Health Committee on May 9th, 2022

[The Chair, Liberal, Sean Casey]

I call the meeting to order.

Welcome to meeting number 20 of the House of Commons Standing Committee on Health. Today we're going to meet for two hours to hear from witnesses for our study of Canada's health workforce.

Before I introduce today's witnesses, I have a few regular reminders to give 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 at their places during proceedings.

I believe most, if not all, of the witnesses with us today have been with us before, but I have a couple of reminders for them, if I could. Please wait until I recognize you by name before speaking. Click on your microphone icon to activate your mike. Please mute it when you're not speaking. You will see on your screen that you have the choice at the bottom of the screen of the floor, English or French.

Furthermore, please not take screenshots or pictures of your screen. Everything we're doing here will be made available via the House of Commons website.

In accordance with our routine motion, I'm informing the committee that all witnesses have completed the required connection tests in advance of the meeting.

I would like now to welcome the witnesses who are with us this afternoon for two hours. From the Canadian Medical Association, we have Dr. Katharine Smart, president; from the Canadian Nurses Association, we have Tim Guest, chief executive officer; and from the College of Family Physicians of Canada, we have Dr. Brady Bouchard, president, and Dr. Francine Lemire, executive director and CEO.

Thank you all for taking the time to appear today. I know that for some of you it isn't your first time, but there was a will among many committee members to have a further discussion on the road map work you were undertaking. It's not that the questions will be limited to the road map, but that's the reason for calling some of you back.

We will now proceed with opening remarks, beginning with Dr. Smart for the next five minutes. Thanks for being with us.

[Dr. Katharine Smart, President, Canadian Medical Association]

Thank you.

I am Dr. Katharine Smart, president of the Canadian Medical Association and a pediatrician based in Yukon. I'm speaking to you today from the traditional territory of the Kwanlin Dün first nation and the Ta'an Kwäch'än Council.

Thank you for this opportunity to address, once again, the growing health human resource emergency. This discussion remains critical.

Canada's health workforce is weathering a storm longer and fiercer than any in collective memory. Health workers are still depleted, distressed and leaving the profession. I'm so pleased to see my fellow health worker leaders appearing here today, those being The College of Family Physicians of Canada and the Canadian Nurses Association. We are unified in the belief that there is no health care system without health care workers.

We come to you today with solutions—transformational ideas and reminders of existing commitments—that can mitigate the current HHR crisis, address backlogs, expand access to primary care, attend to mental and digital health and improve virtual care and data.

First, bring in retention incentives for health workers to improve health care access in areas of need. Health care workers in underserved communities and particular care settings are burned out and exiting their careers, which is creating serious resource constraints. Current commitments to incentives are a start, but more needs to be done.

Second, release the pressure of administrative burdens that health care workers face. Heavy workload compounded by administrative burdens is often the kindling to provider burnout and worsening mental health. A commitment of $300 million over three years through a federal fund could support jurisdictions to improve the well-being of health care workers through administrative and mental health supports in primary and secondary care settings.

It is time to scale up collaborative, interprofessional primary care. Too few Canadians can access primary care when it's needed. It's time the federal government deliver on the $3.2-billion commitment to increase patient access to family doctors and primary care teams.

Primary care reform is health-system innovation that would move us from illness treatment to a focus on keeping Canadians well and out of emergency departments. It would move us from fee-for-service payment structures to blended or capitation payment models, allowing for more in-depth consultations instead of incentivizing short visits, which may be insufficient to address complex patient needs.

Many of the challenges with Canada's health care systems, from funding to efficiencies to patient outcomes, can be solved in concert under one umbrella with a team-based, interprofessional, primary care model. Designed around the patient journey, primary care allows Canadians and their families to navigate the myriad health services when and where they need it. Imagine that.

To add to that, an investment of $400 million over four years can expand the government's existing work through the FPT virtual care and digital table. The pandemic created an almost-overnight digital health revolution, with Canadians accessing care virtually. It cannot replace in-person care, but it has its place.

