SPER Committee Meeting

37th PARLIAMENT, 2nd SESSION

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

EVIDENCE

CONTENTS

Tuesday, March 18, 2003

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1125

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

Dr. Dana Hanson (President, Canadian Medical Association)

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1130

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1135

The Chair

Dr. Ashok Muzumdar (President, Canadian Association of Physicians with Disabilities)

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1140

The Chair

Dr. Blake Woodside (President elect, Canadian Psychiatric Association)

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1145

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1150

The Chair

Dr. Lisa Doupe (Co-Leader, Round Table Project on Safe and Timely Return to Function and Return to Work)

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1155

Â

1200

The Chair

Â

1205

Dr. Hillel Finestone (Physiatrist, Elizabeth Bruyère Health Centre)

The Chair

Dr. Hillel Finestone

Â

1210

Â

1215

The Chair

Â

1220

Mr. Larry Spencer (Regina—Lumsden—Lake Centre, Canadian Alliance)

The Chair

Mr. Larry Spencer

Dr. Dana Hanson

Â

1225

Mr. Larry Spencer

The Chair

Mr. Larry Spencer

Dr. Lisa Doupe

Mr. Larry Spencer

Dr. Lisa Doupe

Dr. Lily Cheung (Past President, Occupational and Environmental Medical Association of Canada)

Â

1230

The Chair

Dr. Ashok Muzumdar

The Chair

Dr. Blake Woodside

Â

1235

The Chair

Dr. Lisa Doupe

The Chair

Dr. Hillel Finestone

The Chair

Dr. Lisa Doupe

The Chair

Mr. Larry Spencer

Dr. Hillel Finestone

Â

1240

Mr. Larry Spencer

The Chair

Dr. Lisa Doupe

The Chair

Dr. Lily Cheung

The Chair

Dr. Lily Cheung

The Chair

Mr. Larry Spencer

The Chair

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CANADA

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

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NUMBER 008

l

2nd SESSION

l

37th PARLIAMENT

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EVIDENCE

Tuesday, March 18, 2003

[Recorded by Electronic Apparatus]

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[English]

    The Chair (Ms. Carolyn Bennett (St. Paul's, Lib.)): I apologize for being late. We have these funny rules that when your motions are being presented in the House, you actually have to be there. They're so strict about this.

    I also apologize that our tiny, perfect committee is sometimes tinier than perfect, particularly as this meeting is at the same time as immigration.... It seems that all of these other committees are meeting at the same time and are tabling motions. There are all kinds of “democracy-at-risk” events this morning. So the fact that we're tiny just means that there will be a test for all of those who weren't here; they'll have to memorize the transcript. As with the truly wonderful Kevin in the Library of Parliament, we'll make sure Bill Young has been apprised of having to take the test too, because we know he's not getting back from Mexico until tonight.

    We want to thank all of you for participating and for all you've done to help us with the electronic version of the consultation. We know that a lot of your members, and anybody else you could talk in to filling out the e-consultation, have participated. We certainly recognize that some of the solutions presented are spectacular, including from the groups who are here this morning.

    We had over 1,300 responses to the electronic consultation that closed last week, including those presenting stories as well as solutions. So we're very happy. There are over 175 stories, and I think there have been upwards of 80,000 hits on the website. We hope we are going to show that this first such experiment in Parliament works. An experiment was all that we were allowed to call it—not a pilot—because they don't want us to get used to this idea.

    So thank you again.

    In view of the limited time we have, we were wondering whether we should hear the presentations and then go to questions. Is this okay? Do you want to just hear all of the witnesses and then we'll go to questions?

    Okay. These are skilled, seasoned presenters who will of course observe the little time we have.

    So go ahead, Dr. Hanson, from the Canadian Medical Association.

    Dr. Dana Hanson (President, Canadian Medical Association): Thank you very much, Madam Chair. It's a great pleasure to be here today and to present before you.

    The Canadian Medical Association appreciates the opportunity to once again participate in the deliberations of the Subcommittee on the Status of Persons with Disabilities. I'm accompanied today by Mr. William Tholl, secretary-general and chief executive officer of the Canadian Medical Association.

    Before I begin my remarks, I want to congratulate this committee, and particularly the chair of the committee, for your efforts in regard to another federal program, the disability tax credit. Your 2002 report on this program, “Getting It Right For Canadians”, no doubt led to some of the important measures in regard to disabilities undertaken by the government in the recent federal budget. The appointment of a technical advisory committee on eligibility criteria and $105 million allocated over the next two years to improve assistance for persons with disabilities are in our view significant progress, and we want to thank you for that very much.

    The CMA appreciates this opportunity to discuss issues relating to the Canada Pension Plan, specifically as the program relates to the disability benefit. I will focus my remarks today on three areas: first, physician experience with federal health programs and forms; second, the need for common criteria; and third, recommendations for action.

    While the subject matter before the subcommittee today is the CPP disability program, we believe a broader focus on the issue of disability itself and federal health programs in general is needed. Issues related to the CPP disability program are issues common to other federal disability assistance programs.

    I don't think I need to tell this committee about the alarming shortage of physicians and other health care providers in Canada. Canada's physicians have been stretched to the limit and beyond. Therefore, it is more important than ever that physicians' time be managed in such a way as to maximize our interaction with patients. Unfortunately, this is not the case. Increasingly, physicians are spending more and more of their time filling out forms, forms for federal health programs such as the CPP, for private health insurance claims, pension benefits, tax credit eligibility, pharmaceutical plans, and workers' compensation to name just a few. To figure out all the various forms and determine eligibility, you almost need to be a physician, a lawyer, and a tax expert.

    The proliferation in the number of forms and their increasing complexity have resulted in less time for what physicians are trained to do, treating illness and providing care to patients. If you were to ask the average physician his or her greatest frustration with the health system, the response would be, too much time spent administering the system and not enough time providing care to patients.

    In regard to the CPP specifically, we have had in the past a good working relationship with the officials who manage this program. We've worked together well in the past in regard to improving the forms and bringing great integrity to the program, which has resulted in a reduction of appeals in the program. The CMA believes that in terms of a federal health program, the CPP set the template both in terms of administrative processes and cooperation, something that should be adopted across all other federal programs in this area.

    That being said, there is still considerable room for improvement. I urge the committee to take into consideration the cumulative impact various health programs such as the CPP have on our health provider workforce. We must look at ways to relieve the heavy administrative burden so physicians can concentrate their efforts on what they do best, patient care.

    As with our presentation on the disability tax credit program, the CMA recommends that a standard of fairness and equity be applied across all federal disability benefit programs. Currently there is virtually a different definition and a different assessment process for each and every program. A common frustration for physicians is that while the patient qualifies as disabled under one disability program, that same patient does not under another.

    When you look at some of the common criteria used to determine the level of a disability, the problem is readily apparent.

