FINA Committee Meeting

STANDING COMMITTEE ON FINANCE

COMITÉ PERMANENT DES FINANCES

EVIDENCE

[Recorded by Electronic Apparatus]

Tuesday, September 22, 1998

• 1533

[English]

The Chairman (Mr. Maurizio Bevilacqua (Vaughan—King—Aurora, Lib.): I'd like to call the meeting to order and welcome everyone here this afternoon.

This afternoon we have the pleasure to have in front of us members of the health care group. We're going to have a round table on the issue of health care, an issue that is really important to millions and millions of Canadians who have stated consistently that this is indeed one of the major issues that should be dealt with in the upcoming budget.

We will begin the hearings with Dr. Taylor Alexander, representing the Health Action Lobby group. Welcome.

Dr. Taylor Alexander (President and Chief Executive Officer, Canadian Association for Community Care): Good afternoon, ladies and gentlemen. I'm Dr. Taylor Alexander and I am the president and CEO of the Canadian Association for Community Care. I'm here today in my capacity as a member of the Health Action Lobby, or HEAL, as we are known.

With me today is Alastair Thomson, who has assisted HEAL with the preparation of our brief. Other members of HEAL join me at this table in support of the HEAL brief while they also bring to you some specific points on behalf of their own organizations.

HEAL has sat at this table many times. Our members joined together in 1991 to provide a unified voice for health care. Today we represent some 29 national health and consumer organizations. Our objective is to work together with other organizations and governments to preserve and strengthen our Canadian health care system. A list of the members of HEAL is contained in the brief you have before you.

• 1535

Our message today responds to the desire expressed by Canadians for a federal investment in health. We are very pleased that the Prime Minister has committed to using any fiscal dividend to meet Canadians' highest priority—medicare. Our brief outlines what the health community believes is the appropriate way to make that investment, and I would like to summarize our recommendations for you.

First, we would like to acknowledge that HEAL was very pleased to have the federal government establish a cash floor of $12.5 billion for the CHST in the 1998 budget. We have consistently called on the government to maintain a cash floor significant enough to allow the federal government to have a strong role in health care.

Today as Canada's fiscal outlook improves, we are asking that the federal government strengthen this role by restoring health funding to the provinces and territories. We recommend that in the interest of providing quality care for Canadians and facilitating a positive federal/provincial/territorial responsibility for health care, $2.5 billion be restored to Canada health and social transfer cash transfers. This restoration of funding will allow the provinces and territories to improve the quality of existing health care services, which has been so badly eroded in the past few years.

HEAL further recommends that the federal government invest an additional $1 billion in the cash floor to broaden the continuum of care to include services such as home and community care, which is a stated priority of this government and is supported by the recommendations of the National Forum on Health. New funding will allow for a true integration of services along the continuum of care and changing service needs to meet the requirements of a growing and aging population.

But we do not believe this new investment should be without some demonstration of accountability from the provinces and territories. While HEAL recognizes that provinces and territories spend significantly more on health care than that provided through the federal health transfers, we believe Canadians would support an agreement that would provide annual public reports on how our health dollars are spent. It is not a case of one government being accountable to another; it is a case of all governments being accountable to Canadians.

In the 1997 budget the Minister of Finance noted that the then $11 billion cash floor under the Canada health and social transfer was a floor, not a ceiling. At this point there is no provision of growth for the CHST $12.5-billion cash floor and therefore its value will be eroded over time. HEAL recommends that the committee consider adding an escalator to maintain the value of the CHST.

A further recommendation relates to the allocation of the CHST among provinces and territories in the interests of a more equitable treatment of provinces that have been penalized by the cap placed previously on Canada assistance plan funds. We recommend that the levelling process be accelerated.

In light of recent media reports regarding social union discussions and, in particular, calls for more flexibility in interpreting the Canada Health Act, HEAL members believe it is essential that the federal government retain the power to ensure compliance with these principles. While we support an open and transparent process and there may be indeed an opportunity to develop some type of joint resolution process, we believe it is in the national interest to have a strong federal role in health. Canadians want to ensure that there is one national health care system and that the federal government can protect the health of Canadians across the country.

Finally, as the committee deliberates on its recommendations, we urge you to consider research funding to support an evidence-based health care system. For example, we need research projects to demonstrate better ways to provide home and community services and drug delivery programs, and we need appropriate dissemination methods so that we can all benefit from new research in a timely manner.

Ladies and gentlemen, these are HEAL's recommendations. Canadians and health care institutions and providers have seen the devastating effects of successive cuts to health care. Canadians have spoken out and we urge you to listen to their concerns. Our brief provides sensible and concrete suggestions on how you can act to make a difference in the lives of Canadians.

• 1540

I thank you for this opportunity and would be pleased to respond to your questions, as would my colleagues around the table.

The Chairman: Thank you very much for your presentation, Mr. Alexander.

We'll now move to the Canadian Healthcare Association, and Ms. Sharon Sholzberg-Gray, president and CEO; Kathryn Tregunna, director of the policy department; and Aileen Leo, director of communications. Welcome.

Ms. Sharon Sholzberg-Gray (President and Chief Executive Officer, Canadian Healthcare Association): Thank you.

Good afternoon, everyone. I'm pleased to be here today on behalf of the Canadian Healthcare Association. We're a federation of provincial and territorial hospital and health care associations, and through our membership we represent over a thousand regional health authorities, hospitals, health facilities and health service agencies across Canada. These organizations employ approximately one million health professionals and front line workers and serve Canadians across the country. They're governed by trustees who act in the public interest of Canadians and who, by and large, act as volunteers. That is, the health care system of Canada is really in the hands of trustees and volunteers acting in the interests of Canadians to deliver health care to Canadians. CHA's mission is to improve the delivery of health services in Canada through policy development, advocacy and leadership.

CHA is also a founding member of the Health Action Lobby, and is pleased to support the recommendations made in HEAL's brief. Along with our partners in HEAL, CHA is concerned about the impact of funding reductions on Canada's health care system.

We are pleased that, as the Minister of Health has stated, the era of cuts to health care is over. However, there have been cuts of some $6 billion to the transfer since 1995-96. Along with previous reductions over ten years totalling some $30 billion, those cuts continue to work their way through our health care system. Every day, members of our federation see the effects of these cuts.

Public confidence in the health care system has plummeted. People are concerned that they won't have access to the services they need, an anxiety the government itself acknowledged in last year's Speech from the Throne. Hospitals, health authorities, health facilities and health service agencies are incurring deficits even when prohibited by law in order to meet their obligations for care.

Privatization of the health care system is reaching a level that will affect access to needed health services as people, ordinary Canadians and employers, absorb more health care costs previously paid for by government.

Frustration amongst health care providers trying to cope with constant change has reached critical levels. On September 13, the Prime Minister stated in Saint John, New Brunswick, before the Canadian Chamber of Commerce, “Universal access to high quality health care is key to reaching our full potential as individuals and as a country”. The Prime Minister also acknowledged that Canadians are apprehensive that the pace and direction of health care restructuring could compromise quality of care and universal access.

The Prime Minister said this past weekend to Liberals meeting in Toronto that our next major investment in this mandate will be in medicare. He noted that medicare is Canada's best economic program. Canadians have spoken loudly and clearly: health care is their number one priority.

CHA recommends the following five commitments from the federal government in the 1999 budget to achieve the end; that is, a health care system that is accessible to Canadians and is of the highest quality:

First, the cash floor of the Canada health and social transfer should be raised by $2.5 billion, from $12.5 billion to $15 billion. This will stabilize the existing hospital- and physician-based medicare system, and will address current needs within this system. CHA is pleased with the decision of the government to raise the cash floor of the CHST from $11 billion to $12.5 billion. However, in the words of the Minister of Finance, government generally, and the National Forum on Health, this figure is a floor and not a ceiling.

Second, a growth factor or an escalator to the cash component to the CHST should be applied to sustain the existing medicare system. This growth factor will meet the future anticipated health needs of a growing and aging population, and will be related to economic growth. Without a growth factor, the real value of the transfer will erode over time. In fact, in cash terms, the transfer is projected to be only $12.5 billion in the year 2002, while the total transfer would by that time be about $28.6 billion. The current escalator formula really means the increases will all be on the tax point side, not the cash side at all, which means the cash will erode as a proportion of the value of the total transfer.

• 1545

Third, an initial $1 billion should be committed to launch a national home and community care program that will eventually be supported by a national pharmacare program and a health information system. This will require the provinces and territories to adhere to new principles outside the Canada Health Act. The amount will need to be reviewed regularly to determine the appropriate contribution of the federal government to support this broader continuum of care. A new home and community care program with some package of national standards will make the broader continuum of needed health services much more accessible to Canadians, and it will also alleviate the care demands that are placed on hospitals.

Fourth, in co-operation with the provinces and territories, resources should be contributed for the development of national standards regarding the involvement of the private sector in delivering health care services. This will ensure accountability from the private sector.

Fifth, there should be support for the ongoing monitoring and evaluation process of private sector involvement—both financing and delivery—in the Canadian health care system.

In conclusion, a strong federal presence in our health care system is necessary to ensure access to comparable health services for all Canadians, regardless of where they live. We think our recommendations will assist in ensuring this end.

On behalf of the Canadian Healthcare Association, thank you for the opportunity to address this committee.

The Chairman: Thank you very much, Mrs. Sholzberg-Gray.

We'll move to the representative from the Canadian Dental Association, Mr. Richard Sandilands, president. Welcome.

Mr. Richard Sandilands (President, Canadian Dental Association): Thank you. My colleague Dr. Ray Wenn and I are pleased to be here this afternoon.

[Translation]

Good afternoon. Thank you for giving the Canadian Dental Association the opportunity to present its views to the committee.

