SPER Committee Meeting

37th PARLIAMENT, 2nd SESSION

Subcommittee on the Status of Persons with Disabilities of the Standing Committee on Human Resources Development and the Status of Persons with Disabilities

EVIDENCE

CONTENTS

Tuesday, April 8, 2003

Á

1110

The Chair (Ms. Carolyn Bennett (St. Paul's, Lib.))

Dr. Patrick Loisel (Professor, Faculty of Medicine, Longueuil Campus, “Université de Sherbrooke”)

Á

1115

The Chair

Dr. Patrick Loisel

The Chair

Dr. Patrick Loisel

Á

1120

Á

1125

Á

1130

Á

1135

The Chair

Mr. Reed Elley (Nanaimo—Cowichan, Canadian Alliance)

Dr. Patrick Loisel

Mr. Reed Elley

Á

1140

Dr. Patrick Loisel

Á

1145

The Chair

Ms. Pauline Picard (Drummond, BQ)

Dr. Patrick Loisel

Ms. Pauline Picard

The Chair

Á

1150

Mr. Bill Young (Committee Researcher)

The Chair

Dr. Patrick Loisel

Á

1155

The Chair

Dr. Patrick Loisel

Â

1200

The Chair

Dr. Patrick Loisel

Â

1205

The Chair

---

CANADA

Subcommittee on the Status of Persons with Disabilities of the Standing Committee on Human Resources Development and the Status of Persons with Disabilities

---

NUMBER 010

l

2nd SESSION

l

37th PARLIAMENT

---

EVIDENCE

Tuesday, April 8, 2003

[Recorded by Electronic Apparatus]

Á  (1110)  

[Translation]

    The Chair (Ms. Carolyn Bennett (St. Paul's, Lib.)): Order, please.

    Good morning. If you wish, you may make your presentation in French. That would be helpful for Ms. Picard. So there will be a slide show in English and an oral presentation in French.

    Welcome, Ms. Picard. You need your whole caucus for this special presentation.

[English]

    I'll just begin by saying that a lot of us were impressed with Dr. Doupe's presentation on the return-to-work round table she's been doing. At the conference where they ran the round table, Dr. Loisel was one of the most important presenters. He is practising what we want preached, isn't that right? You're already doing what everybody thinks should be done.

[Translation]

    Dr. Patrick Loisel (Professor, Faculty of Medicine, Longueuil Campus, “Université de Sherbrooke”): Thank you.

[English]

    I can present in English or in French, as you like. My accent in English is not that good, but if you understand me, it might be easier. If you have some difficulty or some questions, we may have a mix, but I'm used to presenting in English.

Á  (1115)  

    The Chair: Well, we can have a compromise; because this is English, we would prefer you to speak French. It's our little équilibre around here.

[Translation]

    Dr. Patrick Loisel: Very well.

[English]

    The Chair: And we have translation.

[Translation]

    Dr. Patrick Loisel: Thank you very much for inviting me to come before your committee to defend and present our research work as well as the research being done around the world that comes to the same conclusion about disability and disability situations. There is no doubt that these elements need a great deal of clarification right now. So how can we meet the needs of people in disability situations who cannot carry out their social role as a worker? It is in that context that I am going to be presenting to you the implementation in Quebec of a made-in-Canada management model aimed at preventing disability. I want to acknowledge the work of my collaborator, Marie-Josée Durand, and of many other people who are part of our team and have taken part in our work at the University of Sherbrooke. Right now our work is being carried out at the Longueuil Campus of the University of Sherbrooke on the south shore of Montreal.

    With respect to disability costs, you are certainly aware of the fact that these costs are increasing in Canada. Canada is not alone in having this privilege. All industrialized countries are in the same situation, dealing with a considerable increase in disability costs. Musculo-skeletal problems, which are our current focus, are responsible for 39 per cent of these costs. So we are dealing with a major part of the problem. These are Health Canada statistics.

