Human Resources Committee on Sept. 21st, 2006

[The Chair, Conservative, Dean Allison]

Ms. Sholzberg-Gray.

[Sharon Sholzberg-Gray]

I'll try to address all of your issues.

On the issue of prevention, I think every association sitting at this table understands that we need to have a healthy population and to maintain the health of the population. That will ultimately be the best way to reduce the demands on our health system. Of course, that's going to require the participation of health workers as well, particularly in the primary health care system that is going to keep people well, the public health system, and those kinds of things. Those are still health workers.

I'm sure if you look at any of our pre-budget briefs to your colleagues on the finance committee, you'll see that the Canadian Healthcare Association and others focus on the importance of keeping people healthy, managing chronic diseases, and those kinds of things. That's understood.

We're talking about a planning mechanism to meet the needs of the future. That's going to be one of the important focuses of the attention of the health system, and it always should be. We're still going to need the appropriate workers to do that. But when people are ill and need the attention of the health system, we need workers to take care of their needs as well. It's the health system of the future that we're talking about preparing for when we're talking about some kind of pan-Canadian mechanism.

You mentioned the issue of provincial jurisdiction and the federal responsibility for aboriginal people, which is not working now--look at the health status there. We're talking about whether federal funding is adequate or not. Those are issues we tend to deal with at the finance committee. The truth is there is a federal role in the area of health human resources.

We've just heard all about mobility, not only among provinces but around the world. My association is a federation, and provincial hospitals or health care associations belong to it. All they say at our board table is, “You just raised the ante by having a tremendously generous remuneration policy. Now we're going to lose 30% of our front-line providers to you.”

Unless we have an integrated approach and a way of stopping that from happening, we're going to be training people in one province to go to work in another. We've heard that before, so we need to coordinate. That doesn't mean the federal government runs it; it means there's a table or mechanism where everybody is together to agree to a pan-Canadian approach using appropriate research and data.

By the way, there is a lot of research on the retention of the appropriate workforce. For instance, in healthy workplaces you value each worker and share work properly; there's an absence of violence; there's support from management--frankly, my members have to play their rightful roles; people have control over their practices; and there's recognition of the work they do. In other words, a healthy, broadly defined workplace environment is the responsibility of the employers, but it's also the responsibility of governments that could help perhaps set the tone as to what constitutes the kind of environment to retain and recruit health workers for the future.

I think it's important to note that the involvement of the federal government is no guarantee of success, but certainly contributing and being at the table is important. It's not just the provinces alone, it's everybody together. I think that's the message we'd like to leave.

[The Chair, Conservative, Dean Allison]

Thank you very much.

That's all your time, Mr. Lessard.

We'll move on to Ms. Savoie for seven minutes please.

[Denise Savoie, NDP, Victoria, BC]

Thank you.

Thank you very much for your presentations.

It's shocking to think that British Columbia is the recipient of the inflow of health professionals, yet I know that in my riding and in many places in British Columbia people have extreme difficulty getting their own doctors. There are many orphan patients. This is a huge problem.

It's somewhat difficult in a way, because we're looking at the problem, if not in an arbitrary way through this employability study, at least severed from the whole package. I guess that relates to my first question.

To what extent do you think the reduction in the shortage of doctors and nurses could be addressed? I'll put aside the increased training that's required. Could it be reduced if, for example, we had a more integrated system, where a community health clinic did triage so the medical doctor didn't have to deal with everything from a cut on the hand to cancer assessment, where there was the possibility of having different community clinics with different expertise where patients could be triaged? I'm wondering to what extent that might help reduce the shortage, in your assessment.

I have another question specifically related to training.

[The Chair, Conservative, Dean Allison]

Go ahead, Doctor.

[Dr. Colin McMillan]

Thank you for your question.

In principle, I think we agree with you that this is the wave of the future--that we certainly do need more doctors and more nurses--but I would make two points. First, in relation to needs, it has to be the needs of the population and the needs of the patient and not simply numbers, so we have to have a good analysis locally, regionally, provincially, and nationally as to what the needs of the health care system are, and then have the providers match those needs. That's a big challenge, a big issue, but it's part of the national framework we're discussing.