[English]

The Canadian Dental Association is the national voice of Canada's dentists, representing over 16,000 dental professionals across this country. Our mission is to promote optimal oral health for all Canadians. I recognize the limited time we have to make a statement, so I intend to briefly highlight certain key points under three main issue banners: one, the tax deductibility of dental plans for unincorporated self-employed Canadians; two, Canada's evolving retirement income policy; and three, the government's role in the battle to combat tobacco abuse.

Last year the Canadian Dental Association presented an argument to this committee in support of the tax deductibility of dental plans for unincorporated self-employed Canadians. We want to thank you for your strong support and we believe this committee's endorsement contributed in large measure to the government's decision to announce the private health savings plan initiative in the last federal budget. Nevertheless, we are perplexed with the finance department's decision to cap the amount of supplemental health coverage that unincorporated self-employed Canadians are eligible to receive, namely, $1,500 for individuals and spouses, and $750 for each child.

The Minister of Finance has indicated that this measure was proposed to impart equity in the tax code, and we agree with this principle. Therefore, we oppose the application of any discriminatory limits of employee premium deductibility either among businesses in the unincorporated category or between employees of businesses in this category and those in the incorporated business or government categories. We support the principle of equivalency of coverage for all permanent, full-time arm's-length employees. We intend to continue to work actively with government on this important initiative and may potentially present before this committee again when a private health savings plan bill is tabled. In a best-case scenario, your recommendation on this issue could lead to a decision to remove the financial thresholds in the proposed legislation.

Item two: The Canadian Dental Association recognizes the rapidly growing seniors portion of our population and the resulting demographic changes that are substantially altering the underlying financial economics of traditional public pension vehicles. We had substantial concerns with the seniors benefit as proposed and are pleased with the decision to pull back that initiative. Nevertheless, given the magnitude of the demographic changes in our country, we believe that further public pension policy changes may be on the near-term horizon.

• 1550

The Canadian Dental Association strongly opposes isolated, ad hoc changes in areas such as the Canada Pension Plan or old age security and believes that government should consider the whole retirement income picture before making drastic changes. In that way Canadians can knowledgeably plan for their retirement without wondering when the rules will change. We recommend that the government go forward with an in-depth retirement income policy review. We are asking for your endorsement of this platform, and we will continue to work with both the Retirement Income Coalition and the RRSP Alliance in support of advancing workable retirement income solutions.

The Canadian Dental Association has been working with Health Canada to advance tobacco reduction policy and strategies. Dentists regularly see the devastating effects of tobacco. It is a burden on an already overburdened health care system, and although this is a policy area where government has made some encouraging initiatives, in our view they are simply not enough. We believe there is substantial financial room for the government to advance further tobacco reduction initiatives, and we believe that a significantly greater portion of tobacco tax should be applied to tobacco reduction initiatives. Tobacco taxes generate in the order of $2 billion per annum, yet Health Canada currently administers a tobacco reduction budget of less than $20 million per year.

The Canadian Dental Association recommends that the committee endorse a substantial increase in tobacco reduction-related financial resources. Specifically, the Canadian Dental Association would like to see a recommendation to return to the 1994 commitment to spend $185 million over a three-year period. We also endorse an increase in tobacco taxes dedicated to financing tobacco reduction campaigns aimed at Canadian youth.

To quickly reiterate, first, the Canadian Dental Association recommends equitable supplemental health tax treatment for unincorporated and incorporated self-employed businesses, i.e. no limits. Second, the Canadian Dental Association strongly endorses a comprehensive review of existing retirement income policy. Third, the Canadian Dental Association strongly endorses more financial resources committed to combat the use of tobacco in Canada.

Thank you for the opportunity to make this presentation.

[Translation]

I look forward to answering your questions.

[English]

If you or your staff have any questions or require additional information on the Canadian Dental Association or any of the issues presented, please contact my office at the Canadian Dental Association in Ottawa. We remain committed to working with government on these and other important public policy issues.

Thank you.

The Chairman: Thank you very much, Dr. Sandilands.

Now we'll move to the Canadian Medical Association, Dr. Allon Reddoch, president—newly elected president, I understand, congratulations—and Dr. Léo-Paul Landry, secretary general, and chair of RRSP Alliance. Welcome.

Dr. Allon Reddoch (President, Canadian Medical Association): Thank you, Mr. Chairman.

On behalf of the Canadian Medical Association and our 46,000 members, I'm pleased to be able to speak with you today. I'm a family physician from Whitehorse in the Yukon territory, and I was newly elected just two weeks ago.

I commend you for calling together this round table on health, which the CMA recommended in our appearance before this committee last June on the issue of the brain drain.

In my brief remarks I would urge the committee in the strongest possible terms to call on the government to show leadership by reinvesting in our national health care system. Let me say at the outset that the CMA is committed to a strong publicly funded system. Unfortunately, it's slipping from our grasp, as is the confidence of the Canadian public. For my patients and for countless Canadians in every region of the country, maintaining Canada's health care system is vital. It's highly valued, it contributes to a healthy economy and it has a significant impact on their well-being.

Unfortunately, Canadians' confidence in the health care system has reached an unprecedented low. In fact, it's near rock bottom. According to a CMA-Angus Reid poll taken in July, the number of Canadians believing that spending cuts have had a negative impact on the quality of care stands at an all-time high of 70%. If the Prime Minister is waiting until every single Canadian has lost confidence in our health care system before he and his government are prepared to do something about it, then we'd like to warn him that we're almost there.

• 1555

Let me be direct. Our health care system is in crisis. Canadians want to know that their health care system will be there for them and their families when they need it. As you will see from the materials provided to you, poll upon poll shows that Canadians want transfer payments for health care restored.

Since the introduction of the Canada health and social transfer in 1996, $6 billion in transfers to the provinces has been cut. That represents a loss of $2.5 billion annually for health care. I would submit that these cuts have been the main barrier for Canadians' access to quality health care since the inception of Canada's medicare program in the 1960s.

I'm sure that every member of Parliament around this table has personally experienced difficulties or has heard from their constituents about difficulties in accessing health care services. The CMA believes strongly that there is an immediate need for a measured, deliberate and responsible approach to reinvesting in our health care system. The CMA has proposed such an approach to the Prime Minister and the federal cabinet.

Mr. Chairman, without a significant infusion of funding, this crisis of confidence among our patients and providers is only going to deepen. It is with this in mind that the CMA proposes the following recommendations.

First, in order to ensure greater public accountability and visibility, the federal government should introduce a health-specific portion of the cash transfers to the provinces and territories.

Second, in addition to the current level of federal cash transfers to the provinces and territories for health care, the federal government should, at a minimum, restore $2.5 billion in cash on an annual basis to be earmarked for health care effective April 1, 1999.

Third, beginning April 1, 2000, the federal government should fully index the total cash entitlement allocated to health care through the use of a combination of factors that would take into account the changing needs of Canadians, based on population growth, aging, epidemiology, current knowledge, new technologies and economic growth.

In addition to stabilizing our current health care system, the federal government must look to the future and to the renewal of the health care system. Our health care system needs to prepare to meet the challenges of the new millennium. Towards this end, the CMA is recommending a health system renewal fund, a $3 billion one-time expenditure over three years, strategically targeted to areas of need, which will give the federal government sufficient flexibility in how the funds will be allocated, with full recognition for its investment. These include: acute infrastructure support, community care infrastructure support, support for Canadians at risk, and health information technology.

Combined, we believe that our recommendations are a powerful and strategic package for Canada. Taken together, they will help to stabilize the health care system and ensure that Canadians in need do not fall through the cracks. Our detailed recommendations are contained in the kits before you.

I would also like to draw your attention to the full range of CMA recommendations as they relate to other issues, such as tobacco control initiatives, the GST and physician services, RRSP contribution limits, and medical research in Canada.

The diagnosis is that our health care system is in crisis. The treatment starts with making the 1999 budget a health care budget. I urge you, Mr. Chairman, to support the recommendations presented to you and to ensure that the next federal budget is indeed a health care budget. Thank you.

The Chairman: Thank you very much, Dr. Reddoch.

We'll now hear the presentation from the Canadian Nurses Association.

Dr. Mary Ellen Jeans, welcome.

Dr. Mary Ellen Jeans (Executive Director, Canadian Nurses Association): Thank you, Mr. Chairman and ladies and gentlemen. Today, like several of my colleagues here, I'm wearing two hats: that of co-chair of the Health Action Lobby and that of the executive director of the Canadian Nurses Association. Dr. Alexander has provided you with an overview of the HEAL position so that I might spend a few moments speaking with you about the quiet crisis in health care that concerns the nurses of Canada.

The Canadian Nurses Association is a federation of 11 provincial and territorial nurses' associations and is the national voice of registered nursing in Canada. Nurses play a critical role in the health care system, providing health promotion, disease prevention, nursing assessment and intervention, and care and support for patients across the continuum of care.

• 1600

Recent polls indicate that the public believes that nurses, more than any other factor, determine the quality of hospital care.

The CNA fully supports the recommendations of the HEAL brief as our members, who are on the front lines of health care, have continued to witness the diminishing quality of care across Canada. Their distress at no longer being able to provide the care that Canadians deserve continues to mount. They see all too clearly that it is time for an investment in health care.

Within the context of the HEAL recommendations and for the first time, Canadian nurses are calling on the federal government to make a specific investment in nursing care. This is necessary, because unless something is done now, Canadians will soon be deprived of the care they require. This will happen because there are and will be too few qualified nursing human resources to provide the care that is needed today and in the future.