Á  (1130)  

    The CPP criteria define “severe” as preventing an applicant from working regularly at any job and “prolonged” as long-term or as that which may result in death. However, the disability tax credit program notes that “severe” is to be interpreted to mean markedly restricting any of the basic activities of daily living and that a disability must be “prolonged” over a period of at least 12 months. While daily living includes working regularly at any job, it encompasses so much more.

    Under the CPP criteria the physician is responsible for determining how to define long term: 6 months or 12 months. Other programs, such as veterans' benefits, that have entirely different criteria have added more to this mixture.

    This is confusing for physicians and is, very importantly, confusing for patients and others involved in the application process. If the terms, criteria, and information about the programs are not as clear as possible, then we have no doubt that faulty interpretation on the part of physicians when completing the forms can occur. This could then inadvertently disadvantage those who in fact qualify for benefits. There needs to be some consistency in definitions across the various government programs.

    Let me state very clearly, though, that this does not mean that eligibility criteria must be identical. However, there must be a way for a more standardized approach.

    Inconsistency in the application and administration of the program is likely without a more standardized definition. The reality is that certain individuals with conditions or disabilities may qualify for the CPP disability benefit in one region of the country while in other regions an individual with the same condition will be deemed ineligible.

    There are a number of conditions that society would today view as a disability, yet may not fit under the current program. “Severe” and “prolonged” constitute a rigid standard, especially as applied to some medical conditions. The reality is that such a standard cannot be applied fairly in all situations. There need to be greater flexibility and more realistic criteria that take into account the special nature of some medical conditions that may not meet yesterday's standards.

    Canada's physicians offer four specific actions to the committee to consider. The first is that an emphasis be placed on reducing the administrative burden placed on health care providers under all federal health programs. The CPP program, both in terms of consultative and administration process, should serve as the template for the change. Unlike with other federal health programs, the cost of having the eligibility form completed by a physician is subsumed under the program itself. The CMA believes this should be the case for all federal health programs.

    Second, the committee should consider the establishment of a joint government and stakeholder advisory group, one similar to the recently announced DTC advisory committee, to monitor and appraise the performance of the CPP disability program to ensure it meets its stated purpose and objectives. Representation on this advisory group would include senior program officials, health care providers, various disability organizations, and patient advocacy groups.

    The third is that there be some consistency in definitions across the various government programs. This would not circumvent the purposes or mandates of those programs.

    The fourth is that a comprehensive information package be developed for health care providers and the public, one that provides a description of each program, its eligibility criteria, the full range of benefits available, copies of sample forms, physical assessment, and form completion and payment information, etc.

    To conclude, the CMA believes that the CPP is a deserving benefit for those Canadians living with disability. We again congratulate the committee for the progress they have achieved on behalf of people with disabilities in regard to recent initiatives announced in the federal budget. The CMA looks forward to working with all concerned to improve the CPP program and all other federal disability health programs.

    Thank you very much.

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    The Chair: Thank you, Dr. Hanson.

    Now we'll have Dr. Muzumdar.

    Dr. Ashok Muzumdar (President, Canadian Association of Physicians with Disabilities): Thank you, Madame Chair.

    I am here on behalf of the Canadian Association of Physicians with Disabilities, which is an affiliated society of the CMA. I want to thank you for inviting us.

    I have made presentations to this committee in the past. Unfortunately, my e-mail address somehow got lost, it appears, so I did not get the invitation until the end of last week. That's why I am empty-handed.

    Just to digress a little bit, you apologize for being a little late, and I think all of us understand the amount of work you have to do as a member of Parliament. But not to worry, in your absence we were doing business. We were talking to each other, and there was a motion made and seconded that you would be the one to pay for our lunches this afternoon.

    On a serious note, after Dr. Hanson's eloquent presentation, I have very little to say, but I agree with CMA's position with respect to the amount of paperwork. I think most physicians loathe to do that paperwork--and as a physician, you would know that. Paperwork on each and every patient is very time-consuming and takes us away from our clinical work. I think that's one aspect.

    The other thing is the lack of consistency that one notices, which again has been pointed out in the paper presented by Dr. Hanson. One notices that very quickly.

    With respect to that, I want to make a proposal for your consideration.

    It does increase the workload on physicians and the disparity between the amount of work and the number of claimants in the kind of work that I have been doing, mainly for CPP, in my clinical practice. I retired just last year, and over the years there has been a transition in the way things have gone on--and I agree that the CPP has done better, compared to some other departments, like Veterans Affairs Canada and some other disability programs administered by various departments of the federal government.

    What I'd like to suggest is--and this is just something I'm just going to present to you for discussion later on, perhaps--is it feasible to bring all the disability-related programs under one roof so that there would be a sub-department? I'm well aware of the budgetary and turf warfare that's going to go on because of this, but what I'm looking for is to maintain consistency.

    As Dr. Hanson pointed out, “severe and prolonged” may mean two different things to two different agencies, and that causes problems. Sometimes somebody gets disallowed in one area and then they are easily accepted by some other department, with the same condition, the same assessment. If it could be brought under one roof, with one form....

    Let's say they are applying in connection with the Canada Pension Plan, or Veterans Affairs Canada, or something else. At the top, after the patient's information, that box could be checked and the remainder of the information that one needs to fill out--I'm talking only from a physician's perspective--could be the same. The form could be simplified to get the most pertinent information for an agency that's going to look at the disability and provide the benefit, and not have a lot of unnecessary information on some of those forms.

    I don't think the federal government is as guilty in that respect as some private insurance companies, the three- and four-page forms that no doubt you have filled out, as I have. Sometimes one single patient comes in with three or four different forms--mortgage, car payments, loans from the bank, those kinds of things, which I suspect are a little bit outside the jurisdiction of your committee.

    What I am looking for is if within the federal programs there could be one simple item with a similar definition, yet the criteria could be applied if Veterans Affairs said those criteria had to be something related to work with the armed forces, or the RCMP, or what have you, versus for the general population, through the CPP. Those criteria could be applied; however, the basic similarities could be utilized to minimize the paperwork and time consumption that many of us feel quite concerned about. That's one aspect I want to mention to you and the members of your committee, Madame Chair.

    The second thing is--and this is just my perspective on this; others may or may not agree with this--I think it's wonderful to have a society like Canada's. As a naturalized Canadian for close to 30 years now, I feel a sense of pride, as other Canadians do, that we consistently rank number one among nations in an independent survey done by the United Nations utilizing several criteria.

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    One of the things one notices is that when there are social programs of this nature, it does bring a culture of dependency. I'm referring to those people, those individuals who...I'm a disabled person myself, by the way; I'm vision impaired, albeit there is no treatment. But let me give you an example of ALS, amyotrophic lateral sclerosis, or Lou Gehrig's disease, which is, unless you are.... In a large number of patients, the mortality is very high. Only 10% of patients live longer than 10 years. It is a severe condition, a disabling condition, a progressive condition, but not all conditions are like that. Acute back pain may disable a patient for a period of time, but with management, medications, physiotherapy, and other things, they can get better.