    You know how difficult it is to estimate the direct and indirect disability costs, but we now have good research that provides very realistic estimates. The cost in Canada is around $20 billion a year, which is obviously very substantial. This includes health costs, of course, but takes into account the cost of the various funds that replace the income of these people over very long periods.

    Disability reduces the quality of life. That is one thing that has sometimes been challenged over the years. Some people have said that people who did nothing were quite happy, but that is obviously completely unrealistic and false. More and more studies have shown that most of these people have a much reduced quality of life.

    Finally, long-term disability leads to work exclusion. Once a disability has lasted a certain length of time, the individuals concerned are no longer able to return to work and can no longer even think about doing so. Obviously, their financial situation worsens, which impoverishes the nation.

    There is another very important aspect that is little recognized: disability must be considered quite separately from disease. It is one thing to be ill, and it is another thing to have a disability. There are many ill people who have no disability and there are many people who have little in the way of disease but many disabilities. Disease may lead to disability, of course, but disease may heal or stabilize, and disability may persist. Disability may happen even in the absence of real disease. There are people who are excluded from society and unable to work, but they do not necessarily report being affected by disease.

    Unlike disease, disability is a problem faced by a person in his or her environment. Of course, the environment influences the development of certain diseases, and research is increasingly being done in that area. Disability, however, has an impact on the person's environment, with the result that someone in a certain situation will be unable to function in his or her environment.

    As a result, we cannot talk about disability and disability situations without taking the environment into account. That is a big problem, since the health system deals mainly with the person, but not with the environment. Disability means the exclusion of a person unable to function in a specific context. That is why we talk about a work handicap situation, but not about handicaps and handicapped people. So we are dealing with people who cannot work in the system they find themselves in.

Á  (1120)  

    Given these facts, we decided to approach the problem differently than we would a problem of disease, and we determined that disability management should be done differently from disease management. Our approach is being increasingly supported by the accumulation of scientific evidence in this area.

    With respect to the workplace, it has been well demonstrated, in particular with respect to people who have had workplace accidents or occupational injuries, that individuals who are unable to work because of a health problem develop a different relationship with the workplace, since they are absent and no longer productive, as well as new relationships with a certain type of insurance providers. There are many types of insurance: workplace insurance, automobile insurance, this or that insurance. This is a world that the patient will discover.

    The health system is another world that is more or less comprehensive, depending on the jurisdiction, but that has the power to decide whether or not a person will return to work. People with disabilities find themselves in a complex situation, where the various stakeholders talk to each other, or in many cases, do not do so or do so badly. If the stakeholders acted differently, they could facilitate the person's return to the social role of worker, to productive employment and to the improvement of the person's state of health. That is what is called the work disability paradigm.

    To resolve this problem, we developed a management model in Sherbrooke in the early 1990s. This work followed up on a large study carried out by the Quebec Task Force on the Clinical Aspects of Back Injuries. Back pain is responsible for a large number of work disability cases. Many studies have been done in that area over the past 20 years. The task force made recommendations, and we applied those recommendations in real life, in what is called the Sherbrooke model. This was a research project, a randomized controlled experiment supported by the Quebec Institute of Occupational Health and Safety Research. The model brought together early detection, early participatory ergonomics, reassurance of the person and early rehabilitation centralized in the workplace. One of the main original aspects of the model was to have the rehabilitation take place in the person's living environment and work environment. That is a major trend that also exists in the health care system. As you know, the thinking is that people should stay as little as possible in the hospital and return home as quickly as possible.

    Those were the main aspects of the model. It was tested through a randomized trial. There were four randomized groups, including one that worked with people in Sherbrooke. That research included 31 companies in the Sherbrooke region. One group received a more clinical type of intervention and another a workplace-based intervention. Finally, the Sherbrooke model brought clinical intervention into the workplace. You have a statistic here that indicates the time generally required for a person to return to regular work. As you see, the Sherbrooke model resulted in a return to work that was 2.4 times faster, and the main factor for that result is the intervention in the workplace.

