Health Committee on Sept. 29th, 2022

[The Chair, Liberal, Sean Casey]

I call this meeting to order.

Welcome to meeting number 32 of the House of Commons Standing Committee on Health. Today, we're 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, 2022.

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.

There is interpretation—

Go ahead, Monsieur Garon.

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

Thank you, Mr. Chair.

I would like to know if the regulation sound tests were done for all witnesses appearing by videoconference. Could you please tell which of those tests were conclusive?

[The Chair, Liberal, Sean Casey]

I can confirm that the tests were conclusive for all the witnesses. Everything is in order.

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

Thank you, Mr. Chair.

[The Chair, Liberal, Sean Casey]

You're welcome.

Let us continue.

There is interpretation. For those on Zoom, you have the choice at the bottom of your screen of floor, English or French. For those in the room, you can use the earpiece and select the desired channel.

Screenshots or taking photos of your screen are not permitted. The proceedings will be made available via the House of Commons website.

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

I would now like to welcome our witnesses who are with us this afternoon.

Appearing as an individual is Dr. Quynh Doan, a clinician scientist at the department of pediatrics at the University of British Columbia. From the Children's Hospital of Eastern Ontario, we have Alex Munter, president and CEO. From the Hospital for Sick Children in Toronto, we have Dr. James Drake, chief of surgery and chair of the Pediatric Surgical Chiefs of Canada. We also have Bruce Squires, president of McMaster Children’s Hospital and chair of the board of directors of Children's Healthcare Canada.

Thank you to all of you for taking the time to appear today.

Each witness has five minutes for an opening statement.

I'd like to invite Dr. Doan to begin.

Welcome to the committee, Dr. Doan. You now have the floor.

[Dr. Quynh Doan, Clinician Scientist, Department of Pediatrics, University of British Columbia, As an Individual]

Good afternoon.

I'm a pediatric emergency physician at BC Children's Hospital, and a health services researcher at UBC. My research has a focus on children and youth mental health care access and utilization.

We have been observing a consistent 6% to 8% rise in the number of pediatric emergency department visits for a mental health-related problem since at least 2002. This trend was maintained during the pandemic. It is most likely, however, that social isolation and psychological stress related to the pandemic significantly impacted children and youth mental health and wellness that is not entirely captured through emergency department visits. Simply looking at emergency department visits and hospitalization for psychiatric conditions may underestimate the psychological impact of the pandemic on our children and their resource needs.

To estimate the psychosocial hidden burden of the pandemic on children and youth in B.C., my team used MyHEARTSMAP, a validated digital psychosocial screening instrument that triggers customized health services recommendations based on the assessment data filled out by youth or their parents.

MyHEARTSMAP covers 10 psychosocial areas that maps to four domains of a youth's mental health, including psychiatric, social, functional status, and youth health. We also examined the association between demographic variables as well as families' pandemic experiences, such as schooling and employment status, among other variables, and their severity of psychosocial difficulties as reported on MyHEARTSMAP.

Between August 2020 and July 2021, we reached a diverse and representative sample of children and youth in B.C. using social media, family-oriented organizations, and Angus Reid, a private recruitment company. Our analysis included 424 assessments from children and their guardians at entry and three months later with 60% retention. At the three-month follow-up, we also asked if they had accessed any of the recommended mental health support services that were triggered at the initial screening, and explored which factors were associated with accessing care.

The majority of participating youth reported some degree of difficulties across the psychiatric, social and functional domains. Adjusting for all other variables, we found that older youth were statistically more likely to report severe difficulties in the psychiatric domain. Gender also played an important role. Compared to boys, youth who identified as non-binary or questioning genders were four times more likely to report more severe concerns in the psychiatry domains, and girls were twice as more likely to report greater social issues.

In B.C. during the study period, there was no universal school closure policies; however, youth who were not attending any formal educational programs either at home or in person at a time when school would normally be in session were twice as more likely to report greater severity in the psychiatry and youth health domains compared to youth who were in full-time, in-person school.