Three-quarters of the health care professionals are nurses. The stark reality is that Canada faces a severe shortage of nurses with the knowledge and skills to meet the future needs of Canadians. We have used the term “quiet crisis” to emphasize not only the gravity of the situation, but the fact that this problem has gone largely unrecognized by both governments and the public.

As necessary fiscal constraints resulted in profound changes within health care, the costs of restructuring have been high both for nurses and their patients. Many experienced nurses are leaving the profession and many new graduates have left Canada. Those who do stay are often demoralized and casualized.

Our latest statistics show that the number of nurses working part time and in casual jobs has increased from 34% in 1992 to 47.3% in 1997. That's almost half of our profession.

To clarify what we mean by “casual”, it's basically a nurse who is working in two, three or four different health institutions or clinics, and usually with no benefits whatsoever. One nurse in Ottawa explained to me recently that she works in three different emergency rooms, two of them attached to teaching hospitals, one a community emergency. The procedures, the physical plant, the people involved are completely different in those three settings, and yet the nurse has to know these things down pat or it could be a matter of life and death for someone who comes through the doors. So when you look at a profession in which half of the people are working under those kinds of conditions, it's a relatively serious matter.

The biggest impact that casual employment has in terms of quality of care is on the lack of continuity of care—that is, you don't have the same nurses working with patients and families over a period of time. And as an interesting analogy, imagine what your child's education would be like if he or she had a different teacher every day.

A year ago the CNA released a report predicting a shortage of nurses as great as 113,000 by the year 2011. The reasons for this relate to both supply and demand. The average age of nurses is growing. I think it's about 46 years at this point. There are far too few young nurses now and far too few young people entering the profession.

Our population in Canada is predicted to grow by 23% by the year 2011 and a significant proportion of that population is aging. We know that the demand for care increases with age.

You may ask why this is a national concern when the regulation in education of health professionals is a provincial or territorial matter. We've outlined a dozen reasons in our brief, which I will not repeat except to say there's a need for national leadership and vision in the area of health human resources. It is a vital concern to all Canadians.

Canada is not alone in facing such a crisis. A similar situation became so critical in countries such as England, Ireland and Australia that they were forced to strike national commissions to deal with the crisis after it had become disastrous. Let us learn from others' mistakes. They knew they were heading into a shortage and did nothing. We know and have time to act, but we must act now or we will not be able to offset this crisis.

• 1605

Our specific recommendations are modest in the context of the federal budget. We are asking that $40 million per year be allocated over the next five years to address this crisis.

Ten million dollars would be allocated to recruitment and retention strategies across the country, in the provinces and regions. This is an opportunity for the government to support the creation of literally thousands of jobs—knowledge-based jobs that our country needs for the next century's health care. We can't open hospital beds if there are no nurses. We can't move forward on new programs such as home care if there are no nurses. And specific underrepresented groups such as aboriginal students, men and members of multicultural communities must be targeted in our strategies.

An additional $20 million would support nursing research in recruitment and retention, but also to improve patient care and quality of life. While the cure side of health care is vitally important, so is the care side. Nursing research applications have often been ignored in traditional medical research granting processes, as nursing research deals with care, not with cure. Funding for nursing research would support the development of new home and community care programs and address such issues as chronic care as the population ages, palliative care, and pain and symptom management. Research would address new roles for nurses, including the expanding roles of nurses in providing primary health care. Using nurses appropriately in expanded roles offers the opportunity to reduce health care costs.

The remaining $10 million we're requesting would be to support the dissemination and uptake of evidence, using new technologies such as Canadian health infrastructure. Reaching out to Canada's 264,000 registered nurses, the development of a nursing knowledge network would support human resources research and the development of databases and would foster the sharing of evidence.

Ladies and gentlemen, as you carry out the difficult task of determining spending priorities for the next budget, on behalf of the nurses of Canada, I urge you to consider our brief in the context of a health investment. The Canadian public deserve quality care now and in the future. Thank you.

The Chairman: Thank you very much, Dr. Jeans.

Now we will hear from the National Federation of Nurses' Unions, Kathleen Connors, president. Welcome.

Ms. Kathleen Connors (President, National Federation of Nurses' Unions): Well, I think Mary Ellen and I get to provide the nursing one-two punch, and I think it's significant in that as Mary Ellen indicated to members of the committee, three-quarters of the care providers in the health care system are nurses.

I represent the portion of nurses who are on the front lines of health care and who happen to be unionized and work within the health care sector, be it in the acute care system, in large tertiary care centres, in rural and northern facilities, in long-term care, or in communities as public health and home care nurses. I think that front-line involvement in health care has truly allowed us to put our finger on the pulse of what's going on in the health care system, and it's quite fascinating to me that there is such a degree of unanimity within this health care panel that you're hearing today.

I have to say too, though, that we are members of the Canadian Labour Congress since January 1998, and as members, we do endorse the thrust of the Canadian Labour Congress submission to the committee that was made when they appeared before you as they dealt with other issues. But I think you will see very strong similarities in what labour is asking for and what we in the health care sector are requesting with respect to health care.

Certainly for our members, the testimony of what is happening out there on the front lines talks about the very significant impact of the federal reductions in transfer payments on the quality and the safety of health care. To address this, we have found that the most profound impact has occurred since the implementation of the Canada health and social transfer. The National Federation of Nurses' Unions would recommend that we scrap the CHST and move to establish a number of national social investment funds, each with its own funding formula appropriate to the social sector it covers, and each of the funds would have to have its national standards. I'm talking about a national health care fund, a national income support fund, and a post-secondary education fund to replace this CHST.

• 1610

With respect to providing funding for provincial health care programs, our members participated, as did many of the other groups in this room, in the national consultation that the federal government organized with respect to home care in the early months of 1998. People at that conference pleaded with the federal government to move on the home care issue, to establish a national home care program with strong national standards.

We believe you can't have a national home care program without having pharmacare, because when you throw somebody out of the hospital— and I mean, literally, people going home very early after surgery or tests and not being able to have care in the facility. When you're hospitalized, your drugs are paid for; when you're at home, you put your hand in your pocket and pay for those drugs. We firmly believe that any kind of move on home care has to be in lockstep with a pharmacare program. To that end, we believe there has to be dollars, and we're suggesting $2 billion for the home care and $1 billion for pharmacare, and then the $3 billion for the CHST payments.

One of the other issues on which we have come consistently before this committee—so it's for some of you who were here last year—is that the National Federation of Nurses' Unions has also asked for a federal grants program. You know how we built the hospitals of this country with a dollar for dollar matching; maybe this is the way we get the provinces to come in on home care and pharmacare. You match the federal dollar with a provincial dollar, and then you build the kind of infrastructure, but of course you do it under the standards of a national piece of legislation.

We too, like the Canadian Nurses Association, are very concerned about the health human resource issue, particularly as it relates to what is happening to nursing in Canada. Your own minister, the Minister of Health, said to nurses in June of this year: “No professional group has borne the brunt of health care restructuring more than have Canada's nurses.” The federal government has acknowledged it through the Minister of Health, and we're here to call on you to do something about it.

We want the federal government to begin developing a comprehensive national health and human resources strategy. We encourage the government to carefully consider the recommendations contained within the Canadian Nurses Association's brief. The recruitment, the retention issues have to be done; it has to be there.

Mary Ellen has said that it's a quiet crisis. I'm willing to tell you right now that it's not going to be quiet much longer. You watch what's going on at bargaining tables across the country. Nurses are turning up the heat because they're dropping like flies on the front lines as they're striving to give that health care, and we can't allow that to happen to any group of people in this country.

The human resource and public sector jobs do not rest just within the hospital sector. As nurses, we know full well that if you have a decent-paying job that has benefits, then nine times out of ten you're going to be healthy. So the cuts to the public sector have to stop everywhere, and that's at federal and provincial levels, and that means there has to be some leadership once again shown by the federal government in this area.

Another aspect with respect to issues the federal government can deal with is that of safe blood, food, drugs and medical devices. Simply and quite frankly, the recommendation is that the funding be restored to the Health Protection Branch at 1993-94 levels. We understand there is a consultation process currently occurring with respect to Health Protection Branch, but until that consultation process is complete, don't cut the funding; restore it to what it was before.

• 1615

We believe the health care system of Canada should not only be publicly funded but publicly delivered, and to that end we recommend that we look at how we can set up an arm's-length privatization alert group to look at where privatization is actually occurring in this country. We do not want private hospitals or private clinics established, as the Health Resources Group in Calgary is attempting to do.

National standards: We have recommendations with respect to that, and it's merely reporting more fully, enforcing, and monitoring what is going on.

We too, as nurses, believe there should be changes made to the Income Tax Act regulations so that nurses could be included in occupations that are granted special early retirement provisions because of the public safety aspect of the work we do. I think the levels of violence that nurses incur in the workplace are higher than those experienced by members of the police force, for example.

We have concerns with respect to the just terrible levels of aboriginal health, and we call on the government to look at recommending the important recommendations in the Royal Commission on Aboriginal Peoples as they relate to health care.

Last but not least, we are 97% women as nurses, and there has to be something done about how women's issues are being addressed in this country. I stand here today and say to you that the National Federation of Nurses' Unions will not have health care played off against pay equity for the Public Service Alliance of Canada. We want you to settle that dispute. Again, decent-paying jobs mean levels of health.

We are also very concerned with the decisions that were taken with respect to how funding for women's groups occurred. We want the federal government to return to core funding in the provision of a women's program budget and targeted funding to women and children who experience violence.

Our brief has more details, but I will conclude there. I certainly would be pleased to answer any of your questions. Thank you very much.

The Chairman: Thank you very much, Ms. Connors.

That concludes the presentations for the round table. Always, of course, one of the most interesting round tables is the one dedicated to health care.

We will now move to the question and answer session, and we will go to Mr. Epp.