    Is this expensive? Well, we did a follow-up six years later of workers who were included in the model. Here are the four groups: the standard group is on the left and the Sherbrooke model group is on the right. In yellow, at the bottom, the intervention costs are given. The costs were a little higher at the time of intervention, so there was an initial investment. The red shows the income replacement costs, which are just about the same for the first year.

Á  (1125)  

However, in the following years, the costs associated with disability were avoided. Health care costs are in blue and you can see that they are much higher for the control group, not to mention the income replacement costs, which were considerably higher. Why? Well, when we studied the issue more closely, we realized that a certain number of people had developed long-term disabilities. If the same study were carried out today on the same people, the gap would be greater, because those receiving a pension until their retirement would continue to cost money.

    When he saw the positive outcomes, the public health director for the Montérégie, the region which lies south of Montreal, asked me to take charge of the issue and gave me a public health mandate.

    We developed the Prévicap program. The name comes from the expression “prévention de handicap”. The program is based on the Sherbrooke model. We wanted to develop a program suited to a larger population than the original experimental groups, suited to the general population, by taking into account the legislation and approaches adopted in Quebec, where the model was implemented.

    As you can see, this model is basically a replica of the Sherbrooke model. It is based on case detection, since we wanted to detect cases at their earliest possible stage; intervention based on ergonomics; reassuring a person on their state of health and explaining the system to them; early workplace-centred rehabilitation, an intervention which we called the therapeutic return to the workplace; and, finally an inter-organizational approach to address the triangle I showed you a little earlier, which seemed to be the way to go, based on our most recent research. The problem has to do with the environment a person functions in, and therefore we had to focus on the environment. So, we needed a system in which people would talk and act based on the same objective, which was to help the person get back to work and to a productive life.

    These elements are contained in the Prévicap program. The cubes are indicative of the multidimensional complexity of the problem and of its solution. There are two stages. The first stage involves the interview to make the work disability diagnosis, which, among other things, helps to identify and eliminate red flags, that is, potentially serious problems. Of course, if you discover a serious illness, you will treat it. But if, on the contrary, you discover that the illness is not serious, or that there is no treatment to completely cure a person of this illness, you will then identify what we call disability predictors, that is, the reasons why this person cannot work. This is an essential factor.

    A lot of research has been carried out on this issue and clinical trials have shown that several factors associated with the physical person, the psycho-social person, the environment, the workplace, the health care system, etc., will determine whether a person becomes disabled. A diagnosis of disability is made, which is completely different from a diagnosis of illness. We are not dealing with another diagnosis of illness; we are dealing with a diagnosis of disability.

    With the diagnosis, the cube on the right side will help us develop and tailor a person's therapeutic return to the workplace; the progressive rehabilitation is focused on the workplace and the ultimate objective is to get the person back into a regular work situation. Whenever possible, we try to get the person back into a regular work situation—which may be achieved by adapting the physical environment— and back to his or her original social role.

    Let me show you how we slowly help reintegrate a person into their workplace using a therapeutic approach. The time a person spends in the workplace is marked in blue and the time they spend in a clinical setting in yellow. You can see how that breaks down over the first 12 weeks.

Á  (1130)  

    During the first week, the worker has the support of professionals such as occupational therapists. Next, hours and workload are increased. It is not a question of the worker being temporarily assigned to a completely different position but, rather, returning to his or her regular position on a part-time basis.

    Sometimes, if the pain or the problems return, it may be necessary to go back to a previous stage. We take the worker back to the clinic to talk some things over, but we still continue with the progression. The last week is all in blue which means that the worker is in the workplace on a full-time basis. The problem of disability has simply disappeared, since the return to work has been fully completed.