    But one notices oftentimes, despite the fact that there are provisions under CPP to have reassessment done on a periodic basis, it does breed a culture by which people feel very comfortable: “I'm getting my cheque coming every month, so why bother going back to work”. So there are disincentives. There should be incentives to make people go back to work, yet have some way of protecting their income.

    The second aspect of that is people often feel very concerned that even if they go and give it a try--I think that is changing from what I hear--my benefits may be cut off. Insurance companies are very good at that; they're very quick on the draw in those respects. If someone wants to try it out, it may work, or it may not pan out. But there is no provision on a formal basis for them to give it a try for a three-month period. If it doesn't work out, your benefits will be reinstituted without any penalty.

    If those kinds of things were to be used in all the disability programs, I think it would help people to return to work. A 39-year-old patient should not have to collect disability when the condition is not fatal, nor progressive, nor something that's going to worsen over the period of time. They should be able to go back.

    Severe depression, while not my specialty--I'm a physical medicine specialist, a physiatrist by trade, and there are other physiatrists in the room, Dr. Finestone being one of those. My feeling is that someone with severe depression can get better and should be able to go back to work. Those are provisions that could be introduced into the legislation, so that people are not penalized for attempting to go back to work, for trying things out, and there would be a promotion of ability to go back and be a “taxpayer” again, so to speak.

    Those are a couple of points I'd bring to your attention, Madam Chair. Thank you very much.

    The Chair: Thank you very, very much.

    Dr. Woodside.

    Dr. Blake Woodside (President elect, Canadian Psychiatric Association): Thank you very much, Madam Chair.

    Madam Chair and respected members of the committee, my name is Blake Woodside. I'm the president of the Canadian Psychiatric Association. In my day-to-day work, I head an in-patient program in Toronto treating severely ill people with anorexia nervosa.

    Thank you for the opportunity to share our perspective about certain issues surrounding the social policy and the administration of the program, specifically as it affects persons living with a mental illness.

    May I firstly commend this committee for the work you have done to date to seek the views of Canadians about this program, namely the pre-study round table and the web-based consultations. If your report arising out of the disability tax credit consultations is any indication, I have confidence that the views of Canadians presented to you will be well presented in your report and recommendations.

    The CMA has addressed issues that are generic for all physicians, largely around the administration of the program. I will focus my comments on the program as it relates to psychiatric disabilities and on the role psychiatrists play in supporting this program.

    Mental illnesses represent the second-largest class of beneficiaries for CPP. Mental health cases have risen three-fold in the last 10 years and are likely to continue to increase over the next two decades, according to evidence available on the burden of disability due to disease globally. And this is true for private insurance carriers as well as the publicly funded systems like the CPP.

    I'll be speaking on two general issues. The first is the social policy of income support for persons with psychiatric disorders and the current assessment tools to measure impairment and disability due to a mental illness. We will be filing a more detailed brief in the coming weeks.

    First, where does CPP fit in, in terms of income support for individuals disabled on account of mental illness? The CPP program is one of a collection of federal initiatives providing support for those individuals who are disabled because of mental illness. We do not have definitive data about the extent to which the combination of current income support programs is providing support for such individuals. The multitude of programs providing this type of support makes it difficult to assess who is receiving what, from what program.

    While about 63,000 individuals with mental illnesses are supported annually by CPP—that's 2000 data—the best estimate of the prevalence of disabled mentally ill individuals is approximately 2% of the population, or 600,000 people, in Canada. Clearly, while CPP is an important element in the support of these disabled individuals, it's only one of a variety of means of support.

    Disabled Canadians generally have three classes of income protection. The more fortunate individuals are those whose coverage falls under a provincial workmen's compensation program or private long-term disability insurance, or self-employed individuals who take out private insurance. These people are the ones most likely to live above the poverty line.

    For those without private insurance or workmen's compensation coverage, CPP may provide coverage if the person had enough earning years to qualify for a partial or maximum payment. The EI sickness program bridges both for the first 17 weeks of disability.

    The default option for those not fortunate enough to have private insurance or to be eligible for CPP is the various provincial social assistance programs, which are not designed to be long-term income support programs. These programs do not coordinate well among themselves or with the health care system as a whole.

    It should also be recognized that mental illnesses, as distinct from many other causes of disability, often have their onset early in life, before the person has been able to work sufficient years to fully qualify for a full CPP benefit. This relative disadvantage for mental illnesses should be addressed.

    Clearly, access to income replacement or security is not the same for everyone, with many disabled individuals with mental illness living below the poverty line, and there is no clear national strategy to address this problem. The current patchwork arrangement of support is confusing for those who are disabled and for psychiatrists who are attempting to assist patients in accessing support to which they are entitled.

    How equitably are claims handled? Compared with other disability classes, mental health claims appear to be approved at similar rates, and in a broad, general way we're convinced the program is treating those with mental illness equitably. However, we are aware that the assessment of mental health claims is made more complex by a lack of agreed upon standards for the assessment of psychiatric disability and of psychiatric functional impairment.

    At present, the department has not issued a set of comprehensive guidelines that psychiatrists can use to organize their reports to provide the information that is required to assess a claim appropriately. The typical narrative report provided by a psychiatrist is designed for a different purpose—that is, diagnosis and treatment, not the assessment of functional impairment and disability.

    The generation of an assessment instrument, objectively assessing levels of impairment and levels of functioning, to measure disability would assist psychiatrists in providing the department with better information. The usual narrative report would then supplement the more focused information provided on such an instrument.

    This is not to suggest that psychiatrists lack access to information that's relevant to the department, but rather that psychiatrists need some assistance in teasing out, from the great mass of information they have available, that information that is important to the department.

Á  (1145)  

    The association would be happy to consult with the department to help develop an impairment evaluation instrument for mental illness, one that included clear and reliable standards for disability and functional impairment specific to mental illness. We think this instrument should be separate from one for assessing physical disability.

    We have two recommendations. The first is that the current patchwork system of income replacement and support for those disabled as a consequence of mental illness should be transformed into a cohesive system of income replacement and support. The goals of such a program would be to enhance the quality of life for those disabled from mental illness, provide opportunities for rehabilitation where this is possible, and be clear and transparent to disabled individuals and providers alike.

    Such a program could be part of a national strategy on mental health and mental illness that we've spoken about previously, and this should include addressing issues specific to the early onset of mental illness and the effects this has on an individual's ability to work full-time at any point in their life.

    The second is that clear and transparent standards for disability and functional impairment should be developed, and they should include the development of an impairment evaluation instrument specific to mental illness.

    Thank you very much, Madam Chair.

Á  (1150)  

    The Chair: Thank you very much.

    We'll now hear from Dr. Doupe of the Round Table Project on Safe and Timely Return to Function and Return to Work.

    Dr. Lisa Doupe (Co-Leader, Round Table Project on Safe and Timely Return to Function and Return to Work): Thank you very much.

    My name is Dr. Lisa Doupe. I'm the co-leader of the Ontario Round Table Project. I'm here with Dr. Lily Cheung, who's a specialist in occupational and environmental medicine. My background is also in occupational and environmental medicine, the specialty that deals with the relationship between work and health and health and work.

