Health Committee on Sept. 27th, 2022

[The Chair, Liberal, Sean Casey]

I call this meeting to order.

Welcome to meeting number 31 of the House of Commons Standing Committee on Health. Today we are meeting for two hours on our study of children's health.

Today's meeting is taking place in a hybrid format, pursuant to the House order of June 23.

I would like to make a few comments for the benefit of witnesses and members.

Please wait until I recognize you by name before speaking. For those participating by video conference, click on the microphone icon to activate your mike, and please mute it when you're not speaking.

For those of you on Zoom, you have the choice at the bottom of your screen of “floor”, “English” or “French”.

Screenshots or taking photos of your screen is not permitted. The proceedings will be made available on 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 am participating remotely today because of the situation here in Prince Edward Island. I am in one of the few buildings in Charlottetown that has electricity. Hopefully, it will be stable enough to get us through the meeting.

I would now like to welcome our witnesses who are with us this afternoon. From Children's Healthcare Canada, we have Emily Gruenwoldt, president and chief executive officer.

We also have Dr. Marie-Claude Roy, pediatrician and president of the Association des pédiatres du Québec.

From the Canadian Paediatric Society, we have Dr. Mark Feldman, president.

Thank you to all of our witnesses for taking the time to be with us today. Each of you has up to five minutes for an opening statement, followed by a period of questions and answers.

I would like to invite Ms. Gruenwoldt to begin. Welcome to the committee. You now have the floor.

[Emily Gruenwoldt, President and Chief Executive Officer, Children's Healthcare Canada]

Good morning. Thank you for inviting me today.

Children's Healthcare Canada is a national association that represents Canada's 16 children's hospitals as well as community hospitals, rehabilitation centres, and home care, palliative and respite care providers that serve children and youth. Our members span the full continuum of care, giving us a unique perspective into the health systems that serve eight million children and youth, which is a population that continues to grow.

Where Canada once ranked among the top OECD countries with respect to children's health outcomes, the 2020 UNICEF report card reveals that Canada now stands worlds apart from other rich countries when it comes to providing healthy, happy childhoods. Canada's standing has slipped to 30th of 38 countries with respect to physical health and 31st out of 38 countries with respect to mental health.

Relative to our wealth, Canada punches far below its weight when it comes to children's health. In Canada today, over 30% of children and youth suffer from chronic disease. One in five experiences chronic pain. Pre-pandemic, our children were among the least vaccinated among OECD countries. We also have one of the highest rates of adolescent suicide in the developed world. At the same time, in Ontario, over 28,000 children and youth are waiting to access mental health services—some for as long as two and a half years.

In the wake of the COVID-19 pandemic, children's health care systems are facing unprecedented demands. From coast to coast, children's hospital emergency departments are experiencing historic patient volumes that are approximately 30% to 50% higher than usual. Children and youth are often waiting 10 to 12 hours to be seen. Many of those who are admitted for serious health conditions are admitted without beds, which means there is no immediate capacity to care for these children.

In this situation, to create space and free up beds, children's hospitals are cancelling and rescheduling essential surgical procedures, putting children at risk of missing critical developmental milestones.

Mental health visits and admissions are a particular and ongoing concern. Many children's hospitals are experiencing a threefold increase in the number of patients presenting with acute eating disorders and nearly double the number of patients presenting with anxiety and depression. Between lengthy waits for mental health, surgical interventions, diagnostic assessments and child development services, children are now waiting longer than many adults for essential services.

At the same time as children's health systems are facing extraordinary demands for services, these organizations are struggling to recruit and retain a skilled workforce. Children are not tiny adults. The health care providers who care for Canada's smallest patients are among the most highly specialized.

This remains one of the most pressing and complex challenges in our health systems today. I recognize that it has already been a focus of study of this committee.

In 2020, in response to the crisis our children are facing, Children's Healthcare Canada partnered with Pediatric Chairs of Canada, UNICEF and CIHR to launch a pan-Canadian initiative called Inspiring Healthy Futures to measurably improve the health and well-being of children, youth and families. A broad, cross-sector consultation engaging 1,500 individuals and organizations identified five interlinked priorities to create conditions for children to thrive. The report underscores the need for children's health and well-being to be a priority for the public, for funders and for decision-makers.