    Here are the results which we have available at the moment. For those workers who, unfortunately, are sent to us late, in other words, after having been absent from work for an average of 11 months, we see a stable return to work in 65 per cent of cases. These are workers who, under a conventional system, after a year's absence, would, according to statistics, have a 20 per cent chance of returning to work. Yet, in 65 per cent of cases these people return to work. We do follow up after one year and after three years; the return to work is remarkably stable. Only 7 per cent of workers who went back to work relapse during these three years.

    Not only do we get people back to work, but we do so in a stable manner. They tell us that they continue to feel better and to be in better health.

    In light of these preliminary results, we carried out a random trial on construction workers in Montreal, and applied this program to them. We are in the process of analyzing the results. We also have several other research projects to better determine the effectiveness and the impact of the program.

    The CSST (Quebec Workmen's Compensation Commission) in Quebec has already decided to support implementing and evaluating this program on a wider scale. In order to do so, we have set up the Réseau en réadaptation au travail du Québec (Quebec workplace rehabilitation network). It is a management network which facilitates research and education in the field of workplace rehabilitation. The network comprises the Charles-LeMoyne Hospital and 10 public regional rehabilitation institutes in Quebec. Together, they have formed a consortium offering this program.

    This rehabilitation program, the Prévicap program, is available in several cities. The network is responsible for the program, and the institutions are responsible for their teams. We ensure coordination and continuing education, and we monitor the development of the existing program.

    Here, in Quebec, there are currently four participating institutions: one in Montreal, one on the south shore, which is where it all started, one in Quebec, and another in Rouyn-Noranda, in Abitibi.

    Before finishing my presentation, I would like to clarify a few points. It is increasingly clear that in the case of a worker who finds himself disabled due to musculo-skeletal problems, the paradigm is no different than in the case of other problems, even mental health problems. It depends on the various complex aspects of the workplace, the way in which the business operates, the employer and the union, the help that is available via the different sorts of insurance offered by governments and other bodies. Then there is the health care system, in all its complexity; the attending physician and all the other aspects of the health care system can sometimes scare rather than reassure the patient. Finally, there is the complex nature of the person himself, from his physical state to his interpersonal relations. All of the above must be taken into consideration and appropriately applied to the person who, on finding himself or herself in a position of disability, always has to deal with a number of these elements.

Á  (1135)  

    Where should we be heading? We must put the emphasis on teaching the disability paradigm. Currently, medical faculties are primarily focused on disease. This is understandable. It is, clearly, very important for a doctor, but it is also important that a doctor realize that there are people who are no longer ill but who are in a disability situation and who are unhappy. These people must be looked after in a different way. I have made mention of doctors, but there are also all the other stakeholders in the health care system, including the administrators.

    We have to circulate the model in the various Canadian provinces. Ontario's Workplace Safety and Insurance Board is interested and has already approached me on this subject. We have to get other insurance companies, be they public or private, and government bodies interested. We have to ensure that this system is made accessible to all Canadians because, as you know, there are a certain number of disparities due to the variations in people's coverage. When someone hurts himself falling off his roof and, consequently, experiences disability, he ought to have the right, not necessarily to extended protection, but to something which will help him return to active work.

    Elsewhere in the world, the Netherlands are again testing this model by random trial, and several other countries have contacted me to ask me to set up this model on a wider scale in Europe.

    That is what the disability prevention paradigm is all about. I do not think that we should refuse people an acceptable working situation and, rather than simply thinking in terms of compensation, we should think of the sense of self-worth gained by working, something that is extremely important in our society.

    I would like to thank all the organizations which have contributed to this research, the IRSST, the CSST, the FRSQ, the REPAR, HEALNet, the Régie régionale de la Montérégie, and, of course, the workers, employers and unions who have helped with difference stages of this project.

    We have provided you with some references for the work that we have published should you wish to clarify certain points.

[English]

    The Chair: Merci.

    Mr. Elley.

    Mr. Reed Elley (Nanaimo—Cowichan, Canadian Alliance): Thank you very much, Dr. Loisel, for coming and sharing with us today.