Based on their assessment information, consideration for accessing community mental health services was recommended to 74% of participants. While having the assessment done initiated a family discussion about youth mental health support, having a family doctor was the single greatest predictor of accessing community mental health services with an odds of 11 to 1.

In conclusion, psychosocial difficulties were reported by the majority of participating youth during the pandemic. Fortunately, most were mild, thus adequately accessible community mental health supports in the community are essential to curb escalation needs for more intensive, scarce and costly resources. We also note that specific resources to support youth who may be gender questioning or have non-binary gender identities should be considered.

Overall, I'm advocating for nationwide networks of integrated health services through the expansion of multidisciplinary youth health programs, like the Foundry BC model, where primary health care and specialized mental health care providers work collaboratively and cohesively to provide one stop shop health care to youth age 12 and up. This would also address the findings that family doctors and access to primary care are a key resource for youth accessing mental health resources when the needs are identified.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you very much, Dr. Doan.

Next we're going to hear from Alex Munter on behalf of the Children's Hospital of Eastern Ontario.

Welcome to the committee. You have the floor.

[Alex Munter, President and Chief Executive Officer, Children's Hospital of Eastern Ontario]

Thank you, Mr. Chair.

I would like to thank the committee for inviting me.

It's a pleasure to be here. CHEO is the national capital's pediatric health and research centre. We have eight sites across Ottawa and the valley. Our main campus is about three miles from here. In fact, you can see the Peace Tower from the top floors of CHEO.

I would invite each and every one of you to come and visit. I'm happy to give you a tour some time.

If you came today, this is what you would see. You would see an emergency department that was rebuilt 10 years ago for 150 kids, which yesterday saw 213 and regularly sees nearly 300.

The longest length of stay in our emergency department yesterday was 32 hours. That is because we are running at an occupancy today of 105%, which means there are no beds, and so children wait in the emergency department with their parents until a bed is available.

September is on track to be the busiest September in the history of CHEO. CHEO is a 48-year-old organization. May, June and July of this year were the busiest May, June and July in the history of CHEO.

If you came today you would see kids transferred from far, far away because there are no beds in their community.

You would also see amazing people. You would see amazing, committed, passionate staff, physicians, volunteers, parents, caregivers showing grit, determination, compassion, delivering skilled expert care and battling through fatigue and frustration.

This is what you won't see today if you come to CHEO. You won't see the children whose surgery has been cancelled because we have no beds. We need to reallocate surgical beds for kids being admitted for respiratory viruses, including COVID.

You won't see the 1,000 to 1,500 kids who are referred this month and will be referred for diagnostic imaging, medical or surgical clinics, mental health care or rehabilitation care, the 1,000 to 1,500 per month who are above our capacity to see and who are being added to our wait-list. That's 12,000 to 18,000 being added to the wait-list this year.

You won't see the approximately 250 staff and physicians whose positions are vacant because of the mission critical health human resources challenges we face in Canada.

I recognize you could tell this story in almost any health care organization, hospital and other organizations across the country. Why should you care about it happening at CHEO? You should care because it's kids, because it's the future.

When a child has to wait for diagnosis for care or for therapy, they suffer. They suffer today and tomorrow, this year and next year. That's bad enough, but on top of that, it could affect and it will affect for many the entire trajectory of their lives.

As you would well understand, when a child is sick, when a child has a disability and is not getting the therapy they need, it's not just the child, but it is the whole family that is affected and often their parent's ability to engage in the workforce, or in broader society.

CHEO supports the work of Children's Healthcare Canada. We are a member of Children's Healthcare Canada. Children's Healthcare Canada, as you know, has called for a national child and youth health strategy backed up by meaningful federal investment, as words are not enough. I see Bruce Squires, the chair of the board of Children's Healthcare Canada, is here, and I am sure he will speak to it.