The CMA strongly urges the government to initiate a parliamentary review on the regulatory barriers to the mobility and deployment of Canada's health workforce under the Canadian Free Trade Agreement. The current regulatory licensing frameworks have to move to a pan-Canadian licensure model, allowing health professionals to work where they would like and where the needs are the greatest.

Mr. Chair, we cannot discuss the HHR crisis without addressing the mental health of health workers. Long-term sustainable supports are needed now. Through the $4.5-billion election promise in targeted mental health funding, we recommend the creation of a pan-Canadian mental health strategy for health care workers modelled on the federal government's 2019 action plan to support the mental wellness of Canada's public safety personnel.

Finally, let's talk about data. Canada cannot plan for our workforce supply needs or distribution if we do not appropriately collect data. With an investment of $50 million over four years, we can enhance health workforce data standardization and collection processes across provinces and territories and establish a centre of excellence through an existing agency to centrally house the data and uphold jurisdictional planning efforts.

The innovative thinking presented today puts people at the very centre of the solution, ensuring that current and future generations of health care workers have the supports they need to join and remain in their profession. There is a duty to address the emergency before us immediately. From there, we can look forward to long-term, integrated health human resources planning. We have to care for those who care for Canadians.

I look forward to hearing from my health leader colleagues on the realities facing the nurses and family physicians they represent.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Smart.

Next we're going to hear from the Canadian Nurses Association via their chief executive officer, Mr. Guest.

You have the floor for the next five minutes.

[Tim Guest, Chief Executive Officer, Canadian Nurses Association]

Thank you, Mr. Chair and members of the committee.

As you know, my name is Tim Guest. I am a registered nurse and I am the chief executive officer of the Canadian Nurses Association. I want to acknowledge today that I am speaking to you from Mi'kma'ki, the ancestral and unceded territory of the Mi'kmaq.

The Canadian Nurses Association is grateful for the opportunity to appear again on this important study alongside our colleagues, the Canadian Medical Association and the College of Family Physicians of Canada. We continue to hope that the committee's work will lead to meaningful and much-needed action to address Canada's health workforce crisis.

I'd first like to recognize that today marks a very special occasion as we celebrate the start of National Nursing Week and Indigenous Nurses Day. This week, we recognize the important contribution of nurses. Their knowledge, expertise, leadership and compassionate care are an inspiration to us all as they continue to answer the call despite the crisis they face.

Nurses and health care workers are at a breaking point. This is an urgent national issue, and pan-Canadian collaboration is needed to address this multi-faceted crisis.

CNA is grateful for the opportunity to collaborate with the Canadian Medical Association and the College of Family Physicians of Canada in developing a road map of solutions. I want to highlight three key elements from that road map for you today.

First, this is a crisis of retention more than of recruitment. In the short term, we need to stop the bleeding and help keep nurses and health care workers in their jobs. Canada needs to implement retention strategies and improve nurses' well-being. If no effective strategies are put in place to retain the nurses we have now, no other strategy will make a difference. Nurses need mental health supports, and their workloads need to be reasonable to make sure they will stay. Funding for retention bonuses for late-career nurses and federal income tax relief for health care workers can also help. Also, student loan forgiveness shouldn't be exclusive for those practising in rural and remote areas since we are also seeing shortages in urban centres. Hiring more cleaning or support staff could also be effective to allow nurses more time to provide nursing care.

Second, in the medium term, we need to increase system capacity to educate and train health care workers and accelerate the licensing and employment of internationally educated health care workers. Internationally educated nurses, or IENs, report great difficulty in practising in Canada. Barriers include immigration status, long processing times and registration costs. Targeted federal funding could help increase resources for regulatory bodies. Funding could also help offset licensing costs for IENs. Although IENs already living in Canada should be a part of addressing the crisis, they are not a quick-fix solution. CNA also urges caution on the recruitment of IENs currently living in other countries due to the global shortage of nurses. A special focus on ethical recruitment is important.