Canadians imagine a healthier future for their children. The time is right for the federal government to develop a pan-Canadian child and youth health strategy. This strategy must enable better beginnings by prioritizing maternal and newborn health to give families the best start possible, enable advanced precision medicine and wellness through world-class care for sick children requiring hospitalization, and enable children living with neurodiversity, disability and chronic disease to transition from vulnerable to thriving.

A comprehensive strategy would not only address existing gaps, but would also anticipate needs of the future. First and foremost, we have normalized rationing and waiting for mental health services—to the detriment of kids—while we know that early intervention pays lifelong dividends. A commitment to earmarking 25% of the proposed Canada mental health transfer for children would be a great place to start.

A robust maternal and child and youth research agenda is required to contribute to the generation of new knowledge and to leverage this evidence to inform policy, programs and services.

We need a health human resources strategy that includes a focus on unique skills and experience required to delivered care to kids. This strategy must address current labour gaps, but must also look forward to fostering resilience and sustainability.

An integrated cross-sector, cross-jurisdiction health data strategy is overdue in Canada. What gets measured matters. We urgently require a strategy to address delays and access to essential child development, surgical and diagnostic services. We must improve services to rural, remote and indigenous populations.

Finally, access to safe and effective medications for children is paramount. An estimated 80% of medications currently prescribed to children are administered off-label, deviating from dose administration, patient age and, often, indications listed on the Health Canada-approved product monograph.

Colleagues, we stand at a critical juncture. We need to both address the crisis today facing children and youth, and the health systems that serve them, but also plan for our future. We have the expertise, knowledge and tools to restore our global standing in children's health. All we need now is bold leadership, and a commitment from governments to make this possible.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Ms. Gruenwoldt.

Dr. Roy, the floor is yours.

[Dr. Marie-Claude Roy, Pediatrician, Association des pédiatres du Québec]

Good morning.

Thank you, everyone, for this opportunity to appear before you today and to outline our concerns.

As president of the Association des pédiatres du Québec, I represent more than 760 pediatricians in Quebec who are expert practitioners in various fields ranging from neonatology and intensive care to community pediatrics. While challenges vary widely from one pediatric population to another, my members have a common concern for the health of our children, specifically in this post-pandemic context.

Our first concern when discussing children's health is the set of problems associated with their physical health, but there are also problems related to their developmental health. Children are the only population whose development is constantly dynamic. Developmental challenges are extremely important and an integral part of children's health.

We cannot overlook the psychological health of our children, whose lives have been greatly disrupted in the past few years. Then there's what I call “educational” health. Frequent pandemic-related interruptions in classroom instruction have raised significant impediments to continuous learning. The present and future health parameters of these children have been greatly disturbed in recent years.

Despite these concerns, many of these children's health parameters are improving. Survival rates from birth are up; vaccinations, although sub-optimal, are constantly improving; prevention programs across the country are having very positive effects; and our prevention measures have resulted in less severe trauma and other impacts, and we must continue to invest in these areas.

However, many problems are still of major concern. In Quebec, 12% of children 5 years of age and under live in financial insecurity. These are extremely important factors when it comes to monitoring the health of these children. One in 5 children, 20%, enter kindergarten with significant developmental problems, motor, language and social issues.

Quebec's Agir tôt program has been rolled out in recent years. Its purpose is to detect problems in early childhood before they become established, and to ensure that parents and the home environment stimulate children in the initial years of their lives, thus completely altering the path they are on when they arrive at school.

For school-aged children, obesity and overexposure to screens and technologies are problems that result in dependence, which will have a major impact on their health when they reach adulthood.

The health of children and adolescents greatly depends on the physical, financial and even psychological health of their parents. The pandemic obviously left children more vulnerable, and parents experienced more financial insecurity, domestic violence and mental health issues. Unfortunately, few resources are allocated to psychosocial support for those children and their families, and this problem will have to be addressed sooner or later.

In adolescents, we see that problems that began in childhood have become established. Obesity and sedentariness rates have never been this high, and they surged during the pandemic. The pandemic also had a major impact on their developmental trajectory. This population was more affected by the pandemic measures than other groups. We have observed a surge in anxio-depressive and food disorders and an increase in substance abuse. This is a population that will inevitably require attention.

