways for internationally trained Canadian nurses and doctors to come back to practise could help.

But what are the proportions there? Does anybody have any reflections on that? Is there one method that will contribute to the lion's share, or are we looking at an equal contribution from those various modalities?

[Tim Guest]

I don't mind starting.

The simple answer is not one of them that will be the single solution that's going to be the biggest one getting us out of this situation. It's multi-faceted. It's going to need a multi-faceted approach.

From a nursing perspective, we do know there are a number of internationally educated nurses who are in the country and struggling to get through the regulatory process to be able to be in the workforce, but it's not a massive percentage of the current nursing population that's going to be the solution for getting us out of this. It helps.

I think that in the situation where we're in, everything that helps needs to be considered to deal with what is going to be a massive crisis. We are looking at there being growing vacancies, growing numbers of individuals in the current workforce who are wanting to leave it and a growing list of Canadians needing procedures and treatments that have been delayed for months. That is eventually going to have a negative impact on health outcomes, and we're going to be in worse and worse trouble and depending on the same workforce to help get us out of it.

There needs to be an all-hands-on-deck approach. We need to look at all of those situations, both short-term, like helping internationally educated nurses become regulated or registered to be able to practise.... To be honest, I think they would offer something even if they were in the workforce doing all kinds of things, let alone waiting until they're registered. There are things they could do now to help them adjust and learn the system.

But we need to do all of them.

[Adam van Koeverden, Liberal, Milton, ON]

Thank you, Mr. Guest.

Does anybody else have any other reflections on the potential contributions from various modalities, or should I move on to another question?

Dr. Smart.

[Dr. Katharine Smart]

I think I was just going to echo what Mr. Guest said. I think it is really about leveraging all possibilities. I also agree that no one of those things on its own is going to be the full solution. Nonetheless, they're all opportunities to bring more people into the system. Again, we need to make sure that we have a system that people want to be in, so we need to be doing those things simultaneously.

[Adam van Koeverden, Liberal, Milton, ON]

Thank you.

For clarity, I wasn't trying to reduce this to the one thing we can do to solve this massive problem. I was just trying to get an idea of whether we're thinking that 80% of the problem could be solved with these two or three, and then the rest would be sort of rounding errors. But I take the point that it's probably not. We don't know, quite frankly, what the solutions will be until we start employing and engaging them.

I read a relevant reflection this weekend about something totally different, namely that we have all of the solutions and we just have to deploy the solutions. It's not a matter of coming up with new ideas for fighting climate change or creating solutions for human health care resources, or the lack thereof. It's a matter of deploying them.

I have a question regarding the training. Obviously this would be months and years down the road, so it wouldn't address the problem in the next six months. But would more scholarships for people entering this education be a little bit of a cart before the horse type of thing because there are not enough positions?

It also occurs to me that in most lines of work now, there is the capacity to have more people than desks, which could possibly be true, as well, in nursing. We have fewer desks here that could hold everybody in the meeting, but we're managing. So perhaps nursing schools and colleges could be training higher than a general capacity.

Would new scholarships and bursaries for future students encourage more people to get involved?