Finally, in the long term, Canada needs to urgently improve workforce mobility data collection and to establish a dedicated mental health strategy for health care workers to ensure they are supported during crises. As members of a female-dominated profession, nurses are often care providers for their children and family while they are experiencing burnout at work. However, access to mental health supports is lacking, especially in comparison to that available in other public sector jobs, including male-dominated professions such as fire and police services. In 2019, for example, the federal government launched an action plan to help address the mental wellness of public safety officers.

Furthermore, we agree with our colleagues from the Canadian Medical Association and the College of Family Physicians of Canada on the importance of scaling up primary care in Canada, and on the need for further supports for primary care practitioners, including physicians and nurses. We need to strengthen patient-partnered care and respond to the evolving needs of the population by advancing primary care through an interprofessional approach.

In conclusion, when it comes to looking at how we provide better health care in Canada, we need to look first at our health workforce. They are the backbone of the Canadian health care system. They make everything else work. Retaining and caring for them is at the heart of resolving many of the challenges that our health care system faces.

Thank you, Mr. Chair. I'll be happy to take questions.

[The Chair, Liberal, Sean Casey]

Thank you very much, Mr. Guest.

Finally, we're going to hear from the College of Family Physicians of Canada, with Dr. Brady Bouchard, president.

Welcome to the committee. You have the floor.

[Dr. Brady Bouchard, President, College of Family Physicians of Canada]

Thank you.

Mr. Chair and members of the committee, thank you for inviting us back to speak with you again so soon after recently meeting on April 4. This reinforces to us the committee's interest in the acute crisis facing Canada's health workforce.

My thanks go also to my CMA and CNA colleagues for working together with the CFPC in a spirit of collaboration on an issue that is truly important to the well-being of Canadians.

My name is Brady Bouchard. I'm a family physician and the president of the College of Family Physicians of Canada.

I am joining you today from Treaty 6 territory and the homeland of the Métis. I'm joined by Dr. Francine Lemire, executive director and CEO of the CFPC. Francine delivered our remarks at the earlier meeting, and I will speak today and present in English. We will be pleased to respond to questions in both official languages.

We appreciate the committee's interest in the road map document that we developed with our colleagues at the CMA and CNA and appreciate the summaries provided by the previous speakers. This document is more relevant than ever. Over the last week, there were several high-profile articles noting the alarming trends in filling family medicine residency positions.

The 2022 Canadian Residency Matching Service match data continues the slow but steady increase in unfilled family medicine residency spots. Now is the time to address the root causes of that to ensure long-term sustainability.

CaRMS matches the approximately 6,000 medical trainees to the training programs for different medical specialties. In the 2022 match, 1,569 family medicine residency positions were available. Of those, 225 are currently unfilled after the first round—14%. This number has never been higher.

As a practising family physician still in the relatively early stages of my career, I can tell you that family medicine is a fantastic specialty, but these numbers don't lie. There are increasing pressures on our specialty right now that are making it less attractive to medical students.

Practising physicians are reporting record levels of stress and burnout, and some are beginning to retire early, reduce their clinical commitments or leave the profession altogether. With the cohort of new graduates set to be reduced, the potential future implications are significant. This should be a concern to everyone in Canada because of the fundamental role that family doctors fill in our health care system.

The road map developed with the CMA and the CNA provides a series of actions that can be taken to reinforce our health workforce. The CFPC supports these recommendations and stands behind this pragmatic and actionable plan that will support Canadian family medicine and health care in general, but for that to be true, the plan needs to be carried out.

From the perspective of family medicine, there are two areas of focus in the road map to focus on.

The first is the recommendations in support of currently practising family doctors. Our members have highlighted for us that the number one issue that would make a difference right now is to reduce the administrative burden they are carrying. That means reducing the amount of time and energy they are spending on things like the general clinic administration, record-keeping and paperwork that take away from direct patient care. Letting family doctors do what they do best—caring for their patients and coordinating care—will help reduce burnout, increase satisfaction and retain our practising docs.