    You used a graph at one point where you plotted the progress of clients as they went through your program, and I think the graph indicated 12 weeks. Is this always a 12-week program or is there flexibility within that?

[Translation]

    Dr. Patrick Loisel: The program is very flexible. Twelve weeks is the average. When we calculated the average we came up with 12 weeks. The program can, however, be a lot shorter or longer. It depends on the person.

    Therapeutic return to work is an approach adapted to each individual's problems. As it is an approach which also involves the employer, the compensating body, and, possibly, friends and family who have an influence on the worker, all the factors of this complex system have to be taken into consideration. We have, however, developed an approach technology to facilitate this interaction.

[English]

    Mr. Reed Elley: Now, my understanding of it as I look at it, having heard you explain it, is that it's really a wholeness-wellness model, where you're putting together an interdisciplinary team to actually take a look at a person's problem and then work on it with them.

    I've had some people in my own constituency back on Vancouver Island who have come to me and talked to me about this issue, particularly as it pertains to muscular-skeletal problems, that lower back pain all of us seem to suffer at some point in our lives. For some people it's chronic, very acute, and they have a hard time getting back into the workforce. They have experienced some problems with WCB particularly in trying to work this out and get back into the workforce.

    It looks to me as if a large component of what you're actually doing--you can comment, this is maybe a wrong interpretation--is pain management. In some cases it's pain management you're really doing with people. Do you have people who go through your process yet will always live with a certain level of pain? You're not necessarily looking for cures, you're looking for pain management that will help people return to a level of work. You can comment on that.

Á  (1140)  

[Translation]

    Dr. Patrick Loisel: You are absolutely right. We are not a pain clinic. We try to suppress people's pain. Pain is a part of life. I believe that, as we get older, we realize that we have all sorts of pains, and we deal with them.

    There are some very good statistics available both from Quebec and on a national level. When Santé Québec or Health Canada carry out population surveys, they ask people if they suffer from pain. Some answer that they have back pain. Twenty-five percent of people who work tell us that they have back pain all the time or on a regular basis. Fortunately, these people are not absent from work; if they were, our economy would be in dire straits.

    We tend to associate pain with disability, and this is incorrect. There are people who work with a certain level of pain, in the same way that we sometimes go to work with a cold. Obviously, this is not ideal, but that is the way it is.

    There are, however, people who stop work at a lesser level of pain. Why? Because the problem is not simply the pain. Many other things may be going on in their lives. You could have a workplace accident while going through a divorce. Normally, getting divorced does not result in absence from work. It is a fact of life. But when someone gets divorced, and is also dealing with this problem, some other problem, plus a workplace accident, it becomes too much. At this stage, we get into the disability cycle, which can become a vicious circle. There are some outstanding international writers, such as Johan Vlaeyen, in Holland, who detailed this model recently. It is as if someone gets caught in a vicious circle from which he cannot escape. The aim of the program is to help people break this vicious circle.

    When we do our follow-up after one and three years we ask workers to describe their pain level. There are only 10 or 15% who say that they experience no pain. But when we ask them if their health is better, the same, or worse, the vast majority say that they are feeling better or as good as they were at the end of their rehabilitation. They are happy, but their pain level—they do not remember what they told us three years ago, before starting the program—is more or less the same.

    So, it is very important to know—and this is a problem with medical teaching—that we have made a lot of progress over the past 10 years in terms of biological mechanisms for interpreting pain. Stress, problems in one's life, and a negative attitude to life are all factors which, by means of biological, cerebral and nerve centre processes, affect our level of pain. I am not saying that people are crazy or complainers. These are biological processes. It is the way that we are made. That is why one of the most important things that we can do for people is offer them reassurance, because that allows for a positive influence on these biological processes.

Á  (1145)  

    The Chair: Ms. Picard.

    Ms. Pauline Picard (Drummond, BQ): Thank you.

