PARLIAMENT of CANADA
Home Parliamentary Business Senators and Members About Parliament Visitor Information Employment
 
 

The Health of Canadians – The Federal Role

Interim Report

Volume Two: Current Trends and Future Challenges


CHAPTER SEVEN:

Health Research

Health research is about creating new knowledge with respect to health and health care.  Health research can lead to the development of new or improved drug therapy, treatment, medical equipment and devices; as well, its results provide information on new ways of organizing and delivering health care.  Health research contributes to a better understanding of the complex interplay of the determinants that affect our health and susceptibility to disease.

With the creation of the Canadian Institutes for Health Research (CIHR), the federal government expanded its definition of health research.  More precisely, it moved beyond its previous emphasis on basic and applied research – mostly biomedical and clinical research activities – to encompass a wider range of disciplines and components.  This shift was part of the general movement toward a population health approach that acknowledges that health is broader than health care, as well as a response to the increasing need to obtain evidence-based information to allow for effective health care reform and renewal.  Table 7.1 summarizes the four main research components now financed by the CIHR.

TABLE 7.1

CIHR – THE FOUR COMPONENTS OF HEALTH RESEARCH

Biomedical research

Pertaining to biological organisms, organs, and organ systems

Clinical research

Involving direct observation of people undergoing medical care

Health services research

Embracing health care delivery, administration, organization and financing

Population health research

Focusing on the broad factors that influence health status (socio-economic conditions, gender, culture, education, etc.)

Research plays a vital role in the field of health and health care.  The Committee held two sets of hearings on health research.  Testimony was heard with respect to: 1) the role of the federal government in health research; 2) genetics and genomics research as the burgeoning research areas and their implications on health and health care; and 3) the benefits and challenges of health research.

 

7.1     Federal Role in Health Research

The federal government plays a major role in supporting health research carried out in universities, teaching hospitals and research institutes (extramural research), as well as in its own laboratories (intramural research).  According to Kimberly Elmslie, Acting Executive Director, Health Research Secretariat, Health Canada, the federal government’s role in health research and health care research is multi-faceted and includes:

·        Setting research priorities;

·        Undertaking research in areas related to direct federal responsibilities (e.g., health protection, risk management, Aboriginal health);

·        Funding extramural research and related science and engineering research;

·        Supporting the training and development of researchers (e.g., through the Canada Research Chairs Program, the CIHR and the other granting councils);

·        Funding research infrastructure (through the Canadian Foundation of Innovation);

·        Supporting information and systems management (CIHI and Statistics Canada);

·        Funding Networks of Centres of Excellence (Industry Canada and Health Canada).[182]

Only a relatively small proportion of federally funded health research is conducted in federal government facilities (less than 20%).  Federal facilities in which health research is performed include Health Canada, Statistics Canada, the National Research Council, Human Resources Development Canada and Environment Canada (in partnership with Health Canada).  For the most part, health research funded by the federal government is extramural and takes place in universities and hospitals (72%), private non-profit organizations (6%), and business enterprises (1%).[183]

The principal federal funding body for health research is the CIHR (see Table 7.2).  In fact, the CIHR is the only federal entity whose budget is entirely devoted to health research.  Its creation in 1998 involved the merging of the Medical Research Council of Canada with the National Health Research and Development Program (NHRDP), Health Canada’s main financing instrument for extramural health research.  Health Canada is also involved in multiple internal research activities, as well as in extramural research, which are all devoted to the health field.  There are, however, other research-oriented bodies supported by the federal government along with other partners where the focus is entirely health-related.  These include the Canadian Health Services Research Foundation (CHSRF), the Canadian Institute for Health Information (CIHI), and the Canadian Coordinating Office for Health Technology Assessment (CCOHTA).

In addition, several secondary sources of federal health research funding are available.  The federal government is responsible for a number of research councils, agencies and programs where only a portion of their budget goes to health-related research.  These include the Natural Sciences and Engineering Research Council of Canada, the Social Sciences and Humanities Research Council, the Canada Foundation for Innovation, the Canada Research Chairs, and the Networks of Centres of Excellence (it is worth noting that seven networks, of the currently-funded 18 NCEs, conduct health research in the fields of: arthritis, bacterial diseases, vaccines and immunotherapeutics for cancer and viral diseases, stroke, health evidence application, genetic diseases, and protein engineering).

TABLE 7.2

Primary Sources of Federal Health Research Funding in 2000  

Primary Federal
Funding Source

Date Established

Federal Contribution in
or around 2000

Canadian Institutes of Health Research

2000

$402 annual

Health Canada Health Transition Fund

1997

$150 million for 3 years

Health Canada Population Health Fund

1999

$14 million annual

Health Canada Canadian Health
Infostructure Partnerships program

(CHIPP)

2000

$80 million over 2 years

Health Canada Centres of Excellence for Children’s Health

2000

$20 million over 5 years

Health Canada Centres of Excellence for Women’s Health

1996

$12 million over 6 years

Canadian Health Services Research Foundation (CHSRF)

1996

$65 million over 5 years

CHSRF Nursing Research Fund

2000

$2.5 million annual (for 10 years)

Canadian Institute for Health
Information (CIHI)

1994

$328 million over 3-4 years
(1999-03)

CIHI Canadian Population Health
Initiative

1999

$20 million over 4 years
(1999-03)

Canadian Coordinating Office for
Health Technology Assessment

1989

$3.7 million (2000) - $4.34 million per year (2001-04)

Source:  Sonya Norris, Nancy Miller-Chenier and Odette Madore, Federal Funding for Health Research, TIPS 56E, Parliamentary Research  Branch, Library of Parliament, 11 December 2000.

Overall, the federal government plays an important role in funding health research in Canada.  Graph 7.1 indicates that, in 1998, almost $370 million of federal funding was allocated to health research.  This was prior to the establishment of the CIHR.  However, the proportion of health research funding provided by the federal government declined steadily from a high of 28% in 1992 to 16% in 1998.  Since 1994, the pharmaceutical industry has been the leading source of funds for health research.  The federal government believes that its position in terms of health research funding will greatly improve as a result of the establishment of the CIHR along with additional investment announced in both the February 2000 budget and the October 2000 Economic Statement and Budget Update.  The federal government also provided an additional grant of $140 million in February 2001 to Genome Canada bringing their total budget to $300M.

The whole health research community welcomed the new infusion of federal funds.  For example, Dr. Barry D. McLennan, Chair of the Coalition for Biomedical and Health Research (CBHR), stated:

The [federal government] has done its part recently. During the past few years, it has created a modern, new health research funding agency, introduced a broad range of new funding programs for health researchers, announced funding for infrastructure support to ensure that research facilities are conducive to innovation and developed policies that will attract world class research and researchers in Canada.  These initiatives deserve praise for far-sightedness and for the important momentum that they have created with the health research community in Canada.[184]

The Committee was told that, while the increase in federal funding represents significant support for health research, it does not bring Canada to a favourable position worldwide.  In 1997, Canada devoted only 1% of its total health care spending to health research and ranked 6th behind the United Kingdom (6.5%), France (3.7%), Japan (2.4%), the United States (1.7) and Australia (1.4%).  The same year, Canada ranked 5th among 8 OECD countries in terms of overall spending on health research expressed in PPP per capita.[185]  Furthermore, the role of the central government in financing health research, expressed in PPP per capita, was far more important in the United States, the United Kingdom, France and Australia than in Canada.  For example, the American government provided four times more funding per capita to health research than did the Canadian government.  This was prior to the establishment of the CIHR.

Witnesses unanimously recommended that the federal government’s share of total spending on health research should be increased to 1% of total health care spending from its current level of approximately 0.5%.  In their view, this would bring the level of the federal contribution to health research more in line with that of central governments in other countries.  According to Dr. Alan Bernstein, President of the CIHR, such federal investment is essential to maintain a vibrant, innovative and leading-edge health research enterprise:

Text Box: However, despite the significant research funding increases represented by the 1999 budget commitment, Canada does not compare favourably with its major competitors in terms of the amounts government-sponsored agencies dedicate to health research.  In many ways, Canada is simply playing catch-up with the United Kingdom, France and the United States, which have increased funding to health research between 30% and 50% during the past decade.  Canada’s cumulative increase, even taking into account the CIHR commitment, was slightly more than 10% during the same period.  In this fiscal year, the U.S. National Institutes of Health has received five times the funding enjoyed by the formed Medical Research Council (MRC) on a per capita basis.  Even after the CIHR commitment is fully realized in 2002, it is estimated that the U.S. will be providing as much as four times the funding per capita than will Canada.

Murray Elston, President, Rx&D, Brief, p. 7.

(…) health care is Canada’s largest knowledge-based industry. If I were a CEO of Health Canada Inc. and said that we are going to double our spending to 1 per cent of our total budget on research, you would fire me if you were on the board. You would say that 1 per cent is ridiculously low for a knowledge-based industry. Despite Nortel’s problems, Nortel and all the high-tech companies down the road here in Ottawa spend between 20 per cent and 40 per cent of their revenues on research. How else can they be at the leading edge?[186]

 

7.2     Genetics and Genomics

Witnesses told the Committee that health research in Canada and throughout the world is currently undergoing a scientific revolution.  They explained that this revolution in health research is fuelled by the ongoing advances in genetics and genomics (see Table 7.3 for some definitions).

In the view of witnesses, the revolution in health research can be seen as a significant driver of change in Canada’s health care system.  For example:

Text Box: Ten to 20 years from now, our health care system will undoubtedly be vastly different than it is today. These profound tectonic shifts will be largely driven by science. The health care sector is truly Canada's largest knowledge-based industry, and to contribute to this global health revolution for the health and wealth of all Canadians our country needs a robust, innovative and evidence-based health care system. We require a culture that can respond to change, that can innovate and originate change, a culture that recognizes and awards excellence and evidence-based decision making.

Dr. Alan Bernstein,CIHR (9:10)

·        Genetic research offers a new capability to predict, decades in advance, who is susceptible to a given disease.  This new capability is based on the identification of the gene(s) that cause or predispose an individual to certain diseases.  Dr. Bernstein told the Committee that we already have this capability now for about 5-10% of all breast and colon cancers, Alzheimer’s Disease, and other less common diseases.  Because early diagnosis can often lead to better health outcomes at lower cost, experts in health research predict that the next 10-20 years will be marked by a significant shift in health care delivery from disease treatment to prevention strategies.  

TABLE 7.3: BASIC GENETIC LEXICON

Human Cells

All living organisms are composed of one or more cells. They are the individual units from which tissues of the body are formed.  The human body is composed of some 100 trillion cells.

DNA

Abbreviation for “deoxyribonucleic acid,” the chemical building blocks of which genes are constructed.

Chromosome

Discrete unit of the genome that carries many genes and consists of histone proteins and a very long molecule of DNA that is tightly coiled.  Human cells (except the reproductive and red blood cells) carry 23 pairs of chromosomes, one chromosome of each pair having originated from either genetic parent.

Genes

The unit of hereditary material, which is the physical basis for the transmission of the characteristics of living organisms from one generation to another.  Genes are made of DNA and occupy a specific place on a chromosome. 

Genome

The entire hereditary or genetic material contained in a cell, including both the nuclear and mitochondrial DNA.  The human genome project involves research and development activities aimed at mapping and sequencing the entire human genome.

Stem Cells

The primitive undifferentiated cells that have the potential to differentiate into any cell type.  Stem cells have been identified in embryonic, foetal, child and adult sources but embryonic stem cells are believed to have the greatest potential in terms of differentiating into virtually any cell or tissue type.

Genetics

Genetics is the study of traits (genes) that are passed on from parents to offspring and the variation of those traits in individuals.

Genomics

The study of genes and their role in an organism’s structure, growth, health and disease.  Genomics is distinct from genetics in that it acknowledges that rarely is the manifestation of a disease dependent solely on the presence of a single gene.  More often disease will involve multiple genes, compounded perhaps by the absence of another, and influenced by seemingly random environmental factors that are difficult to define.

Biotechnology

The means of manipulating other organisms to provide desirable products for human use.  Biotechnology in the field of health and health care is used for disease surveillance, diagnosis, treatment and prevention. It permits the identification of disease agents where conventional means do not succeed, allows better tracking of pathogens, facilitates earlier detection of disease and provides therapeutic products and processes. Biotechnology is also used as a product base in the health industrial sector, and as an enabling technology in health sciences.

Source: Library of Parliament.  Adapted from the National Human Genome Research Institute, National Institute of Health (US), Genetics – The Future of Medicine (www.nhgri.nih.gov); Industry Canada, The Biotechnology Gateway (http://strategis.ic.gc.ca/SSG/bo01376e.html), and Kimball R. Nill, Glossary of Biotechnology Terms, (http://biotechterms.org).

·        New insights into the molecular mechanisms that underlie most illnesses will enhance our understanding of the basic biology of disease.  This will change how disease is diagnosed and how it can be treated.  It will also change how drugs are designed.  An entirely new generation of drugs, which is likely to be more effective, with fewer side-effects but more expensive, will be designed according to the molecular pathology of disease.  These changes will have a significant impact on Canada’s health care system.

Text Box: We know already that early diagnosis provides a better and cheaper therapy than anything after-the-fact. If genomics research can help us identify the conditions to which we are most susceptible, then it will be possible to take preventative measures early in the process.  As a result, during the coming decades, it is likely that disease management will shift from treatment of contracted conditions to prevention strategies. 

Dr. McLennan, Brief, p. 4.

·        Genetic research will change the focus of the practice of medicine from a generalized to a highly targeted, individualized approach.  Currently, clinical practice guidelines and provincial drug formularies are developed on the basis of disease uniformity.  With advances in health research, however, we will move towards tailored care, based on patient variability.

·        Stem cell technology is another good example of the potential impact health research can have on health and health care. Currently the research community is very enthusiastic about the potential of stem cells, particularly embryonic stem cells.  It is anticipated that research on these cells will lead to treatments for serious diseases such as Parkinson’s and Alzheimer’s.  It is also widely believed that these cells can ultimately be manipulated to grow into virtually any tissue or organ thus providing much needed organs for transplant.  Recent research has been successful in ‘re-programming’ undifferentiated stem cells into producing insulin.  This is a function only performed by pancreatic islet cells.  Should this treatment prove to be successful in the treatment of diabetes (a cure really) it will not only improve the quality of life for the individual, but will save the cost of care for the primary disease and its secondary complications as well.  The federal government has unveiled, under its Proposals for Legislation Governing Assisted Human Reproduction, draft legislation that would allow for embryo research, including stem cell research.  The proposals, which include regulation of such research, is currently under review by the House of Commons Standing Committee on Health.

The genetics and genomics revolution is raising ethical, legal and social issues.  As Dr. Bernstein clearly pointed out:

The ability to predict disease, decades in advance, has profound implications for how we view our lives and make life decisions.  How will this new genetic information affect our decisions about whether to have children – and what should we tell them?  What should they tell us?  Do our employers and insurance agents have the right to access our genetic information?[187]

In the same vein, Ms. Elmslie noted:

We are seeing rapid advances in science and technology. They are very exciting. However, we cannot forget the social and ethical issues that they raise for us as a society and as a population. Research that moves us forward, for instance, in genetics and genomics, needs to be accompanied by a vigorous research agenda in the ethical and social aspects and implications of that research. The purpose of the agenda is not in any way to prevent bringing the benefits of that research to the population. Its purpose is to understand the impacts on what we value as a society and what we need to do to put the pieces together in a way that Canadians can understand and make informed choices concerning the options that become available to them.[188]

With respect to stem cells, the CBHR stressed in its brief the need to protect basic human rights and guard against long-term damage to life and the environment.  The Coalition suggested that a national oversight body should be established to provide ethical review of all publicly and privately funded research using human embryo or foetal tissue, including embryonic stem cell  research.  Full ethical review should include review by both the local research ethics board and the national oversight body.

