Health Committee on May 9th, 2022

[Dr. Katharine Smart]

I'll make a comment from the medical side.

Right now we don't have enough seats in our medical schools for the number of people who want to train to be physicians. They are oversubscribed, and that's why you see many Canadians choosing to go overseas, primarily to Ireland and Australia. Those seem to be the two most popular places for Canadians to train in medicine. That's largely because folks haven't been able to access medical schools here. I think more capacity in our system is important.

I think scholarships are really important when you look at the challenge of improving the diversity in our workforce and allowing the workforce to be more representative of all Canadians. Medical school is incredibly expensive. Some of the things that are prioritized by people who apply in terms of extracurriculars really speak to privilege; they're not things that many Canadians would have been able to do.

From my perspective, a really important part of serving Canadians well as a profession is making sure that our workforce is diverse. I think eliminating financial barriers to allow different types of people from different backgrounds to become physicians is going to be critical for the future.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Smart.

Thank you, Mr. Garon, you have the floor for two and a half minutes.

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

Thank you, Mr. Chair.

Dr. Smart, I was moved by your comments earlier about access to care. Personally, I am very concerned about access to care in the regions. In Senneterre, for instance, in the Abitibi-Temiscamingue region of Quebec, there have been instances where the hospital had to close because of a shortage of doctors and staff.

During the pandemic, we saw a number of significant improvements very quickly, such as telemedicine. The college of physicians was able to change its practice standards quite quickly so that patients could access virtual consultations, which facilitated a smoother flow of services. I understand of course that not all care can be provided this way.

From your point of view, in order for us to use this new consultation method in the longer term, what investments or resources would be needed, and what would have to be done by faculties of medicine in particular?

[Dr. Katharine Smart]

I think there are a few things. One of the biggest challenges in remote areas, both for patient care and potentially for the idea of decentralizing some aspects of medical education to improve access for rural and remote Canadians, is the Internet itself. I'm speaking to you from Yukon today. The Internet service here is very expensive and not of high quality. I would say it's more than what most people can afford. I personally pay over $200 a month for my Internet, which is sort of a shocking number.

We need to make sure that all Canadians have equitable access to communications technology. This virtual care revolution that happened so quickly because the pandemic has been revolutionary in many ways. We're still figuring out exactly how to leverage that in the best way. I think we're going to see some of those changes come for education as well, and we'll get away from thinking that everything has to happen in the big city at the university.

There are some excellent examples already of distributed medical education across the country. I think we can continue to build on those models. We need to look at what's working and how those are servicing Canadians wanting to be doctors. We're going to have to make sure that the infrastructure is there for people so they can get online effectively and participate in these virtual experiences. I think there's an equity concern there if it's not available to everybody. You start creating two different tiers of access both educationally and in terms of patient care. I think that's an important area to focus on.

[The Chair, Liberal, Sean Casey]

Than you, Dr. Smart.

Next is Mr. Davies for two and a half minutes.

[Don Davies, NDP, Vancouver Kingsway, BC]

Dr. Bouchard and Dr. Lemire, the primary care integration fund seems to be a core piece of your suggestions.

What advice would you give us on the implementation elements that we should bear in mind as we create and administer this fund?

[Dr. Francine Lemire]

I think that we see the primary care integration fund as a fund that would be put in place for a temporary period of time to enable scaling up of some models of care that already show promise. Examples of this would be groupe de médecine de famille au Québec, Ontario health teams, and primary care networks in Alberta. These are some examples that are models of care that support good integration and team-based care, and they have shown promise in terms of reduced visits to the emergency department, better adherence to preventative measures and better satisfaction by patients and providers alike.

This fund would enable scaling up, assisting and providing support to family practices to get to that model of care, because we know that investments are required up front so that you can reap the benefits at the back end in some of the outcomes that have been described, as well as savings from a health care delivery perspective.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

I'm sorry, did you have more to say?

[Dr. Francine Lemire]

You and I have discussed this already: make a targeted fund available with the specific purpose of doing some of the things I've just finished talking about, to which the provinces could apply. Hopefully, they'd all be interested in accessing the fund to bring about that scaling-up of innovation.

[Don Davies, NDP, Vancouver Kingsway, BC]

Mr. Guest, I'm going to revisit a question that I don't think I put to you properly before.

The question I asked you is whether there is a viable IT solution. I know one problem is that hospitals and provinces aren't talking to each other, and it seems this is a major cause of grief. Is there an IT solution out there for that? That's what I'm asking.

[Tim Guest]

To our knowledge, no.

We certainly have seen, across the globe, some countries doing a fairly good job at this. I think there are some examples we can learn from. The United States has a program for doing this. I don't think we have to start from scratch and recreate the wheel. There is information out there and knowledge that we can leverage.

I think the big thing here is.... It's not so much the IT solution itself, but the infrastructure needed to pull it off. A really good example of where this is already happening in the health system in Canada is CIHI. This federal agency has the task of pulling together the health data collected by all of the provinces, which goes in a central repository. It's analyzed and provided back to the health systems so they can use it for planning. That's kind of what we're talking about: an organization to help standardize data collection, which the provinces and territories would flow up so that it could be analyzed and provided back to decision-makers in the provinces and territories for better planning of health human resources strategies, whether that be in the number of educational seats that need to increase, or investment that needs to happen to support clinicians so they can practise some specialty that may need to be grown.

Those are a couple of examples.

[The Chair, Liberal, Sean Casey]

Thanks, Mr. Guest.

Dr. Ellis, please go ahead. You have five minutes.

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

Thank you, Mr. Chair.

I want to say how wonderfully efficient we are today. We've gone through many rounds of questions, which is unusual for us. There were no interruptions from bells, which is also great.