    Dr. Loisel, I have to congratulate you for having come up with this model, which is beginning to be recognized across Canada. You say that Ontario and certain European countries have asked you to set up such a model for them. I am very proud to have this opportunity to congratulate you and your team.

    You have already answered most of the questions that I had prepared. I have only got one left. In Quebec, how does the process work in the case of a person who has a disability or cannot work? Does the person go to his doctor who would then take the necessary steps? How can the person be compensated? Is it the Department of Health which compensates them by a tax credit or by some other means? We know that there are insurance companies and other bodies who can compensate the person who cannot work to allow him to continue to live. We have to avoid doing the same thing twice. How does it work?

    Dr. Patrick Loisel: As I said earlier, the program is currently supported by the CSST. Therefore, it is for people who have had a workplace accident.

    Recently, we have developed links with some companies, who are in a position to send some workers directly to us, whether they have had a workplace accident or not. The CSST may be involved, but it could also be, for example, people who are getting payouts from a company's disability insurance fund.

    This is a problem at the moment. Aside from those few cases which are sent to us by certain companies, we essentially just have cases which are sent to us by the CSST and its rehabilitation counsellors. Only a limited group in the population have access to these services.

    In the future, we have to open up these services. Usually, because of the way in which our health care system is organized, it is the attending physician who sends these cases directly to us. But it is still an experimental program. I forgot to mention that the Réseau en réadaptation au travail is currently being evaluated by researchers from the Groupe de recherche interdisciplinaire en santé of the Université de Montréal. So, an external assessment is currently underway. That is one way of going about it. I mentioned The Netherlands, where a random trial is under way. There are many studies. The program was developed based on scientific evidence, and furthermore, it is being evaluated.

    So, as we evaluate it, and as evidence of its effectiveness increases, we should certainly be able to extend it to other people.

    I am here before you because I am not the one in a position to be able to do that. You are the ones who can act in this field. Clearly, it is up to government to decide to adopt this disability paradigm and to offer people treatment for their disability. The model can be applied in a flexible manner to take into consideration provincial and regional contexts, etc. The key elements, however, apply to everybody.

    Ms. Pauline Picard: Thank you very much.

[English]

    The Chair: Thank you.

    There are a number of aspects of your program that obviously we would want...we're trying to figure out how we can get into some recommendations in our report. Obviously, the number one point in the Sherbrooke model is early detection, right? I guess we've noodled with the idea of, should there be some, what did you call it, a red flag? Is there something that, in terms of the sharing of employment insurance, sickness benefits, and CPP in terms of a joint program to do early detecting, would be good for both things? That is one question.

    Also, let me throw out ideas in terms of how we could tie this into our report. Obviously, there are good employers and lesser employers in terms of best practices on this, and is there some way we could reward, say in premium reductions, the good employers who have in place the interventions and the...? What did you call it, Bill, “experience rating”?

Á  (1150)  

    Mr. Bill Young (Committee Researcher): Yes.

    The Chair: People who actually are shown to be doing this in the workplace would obviously get a premium reduction because they're going to ultimately cost more.

    When you look at your graph here in terms of the six-year follow-up, is there something we should be doing to show people that the places that spend a little bit more on intervention up front save huge amounts of dollars downstream? That makes sense to all of us on almost anything to do with prevention, but there obviously needs to be a bit of a sales job on this in persuading people to spend a little bit more up front to save them a whole bunch of money later on. Those were just the kinds of things....

    If you were going to write our report, what could be in our report that would demonstrate that we had heard you and that we think, in terms of sharing best practices and moving to a different paradigm in terms of disability, we were learning from you and not just writing people off? I think we keep hearing that this is very expensive in many ways, from self-esteem to all of the other things around individuals, so help us write the report.