 

7.3     Benefits and Challenges of Health Research

The benefits of health research are significant.  Health research leads to improved drug therapy and diagnosis, enhanced prevention, and targeted treatment.  Health research fosters the creation of knowledge-based employment and it contributes to stemming the brain drain.  The Committee heard that it improves the personal and economic health of Canadians:

Health research provides enormous economic, social and health care rewards to society.  The jobs that are created by these investments are high quality, well-paying, knowledge-based positions that generate worldwide recognition for Canadians.  These investments also support the rejuvenation of academic institutions across the country.  They help train new health professionals in the latest technologies and techniques and they provide important support for the health care delivery system in Canada.  Most importantly, the results of these activities lead directly to better ways to treat patients, which ensures a healthier and more productive population.[189]

Dr. Pat Armstrong from the Centre for Excellence in Women’s Health told the Committee that health research is important not only to discover new treatments and drug therapies; it is also essential to chart the future of the Canadian health care system and the impact of changes on women, men and children in their different physical, economic, social and cultural locations across the country.  In her view, sex and gender differences should be taken into account in health research.[190]  Failure to do so makes health research partial at best and greatly incomplete at most:

For example, it has become increasingly clear that some forms of medical intervention in the natural events of women’s lives, such as pregnancy, childbirth and menopause, are costly and unnecessary.  Other significant issues, such as the extent and impact of violence and stress on women’s health, have been overlooked or ignored.

Women are often under-represented in clinical trials of new medical treatments and drugs. This can be true even when the product or therapy under review is intended to treat ailments like heart disease – the number one killer of Canadian women. New therapies are often approved without a clear understanding of how they will affect women and men differently.[191]

Ms. Elmslie told the Committee that: “Research is a critical element and important tool, but the tool is only as good as the use we make of it.  Without investing in the transfer [of knowledge] (…), we are really missing the opportunity to be able to see positive outcomes in the health of the population.”[192]  The outcomes of health research must be made available to policy-makers, health care providers as well as to the public.

Dr. Bernstein told the Committee that the CIHR will be developing a multi-faceted “knowledge translation” initiative.  He explained that a website called “Research Net” will be available for the use of all Canadians, be they researchers, health care providers, consumers, etc.  The site will contain information for everyone, from students in grade 6 doing a science project on health, to health professionals learning the very latest in the field, to researchers who want to know how to apply for funding, to policy-makers across the country who are interested in the latest evidence-based decision-making issues with which they must deal.  It is expected to be ready in late 2002.

One organization, the Canadian Health Services Research Foundation (CHSRF), is dedicated to knowledge transfer.  The CHSRF is a not-for-profit organization established with federal funding whose mission is to sponsor and promote applied research on the health care system to enhance its quality and relevance, and to facilitate its use in evidence-based decision-making by policy-makers and health care managers.  Similarly, CIHI is another entity that brings data into the decision-making process.

With respect to the lack of information to the general public, Murray J. Elston, President of Canada’s Research-Based Pharmaceutical Companies (Rx&D), told the Committee:

The issue of public awareness and public education is also very important.  This is an area of which the public is well-aware, but not necessarily well-informed.  Today concerns about genetic research in medicine, animal cloning, embryo research and genetically modified foods are mixed in the public consciousness.  It is vital that the level of public understanding is increased, so that the role of genetics in medical research is separated from the sensationalism of the newspaper headlines.[193]

Another major challenge in health research is the low level of training capacity.  The Committee heard that academic health centres are currently under-funded and unable to respond to the challenges of contributing to Canada’s success in developing a globally competitive health research sector.  There is also great regional disparity in terms of health research capacity.  For example, certain medical faculties and academic health centres in the Atlantic Provinces and in the Prairies lack the capacity to sustain and nurture growth.  Dr. McLennan told the Committee:

Given the paucity of well-trained and talented clinical faculty in many specialities across the country, those provinces with healthy budgets are able to offer salaries and resources that attract away these critical faculty from the under funded centres.  The less-well resourced provinces then face a double jeopardy – the inability to recruit replacement faculty and the added stress and workload that fall upon those who are left behind.  This scenario curtails teaching and research time, which eventually entices the remaining group to look for better opportunities in more financially endowed centres.  This internal competition for talented people is counter-productive.  It is an urgent matter that requires rapid attention at the federal level.[194]

 

7.4     Committee Commentary

The Committee acknowledges that the federal government has, in recent years, contributed to the strengthening and better integration of the health research infrastructure.  In particular, the creation of the CIHR in April 2000 – a model unique in the world – is a key element in ensuring that Canada is at the leading edge of the knowledge-based economy.

The Committee also agrees with the witnesses that Canada needs a robust, integrated and proactive health research sector.  However, OECD data clearly show that Canada does not compare favourably with its major competitors in terms of public funding for health research.  The role of central governments in many countries in financing health research is far more important than it is in Canada.  It is imperative that the federal government addresses this concern.

Health research and innovation will be a major driver of change in Canada’s health care system in the coming years.  The knowledge gained as a result of health research translates directly into better diagnosis, treatment, cure and prevention of many diseases.  The federal government’s strategic investments in programs such as CFI, CHSRF, CIHR, Genome Canada and the Canada Research Chairs today will pay huge dividends for our health care system tomorrow.

We also agree that rapid advances in genetics and genomics will revolutionalize health care delivery in unprecedented ways.  This highlights the need for multi-disciplinary research that will examine the societal costs and benefits, the ethical considerations and potential unintended impact of advances in genetic and genomic research.

The Committee also concurs with the witnesses in regard to the transfer of knowledge generated by health research.  The dissemination of health research results should reach everyone – government officials and policy-makers, health care providers and the general public.  In our view, this will greatly enhance evidence-based decision-making with respect to health and health care to the benefit of all Canadians.


CHAPTER EIGHT:

Health-Related Information:
A Canadian Health Infostructure

Health and health care are, and have always been, two fields that rely intensively on information.  With the right information, a health care provider can order the right treatment, prescribe the most appropriate medication, or recommend the best preventive approach.  With the right information, an individual is better able to take good decisions with respect to his/her health and lifestyle.  With the right information, health care policy-makers and managers can decide on how to allocate financial, physical and human resources in the most cost-effective and efficient way.

Getting the right information, however, is not an easy task.  For example, the Committee was told that doctors would currently need to read 19 scientific articles a day,
365 day a year, just to keep abreast of progress in medicine.[195]  Obviously, it is almost impossible to keep pace with such overwhelming information.  Similarly, individuals and patients are faced with an abundance of health-related information, with an estimated 40,000 health websites accessible to the general public.[196]  It can be very difficult for them to discern between the good and the bad information.

Text Box: I believe that we do a wonderful job of creating data in the system, a mediocre job of turning it into information, a lousy job of turning it into knowledge, and an even worse job of sharing that knowledge.  It is not because people do not want to do it.  It is because people are so hard pressed by what they are doing that it is hard to step back and do broad-system thinking.

William J. Pascal, Director General, OHIH, Health Canada (12:6)

And yet, despite the volume of information available, there is still a lot that we do not know about health and health care.  According to witnesses, this is mainly because Canada’s health care system is not integrated: physicians and other health care providers, hospitals, laboratories and pharmacies all operate as independent entities, with limited linkages to allow for the sharing of information about patients.  While each entity holds a vast amount of current, relevant and valuable information on the health of individuals, such information is not standardized, it is stored in inconsistent means and, thus, it cannot be shared efficiently.  This lack of integration impedes the establishment of a direct relationship between the inputs we use in the health care system and the resulting outputs or outcomes.  This creates a significant barrier in evidence-based decision-making by both health care managers and policy-makers.

The Committee was told that the availability of, the accessibility to, and the sharing of the “right information” on health and health care could be greatly enhanced through the use of information and communications technology (ICT).  Many witnesses stressed that the health care sector is far behind other information-intensive sectors – such as the banking industry, insurance companies and the airlines – in terms of investing in ICT for collecting, managing and analysing data.  Dr. John S. Millar, Vice-President of Research and Analysis at the Canadian Institute for Health Information, described Canada’s health care system as a “cottage industry”:

Hospitals, agencies and providers have long been used to working (…) as “cottage industry,” looking after themselves and their own quality processes but not wanting to share that publicly. There has to be an increased stress on accountability and informing consumers who (…) are largely uninformed.[197]

In the same vein, David Cowperthwaite, Director of Information Systems at the New Brunswick Department of Health and Wellness, stated:

By any measure, private sector or public, we are far behind an appropriate level of investment in infostructure for health care.  We are behind government norms for good management compared to other programs, and we are certainly behind private sector norms for any information intensive industry.[198]

 8.1     Concepts and Definitions

The use of ICT in the field of health care is often referred to as “telehealth”.  The purpose of telehealth is twofold: to share health-related information among various health care providers and health care settings; and to deliver health services over large and small distances.  Telehealth applications can improve quality of care and enhance health care system management.

Text Box: What advanced information and communications technologies (ICTs) have to offer to the health sector is timely access to the most current information where it is needed, when it is needed for those who need it to take action.

William J. Pascal, OHIH,
Brief, p. 3.

Dr. Robert Filler, President of the Canadian Society of TeleHealth (CST), told the Committee that telehealth encompasses five broad applications: electronic health record; health information networks; telemedicine; tele-homecare; and distance continuing education and training.  Each of these applications is described briefly in Table 8.1.

The telehealth applications that are envisioned in Canada for the purpose of sharing the right information and integrating health care delivery include a system of EHR and an Internet-based health information system:

·        The foundation of an EHR is electronic patient records (EPR) which represent the results of a series of encounters between an individual and a health care provider.  EHR systems are composed of all lifelong EPR records for that individual incorporating data from all sources: health care providers (e.g., physicians, hospitals, community and home care), as well as support and feeder systems (e.g., pharmacies and laboratories).  An EHR system can make the data available to health care providers anywhere on a need-to-know basis by connecting interoperable databases that have adopted the required data and technical standards.

TABLE 8.1  

TELEHEALTH APPLICATIONS

Electronic Health Record (EHR)

The EHR is an automated provider-based system within an electronic network that provides complete patients’ health records in terms of visits to physicians, hospital stays, prescribed drugs, lab tests, and so on.

Health Information Networks

These networks refer to Internet-based health information with the purpose of empowering individuals to make informed choices about their own health and well-being, their health care system and health care policy.

Telemedicine

Telemedicine makes use of video conferencing equipment to provide health care at a distance.  The video conferencing, which uses a relatively high bandwidth, is live and interactive. A large bandwidth can simultaneously accommodate television, voice, data and many other services.

Tele-homecare

Tele-homecare uses ICT to deliver and manage health care at a patient’s residence from a health care facility.  This includes, for example, triage call centres and telemonitoring.

Distance Continuing Education and Training

Video conferencing equipment is also used for providing continuing education and training.  This is of particular interest to health care providers located in remote communities.

Source: Glossary of Terms, OHIH’s Website (http://www.hc-sc.gc.ca/ohih-bsi/menu_e.html) and Library of Parliament.

·        An Internet-based health information network is a system that empowers individuals to make informed choices about their own health and well-being, their health care and about health policy.  Health information to the general public could include for example: 1) general health information (health promotion and disease prevention); 2) information on treatment options and drugs, as well as on illness management (e.g. blood pressure, diabetes or obesity); 3) information on public health issues (e.g. quality of air, water and food); 4) information on the effects of health determinants; 5) health and health care policies at the federal, provincial and territorial levels as well as the policies in other countries; 6) data on health outcomes of public policies; 7) accountability data (such as report cards on the performance of the health services and providers).

Not only can telehealth applications improve the sharing of the right information, but they also offer the possibility to deliver care over large and small distances.  For example, “telemedicine” is used in Canada in the areas of teleconsultations, teleradiology, telepsychiatry, telepathology, teledermatology and telecardiology.  Similarly, tele-homecare allows individuals to obtain medical information 24 hours a day by calling a nurse call centre, which can advise them on whether their condition requires immediate medical attention.

Dr. Feller told the Committee that, while each of the main five telehealth applications stands as an individual component, they must act together to create the seamless technology system that will be able to deliver the right information at the right time and at the right place.  He stressed that the EHR is the central piece that ties all the components together.

 

8.2     Provincial and Federal Initiatives With Respect to a Pan-Canadian Health Infostructure

Telehealth is the foundation of what many people in Canada call the health information infrastructure or “health infostructure”[199]  Various components of a health infostructure are currently being implemented at all levels of government.  For example:

·        The provincial ministry of health in British Columbia operates HealthNet/BC, an electronic network that connects virtually all hospitals, health agencies and health authority offices across the province.

·        In Newfoundland, the government is currently launching Phase 1 of an eight-phase, five-year implementation EHR system that will enable exchange of information between the health boards, health care providers and the provincial ministry of health. 

·        In Saskatchewan, the Saskatchewan Health Information Network (SHIN) is linking all health care providers and health care settings across the province.

·        Nova Scotia has installed one of the most comprehensive and active telemedicine networks in Canada, reaching 42 health care facilities throughout the province. Approximately 53 videoconferencing systems provide for educational and medical consultations.  There are 36 teleradiology sending stations and 11 reading stations.

·        The health ministry in Quebec has implemented the Réseaux de telecommunications sociosanitaire (RTSS) which enables the secure exchange of clinical and administrative information between health care facilities.

·        The Alberta We//net is currently developing a telephone triage service, available 24 hours a day, seven days a week, that will give people advice about how best to treat minor ailments or where to seek appropriate treatment.

·        The federal government, through Health Canada, provides telemedicine services into 5 First Nations communities located in different provinces (British Columbia, Alberta, Saskatchewan, Manitoba and Quebec).

·        The Canadian Institute for Health Information (CIHI) - which was established in 1994 as a national, independent, not-for-profit organization - is doing a great job at collecting and analysing the currently available information on the health of Canadians and on the state of the Canadian health care system.

These initiatives are all at different stages of development.  Moreover, they are isolated within organizations, institutions and provinces and are considered as “a patchwork of unconnected projects, whose value would increase immensely if part of a coherent whole.”[200]  The key element is how to bring all those infostructures together.  It is a great challenge to integrate 14 jurisdictions (10 provinces, 3 territories and the federal government).  It is obviously an ambitious, costly and long-term undertaking which will take years to bring into being.  Most experts believe, however, that it is essential to do so if we wish to acquire sound information on the health of Canadians, the state of our health care system, and on the efficiency and effectiveness of health services delivery and distribution, and most importantly, if we want to improve the quality of health care Canadians receive, particularly if they live in rural or remote communities.[201]

Text Box: [Provincial and territorial] respective initiatives toward building health information systems constitute the base for a pan-Canadian health infostructure.  Each of them face the same issues and must find solutions to similar problems.  Their responsibility for the management and delivery of health services make them key actors on the scene of health information, but also confines them to looking at their own needs and delivery mechanisms.  Understandably, the need for inter-jurisdictional linkages is not at the forefront of their concerns.

William J. Pascal, OHIH,
 Brief, p. 6.

The federal government wants to champion the development of a Canadian Health Infostructure that it defines as “an integrated network of computer and communication networks that virtually connects physical infrastructure, health professionals, facilities, communities and patients to enhance health care delivery and the sharing of health-related knowledge for the better health of Canadians.”[202]  The envisioned Canadian Health Infostructure will not be a single massive structure, but a network of networks, building on the initiatives that are already in place or under development at the federal, provincial and territorial levels.

As Table 8.2 shows, many reports have recommended the development of a pan-Canadian health information infrastructure and have stressed the need for federal leadership and a cohesive national vision for the health infostructure.  The federal government has been making financial contributions to the Canadian Health Infostructure since 1997.  The Office of Health and the Information Highway (OHIH), established within Health Canada in the summer of 1997, is the focal point for all matters concerning the use of ICT in the field of health and health care.

 

TABLE 8.2: 

CANADIAN HEALTH INFOSTRUCTURE:  
CHRONOLOGY OF FEDERAL GOVERNMENT INITIATIVES

April
1994

The federal government mandated the Information Highway Advisory Council to investigate the development and use of the information highway for the economic, cultural and social advantage of all Canadians.

October
1994

The Prime Minister of Canada launched the National Forum on Health to advise the federal government on innovative ways to improve the health care system.