The second area, made obvious by my comments about CaRMS, is about changing the practice model of family medicine in the long term so that the specialty again becomes an attractive first choice for our doctors of the future. Newly graduating medical students want to work in teams, where their skills are put to best use and they have the resources they need to care for their patients but are also able to find that work-life balance that is sorely lacking for so many of us.

This is why the CFPC strongly supports the recommendation to adopt the primary care integration fund, which will allow practices across Canada to evolve into high-functioning collaborative teams and, in turn, improve access to care for all in Canada. Progress on this front has been made, but we need to see a standardized, well-supported approach that leaves no province, territory or community behind.

We look forward to the upcoming question-and-answer section of this meeting. Thank you again for your time and interest.

[The Chair, Liberal, Sean Casey]

Thank you very much, Dr. Bouchard.

We're going to move right to those questions and answers now, beginning with the Conservatives for six minutes, please.

You have the floor, Dr. Ellis.

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

Thank you, Mr. Chair, and thank you to all the witnesses for returning. I apologize for not being there in person, but I guess you guys aren't there either, so it doesn't really matter.

That being said, I want to say happy National Nurses Week to all the nurses out there, who I know are tuned in and listening intently to us—all my former colleagues. Not to be disparaging to physicians, but as we know, if we didn't have bedside nursing, the whole system would grind to a halt very quickly, which really leads me to one of my questions.

Perhaps I'll start with Dr. Smart.

We have seen a tiny bit of movement in terms of retention about the loan forgiveness commitment from the government. Obviously I think the road map is very comprehensive. If we could pick one thing out of this, what would the number one priority be?

[Dr. Katharine Smart]

Thank you for the question. It's a difficult one, because there are clearly so many issues.

From my perspective, probably the biggest crisis in front of us where there are some options, but what we could work on, is the crisis in primary care. When that part of the system is not working, it directly leads into the overload we're seeing on secondary care systems like emergency departments and specialist access, etc. That's the beginning of the challenge.

The challenge in primary care impacts physicians, nurses and other health care professionals, as well. If we can start to understand what that is.... I think you've heard from the witnesses today and in our briefs that we provided to you what those problems and issues are that are preventing that system from operating well. That will be the beginning of the systems transformation that we need to get things back on track.

We need to understand that we need to be committed to the team-based care. That's what everybody wants across health professions. We need to address the administrative burden, and that primary care applies to physicians.

We are hearing examples of how nurses are also pulled into these other duties in hospitals that aren't appropriate. It's looking at getting the right people to do the right things and getting people on track, recognizing that this old way of doing things is not working. It's not going to attract or retain people in family medicine. This problem is only going to grow if we don't get serious about transforming that system.

If I had to pick one thing—which, like I said, is hard to do, because it's all very important—that piece is very foundational in terms of how the rest of the things roll forward. The other aspect to that is the national licensure, because that impacts the sustainability of primary care in rural and remote settings, and being able to make sure that physicians in those communities can get relief is critical to retaining them.

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

Thanks, Dr. Smart.

Through you, Mr. Chair, I have two specific questions. One is for Mr. Guest and one is for Dr. Bouchard.

Mr. Guest, you talked specifically about nursing training. How many more nursing spots do we need in Canada to increase that training amount? Do we have any idea now?

We've talked about the need for 60,000 or 70,000 nurses. How many training spots do we need to begin to catch up with the numbers we need?

[Tim Guest]

It's an interesting question that is difficult to answer, largely because we don't have enough data to tell us where we need the people and what skill sets we need. That adds to the challenge to really know.

We know that there are more people interested in going into nursing programs and becoming nurses than there are seats to take them. The exact number, I would say, is a shot in the dark at the moment without an adequate national data strategy.

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

Thanks, Mr. Guest.

That rolls into some of the data collection that we all know we desperately need.

Finally, Mr. Chair, through you to Dr. Bouchard, we've talked a lot about administrative burden, that we need to help with it and need to have people doing the jobs they're trained to do.

Are there specific examples you could give the committee about the administrative burden in, say, a family doctor's office and how we might be able to reduce it?

