Human Resources Committee on April 25th, 2012

[The Chair, Conservative, Ed Komarnicki]

All right. We'll attempt to bring this meeting to order.

I'll remind the committee that we'll devote the last 15 minutes to committee business. That will be at about 5:15.

We'll hear from the presenters and, of course, we'll be able to ask questions. At about 4:30, we will break for a few moments and then recommence.

We have with us Mr. Arthur Sweetman, who will be presenting. Also, on behalf of the Canadian Institute for Health Information, we have with us Jean-Marie Berthelot, vice-president of programs and executive director of the Quebec office. We have the Canadian Nurses Association with us as well.

With that, we'll start with Mr. Sweetman.

Go ahead.

[Dr. Arthur Sweetman, Professor, Department of Economics, McMaster University, As an Individual]

Thank you very much.

Since much of what you've been looking at has to do with the private sector, I thought it would be good to start by addressing the need for health human resources, which in the health sector are quite different. Canada's single-payer medicare system is the primary source of divergence between the public and private sectors. While many health service occupations are outside of medicare, its influence remains substantial. As a result, the affected labour markets are not competitive, and what we normally think of as supply and demand do not operate.

Consider the extreme example of physicians. In each province there's only one employer, and fees are bargained collectively. On the supply side, the provinces, with some consultation, set the number of domestic applicants admitted to medical schools, as well as the number of international medical graduates admitted to practise. Provincial governments also legislate the regulatory colleges that provide quality control and oversight.

In determining the number of open slots for new physicians, provinces need to play a balancing game. They need to take into account the health care requirements of their populations. Also, they need to take into account the tax revenue or debt financing needed to fund those positions. This is extremely challenging. In this context, a lot of data and a lot of information and planning are required.

This process has generated a perceived shortage that is slowly being reduced. In fact, in the last decade, many provincial governments have moved very aggressively to increase the number of physicians per capita.

In Ontario, for example, beyond physicians, the Regulated Health Professions Act traditionally covered 24 professions and, at the moment, two or three occupations are in the process of being brought under the act. As well, many health services occupations that are not regulated are primarily employed by provincially funded hospitals or other institutions. None of these occupations operate in the way we traditionally think of labour markets operating.

So what's the federal role? I'd like to raise two issues for you to consider. First, my personal view is that while many of the appropriate institutions are in place, they are frequently not as active as they could or should be. I believe that communication and coordination among the provinces and the federal government are still not sufficient, and there's a need for increased information sharing. Health Canada and CIHI play very important roles, as does Statistics Canada. Also, since it has a lot of capacity in the area, HRSDC also plays a role, though it could play a larger one.

I should note that what I'm talking about is routine. It's what I consider well below the radar screen.

One of the examples that I might think of as a structure for facilitating this is the existing federal-provincial-territorial Advisory Committee on Health Delivery and Human Resources. This is a standing committee of the federal-provincial-territorial Conference of Deputy Ministers of Health. In my ideal world, an invigorated version of this group would, in coordination with CIHI, generate substantial sharing of health human resource data and practical experience between governments and other relevant stakeholders, such as the Canadian Nurses Association and the Canadian Medical Association.

The second issue is a focus on immigration, which plays a very important role in these areas. I believe that immigrant selection for individuals working in health professions, where the provincial governments are the principal payers, should be taken out of the federal skilled worker program and put into the provincial nominee program.

The current points system is very poorly suited to regulated health professions under our single-payer system. A coordination problem arises from having immigrant selection at the federal level while employment and planning occur almost exclusively at the provincial level. This is completely different from private sector markets. I suspect that the most useful approach would be to shift this responsibility to the provinces, since they have the levers to verify credentials in the health area and to implement their health human resource planning.

Thank you very much.

[The Chair, Conservative, Ed Komarnicki]

Thank you for that presentation and for those comments regarding the skilled worker program and the provincial nominee program. It operates differently from province to province, but it's certainly an area that might be used going forward.

Now we'll let you present, go ahead.

[Jean-Marie Berthelot, Vice-President, Programs and Executive Director, Quebec Office, Canadian Institute for Health Information]

Thank you very much.

Good afternoon. On behalf of the Canadian Institute for Health Information, I would like to thank you for inviting us to participate in your study of labour shortages.

I am accompanied by Carole Brulé, who is one of our managers of the HHR databases we collect in CIHI.

CIHI is an independent, not-for-profit corporation that provides essential information on Canada's health system and the health of Canadians. Established in 1994, we are funded by federal, provincial and territorial governments. We report to an independent board of directors representing government health departments, regional health authorities, hospitals and health-sector leaders across the country.