September
1995

The Information Highway Advisory Council released its report entitled Connection Community Content: The Challenge of the Information Highway. One of its 300 recommendations called for the creation of an advisory council to identify new information technology applications specifically for the health care sector.

February
1997

In its final report entitled Canada Health Action: Building on the Legacy, the National Forum on Health recommended that the federal Minister of Health take a leadership role in the development of a nationwide health information system. Such a system would serve as the foundation of an “evidence-based” health care system.

February
1997

The 1997 Budget provided $50 million over three years for a Canada Health Information System.

August
1997

The federal Minister of Health established the Advisory Council on Health Info-Structure to provide strategic advice on the development of a national strategy for a Canadian health info-structure.

August
1997

The federal government created the Office of Health and the Information Highway (OHIH) to assist in addressing new and evolving issues and develop a longer term strategy regarding the Canadian Health Info-structure. OHIH is now the federal government’s focal point for all health info-structure-related activities.

September
1997

The Canadian Network for the Advancement of Research, Industry and Education (now CANARIE Inc. – Canada’s Advanced Internet Development Organization) issued a paper entitled Towards a Canadian Health Iway: Vision, Opportunities and Future Steps.  This paper envisioned the Canadian Health Iway as “a virtual "information centre” open and accessible, yet confidential, system to assist decision-making by health professionals, patients, researchers and policy-makers.

February
1998

Health Canada sponsored a two-day National Conference on Health Infostructure to discuss impediments to the application of information management and information technology within Canada’s health care system. Participants stressed the need to develop a consensus regarding the vision of Canada’s Health Infostructure and called on Health Canada to play a leadership role in engaging all stakeholders.

March
1998

Health Canada launched the Health Infostructure Support Program (HISP). HISP was a shared-cost contribution program supporting pilot projects using new information technologies and applications in areas such as public health, health surveillance, Pharmacare, First Nations health, homecare and telehealth.

February
1999

The Advisory Council on Health Info-Structure released its final report, Canada Health Infoway: Paths to Better Health. It affirmed that setting up a nationwide health information highway could significantly improve the quality, accessibility and efficiency of health services across the entire spectrum of care in Canada. The Council’s four objectives include: developing a Canadian vision of a health information highway and identifying the essential needs it should meet; generating a federal action agenda to implement the most vital components of the system; suggesting collaborative mechanisms to achieve a Canadian consensus on an integrated health information system; and identifying issues, challenges and barriers to the effective use of information and communications technologies, and recommending possible solutions.

February
1999

The 1999 Budget provided $328 million to further develop health information systems in Canada (Canadian Health Network, National Health Surveillance Network, Federal Accountability Initiative, and a $95 million grant to CIHI) and $190 million for the First Nations Health Information System.

June
1999

The F/P/T Deputy Ministers of Health established an Advisory Committee on Health Info-structure with working groups to examine key issues regarding the development and implementation of the Canadian Health Infostructure.

October
1999

The F/P/T Deputy Ministers’ Advisory Committee on Health Infostructure released a strategic blueprint to identify the technology components required to achieve a cohesive national health infostructure.  Entitled National Health Technical Infostructure: Blueprint and Preliminary Tactical Plan, the report stressed that the Canadian Health Infostructure must be guided by the following set of values: strengthening Medicare, protecting personal health information, including all stakeholders, being based on collective and personal responsibility.

November
1999

The federal government launched three different initiatives: Canadian Health Network; National Health Surveillance Infostructure; First Nations Health Information System.

February
2000

The 2000 Budget provided $366 million over four years for health information and information technologies.

June
2000

Health Canada launched the Canada Health Infostructure Partnerships Program (CHIPP).  CHIPP is a two-year, $80 million, shared-cost incentive program aimed at supporting the implementation of innovative applications of ICT in health care (namely telehealth and electronic health records).  The deadline for applications for funding was 31 August 2000.

October
2000

The federal government enacted Bill C-45, the Canada Health Care, Early Childhood Development and Other Social Services Funding Act.  This Act provides $500 million in 2001-02 for the purpose of developing and supporting the adoption of Canada-wide information standards and compatible communications technologies for health care.

Source: Information on Health Canada’s website summarized by the Library of Parliament.

The provinces and territories also want to be involved in the development of the Canadian Health Infostructure.  On September 11, 2000, the First Ministers agreed to work together to: 1) strengthen a Canada-wide health infostructure to improve quality, access and timeliness of health care for Canadians; 2) develop an electronic health record system and enhance technologies such as telehealth over the next few years; 3) work collaboratively to develop common data standards to ensure compatibility of health information networks; 4) ensure stringent protection of privacy, confidentiality and security of personal health information; and 5) report regularly to Canadians on health status, health outcomes, and the performance of publicly funded health services.”[203]  In support of the agreement reached by First Ministers, the federal government committed $500 million to accelerate the adoption of modern information technologies to provide better health care.[204]  The Committee was told that this money will be invested in a not-for-profit organization, known as Canada Health Infoway Inc., which will work with provinces and territories to create the necessary common components of an EHR over the next three to five years.  This will be a major step towards the full integration of the health infostructures being developed.

Witnesses welcomed this collaboration between the federal government and the provinces and territories.  For example, David Cowperthwaite told the Committee:

We are currently enjoying a wave of collaboration between the federal government and the provinces and territories, as well as among the provinces and territories.  This cooperative attitude provides a significant opportunity to advance the development of the health infostructure in a more cost-effective manner than any of us could do individually.

This wave of cooperation has developed, in part, because of a genuine interest to do the best job we can with the resources available.  But there is another significant issue driving collaboration and that is a sense of desperation.  Our infostructure needs in provinces and territories are great, and the resources available to meet the needs are woefully insufficient.  The result is a willingness to collaborate, albeit a somewhat forced willingness.  This situation does provide a window of opportunity for change, and we must take advantage of it.[205]

The Committee agrees with the witnesses that the federal government has a definite role to play in the area of health-related information:

Considerable agreement exists among provinces and territories and other stakeholders that the federal government should foster collaboration in this area.  Indeed, without a federal effort to ensure compatibility among these health information initiatives, little exchange between jurisdictions would have happened, and expenditures by all orders of governments within their respective jurisdictions could be significantly less
productive. [206]

Federal investment should also help reduce the current disparities between provinces and territories in the field of health-related information.  However, the Committee was told that current federal programs may be encouraging more disparity.  For example, under CHIPP, federal funding requires matching funds from the applicant.  The relative needs for service improvements, or health service deficiencies in one region over another, were not considered in the project selection.  According to Cowperthwaite, those who had the money got more money, and those in great financial need did not have an opportunity to apply.  He pointed outthat, while the opportunity to change the design of CHIPP has passed, the federal government should ensure that the investment strategy of Canada Health Infoway Inc. should not be as it was in the CHIPP program.  Rather, it should place greater emphasis on projects in locations that have the greatest need, the willingness to act, and the commitment to implement system change.

 

8.3     Costs and Benefits

The implementation and deployment of the pan-Canadian Health Infostructure is a costly undertaking involving a vast array of patients, health care providers and institutions.  For example:

·        Over 800 hospitals across the country provide 132,000 in-patient beds;

·        Approximately 28,000 family doctors and 27,000 specialists provide care;

·        Approximately 228,000 registered nurses are working in the health care system.

Given the complexity of our health care system and the variety of stakeholders, it is difficult to evaluate the total costs associated with the deployment of a pan-Canadian Health Infostructure.  William J. Pascal suggested that between $6 and $10 billion would be needed to achieve full implementation:

(…) over a horizon of seven to eight years, based on some current expenditures related to implementation and operation of information systems in different settings, it is estimated that somewhere between six to ten billion dollars will be needed to achieve full implementation.  Decisions on such things as the rate of replacement of current systems used in the health care sector or the type of connections needed – low or broad bandwidth – and our success at pooling resources, or at least sharing best practices and successful applications, at the pan-Canadian level will determine the true level of investment needed.  But it is clear that this will not come at a small price for any of those involved, and we should not underestimate the task ahead.[207]

Nonetheless, there is a wide consensus that the benefits of a pan-Canadian Health Infostructure will be numerous.[208]

·        The health infostructure will enable effective medical care at patients’ homes and in remote rural areas. This will also improve accessibility of specialized care. Patients will be able to perform specialized tests at homes and transmit data from electronic sensors via telecommunication networks.  Post-surgical patients would wear wireless sensors, continuously transmitting physiological information to their physician’s office. This information would be continuously analyzed by a computer, which would alert a physician to significant deviations.  Using telehealth links with two-way audio and video capabilities, major medical centres will be connected with general practitioners and nurse practitioners in remote communities, assisting them in appropriate diagnosis and treatment of patients.

·        The quality of medical care will be improved dramatically by bringing reliable information to physicians, through national data on treatment outcomes and extended information on the effectiveness of previous treatment received by a patient. The patient file will provide medical professionals not only with descriptive information, but also with most of the previous X-rays, MRIs and detailed biochemical analyses. This information will prove to be life saving in emergencies, when survival, often determined by minutes, depends on availability of essential data (e.g., blood type or known allergies).

·        A pan-Canadian Health Infostructure based on the electronic transfer of health information between jurisdictions would result from a macroeconomic effect on the development of the information and communication industries, health care industries and educational institutions.

·        Many people work on contract and visit their client companies in different provinces. Many people travel. Ability to transfer health information would enable local physicians and nurses to access the visiting patient’s records on an as-needed basis.

·        Information exchange is the core of public health and epidemiology. It is crucial for the well-being of the population that reliable public health surveillance information be communicated among different countries, provinces and territories. Diseases do not abide by jurisdictions, nor should the information about them.

·        The ability to transfer health information between jurisdictions also holds vast potential for facilitating research by groups of biomedical scientists working in different parts of the country. The results of such research would benefit all people of Canada.

·        The Canadian federal government is a major provider and purchaser of health care services through its health care responsibilities for military personnel, public service, veterans, immigrants and First Nations.  Implementation of interoperable health records systems across the country could enable both the federal government and the local providers of health care to decrease expenditures through decreasing duplication of records and eliminating excessive paperwork.

·        Unrestricted flow of health information between jurisdictions, enhanced by unique identification of patients and providers, would enable fraud detection, and therefore save considerable costs.

·        The economic benefits of inter-jurisdictional transfer of health information could be realized mainly through the replacement of existing paper flow between the provinces and territories by electronic technology.  In addition, should provinces decide to jointly participate in the design and implementation of the pan-Canadian Health Infostructure, economy of scope could be realized.

·        In terms of technological benefits, federal/provincial/territorial collaboration in the development of the pan-Canadian Health Infostructure would facilitate diffusion of new technologies and result in comparable technological capacity for transmitting multimedia health information between jurisdictions. It would also contribute to the faster development of interoperability standards between federal/provincial/territorial information system platforms.

·        A pan-Canadian Health Infostructure could contribute to the elimination of sharp differences in social and health care infrastructures of rural and urban areas of different provinces and territories. Inter-jurisdictional transfers of health information could drastically improve access to health information by patients and health professionals.

·        A pan-Canadian Health Infostructure could facilitate the development of the virtual health care environment extending over provincial and territorial borders and enable true portability of health care. This environment would make possible the effective maintenance of virtual networks of health specialists across the country, thus resolving the issue of relative professional isolation in rural areas. This could have a positive effect on human resource issues in remote communities of different provinces and territories.

·        Sharing health and economic outcomes information across the country could enable continuous cost-effectiveness analysis and analysis of quality of life indicators on a national scale, thus facilitating the sharing of best practices.

·        Health care management issues posed by the increasing rate of change, demographic shifts, technological revolution, etc., are roughly the same across the country. The capacity to exchange hard data on organizational levels between similar facilities in different jurisdictions and discuss management issues and solutions would enhance the quality of health care management.

·        The information generated by the health infostructure would provide the basis for preparing regular reports on health outcomes, health care providers and on the performance of health services delivery.  This is very important as a tool to improve the health care system.

·        The development of the pan-Canadian health infostructure could consolidate and virtually integrate provincial and territorial health care systems into a new, more efficient and streamlined national health care system, without actually interfering with the management and delivery of services by provincial/territorial health care systems.

Overall, a pan-Canadian Health Infostructure that virtually connects physical infrastructure, health professionals, facilities, communities and patients will enhance health care delivery and the sharing of health-related knowledge for the better health of Canadians.  This will lead to a truly patient-oriented health care system:

(…) the return on investment will be tremendous for all stakeholders.  But the real winners will be Canadians, because they will gain better and easier access to continued quality health services, because they will profit from the knowledge that they will be able to acquire themselves, because they will gain improved understanding of how their health care system fares and meets their needs. [209]

 

8.4     Issues

According to witnesses, the implementation and full deployment of the pan-Canadian Health Infostructure faces three major barriers: the protection of personal information, legal and ethical issues, and the interoperability of the various systems.

The issue of privacy, confidentiality and security related to personal health information in the electronic world is certainly the most crucial one.  The privacy issue refers to the extent of authorized access to personal health information.  The subject of confidentiality is the extent of permissible distribution of available personal health information.  Security refers to the set of standards in and around information systems that protect access to the system and the information it contains. 

Protection of privacy in Canada is a shared responsibility between the federal and provincial/territorial governments.  Current legal protection of privacy represents a patchwork of various laws, policies, regulations and voluntary codes of practice.  The Committee was told that the first step is certainly to attempt to gain support for the harmonization of legislation and regulation across Canada that will protect the privacy of Canadians in matters of health.  Witnesses stressed that Canadians need to be assured that governments are taking all the necessary steps to implement stringent rules in these matters.  Already, a resolution for the harmonization of legislation is being examined by all jurisdictions and agreement is expected in the coming weeks.  At the technological level, it has been demonstrated that confidentiality and security of personal health data can be achieved currently at a level that is not achievable in a paper world.  The problems that we face right now concern mostly the architecture of the systems that would be put in place, and their governance from a pan-Canadian perspective.

Text Box: How can we as Governments expect the other stakeholders who hold the information to participate with us in building the EHR if we cannot demonstrate the ability to manage our own information well?  How can we expect an individual to grant us permission to share information through an EHR if we cannot show that we are competent and efficient managers of the data we currently hold?  Governments must lead by example in the effective management of information to demonstrate the value of an EHR and to draw the rest of the stakeholders into the EHR process.

David Cowperthwaite,
New Brunswick Department of Health and Wellness, Brief, p.3.

The Committee was concerned by the evident lack of progress among stakeholders with respect to Bill C-6, Personal Information Protection and Electronic Documents Act.  In November and December 1999, the Committee held hearings on this bill.  The hearings focused largely on concerns regarding the application of Part 1 of the bill to the collection, use and disclosure of personal information. The Committee was of the view that, while Part 1 may be adequate in setting minimum legal standards for protecting the personal information of Canadians in the commercial arena, the adequacy of these standards for the health care sector was open to question.  It amended the bill so that its application to personal health information be delayed for one year following the coming into force of the legislation.  The purpose of this amendment was to provide health care stakeholders with an opportunity to formulate legislative measures appropriate to the special nature of personal health information.  The amendment was accepted by the House of Commons, and the bill received Royal Assent on 13 April 2000.

When the Committee met on the issue of health-related information in May 2001, witnesses indicated that no consensus had been reached yet among them on the changes that are required to Bill C-6 to ensure the flow of data between health care stakeholders involved in the health infostructure.  The application of Bill C-6 to organizations involved in health information systems as well as in health research must be clarified in order that they may continue to provide critical information to improve the health of all Canadians.  It is the hope of the Committee that solutions will be found to this problem before the end of the one-year moratorium in December 2001.

Legal and ethical concerns relate mostly to the licensure, reimbursement and liability of health care providers in delivering services from a distance.  Clearly, there will need to be some form of incentive to foster the use of these new technologies in health care settings.  These technologies will bring changes in work processes that will need to be carefully monitored to ensure success, and supported by the necessary skills and knowledge training programs, whether in academic or work settings.