The concern for us at the Association des pédiatres du Québec is to make children a priority again. Under the living conditions that technological developments have afforded us, life has never been easier, and yet the younger generation are facing health problems specific to the 21st century. The pace of life has accelerated, and everything takes place on screens and social media, which is very hard for these patients. On the other hand, technology has also helped optimize the life expectancy of very sick children who previously didn't live past the age of 5, 6 or 7 years. Even if patients are saved in the first years of their lives, there are no resources for them once they leave hospital.

I'm thinking of extremely premature babies and patients who have undergone a gastrostomy or tracheostomy. These children now have greater survival potential, but their parents, the caregivers of those children, have little support to help them carry on.

In future, we hope to provide parents, the children's mothers and fathers, with better tools from the conception of their children in order to optimize the family environment in which those children grow up.

We want to rely more on prevention to limit the impacts on children's health. We also have to ensure that children's environments—child care, early childhood centres and school environments—are stimulating.

We must understand the impact our lifestyles have on the young generation's health. We also need to continue efforts to provide greater access to care.

Lastly, we must bear in mind the situation of chronically ill patients as they mature into adults. As I noted earlier, sick children now have better survival potential, but we have little expertise in supporting adolescents 15, 16, 17 or 18 years old who are diagnosed with serious conditions or who require extensive care.

In speaking with my counterparts from other provinces, I have observed that pediatric populations are similar across the country. The structures in place and the problems experienced vary greatly from province to province, and that fact must be taken into consideration.

Thank you very much.

[The Chair, Liberal, Sean Casey]

Thank you very much, Dr. Roy.

Next, representing the Canadian Pediatric Society, we have Dr. Mark Feldman.

Welcome to the committee, Dr. Feldman. You have the floor.

[Dr. Mark Feldman, President, Canadian Paediatric Society]

Bonjour. Thank you for the opportunity to speak to you today.

My name is Dr. Mark Feldman. I am a pediatrician. I have worked at the Hospital for Sick Children in Toronto for the past 30 years. I am speaking to you today, however, on behalf of the Canadian Paediatric Society as its 101st president. The CPS is a voluntary professional association that represents approximately 4,000 pediatricians across our country.

You've just heard that there's a critical gap in timely, affordable and equitable access to mental health care across Canada for children and youth. What I wish to do today is to provide some additional context and the perspective of pediatricians from your provinces, and to offer some potential solutions.

The other day, Dr. Ungar spoke to this committee about the concept of resilience. Resilience is in part mediated by brain plasticity. Brain plasticity is the ability of the growing brain to adapt, heal and develop normally if positive changes are made early. Dr. Ungar emphasized that missed opportunities to treat mental health disease during childhood has devastating consequences later in life.

Children with attention deficit disorder, for example, will have more typical, more normal development of their brains, as demonstrated on pictures of brains—serial imaging studies with magnetic resonance imaging—if they receive treatment early for their ADHD.

I'll give you an example of what early intervention might look like. I have a patient who I think illustrates it well.

Kareem was referred to me at the age of 10 with behaviour problems. His father was not involved. His mother struggled with alcoholism. His brother was in jail. Kareem was a good kid, however. He was smart, kind and charming. But he struggled with impulsivity and inattention, so he struggled socially and academically. He was diagnosed with ADHD, received treatment at a critical time in his brain development and improved dramatically and rapidly. Fast-forward 15 years: I had the honour of attending his university convocation along with his mother and his fiancé. He is now a loved, respected, taxpaying member of society.

Was this a one-off? High-quality research has demonstrated that intervention for children and youth with ADHD, for example, can lower the risk of school failure, suicide, drug addiction, teen pregnancy, car accidents and incarceration. It improves the quality of life. It improves the likelihood of higher education and even lifespan.

The implication of early intervention in cost-averted care for children and youth with mental health disease is significant. Mental health problems serious enough to disrupt functioning and development affect approximately 1.2 million children and youth in Canada—that we know of—yet fewer than 20% of those receive appropriate treatment. This gap existed long before the pandemic. Children and youth who are immigrants or refugees or BIPOC or who live in remote communities are even less likely than their peers to receive appropriate mental health care, and are more likely to use services like emergency rooms when in crisis.