CIHI works in partnership with stakeholders to create and maintain a broad range of databases, measurement tools and standards on health information. We produce reports on health care services, population health, health spending and health human resources.

CIHI has been collecting detailed information on physicians and nurses since its inception. More recently, we created new databases that provide demographic and workforce information on pharmacists, occupational therapists, physiotherapists, medical laboratory technologists, and medical radiation technologists. CIHI also collects aggregate data for an additional 17 health professional groups, such as dentists, midwives, and psychologists.

Altogether, more than one million people in Canada, over 6% of the total Canadian workforce, are employed directly in the heath care system. In 2010, approximately 70,000 of these health care professionals were active physicians.

Over the past five years, the growth in the number of these professionals has consistently outpaced population growth. In fact, there were 203 active physicians per 100,000 Canadians in 2010, the greatest proportion there has ever been in this country. Most of the growth in the physician workforce is due to an increase in the number of medical graduates from Canadian faculties of medicine. Since 2003, it has increased by nearly 60% to more than 2,400 graduates in 2010.

The overall number of training seats continues to grow, so the upward trend in the supply of physicians is expected to continue.

Regulated nurses, the largest group of regulated health professionals in Canada, are also increasing in number: in 2010, there were close to 35,000 registered nurses, licensed practical nurses and registered psychiatric nurses working in nursing in Canada—an increase of nearly 9% since 2006, about twice the rate of the increase in the Canadian population for the same period.

The nursing representative will no doubt cover nursing care in depth, but still, it is interesting to note that the supply of new nursing graduates was over 14,000 in 2006 and over 16,000 in 2010—a growth rate of 17%—so the increase in workforce numbers is likely to continue.

There are also increases in the supply of other health professionals. For example, the per-population supply of all pharmacists in Canada has increased consistently from 82 per 100,000 in 2006, to 91 per 100,000 in 2010. Supply as a whole grew by 16% in that period, reaching a total of approximately 32,000 physicians in 2010.

CIHI data shows that the number of all regulated health professionals, other than physicians, nurses, and pharmacists, also increased by 16% from 2006 to 2010. In total there were approximately 160,000 in the 18 other professions for which CIHI collects data.

Supply-based trend information for all of these professionals is available through a series of reports called “Canada's Health Care Providers”. They contain a broad variety of other supply and graduate data to support health services management and research.

We also have separate and detailed analyses on doctors, nurses, pharmacists, occupational therapists, physiotherapists, medical radiation technologists, and medical laboratory technologists. All of our reports are available on our website.

The brief we are presenting to the committee contains further information, including interesting provincial variations, details about the nursing workforce and a list of groups on which we are collecting data.

We know that Canada has more doctors and pharmacists than ever, and that nurses have yet to return to their pre-1990 numbers—but we also know that numbers alone do not tell the whole story.

The demand for services from all health professionals depends on a number of factors. These include population health care needs, the hours professionals spend on patient care, the individual professional's scope of practice, demographic changes to medical and health workforces, and the way care is organized.

The issue of labour supply among health and medical professionals is especially complex. We hope that our data on health human resources help inform discussion on the subject.

We would be pleased to answer any questions you may have in the official language of your choice.

Merci beaucoup.

[The Chair, Conservative, Ed Komarnicki]

Thank you very much.

Ms. Bard, will you be presenting?

[Rachel Bard, Chief Executive Officer, Canadian Nurses Association]

Good afternoon.

On behalf of Canada's quarter of a million registered nurses, I really appreciate the opportunity to speak to you today concerning health labour force issues.

Evidence of a nursing shortage in Canada has long been clear, from frustrating wait times in clinics and hospitals to poorer results for patients. The negative impact of the shortage of registered nurses and other health professionals is something that Canadians face every day.

Current research puts Canada's shortage of registered nurses at approximately 11,000 full-time equivalents. Left unaddressed, that shortage is projected to reach 60,000 full-time equivalent RNs by 2022, a reality that stands to risk future health outcomes. That my colleague said that the numbers are increasing is a good sign. However, there are still some other matters that need to be addressed.

A labour shortage implies an imbalance in both supply and demand. Comprehensive thinking about the supply of registered nurses will help us better meet the health needs of Canadians. We need to go beyond the narrow thinking of strict numbers of nurses and think about their participation in the workforce based on the level of activities—that is, whether they are full time or part time—the rates of absenteeism, and how productive the workforce actually is. The number of services that registered nurses can actually supply in a day is affected by the model of care delivery in place, the composition of health teams, and how efficiently health teams work together. It also includes whether or not barriers exist that prevent health professionals from offering the complete range of care for which they are qualified—that is, working to their full scope of practice.