Another major obstacle, and not the least, is the issue of standardization which is at the heart of interoperability of the various health information systems.  When people refer to standards in the health infostructure domain, they refer as much to the technology, hardware and software, as to nomenclatures or to patient or provider identification.  Currently, none of those are fully compatible and readily interoperable across Canada.  The Committee was told that even within the same institution, information systems often cannot connect with each other to exchange data.  This situation can be multiplied over and over again across the country.  A lot of work remains to be done to ensure full compatibility at all levels from coast to coast.  A proposal is currently being developed for the Advisory Committee on Health Infostructure to improve the way in which standards related to health information are dealt with in Canada in order to harmonize standards used in the different jurisdictions, the federal government included.

Finally, the Committee was told that a balance is needed between development and deployment.  Witnesses indicated that many of the components needed for a pan-Canadian Health Infostructure exist today and we should start its deployment now:

Development without deployment creates expensive “white elephants” that do not deliver improvements to the health of Canadians. We will be far better served by limited systems that are fully implemented and used for everyday service delivery than to develop a technology showcase system that never makes it out to the real world.[210]

 

8.5     Committee Commentary

Overall, the use of telehealth applications in implementing the Canadian Health Infostructure can support and enable the development of a true patient-oriented health care system by providing the base for vertical and horizontal integration of services.  The health infostructure can help create the information pools that will facilitate evidence-based decision-making throughout the system by all the users, be they patients, health care providers, managers, researchers, or policy-makers.

The Committee agrees that to remain sustainable in the long term, the health care system must move from its current model of an array of disjointed entities to a fully integrated continuum of services that can be accessed by people at any of the points of service, whether at home, at a private clinic, at the hospital, etc., wherever they live in Canada.  Therefore, good health-related information and the need to ensure its accessibility for all those concerned with health and health care is key to the successful renewal of Canada’s health care system.  Many benefits will come simply by standardizing, connecting and sharing what we have. 

The Committee also believes that the federal government has a critical role to play in fostering collaboration, developing common standards, and encouraging the harmonization of legislation.  More importantly, the federal government must maintain its leadership role and provide a level of funding that can sustain the deployment of the Canadian Health Infostructure.


CHAPTER NINE:

Home Care

9.1     What is Home Care?

Home care is generally defined in terms of services provided to individuals in their homes.  Home care does not include care provided privately or publicly in a residential facility for long-term or continuing care purposes.  

Text Box: Home care is the program that plans in-home supports. It monitors and evaluates clients' needs, provides nursing services, helps with activities of daily living and provides homemaking or offers assistance to enable independent living. Home care programs work with other services, including community support services such as meals on wheels, day centres, respite care and volunteer services. Home care also works with acute care hospitals, palliative care and respite facilities, long-term care services, mental health services and independent living programs - all to assist the client in the home and community.

Nadine Henningsen, Executive Director, Canadian Home Care Association (14:7)

Home care services can extend along a continuum that incorporates medical interventions as well as societal supports.  It can also include assistance needed for family and volunteer caregivers.  Home care can thus encompass an array of health, social or educational services that enable an individual requiring support to live and participate in society outside an acute or long-term care setting.

However, there is no single, universal agreement about what services should be included in the definition.  Home care services can cover acute care such as intravenous therapy and dialysis, long-term care provided for individuals with progressive diseases such as Alzheimer’s or chronic physical or mental disabilities, end-of-life care for people with terminal conditions, or personal support services such as attendant services and technical aids.  Formal home care can include both health care and social support services such as monitoring, assessment, coordination, nursing, homemaking, nutritional counselling and meal preparation, occupational and physical therapies, pain control, emotional support and self-care instruction.

Home care can be provided by formal providers who are predominately nurses, therapists, homemakers, and personal support workers.  These formal providers can be part of a community organization or a quick response team.  They can provide care in person or via communication technology.  While these formal services have evolved steadily over the past three decades, informal home care provided by friends and family has a long history.  These informal providers - often mothers, wives and sisters - also need to be considered as recipients of home care programming to prevent the often costly crisis created by caregiver burnout.  In particular, there is an identified need for respite care offering two types of services: caregiver replacement and direct services to caregivers.

Witnesses saw home care as part of the continuum of care related to health and well-being.  They stressed the need to include it in considerations relating across the health and social spectrum of primary care, acute care, long-term residential care, end-of-life care, community support programs, and personal support.  They emphasized that effective home care contributes to lower long-term costs for the health care system through its three primary functions of:

·        substitution for services provided by institutions, either acute care hospitals, long-term care institutions or palliative care facilities;

·        maintenance enabling individuals to remain in their current environment; and

·        prevention through ongoing monitoring and assessment.

Focusing particularly on the health care system, the Canadian Home Care Association stressed that home care is not facility based and requires no major capital investment or overhead.  It does not depend on physicians for access.  It can go beyond physical health care to engage social supports for comprehensive client care.[211]

TABLE 9.1

BENEFITS OF HOME CARE

§         Enables the health care system as a whole to operate more cost-efficiently;

§         Reduces the pressure on acute care beds and emergency rooms by providing medical interventions in alternate settings and using hospital resources only when they are needed;

§         Reduces the demand for long-term beds by providing a viable choice for aging Canadians to maintain their independence and dignity in their own homes and community;

§         Helps support family caregivers and sustain their commitment.

Source: Nadine Henningsen (14:8).

 

9.2     Current Demand for Home Care

The 1998/99 National Population Health Survey provided some data relevant to the use of publicly funded home care.[212]  It found that publicly funded home care use increased with: age; disability; and diminished income.  Thus:

·        While less than 1 percent of adults under 65 years of age received care,
37 percent of thus over age 85 years did so. 

·        People needing help with activities of daily living were six times more likely to receive care than those who did not need this help.

·        People in the lowest two income brackets were much more likely to receive care than those in the highest income bracket.

Witnesses also identified various forces that reinforce the demand for further growth.  In their view, four key variables must be considered:

 

9.2.1   Hospital Bed Reductions

The current trend is towards shorter hospital stays, early discharge and the use of outpatient procedures; all of which places more reliance upon community services.  While home care is critical to sustaining a hospital system with fewer beds, it needs dedicated resources.  With the substantially reduced capacity within the acute care hospital sector in the 1990s, shorter periods of hospitalization became the norm and people were sent home to the community without the subsequent investment in the home care side of the provision of health care services.[213]  Concerns about “bed blocking” in acute care hospitals focused on situations where an acute episode of treatment was completed but inadequate home support services prevented discharge, leaving a person in an acute care bed at a phenomenal cost to the system.[214]  When the hospital sector downsized, there was no funding put in place for the transition to the community and no investment in the community.[215] 

9.2.2   Rapid Population Growth over 65 Years of Age

Available data indicates that while many seniors live at home, their home care use increases with age and disability.  Projections suggest that, where the percentage of the population aged 65 years and over reached 12.5 percent in 2000, by 2025, this population will have increased to over 21 percent of the general population.  Statistics Canada noted that in 1996, approximately 95 per cent of seniors aged 65 and over lived at home.[216]  According to the 1998/99 National Population Health Survey, about 400,000, or 12 percent of seniors received care through provincial home care programs.[217]  The highest use of home care occurred in the senior population aged 85 years and up at 37 percent, compared to 20 percent for the age group 80 to 84 years.[218]  The likelihood of a person having a disability increases with age and in 1991, 35 percent of people with disabilities were over age 65.[219]

 

9.2.3   Pressures on Informal Caregivers

The majority of informal caregivers are women who support their family members and who must often manage simultaneously responsibility for aging parents, for their own children and full-time paid work.[220]  More than three million Canadians - mostly women - provide unpaid care to ill family members in the home.[221]  A survey in Alberta indicated that, up to age 75, women were more likely than men to have provided health care support to a family member.[222]  More than 60 percent of family and friend caregivers for seniors were women.[223]  More women are being conscripted into unpaid health care work and do so without training and with few supports.[224]  The combination of pressures can lead to not only stress-related illness and loss of work time for the caregiver, but can also increase the risk of neglect and mistreatment of the care recipient.

 

9.2.4   Advances in Technology

Medical advances have increased life expectancy, decreased the length of hospital stays and resulted in more outpatient services.  Conditions that previously required hospitalization - e.g. pain control - can now be managed at home. Advances in treatment protocols and accessibility to high-tech equipment make palliative care in the home a real option for Canadians.[225]  Telehealth offers increased possibilities for diagnosis, monitoring, assessment, and maintenance.  With tele-homecare, care can be provided using video conferencing in people’s homes whereby data is received from the home and people are kept away from hospitals.[226]

 

9.3     Public and Private Spending

Witnesses suggested that public home care spending in Canada has grown from 1.2 percent of public health care expenditures in 1980-81 to approximately 4 percent in 1997-98.  This 4 percent of all public expenditures on health care devoted to home care amounted to about $2.1 billion per year.

Health Canada’s data on public home care expenditures show that such expenditures more than doubled from 1990-91 to 1997-98, with an average annual rate of increase of almost 11.0 percent (see Graph 9.1).  At the same time, public home care spending accounted for a small but increasing percentage of total public health care spending in Canada: 4.0 percent in 1997-1998, up from 2.3 percent at the beginning of the decade (1990-91).

Existing analysis of private home care costs is more limited.  For example, assessments of how much Canadians pay out-of-pocket for services and costs associated with care, drugs, equipment and supplies appear occasionally in newspapers.[227]  Thus, The Toronto Star (27 November 1999) reported on a cross-Canada survey that showed home care clients spending an average of $283 a week for in-home nursing care and other home support services such as personal care, bathing and meal preparation. This cost was estimated to cover about 25% of nursing services and 60% of home support services.  Shortly afterward, the Globe and Mail (6 December 1999) also found that home care clients incurred significant costs for post-acute nursing services at about $202 a week. General home care was estimated at $407 a month with another $138 for prescription drugs.

Witnesses emphasized that, while home care provision has increased in most provinces, spending on home care is still a small portion of the overall provincial health care budgets.  In addition, there are wide variations among the provinces and territories regarding the proportion of public spending on home care.  This leads to disparities in the provision and scope of services across the country with differences from province to province and from region to region.  Also, some noted that financial expenditure data may omit paraprofessionals who provide most of the care in the home.

Witnesses were especially concerned that many individuals who need home care services may do without them because they cannot afford the costs.  Dr. Taylor Alexander, President and CEO of the Canadian Association for Community Care, cited a Health Canada study indicating that “20 per cent of family caregivers reported that their loved ones did without services because they could not afford them.”[228]  Currently, most provinces have a system where individuals pay according to ability; however, the rules for what is established as a baseline for payment is different in every province.  Some noted that whereas some provincial governments support almost the full cost of home care, in other jurisdictions, people may be drained of their assets in order to receive the same care.

Evidence presented to the Committee provided specific data relevant to cost-effectiveness evaluations.  Preliminary results from a cost-effectiveness study of home care at the Centre of Aging at the University of Victoria indicated an average of $12,504 per year to provide lowest-level care for a client in a facility compared to $5,413 at home. For clients with the highest-level needs, requiring nursing coverage 24 hours a day, the average cost was $41,023 in an institution and $33,579 at home.[229]  The Manitoba Centre for Health Policy and Evaluation at the University of Manitoba provided an example suggesting that the average case cost of providing care in hospital would be $2,652 compared with the cost of $1,882 for providing home care as well as drug therapy.[230] A study on home care in Saskatchewan indicated that, while outcomes are the same, it cost $830 more overall to provide a patient with non-acute care in hospital than to discharge them home with alternate follow-up care.[231]

 

9.4     Future Actions

Witnesses strongly supported changes to the way that home care is currently organized, delivered and financed.  They were consistent in calling for actions related to national standards and human resources.  They did not, however, have a single perspective on the methods of financing home care, whether through public funds or private non-profit or for-profit organizations.  Most witnesses focussed attention on informal caregiver needs, while others touched on information, research, prescription drugs, and technology issues.  Several key areas for future action emerged during the Committee study.

TABLE 9.2

CHRONOLOGY OF RECENT FEDERAL INVOLVEMENT IN HOME CARE

Date and Activity

Outcomes

February 1997:

National Forum on Health

The National Forum report noted the shift toward non-institutionalized care with a resulting increase in home care and other community-based services. It called for increased data collection and assessment and for greater integration of home care with other health services.

February 1997:

Federal Budget

The federal government announced the Health Transition Fund (HTF) in its 1997 Federal Budget. This three-year $150 million fund supported innovations leading to a more integrated health care system. Home care was one of the priority areas included in national, provincial and territorial evaluation and pilot projects.

March 1998:

National Conference on Home Care

Conference participants emphasized the need for: common principles framing a national approach to home care; clear standards; and agreement on program scope and content of coverage.

February 1999:

National Roundtable on Home and Community Care

Consensus positions highlighted the development of common standards, information systems, integrated human resources, strong research, knowledge and dissemination, and technological innovations.

February 1999:

Federal Budget

The federal government allocated $1.4 billion over three years for health initiatives with relevance for home care.  These included: $50 million over three years to develop innovative approaches to home and community care and access to quality health services, particularly in rural communities; an enhanced First Nations and Inuit home care and community care program and a First Nations health information system; increased funding for health research; and improving information technology for health care delivery, system accountability and citizen access.

June 1999:

Working Group on Continuing Care of the F/P/T Advisory Committee on Health Services

The Working Group document, Provincial and Territorial Home Care Programs:
A Synthesis for Canada
provided analysis of home care programs by descriptive factors including: organization and governance, legislation, services and providers, eligibility, assessment and case management, coverage and co-payment charges, funding and utilization data.

March 2000:

National Advisory Council on Aging

NACA advised the Minister of Health that the federal government should act as a role model and leader in home care development. In its Position Paper on Home Care, NACA presented 15 recommendations to advance the development of home care.

September 2000:

First Ministers’ Meeting

First Ministers, in their Communiqué on Health, directed Health Ministers to report on home and community services as part of the larger commitment to measuring, tracking and reporting on the performance of health services and programs.

2000:

F/P/T Ministers Responsible for Social Services

The report titled In Unison 2000: Persons with Disabilities in Canada highlights the need for accessible, portable and individualized disability supports (human, technical, and other) in the home and community to facilitate the inclusion of the disabled.

Source: Parliamentary Research Branch, Library of Parliament.

 

9.4.1   National Standards

Discussion over national standards for home care referred to organization, service delivery and training.  The emphasis was on quality of care and equity in access.  Nadine Henningsen saw national standards as a way of ensuring “both an effective Canadian health care system and equitable treatment of Canadians in all parts of our country.” [232]  Dr. Taylor Alexander believed that “Canadians living in the so-called “have-not” provinces should not be further disadvantaged and put at risk if their province lacks the funds to provide home and community services that are comparable to more affluent jurisdictions.”[233]  Diane McLeod, Vice-President, Policy, Planning and Government Relations, at the Victoria Order of Nurses for Canada (VON) asserted that “without these standards, there is really no hope of having a unified health care program in the community sector.”[234]

Text Box: There are many kinds of national standards. There are, for example, the standards that have been developed by the Canadian Council on Health Services on accreditation for home care and long-term care. Long-term care facilities and home care programs across the country are being accredited Those standards relate primarily to program administration and organization of the program, et cetera.  There are standards with regard to training. Those standards are not in place across the country. There are no national training standards for home care workers. They will occur within individual provinces; each province is different. Some provinces financially support them; some do not. Sometimes home care certificate workers must pay for their own training out of their wages.

Dr. Taylor Alexander, President and CEO, Canadian Association for Community Care (14:17)

While witnesses were clear that services and training should be comparable across the country, they did not specify one way to achieve this goal.  With regard to national standards,
Dr. Taylor Alexander believed that standards developed around the provision of core services should weave together the principles from the Canada Health Act.[235]  He called for a federal/provincial/territorial agreement on a “core basket” of essential home and community care services to which the principles of the Canada Health Act would apply. These insured services would include paraprofessional home support, nursing, social work, physiotherapy, occupational therapy, palliative care, prescription drugs, respite and case management.  Nadine Henningsen stressed that while “the method by which these standards are incorporated into national legislation may be debated, the time for debate about the importance of the standards has passed.[236]

 

9.4.2   Human Resources

Witnesses saw a growing national crisis in the supply, distribution, recruitment and retention of staff in home and community care programs.  They argued that years of health care cuts, nursing layoffs, low wages, difficult working conditions, poor training and greater complexity of care have made the sector an increasingly unattractive work environment.  Their human resources concerns generally focused on training, compensation, work conditions, and retention for those involved in home care.  The issue of substitution or crossover among professionals and between professionals and paraprofessionals was also raised.