The second thing you touch on is the notion of collaborative practice. It is our feeling, certainly in my area of cardiovascular medicine, that although we have shortages, and shortages will remain for the foreseeable future, there is going to have to be some element of collaborative practice among all the health care professionals in those fields, a collaborative practice that matches the needs of the patients and the population. We have established a number of principles for that, including deciding who does what, when, and under what conditions. It is really a work in progress, but it very much fits in with what you're talking about.

[The Chair, Conservative, Dean Allison]

Ms. Cooper is next.

[Janet Cooper, Senior Director, Professional Affairs, Canadian Pharmacists Association]

Thank you.

I am speaking next to our colleague from the CMA. It certainly is an issue with pharmacists, and within the communities we are seeing some huge changes in pharmacy practice at the primary care level. We have pharmacists who are graduating and practising, and probably one of the biggest concerns is that their expertise is not being utilized. Certainly with the challenges in drug therapy that we have now, whether in costs or safety or effectiveness, we're looking at the need for greater collaborative practice and interprofessional work.

To do that, we also have to look at what pharmacists are doing day to day. One of those things will be actually looking at the role that pharmacy technicians are playing. They're not regulated, but they could be taking on a lot of the technical aspects of pharmacy practice that pharmacists are spending too much time on now; it scopes a practice for a number of professionals, then, as well as the assistants who help us.

[The Chair, Conservative, Dean Allison]

Ms. Fralick is next.

[Pamela Fralick]

Thank you.

I will add one comment. In deference to the professions you see in front of you here, I would remind all the committee members that I'm here reflecting the voices of another 26 or so professions that cannot be here and reflecting as well the roles they play in the health system. All our discussions must focus on those other professions as well.

I want to make sure as well that the committee is familiar with an initiative funded by the government under the Primary Health Care Transition Fund. It is called EICP, for enhancing interdisciplinary collaboration in primary health care. It's one of the five nationally funded initiatives. It just concluded its work officially a few weeks ago. This was an initiative to establish the guiding principles and framework pieces for collaborative interdisciplinary care.

Around the table were sitting physicians, nurses, pharmacists, psychologists, dieticians, physiotherapists, occupational therapists, etc., and they've done a huge piece of work to contribute to that ability to enhance collaborative care moving forward.

Thank you.

[The Chair, Conservative, Dean Allison]

We have a minute and a half left.

[Denise Savoie, NDP, Victoria, BC]

Very quickly, then, aside from funding this kind of initiative...I'm surprised that we're still funding an initiative and that this isn't happening on a broader scope. I'm wondering if there's anything more we can do.

The second quick question relates to credentials and foreign doctors. I understand from speaking to people in British Columbia that there's a problem in residency, a lack of residency. I'm post-secondary training critic for the NDP. I'm wondering to what extent the government could be infusing more funds specifically to the transfers of education, but relating to residencies, to increase those possibilities.

[Dr. Colin McMillan]

Briefly, Mr. Chair, that's really the core of the problem. It's really what we call capacity within the training centres to fit these graduates, even if you had the funding and the qualifications. You're exactly dead-on; yes.

[The Chair, Conservative, Dean Allison]

Thank you.

We have a quick supplemental there.

[Sharon Sholzberg-Gray]

I just wanted to note that it's not only clinical practice positions for physicians; residencies are important, but every front-line provider needs a placement. There is an integration of foreign workers, and, frankly, current workers too, and that's an area that needs funding.

[The Chair, Conservative, Dean Allison]

Thank you very much.

We're going to move to Mr. Brown, the last questioner in this round. You have seven minutes, sir.

[Patrick Brown, Conservative, Barrie, ON]

Thank you, Mr. Chair.

Thank you for being here today.

I come from a community where the doctor shortage is very severe, and it's a pleasant coincidence that you're here today, the same week as the PAIRO tour, where underserviced communities get to go to medical schools around the province to make their pitches. I was in Kingston on Monday night, trying to make a pitch on behalf of our hospital at the PAIRO event there.