I recently had the privilege of meeting with the presidents of provincial pediatric societies across Canada to identify priorities nationally and to share strategies locally. Without exception, each provincial lead identified the mental health care access gap for children and youth to be a number one issue.

As you know, in 1985 the Canada Health Act was created to “protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers”. In Toronto, there's a clinic in North York that offers care for children with learning, mood and anxiety issues. The initial assessment by a physician costs $2,000. That's followed by a psycho-educational assessment at a cost of $5,000. Therapy sessions, if necessary, quickly add up to another $3,000. That's a $10,000 bill.

The wait time for publicly funded mental health care in different provinces, to see somebody like me, is anywhere between six months and two and a half years. If I then refer them for therapy, such as talk therapy, psychology services are generally not publicly funded in Canada.

On behalf of the Canadian Paediatric Society, we ask the federal government to uphold the commitment to establish a fully funded permanent Canada mental health transfer, and that 30% of federal mental health transfer payments are directed towards those under the age of 25 to ensure timely and equitable access to mental health care.

Some of the ways that money can be spent are funding the development of clinical practice guidelines, educational tools, navigational resources and systems as well as funding continuing professional development training programs for practising health care providers to upscale our skills and to support evidence-based mental health care for children and youth.

We would like to see that money is spent to ensure that assessments performed by psychologists and therapies delivered by psychologists or by other non-physician mental health care practitioners are similarly publicly funded, regulated and evidence-based.

I have all kinds of potential solutions, and I look forward to your questions.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you very much, Dr. Feldman.

We're going right to questions now beginning with the Conservatives.

Dr. Ellis, you have six minutes, please.

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

Thank you very much, Mr. Chair.

I want to thank all the witnesses for being here. It's a very important topic for all of us as Canadians. Certainly, we look forward to digging a little bit deeper.

Primarily, the unfortunate thing is that this study has morphed a bit into something that we didn't really anticipate in the beginning. One of the things I would like to get out there right away is, if it really becomes the will of this committee to create a child and youth strategy for Canada, certainly we're going to need more meetings and more time to develop such a strategy or put us on the right path to do that. I'll leave that seed as it is.

First and foremost, perhaps I'll start with Emily.

You talked a bit about outcomes in your opening statement. I realize it's a big topic, but I'm wondering if you might comment a bit on how our outcomes for children in Canada fell from perhaps 10th out of 38 wealthy countries to 30th and 31st of 38 countries.

If you could start with that, please, I would appreciate it.

[Emily Gruenwoldt]

Thank you.

This is in reference to the UNICEF Report Card 16 that was published in 2020. Just to summarize, Canada now ranks 30th out of 38 countries with respect to children's physical health and 31st out of 38 countries with respect to children's mental health.

As recently as 2007, we were ranked 12th in a comparable ranking conducted by UNICEF, so our rankings have fallen. The scorecards are not directly comparable, but the pattern is clear, and the outcomes continue to worsen for many Canadian children and youth.

Just to give you an idea, with respect to mental health and happiness, almost one in four children report low life satisfaction, which ranks us 28th. Canada again has one of the highest suicide rates for adolescents, 35th out of 38 countries. With respect to physical health, Canada has an infant mortality rate of 0.98 deaths per 1,000 births, which puts us in 28th place. To comments by Dr. Feldman, I believe it was earlier, one in three children are overweight or obese in this country.

In almost every ranking with respect to physical and mental health, we are in the bottom third if not the bottom quarter of rankings of comparable international countries.

To a comment I made earlier, compared to our relative wealth as a nation, we would expect our outcomes to be significantly higher, especially when we look at the investments we are making and the outcomes that are tracking towards those investments.

It is an opportunity, I think, where not only would extra investments make a difference, but a broader strategy that incorporates both health and well-being metrics is overdue for this country if we're going to measurably improve the health and well-being of children and youth.

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

Thank you very much for that. I appreciate it.