Mr. Ken Epp (Elk Island, Ref.): Thank you.

I'd like to commend all of you for giving us not only a large amount of information but information that is well put together. I worked in the education sector for 31 years and I think you have presented your materials in such a way that they can be easily assimilated.

I have a question for all of you, and it's just a very simple question that you could probably answer with a nod of the head. In your opinion, has the quality of health care gone down in the last ten years in terms of the actual availability of medical procedures and care for patients? Yes or no?

The Chairman: We have a chorus to choose from.

Mr. Ken Epp: It has gone down?

Dr. Allon Reddoch: Yes.

Mr. Ken Epp: Who says yes? Let's see a show of hands. Who says no? So the rest of you don't know. Okay.

Well, maybe we'll need some comments on that. I'm just asking the question. As a member of Parliament, I receive complaints frequently from people who have tried to access the health care system who say “What's happening to it? It's going down the tube.” Yet I have other people say “Hey, I just went to the hospital and I've never had such good care in my life.” So maybe we'll need some comments.

The Chairman: Dr. Reddoch.

Dr. Allon Reddoch: Mr. Chairman, thank you.

I think the level of care Canadians are getting is good, but the real difficulty is in accessing that care. We're finding that the waiting lists are going up and up and up. Once you get to the head of the line, then you're getting good care. Part of that is because the doctors are working hard. You've heard the nursing groups talking about how hard-working they are, and I can attest to that. We are all working as hard as we can to try to provide that care, and in essence we've almost been insulating the Canadian public from this impending crisis because we've all been working so hard.

You've heard today that the nursing profession is close to the breaking point, that the medical profession has gone to the limits that we're able to go. In saying that the health care system is in crisis, we don't come lightly to the term, but we believe it quite strongly. I think this is the time something is going to have to happen.

• 1620

The Chairman: Ms. Sholzberg-Gray, followed by Dr. Jeans.

Ms. Sharon Sholzberg-Gray: With respect to the quality issue, I think people who are providing health care are just jumping through hoops at their own personal expense to provide Canadians with the best possible quality care they can in light of the resources they have. We do know that Canadians, of course, see that often when they enter hospital they are kicked out in 24 hours and are not referred to a home care program. Obviously, quality is suffering if someone is home alone taking care of themselves without somebody helping to take care of them. That's one example of a reduction in quality.

On the non-acute care side, most people know that unless you go to feed your relatives in a long-term care facility, your relatives might not be fed or might not be changed. That to me is a sign of reduced quality in the health care system.

We also have seen that in efforts to cut costs to budget and not have deficits, all kinds of hospitals and health facilities have had to cut certain things. Basically, they are trying to produce as much care and services with as low-paying a staff as possible. That really means, in some cases, casual help caring for patients.

Obviously, that type of thing is not the best thing for Canadians. We have to have clear standards as to what level of training is required for what kinds of care.

That's not to say Canadians should be alarmed, because we're not trying to say that they're at risk when they go into health care or health care facilities, or retain health services. What we're trying to say is that the system is doing beyond the call of duty with the resources available, and that if we don't do something to reinvest we're going to have a real crisis in the future.

You might also want to speak to the Canadian Council on Health Facilities Accreditation, which accredits health services and health facilities across this country. I think they might say that in terms of their accreditation processes, they're starting to see problems with quality. I think that should be of some concern to Canadians.

The Chairman: Dr. Jeans.

Dr. Mary Ellen Jeans: Thank you.

Thank you for the question, sir. You mentioned that you were an educator. You may remember, as I do, when our educational institutions used to have a school nurse. Today, one nurse is asked to serve 17 to 20 different schools. There is no possibility that the quality of care of the children in those schools, identifying children at risk and so on, can be anywhere near what it was 10 to 15 years ago.

I'd also like to point out that in addition to public polls that report diminishing quality a couple of other things are happening. One is that there is mounting evidence now that the more registered nurses you have working in the system, the fewer negative patient outcomes that exist.

For example, for people who are discharged early from hospital and who go home without home care, more of those people are readmitted to hospital with infections and other kinds of complications. A number of studies are going on throughout the world, actually, studying the relationship of knowledgeable health care providers and the quality of patient outcomes. We need to do more of this in Canada.

I also point out that recently you could read in the press about the rising infection rates in many of our hospitals. People make ridiculous statements, such as the nurses being so busy they don't have time to wash their hands. The fact of the matter is, there aren't enough nurses, and there are people providing care with no knowledge whatsoever of microbiology. So the quality of care is definitely diminishing.

The Chairman: Thank you, Dr. Jeans. Dr. Alexander.

Dr. Taylor Alexander: I would just like to echo and add to some comments. Ms. Sholzberg-Gray mentioned a moment ago the area of home care, for example, and the serious issue with regard to the caps that provinces place on the numbers of hours they will compensate agencies for in terms of providing services.

We are hearing stories of home support workers, for example, coming in on their own time, after hours, to make sure the individual is well and doesn't require any additional services. They are often filling gaps at great personal inconvenience and expense to themselves, for free. These are individuals who themselves have a very low income.

The other dimension to that is the whole issue of recruitment and retention of individuals such as home support workers, because wage rates are typically very low across the country. There's a problem with staff turnover, which impacts on the issue of continuity of care, as Dr. Jeans recently mentioned. It's a serious issue that also has to be addressed. So these are other ways that the current climate is impacting on quality, which may not be as apparent at the outset.

• 1625

The Chairman: Thank you.

Mr. Ken Epp: I have another question.

The Chairman: This is your final question.

Mr. Ken Epp: I know the answer to this, but I want to get it on the record and maybe some of you then can tell us: Is there empirical evidence that our waiting lists are longer, or is that just a gut feeling?

The Chairman: Ms. Connors.

Ms. Kathleen Connors: I think it depends which report you read with respect to waiting lists. Certainly the Fraser Institute would have us believe that the waiting lists are getting longer, but I've also seen another more recent report that I think refutes some of that.

I think the issue for Canadians— and again, while we as nurses are blowing the whistle on the safety and quality, the reality is that because we have a publicly funded, publicly delivered acute care system in this country, if you were acutely ill in Canada and requiring care, the care is there and I believe it is world class.

It is world class because the health care providers in there quite often take the toll on their own personal health to ensure that the care is there. Care is more than the physical care; it's the patient teaching, the emotional and psychological support of the individual and the family that is with that individual, those things. When it can't be done, when there's only time in a day to do the physical kind of care, that's when it takes a toll on the professions that are working in the system, with respect to feelings like “I know I should have done more” and “What if something were to happen?”—those kinds of concerns.

The waiting list issue is a difficult one. But I can tell you that in New Zealand, before they moved to a public-private mix in the health care system, waiting lists were escalating. Since they've changed the way and have introduced the private sector into the system, waiting lists have doubled. How the New Zealand government dealt with it is they've changed the criteria for how you get on their waiting lists. So it's a fascinating scenario, and to point to waiting lists I think we have to be somewhat cautious.

The Chairman: Thank you very much, Ms. Connors.

Thank you, Mr. Epp. You get ten minutes.

Mr. Ken Epp: I'm at that, so I'd like to conclude with a little statement.

I have the privilege of having been born in a jurisdiction in Saskatchewan where I think the first public health care system started. As far as I know, the Swift Current health unit was the first one, way back in the 1940s, and that's where I was born.

So I've long been an advocate of a solid health care system, and it may come as a surprise to you because of all of the negative rhetoric we get that one of the things that attracted me to the party to which I belong is that they believe in doing government right, so that we do have the financial resources to provide those programs that Canadians truly value. And right at the top of the list is health care.

With that, I'll end. Thanks.

The Chairman: That's a comment. You don't want a response from anybody.

Mr. Ken Epp: That's a comment, unless they want to say they support what I've said.

The Chairman: Okay, we'll move right along.

Madame Picard.

[Translation]

Ms. Pauline Picard (Drummond, BQ): I'd like to welcome all of the witnesses representing various health care organizations.

Earlier on, someone stated that our health care system was in crisis. Yet, in the past, everyone agreed—and I agree with you that the health care system is in crisis—that the provinces launched health care reform, not simply on a whim, but because they had no choice given the aging of the population, new technologies, higher drug costs and so forth.

All of the provinces initiated health care reform under very difficult circumstances owing to budget cutbacks. They themselves were forced to reduce health care administration costs and to make other cuts in conjunction with other reforms. This proved to be very difficult because the federal government reduced the Canadian Social Transfer. You yourself have said that a total of $6 billion has been cut from the overall health care budget.

• 1630

This is an astounding amount of money and the provinces are currently having a very hard time upholding the five major health care principles. All of these cutbacks—and Ms. Mary Ellen Jeans talked to us about this earlier—have an impact on human resources.

Provincial premiers have now agreed to ask the federal government to reinvest in health care through the Canadian Social Transfer.

What's going to happen if the federal government fails to heed the call to reinvest in health care? How will surplus budget funds be used? What's going to happen to the five important Canadian principles, principles to which the Canadian public holds dear and which are part of our social values?

[English]

The Chairman: Who would like to comment? Mr. Landry.

[Translation]

Dr. Léo-Paul Landry (Secretary-General, Canadian Medical Association): That's an important question. What will happen if the federal government turns a deaf ear to the provinces? That all depends on whether you consider things from a political or from a health care standpoint. The level of health care provided must also be considered. Today, we are presenting more or less a united front to the committee. Even though some of us had never met before today, we are here to deliver to you a message from the Canadian public, namely that health care should be your top priority.