I'll respectfully disagree with one of my colleagues, Mr. Van Koeverden, who talked about whether we have the solutions. Part of the difficulty here is understanding the breadth of this problem and the significant change required. We need people. We need to create physicians and nurses, and that takes time. We also understand there's a tremendous shift away from choosing family medicine as a profession. We heard about the unmatched seats during the CaRMS process, and that is a tremendous change we've seen over the last generation or so. To me, that creates a significant problem.

There are two other comments I would like to make, and then I will farm out some questions.

First, team-based care is exceedingly inefficient. I've practised team-based care at a chronic pain clinic for the last 15 years or so, and the speed with which we're able to see patients is much slower. We have to discuss them and we have to chart them, etc. That's a difficulty.

Second, I'm not entirely sure the government understands how dire the situation is. I'm not entirely certain that every Canadian understands how dire the situation is. Because team-based care is a significant part of the road map here, I would like to ask Dr. Bouchard to comment on the inefficiency of team-based care. There certainly are many cases in family medicine—and I understand that I'm biased because I'm a late-generation family doctor—where you don't necessarily need to see a team. How do you sort that out?

[Dr. Brady Bouchard]

I think rather than the term “efficiency”, what you're perhaps alluding to is the time per visit or the time per patient. Certainly that would increase in a team-based practice, and it should. Patients are more complex. It takes longer to sort out problems. We were just talking about the mental health burden for providers but also for patients, and that certainly takes more time.

A team-based care model that's implemented well doesn't necessarily equate to increased resources and increased dollars. Different team members working at their top of scope and many team members that are not as highly trained and, to be frank, paid at the same level as family physicians are would be incorporated as part of that, but it's also about the health care savings we see.

Dr. Lemire touched on how even if a team-based primary care clinic or network costs more directly, there would be significant indirect savings from reduced emergency department visits, which are much more expensive, and reduced hospital admissions certainly.

Per visit, per patient coming into clinic, that may change. It may take more time. However, having worked under both models myself, I think patients value—and as a family physician, I certainly value—being able to take that extra time to sort out all of the issues. We hear across the country about one issue per patient and one issue per visit. Patients don't like that, and family physicians don't like that, and I think we can do better.

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

Thank you, Doctor.

[Dr. Francine Lemire]

I'd simply add perhaps that it takes time and energy to work effectively as a team. I have experienced the same thing you've described. You see a patient who has been seen by several different people before they get to you, and that's not efficient. Energy needs to be spent on supporting people to work well as a team. That needs to be a part of it.

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

Thank you very much.

Through you, Mr. Chair, to Dr. Lemire, kudos on the amount of work you've done on this particular project over the years. You've seen this through many iterations and many reports. What's your confidence level that we're actually going to be able to get there this time?

I know that's a politically loaded question. I appreciate that, Doctor. I do.

[Dr. Francine Lemire]

The only thing I will say is that I think all of us here today realize that we are at a point of inflection with regard to how primary care and community-based care are functioning. I think we all realize this now more than ever. I would suggest that we are at an important crossroads, and I sense that there is a genuine will to invest in a future that will not be a repeat of the past.

I am more confident than I have been in the past, but I certainly will not put a percentage on it.

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

Well said. What a great way to end, Mr. Chair.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Lemire.

Dr. Powlowski, go ahead, please, for five minutes.

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

Having practised medicine for a lot of years and having worked with a lot of nurses over those years and certainly recognizing the key pivotal role of nurses in the health care system, I will ask Mr. Guest some things about the problems facing the nursing profession. Any of us who work in medicine realize how overworked a lot of nurses are, particularly in hospitals, and how they are always being asked to work overtime and extra shifts and they have too much work to do because they're understaffed.

In your recommendation number six, you suggest that, presumably the government, should support and expand opportunities for registration and deployment of internationally educated nurses in order to provide immediate supply into the workforce as is done in provinces such as Manitoba and Ontario.

We haven't been doing this long enough to have talked to people from each of the provinces.

Mr. Guest, could you tell us what Ontario and Manitoba have done?

[Tim Guest]

Ontario is more recent. I'll give you an example. They put resources in place very quickly during the pandemic to work with the regulator to expedite getting those individuals through the process. The primary issue we hear with internationally educated nurses is that there are three main issues that cause them to get into the workforce.

The first is their immigration status, which sometimes impacts their ability to access programs. It impacts career laddering opportunities, because they're not necessarily seen as permanent residents yet.

The second one is associated with the cost of going through the regulatory process. Not all individuals have the resources to pay the costs associated. In B.C., as an example, we've seen it can cost up to $15,000 for an internationally educated nurse to be registered in that province.

The third thing is long processing times. We've heard examples in provinces that it can take up to three years for an individual to make their way through that process. One of the things Ontario did was work with the college to expedite that process and provide resources for them, so they had more people to assess individuals.

It's about matching the individual with their capabilities and helping them get registered into the right classification of nursing. What often happens is they find that they're not able to be registered in one and have to start the whole process all over again to be registered in another.

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

From what you're saying, it sounds like it is possible with more resources to license more foreign graduates. Can you tell me approximately how many extra nurses were licensed in Ontario as a result of this expedited process?

[Tim Guest]

I can't give you the number off the top of my head, but I can certainly try to get you a clearer number.

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

That would be great.

Is it true that nurses also have to be licensed province by province? Because my wife went to nursing school in the Philippines, I know that of her classmates, some were able to practise in Alberta and some were able to practise in California, yet others couldn't get licensed in Ontario. Does this make any sense? Is Ontario's quality of nursing that much higher than California's and Alberta's? I don't think so.

What about the possibility of national requirements for licensure in nursing? We've heard it from the medical profession. Have you considered it for nursing?