Dr. Feldman, if I may, you made a few comments with respect to access to mental health care being the number one issue. I have a couple of questions around that.

I have two parts to the question. Do we have enough pediatricians? If yes, great. If not, how do we entice them to become pediatricians through training? Are they paid enough, etc.?

Second, you talked, sir, a bit about psychologists and understanding.... Certainly in my practice lifetime, it appears that we don't have enough psychologists either, certainly not in the adult world or the pediatric world. You did mention a bit about funding.

Could you comment on the availability of those specialists and how you think that might be solved?

[Dr. Mark Feldman]

Thanks. That's a great question.

I should say that the number one issue identified was mental health issues during that recent meeting. The number two issue was human resources, the shortage of family doctors and pediatricians, and that's part of the access issue. There are a number of potential solutions.

One of them is that the youth hub model of delivery of mental health care might be further expanded. I work in a rural area once a month, where there's a nurse practitioner and several workers who are trained in the delivery of psychological therapy, cognitive behavioural therapy. So perhaps a more effective use of physicians' time in partnership with colleagues in a youth hub model could be explored and grown.

The second thing is that the physicians who are out there should be perhaps better trained to manage mental health issues. I think funding for continuing professional development opportunities might be a way to address the shortages in mental health care. In Manitoba, for example, the CanREACH program is funded, is subsidized. If there are programs like that that can be subsidized then we can get better and more efficient and refer less, and fewer people end up in the emergency department.

In terms of addressing human resource issues, we need to train more physicians. The demographic is there are a lot of us retiring. I hope to go for another five years or so but I would like to see the young folks get out there, perhaps with a little bit of additional curricula with regard to mental health training. For example, the family medicine program is expected to change from a two-year program to a three-year program over the next five to 10 years, recognizing increasing complexity. If mental health care competencies can be a greater part of their curricula, that's another way to deal with that.

In terms of additional training for pediatrics, in the last 10 years at SickKids, we've had a program called community pediatrics, which is an additional year of training to teach the skills needed out in the community in pediatrics. The curriculum is heavy on mental health care delivery.

There are a number of different ways of doing it but we need to train some more generalists, we need to train them better, we need to use them more effectively, perhaps in a youth hub model. I think until we address the human resource issue and the efficiency of the system, we're going to be struggling.

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

Thank you.

[The Chair, Liberal, Sean Casey]

Next we're going to go to Dr. Powlowski, please, for six minutes.

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

Thank you.

Certainly I understand and can appreciate that under COVID there have been worsening rates of mental health problems and suicide, but I did want to comment on Dr. Gruenwoldt's comment on Canada's high infant mortality rate. My understanding is we're 31st of 37 OECD countries in terms of infant mortality. However, part of that difference is attributed to the fact that most European countries don't include newborns weighing less than 500 grams. Those newborns would certainly have a higher mortality rate and most European countries don't count them as live births. So that's part of the explanation as to why we have a higher than normal infant mortality rate.

Is that true?

[Emily Gruenwoldt]

I don't have that data at my fingertips, and just as a correction, I'm not a physician, sir.

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

Okay. The second thing I wanted to talk about is that we have a lot of doom and gloom on children's health but as somebody who has worked 35 years as an acute care doctor, and certainly a big part of that has been looking after children, it would seem to me that if you look at infectious disease, which is a big cause of physical morbidity and mortality in children, that has really, in my experience, in 35 years from when I started practising, appreciably decreased.

Now we have vaccinations for haemophilus influenzae, meningococcus, pneumococcus and certainly now.... When I started my practice, meningitis wasn't uncommon, bacterial meningitis.... Now you practically never see bacterial meningitis. Epiglottitis, usually caused by influenza, you hardly ever see it anymore. I think there's a lot less pneumonia. Even a colleague of mine who I went to medical school with, who does family practice, was saying he sees a lot less otitis media, again probably as a result of those vaccinations.

Now having said that, we're seeing some troubling numbers in terms of vaccination in Canada. Apparently only 76% of children are vaccinated with DPT, polio, and under...COVID apparently in parts of the country, Manitoba, Alberta, we're seeing a 20% decrease in vaccination.