    Dr. Patrick Loisel: I would be pleased to do so, but I feel that this is something which merits in-depth discussion and which, moreover, should be a shared undertaking, between people such as myself, who understand the scientific facts and who are involved in the development of such programs, and administrators who see how we could influence the development of health care, people who understand the business world and who know how we could influence major companies.

     There are already a certain number of businesses and unions who are interested and who have approached me, but, clearly, this requires a far broader perspective. I think that we have to raise awareness and educate on all levels. We know that knowledge transfer is important. The Canadian Institutes of Health Research are amongst those who subsidize us. I have just got funding for a researchers' training program on this problem from the Canadian Institutes of Health Research.

     We have to train the researchers of the future, as well as the administrators. In the folders that I brought, you will find several programs which have recently been developed at the Université de Sherbrooke for dealing with this problem. We need broader training so that people understand the disability paradigm. I have noticed that when people do not understand the disability paradigm, they refer to the disease paradigm, an old model which everybody understands well. That stands in the way of their focusing on disability. I feel, therefore, that we should make a big effort in terms of training, both in the field of health and administration.

     There are incentives for businesses. I think that the CSST, in Quebec, has made a considerable effort on this front. I can assure you that the costs for the employer are very high when a lot of employees suffer from a disability. The CSST gives them a considerable amount, but employers do not necessarily know what to do because it is not their job. This means that the solutions which they introduce are not always adequate, and are sometimes even counterproductive. We need, therefore, systems which ensure that we do not simply tax employers who have had difficulties with this, but that we also give them means to improve the situation.

     We are currently holding discussions with some major companies. We want to develop a program to enable companies to adequately deal with these issues themselves. A few days ago, I was talking with a colleague who has developed a training program for supervisors. He said to the supervisors, for example, that if somebody was absent, that they should phone them, ask them how they were, tell them that they were needed. By acting in a humane fashion rather than singling out the employee as being a bad guy, it is possible to make real changes.

     I think that it is important to develop training programs. We have to refine and develop programs better adapted to regional contexts, because the program has to be adapted and integrated into federal and provincial legislation. It is clear that in Ontario, if we continue our work with the WSIB, the program will not be identical to the one set up in Quebec. The foundation will be the same, but it will have been adapted to an Ontario context because, for example, the role of the attending physician is not the same in Ontario as it is in Quebec. The WSIB's legislative responsibilities are not the same as those of the CSST. It is important, therefore, that study groups focus on this.

     I think that it would be a good idea to bring expertise in this field together somewhere in the country— and it could be in Quebec. This would be helpful; such a group could develop implementation approaches, different ways of going about things. I think that these different approaches ought to be developed and concentrated in one place which would then network with the other provinces. This would allow us to better understand and adapt this new vision.

Á  (1155)  

    The Chair: Dr. Loisel, I'm an impatient person. As a family physician, one of my frustrations is that we can only train eight new family doctors every year. In terms of your beginning to teach in the medical schools, one of the problems with this is, is it health, disabilities, or social services? It's the physicians signing the forms and writing the prescriptions for the painkillers. It's the employers who don't really seem to know what light duties are.

    I think the committee would agree that we would like your model mainstreamed across this country as quickly as possible. We'd save a whole bunch of money, and we'd have a whole bunch of Canadians with more self-esteem. If all of a sudden, abracadabra, your model was everywhere, it would be a good thing.

    How do we get there? I think using all of the institutes and research and collaboration province to province in getting the message out is really important. But in terms of carrots and sticks, are there incentives you can think of that would make this work? Should collaborative clinics like yours in terms of return-to-work modules be replicated across the country, as you've been doing? Should you have to have a keyhole so that no one gets CPP disability until they've been through at least an attempt at some sort of accommodation? Would we just turn everybody down until they've had a go at some more impressive rehab? How would you put the incentives in place to get this working?

[Translation]

    Dr. Patrick Loisel: Your question is very interesting, but it is not necessarily easy to answer.

    There is a danger, and that is why in Quebec, I wanted us to set up the Réseau en réadaptation au travail du Québec, to ensure that the program that is delivered in various places is not completely different.