There are two problems to contend with: first of all, a lack of confidence in the health care system, and secondly, the problem of accessibility. What's going to happen if the federal government ignores this message? The public will continue to lack confidence in the system and accessibility problems will undoubtedly worsen in view of the factors that you listed earlier, namely the aging of the population and rising demographics. Another point worth mentioning is this: Canada ranks 23rd among the 28 OECD countries. We have the figures for 27 countries, and Canada's health care system has become the most privatized of all.

If governments continue to withdraw from health care funding, the void left behind will be so great that ultimately, we will end up with the very thing we don't want, that is a privatized health care system along the lines of the American one.

My colleagues and I are saying that the Canadian government can't afford to ignore any longer the message that the public and all health care stakeholders are sending out.

However, it is reassuring to hear the Prime Minister say that these five principles are not negotiable, because that is precisely our position. Therefore, something has to happen, not in two or three years' time, but when the 1999 budget is brought down.

The Chairman: Do you have any further questions, Ms. Picard?

Ms. Pauline Picard: No, that's all.

[English]

The Chairman: Ms. Wasylycia-Leis.

Ms. Judy Wasylycia-Leis (Winnipeg North Centre, NDP): Thank you, Mr. Chairperson.

I would like to begin by acknowledging what's happening here today, what I see as unprecedented unanimity of opinion and determination from every aspect of our health care system. I think for the first time we are seeing doctors, nurses, professional associations, health care associations, hospitals, along with the Canadian public and all provincial governments saying one thing, that we have an urgent situation in our health care system today and there has to be, as I read and hear what you're saying today, an immediate and minimal injection of $2.5 billion, or more if possible, in health cash transfer payments from the federal government.

The other thing that's important to note, Mr. Chairperson, is the kind of urgency you bring to these discussions. You're certainly reflecting what many of us have heard from constituents over the last year or more, such as people's concerns about waiting lists, access to quality services, ability to access diagnostic services, and emergency situations. I think that's the kind of sentiment we have to use to convince the federal government that this is real and that we have to find a way to deal with it immediately. So I'm very encouraged by what you all have to say.

• 1635

I think trial balloons are floating around, and we're hearing now from the federal government that we should not expect a massive injection. It might be even less than $1 billion, and we may not have the kind of health care budget we need for 1999. So my question is, if we get less then a $2 billion to $3 billion injection in this budget, what will it mean in terms of the ability of medicare to survive? What will it do in terms of creating even more of a two-tier health care system and the eventual erosion of public support for universally accessible, single-parent health care? What can you tell us we need to do in terms of convincing Liberal members of Parliament that this is absolutely imperative?

My questions are addressed to anyone who's interested in answering. I'm looking for advice from all fronts.

The Chairman: Dr. Jeans.

Dr. Mary Ellen Jeans: The first answer is that you will continue to see increasing privatization. We know that care is becoming more and more ambulatory, and we know that people are being discharged early and so on. The fastest-growing private enterprise will be home care. It is not at the moment covered by medicare in any standard way across the country. Some provinces have made changes and others have not. But privatization is the fastest-growing area. I think that you'll continue to see that grow and to see the quality of care diminish.

Certainly our position is that we'll stay the course. We'll continue to ask for what we believe to be a responsible position, which we've all taken around the CHST. We're not asking for the $6 billion to be put back. We're trying to be reasonable, and we're trying to stop the erosion and the increase of privatization, which is now in excess of 30%.

The Chairman: Ms. Sholzberg-Gray.

Ms. Sharon Sholzberg-Gray: I'd like to say that I perfectly agree with the remarks of my co-chair of the Health Action Lobby, Mary Ellen Jeans. I'd just like to add one or two points that aren't always very clear to Canadians.

I think Canadians think they have a medicare system that covers the entire continuum of care, and they usually don't find out they don't have that until they have to access the parts of care that aren't part of medicare.

So on the one side it's our very strongly held principle that there has to exist a medicare system with access to quality care on the acute care hospital, physician-based side. That side has been cut terribly in recent years, and we have to ensure that there's enough money to ensure access and quality.

But so much less is being done in hospitals than used to be done years ago. Years ago long-term care patients used to be able to stay in hospital as long as they wanted, and people who had procedures done on an out-patient basis or through pharmaceuticals used to stay in hospital, so they had medicare. Of course, medicare is disappearing as more and more is being done outside of hospitals, and the government really has to recognize that by ensuring there's a single-tier system across the continuum. Right now, of course, we have a two-tier system. We have a single-tier system on the acute care side and a two-tier system on the other side. And what we're saying is that Canadians expect medicare across the continuum, and somehow the federal and provincial governments have to get together to ensure that's the case for Canadians.

We have to make sure, of course, that we have not just $0.5 billion or $1 billion but really the $2.5 billion we're asking for for the existing health care system, which even now extends way beyond hospitals and physicians, and $1 billion to ensure that Canadians, wherever they live in this country, have access to the services that are now being provided outside of hospitals.

It's unfair, for instance, that in some provinces people get home care without co-payments or get an automatic referral, whereas in some provinces they don't. It's unfair that in the maritime provinces people pay $3,000 or $4,000 a month in co-payments for long-term care and are tested against their assets and their income, but in other provinces—let's say Ontario—they get their long-term care for $1,200 a month. This is not what we mean by reasonably comparable access to health services.

Is it fair that if you have a procedure related to heart disease or cancer and ongoing needs in that regard somehow the medicare system covers you, but if you have Alzheimer's disease—and we all know that disease is going to be more prevalent with the growth of our aging population—by and large it is not covered in our medicare system?

So we have to find ways of making sure that the existing system is there for all Canadians across the continuum. And the only way to do that and to ensure comparable access is for the federal government to invest. If it doesn't, Mary Ellen's suggestion of increased privatization will certainly take place. It's bad enough that we're already close to the highest private spender among the OECD countries

• 1640

The Chairman: Dr. Alexander.

Dr. Taylor Alexander: I would just add to Ms. Sholzberg-Gray's comments that according to some estimates, there are currently between 500,000 and 800,000 Canadians receiving home care services—and that estimate is considered conservative. Of that number, approximately two-thirds are seniors, and that number is expected to double within the next three to five years. Public spending on home care currently is a very small proportion of the total amount of health care. Without an injection of cash into the home care system, I think the kind of scenario that you've referred to is very likely indeed.

The Chairman: Dr. Reddoch.

Dr. Allon Reddoch: Thank you.

I think you've summarized the situation very well, but I'd like to bring it down to a little bit more personal level with a couple of anecdotes.

I recognize that we have to get down to evidence, but I have a friend in Ontario whose father has been losing the ability to use his legs. He went to see a neurologist, who said that he really needed an MRI because he might have a slow-growing tumour in his spinal cord. This was in August. The earliest appointment is April 1999. That's totally unacceptable.

In my own practice, I had a patient this summer who had a spot on her lung. It showed up on an X-ray. My worry—and hers, of course—was that this may very well be lung cancer. If it is, she needs to know and she needs treatment very quickly. In the past I was able to access the specialized care in Vancouver quite quickly. She was on a six-week waiting list. Despite all my callings and protestations, which in the past allowed allowed me to move her up in the queue, she ended up waiting six weeks while suffering from not knowing whether or not she had this malignancy.

You were asking what we can do. We're doing our part. We're bringing the information to you, the people who can make the decision, but I think what's going to happen is that the Canadian public is going to say we can't put up with this suffering in the system. There has to be some reinfusion of funding.

The Chairman: Ms. Connors.

Ms. Kathleen Connors: With respect to the comments made around the emerging home care issue, I think the thing of importance is strong national standards. Put in place a home care program like the one that exists and is delivered through the CLSC system in Quebec, or the Manitoba home care system in which there are no co-pays and which is a publicly funded, publicly delivered system. There are models that exist in this country that need to be moved and implemented, where we have the kinds of medical devices and supports through pharmaceuticals. Those kinds of provisions have to be there.

We don't need to go looking elsewhere in the world. There are models in existence. I can tell you, though, that if it isn't publicly funded, publicly delivered home care, long-term care and acute care, you're going to have things like those that exist in Ontario, where home care nurses are working for $12 an hour as compared to the $18 to $20 an hour that the hospital nurses are getting. They work for 48 hours a week in a casual position without access to pension benefits, without access to overtime. The private companies, many of which are based in the U.S., see a lucrative market in our country. They are going to come here to provide those kinds of programs because the political will to deliver home care in a publicly funded, publicly delivered system isn't apparent in certain provincial governments.

I think the importance of strong national standards and leadership on the part of the federal government is absolutely incumbent here. If you're going to have a scrap with the provinces, I can tell you that Canadians are with you on this scrap. We want those kinds of national standards. The polling is there talking about those kinds of things. It's a matter of political courage.

The Chairman: Thank you, Ms. Connors.

Ms. Bennett.

• 1645

Ms. Carolyn Bennett (St. Paul's, Lib.): Thank you all.

As you know, one of my concerns has been that the Canada Health Act in its five principles presumed high-quality care, and that when we talked about accessibility and portability, it didn't presume that provinces could give a huge tax cut and bargain-basement care. My concern is that now, as we start negotiations in terms of a social union, it's the first time we've heard the word “accountability”. I think it's an exciting time, but I think we as the government will require your help. Even the Prime Minister is beginning to talk about report cards.

I think some of us who have been on the receiving end of some of those report cards have some concerns that unless the consumers are consulted and unless family doctors are consulted, what looks like a report card— As the Canadian Healthcare Association would tell you, in Ontario the average length of stay includes the people who die. So if you have a terrible unit and lots of people dying, that looks like a good unit, because the length of stay is really short.