Productivity gains can be made through facility design, use of technology, and health delivery innovations. We see productivity gains with nurse practitioners in Newfoundland and Labrador, who are supported by teams and telehealth technology while providing care in rural and remote communities. By doing things differently we can enhance the use of the existing supply of nurses already working within the system, all the while providing more patient-centred care. As you can see in our brief, implementing measures to increase RN productivity by 1% per year would have a dramatic and immediate effect on the shortage.

We can also improve our access to and use of labour market information through the Canadian Institute for Health Information. To ensure that we have accurate information on where registered nurses are working, a national unique identifier should be employed. This in essence would be a number assigned to a registered nursing student that would enable us to track when and where they are entering the workforce, and their practice patterns. Implementing this identifier would significantly improve our ability to track the mobility of our nursing workforce both internally between provinces and territories, and externally, for example, when nurses leave Canada to work in the U.S. or other countries.

To better understand the capacity of the nursing workforce, a national study on the health and work of nurses should be repeated. When CIHI conducted a study of this in 2006 it revealed that registered nurses had an absenteeism and sick rate that was double the Canadian average of seven days. These 2006 survey results have led to some innovations in creating healthy workplaces. Repeating the survey now would provide us with current, accurate data, and allow us to evaluate the effectiveness of these innovations.

A third recommendation deals with pan-Canadian health human resources planning and mirrors one of the main recommendations made recently by the Senate Committee on Social Affairs, Science and Technology in its review of the 2004 health accord. The federal government should conduct a feasibility study to determine the benefit of establishing a pan-Canadian health human resource observatory.

Health human resource observatories have been implemented in some European and South American countries to analyze trends and health human resources needs and to identify opportunities to implement best practices, which ultimately lead to more value and better care within our health care system.

The opportunity exists to build this innovation into existing federal agencies to ensure that health human resource planners have coordinated resources and best information at their disposal to better meet the planning challenges of Canada's multi-jurisdictional health care system.

While it is important to explore ways to increase the supply of nurses, it is also critical that we take opportunities to reduce demand for health services, through illness prevention, health promotion, and especially the prevention of chronic diseases like heart disease, diabetes, and cancer.

Canadians benefit from federal programs that encourage smoking cessation or healthier living. CNA is concerned about cuts to these programs, the results of which are as threatening to the supply curve as the shortage of surgical nurses or emergency room doctors.

The stable and sufficient supply and deployment of Canada's health professionals continues to be one of our greatest health care challenges. By looking at these recommendations in concert with a comprehensive view to reducing demand through health promotion and disease prevention, we can take steps to address the nursing shortage and enhance the health of Canadians.

Merci beaucoup.

[The Chair, Conservative, Ed Komarnicki]

Thank you very much for that presentation. Generally it's good to go beyond our narrow thinking, and being prepared to do things differently is always a good piece of advice, I'm sure.

We're going to have seven-minute-rounds of questioning. We'll try to keep members' questions to around the seven-minute area.

We'll start with Ms. Charlton.

Go ahead.

[Chris Charlton, NDP, Hamilton Mountain, ON]

Thank you very much, Chair.

Thanks to all three of you for your excellent presentations.

We'll each be asking questions, so I'm going to focus my questions for the moment to Ms. Bard and deal with the nursing shortage in particular.

I know that the two challenges are both retention and the attraction of new nurses to the field, and I want to explore that a little further. Yesterday we had a witness who said that we needed to change the narrative in attracting people, and I think there is much merit to that with respect to the health field as well.

We've seen a bit of credential creep, if you will, whereby nurses who want to enter the field need to have increasingly higher levels of education. Yet, because of the way salaries are negotiated in the field, these aren't really keeping pace with the cost of that education. It's difficult to attract young people to a field where the tuition fees are unbelievably high.

I wonder if you would comment on whether it might make sense to explore ways to reduce the barriers to that kind of education, whether it's through incentive programs and loan forgiveness perhaps—if nurses were to practise in areas where there are acute shortages.

If you're comfortable with this, I'm going to pose a whole whack of questions and then turn the floor over to you for answers to all of them.

If we're changing the narrative in the nursing profession, I do know that it's one of the professions that has the highest rates of occupational injury and that retaining nurses is incredibly difficult in an environment where sick days are often higher than the national average. You've largely addressed that.

We are now also faced with a policy on the government's part, where we're potentially going to increase the age at which people can collect the OAS from 65 to 67. Nursing is an unbelievably physically demanding occupation. I wonder if you could comment on whether it would be possible for nurses to continue to work until they're 67 and do the jobs they're doing. Again, that speaks to retention, but perhaps from a bit of a different angle.