    Who are the persons with disabilities and what do they want? We all know the statistics. It's estimated that some 3.6 million Canadians--one in eight people--have a disability. But let's get past the numbers. Persons with disabilities are people. They are “us” and we are “them”. Persons with disabilities are our friends and our families.

    Today, I'd like to make three key points. First, the system by which a person with a disability enters, participates, or returns to life activities and to work is dysfunctional. We have created a system of chaos. The federal government can play a leadership role in sorting out this chaos through a collaborative mechanism like the national round table modelled on the Ontario Round Table Project.

    Second, 15 stakeholder sectors, both provincial and national, are working together to create a better system and a clear path from disability to function and to work. HRDC has done a good job on their skills and learning agenda; however, physicians have not been educated to support their patients to navigate through this varied, and increasingly complex, system. The priority should be on educating physicians to deal with the administrative processes and to teach them additional skills to support their patients in this increasingly complex and chaotic environment.

    Third, there is new knowledge that will help stakeholders create a coherent and seamless system. Research now exists that will push our thinking beyond managing disability to preventing disability. The federal government can support projects, such as a common assessment tool or a disability prevention model of care, that all stakeholders can become knowledgeable about and can participate in.

    Before I begin to describe the problems of the present system, I'd like to emphasize one point: return to function, return to work, is just not about good medical management; it is really a test of how well the systems work together. Medicine's traditional role has been to diagnose and treat. However, in the mid-1990s, the Canadian Medical Association issued a policy on the role of physicians in return to work. Other provinces have also issued a policy on this subject.

    This essentially redefined the role of all physicians from that of diagnosis and treatment to include facilitating patients as they returned to work. This step connected society's expectation of medicine to medical policy. Feedback from the stakeholders provided through a focus group held by the OMA resulted in stakeholders asking when medicine was going to implement this policy.

    However, for physicians to truly support their patients' ability to function in daily life, and particularly in the workforce, the system must be redesigned with this as the goal in mind. The stakeholder sectors are the groups that support PWDs, either directly or indirectly. These stakeholders are listed on page 2 of the presentation. I think each of you have a copy of it.

    Individuals and organizations who work in these sectors have the best of intentions. They are good people, good organizations, who want to support people with disabilities. But unfortunately, these sectors have often designed and evolved their policies and programs independently. The unintended result has been the creation of barriers for people with disabilities. Whether intentionally or not, we have created a system that contributes to the social isolation, discrimination, economic hardship, and poverty of people with mental disabilities.

    As a practising health care professional and former medical director of General Motors of Canada, I've experienced the problems of the current system. There are gaps in the communication and the coordination of return-to-work supports. There are overlaps. Sectors do not work together, and there are obviously significant delays in the system. There is a visual aid in the presentation showing the complex overlap of programs and services provided by only two layers of government, provincial and federal, to someone trying to enter the system. And that depicts only two out of the fifteen sectors.

    From my own practice, I can provide numerous examples of system dysfunction. Let me tell you of one of the stories from our most recent round table. A young, upper-middle-class man with very supportive parents--his mother was a nurse, his father was a retired CEO--was beaten on the street and as a result developed an acquired brain injury.

Á  (1155)  

    It has taken the father and the family over five years and 18 assessments to finalize the case, but only through the legal system, yet he still did not know all the public programs that were available to assist his son cope with his permanent disability. In fact, he only learned of another one available while attending the round table conference in February.

    Identified problems with the current system challenge healthy individuals who are blessed with full ability, let alone a patient with no support or with a mental health problem. Can you imagine the frustration, hopelessness, and bewilderment felt by the patients and their families as they navigate the maze to obtain what many of us take for granted, full inclusion as citizens in Canadian society?

    The need to work together to create a better system has been supported by the Canadian Medical Association and the research community. In 1997 Dr. Judith Kazimirski, then president of the CMA, wrote that the development of a Canadian approach to return to work for injured workers should involve physicians, workers, employers, and the public in an equitable, effective system that contributes to the economic productivity of the country.

    In 1997 as well, John Frank and a team of researchers at the Institute of Work & Health wrote that the evidence suggests that a piecemeal approach to prevent disability, an approach based on only one stakeholder's site or addressing only one phase of the disability and targeted only at underlying factors, will not work well.

    Do stakeholders want to work together to create a better system? Yes, they do, and this leads to my second point. The success of the Ontario Round Table Project provides the evidence that stakeholder sectors do indeed want to work together. The Round Table Project objectives are ambitious. They are to transfer knowledge, to facilitate cooperative relationships, and to identify and help support projects that promote the safe and timely return to function.

    At the first meeting of the Round Table Project in 1998, eight stakeholder sectors attended. Most of them, although working on the same topic, did not know each other.

    During the second meeting in 1999, 11 sectors showed that they could work together to develop a draft vision and priorities. The vision they developed was to improve the systems that helped people with illness, injury, or disability from any cause to develop and secure their social, personal, and economic self-sufficiency and to help stakeholders in the field identify and overcome barriers together.

    At the third round table just held recently in February, 15 sectors reaffirmed the vision and identified the need to strengthen this round table approach and to work together on projects. The stakeholders are still in the early stages of working together to help create a better system.

    The process is a fragile one. Stakeholders don't have a history of good collaboration. A practical issue is, how can we work together when some sectors have historically taken a narrow, self-interested view through such things as reducing costs or pushing problems onto another sector? The challenge becomes an organizational one for all. Each sector must be committed to the vision and remember the benefits as well as the pain of the people we are supposed to serve. No one has all the answers; we must look for solutions together.

    Can stakeholders work together? The Physician Education Project in Workplace Health is an example of a multi-stakeholder initiative in this area. The project began as an initiative of the Ontario Medical Association's section on occupational and environmental medicine and the Institute for Work & Health in 1994. It was co-founded by Lily Cheung and myself. Our vision was that the group would implement the Ontario and Canadian Medical Associations' policy on the physician's role in the return to work after a patient's illness or injury. The project's mission is to improve Ontario's medical education related to work and health and to better match the knowledge, skills, and behaviours of physicians with their patients' needs.

    As a result, health and work is now taught to all undergraduate physicians in Ontario medical schools. Progress has been made in this area, and now we're in the midst of discussing a national strategy to educate all physicians on these issues, not just the undergraduate ones.

    Early results show that educating physicians in work and health is cost-effective. In 2001 a two-day disability management course was held for 29 physicians in New Brunswick at a cost of $30,000. After seven months, estimated total savings to the workers compensation system was approximately $154,000 for only 44 claimants.

  (1200)  

    Here is my third point. There is new knowledge that will help stakeholders create this coherent, seamless system. Research exists that will push our thinking beyond managing disability to preventing disability. One of the best kept secrets of the past decade is a disability prevention model pioneered by Dr. Patrick Loisel and his team at the University of Sherbrooke. The PREVICAP model has been developed and researched with positive outcomes not only in return to work but in quality of life, in cost-benefit comparisons, and in cost-effectiveness.