[Dr. Brady Bouchard]

The administrative and paperwork burdens vary across the country. There are many examples to give.

One is how our EMRs—electronic medical records—function across the country, the varied number we have and the different vendors. Integration between the EMRs would certainly help. There's a lot of manual faxing that goes back and forth, tracking down additional results. To be quite honest, there are repeated lab tests and diagnostic tests, because you can't track down results. That would be one concrete example.

The other one is integration between family physicians and all the specialists they refer to. Most of that is done via fax. There's back-and-forth with specific forms or different types of forms. If we had an integrated EMR system, either a single source system or systems that talk to each other, it would greatly decrease that burden.

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

Thank you for that.

Mr. Chair, I think I have a few seconds left.

Dr. Smart, can you talk quickly about the pan-Canadian licence? Do you have any concerns about that adding to the administrative burden in the sense of another layer of government?

[Dr. Katharine Smart]

That's an important question. Our vision for it is not that; it's that it would be a seamless process with all of the provinces and territories participating. You might want to think of it as one-stop shopping, so to speak, if those agreements were in place.

The goal is not to increase the burden on physicians in pursuing their licence, rather to streamline it and recognize that the requirements are essentially the same now. There are all these administrative steps that people have and costs to pursue licences. If we were able to streamline that, it could make the administrative aspect and the cost less, bringing that burden down and giving us much more workforce, deployability and flexibility.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Smart and Mr. Ellis.

We're going to go to the Liberals and Ms. Sidhu, please, for six minutes.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you, Mr. Chair.

Thank you to all of the witnesses for appearing today.

Like you, I also want to recognize that this week is National Nursing Week and Indigenous Nurses Day. I want to thank all Canadian nurses for their tireless work.

My first question is for Mr. Guest. We all heard at the committee that nurses are leaving their profession. What kinds of resources and supports do we need to give them so they will not leave this profession?

[Tim Guest]

I think it's multi-faceted. We hear from nurses that one of the reasons they're choosing to consider leaving the profession is their workplace environments. They're talking about having to work short of people, having excessive workloads where they're looking after twice as many patients as they normally should be. They're complaining about feeling like the quality of care has deteriorated, along with those environments. They're talking about situations where they're being asked to work 24-hour shifts. We wouldn't allow a pilot to fly a plane doing a 24-hour shift, yet in some places we'll allow a nurse to work 24 hours. We're hearing a lot about burnout issues that are continuing to impact nurses, a significant deterioration in the self-reported mental health status of nurses, which was already an issue prior to the pandemic and has drastically worsened.

We need to address some of those situations in workplaces that are creating stress, and there also need to be mental health supports and other supports to help clinicians to get past the very challenging experiences they have faced during the pandemic This would be very similar to the supports that have been put in place for first responders, like PTSD supports and some of those mental health supports, to help clinicians deal with some of the tragic things they have experienced.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you, Mr. Guest.

My next question is for Dr. Smart. We need to increase the number of trained health care workers. The budget proposes $115 million, with $30 million ongoing, to expand the foreign credential recognition program and clear the way for 11,000 internationally trained professionals. How do you think that working with the provinces and territories will help lessen the burden?

[Dr. Katharine Smart]

I think it's really important that we try to bring the health care professionals who are already in Canada into our system, We know there are many examples of physicians, nurses and other health care providers who are already here in Canada, who have really struggled to access the system for multiple reasons. I think this funding could go to try to streamline that process.

It's very expensive to go through the process. I'm now speaking specifically of medicine, because that's what I am more familiar with. We know there are issues with the cost of pursuing that training. There are issues with having enough access to the apprenticeship model we use, because foreign-trained physicians need to spend some time with a Canadian provider for practice readiness assessment, which is often unpaid work. Access to Canadian physicians who can provide that support and help integrate and orient people into our system is limited, so that is a barrier too. Then there's the cost. The regulatory aspect, again, of then having their documents assessed through our regulatory bodies and then being licensed is very expensive.