We have all kinds of examples where if people aren't very careful about how things are related— I think some of us as family doctors, even at the CMA convention, were concerned that when you look at cardiac care units, cardiac care waiting lists run by tertiary cardiologists start measuring after people have had their angiogram. They don't start measuring at the first chest pain. We aren't measuring how long it took to get to the GP, to the primary cardiologist, and to the secondary cardiologist to get that angiogram done. So unless we, as we start to look at how we measure, start involving consumers—

I guess I would like to know from the people here how far along they are, in their various groups, in helping us with this whole hope for a national standard, or an ability for the government to yank the chains of places where they're putting the money in the wrong place.

My second question is that we know there still is some duplication. There are some patients who are getting the same test four times because we have such poor information systems and connectivity amongst GPs' offices. Nobody can find the results.

How do we begin the whole business of measuring, and how will we make sure that when we design report cards, they don't just alarm consumers but actually increase the confidence of consumers in terms of people being able to see what's going on?

The Chairman: Dr. Reddoch.

Dr. Allon Reddoch: For the past year one of our major priorities has been a project called Access to Quality Health Care, which has been designed to try to get the objective evidence you've described. That requires co-operation on different levels, and that's the stage we're at now. We're certainly willing to work with any groups to try to be able to develop the objective criteria required.

Ms. Carolyn Bennett: Are the guidelines you've done part of—

Dr. Allon Reddoch: Our project on quality health care has been quite well developed.

Ms. Carolyn Bennett: Are there any consumers on the committee?

Dr. Allon Reddoch: I don't believe so, but we're still at the development stage. As I say, we require co-operation at different levels, including governments. We want to try to get that started, but we think that's really critical. We're talking about public accountability and visibility. We want things to be objective, not just anecdotal.

The Chairman: Dr. Jeans.

Dr. Mary Ellen Jeans: I just wanted to respond to your question, Dr. Bennett, by expanding it a little bit. You're absolutely right, we don't have the health infrastructure at the moment, but as you probably know, the federal Minister of Health struck an advisory council on health infrastructure last year.

• 1650

Ms. Carolyn Bennett: Are there any patients or family doctors on that council?

Dr. Mary Ellen Jeans: There are members of the public on the committee. I'm on the committee and there are physicians on the committee, as well as a number of other people.

One of the working groups is about consumer input. We are trying to do consultations across the country with consumer organizations to ensure that consumers are at the heart of it. What we in Canada have to get our heads around is the fact that the patient or the member of the public has to be at the centre. I really don't like the words “client” or “user” because none of us set out to purchase health care. The patient or the member of the public has to be at the centre and the money has to follow the person, not our turf battles.

I also want to point out, and I would beg the committee to understand this, that health information isn't just physician information. We talked to CIHI, the Canadian Institute for Health Information, and said that we also need to have the nursing aspects of health information in there, because, as I said earlier, three-quarters of health professionals are nurses and we collect a lot of information. Physicians and nurses and all of us in the health system need support to develop these information systems so the public can have access to that outcome data. Then the public can make decisions about us doing a good job, not just as a system but as professionals.

Ms. Carolyn Bennett: Has that committee looked at the SF-36 out of the HMOs, the patient satisfaction questionnaire? Should patients and clients or the public have a way of evaluating how their health care is being delivered at each interaction with the system?

Dr. Mary Ellen Jeans: That's one of the things that we have under discussion. We're discussing how to make that happen effectively and how to empower the public to participate in the policy decisions themselves.

Ms. Carolyn Bennett: You gave a figure of 47% casual and part-time. Some of my patients who are working in that area have actually chosen that because it is more in keeping with their family life. Can you break that down with respect to the people doing that against their will?

Dr. Mary Ellen Jeans: I think “casual” is not something anybody chooses to do.

Ms. Carolyn Bennett: Yes.

Dr. Mary Ellen Jeans: For part-time, I agree. Obviously, a lot of your own colleagues—

Ms. Carolyn Bennett: Particularly in home care.

Dr. Mary Ellen Jeans: And particularly women. Women physicians and women nurses, if they are raising families, do often choose part-time work.

But one-quarter of my number is casual. I know that my colleague, Kathleen, can probably speak even more passionately to that than I can, but one-quarter of them are casual and that's significant in such a large profession.

Ms. Carolyn Bennett: I'll just ask you about this CHST business as well. You are now proposing separate funds. One of the problems in government is that we already have a problem with silos, and if we're actually going to be talking about social determinates of health, why wouldn't we want to bundle these two things together? We would be dealing with poverty all together so that there would actually be an incentive in terms of being able to ultimately afford a health care system by putting some dollars into prevention.

Ms. Kathleen Connors: I want to take a crack at that question, but I also want to respond to the issue of the casuals and to one other broader issue. I will try to be succinct.

With respect to the silos that you're talking about, one of the realities—and I think all of us within the health care sector will acknowledge it—is probably that the health care sector vis-à-vis post-secondary education vis-à-vis income support does better. And we know that with respect to the social determinants of health, when you don't put the money there—and certainly, millions of dollars have been yanked out of social services programs and we don't have the money there—that ultimately comes back into costs in the health care sector. If people have not had adequate food and housing and that sort of thing, that's where it comes in. So let's set up those silos—somewhat—but they have to be talking to each other.

With respect to casualization, I can tell you that for just about every newly graduated nurse in this country for the last five years, the only employment he or she was able to obtain in this country was casual employment, working full-time hours without benefits. It was either that or go south of the border. There are nurses filling part-time positions who want full-time employment and simply cannot get it. It's more cost-effective for the employers to have a contingent workforce that's available on an on-call basis so they don't have to have the so-called minimum full-time staffing level and can bring them in on an on-call basis. For women to have an income, they work for two or three employers, they're available, all those sorts of things.

• 1655

My last comment is with respect to your asking how we could help you with respect to the national standards and those issues. The whole discussion around the social union has to become much more transparent. I'd like to see the federal government's response and position on the social union. I'd like to see the position of some of the provinces.

If you will make the process with respect to the discussion of the social union accountable and transparent, then Canadians will be supportive of saying why there needs to be national legislation, national standards, national involvement and leadership and support for the funding. I think there are some interesting statistics to suggest that people are supportive of putting money into health care rather than tax cuts. I think the Registered Nurses' Association of Ontario had some polling data around that very interesting fact, too.

Ms. Carolyn Bennett: I don't want to let the dentists off.

I was in Banff recently at the Federation of Medical Women meeting and two pediatricians came to me who I think were politically aligned with the loyal opposition in that they were very worried about the debt; but they were also very worried that the last four admissions they'd had were for dental abscesses in children. I'd like to know, on the prevention side, how many Canadians do you believe can't afford to go to the dentist?

Dr. Raymond Wenn (Member, Government Relations Steering Committee, Canadian Dental Association): I'm not so sure we have a number we can just pull out of our heads to tell you that.

Ms. Carolyn Bennett: How many have a dental plan?

Dr. Raymond Wenn: Oh, a very high number have dental plans. We're probably upwards of 80% or higher, and we're working on that trying to drive it higher all the time.

Ms. Carolyn Bennett: And what are we doing for the 20%?

Dr. Raymond Wenn: Well, 80% is a rough number. Our last time here we've shown you that it is probably closer to 88%. We're working with other groups, CLHIA and CFIB, and other national groups to try to provide even more dental plans at a reasonable cost so people can be covered.

We've been very quiet here today because the whole left side of the table here is dealing with the public funding of health care in this country, and we would never argue with what's been said here. We don't have the qualifications to discuss this. But in general you have to take into account, too, that there are only so many dollars to be spent on health care in this country. If 70% is publicly funded and roughly 30% is privately funded, and if that ratio changes, more money then has to come out of the private pocket. Let's say it goes to 60-40, 40% out of the private pocket; eventually it's going to affect the ability of Canadians to pay for their dental care. There are only so many dollars to spend on health care.

Ms. Carolyn Bennett: You must admit that if people are being admitted to hospital for dental abscesses, that is coming out of the public side.

Dr. Raymond Wenn: Yes, but I'm not too sure that's a very large number of people, and I have no way of pulling that number off the top of my head.

Ms. Carolyn Bennett: It's certainly a huge problem in the homeless population too, right? Dental care is, I think, one of the biggest problems the metro task force is looking at—I think probably because Anne Golden's husband is a dentist.

Dr. Raymond Wenn: We certainly couldn't argue with that. There are certain segments of our society that definitely have great difficulty accessing dental care, because it isn't publicly funded.

Ms. Carolyn Bennett: Right.

Dr. Raymond Wenn: That's a given.

Ms. Carolyn Bennett: Is it a given?

Dr. Raymond Wenn: Well, it's a given at this point in history.

Ms. Carolyn Bennett: Well, that's what we're here for.

Dr. Raymond Wenn: If you want to discuss the possibility of the government being involved in public funding of dental care, that's a whole different issue. It would take a lot of the discussion to try to work out those types of plans.

Ms. Carolyn Bennett: Okay. Well, hopefully we'll be here for awhile.

The other thing was pharmacare. I believe only 12% of Canadians don't have a drug plan.

Ms. Kathleen Connors: I think there was considerable discussion around what percentage of the Canadian population is not covered. I think, quite frankly, the number covered by dental plans is high. I think it's lower than that. I think the number not covered by supplementary health benefits is considerably lower. With the job losses and the move into individual employment, there has been a substantial loss of third-party coverage for supplementary health benefits, including dental care. I think those numbers are increasing.

• 1700

I happen to believe, as does our organization, that we should cover dental and pharmacy. That was the dream way back in Swift Current. Tommy Douglas believed all aspects of health care should be covered under a comprehensive, universal health care plan. He said the hospital and the medical services were the first step, and that we'd then have to introduce the others. Well, I think the time is quickly coming when we have to have this kind of debate.