I wonder if you could comment. I see Dr. Roy shaking her head there. Could you comment on how important vaccines have been in terms of improving children's health and what is happening in terms of decreased vaccination rates in Canada?

[Dr. Marie-Claude Roy]

Yes, it's very important. I've spoken at length about the impact of social media and disinformation on adolescent anxiety. I nevertheless think there are a lot of echo chambers in all the sources of information parents use. This generation of parents wants to understand, know and control the situation and that directly feeds into a collective anxiety. As they look for various sources of information, each of which is less reliable than the next, they become lost at sea. Parents seeking greater control over their children's health unfortunately encounter disinformation. That's what constantly brings us back to prevention. People swing into action once the problems are established, but all prevention programs are unfortunately viewed as an inferior solution, even though studies clearly show they have major positive impacts on children's health.

One of my colleagues here in Sherbrooke is working hard to raise vaccination awareness. His research project has proven its worth and has gone international. It's simple: within a few hours of a child's birth, he meets with the parents to dedramatize the situation, answer questions and deconstruct the myths surrounding vaccination, all in a non-threatening way. When a doctor tells parents they have to vaccinate their child, they immediately go on the defensive. However, when you inform them and listen to their concerns in the few hours after the child is born, that has a major positive impact on the vaccination rate in the following months. So the paternalistic approach should be avoided. Parents need to control the situation and to understand why things are as they are. By listening to their questions, you can better deconstruct the myths.

You're correct in noting that, despite the enormous progress made in the past 20 years to improve living conditions and treat infectious diseases, the threat at this stage is still disinformation. You have to be open to parental concerns.

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

Mr. Chair, is there any time left on the same issue?

[The Chair, Liberal, Sean Casey]

You still have a little over a minute, Dr. Powlowski.

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

I wonder if Dr. Feldman wanted to reply to that. I'm sensing he may be a pediatrician or psychiatrist.

[Dr. Mark Feldman]

I'm a general pediatrician.

I saw haemophilus influenzae type b wiped out of ICUs. I completely agree that vaccination has been a huge success in my lifetime, but we're seeing polio come back now.

The disinformation that Dr. Roy spoke about is huge. Managing disinformation is a huge priority for us. I've seen acute care issues and infectious disease issues improve, but I see mental health deteriorate.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Feldman and Dr. Powlowski.

Welcome to the committee, Mr. Villemure. You have the floor for six minutes.

[René Villemure, Bloc, Trois-Rivières, QC]

Thank you, Mr. Chair.

Thanks to the witnesses for being with us this morning.

My questions will be for Dr. Roy. We're going to discuss health care funding and organization.

Dr. Roy, what's your position on the unanimous demand of the provinces and territories for an unconditional, recurring increase in federal health transfers of 25% to 35% of costs?

[Dr. Marie-Claude Roy]

That's an excellent question.

Under the Canada Health Act, the transfer was initially supposed to be about 50%. Now it's 22%. I'm concerned about children's health, and I know my colleagues in adult medicine have the same concerns for their adult clientele. Approximately 40% of Quebec's budget is allocated to health, which can be explained in part by the province's aging population. That leaves little room to invest in the other parameters that have a major impact on children's health.

You have to remember that health is a provincial jurisdiction. That's never been questioned, but, if health transfers were increased, the provinces would have the necessary leeway to invest in the other parameters related to children's health. I'm thinking of education, for example, which I briefly discussed earlier. The state of our school system across the country is appalling. Our lagging performance in education, literacy, numeracy and the fight against students dropping out of school will have a major impact on the health of those children, who are tomorrow's adults.

Health transfers must be increased to give a free hand to the provinces, which are more familiar with the structure of health systems than anyone else. The problems in the pediatric population are the same in all provinces. The mental health problems mentioned earlier are everywhere, but it's obvious that the structures in place from province to province aren't the same. The deficiencies aren't in the same areas. In my view, these transfers must definitely be increased to give the provinces a free hand to act in accordance with the health parameters specific to each province, as in education and the environment. That will have a major impact on children's health.

[René Villemure, Bloc, Trois-Rivières, QC]

Thank you very much.

You don't feel the federal government is more qualified than the provinces to invest the amounts in question.

Am I correctly interpreting your remarks?