    Based on the evidence the PREVICAP model provides, I will also recommend that under any new system, sectors be provided with incentives to work together to prevent disability and promote wellness. We now know enough that we should not be content with merely providing adequate supports for those who are disabled.

    The World Health Organization is shifting the paradigm from a disability perspective to an ability perspective. Based on the new World Health Organization approach, I would recommend that this new system promote function and ability rather than disability. As well, new research arising from the Institute for Health and Productivity Management is giving evidence of something many of us have known intuitively, that individual health and functioning drives economic productivity.

    This focus on function will provide the economic rationale for governments to view people with disabilities as a human capital asset and not a cost. If we improve the health and productivity of all human resources and turn health into an asset rather than a liability, then it stands to reason that we as a country reap the benefits of a healthier and more productive population. This is where good social policy marries with good economic policy.

    We have new important data and knowledge. We also have the will of the round table stakeholders. The next step is to map out the system to create in our collective minds a clear path from disability to function and to work and then make it a reality by implementing a model to prevent disability with a focus on ability. New thinking and research support both directions.

    Our long-term vision is that the federal government will create a different approach, a new office, perhaps comparable to U.S. Homeland Security, whose sole responsibility will be to coordinate the processes and outcomes of return to function and return to work for all Canadian citizens.

    I'd like to close by just restating my major points. First, we know the system of supporting people with disabilities to achieve active roles in life and the workplace is not working. The federal government can play a lead role in solving the chaos. In Ontario 15 stakeholders are willing to work together to create a better system, as indicated by the Ontario Round Table Project and the Physician Education Project. The federal government needs to support these worthwhile projects.

    My last point is, let's use stakeholder energy to build this comprehensive system. We need federal government support for these projects. This will help create a clear path from disability to ability and support those who do not have the ability. The benefits of a better system of return to function will result in improved function, health, and productivity at all levels, at the levels of individuals, organizations, communities, and the country. The process must support the person.

    Thank you.

    The Chair: Thanks very much.

    We'll now hear from the Elizabeth Bruyère Health Centre. Dr. Finestone.

  (1205)  

    Dr. Hillel Finestone (Physiatrist, Elizabeth Bruyère Health Centre): I decided to give a PowerPoint presentation here. Can everybody see it?

    The Chair: Yes. Go ahead.

    Dr. Hillel Finestone: I'm a physiatrist—which is a specialist in physical medicine and rehabilitation—and the head of a department, and I also work in the university. I am asked by the Canada Pension Plan on occasion to assess patients to evaluate the disability.

    Knowing there would be more “macro” analyses, I took a more micro approach—more the ongoing process and the physician's responsibilities with regard to the Canada Pension Plan.

    My objectives are to highlight specific issues that involve physicians' responsibilities when they are assessing and determining patients' disabilities for the Canada Pension Plan. I thought I would present a typical case.

    Some of the dilemmas for the physician involve questions about who is eligible for the benefits and what the role of the physician is in this process.

    Our case is an everyday case, just one of many. My practice previously was in southwestern Ontario, so I decided to carry on. I've been in Ottawa for the last few years.

    Our case is a 51-year-old male who comes to Canada in 1971 with great intentions, from a Mediterranean country. He finds work immediately as a bricklayer. He doesn't need to take courses or learn English, because he's immersed in his trade, he's busy 15 hours a day, and he's very successful.

    Thirty years into his trade, he falls off a scaffold. He injures his back. The X-rays are normal. Surgery is not required, but he's left with chronic, disabling back pain. He asks his family doctor, “Doctor, can you please fill out these forms for the Canada Pension Plan for a pension?” He's miserable. He wants to return to work, but he really doesn't see any way he can.

    We're going to carry this a little bit forward. Let's examine some of the issues specifically—not only for this case, but we'll try to refer to this case. What are some of the specific issues that will go into play when a physician is helping with respect to the determination of disability? There are numerous factors that could potentially play a role in the same assessment being carried out in hundreds of thousands of offices across Canada, and subsequently in the way the documentation will be filled out.

    What are some of these issues? I think there could be a little bit better order, but with two weeks' time.... I would now probably use “internal” and “external” as one way to classify. But specifically in terms of medical issues, where there are specific statistics with respect to specific injuries—for instance, we call one “low back strain without a fracture”—we know there is specific research out there that says if an individual has a disabling back condition that has prevented him from returning to work.... There's some Quebec data, for instance, when they did a med analysis of the literature, that says the chances of that person returning to work after six months are extremely small.

    There are personal issues with the physician and their evaluation of this individual who's in front of him in their office. They may have a specific relative who has a specific disability; they may go to work on a regular basis with their own chronic pain, and still do. That colours their assessment, and it's just something we have to realize: that's a reality.

    There are legal and social issues that go into the physician's—hers or his—evaluation, and when we get this documentation the average physician is looking at the implications. I don't think they're really concerned about being sued for not doing the right thing, but there have been some issues, with patients even standing in front of offices with a placard because of a physician not giving in to a certain disability. I don't like that phrase “giving in”, but it indicates the sort of societal pressures: “being excessively tough”.

    The physician as advocate, the physician as the responsible physician to society--I think in this situation, taking the position of society is really an impossible situation, and I don't think it's a question necessarily of being an advocate. It's a question of representing the disability on as factual a basis as possible.

    Among other issues, what interests me, for instance, is the epidemiological issues. For instance, I think physicians—and we'll talk about it later—need to know more about prognosis and what the epidemiology is. What happens to construction workers, to labourers, to bricklayers? How many of them are actually achieving age-of-65 retirement? I tried to look at the literature in this regard, and it's very sparse. From surveys of my colleagues, it seems we feel that the average labourer does not really reach that 65, or it's more rare.

  (1210)  

    So if we have this information in hand, we can make better decisions because our expectations will be set a little lower perhaps.

    Psychological factors have been alluded to. I'm talking here a bit more about the psychological sequela of having a chronic disabling condition and how that could compound, perhaps, a primary problem, besides psychological being the primary problem. I'm not talking about malingering because I don't think this constitutes a major factor in the disability evaluation, but of course we all have to be aware of it.

    The dependency on physicians for non-medical assessments is another issue. We're now inundated with all kinds of assessments. For instance, this individual may be taken into a room and told to actually carry out bricklaying in an environment that's made, perhaps, warmer and he's observed. These are called FAEs, FAAs, FCEs, all these names that you see, functional capacity evaluations and so on.

    I've been asked by the Canada Pension Plan about how I see them, how physicians look at them. Well, they are used quite a bit, but if you look at the scientific literature, it doesn't really help to look at the literature because there is not a strong science behind them, even though millions of dollars have been expended.

    They're frequently used, I find, in a very derogatory way--you know, patients are pain limited. In other words, they can't do something so they're excessively complaining about their pain. Unfortunately, it doesn't help overall, when we look at the role of pain, in making our evaluations on disability, although it potentially can.