With regard to training, there was an emphasis on education and training as part of the standard curricula for all individuals connected to home care.  Without adequate numbers of trained staff, home care programs were unable to fulfil their mandates, thereby threatening the independence of clients and adding pressures on the acute care system.  Some witnesses noted that more time and investment would be needed in helping to teach physicians about the concept of home care and how to discuss it with their patients.  Others pointed out that training requirements depend on the policy of each province.

Text Box: Improved training and retention strategies are needed to counter the shortage of nurses, home support workers and therapists in some regions across Canada. While these personnel shortages are part of a larger picture of scarcity of health workers, they are often exacerbated in home care by lower wages and benefits than those paid to workers in hospital and care facilities. Both the wages and supply of community workers are a serious challenge. We must provide compensation that is competitive with care facilities and hospitals. Ongoing professional training must become a priority to ensure that the highest standards of care are maintained. We must continue to investigate the most effective working relationships with the health care team, including the primary care physician and other components of the health care system.

Nadine Henningsen, Executive Director,
Canadian Home Care Association (14:8)

For example, Ontario was noted for its stringent training program - a three-year program for a home support worker. In Nova Scotia, a training curriculum is currently being designed but is not instituted yet. In Saskatchewan, there is no training program for home support workers; it is managed by the service agency.  Another witness explored provincial differences related to the proportion of registered nurses to auxiliary nurses.  Régis Paradis, President, Ordre des infirmières et infirmiers auxiliaires du Québec, pointed out that, in Quebec, auxiliary nurses are almost absent from health care. However, in Ontario and the United States, where the proportion of registered nurses to auxiliary nurses is three to one, auxiliary nurses are heavily involved in home support services.[237]  According to this witness, if Quebec had the same proportion as Ontario, it would now have almost 4,500 more auxiliary nurses, which would lead to savings of approximately $50 million annually.

Deficiencies in wages and benefits for home care workers is another key issue.  In particular, the fact that they are paid lower wages than institutional providers was cited as one reason for shortages.  Dr. Taylor Alexander noted that, in Ontario, there are some circumstances where community nurses are being paid as much as 25 per cent less than their counterparts who work in institutions.

The home care sector is characterized by lower wages and benefits than provided by hospitals, especially for paraprofessionals who, in some provinces, earn roughly minimum wages.  It was also noted that virtually all of the paraprofessionals are female and that many are recent immigrants with low education who speak English as a second language. Many home care workers are subject to various forms of abuse in client’s homes.  Also, many provide service after hours without pay to assure that the clients receive the support that they need.

The wide disparities in wages and benefits across the country draw workers to areas of higher pay, thereby creating even worse shortages in areas with low wages, such as some Atlantic provinces.  Reference was made to work by Human Resources Development Canada and Health Canada on home care human resources.  Working with relevant organizations, this study will involve research and analysis of the issue of wage disparity for nurses and home support workers, workplace conditions for all staff who work in the community, as well as training needs for the community.[238]

Overall, witnesses called for close cooperation between the federal government and the provinces and territories in developing a national home and community care human resources strategy that will help ensure an adequate supply and distribution of appropriately trained home and community care workers across Canada.  They saw the strategy including provisions to enable: the provinces to support the training and skill development, particularly of paraprofessionals; and agencies to offer adequate wages and benefits that will allow them to recruit and retain staff and prevent their loss to the institutional care sector or to other sectors.

 

9.4.3   Organization and Financing

Emerging evidence indicates that home care is more cost effective than care in acute care hospitals and that it presents a cost- effective alternative to premature use of long-term care facilities.[239]  In relation to long-term residential care, preliminary work found that savings of 50 percent could be obtained if home care replaced residential care for elderly clients who were stable in their type and level of care. The more unstable the client’s health, and the more he or she moved through increasing levels of care, the more home care costs approached, and ultimately exceeded, the costs of residential care.  Researchers also suggest that savings result from the way service delivery systems are structured in some parts of Canada and argue that policy-makers could consider mandating a “best practices” approach to organizing the home care delivery system.

Text Box: We cannot simply pour new health care resources into the same old silos in the same proportions. Health care renewal should aim for a sustainable health care system for all Canadians, no matter where their care is provided. Often home supports can be provided at fewer costs than new hospital beds. It is imperative that we build the basic infrastructure of home and community care so that services are accessible, properly managed and available. We must invest to increase the quality and quantity of home care services. We must also ensure that there is a capacity to support people of all ages with many different needs.

Nadine Henningsen, Executive Director
Canadian Home Care Association (14:9)

Palliative care or end-of-life care was mentioned as one area where home care could substitute for hospital beds.   End-of-life care is different from acute care and from long-term care but can involve both high and low intensity of care.  Witnesses noted the lack of studies on the costs of palliative care and were unsure about the merits of initiating a national home care program targeted only at people requiring end-of-life care.  They noted that provinces have often expressed concerns about targeted programs that intrude into their sphere and that most of the available data suggests that acute care substitution is the quickest and easiest way to see the value of home care, because you could compare it to the cost of keeping the patient in a hospital bed.[240]  

Text Box: About 225,000 persons die in Canada each year. In 1997, an Angus Reid poll found that about 80 per cent of Canadians prefer to die at home. However, this is often not possible because of the lack of home-based palliative care services. Such services vary across the country; rural and remote areas are particularly under serviced. Overall, only about 10 per cent of Canadians have access to palliative care services.

Dr Taylor Alexander, President and CEO
Canadian Association for Community Care (14:14)

Bonnie Pape from the Canadian Mental Health Association touched on home care in relation to mental illness and indicated that, in general, it is not working for mentally ill people.  She pointed out that: “People with mental illness often are not eligible for home care unless they have another primary diagnosis. When they do get home care, the services are often not appropriate to mental illness, which has very specific needs. That is tragic because we know from small pilot studies that home care can make a big difference in the lives of people with mental illness, particularly those with complex needs. Home care can even prevent the need for institutionalization.”[241]

One of the unsettled issues around both organization and financing concerned the appropriate place for the public sector and the private sector.  Currently, home care in Canada is provided through a mixture of public and private involvement.  Aside from the limited role of the federal government in home care for specific groups such First Nations and veterans, the budgets and public spending for home care are controlled primarily by provincial and territorial governments.

However, when it comes to delivery of services, both the public and private sectors have a role.  In the private sphere, service delivery can be through not-for-profit agencies such as the Victorian Order of Nurses and for-profit companies such as ComCare.  For most witnesses, the key concern was to eliminate financial barriers for people seeking care at a vulnerable time in their lives.  Several witnesses noted studies showing that when people are aware that they have to pay for care, they tend not to access that care.

Some witnesses noted that the private factor in home care is not divergent from the rest of the organization of health care. Dr. Taylor Alexander pointed out that “physicians in our country are virtually private practitioners paid by public funding. Hospitals are private institutions paid by public funding.”[242]  By extension, home care could be dealt with in the same manner as physicians and hospitals, as private services paid by public funding but with the four patient-oriented principles of the Canada Health Act applying.

For Nadine Henningsen, one of the key variables in the profit versus the not-for-profit debate around home care was that the case management function should be a government, publicly administered role.  According to her, home and community care is unique in its case management function and almost all jurisdictions now have single entry, standardized assessment and placement to home care services with ongoing case management.  She noted that, unlike hospitals, in the area of home care, the case managers are the drivers or the controllers while the service providers, whether equipment or personnel, follow a pre-established and controlled case management plan.[243]

Other witnesses had concerns about private for-profit provision of home care.  Kathleen Connors, President of the Canadian Federation of Nurses Unions observed that, in Manitoba, the government’s experiment with private-for-profit home care was a failure. They could not obtain bids that were more cost effective in the delivery of quality home care services and so they reverted to the publicly funded and publicly delivered system.[244] 

Witnesses generally felt that the federal government had a role, both in terms of research support to establish best practices and also with respect to an appropriate level of federal financial support.  In relation to best practices, they pointed to a model in Manitoba where the home care programs are permitted to spend for home care services up to the amount that it would cost to have someone in a long-term care institution.  On federal funding, they called for immediate allocation of funds targeted to home care by the provinces and territories with accountability for their appropriate allocation.

 

9.4.4   Informal Caregivers

Witnesses expressed concerns that the reduction in inpatient hospital services has increased the burden of care on families and friends.  This shifting of the care from the public to the formal and informal private sector is occurring at the same time that family size is diminishing and the older population is increasing. 

Text Box: We see over and over again, informal caregivers being pressured by the lack of services in the community and no support for them.  It is a critical situation that needs to be addressed for chronically ill, disabled or dying patients.

Diane McLeod, VON, (14:17)

The financial burden for family members and close friends who assume care of a person discharged from acute care or released into home palliative care can be high.  In the 1996 General Social Survey on social and community support, 86 percent of caregivers provided unpaid informal care.  Overall, about 15 percent indicated that their informal caregiver duties were taking an economic toll on them and their families.  Women aged 45 to 65 years were most likely to provide care.[245]   The National Advisory Committee on Aging, in its advisory role to the federal Minister of Health, recommended that the Canada Pension Plan and Employment Insurance be adjusted to accommodate individuals who leave the workforce temporarily to provide informal care.[246]

With the process of deinstitutionalization, both for acute care and with mental health, witnesses observed that the dollars did not follow the patients into the community but were used for other purposes.  As a result, individuals needing care turned to family members and close friends for support.  These informal caregivers in turn spend hours of their time as well as money arranging needed supports and services for the family member or friend shifted from the institution to the community.   According to the Roeher Institute - a national research organization focusing on public policy concerns of persons with intellectual and other disabilities - the time-consuming process of finding funding, working with several agencies, managing schedules for several therapists, and obtaining respite services can lead to serious physical and mental burnout for informal caregivers.[247]

The need to prevent physical and mental burnout of informal caregivers is an issue for all families caring for someone at home.  Witnesses argued that when home care is considered, the financial cost of respite programs for the unpaid caregiver must be part of health costs.  They advocated for low-cost interventions that included: information and advice, time for themselves, psychosocial support through self-help and other groups and advocacy on their behalf.

Witnesses called for the federal government to work closely with the provinces and territories in the development of a national respite strategy to give people time off from their care-giving so that they can recuperate and have a personal life and some recreation.  The strategy could include a wide variety of financial mechanisms to support caregivers such as the tax system, employment policies, employment insurance and pension systems as well as direct payments.

 

9.4.5   Information and Research

Witnesses pointed to the large number of unanswered questions in relation to home care and called for enhanced information systems and increased research.  Like other witnesses in the Committee study, those talking specifically about home care emphasized that more evidence is needed in order to make responsible decisions.  In their view, all aspects of care delivery need to be documented and evaluated including looking at who would be the best-qualified, trained and supported home care workers and whether the organization providing services is utilizing the “best practices” in all aspects from worker training to care delivery.

Text Box: There is little statistical information in the community sector to help in decision making critical to the effect of delivery of care. At the present time, we basically have a paper-based system. This not only causes enormous inefficiencies and extra cost but also, perhaps more importantly leads, to an inadequate capacity to assess quality of services. Unlike the institutional sector, governments across Canada have not made a significant investment in development of an information system for home care.

Diane MacLeod, VON (14:16)

Witnesses on health information generally pointed out that the area is currently hospital- and physician-dominated.  This was reiterated by witnesses on home care generally and those addressing mental health concerns.  It was noted that, although most mental disorders are treated in the community, rather than in hospital, data on mental illness come primarily from hospital data with a growing body of knowledge based on national health surveys.[248]

In relation to home care information systems, witnesses envisioned needs that included: a common assessment system oriented to client outcomes; a common service classification system; and a clinical information system to support multi-disciplinary teams.  Régis Paradis, from the Ordre des infirmières et infirmiers auxiliaires du Québec, stressed the need for uniform data collection after standardized surveillance:

(…) we need reliable and well-documented interprovincial data on the performance and effectiveness of the health care system, particularly as regards home support services. The Canadian Institute for Health Information is an example of what can be done. The work done by Human Resources Development Canada is also important as it provides an overall assessment of the problem of human resources in a given area.[249]

On home care research, witnesses advocated shifting research funding away from its current channel through established organizations such as hospitals and universities to targeted research funding for the community sector.  Research questions included broad ones about the role of government and the role of private for profit and private not-for-profit organizations; the role of family and friends and community; and more specific ones about the level of per capita spending on home care compared to hospitals and residential care and quantitative data about the effect of the change from CAP to CHST on home care.

For those closely involved in home care, little is known about ways that home care can be incorporated as part of hospital downsizing exercises or into primary care innovations.  They want to know the effectiveness and efficiency of offering incentives to physicians to collaborate with home care nurses and case managers, of developing professional and paraprofessional teams, of organizing physical, technical and human resources differently.  In particular, they want to develop common outcome-oriented assessments and common classification that will permit wider application of research results.

 

9.4.6   Prescription Drugs

For many witnesses, the impact on the home care sector of discharging sicker patients earlier into the community has significance for the drug costs as well as other costs that must be paid for by an in-home care patient.  As Dr. Taylor Alexander emphasized: “Home care, which was designed to support people not only in an acute phase but over a long period of time, is being required to shift increasing resources into what is called “acute care substitution.” In other words, it is like the hospital at home with all of the accompanying high-tech and high-cost resources.”[250]  Prescription drugs are among the high-cost resources that are covered by medicare while persons are in hospital, but not when they return home.

There is a fear that the lack of coverage for prescription drug costs can place the health of a person at risk, especially for those who cannot afford to buy all the drugs they require.  One at-risk group is the de-institutionalized mentally ill who may lack both financial and other resources for appropriate drug treatment at home.

In relation to palliative care, witnesses emphasized that one critical element of an effective palliative care is for the patient to be pain free.  Dr. Taylor Alexander referred to palliative care situations where there is a widespread lack of adequate pain management, often because patients and families simply cannot afford the drugs to control the pain. This tragic situation results in unnecessary suffering for persons who are ill.[251]

The Senate report on end-of-life care provided an overview of provincial responses to questions about the removal of financial barriers to community palliative care caused by the cost of drugs and other medical supplies.  It indicated that many provinces had already taken steps or were in the process of providing drugs to people designated as palliative by physicians or case management assessments.[252]

 

9.4.7   Telehealth

Technology in various telehealth applications is seen as vital to the home care discussion.  The ability to connect a patient’s in-home monitoring equipment to local health facilities over telephone lines is already a reality.  Other possibilities are close to realization. Various telehealth applications relevant to home care include: telemedicine involving medical consultations, diagnosis, rehabilitation for the home care patient from a distance; tele-education for information exchange between professionals and the home care patient; telemonitoring where patients undergoing hemodialysis, cardiac, oncological treatments can be monitored or elderly persons can be assisted at home; and tele-networking for linkages of home care patient records with pharmacies and laboratories.

Text Box: In about 10 years, you will have a communication device in your home. It will not be a television. It will be a flat screen TV, probably a plasma screen, on your wall. It will be voice-activated. You will talk to it. You will say, "Connect me to my doctor." It will dial automatically for you. You will have a discussion. You will have a slot to put your finger in; it will do a blood test and take your pulse. This technology exists now. This is not dreaming.