Those, I think, are all processes that could be simplified, streamlined and supported, as well as financial supports for those health care providers who are foreign-trained physicians themselves as they're going through that process, which would then allow folks to be successfully onboarded into our system. Right now, because the regulatory aspects of it are so varied, it's very difficult, and many people are never able to actually complete the process and remain outside the practice of medicine. I believe this is a challenge across health professions. If those dollars could be invested into better understanding how we can streamline that process and support people, I think we would have more chance of successfully integrating those health care professionals into our system.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you, Dr. Smart.

My next question is for Dr. Bouchard. How does Canada compare with other countries when it comes to foreign credentials and medical school acceptance? You said that the matching number is very low.

[Dr. Brady Bouchard]

I think the entry into residency in different countries is significantly different and thus difficult to compare. I would certainly say, as you mentioned, that the number we're worried about is matching Canadian medical graduates into family medicine residencies in Canada. That's the worrying trend over recent years as far as training enough family physicians into the future is concerned. Dr. Smart already touched on increasing the credential pipeline for international medical graduates—absolutely, I agree with that. I would also point out there are a significant number of Canadians studying abroad who have finished their medical degree abroad and are then unable to match into a residency here. It's about both having more residency positions and also making family medicine a more attractive specialty.

[The Chair, Liberal, Sean Casey]

Thank you, Ms. Sidhu and Dr. Bouchard.

I will now give the floor to Mr. Garon, from the Bloc Québécois, for six minutes.

[Jean-Denis Garon, Bloc, Mirabel, QC]

Thank you, Mr. Chair.

With the witnesses appearing today, I would like to take the opportunity to say hello and thank you to all the health care workers in Quebec for their outstanding work during the pandemic. This of course applies to all the members of the associations who represent them.

To begin, let me say how much I liked your presentation. It gave a timeline, a graphical tool to help us understand your plan and its time frame. That makes my work easier, so thank you very much.

After reading your brief, I went ahead and made a list of the budget measures that would be required to implement the plan you suggested. You recommend $300 million in incentives for retention of health care workers, $300 million over three years for administrative costs $3.2 billion to increase access to primary care, $4.5 billion for a national mental health strategy for health care workers, and a certain amount for workforce data. With the $2 billion just earmarked in the last budget for delayed surgeries, the figure is $10.75 billion, or close to $11 billion in additional funding required over five years to address the problems exacerbated by the pandemic, and which we had quantified. I am thinking for instance of the issue of staff retention.

Looking at these figures, I wonder if it would not be better to simply grant the provinces' request to increase their funding under the Canada health transfer, on an unconditional basis. This would be less expensive to administer and would give the provinces all the flexibility they need, given the large amounts involved.

What do you think of that, Dr. Smart?

[Dr. Katharine Smart]

I think we definitely find ourselves in a challenge now as to how we try to leverage some of these ideas, which are pan-Canadian issues, and to get some momentum on solving issues that impact everyone, as opposed to continuing to be completely siloed with the current 13, arguably 14, health care systems that we have.

We absolutely appreciate that the provinces need to deliver on health care, and there's that important role, and more local knowledge is important, but we also struggle with being able to take and learn from lessons of what's working and scaling it in other jurisdictions, and what we end up with is no real transformative change happening.

We absolutely support the idea of increasing the Canada health transfer so that the provinces would have more predictability in terms of the sustainability of funding that's available to them. That said, we also see that several of these problems we've outlined are pan-Canadian problems and may be more efficiently handled by having solutions that every province and territory can collaborate on and move forward together on, rather than re-creating solutions in each province and territory and not learning or scaling things that do work. We also recognize that this has been our pattern of funding now for many years, and we have not seen significant health care transformation.

I think our real concern is how we move past the status quo. We've been talking about integrated team-based care for 20 years, but we haven't seen any really high-level commitment towards making that the system of care, so how do we get past the status quo? How do we get the provinces, territories and federal government co-operating towards the action that's needed to transform the system? How do we move forward out of this crisis mode? I think the worry is that more of the same is not going to get us there.