The Chairman: I just have a question in reference to information, the availability of data and all sorts of things. It's not just with this issue, because with practically everything that comes in front of this committee there are people with different numbers on most issues. We see it in the bank merger situation. We see it with health care today. There's admission that perhaps the information networks aren't really functioning as well as they should. As a nation, when are we going to develop an information system that is standardized so that we, as committee members, can actually look at real numbers that people agree with; so that we can make decisions that make sense to most Canadians?

I can tell you that health care is a very important issue for Canadians. I think everybody knows that. But when it comes to numbers and statistics, we get hit from all sides. I'm just wondering whether or not you, as professionals, should dedicate a little more time to making sure—and this goes for the government as well—we clearly identify the players, the percentages, the statistics, the numbers on this particular issue and many other issues.

Ms. Carolyn Bennett: Maybe we could ask Mary Ellen. Based on the work you're doing on that health information subcommittee, do you think that if you came up with a plan on how we would get this country connected in terms of health care, all of the health care groups would support it? Or would they say they don't want that, they want dollars in direct patient care?

Dr. Mary Ellen Jeans: I think they'd say they want both.

There's no question we need the system. Even with the numbers we presented on the nursing human resource issue, we are relatively confident in those numbers because our federation collects the numbers and has analyzed them and so on. But there are lots of numbers for which we simply don't have accurate data.

I think the role of the advisory committee is to make recommendations, but there's no question that for us to be connected—and I think most of the health care professionals would support this, because we all need that information to make decisions ourselves—it's going to cost money. I would hate to be in the position of you folks, having to ask what we do first.

There are arguments that if we had a health information system, we could probably save money. If we could really make decisions based on accurate information, chances are we would save money in the long term. But if I had to ask what I would do this year—invest in health infrastructure or invest in patient services—that's really between a rock and a hard place.

Ms. Carolyn Bennett: Is it that there is no right year to do health information? If it's always going to be put up against patient care, we have to do it.

Dr. Mary Ellen Jeans: We have to do it. Maybe there are ways to at least start it and to share some of the costs of doing it. In our brief, we're asking for some funding to help with that, but it'll cost far more than what we're asking for. I'm speaking on behalf of the nurses of Canada, who will also contribute financially to make this happen.

The Chairman: This raises the important point about funding. Is it $2.5 billion you're asking for? What's that based on? What sort of criteria are we looking at? Why $2.5 billion? Why not $3.5 billion? Why not $5 billion?

Ms. Sharon Sholzberg-Gray: I could tell you that if you'd like.

First of all, we all know the National Forum on Health said there is no magic number. They said they wanted a $12.5 billion cash floor at the time when the cash floor was only $11 billion and there were further cuts to take place. They also said that figure was just latched onto because it was to prevent future cuts. It said recently, remember, that the $12.5 billion is a floor and not a ceiling. This meant it wasn't necessarily so that $12.5 billion is written in stone.

• 1705

We're saying that we have now identified a number of needs, and I could list them for you right now. Shortfalls in the budgets of hospitals and regional health authorities and health agencies: If you're doing deficit financing to meet the needs of Canadians and the money is not there, somehow those deficits have to be covered.

We can't have a country in which there exist disparities across the country in terms of insured services and non-insured services. We have to invest some money to make sure there's some kind of evening out.

There are all kinds of administrative demands on the health care system right now that we have to meet. We haven't been talking about the year 2000 needs. The change in the health care system required to meet those needs is going to be extraordinary.

We don't want people to be paid less than what is due. We don't want the casualization of workers. Labour agreements resulting in increased salary levels are going to be entered into and those labour agreements have to be met. If, for instance, you increase hospital budgets 4.5%, that would be break-even in terms of labour agreements in the year 2000 and we will be serving increased populations.

The information system demands we've already talked about. How, for instance, are health facilities and hospitals going to cope with the increased demands put on them to provide information on a new safe blood system—the follow up, the trace backs? You're asking where the $2.5 billion is needed. Capital expenditures will be needed as we go through restructuring in all parts of the country. An aging population I've mentioned, a growing population. There are also improvements and innovations like new technology and new pharmaceuticals.

You are asking why $2.5 billion? I don't think $2.5 billion is going to cover this list of needs. We're trying to be fiscally responsible, so we're only asking for $2.5 billion for the CHST and we're asking for another $1 billion to extend the continuum in a fair way. We probably need more, and I don't think we can really do with less if we're to meet these needs.

In terms of numbers, I think it all depends too on how you use the numbers. A lot of people say, gee, we spent $76.6 billion a year on health care. We did in 1997, and that's a lot. Of course they don't tell you that includes the private spending, which is almost 32% of the total and growing. So you have to know what is the appropriate public amount. It seems to me that we're not there yet. The amount we're talking about is approaching the amount that's needed.

When people say we spend 9.2% of our GDP on health—we're now fifth, no longer second, in big spending—remember that includes private sector spending. In terms of public sector spending, we're very low indeed as compared to comparable countries.

So I think there's room to say that $2.5 billion isn't a magic number plucked from the sky. It's a realistic number given the fact that $6 billion was cut.

The Chairman: Okay. Mr. Szabo.

Mr. Paul Szabo (Mississauga South, Lib.): Thank you, Mr. Chairman. I wanted to cover a gamut of things as well, but we're going to go have a vote soon so I want to get on to my question.

We all know that the federal government is not the health care deliverer by itself. We're in partnership with health care professions as well as with the provinces. There are numerous examples of cases where everybody could probably make a better contribution to the ultimate care of Canadians, when you consider, for instance, the tax cut in the province of Ontario of $4.3 billion and the reduction of the CHST to Ontario's $1.2 billion. Priorities tend to get skewed for different reasons, but Canadians have made it very clear, and I think your interventions today have made it very clear, that this is going to be a health budget and it should be a health budget. We deserve it.

I did want, however, to ask for your help and your opinion with regard to one aspect of the National Forum on Health reports. They stated that there was a critical need to invest in children. Physical, mental and social health outcomes of children are of deep concern to the National Forum on Health.

These are not the kinds of things you've been talking about, about meeting the acute care needs of Canadians, but the preventative component of the health care system can't be ignored, so I ask for anyone who cares to table their thoughts. I think it's important for the health minister, for the finance minister, for Parliament to know how you feel about investing in children as a component of Canada's health system.

The Chairman: Dr. Jeans.

Dr. Léo-Paul Landry: I'd like to jump in. Although I'm a few years removed from that, it was part of my life for a good number of years.

First of all, let me say that we have made a statement about that today in relation to nursing. Mary Ellen Jeans clearly said that we used to have one nurse per institution; now it's 17 to 20. That quality of care has really gone down because it has disappeared. That's number one.

• 1710

Number two, it also starts with food at home and food at school. The neuropsychological development of kids is critically important to their well-being later on, but that's part of a whole list of needs that are not adequately addressed, and to which Mary Ellen alluded in giving the example of nursing awhile ago. So, absolutely, that's one of the list of things that needs to be looked at. We didn't get into that list, but I'm sure everybody around the table can get into it. It's critically important, and that has been recognized internationally.

Dr. Mary Ellen Jeans: I would just add to that, Mr. Szabo. I think you know we are committed to the health of children, both from the Health Action Lobby position, from all of our separate particular concerns that we have in moving to the broader continuum of health care, and in supporting health promotion, disease prevention. Children have to be at the focus of those things.

We're all committed to the health of Canadians, not just the health care of Canadians. The next generation of Canadians needs to have that kind of investment. I believe that's a part of what we all mean when we talk about expanding that continuum and putting resources into things like public health, looking after our kids, and the broader determinants are a part of that.

Mr. Paul Szabo: Thanks, Mr. Chairman.

The Chairman: Another colleague wants a question.

Mrs. Karen Redman (Kitchener Centre, Lib.): Thank you, Mr. Chairman.

When we travelled across Canada last year in the pre-budget hearings, we did hear that wrestling down the deficit had come at a cost to Canadians. One of the things that came up time and again was the CHST, whether it was the social aspect, the welfare aspect, or the education aspect, and certainly health was spotlighted. We did hear that we should not just put more money into the CHST—and that was not only in one province, but I would tell you several. We heard that we should put strings on it, colour-code it, make sure it's directed at health care. That theme has been heard by people other than health care professionals who deliver the service.

The question I really have—I don't know if it's been answered—is whether there are other models that would serve Canadians better than the current system that we have. I've heard a couple of people refer to studying some that have and haven't worked, but are there models we can look at as Canadians besides merely just putting more money on the CHST? I know Ms. Connors has talked about some other strategies, but are there other ways to apply money to health care that are going to make sure it continues to be a universal medicare system for all Canadians?

Ms. Sharon Sholzberg-Gray: First of all, I know the federal government probably is having second thoughts about the CHST, and there are some people around this table who could sit here and say we told you so. Before the government introduced the CHST, we were quite hostile to the notion of a big block transfer attached merely to the five conditions in the Canada Health Act and very minor conditions applied to social programs generally. Of course, now that you're faced with the CHST, it's really the only game in town as we sit here right now. If you want to transfer money to the provinces for health and social services with strings, with conditions, the only conditions that there are today are the Canada Health Act conditions, the non-residency requirement conditions, and other very minor ones that used to apply to CAP.

You might want to take a look at adding more conditionality to the CHST. My guess is that you can't add more conditionality without raising the CHST. It seems to me it would not be politically appropriate to tell the provinces you're not giving them more money, but here are some more conditions. I think that's really a problem.

As to whether you could do something other than the CHST—which, it must be remembered, is a block transfer and not a shared-cost transfer—I think it's probably true the days of shared-cost programs or new ones are pretty well over. I don't really see that happening very much in the context of the social union. It's possible one could come to some agreement—for instance, on extending the continuum of care. On the other hand, you could do it by a block transfer with conditions as well.