At CHEO we call this pedianomics. I know there is at least one economist on the committee. Pedianomics is the economics of investing in child health, the obvious return on investment of putting children on the path to lifelong health when they are tomorrow's innovators, taxpayers, caregivers and parents. Obviously, investing in children's health produces significant returns to our society. It also helps relieve pressure on the health care system.

In the broader health care system—what in the pediatric world we call the adult health care system—two dollars of every three dollars is on the management of chronic disease. Our health care system is a chronic disease system, and so the degree to which we can put children on the path to lifelong health and address from mental health to physical health, development, address their health issues and their developmental issues early, we will relieve pressure on the health care system later.

Our current circumstances are not caused by COVID. They are not caused by the pandemic. They have been accelerated and amplified by the pandemic. As you've heard from Dr. Doan, and as I'm sure you'll hear from the other presenters, the pandemic has had an outsized impact on the development, physical and mental health of children and youth. We owe them and we owe our country a singular focus on addressing those needs and putting them on the path to lifelong health.

Thank you for doing this study. Thank you for this opportunity. I look forward to the opportunity over the next two hours to have further engagement with you about it.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Munter.

Next, from the Hospital for Sick Children in Toronto, we have Dr. James Drake.

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

[Dr. James Drake, Chief of Surgery, Hospital for Sick Children]

Thank you very much.

Good morning ladies and gentleman. Thank you very much for the opportunity to speak here today.

I am a pediatric neurosurgeon at the Hospital for Sick Children. I am surgeon in chief there and also chair of the Pediatric Surgical Chiefs of Canada.

I'm extremely proud of the fact that the Hospital for Sick Children was last year ranked number one and this year ranked number two in the world by Newsweek magazine, but to be honest, SickKids is struggling.

I'm here to talk to you today about the issues about children accessing scheduled surgical care, which I think is in a crisis across Canada.

As you know, children have time-sensitive developments, which are adversely affected by delay. I've including in the briefing four common conditions, which are strabismus, undescended testicles, orthopaedic deformity and hearing impairment. These lead to lifelong issues of blindness, infertility, chronic pain and disability, and impaired speech development, as a few examples.

We are using every possible resource we can to try to address this issue, but for many hospitals such as SickKids, our wait-list actually continues to grow. The barriers we face are pediatric human health resources, underfunding, lack of operating room space and a regional approach to pediatric surgical care.

Like the other speakers who have been here, we see some of the solutions to be national support for pediatric health care, including surgery, and making it an absolute top priority; national specialized human health resource recruitment and training for nursing, allied health professionals and physicians; and adequate funding models that reflect the complexity of pediatric surgical, anaesthetic and hospital care.

You can imagine the difference between wheeling a 30-year-old patient in for hernia repair and a two-year-old when faced with a large room full of surgical equipment, masked individuals and large needles. Caring for children is very different from caring for adults. As you'll see, the wait-list for children is at or greater than that for adults.

In the brief, I provided some appendices, which I will refer to now.

The first one shows the surgical wait-list for SickKids over the last three years. Because of the pandemic and the current resources we're facing, we have a 150% increase in our surgical wait-list over the last five years. At the moment, 60% of our patients are scheduled beyond the ideal date for their surgery. This has increased dramatically since the beginning of the pandemic.

In appendix 2, the distribution of cases by surgical speciality is listed. You will see, for example, that urology has 2,000 patients on the wait-list at SickKids who are beyond their ideal treatment time.

Like in the adult sectors, our biggest waits are in orthopaedic surgery, plastic surgery, and ear, nose and throat surgery.

We are part of a region. I've shown here in appendix 3 the data around the surgical wait-list in the greater Toronto area. You'll see that the Toronto region has over 4,000 patients who are out-of-window, awaiting surgery. It equals that of the other largest groups of adults, including orthopaedic surgery and ophthalmology. This is not a minor problem for pediatric patients.