To give you an example of a typical Canadian community, in Barrie we number 135,000 and one-quarter of our population doesn't have a family doctor. Consistently, our doctor shortages are 27 to 30, and we have a very active recruitment effort. We spend $220,000 through donations by the local communities of Barrie and surrounding municipalities simply on recruitment efforts—moving expenses, gadgets we give out at conferences.

When I was there on Monday night at the PAIRO event, I was thinking about how we're competing among friends. We're competing against other municipalities that face the same shortages. We're all spending money, giving out trinkets, and telling people how great our cities are and how great a place it is to live.

I wanted to know what advice you could give us about federal solutions in the three areas that I see to be particularly problematic in my community. I imagine they are similar to those in other communities.

The one you've already touched on is the foreign-trained physicians. The stat that the CMA gave in the pre-budget consultations in 2005 was that there were 600 currently who haven't been integrated into medical practice. I know in my riding there are five who approached my office, and I've heard concerns from these foreign-trained doctors on the grounds that the equivalency exams are too expensive and they can't afford them, or the prospects of residency spots are difficult.

We talk a lot about the urban-rural divide, where there are more doctor spots in urban areas and less in small towns and rural communities. A concern I see there is that when medical students go to school, they develop roots, they develop friends, they develop a level of comfort in the larger cities. I look at Kingston, where there is not an apparent doctor shortage. It is the same size as my community, yet I'm 30 doctors short in Barrie.

What opportunities are there to encourage more rotations, more residencies, more medical experiences in small towns and rural areas, where we can develop a sense of familiarity with those areas?

With regard to retention, the stat that the CMA gave us was that 3,887 doctors were a net loss between 1991 and 2004. I see that in my community, particularly with an aging medical profession. I've seen many good doctors retire. What can we do toward greater retention? I know we've looked at that in the different ways we spend money and try to make doctors as welcome and encouraged to stay in practice in Barrie. What federal solutions do you see?

I see a tendency that whenever we look at the doctor shortage, we pass it off. I know when I was a city councillor, when our hospital came to city council asking for help, some said, “Don't worry about that, it's the province or the federal government's responsibility”. Then there's a tendency on the federal level to say, “Don't worry, that's a local problem or a provincial problem”. We all seem to be passing the buck, but this really is a national concern.

I saw one survey in my riding where this was ranked in the top three issues. What solutions can you think of at the federal level that we could get involved in to make a tangible difference?

[Dr. Colin McMillan]

Mr. Chair, through you to Mr. Brown, if I had all the answers, I probably wouldn't be sitting here right now, but the questions you raise are germane and I shall try to at least offer some things we're looking at and possible solutions.

In relation to the foreign graduate situation, it is very complex, but we think that even though there are a large number of foreign graduates in the country, or foreign-trained physicians, not all of whom would qualify under any circumstances from some areas to ever practice, there is a substantial number above the current ones who could.

I think this is an area the federal government could look at. If we can get some federal funding, and maybe some capacity within the system, the sort of thing my colleague here referred to, then I think we could get more than 400 per year, fully trained and qualified in the short term, to get in the system, to help areas like your own.

As far as your own individual recruitment and retention issue is concerned, one of the things you might look at in relation to your discussions with the medical school is maybe talk about having a campus in Barrie, like they do in Prince George in B.C. and other areas. My daughter just trained in Newfoundland, and some of the best training--and this was recognized at her graduation--was in rural and remote areas that are part of the Memorial campus. They are now noticing, in some of the literature that's recently been reported about the province of Newfoundland, that they are now getting more applicants, more medical students, and more trainees from rural and remote areas of Newfoundland who are going to medical school, not only in Newfoundland but they are going back to those areas.

Maybe a campus in Barrie might be something you could look at, with a welcome mat and the sorts of incentives you were talking about.