William Pascal, Office of Health and the Information Highway,  Health Canada (12:24)

Various provinces are trying different approaches to link home care and professionals.  Ontario and New Brunswick have recently established centres with 24-hour nurse call centres for people to phone for medical information and advice.  Health Canada has worked with Ontario to set up projects where a monitoring station within a hospital links nurses and physicians to home care health workers operating through community care access centres.[253]

As witnesses noted, the efficiencies of telehealth in relation to home care still need to be assessed.  Current cost analysis suggests that links to a person’s home can save money in several ways.  From the health professional’s perspective, one nurse could see many more people in their homes if the nurse was not required to drive long distances by car each day.  From the health care system perspective, information from the United States suggests that the management of children with asthma using computer systems in schools could result in a decrease in hospitalization and an improvement in wellness.  From the family perspective, it could save money on travel costs.  For example, the cost of transporting a child and the family from Thunder Bay to Toronto could be $1,300 per family.[254]

The Committee also heard that another benefit of telehealth in the home as well as elsewhere is that such technology can reduce language and literacy problems for people interacting with the health care system.  Dr. Thomas Ward of the F/P/T Advisory Committee on Health Human Resources pointed out that: “In the Maritimes we have a significant problem with literacy, particularly in the adult population. Most people leave school at a young age to work on the fishing boats or in the mines. That population can be maintained at home through the opportunity for some sort of interactive link through television sets. The technology is there such that someone at the other end - a face - can answer a question, and it does not require someone to sit down and read through some technical document.[255]

 

9.5     Committee Commentary

The Committee agrees with witnesses that the home care issues related to national standards, human resources, organizing and financing, informal caregivers, information and research, prescription drugs, and technology must be addressed quickly.  It favours increased public policy being given to home care and alternative care provision.  The mounting evidence of cost effectiveness in home care delivery is encouraging, as is the extensive participation by community organizations in articulating the needs of those members of the Canadian population who could most benefit from increased home care services.

The Committee also recognizes that while extensive discussion has ensued around the issue of home care as a substitute for acute care, insufficient attention has been given to home care as a substitution for services in long-term and residential facilities.  There is also a lack of data and research about home care in relation to palliative care and home care with respect to prevention of incapacity through social and other supports.

The Committee also acknowledges that the federal government currently has several avenues for influencing home care outcomes in Canada.[256]  To further the development of home care as a national program, the federal government could continue and expand its funding for direct home care programs and services for specific groups under its jurisdiction.  It could increase federal transfers under the CHST to assist provinces in developing home care programs in their respective jurisdictions or design a targeted program for specific aspects of home care.  It could offer additional financial assistance to home care consumers through tax credits and deductions.  It could collect and analyze home care data and increase research funding in the area.  It could promote telehealth projects in the area of home care.  It could enlarge the scope of the Canada Health Act so that necessary health care services are provided in care settings other than hospitals and physician’s offices  And finally, to accomplish all this, it could ensure that there is extensive federal, provincial and territorial consultation.


CHAPTER TEN:

Rural Health

Rural Canada occupies 9.5 million square kilometres, or about 95 percent of Canada’s territory.  Approximately nine million Canadians, or about 30 percent of the total population, live in rural and remote areas of the country.  Rural and remote areas in Canada embrace varied terrain and economic activities spanning resource, manufacturing and service industries.  Observations about rural Canada suggest some defining characteristics:

·        Rural Canada includes rural and remote communities as well as small towns outside major urban centres.

·        Rural populations that are more distanced from urban centres continue to decline, particularly as young people leave for educational and employment opportunities and as seniors leave to seek greater access to long-term care.

·        Rural populations in closer proximity to cities or in recreational areas are increasing.

·        Across Canada, more than half of the Aboriginal peoples (whether on reserves or in Inuit or Métis communities) live in rural areas.

·        Ontario and British Columbia have the lowest percentage of rural residents while the territories and Atlantic provinces have the highest.  Almost half of the population in Atlantic Canada live in rural areas.

·        Seniors, children and youth under the age of 20 are over-represented in rural regions of Canada.  More precisely, the 1996 Census shows that, compared with the national average, rural Canada has a higher percentage of children between the ages of 5 and 19, a lower percentage of males between 20 and 39 and females between 20 and 49, and a higher percentage of males over 55 and females between 60 and 69.

·        Rural areas have generally higher unemployment rates and lower formal education levels.

·        Rural people living in the Prairie provinces have a lower unemployment rate than do people living in Atlantic Canada.[257]

 

10.1   Health Status Indicators

A recent report, entitled Rural, Remote and Northern Health Research: The Quest for Equitable Health Status for All Canadians, points out that there is not a great deal of information available on the health of rural Canadians, although data on life expectancy, death rates and infant mortality rates give some broad indicators of health.  Overall, compared to urban areas, life expectancy in rural regions is shorter while death rates and infant mortality rates are higher.  In 1996, life expectancy for rural females was 80.82 years as opposed to 81.31 years for urban females. The comparable figures for rural and urban males were 74.67 years and 75.67 years, respectively.[258]

Text Box: There is a trend towards a progressive deterioration in health as one moves from an area bordering urban centres into the very remote hinterland.

Dr. Peter Hutten-Czapski, President, Society of Rural Physicians of Canada  (17:13)

Overall, the health status of rural and remote residents is lower than that of their urban counterparts.  Dr. Peter Hutten-Czapski, President of the Society of Rural Physicians of Canada, noted:

Health status decreases as one travels to more rural and remote regions. As an example, heart disease is common in northern Ontario.  Certain types of cancer are found among miners and farmers.  There are substantially higher rates of diabetes, respiratory and infectious diseases, as well as violence-related deaths, in some aboriginal communities. Combined, there is an increase in mortality in rural regions as evidenced by life span.

The lower life expectancies are not associated with just a few specific causes; rather, the mortality rates in these regions are higher for most causes of death. Consistent with other measures of the health of the population, there is an association with socio-economic factors: life expectancy decreases as the rate of unemployment increases and the level of education decreases.[259]

The health and health care needs of rural Canadians are different from those of Canadians living in urban areas.  As Health Canada’s Office of Rural Health pointed out:

Rural realities and health needs differ from those of urban areas.  These needs may be particular to the environment (e.g., the need for education on tractor roll-over prevention), changing demographics (e.g., an increase in the seniors’ population in some rural areas), a common health need present in a rural environment (e.g., the health status of First Nations’ communities), or the need for health concerns to be expressed in a ‘rurally sensitive’ way (e.g., obstetrical services that do not generate an excessive ‘travel burden’ on rural women). [260]

This statement highlights some of the particular populations in rural Canada that may have special needs based on factors such as age, gender, ethnicity, and occupation.  For example, various studies have shown that:

·        Seniors in Canada are over-represented in rural regions, as are children and youth under the age of 20.  There are particular issues for seniors needing assisted home care or long-term care and for children and youth with special medical needs or who are in abusive situations.

·        Farmers, fishers, foresters, and miners can face serious health hazards in their jobs.  In addition to accidents related to the increasingly complex machinery used in these occupations, there are hazardous exposures to chemicals, noise, long working hours, temperature extremes, infectious diseases, and stress.

·        While Aboriginal peoples face an array of health problems related to their socio-economic status, they also experience some of the cultural insensitivity experienced by new immigrants such as lack of services in their own language, health care personnel who are unaware of cultural practices, and problems associated with services designed for a mainstream population.[261]

 

10.2   Access to Health Services in Remote and Rural Areas

The accessibility criterion of the Canada Health Act requires that reasonable access to insured health services be provided to all Canadians on uniform terms and conditions and without financial or other barriers.  Dr. John Wootton, former Executive Director of the Office of Rural Health (now Special Advisor on Rural Health, Population and Public Health Branch, Health Canada) raised the problem of accessibility for rural residents, when he stated: “If there is two-tiered medicine in Canada, it’s not rich and poor, it’s urban versus rural.”[262]

Text Box: If there is two-tiered medicine in Canada, it’s not rich and poor, it’s urban versus rural.

Dr. John Wootton, quoted in Farm Family Health.

Canadians living in rural and remote areas are limited to a smaller range of health care providers when seeking care than are their urban counterparts.  Rural hospital closures and centralization of health services have had an impact on rural residents.  Rural physicians explained that, when the insured health services are not available from local providers in local health care facilities, rural residents must travel long distances and incur additional costs for transportation and other needs such as hotels.  This can also negatively affect their health:

We must understand that if rural people are forced to travel for care, some will not travel. If they do not travel, they cannot achieve the health outcomes of people who are able or willing to travel. Some will travel, but the delay caused by the travelling or the need to travel will be costly to them. Others will be subject to the hazards of transport or inclement weather. Collectively forcing people to travel long distances for health care, even to a centre of the highest standards, will adversely affect health outcomes.

This is a particular concern for women's health. Studies show that women do poorly if they must travel long distance to give birth. In Saskatchewan, it should be noted, the 1993 closure of 53 rural hospitals was followed by an increase in its perinatal mortality rate. We cannot say that these things are causal, but it is certainly concerning.[263]

The recruitment and retention of health care personnel including physicians, specialists, nurses, technicians, social workers, physiologists and nutritionists, in remote and rural areas of Canada have been ongoing concerns.  Access to physician services is a particular problem.  For example, Dr. Hutten-Czapski stated:

Text Box: Statistical modeling predicted a decrease of rural physicians from 5,531 in 1998 to 4,529 in 2021. The ratio of physicians per 1000 population will decrease from an already low 0.79 physicians per 1000 population in 1999 to 0.53 by 2021 (a 33% decrease).

Society of Rural Physicians of Canada, Brief, p. 1

Doctors are concentrated where the most healthy people in the country live, and the sickest populations have the least access to health care, so the gap between urban and rural grows.[264]

Physician shortages in rural and remote communities have been persistent and are expected to continue.  According to the Canadian Medical Association:

·        While approximately 30% of Canadians live in rural or remote areas, only 10% of Canadian physicians practise outside Census Metropolitan Areas or Census Agglomerations;

·        Of the approximately 5,700 rural physicians, 87% are family physicians;

·        While the majority of rural physicians (72%) graduate from Canadian medical schools, the number of Canadian graduates varies from region to region.  In Newfoundland, one-third of the rural physicians are Canadian graduates; in Saskatchewan, one-fifth of rural doctors have graduated from Canadian medical schools.  In Quebec, 95% of rural physicians have been trained in Canada.[265]

Text Box: (…) the rural physician currently is produced by accident and not by design.  In fact, the largest source of medical school that is more pertinent to rural Canada is the University of Johannesburg.  We have 1,500 physicians from South Africa in Saskatchewan.

Dr. Hutten-Czapski (17:29)

In the early 1990s, the federal and provincial/territorial Ministers of Health considered strategies for physician resource management and by the end of the decade were examining options for both physicians and nurses through the Federal/Provincial/Territorial Advisory Committee on Health Human Resources.  A discussion paper prepared for this Committee in 1999, entitled Improving Access to Needed Medical Services in Rural and Remote Canadian Communities: Recruitment and Retention Revisited (Barer and Stoddart, 1999), attributed the lack of access to physicians services in remote and rural areas compared to urban settings to “a fundamental mismatch between the needs of rural and remote communities … and the needs and choices of (and influences on) those who become physicians.”[266]  Barer and Stoddart also pointed out:

There are many communities across the country that are simply too small to support a general practitioner, or that are large enough to support one but too small to support two or three, let alone the full range of specialists found in large urban centres.  For their part, most Canadians who are accepted into the medical schools across the country have grown up in urban settings; the bulk of their medical training occurs in urban settings; that training takes place largely in tertiary hospitals which are only found in urban settings; much of the training is provided by physician-educators who work in urban settings; there are (given in per capita terms) more practice opportunities in urban settings; access to specialist colleagues and other complementary treatment and diagnostic resources are more plentiful in urban settings; hours of work are more likely to be ‘regular’ in urban settings and, in particular, call schedules are less onerous; and there are many more social, educational, recreational, employment and cultural opportunities for physicians and their families in urban settings.[267]

Experts suggest that, while policy approaches to dealing with physician shortages in rural and remote areas have been economic or financial, most of the determinants of practice location involve a complex mix of factors involving far more than financial considerations.[268]  Personal background, professional education and practice factors, personal considerations
(e.g., children’s education, recreation, spousal job opportunities) and community size and are also important influences in practice locations.  Financial considerations, however, are not as important as personal factors.  The physicians who moved for professional reasons also indicated that the presence of certain factors such as additional colleagues, locum tenens (physicians who temporarily carry on the practice for an absent colleague), opportunities for group practice, specialist services and alternative compensation would have influenced them to remain in rural practice.[269]

Unfortunately, there is very little data on registered nurses or other health care providers in similar settings.

A variety of measures have been proposed to help alleviate the shortage of physicians in under-serviced areas.  For example, these include:

·        Reserving undergraduate medical school places for qualified applicants willing to commit to rural area practice;

·        Revising admission criteria for medical schools to favour qualified rural applicants;

·        Enhancing rural area exposure in both undergraduate and post-MD training;

·        Developing new residency training programs designed explicitly to prepare specialists to serve as rural regional consultants; and

·        Introducing or increasing financial incentives to encourage choices of specialties in short rural supply.

Text Box: Many doctors do come to rural communities as a result of (…) incentive programs.  The problem is that doctors are not staying.

Dr. Peter Hutten-Czapski (17:13)

Provincial and territorial governments have used a number of incentive programs to attract physicians to practice in rural and remote areas.  Most of these are financial in nature, but some focus on working conditions, some seek to direct where physicians can establish practices, others recruit foreign medical graduates and others focus on attracting rural residents to attend medical school and providing rural exposure in the course of medical training.  Research demonstrates that a greater proportion of trainees from rural settings will return to rural areas because they are already comfortable with the rural culture.  As governments acknowledge that it may be easier to retain physicians in rural and remote areas if they have grown up there, programs to attract rural residents to become doctors are becoming more common.  One such program will be the creation of a rural medical school in northern Ontario – the “Thunder-Barrie Medical School”.  Rural physicians challenged the federal government to commit half of the funding for the establishment of rural medical schools in Canada.

Text Box: The failure to develop any pan-Canadian initiatives has meant a history of destructive competition rather than co-operation.

Barer, Woods and Schneider (1999)

Barer, Wood and Schneider (1999) also pointed out that while all provinces and territories face similar issues and problems in relation to the distribution of health services and personnel, there has not been a great deal of
cooperation among them in attempting to solve these problems.

William Tholl, Secretary General and CEO of the Canadian Medical Association (CMA), attributes this lack of success to the fact that these financial programs have little to do with the major factors involved in a physician’s decision to locate and stay in a rural or remote area – those that are non-financial in nature.[270]  Moreover, the lack of cooperation among the provinces suggests that the federal government could play a useful role in fostering inter-provincial collaboration.

It is important to note that Canada is not alone in experiencing problems in providing health services to rural and remote locations. Significant variations in the geographic supply of health services occur in virtually every industrialized country.  The United States, Australia and New Zealand, for example, are experiencing health care personnel distribution problems similar to those found in Canada.  Like Canada, these countries have adopted a number of policy approaches to deal with these problems.

 

10.3   Telehealth

Many experts see telehealth as an important vehicle for delivering health services to rural and remote areas.  Supporters of telehealth believe that it holds significant promise in this regard.  The Office of Health and the Information Highway at Health Canada is promoting telehealth as a way to offer fairer distribution of health resources and to connect patients and health care providers separated by geographic distance.  The Society of Rural Physicians of Canada sees both potential and risks in telehealth.  The potential lies in its ability to supplement the skills and abilities of existing rural health care workers to deal with problems that would otherwise require patients to travel out of the community to access needed care.  The risks, on the other hand, lie in its potential to divert resources away from the local community with the result that needed care can be accessed only from outside sources.[271]  

Text Box: Telehealth is a very positive step of providing health care to rural residents of our country. 