    Restrictions versus determination of disability. I think this is an issue. What I'm talking about is that for the Canada Pension Plan, physicians really have to step up to the plate and make a declaration of disability or not. And I think that's fair. I think there's some dichotomy or some sort of schism with other organizations that ask us specifically not to carry out that sort of finite disability assessment.

    For instance, our colleagues in Canada Post...when the documentation is provided to physicians, it specifically says they don't want the diagnosis, they don't want to know about those things, they simply want to be told what are the things the person can or cannot do, and Canada Post will take on the responsibility.

    The Canadian Medical Association, in fairness, has indicated restrictions. In other words, saying you can bend, you can lift in a certain way, are the responsibility of the physician, but that the disability determination is often the responsibility of the industry, the employer.

    As my slide says here, I still think someone has to do it, and I think that passing it on sometimes is beneficial. It's a good idea to get industry and business involved, but I still think the physician right now is capable--not always equipped--to make this disability determination and has to play a major role in the process of disability determination.

    The definition of “disability” is a physician issue because we're provided with disability definitions. It seems to be very clear on the surface, as other people have alluded to, that it should be prolonged, it should be severe, that a person should not be capable of working. But as this document that I've been provided with in preparation for this talk--the future of the Canada Pension Plan disability issue poll--says, there are other important issues, such as the age of the individual, such as the area of employment the person is working in, a one-company town, an industry that's failing, the skill set of the individual, such as being a blue collar worker and having a specific back pain. Such a person could have a profounder disability than a white collar worker, who could have some office adaptations but having exactly the same physiological injury.

    These factors have not been identified by themselves. They've been identified in this document as playing a major role in the disability.

    I threw this in, in some ways for humour. I guess we should have a picture, because we still get the question “Can he work as a parking lot attendant?” It's still at the end sometimes, forcing the physician to make this declaration when, as we see, there are so many other factors. I think we should throw out this question.

    This is the last section of the talk. I just called it some of the pitfalls in the physician's daily determinations. We've been asked, though, in some of the documentation, should the Canada Pension Plan criteria be broadened, should rehabilitation be offered, should part-time work be allowed? I was very impressed that these issues were put forth in such a document.

    I think these are societal issues, and I'm certainly not going to address this in a seven-minute talk here, but I think rehabilitation certainly needs to be offered.

    As I identify here, I'm a specialist in rehabilitation medicine. When we rehabilitate or are involved in rehabilitation of a patient subsequent to a stroke or a musculoskeletal injury, this requires an intense multidisciplinary effort. Certainly, the physician is only one individual on this team. We're talking about physiotherapists often, or occupational therapists, psychologists, dieticians, social workers, and, as you see, vocational counsellors.

  (1215)  

    As this document by Mr. Young indicated--and I thought it was a good document--on disability issues, access to disability support is complicated and currently not freely available to.... For instance, I am a little bit luckier; I'm associated with a rehabilitation centre, but even then it's difficult, and certainly to the average family physician it's very difficult to negotiate.

    Really we have to acknowledge, and I thought this was a good forum, that there are going to be disagreements among physicians on what constitutes disability and what constitutes total disability. We could do a survey among Canadian Medical Association...and it's going to be different, and we know that different physicians are often more on one side, providing opinions on behalf of insurance companies, and others are more providing opinions on behalf of “the plaintiff of legal firms”. I think the Canada Pension Plan is aware of this and is trying to find the individuals who they feel more comfortable in dealing with.

    Lastly, are there any solutions? I think there are solutions and I think we can be positive. I think you have to acknowledge the emotional mental illness to a greater extent. I think that is a difficulty. It's been alluded to by the Canadian Psychiatric Association, and also the sequela of depression that sets in, in an individual who is not working, and how that even contributes further to the person's disability and can contribute to a greater extent to their disability.

    I think the epidemiology is something that needs to be worked on, and I think it's something the Canada Pension Plan can play a role in, in specifically identifying prognoses of various populations, of subgroups. For instance, the brick-laying population of Mr. S--they're needed, we don't really have them enough, and physicians need to consult them more. But the information I think is potentially available.

    I'm asking the Canada Pension Plan to try to be as specific as possible with regard to the information provided to physicians, because, for instance, if the definition of not being able to work is not quantified as well as it can be right on the form--and there's some information but it's certainly not adequate right now--if we can't provide that definition, then expectations of the physicians in carrying this out can't be considered to be great.

    So back to our gentleman, Mr. S. Can he work? Can he be retrained at age 51? Can he reasonably learn to read and write English at this point in time? What is the epidemiology of 51-year-old labourers after they become injured? These are some of the questions. I think we can find some of the answers.

    I said I'd put my stake here by saying that I think he does meet Canada Pension Plan criteria for disability. In the present condition, I'd be supporting him. Thank you.

    The Chair: Thanks very much.

    That was hugely interesting--and probably Larry will help us--but I think what's happened over the series of round tables is the committee is looking at these issues: Are there short-term things we should do to fix the system right now to make it fair, more flexible, all of that? Are there long-term things we should be doing around some of the prevention in terms of the integration, looking at what some of the academics had suggested in terms of other language than disability? So what are we actually talking about in terms of getting a more coherent approach that's more integrated across?

    I don't know, Lisa, whether the rest of the panellists saw my favourite slide.... Did you all see Dr. Doupe's slide of the 2 out of the 15, this one? Did you see this one?

    How anybody could find their way through this maze in the system is beyond me, and if that's just 2 out of 15, you feel the way we felt in our offices every day, not really knowing what on earth to do. As Lisa said, at the round table in February it was that couple who actually drove me downtown after the dinner. When you realize that these people have been at it for a year and a half and still don't know some of the programs that are available, so that there's this whole issue of people not knowing actually what they're entitled to, it's an extraordinarily sad story.

    Mr. Spencer will help us with the.... And also I think what we would hope from a round table such as this, especially by putting the two groups together--and I think Mr. Spencer would be agreeable--is that if anybody wants to comment on anything, or if there are any questions you have for another.... Because I think that sometimes what the CMA is allowed to say...but what actually practising occupational therapies see every day is interesting.

  (1220)  

    Mr. Larry Spencer (Regina—Lumsden—Lake Centre, Canadian Alliance): Thank you, Madam Chair. It's great to be that small and perfect committee.

    The Chair: You see, it was just named after you.

    Mr. Larry Spencer: I have to take that information back to my wife. I am small and perfect.

    I find some of your comments very interesting, especially having gone through the DTC--disability tax credit--study and to see your contrasting definitions here for the disability plan under CPP, as compared to the disability tax credit. Let me outline those again.

    Dr. Finestone mentioned, and someone else did the same thing, that the bottom line of that credit, of the Canada disability pension, is, are they able to work? And the bottom line of the disability tax credit is, is he able to stay alive? Then they contradict themselves by saying someone who's able to stay alive quite well and even work, like Dr. Muzumdar, with a visual impairment, can quite ably work. Many visually impaired people can quite ably work, but they do qualify for disability tax credit. Where Mr. S--and by the way, that's me, I suppose--cannot work and still would qualify on part of your definition, he can't do his trade but he can still do something perhaps, but he wouldn't qualify under the other because he can live quite well.