I think there is a whole issue around what conditions should be attached to transfers; whether or not the provinces will accept the cash in return for carrying out those programs; whether you can opt out; whether you opt out on condition that you have a program with similar objectives—and in that case, is it really opting out if the conditions are sort of broadly defined in any event? All of those things really have to be determined at the social union.

• 1715

The reality is that the CHST might not be the best thing, but it's the only thing we have now. You could presumably add another piece of legislation alongside the Canada Health Act that would assert more conditionality, but as I say, that's not something you could do unless you added more money. Of course we're asking for more money, so hopefully that's one way of doing it.

We at the Health Action Lobby proposed to Health Canada that we do a project to investigate the various ways by which the federal government could transfer moneys to the provinces for health and social services and assert some kind of conditionality that would assure Canadians of access to comparable services across this country. We didn't get any financial support for doing that, but it's something we feel has to be done, if it's not being done internally within government, because clearly the CHST isn't the desired vessel for social programs and health programs in this country.

I don't have an easy answer, but I certainly know how to talk about the problems.

The Chairman: Thank you. Dr. Landry.

Dr. Léo-Paul Landry: I would just add to what President Allon Reddoch said awhile ago. Maybe the focus of all of these debates has to change from one of how to package the funding, whether it's within the CHST or outside and all of that, to a focus on need first of all. The Canadian Medical Association, over the last number of months, has picked up on the challenge given to it at last year's meeting by Mr. Allan Rock and developed the clinical governance approach, which is basically called our Access to Quality Health Care project.

What we're proposing is a governance model based on need—not doctors' needs, not institutional needs, not nurses' needs, but patient needs. That's a concept that was developed in Europe. We've looked at that in great depth and we've adapted it to the Canadian situation. We are proposing an access to quality of care model: it's clinical governance, it's driven by patient needs, and it could be adapted across the country.

An example of that today in this country is the coronary care network in Ontario. They are applying that model very effectively. The New Brunswick government, about a year ago, did a similar study on the lengthening waiting lists in New Brunswick. They said there was really a problem, and they reallocated resources based on the results of that kind of study. That's what we're proposing.

Consistent with what Mary Ellen said awhile ago, this is not a doctors' model; this is a model where everybody involved would share the information. Right now we don't even agree on the validity, or lack of, of the waiting list. We don't agree on the information that we have. We have to have that as a support system, and that's what we're proposing, driven by patient need with a system that's transparent and built by everybody so we can all use it and allocate resources effectively.

By the way, western provinces, institutions, groups of providers, including the community—they liked the project. We submitted a request through that consortium in the west, and the federal government has just approved a $2.2 million budget to develop the model and test it.

The Chairman: Thank you, Dr. Landry.

You may hear bells. They tell us to go and vote, and we have approximately 12 minutes to get there. Mr. Brison has not asked a question yet, so I'll get him to ask his questions.

Mr. Scott Brison (Kings—Hants, PC): Thank you, Mr. Chairman.

I appreciate your presentations today. I represent a riding in Nova Scotia, and the cuts in transfers have been particularly destructive in provinces like Nova Scotia, where frankly we don't have the local tax base or the provincial tax base to pick up the slack. Our local hospital has gone from 128 beds to about 30 beds in a four-year period. That's a very serious hit.

There seems to be a not-so-subtle aversion to any privatization in the delivery of the health care. I note that in the Canadian Healthcare Association's brief the fifth point calls for a planned and appropriate mix of public and private health care funding, which would indicate some level of private delivery, wouldn't it? Was that the intention of that, to indicate some level of private delivery?

• 1720

Ms. Sharon Sholzberg-Gray: First of all, I think one of the problems is that we often mix up funding and delivery. Right now obviously 68% of our system is publicly funded, but a large part of that publicly funded system is privately delivered. There's contracting out of laundry services and similar kinds of services and all kind of things, and we have no objection to that, and there's all kinds of contracting out of laboratory services and all kinds of things. So there's a private delivery permeating that publicly funded system in most provinces in this country. A lot of publicly funded long-term care facilities are private facilities, and a lot of publicly funded home care programs are delivered by private companies.

So there could be public funding and public delivery, public funding and private delivery, and private delivery with private funding. There could be all kinds of permutations and combinations, and what we're trying to say is that you really have to be very clear on where you want to go as a country.

Mr. Scott Brison: My point is that I think sometimes we have to take a more pragmatic approach to issues. If we are putting the patient first, if in fact the patient, as you mentioned earlier, should be at the centre of the system, we shouldn't necessarily reject offhand all elements of private delivery.

For instance, I was glad to hear someone acknowledge the two-tier health care system that does currently exist. I would question our ability, as a nation bordering on the U.S., to prevent a two-tier system completely. The fear I have is that Canadian money is going to be choosing the private services and clinics in the U.S., and contributing to centres of excellence in the U.S., if we ignore the fact that there needs to be, at some level, some market forces introduced in the delivery of health care in Canada.

I know some people who demonize the public service, and that's wrong. I think it's equally wrong to demonize private delivery, because I know there's an ongoing debate within the CMA relative to the whole issue. It's like “two-tier health care system” is a four-letter word, but there is a bit of a debate on that. If we are going to be seeking the most creative ways to maximize societal return on investment, which should not be a dirty phrase either, to ensure that the maximum return is gained for each taxpayer's dollar and we have the best health care system, isn't it irresponsible for us not to be exploring fully all potential models for delivery?

The Chairman: Dr. Jeans.

Dr. Mary Ellen Jeans: If I could begin, I think one of the things that distinguish Canada as a separate culture, as a separate country, is our values. I think it's been clear for a number of years that Canadians value each other, value looking after each other, and personally I think countries that invest in the health of their citizens are much more likely to succeed on any number of fronts. And we just heard that Canada is still the best place to live. I would hate to see us go the route of the United States, with increasing privatization.

Mr. Scott Brison: But I'm not suggesting that. I'm suggesting there may be elements of not necessarily their system— I'm saying there are elements of the health care system that may be improved through the introduction of market forces, in the same way as the education system can potentially be, and has been, improved in some areas. Charter schools in some areas have been successful; charter schools in other areas have not been successful. Public education in some areas has failed and in others— There are elements, that's all I'm saying.

I lived in the U.S. for five years, and I'm not interested in their health care system. However, I did see that it wasn't quite as bad as some of the stories I've witnessed in Canada through both first-hand experience and anecdotal evidence that would make an HMO blush. So we have some real issues in Canada that need to be addressed as well.

• 1725

The Chairman: Ms. Connors.

Ms. Kathleen Connors: I feel quite passionate about this, and I will demonize the private delivery, for profit, of health care services. I think we need to look as a country at the experience with respect to the increasing public-private partnerships in the provision of laboratory and X-ray services.

A recent study by the Canadian Union of Public Employees validated and quantified the cost-effectiveness of using public labs vis-à-vis entering the Dynacare hospital lab services. What happens in those kinds of mixes is that cream skimming occurs, and the cost-effectiveness of simple tests that are repeated quickly gets taken up by the private sector. Who gets the difficult, complex cases? The public sector, and the funding. So there's that kind of aspect there.

We've been talking about some of the social determinants of health. One of the things that happens in generating profits for corporations in health care delivery is the downward impact on wages and working conditions. I think Sharon would have to agree that with many of the contracting-out scenarios with respect to the so-called hotel services, such as laundry, housekeeping and dietary, one of the first things that happens is the downward spiral on wages. If we are going to address the social determinants of health that keep people well, it's those kinds of things. So there is that whole issue around that.

We have to acknowledge that the public sector does not create the medical devices or the pharmaceuticals that we use in our health care system. So, yes, there is a role for the private sector in that. It has to be appropriately monitored, and that's why we have concerns around the Health Protection Branch. The reality is that more than 30% is spent on health care.

The other reality I think we have to acknowledge is that a single-payer system is what saves the dollars. If you get into introducing more third-party liability types of things, that's where you drive your costs up.

The Chairman: Ms. Connors, I'm going to ask Dr. Landry to make some final remarks. As you know, the bells are ringing. We must go and vote and do our duty.

Dr. Léo-Paul Landry: I will be brief, sir, but I think my duty would be to address the comment made concerning the ongoing debate within the CMA about privatization.

The Canadian Medical Association has thought long and hard about this, and there is no ongoing debate within the Canadian Medical Association on this. Our position is quite clear. It is contained in the following elements.

One, the private and public is a reality. It's not whether or not we will let the private sector develop. It is there. It is thriving. It's a reality.

Two, whether or not there is increased privatization will not be decided by the Canadian Medical Association, will not be decided by this committee, and with all due respect, will not be decided by the Canadian government or the provincial and territorial governments. Market forces are well. They're alive. They're going ahead. Suppliers, by and large, are the private sector. Home care, by and large, is privatized to a great degree. Up to 68% of the expenditures on drugs in this country are done privately. Preventive care and everything that's called employee assistance plans in organizations today are by and large private. Very little is covered by the private sector.

What the Canadian Medical Association has also said is that we want to protect our health care system and the five principles, and we do not want an American-style health care system.

The question we've been asking the Canadian government repeatedly is, where do we stop the privatization? Do we let it go unregulated or should we be doing something? That was, by the way, a point made earlier on by one of my colleagues.

So that's where the Canadian Medical Association stands.

• 1730

The Chairman: Thank you very much, Dr. Landry.

On behalf of the committee, I must tell you this has been a very interesting round table, as always. Every year you bring forth and make a very strong case for investment in health care. You can rest assured that your message has been received. It was a message that of course was loud and clear, and also a message that we hear from Canadians from coast to coast to coast. Thank you very much.

The meeting is adjourned.