In appendix 4, I've listed the self-reported wait-lists by pediatric hospitals across Canada. This does not represent all of the hospitals. This is self-reported information. Nevertheless, as I have shown, there are 21,000 children within these eight hospitals who are on surgical wait-lists. Half of them are beyond the ideal treatment time.

Finally, just to illustrate the impact of the pandemic on children, I have shown CIHI data up to December 2021 in appendix 5. The delay in surgery for children is greater than that for those who are either middle-aged or older adults.

I cannot emphasize to you enough the impact that the delay in access to surgical care is having on children across Canada.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Drake.

Next is Bruce Squires, president and chair of the board of directors of Children's Healthcare Canada.

Welcome to the committee, Mr. Squires. You have the floor.

[Bruce Squires, President, McMaster Children's Hospital, and Chair of the Board of Directors, Children's Healthcare Canada]

Thank you very much and good morning. I really appreciate this opportunity to speak to you about this vitally important topic.

As noted, I'm joining you today as president of McMaster Children's Hospital and as chair of the board of directors of Children's Healthcare Canada. I'll note that I'm joining from Hamilton, which is located on the traditional territories of Mississauga and Haudenosaunee nations within the lands protected by A Dish with One Spoon Wampum agreement.

The McMaster Children's Hospital is one of the 16 dedicated children's hospitals across Canada. We serve a catchment area of two and a half million people, including half a million children, youth and their families, and provide comprehensive specialized health care to newborn, children and youth and their families from across this region.

Like all of the others you've heard from today, I am here because our teams and the families they serve believe we need to sound the alarm on the health and well-being of Canada's children and youth, and we need to make their health a top priority going forward.

Our teams and the families are worried that what they see and experience directly is not recognized by the public or by our leaders. They believe we need a clear commitment to refocus on the health of our kids. In my view, that's the greatest opportunity for this study by your standing committee.

Why do we need to sound that alarm? You've already heard from my colleagues. You've heard about the 2020 UNICEF report card. Canada ranks 30th and 31st for children's physical and mental health, respectively, out of 38 OECD countries. We're in the bottom third of the report for such key indicators as child mortality, obesity, teen suicide and immunizations. In a country as rich and as developed as Canada, it's inconceivable to most of us that we're performing so poorly. Those working directly with children, youth and families in schools and community agencies and hospitals are not surprised by those figures. That's because they see the impacts on a day-to-day basis.

Our mental health teams see the children who have been waiting as long as two and a half years to access specialized mental health services.

Our child development rehab teams struggle to support parents of children needing school-based rehab as they wait three years for that. And our in-patient teams struggle to provide care to critically ill children and youth following suicide attempts, overdose and substance use and severe eating disorders.

That data was collected before the pandemic. As you've heard, Canada's children and youth have borne the brunt. Their development—physical, emotional, social and spiritual—has been impacted severely by learning loss, reductions in access to physical activity, social isolation, and delays in access to care. Again the data are striking.

You've heard from Dr. Doan about the mental health of Canada's children. At McMaster Children's Hospital, we're seeing a doubling of admissions to our in-patient wards for treatment for substance-use disorders, and a 90% increase in admissions to our eating disorders and patient treatment unit.

Delays in care and increasing demand aren't limited to those related to mental health. You've heard from Dr. Drake. Think about that. Here at MCH, nearly two-thirds of parents of children waiting for surgery have already seen their kids miss the recommended window. Across Canada, hospitals are experiencing unprecedented volumes, occupancy and waits.

This morning at MCH, our emergency department had 10 children who had been admitted to the hospital but who were waiting because we didn't have an in-patient bed. That's because we were operating at 119% occupancy of those beds as of yesterday. What those numbers really mean is kids waiting up to more than 24 hours and critically ill children and their families being transferred across the province, for example, from Hamilton to Ottawa, because we don't have an ICU bed.

I could go on and on. The data clearly paint a picture of how the health of Canada's children and youth is not where it should be.