    So which one of these criteria would you lean towards as your definition? Do you think the disability tax credit is closer to right, or do you think the one here that being able to work is a primary function of living is what we ought to take into consideration?

    Dr. Dana Hanson: What I think we have to do is step back and look at two things. One, we have to look at where the science is, and I would agree with Dr. Finestone that the science is still in an evolutionary phase of looking at technically determining what is the disability. We have to look at how we measure disability and how we can do that, and we have to bring this forward from when this program began. We have to have mechanisms for us to allow us to take into account new ways of doing it, different ways of assessing people, and making sure that those are reasonable. So I think there's that level of it.

    The second level I think comes to your other question as to what's the best definition. I think we have to step back and see what is the purpose of the program and what is the focus of that program, as to how does the definition then apply to that--not different definitions, but on the other hand, what is the purpose of the disability tax credit and what's the purpose of the CPP? If they're the same purpose, you should have the same definition. If there's a different purpose for them, I think one has to....

    As we had said in our brief, we're not saying you should just wipe the slate clean and have the same thing for everyone; there are different foci for different programs. In that way, I think, we have to use the first part about getting definitions into it, getting flexibility, as Dr. Bennett has said on many occasions, looking at the best we can do with that and then applying that to what is the focus of the veterans' one, what is the focus of disability tax credit.

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    Mr. Larry Spencer: This is true, but the disability tax credit names as one of its focal points the ability to pay taxes. And we found it rather humorous that the inability to work didn't adversely impact your ability to pay taxes.

    I have a couple of other questions here. I don't want to hog all the time from the rest of the committee. We'll make this fairly short here.

    The Chair: Go on. I have to confess that I'm on a short leash in terms of being dragged back to the House.

    Mr. Larry Spencer: Going back to what Dr. Doupe mentioned, I have a couple of questions here. How do you propose to promote function and ability rather than disability?

    Dr. Lisa Doupe: With the new classification system that has been developed by the World Health Organization. It's called the international classification of functioning and disability. It's just recently been issued. It changes the focus from the disability perspective to an ability perspective. There is this new version out that now includes the environment. So a person's background is there, and whether he's a construction worker or a doctor is taken into account.

    The other advantage of the new classification is that it looks to the resolution of the original problem. Right now, we don't have that, so I think we have to look at what's new on the horizon. This is very new and it's very exciting, because it takes in the environment as well as solving the problem.

    Mr. Larry Spencer: I was reminded here of one of my constituents who has Parkinson's disease. What you're talking about is designing a system where you don't look so much at the name of the disease or the name of the handicap as much as you do the impact on the person's life or ability to work.

    Dr. Lisa Doupe: What his abilities are.

    Dr. Lily Cheung (Past President, Occupational and Environmental Medical Association of Canada): I think the new definition is in relation to the job environment, or whatever environment the person is in, as well as the level of functioning. So that's why in the CMA policy we want the employer to play a role in determining disability. If a person has a lesser level of functioning, he may not be disabled if the employer can accommodate him in another job, or a similar job with the same pay. If they can accommodate an individual despite their lower level of functioning, the person can work.

    I have returned people back to work after they've been absent for seven years. They are so happy after they return to work. A person with a psychiatric illness, an actual organic psychiatric illness adequately treated, was so happy that he would say hello to me two blocks away. He was so thankful.

    I recall an individual who was a paraplegic after a car accident and didn't know the company could accommodate him. He had been absent about three or four years and didn't know about our return to work program. When he returned to work we had to get a special toilet for him, we had to have people help him with the job, but he was doing a useful job. Although he is impaired, he has a lesser level of functioning, he is not disabled according to definition. He is earning income. He is paying taxes. He may be impaired, with a lesser level of functioning, but he is not disabled.

    Dr. Muzumdar is another example. Because of his environment, he can work, although he says he's retired. He can work. Although he may have a lesser level of functioning, he is not disabled according to the new definition.

    So it depends on how the environment can accommodate the person with a lesser level of functioning, whether it's psychiatric illnesses or physical illness. We have to take that into account.

    Before I finish, I also want to echo Dr. Muzumdar's so-called personal point of view on the CPP legislation. Yes, the CPP benefit, in my view--I have experience--has prevented people from coming back to work. To continue the benefit they spend all their energy in proving they cannot work, because they don't want to lose the benefit.

    So legislation may have to be changed in a way that allows them to return to work and maintain the benefit before they can return to work entirely, which is part-time work. If they could change that rule and then also reward them with more benefit, instead of maintaining the same benefit....

    They are afraid. People are afraid of losing the benefit, which is $1,000 per month. If they go back to work part-time and they don't have the salary equal to that amount, they won't want to come back to work. So something has to be done with the legislation to allow that to happen.

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    The Chair: Dr. Muzumdar.

    Dr. Ashok Muzumdar: Madam Chair, I think that at the dawn of the 21st century there has been a fundamental shift in philosophy, as Dr. Lisa Doupe mentioned. The emphasis now is on ability. We used to be taught this in medical school when I went through the training as well that you emphasize a person's ability, what he or she can do versus what he or she cannot do. It's nice to see that is now being put into practice by the WHO, that it is ability you look at even though you do take into consideration their disability, what they cannot do. Because of that there has been a shift in the position, and it will change.

    That reminds me of the judiciary in some countries. The Canadian judicial system follows British law, which means you're innocent until proven guilty. There are some countries, I think mostly in the Hispanic world, where you're guilty unless proven innocent. Now, that's a fundamental shift in philosophy, and that's what is happening with respect to disability versus lack of disability and those kinds of things. That's number one.

    The points have been made--and I think your round table group has brought that up among many other good points brought forward--that there should be some emphasis from the beginning on prevention of disability. Many conditions are preventable. Some are not, of course. Some are permanent and cannot be cured, and those should be classified separately. When there's no treatment and they're going to have difficulty, that's understood, but there are many conditions that are treatable. They will get better. They're also preventable in the early stages, and that should be put into motion right from the beginning.

    There should be incentives for people to return to work as long as their income is protected while they're disabled on a temporary or partial basis, or what have you, so there is a provision from the beginning. They know this is not for the rest of their life; you don't take the disability benefits and live happily ever after. There should be promotion and philosophy to say that, okay, while you're disabled and it's medically proven, your income will be protected. But once you've gone past this state, it's time to return to work, with all the benefits we can give in terms of having you go back to work, with therapy, medication, and all the support systems.

    Mr. Spencer, just to qualify what you mentioned, yes, indeed, I have been vision-impaired for at least the last 10 years of my work. It happened gradually; I started to lose my vision little by little. Without a support system I would not have done that...mainly at home. I call my wife HBOM, which stands for “home-based office manager”. She does everything. At work I also have people who read files to me. In terms of computers I'm a neophyte, or a better word would be “caveman”. I find that with the proper support system people can do that.