Dr. Judith Kulig, Consortium for Rural Health Research  (17:6)

10.4   Rural Health Research

Witnesses confirmed that many gaps exist in information on the health status of individuals and communities in rural Canada.  Similarly, there is not a substantial body of research on rural health issues.  In the view of witnesses, rural health issues tend to be eclipsed by those in urban areas.  Policy solutions often are based on experiences in urban areas and rely on urban data and research.  A position paper prepared for the Canadian Health Services Research Foundation and the Social Science and Humanities Research Council pointed out:

Because the health problems confronting rural Canada are serious, complex, interrelated and evolving, research should have a critical role to play in examining the nature of these problems, monitor their progress or deterioration, identifying their causes, finding solutions and evaluating the effectiveness of various interventions. However, to date, rural health research has not received substantial or sustained support from major health research granting agencies in Canada.  Generally speaking, within the health research community, rural health issues are either overlooked or dealt within a “generic” manner.  In “generic” studies, even when rural is mentioned, it is commonly used as a convenient comparison category to illustrate urban-rural differences.  Rural is rarely the focus of attention, yet findings and recommendations from urban-based research are often considered universally applicable or are extrapolated to rural settings.[272]

One of the weaknesses identified in rural health research is lack of coordination and planning.  A 1999 Rural Health Research Summit was held to develop a “Blueprint” for future action in rural health research.  Other initiatives such as the development of the Canadian Institutes of Health Research (CIHR), increases in health research budgets and the appointment of a special advisor on rural health to CIHR’s President have been important developments in rural health research.  In addition, a Rural Health Research Consortium was formed in 1999 to build capacity in research endeavours related to health in rural and remote areas.

 

10.5   The Federal Role

The federal government has responded to the concerns of rural Canadians in a number of ways.  For example, the Office of Rural Health was established in September 1998 to ensure that the views and concerns of rural Canadians are better reflected in national health policy and health care system renewal strategies.  In February 1999, the federal government announced funding of $50 million over three years (from 1999-00 to 2001-02) to support pilot projects under the “Innovations in Rural and Community Health Initiative.”

In June 2000, the federal government announced a National Strategy on Rural Health that it sees as an important milestone on the road to ensuring that all Canadians have reliable access to quality health care.  Then, in July 2001, the federal government announced the establishment of a Ministerial Advisory Committee on Rural Health to provide advice to the federal Minister of Health on how the federal government can improve the health of rural communities and individuals.

 

10.6   Committee Commentary

The Canadian health care system faces many challenges, some of the greatest of which are providing for the health care needs of those who live in rural and remote areas of the country.  We know that, generally, rural Canadians have: higher death rates; higher infant mortality rates; and shorter life expectancies than do urban Canadians. We also know that certain types of diseases and conditions are more prevalent in rural areas and among occupations associated with a rural environment.  But witnesses pointed out that little is known about the overall health status of rural Canadians.  Dr. Judith Kulig, Consortium for Rural Health Research, characterized the adequacy of information on the health status of rural residents as very poor.[273]  She attributed this to the limited number of individuals pursuing rural health topics and the limited number of dollars to support research in this field.

Providing equal access to health care is a challenge in rural and remote areas of Canada.  The Committee was told that systemic trends such as inadequate numbers of rural doctors and increasing centralization of medical services have the effect of impeding access.  The current medical education system is not geared to producing sufficient numbers of doctors who are interested in committing to rural practices; as well, provincial financial incentive programs to attract and retain rural physicians have not had high success rates.  Telehealth applications can help solve some of these problems, but they constitute only one part of the solution.

Witnesses emphasized the importance of federal, provincial, and territorial cooperation in developing national strategies to deal with rural health issues whether in the areas of planning, research, health human resources or reducing structural barriers to national rural health policy advancement.  They argued for a federal presence in areas such as funding, immigration, planning, evaluation, information-sharing and co-ordination, technology, facilitating consensus, promoting innovative solutions to rural health issues, and an expansion of the mandate of the Health Canada’s Office of Rural Health.[274]

The Committee hopes that the recently established Ministerial Advisory Committee on Rural Health will lead to concrete policies and programs that will effectively contribute to enhancing the health of rural Canadians.


CHAPTER ELEVEN:

Myths And Realities

As mentioned in the Phase One report, the debate about Canada’s health care system and its future has generated a great deal of confusion.  In this chapter, the Committee briefly analyzes a series of arguments in order to help separate myth from reality.  We hope that this information will contribute to an informed, fact-based debate on health and health care.

 

11.1   Demographic Aging

Myth: The single biggest increase in health care spending is attributable to the needs of older Canadians.

Reality: Persons over 65 consume, on average, more health services than those under 65.  However, the aging of the population is only one of the many factors – related to both supply and demand – contributing to increasing health care costs.  Other cost drivers include the use of new technology, the cost of new drugs, changing public expectations, and new and changing patterns of diseases.  These all have a significant influence on the cost of health care.

Canadians are living both longer and more healthily.  Therefore, the anticipated demographic impact of aging on the health care system needs to be revisited.  Moreover, while the costs associated with aging must be analyzed and managed, a more significant issue concerns the health care costs that are generally incurred during the last six months of life, regardless of age.  The cost of medical care that individuals receive skyrockets as they near the end of their life.  As a result, it is not the aging per se of the population which has an impact on health care costs, but rather the overall increase in the population.

 

11.2   Spending on Drugs

Myth:  Spending on drugs is increasing because of higher drug prices.

Reality:  A number of factors are responsible for increased spending on drugs such as increased utilization, a shift in prescribing patterns away for older less expensive drugs to newer costlier medications, and prices increases.  Using data from British Columbia, the Federal/Provincial/Territorial Task Force on Drug Utilization (see Chapter Two) found that that changes in prescription drug spending could be attributed to the following cost drivers:  increased utilization of existing drugs (50%), sales of new drugs in their first full year (32%) and price increases of existing drugs (18%).  Thus, increased utilization and a shift to newer drugs, not prices increases have been largely responsible for recent increases in spending on drugs.

Myth: Canadians in all parts of Canada have equal access to prescription drugs under provincial government Pharmacare plans.

Reality: There are significant regional variations in who is eligible for coverage and the reimbursement levels under government drug insurance plans.  Residents of Atlantic Canada do not fare as well as residents in other parts of Canada.  Also, substantial numbers of people have inadequate coverage or no coverage at all.  Part-time and low-income workers are particularly vulnerable because they often do not qualify for government plan coverage and do not have access to employee benefits plans with drug coverage.

Myth: Drugs prices are the same throughout Canada.

Reality: Drug prices vary from province to province.  The Federal/Provincial/Territorial Task Force on Pharmaceutical Prices reported significant differences in the manufacturers’ prices across Canada for the same drug products.  In 1993, prices in Ontario (the highest-price province) were 8.8% higher than the prices in British Columbia (the lowest-price province).  By 1997, the last year covered by the report, price differences had been reduced, with Nova Scotia (the highest-price province) having prices that were 5% higher than the lowest-price province, Manitoba.  The Task Force also found that if all provinces in the study had paid the lowest available prices for the same products in 1997,
$60 million would have been saved.

Despite various efforts to control prices, drug spending is expected to continue to escalate largely because of increased utilization and increased consumption of newer more expensive drugs.

 

11.3   Health Care Technology

Myth: All health care technologies currently used within the Canadian health care system have been evaluated in term of their safety, clinical efficacy and cost-effectiveness.

Reality: Unfortunately, this is not the case.  As mentioned in Chapter Three, Canada does not devote a great deal of money to health care technology assessment (HTA).  On a worldwide basis, Canada spends less on HTA activities than do other countries.  For example, all levels of government invest less than $8 million in Canada, whereas the United Kingdom provides some $100 million to its national HTA body – the National Institute for Clinical Excellence (NICE).  As a result, health care technologies are often introduced into the Canadian health care system with only superficial knowledge of their safety, effectiveness and cost.

 

11.4   Aboriginal Health

Myth: The federal government pays for the health services for all Aboriginal people in Canada.

Reality: Health care to Aboriginal Canadians is delivered through a complex array of federal, provincial and Aboriginal-run programs and services.  Métis and non-status Indians are not eligible for most federal health-related programs.  Health Canada provides services to First Nations (status Indians) and Inuit.  These include:

·        community-based health promotion and prevention programs to status Indians living on reserves and in Inuit communities;

·        non-insured health benefits (NIHB) to status Indians and Inuit peoples regardless of residence in Canada. (As explained in Chapter Five, the NIHB program provides a range of health-related services to eligible beneficiaries who are status Indians, recognized Inuit or Labrador Innu.  Benefits include drugs, medical supplies and equipment, dental care, vision care, medical transportation, provincial health care premiums, and crisis mental health counselling.);

·        primary care and emergency services in nearly 200 isolated and semi-isolated areas where no provincial services are available;

·        public health services in over 400 communities;

·        funding for addiction services through treatment centres and addiction treatment workers.

Myth: The Aboriginal population enjoys the same health status as other Canadians.

Reality: The life expectancy of Aboriginal peoples in Canada is at least five years below the average for all Canadians.  This is an enormous gap.  It has been estimated that increasing the life expectancy of the Aboriginal population by five years would require the elimination of all deaths from cardiovascular diseases (the leading cause) and almost all deaths from cancer (the second cause of death).  Although this would appear to be an insurmountable obstacle, the Committee was told that some progress is being made.

Although the discrepancies in the health status of the Aboriginal population are evident, the underlying causes are not easily identified.  Aboriginal Canadians are less likely to have finished high school, and are twice as likely to be under Statistics Canada’s low income cut-offs.  This could help explain some of the factors contributing to the Aboriginal population’s higher incidence of health problems.

Overall, a variety of determinants affect the health of Aboriginal Canadians.  Witnesses told the Committee that, because many federal departments are currently responsible for delivering a wide range of programs that can have an impact on Aboriginal health, the federal government is, therefore, well positioned to develop and implement population health strategy designed specifically for Aboriginal Canadians.

 

11.5   Human Resources in Health Care

Myth: Fee-for-service is the only model that physicians will accept.

Reality: Most physicians are currently paid under a fee-for-service scheme in Canada.  There is evidence, however, that many physicians would prefer an alternative mode of remuneration.  A 1999 survey by the Canadian Medical Association reported that only 33% of respondents would prefer to be paid on a fee-for-service basis.  Another 21% would prefer to be salaried, while less than 1% would select capitation.  Approxiamately 35% indicated a preference for a blend of payments (e.g. mix of fee-for-service and capitation).  Data from CIHI (2000) shows that, at present, the proportion of physicians remunerated by non fee-for-service mechanisms ranges from 2% in Alberta to 53% in Manitoba.

The fee-for-service scheme has some drawbacks.  First, fee-for-service actively discourages physicians from promoting teamwork, as their individual remuneration depends on the number of patients they see.  Second, fee-for-service encourages family physicians to refer as a matter of course many of the more complex cases to specialists because they have no incentive to spend more time with “difficult” cases.  Finally, fee-for-service reinforces the public’s perception of the current “hierarchy” within the health care system, and can only serve to accentuate demand on the part of individual patients to always consult the most “highly” qualified provider, regardless of whether or not they are the one best-suited to meeting the patient’s needs.

 

11.6   Health Information Systems

Myth: Canada’s health care system is structured like a 21st century service industry.

Reality: On the contrary, witnesses stressed that a major weakness in our current health care system is that it still operates as a “cottage industry”, despite the fact that the health care sector is an extremely information-intensive industry.  Indeed, the most important single ingredient in any diagnosis, treatment and prevention is information.  As mentioned in Chapter 8, the health care sector in Canada is not making use of information and communications technology to the same extent as do other information-intensive industries.  Moreover, the health care system is not integrated:  physicians and other health care providers, hospitals, laboratories and pharmacies all operate as independent entities with limited access to electronic linkages that would enable a better sharing of information.

Greater use of information and communications technology along with better integration of health care providers and institutions would facilitate the determination of causal relationships between the various inputs typical of the health care system and the resulting outputs or outcomes.  This would greatly improve evidence-based decision-making by health care providers, health care managers and health care policy-makers.  This would allow us to answer such questions as: Are we investing enough, too much, or too little in health care technology? Are there too many, too few, or just enough physicians, nurses, or other health care professionals? Are we getting our money’s worth?  Currently, we simply do not know the answers to these questions.

The Committee believes that many of the problems facing the health care sector can be successfully addressed only if the industry is prepared to transform itself into a
21st century service industry, rather than remaining mired in a 19th century structure and outlook.  In our view, the federal government could provide assistance to encourage this transformation.

 

11.7   Home Care

Myth: Home care is only for people who are old.

Reality: Although many home care services are aimed at the frail elderly, there are no upper or lower age or other limits for home care requirements.  Home care may be appropriate for people with minor health problems and disabilities as well as for those who are acutely ill requiring intensive and sophisticated services and equipment.  Services are available to children recovering from acute illness, adults with chronic diseases such as diabetes, persons with physical or mental disabilities, and individuals needing end-of-life care.

 

11.8   Rural Health

Myth:  The health and health care needs of rural Canadians are the same as those of Canadians living in urban settings.

Reality: Health Canada’s Office of Rural Health points out that rural health needs differ from those of urban areas.  These needs stem from the particular environment, such as the hazards associated with rural occupations including mining, fishing and farming; demographic trends such as an increase in the seniors’ population in some rural areas; and the common health needs associated with the presence of a significant number of Aboriginal communities.  In addition, there are more problems associated with delivering health services in rural and remote environments compared to an urban setting – distances are greater, the numbers of health care providers are smaller and specialist services may not be readily available.

Myth: The rural health issues faced by Canada are unique to this country.

Reality: Rural health issues tend to be similar throughout the world.  Significant variations in the geographic supply of health services occur in virtually every industrialized country.  The United States, Australia and New Zealand, for example, are experiencing health care personnel distribution problems similar to those found in Canada.


CONCLUSION

This report completes Phase Two of the Committee’s study on health care.  It summarizes the evidence we heard from March 2001 to June 2001, and makes reference to documents that were either tabled with the Committee or brought to the attention of the Members.

During Phase Two, the Committee learned a great deal about the major trends that are having an impact on the cost and the method of delivery of health services and the implications of these trends for future public policy and funding.  We have heard that issues with respect to demographic aging, the growing cost of new drugs and technologies, shortages of health care providers, the burden of illness, and the particular needs of rural Canadians and Aboriginal peoples all need to be addressed if Canada is to sustain its health care system.  The Committee now has a better understanding of how health research and the deployment of a pan-Canadian health info-structure can help improve both the quality of care and the effectiveness of health services delivery in the future.  We also understand that health and wellness promotion, disease prevention and population health strategies can contribute to curbing the costs of health care by enhancing the overall health status of Canadians.

With all this background information, we attempted, as in the Phase One report, to shed some light on the current debate over health care in Canada by separating myths from realities.  We hope that this report will serve as a useful reference document to anyone who wishes to participate in future phases of the Committee’s study on health care.