    Basically, I am a clinician, since I am an orthopaedic surgeon by training, but I am very wary of clinicians. That is a joke, my point being that clinicians tend to do a lot of work in the clinic and try to take a great deal of care of the patient. I am not saying that we should not be taking care of the patients, of course, but I am saying that we must avoid making a problem a medical issue when it is not really a medical issue, but a social issue, at least for the most part.

    So if clinics were to spread everywhere, we would run the risk of achieving the opposite of what we want, in other words the problem could be turned into a medical issue. We have noted that if we make an issue a medical one, we increase the handicap, because we frighten the patient who, in the end, thinks that his condition is worse then it really is.

    I think we would need a working committee that would bring together researchers who are experts in the field, competent administrators and people interested in the topic, people who see how we can apply these things. You cannot ask me alone how to put this model in place throughout Canada, when I do not even know how the system in Manitoba works, for example. You are aware that the provincial jurisdictions that are responsible for these fields are different, and that is legitimate. Once again, if we do not want this model to have perverse effects and for people to misunderstand it, we must ensure it is implemented adequately.

    I think that it could be a very good idea to have a committee at the national level to think about that, and now that we have scientific evidence and a system, to see how we could apply this evidence and develop the system.

    That is why I said that we probably need at least one place where there would be a specific concentration, a place that would attract the people with the knowledge in this field and that would enable us to develop and implement the model as quickly as possible. It is all well and good to move quickly, of course, but we must also do a good job and think carefully before making any decisions. Investments will inevitably be required at the outset. They will certainly be very well rewarded, not only in financial terms but also in terms of quality of life for many Canadians, but everything must be done appropriately.

  (1200)  

[English]

    The Chair: In the research that you're asking for, I'm pretty impressed with your evidence here in terms of the “what”. Are you saying you would like us to be developing, with the provinces, research in the “how”? The research now needs to be on implementation and best practices and how to get it implemented, because clearly the evidence here is that what you're doing works. There's no question about that, is there?

    Dr. Patrick Loisel: No, I don't think so. The problem is not, does this work--it does work--but how to apply it. This is a problem of knowledge transfer, and we know knowledge transfer is a difficult part of the thing. There is a lot of research that's beginning to be implemented in research transfer now. We have to think how to best do this knowledge transfer in this field.

[Translation]

    I think we have to do exactly what you said. That is why I suggested creating a working group that will think about the ways of transferring this knowledge. We know that my turning to the blackboard is not a good way of transferring this knowledge. We know that simply sending documents is not a good way of transferring this knowledge.

    The issue of effectively transferring knowledge is a growing field. We already have some idea as to what works and what does not. We would need a committee made up of a certain number of people in different but related fields, like people from business, and unions, to tell us what is acceptable and what can work in a business.

    There are large corporations, but the majority of workers are in small businesses. This model works very well in small businesses. Initially, the CSST was leery. In Sherbrooke, a study of businesses with more than 175 employees was conducted, if I'm not mistaken. The CSST said that it would work for large corporations, but that it would not work for small businesses. But it works very well in small businesses. That is our experience to date.

    We need people who are very familiar with the systems to sit down together and look at how it could work.

[English]

a made-in-Canada model that is applied.

  (1205)  

    The Chair: Merci beaucoup.

    It's spectacular what you're doing, and in the next chapter I hope we will be able to find a way within this country to reward the models and give prizes of big cash to provinces that come up with interesting, innovative ways to do things that then is part of the dissemination, the knowledge transfer. I think we've come beyond clawing back provinces that aren't able to do things, and we should be rewarding provinces that have been innovative and creative, because it is only by celebrating the little points of excellence across this country that we're actually going to raise the playing field for all Canadians.

    So thank you so much for coming. We will see what we can do to be part of the knowledge transfer and cheerleaders for what you're doing.

    The meeting is adjourned.