    Employers are different kinds of animals. There are employers who will bend over backwards to accommodate their employees, but there are also ones who will say, well, if you can't do the job, there is the door. That also happens. The legislation may have an impact to change those kinds of ways of managing workers and all this.

    There are different facets to this. If we change our thinking in terms of ability versus disability, that's a very fundamental shift and it's a very good philosophy, I think. That's all I have to say.

    The Chair: Thank you.

    Dr. Woodside.

    Dr. Blake Woodside: Limitation issues are particularly germane to mental illness, and they're especially troubling when you think about the proportion of mentally ill people who are diverted into the social assistance stream, where there's no focus on rehabilitation whatsoever. We'll expand on that in the brief we'll submit in the coming weeks, but I want to highlight that as a really important thing for mental illness.

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    The Chair: I think that's what we would like to know, what you would think as to how we could help people if this were an integrated program. When the patient says they're being followed around by a brown panel van, and you think they're paranoid, when indeed they were being followed--somebody is trying to cut them off CPP disability. This just doesn't seem like a reasonable approach to a program.

    Yet to think somebody can go back into something that as a family physician I felt was a totally toxic work environment for somebody who has a mental illness.... There's no way you are going to do that unless you've got the cooperation of the.... You can say, get another job, go work somewhere else, but that's stressing and all of that. Obviously, there's work, and I think maybe, Lisa, you have some experience as to how the round table is working on those.

    Dr. Lisa Doupe: One of my comments is that physicians and health care providers can do all the right things, we can focus on abilities and we can focus on appropriate care, but unless the workplace parties come to the table, it doesn't matter how good we are. They need to develop accommodation programs. They need not only their CEOs to have it as a policy, but they also need to translate that down to the first-line supervisor who's actually going to be the one implementing the policy itself. If it breaks down in their line of command, then that person who returns to work will not get the appropriate job placement and will not be successful. That's why it requires everybody to come to the table, really, to talk about how we're going to do it and to map the system out and figure out who does what.

    The Chair: Are you saying...? That's a collaborative, voluntary model. Is there a legislative framework you would put around this in terms of dealing with employers or dealing with “thou shalt cooperate”?

    Dr. Hillel Finestone: The workers compensation model, for instance, in Ontario is a good model. It says that for two years the employer is obligated to provide modified work for a return. To me, it's the only way these things are going to happen. I don't think we can rely on the goodness of industry's heart; it has to be legislated. As we can see, that's one model. You legislate that for two years after a work-related injury, but if someone falls downstairs or is involved in a car accident, then they're not entitled. The workplace is not obligated; it doesn't have to do it.

    The Chair: Yes, but the question is, can that be part of some sort of bridge with the Employment Equity Act in terms of whether you need to accommodate those kinds of things? Is there a way you bring this together, where there's actually been an assessment made as to what would work? I've said in this committee before, I never knew what light duties were. I just knew that if you were a nursing assistant, it was pretty well impossible to send somebody back to light duties when they would sit there at the nursing station being resented until finally everybody made their life miserable.

    Dr. Lisa Doupe: If you're looking for a model, that's where Dr. Loisel and the occupational medical model have an example to present to people. He's done research. The occupational medical model integrates the workplace and the health care provider right at the work site so that accommodation in solving the problems can occur.

    The Chair: Is that model something we could look at? Obviously, we could call Dr. Loisel, and certainly the researchers would like to see that.

    Mr. Larry Spencer: I just have a comment and a question about that. You said that's the only way we can do it, but I doubt whether that's entirely accurate. For instance, what if the program assisted employers in taking care of their employees when this situation happened? What if part of our money was going there to enable people to work instead of paying people who couldn't work? Wouldn't that also be a consideration?

    Dr. Hillel Finestone: It's still an initiative that has to be documented, written down, and shown to do it. They would do it then on the basis of receiving moneys, with the moneys replacing lost earnings or whatever.

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    Mr. Larry Spencer: But it wouldn't be forcing someone to do it; it would be assisting them. There's quite a big difference.

    The Chair: Has the group looked at what that would look like in terms of a federal program, where you don't make them pay the CPP, that part of the premium, any more or there's some inducement for employers to retrain, to do those sorts of things? The other question is, what else would you need in a program that was really going to reintegrate people? Do you need training dollars associated with the CPP disability plan? Do you need education, and what about prescriptions? Do you have...?

    Dr. Lisa Doupe: It's a multidisciplinary team, and that's one of the problems right now. There aren't enough human resources that cover all the different disciplines that need to work together.

    The Chair: My question was...and maybe you have some experience. When I first became chair of this committee, they gave me a big binder that showed the whole of government, the accountability framework for the various programs. One of the things they measure is the number of people who come off CPP disability, but they don't tell you what happened to those people. I don't know whether the blind person got the wonderful piece of equipment that allowed them to go back to work or whether that person is on municipal welfare now.

    I don't think we can evaluate the program without those sorts of exit interviews that would allow us to find out if we're just cutting people off and they then go on municipal welfare. Do you have an idea of what those kinds of numbers would be, of the people cut off CPP disability? Do the physicians have any...?

    I found it completely traumatic in my practice when somebody got cut off a program. I just felt impotent to do anything, and as MPs in our constituency office, I think we feel exactly the same thing. Somebody gets cut off and wants us to help, and we don't know what to do.

    Dr. Lily Cheung: Think about incentives for employers; the Ontario WSIB has as an incentive in the “Work Well” program. People don't use it that much. They do encourage employers regarding accommodating and they do give an incentive. It would be good if the federal government had something like that. They do a kind of incentive for employers to re-employ the individual, to accommodate individuals. It would be good.

    This is for compensable illnesses and injuries, but there's no parallel program--for different companies such as where I worked before they do have the same program for non-compensable cases, but for other--

    The Chair: So for Mr. Spencer's patient with Parkinson's, there's nothing for that, but if you fall off the scaffolding, then--

    Dr. Lily Cheung: I used to work for a very big company, and they had all sorts of illnesses, multiple sclerosis, Parkinson's, depression--depression, depression, depression. We would contact them and tell them we had a worker accommodation program and encourage them to come back to work. We accommodated them to the nth degree and provided them...and they were all happy, even though they hadn't known and had been afraid to go back. That's very natural for people who have been off work, and this is the problem. Once off work they are afraid of coming back to work, and they need encouragement that way. The more time you offer, the less chance there is they will go back to work. If we gave that kind of incentive, that would be nice.

    The Chair: Mr. Spencer has one comment and then I'm being dragged to the House. We do let you know that all of this will go on the website as testimony. It's an ongoing communication we have with the people of Canada as to what we've heard and how we're going to make our decisions in our little attempt at transparency.

    Mr. Larry Spencer: I just want to say that I appreciate the testimony of the witnesses today because it's been a breath of fresh air. These are people who know people. You've been out in the real world, and we appreciate that approach, instead of the defensive approach of some bureaucratic system with a form to fill out. So we thank you for your testimony today.

    The Chair: Thank you all very much for coming. We are adjourned.