That leads to what I think really is the overriding ask for this committee, that you recommend that Canada prioritize improving the health and well-being of our children and youth.

There is great impact from the federal government making a public commitment to work with others to prioritize improving the lives of kids. That will of course need to be followed by tangible actions, and you've heard excellent recommendations from experts over the past few days.

I would add first that the “Inspiring Healthy Futures” report can form the basis for the development of a pan-Canadian child and youth health strategy. That is the key first step.

Second, I'd call out some additional key developments. Canada requires a sustained and focused effort to understand and report on the health care of our children and youth. We need to collect extensive data on a longitudinal basis to inform best policy and action. That will link directly to the need for a targeted child and youth health research agenda targeted towards new knowledge on maternal, newborn, child and youth health that, in turn, points towards better support and coordination for the sharing, dissemination, mobilization and adoption of that knowledge across the country.

Third, I'd highlight again a couple of the most pressing areas for focus of a child health strategy. Improving access to specialized services for rural and remote, particularly indigenous, populations remains critical to addressing health disparities and promoting health equity in children's health care and health. Children and youth require timely access to appropriate mental health services close to home. A commitment to earmarking 25% of the Canada mental health transfer for children under 18 would be a crucial first step. There are so many other key areas as you've heard.

As I close, I'd like to thank all of the members of the committee for their decision to undertake the study of child health. As I've said, this is a crucial first step towards beginning to address the crisis that we see in child and youth health across Canada. It's my hope that that first step will lead you to recommend a public commitment and associated action steps to prioritize kids' health and well-being across Canada.

Thank you sincerely for your time and attention.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Squires.

We're going to proceed with rounds of questions, beginning with Dr. Ellis for six minutes.

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

Thank you, Chair, and thank you to all the witnesses for being here today.

It's clear that the difficulties facing children are certainly as great as those for adults, and perhaps even greater. As Mr. Munter said, they are our future; there's no doubt about that.

One thing I spoke about the last time we met was the need for a national strategy on child and youth health, and the sad part is, with the number of meetings that we have at the current time, that's beyond the scope of where we are. I'll appeal to committee members again to give due consideration at the appropriate time that we're going to have to devote some more time to this particular topic if we're going to take leadership and help be a part of creating that strategy.

Mr. Munter, one of the things that we hear about, whether it be adults or children, is the health human resource difficulty we all face. Could you expand a bit on that? Maybe it's outside your area of expertise, but I know you're a well-respected expert in children and youth health.

Do pediatricians need to be funded better? Do we need more residency spots? What exactly does this boil down to?

[Alex Munter]

All the above would be the answer.

We have known for some time that we are running short. Before the pandemic, the Canadian Nurses Association projected a gap of 60,000. What happened at the outset of the pandemic was people deferred retirement, and in fact, people “unretired”. A lot of the pandemic response was from nurses, physicians and others who came back to work. Now we have a circumstance of people going back to retirement, deferred retirements happening, and we have a retention problem as the environment, the workplace, becomes that much more challenging.

There are two categories of things we need to do. The first is we need to keep the people we have. For sure, there are issues about remuneration, working conditions and so on. The second is we need to increase the pipeline and we need to increase enrolment. We need to make it easier to bring people in. We have eight physicians, mostly Americans, but also from elsewhere in the world, who are ready to start working at CHEO, who will help us with our wait-lists. For example, Jim talked about urology. We have funding for three urologists. We have one on staff now. We have two vacancies. We have a urologist waiting to come to us from California. We need to speed up from an immigration perspective. We need to speed up from a credentialing process perspective, bringing people in. We have people in Canada who could work. We need that to be expedited as well.

Frankly, Canada is one of the only countries in the western world that doesn't actually have a national health human resources strategy, so that's a gap.

Jim and I were talking before the meeting, As with many things, given the specialized nature, there are probably about 30 pediatric neurosurgeons in all of Canada. If two or three retire, that's a significant impact on wait-lists.