As far as the net losses are concerned, again I made reference in a previous question to the fact that we think we may be on the cusp of reversing this. We don't know why. It may be economic and demographic, but we think there's a real possibility there, that there are a number of full-time, active physicians in the United States, more than 1,000 of whom have kept their licences in Canada, who we could entice back on the short term.

So in addition to the foreign graduates, there are the Canadians in the United States, and then there is another group, the number of which we're not too sure about, who are actually training outside of Canada, who we think we'd like to get back in. A very large number of students who are Canadians trained in the Caribbean and Ireland. So we're looking at that as well.

These are some of the solutions we're actively looking at, but the short answer might be, maybe you need a campus in Barrie for one of your medical schools.

[The Chair, Conservative, Dean Allison]

Dr. Tholl.

[Dr. William Tholl, Secretary General and Chief Executive Officer, Canadian Medical Association]

Thank you, Mr. Chair.

Just to elaborate a little bit on the welcome back mat, we've done some preliminary analysis of the physicians, 10,000 or so who did go down to the United States between 1993 and roughly 2001, and we think the following four or five factors are at play.

One, they are tired of the malpractice situation down in the United States, where you have malpractice fees that are ten times what they are in Canada, and going up.

Two, they are tired of 1-800 control medicine, being told by the HMOs what they can and can't do.

Three, they are getting older and they've paid off the debt. The debt these days for medical students is in the neighbourhood of a large or medium-sized mortgage on a house, so they've paid off their debt.

Four, their grandchildren are a little older.

And five, they're looking forward to retiring and they want a medicare system to retire in.

[The Chair, Conservative, Dean Allison]

Thank you.

That's all the time we have. We're going to move now into our second round, which will be five minutes of questions, and we're going to move to Ms. Brown.

[Bonnie Brown, Liberal, Oakville, ON]

Thank you, Mr. Chairman.

You'll recall that I think two of our presenters talked about the need for an all-Canadian planning mechanism or consultation body, something that will collect the facts and do needs-based planning, not dollars-based planning. I can see that happening, but I'm wondering if either presenter has thought about how that might happen.

Are they looking for the federal government to create a new body with new facilities, etc., for such a council to meet at, with a necessary staff, etc.? If that's the case, have they predicted how much that would cost the federal government?

Secondly, if we don't need a brand-new creation, could it be attached to some other existing body, like CIHI, which is the provider of most facts anyway, or some other federal institution?

[Dr. William Tholl]

Mr. Chair, through you, ideally what we'd want to see is the creation of a health sector table much like what exists in other areas, like engineering, forestry, and mining. We've generally run into a brick wall with respect to applications for that, largely having to do with federal-provincial-territorial responsibilities.

Failing that, what we've discussed is turning Health Action Lobby into such a round table. It already exists. It already has 30 organizations, 30 professions, represented around it.

No, we don't imagine having to establish a new institute, or a new agency or a new office. This could be housed, depending upon what the primary purpose would be, either within the Canadian Institutes of Health Research, if it's needs-based planning, the Canadian Institute for Health Information, if it's primarily data gathering and dissemination, or it could be under the Health Council of Canada. The problem there is you have two provinces that aren't participating: Alberta and Quebec.

We would see this as minimalist in terms of machinery issues.

[The Chair, Conservative, Dean Allison]

We'll go to Ms. Cooper.

[Janet Cooper]

Thank you.

We haven't actually costed it out or anything like that. One of the things we looked at was having something like the Canadian Patient Safety Institute, which was set up very recently by the federal government to look at a lot of the safety challenges in health care.

There does need to be some kind of mechanism. Actually the FPT governments have done a lot in the past few years with Health Canada having the health human resources strategies division. There is also the advisory committee on health delivery and human resources, which is looking at a lot of the same issues we're looking at.

The problem is that right now that's a government committee, and the health care professionals at our organizations and in our stakeholders and in other stakeholders aren't part of that education system. So it's kind of happening in its own silo. We're talking about some kind of mechanism--perhaps a centre, an institute--to bring the different stakeholders together, to look at this issue from the different perspectives.