And lastly, I'm from Ontario, and I remember the Mike Harris years. The premier, I think, infamously compared nurses to hula hoops, that their time had come and gone. At that time we had a huge out-migration of nurses from Ontario to the States in particular—to Florida and Arizona—which then created a shortage at home from which I don't think we've recovered.

If we're looking at retention of nurses, there are work environment morale issues as well. I wonder if you could speak to that and give us some guidance as to what we can do, as federal legislators, to improve the work environment in all three of those respects.

Thank you.

[Rachel Bard]

Thank you very much for your question.

I will refer you to our report, Tested Solutions for Eliminating Canada's Registered Nurses Shortage, because it addresses some of your questions.

Starting with student retention, we know that a high percentage of students leave in their first year of learning, and it's clear that we do need to have some programs that will help retain students. We know that if we can reduce by even 10% the number of students who leave, that will actually have an impact on the numbers of nurses graduating and who are able to enter the workforce.

So we do need to provide some support. We have students who are starting a second or third career. They have families and therefore they need to have some social programs that will help them, certainly from a financial perspective, or even in terms of better support to help with adjustment and so on.

So I think that has been identified. We've seen this is a policy direction that needs to be addressed.

In relation to absenteeism in the workforce, and certainly the quality of work life of nurses, again I think our report identifies the high percentage involved. If we can address some policy to retaining our nurses and improving the work life and work conditions of nurses, removing barriers for them so that they can practise to their full scope, and providing them with the necessary support, that will have an impact on retention of our nurses and on keeping our nurses in a healthy workplace environment. So definitely, there's a need to address some of that.

CNA has also produced, in collaboration with RNAO, which is within one of our jurisdictions, a report on nurse fatigue. That report identifies some evidence that we need to pay attention to. It requires a collaborative and collective approach between the employers, the nurses, the professional body, such as our association, the Canadian Nurses Association, and the government to create an environment and address some of the barriers and the hindrances in the workplace. It takes a collective effort. It's not just one side: it requires federal intervention as well as provincial intervention.

Retaining nurses over the age of 60 was another policy direction in our Tested Solutions report, where we see there are models for doing so. We can retain nurses so that they work beyond the age of 60 and over 65, provided we create a climate that will address their work balance. There are models right now that have been tested, where there's an 80-20 situation. So nurses who are more senior in their practice and more experienced and are older can become mentors for the younger generation and provide other types of services so they're not fully into direct care. Again, you try to retain them as long as you can, but you need to adjust their work conditions.

[The Chair, Conservative, Ed Komarnicki]

You've got about 30 seconds. I don't know whether you want to ask a short question.

[Chris Charlton, NDP, Hamilton Mountain, ON]

I'll ask a really quick question, because it's really just for clarification.

With respect to reducing international in-migration, there's a note here that says:

Reducing international in-migration by 50% would result in a larger shortage of RNs; however, the effect of this change is not at all substantial (less than 10%) even in the long term.

I don't understand the bullet. I just need you to explain to me what that actually says.

[Rachel Bard]

What it says for us is that if we can address the four policy directions that we've identified for retaining our nurses and improving the conditions in the workplace, we don't necessarily need to rely on international recruitment of nurses, because this is not where it's going to have the greatest impact. It has very minimal impact in addressing the shortfall and that's why we're saying let's not put all our energy there.

[The Chair, Conservative, Ed Komarnicki]

Thank you for that.

Ms. Leitch, go ahead.

[Kellie Leitch, Conservative, Simcoe—Grey, ON]

Thank you very much.

Thank you, everyone, for being here today. I greatly appreciate your time and your effort to get here. I have two sets of questions, and I hope we can stay short and succinct.

The first set is about data. I wanted to ask you if you have recommendations for improving the Canadian occupational projection system. Just looking at our notes, I find it interesting that physicians and veterinarians and dentists are all in the same category. It's great to know there's a shortage there, but is there a shortage in all three, or in one or two?

Also, can you identify any additional challenges for the medical sector that are not adequately represented in the data sets that either you currently use—either yourself, Dr. Sweetman, as a professor, or at CIHI—or in the other data sets that you may access for providing information?

[Dr. Arthur Sweetman]

Let me answer your question in some sense and also come back to the first one a little.

The first question in particular seemed to assume that the labour market for nurses is similar to a private sector labour market, and I would argue that is not a useful way to think about it. I think it's the same in relation to the question you're posing now.

A COPS model does not work very well for physicians and nurses, because there is only one employer for 99% of physicians and nurses, namely the provincial governments; and demand for physicians and nurses can turn on a dime with a provincial budget or a series of provincial budgets. If a province is in deficit, the number of nurses being hired goes down dramatically, and it's the same with physicians. Since the provincial governments have substantial control over the number of places in medical schools, for example, they can reduce the supply very substantially.