We need both a global strategy and a child HHR strategy.

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

Thank you.

Through you, Mr. Chair, to you, Mr. Munter again, we're at this significant and terrifying—if I might use that word—crossroads in the sense that we want to improve working conditions, but in order to do that, we need more people. It takes a long time to create a pediatrician, especially a subspecialist, as we all well know, so that's a gigantic issue.

There is another comment that I would make, and I hope you can comment on both of these things in the little time we have left. What do you think about the role of family doctors? Again, it may be beyond your area of expertise, but there's certainly an interplay between how we train family physicians and the need for pediatric care, generalist pediatric care and subspecialists.

Could you comment on that and on where you think we need to go?

[Alex Munter]

One of the things we're seeing, of course, one of the reasons for that surge in demand in emergency departments is that we often end up seeing children in pediatric emergency departments who could be seen by family practice and who either don't have a family doctor or are not able to get in to see their family doctor. Bolstering our primary care capacity is absolutely a crucial piece of that.

Here locally we are working. We have something called the Kids Come First health team that works with primary care physicians and community pediatricians. We've set up a couple of urgent care clinics. I think we need a system-wide view of how we support primary care to be able to deliver in team-based models on that first-line response that can help keep children and adults out of hospital.

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

Thank you very much.

I think I have about 20 seconds left, Mr. Chair.

Interestingly enough, we've seen this change to team-based care. I was a family doctor for a very, very long time. It's certainly less efficient, but is it better care? What do you think about that, Mr. Munter? I know that's a bit—

[Alex Munter]

In 20 seconds?

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

In 20 seconds or less, sir, absolutely.

[Alex Munter]

That's a longer discussion.

It doesn't need to be less efficient. It depends on what the incentives are that you build in.

Certainly, if I look at some of our most efficient primary care practices locally, when they have psychologists, OTs, social workers and other professionals working with family physicians, they can provide that care in a very timely way to families.

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

Thank you. I appreciate it.

[The Chair, Liberal, Sean Casey]

Thank you very much, Dr. Ellis and Mr. Munter.

Next is Ms. Sidhu, please, for six minutes.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you, Mr. Chair.

Thank you to all the witnesses for being with us.

My first question is for Dr. Drake.

Dr. Drake, we did a study on the human resources shortage. Can you suggest to us what role technology and innovation could play in reducing surgical backlogs? Do you have any advice to reduce the wait-list of patients?

[Dr. James Drake]

I think that one key way technology can help us is by implementing systems that accurately reflect the number of patients on waiting lists throughout a region, for example, in the greater Toronto area.

We've had several endeavours that have been funded by the province in terms of trying to centralize wait-lists so that children see the first available surgeon who can look after them at a hospital that's very near to where they live rather than coming down to Toronto to receive care there.

The issue we face is that our community partners are also struggling with the impact of the pandemic. That's one big problem, but a second problem, which is just as large, is that children's health care is not always seen as a surgical priority by the hospitals. One of the reasons is that it's not particularly well reimbursed. An anaesthetic for a child is seen as an operation on an otherwise healthy individual, but, as I mentioned in my opening remarks, bringing a child into the operating room is not a simple process. The complexity around providing care for children is higher than for an adult with the same medical problem.

We're working very hard with our regional partners—and I'm talking now about SickKids—in terms of trying to have more children operated on close to where they live, in a community hospital where the majority of the large volume of low-acuity and high-volume cases could be done. I think that's one of the ways of using technology to try to help.

The other thing we're doing is accurate modelling on optimizing the flow of patients through the hospital. We can look at what their underlying problem is, how long their operation is likely to take, where they need to go afterwards and whether they need an intensive care unit bed, and we can adjust the operating room schedules to maximize our throughput.

Finally, the other thing we're doing at SickKids is operating on the weekends. We don't have enough operating space, so we're now operating on weekends to try to address the surgical wait times.