APPENDIX:

List of Witnesses (March – June 2001)

Wednesday, March 21, 2001  

Statistics Canada:  
Réjean Lachapelle, Director, Demography Division
Jean-Marie Berthelot, Manager, Health Analysis and Modeling Group, Social and Economic Studies Division
Brian Murphy, Senior Research Analyst, Socio-Economic Modeling Group

Canadian Institute of Actuaries:  
David Oakden, President
Rob Brown, Manager of Task Force on Health Care Financing
Daryl Leech, Chair, Committee on Health Care 

National Advisory Council on Aging:  
Dr. Michael Gordon, Member 

Conference Board of Canada:  
James G. Frank, Ph.D., Chief Economist and Vice-President
Glenn Brimacombe, Director of Health Program

 

Thursday, March 22, 2001

C.D. Howe Institute:  
William B.P. Robson, Vice-President and Director of Research 

McMaster University:  
Byron G. Spencer, Professor 

University of Ottawa:  
Dr. William Dalziel 

 

Wednesday, March 28, 2001

IMS Health Canada:  
Dr. Roger A. Korman, President 

Canadian Association of Pharmacists:  
Dr. Jeff Poston, Executive Director 

Health Promotion Research:  
Dr. Robert Coambs, President and CEO 

Health Canada:  
Barbara Ouellet, Director of Home Care and Pharmaceuticals, Health Care Directorate, Policy and Consultation Branch 

Thursday, March 29, 2001

Canadian Association of Radiologists:  
Dr. John Radomsky

 

Thursday, March 29, 2001 (cont’d)  

Canadian Coordinating Office for Health Technology Assessment (CCHOTA):  
Dr. Jill Sanders, President and CEO 

The Fraser Institute:  
Martin Zelder, Director of Health Policy Research 

As an individual:  
Professor David  Feeny

 

Wednesday, April 4, 2001

Health Canada:  
Dr. Christina Mills, Director General, Centre for Chronic Disease Prevention and Control – Population Public Health Branch
Dr. Paul Gully, Acting Director General, Centre for Infectious Disease Prevention and Control
Dr. Clarence Clottey, Acting Director, Diabetes Division, Bureau of Cardio-Respiratory Diseases and Diabetes, Centre for Chronic Disease prevention and Control
Nancy Garrard, Director, Division of Aging and Seniors 

Dalhousie University:  
Dr. David MacLean, Departmental Head, Community Health and Epidemiology 

 

Thursday, April 5, 2001

Health Canada:
Abby Hoffman, Director General, Health Care Directorate – Health Policy and Communications Branch
Cliff Halliwell, Director General, Applied Research & Analysis Directorate, Information, Analysis and Connectivity Branch
Nancy Garrard, Director, Division of Aging and Seniors

 

 

Thursday, April 26, 2001

Canadian Institute of Health Research:  
Dr. Alan Bernstein, President 

Health Canada:  
Kimberly Elmslie, Acting Executive Director, Health Research Secretariat 

Statistics Canada:  
T. Scott Murray, Director General, Institutions and Social Statistics Branch

 

Wednesday, May 9, 2001

Canada’s Research-Based Pharmaceutical Companies:  
Murray Elston, President 

Coalition for Biomedical and Health Research:  
Dr. Barry McLennan, Chairman
Charles Pitts, Executive Director 

Centre for Excellence for Women’s Health:  
Dr. Pat Armstrong

 

Wednesday, May 9, 2001 (cont’d)

Canadian Genetic Diseases Network:  
Dr. Ronald Worton, CEO & Scientific Director

 

Thursday, May 10, 2001  

Health Canada:  
William J. Pascal, Director General, Office of Health and Information Highway, Information, Analysis and Connectivity Branch

Canadian Institute for Health Information:
Dr. John S. Millar, Vice-President, Research and Analysis 

Canadian Society of Telehealth:  
Dr. Robert Filler, President 

Department of Health and Wellness of New Brunswick  
David Cowperthwaite, Director of Information System

 

Wednesday, May 16, 2001  

Canadian Medical Association:  
Dr. Peter Barrett, President 

Canadian Medical Forum Task Force 1:  
Dr. Hugh Scully, President 

Federal Provincial Territorial Advisory Committee on Health Human Resources:  
Dr. Thomas Ward, Chair 

Canadian Nurses Association:  
Sandra MacDonald-Remecz, Director of Policy, Regulation and Research

Canadian Federation of Nurses Unions:  
Kathleen Connors, President  

Ordre des infirmières et infirmiers auxiliaires du Québec:  
Régis Paradis, President 

Nurse Practitioners Association of Ontario:  
Linda Jones 

Canadian Radiation and Imaging Societies in Medicine (CRISM):  
Dr. Paul C. Johns, Past Chair 

The Canadian Chiropractic Association:  
Dr. Tim St. Dennis, President 

Canadian Society for Medical Laboratory Science:  
Kurt Davis, Executive Director

 

Thursday, May 17, 2001

Canadian Home Care Association (CHCA):  
Nadine Henningsen, Executive Director 

Canadian Association for Community Care (CACC):  
Dr. Taylor Alexander, President 

Victorian Order of Nurses for Canada (VON Canada):  
Diane McLeod, Vice-President, Policy, Planning and Government Relations, Central Region

 

Wednesday, May 30, 2001

Health Canada:  
Ian Potter, Assistant Deputy Minister, First Nations and Inuit Health Branch
Jerome Berthelette, Special Advisor, Office of the Special Advisor Aboriginal Health, First Nations Inuit Health Branch
Dr. Peter Cooney, Acting Director General, Non-Insured Health Benefits, First Nations and Inuit Health 

Indian and Northern Affairs Canada:  
Chantal Bernier, Assistant Deputy Minister, Socio-economic Development Policy and Programs
Terry Harrison, Director, Social Services and Justice 

Assembly of First Nations:  
Elaine Johnston, Director of Health 

Métis National Council:  
Gerald Morin, President 

Native Women’s Association of Canada:  
Michelle Audette, Interim Speaker and President of the Native Women Association of Quebec 

Congress of Aboriginal Peoples:  
Scott Clark, President, United Native Nations 

Inuit Tapirisat of Canada:  
Larry Gordon, Member ITC, Health Committee 

Pauktuutit Inuit Women’s Association:  
Veronica N. Dewar, President 

National Aboriginal Health Organization:  
Dr. Judith Bartlett, Chair
Richard Jock, Executive Director 

Canadian Institutes of Health Research:  
Dr. Jeff Reading, Scientific Director, Institute of Aboriginal People’s Health 

Wikwemikong Health Centre:  
Ron Wakegijig, Healer 

National Indian and Inuit Community Health Representatives Organization:  
Margaret Horn, Executive Director

 

Thursday, May 31, 2001

Health Canada:  
Dr. John Wooton, Special Advisor on Rural Health, Population and Public Health Branch 

Canadian Medical Association:  
William Tholl, Secretary General and Chief Executive Officer

Society of Rural Physicians of Canada:  
Dr. Peter-Hutten-Czapski, President 

Consortium for Rural Health Research:  
Dr. Judith Kulig 

 

Wednesday, June 6, 2001

University of Ottawa:  
Professor Martha Jackman, Faculty of Law

University of Calgary: (by videoconference)
Professor Sheilah Martin, Faculty of Law 

 

Thursday, June 7, 2001 (11:00 a.m.)

Health Canada:  
Nancy Garrard, Acting Director General, Centre for Healthy Human Development, Population and Public Health Branch
Tom Lips, Senior Policy Advisor for Mental Health, Population and Public Health Branch
Carl Lakaski, Senior Analyst, Mental Health, Health Human Resources Strategies Division, Health Policy and Communications Branch 

Canadian Psychological Association:  
Dr. John Service, Executive Director 

Canadian Alliance on Mental Illness and Mental Health:  
Phil Upshall, Coordinator

Canadian Mental Health Association:  
Bonnie Pape 

Department of Health and Wellness of New Brunswick:  
Ken Ross, Assistant Deputy Minister, Mental Health Services


[182] Kimberly Elmslie, Health Research Secretariat (Health Canada), Brief to the Committee, 26 April 2001, p. 1

[183] Sonya Norris, Nancy Miller-Chenier and Odette Madore, Federal Funding for Health Research, TIPS 56E, Parliamentary Research Branch, Library of Parliament, 11December, 2000.

[184] Dr. McLennan, The Improving Climate for Health Research in Canada, Brief to the Committee, 9 May 2001, p. 2.

[185] The conversion into purchasing power parity (PPP) per capita eliminates price disparities between countries and evaluates spending that is adjusted to population size.

[186] Dr. Alan Bernstein (9:17).

[187] Dr. Alan Bernstein, Brief to the Committee, p. 5.

[188] Kimberly Elmslie, Health Canada (9:24).

[189] Dr. McLennan, Brief to the Committee, p. 2.

[190] While sex refers to the biological differences between men and women, gender refers to the social or cultural roles and characteristics that define them. 

[191] Centre for Excellence in Women’s Health, Champions of Research Innovation, p. 2.

[192] Kimberly Elmslie (9:23).

[193] Murray J. Elston, The Implications of the Revolution in Genetics Research on Public Policy Development, Brief to the Committee, 9 May 2001, p. 4.

[194] McLennan, Brief to the Committee, pp. 8-9.

[195] William J. Pascal, Office of Health and the Information Highway (Health Canada), A Health Infostructure for Canada, Brief to the Committee, 10 May 2001, p. 1.

[196] Dr. Jill Sanders, CCOHTA (5:16).

[197] Dr. John S. Millar, CIHI (12:13).

[198] David Cowperthwaite, Director, Information Systems, New Brunswick Department of Health and Wellness,
A Provincial Perspective on Health Related Information, Brief to the Committee, 10 May 2001, p. 1.

[199] The concepts of “health infoway” or “health information highway” can also be used interchangeably.

[200] Report of the National Conference on Health Info-Structure, February 1998, p. 19.

[201] Michel Léger, The Canadian Health Infoway: A Vital Link to the Future, May 2000.

[202] Office of Health and the Information Highway (Health Canada), Virtual Integration for Better Health: from Concept to Reality, September 1998, p. 1.

[203] First Ministers Meeting, Communiqué on Health, News Release, 11 September 2000.

[204] First Ministers Meeting, Funding Commitment of the Government of Canada, News Release, 11 September 2000.

[205] David Cowperthwaite, Brief to the Committee, p. 1.

[206] William J. Pascal, OHIH, Brief to the Committee, p. 7.

[207] William J. Pascal, OHIH, Brief to the Committee, p. 8.

[208] OHIH (Health Canada), Virtual Integration for Better Health: from Concept to Reality, September 1998.

[209] William J. Pascal, OHIH, Brief to the Committee, pp. 8-9.

[210] David Cowperthwaite, Brief to the Committee, p. 4.

[211] Nadine Henningsen (14:8).

[212] Canadian Institute for Health Information, Health Care in Canada: A First Annual Report, Ottawa: 2000, p. 58.

[213] Kathleen Connors (13:70).

[214] Dr. Taylor Alexander (14:24).

[215] Dr. Thomas Ward (13:24).

[216] Jean-Marie Berthelot (2:10).

[217] Dr. Taylor Alexander (14:10).

[218] Canadian Institute for Health Information, Health Care in Canada: A First Annual Report, Ottawa: 2000, p. 58.

[219] Federal, Provincial and Territorial Ministers Responsible for Social Services, In Unison: Persons with Disabilities in Canada, Ottawa: 2000, p. 5.

[220] Nadine Hennigsen (14:8).

[221] Dr. Taylor Alexander (14:10).

[222] CIHI, Health Care in Canada 2001, Ottawa: 2001, p. 54.

[223] CIHI, Health Care in Canada, A First Annual Report, Ottawa: 2000, p. 60.

[224] Dr. Patricia Armstrong (11:22).

[225] Nadine Hennigsen (14:8).

[226] Dr. Robert Filler (12:15).

[227] Nancy Miller Chenier, Home Care: A Federal Perspective, Ottawa: Parliamentary Research Branch, Library of Parliament, TIP 77-E December 19, 2000.

[228] Dr. Taylor Alexander (14: 11).

[229] Centre of Aging, University of Victoria, “The National Evaluation of the Cost Effectiveness of Home Care”, Newsletter, 1(1), March 2000.

[230] Manitoba Centre for Health Policy and Evaluation, “A New Tool for Costing Health Care in Canada,” Cost List example comparing the cost of providing care in hospital with the cost of providing home care plus drug therapy, April 1999.

[231] Health Services Utilization and Research Commission, Hospital and Home Care Study, Summary Report No. 10, March 1998.

[232] Nadine Henningsen (14:8).

[233] Dr. Taylor Alexander (14:12).

[234] Diane McLeod (14:16).

[235] Dr. Taylor Alexander (14:12).

[236] Nadine Henningsen (14:8).

[237] Régis Paradis (13:52).

[238] See Canadian Home Care Human Resources Study website at www.homecarestudy.ca

[239] Hollander Analytic Services et al., The National Evaluation of the Cost Effectiveness of Home Care, ongoing studies, website: http://www.homecarestudy.com

[240] Dr. Alexander Taylor (14:32) and Nadine Hennigsen (14:33).

[241] Bonnie Pape (19:41).

[242] Dr. Taylor Alexander (14:20).

[243] Nadine Henningsen (14:20).

[244] Kathleen Connors (13:71).

[245] Kelly Cranswick, “Canada's Caregivers,” Canadian Social Trends, Winter 1997, Statistics Canada, No. 11-008-XPE.

[246] National Advisory Council on Aging, Position on Home Care, No. 20, Ottawa: March 2000.

[247] Roeher Institute, When Kids Belong: Supporting Children with Complex Needs – At Home and In the Community,  North York (Ont.) Roeher Institute, 2000.

[248] Tom Lips (19:20).

[249] Régis Paradis (13:53).

[250] Dr. Taylor Alexander (14:25).

[251] Dr. Taylor Alexander (14:14).

[252] Senate Subcommittee to Update of Life and Death, Quality End-of-Life Care: The Right of Every Canadian, June 2000, Appendix I: Update 2000.

[253] William Pascal (12:24).

[254] Ibid.

[255] Dr. Thomas Ward (13:26).

[256] Nancy Miller Chenier, Home Care: A Federal Perspective, Ottawa: Parliamentary Research Branch, Library of Parliament, TIP 77-E 19 December 2000.

[257] Canada, Canadian Rural Partnership, Questions for Rural Canadians: Rural Dialogue Workbook, Ottawa, 1998; Canada, Rural Secretariat, Working Together in Rural Canada: Annual Report to Parliament, Agriculture and Agri-Food Canada, May 2000.

[258] M. Watanabe with A. Casebeer, Rural, Remote and Northern Health Research: The Quest for Equitable Health Status for All Canadians, A Report of the Rural Health Research Summit, January 2000, p. 21.

[259] Peter Hutten-Czapski, State of Rural Health Care, Brief to the Committee, 31 May 2001, p. 3.

[260] Health Canada, Rural Health (http://www.hc-sc.gc.ca/ruralhealth/).

[261] For an overview of these factors, see Therese Jennissen, Health Issues in Rural Canada, Parliamentary Research Branch, BP-235E, 1993.

[262] Interview with Dr. John Wootton, “New Office to Focus on Rural Health Issues,” Farm Family Health, 7(1) Spring 1999.

[263] Dr. Peter Hutten-Czapski (17:13).

[264] Ibid.

[265] Canadian Medical Association, Rural and Remote Health in Canada, Brief to the Committee, 31 May 2001.

[266] Morris L. Barer and Greg L. Stoddart, Improving Access to Needed Medical Services in Rural and Remote Canadian Communities: Recruitment and Retention Revisited, Discussion paper prepared for the Federal/Provincial/Territorial Advisory Committee on Health Human Resources, June 1999, p. 3 (available on the Internet at http://www.srpc.ca/librarydocs/BarSto99.htm).

[267] Ibid.

[268] Morris L. Barer, Laura Wood, and David G. Schneider, Toward Improved Access to Medical Services for Relatively Underserved Populations: Canadian Approaches, Foreign Lessons, Centre for Health Services and Policy Research, The University of British Columbia, May 1999, p. 7.

[269] William Tholl, Secretary General and Chief Executive Officer, Canadian Medical Association (17:8).

[270] William Tholl (17:9).

[271] Society of Rural Physicians of Canada, Brief, p. 4.

[272] Raymond W. Pong, Anne Marie Atkinson, Andrew Irvine, Martha MacLeod, Bruce Minore, Ann Pegoraro,
J. Roger Pitblado, Michael Stones, and Geoff Tesson, Rural Health Research in the Canadian Institutes of Health Research, A position paper prepared for Canadian Health Services Research Foundation and Socia Sciences and Humanities Research Council, p.3.

[273] Dr. Judith Kulig (17:4).

[274] In September 1998, the Office of Rural Health was established in Health Canada to apply a “rural lens” to the federal government’s policies, programs and services.  The Office’s mandate is to:

·         Provide policy advice on rural health issues;

·         Identify rural health issues in relation to broad federal, departmental and regional priorities;

·         Foster understanding about rural health issues of national concern and build consensus on how to address them;

·         Identify emerging trends;

·         Work with others to promote, encourage or influence action on rural health issues; and

·         Promote the involvement of rural citizens, communities and health care providers.


PDF FORMAT

The Committee report is available in PDF format (Portable Document Format). These type of electronic documents retain the original look and feel -- complete with text, graphics, photos and colour -- of their printed versions, and can be disseminated independently of computer platform or distribution media.

Acrobat Readers are freely available and enable Windows, Macintosh, DOS and UNIX users to view, navigate through and print any PDF document.

If you need more information on how to use this format or require a reader for your platform, you may wish to visit Adobe Systems Incorporated.


Top of document