Even though right now there's this popular perception of a shortage of nurses, there are actually a substantial number of unemployed nurses.

The problem is that this is not a private sector where you have supply and demand that equilibrate, but a situation where you have in each province a union that negotiates with the province and comes up with a wage or a set of fees for physicians. It's not a market the way you might think about a market, the way the first question posited a private sector market. It's not like that.

I think this is a situation where provincial governments plan and the provincial governments hire, though there are some rare exceptions. They are pretty much the only people who hire. There is a popular perception of shortages because physician and nursing care is for the most part free in Canada, but there is also a perception that taxes are too high, so we don't want to pay for that physician and nursing care that we think we have a shortage of.

Fundamentally, our medicare system makes this a political problem, whereby everybody wants free medicare but doesn't want to pay the taxes to pay for the free medicare.

I don't think there's an easy solution to this. I don't think that the private sector models fit. I think what we need more than anything else is really good provincial planning. This is a provincial responsibility at the end of the day, but that can be facilitated by really good assistance from the federal government in providing planning assistance, information, data, and the like.

As much as CIHI does have great data on some things, it doesn't yet have great data on everything, and not at the detailed level that provinces need for planning.

I think that type of information would be extremely useful to provinces and aid the kind of capacity that HRSDC has for planning. A lot of the provinces could use assistance with that type of detailed planning.

[Kellie Leitch, Conservative, Simcoe—Grey, ON]

Mr. Berthelot.

[Jean-Marie Berthelot]

In terms of the occupational projections, if you don't mind I'll quote Yogi Berra, who said “It is difficult to make predictions, especially about the future”.

The challenge here is exactly what you mentioned. The number of seats in the faculty of medicine is controlled. The number of jobs available is controlled. Immigration, in some ways, is controlled.

You can make projections at the national level in the short term about how many physicians there will be five years from now, but to make long-term projections is very difficult.

It's the same thing with nurses. It depends how many seats are available. I don't think there's a shortage of people applying for nursing and medicine. There are the issues about how many seats are open.

In terms of data, CIHI has data about the supply. Provinces are working...and each province has its model for doing its health human resources planning. They're trying to focus on needs, but it's very difficult to do. Health human resources need planning because the scope of practice varies, depending on the needs of your population.

Interprovincial migration also plays a role. In Canada, we have observed in the last 30 years that places that have rapid economic growth effectively see an increase in their population and an increase in their health professionals, even though they may not have trained more of them than they have in the past.

In terms of the information, I think CIHI could probably do something regarding health human resources projections, but you have to take into account that those projections can only be short term if you want them to be relatively reliable because they are determined by policy more than natural phenomena or the market.

[Kellie Leitch, Conservative, Simcoe—Grey, ON]

I appreciate both of you commenting that this is really provincial jurisdiction from the standpoint of what's driving the numbers. I'm a physician myself, an orthopedic surgeon, and yes, the destiny of my operating room was determined by a provincial budget.

My second set of questions is focused on a different subject matter.

[The Chair, Conservative, Ed Komarnicki]

You have...[Inaudible--Editor].

[Kellie Leitch, Conservative, Simcoe—Grey, ON]

I got it. I understand, Mr. Chair. And you just took up 15 of my seconds.

[The Chair, Conservative, Ed Komarnicki]

Well, we won't hold that against you.

[Voices]

Oh, oh!

[Kellie Leitch, Conservative, Simcoe—Grey, ON]

You won't hold that against me.

I appreciated your comments, Ms. Bard, with respect to workplace conditions—again, a provincial jurisdiction issue. My question is how do we encourage young men to actually enter into nursing? We always talk about women not entering into certain subspecialties, but my understanding is that 80% to 85% of nurses are women. How do we get that 49% of guys who are looking for a profession to consider nursing?

[Rachel Bard]

It's an interesting question, because actually we do. The numbers are starting to increase.

I think there is work to be done in the education system through career counselling, so that the profession of nursing can be seen as attractive and men can be directed there. Recently there was an example of a male nurse who said that when he went through career counselling, that's not where he was directed.

So there are some myths that we need to correct, i.e., that it's just for women. But the numbers are actually starting to increase, for sure.

[The Chair, Conservative, Ed Komarnicki]

Thank you, Ms. Bard.

We'll move on to the next questioner.

I must say, I heard you when you said that it's not a question of a shortage of people who apply but how many seats are available, which is directly related to provincial budgetary measures. So there's that at play.

Mr. Cleary, go ahead.