Thank you, and good morning. Thank you for that introduction.
I am Glenda Yeates, the president and CEO of the Canadian Institute for Health Information, or CIHI. Thank you for inviting me to be present before the committee.
As you may be aware, I'm going to focus on the data slides we have presented, which are in front of you. The CIHI is an independent organization that provides accurate, timely, and unbiased health information. It's not our role at CIHI to forecast or to offer recommendations or opinions, and therefore my presentation will focus on data.
What we do at CIHI is collect and process databases and registries. We coordinate and promote the development of data standards across the country, we identify health indicators, and we produce analytical products and reports.
In terms of our relationship to the 2004 health accord, this is an accord that had a series of commitments, one of which was reducing wait times and improving access. CIHI is named specifically in the accord and asked to report on progress on wait times across the jurisdictions.
You'll see that we have produced four reports on wait times since the 2004 accord, between the period of March 2006 and the most recent one this last February 2008.
I'll put some of the information on wait times before you today. I'm going to organize it in two ways. The first is to talk about the volume of activity of procedures in the priority areas and the second is to tell us what we know about wait times, or perhaps changes in wait times.
Slide 6 of our presentation looks at what we know about surgical volumes in the priority areas that are named in the accord. They are listed there.
We look at volumes because our data there is more comprehensive and therefore easier to measure. Also, increasing the volume of activity in these areas has been one of the strategies the provinces have specifically named as they try to move forward to reduce wait times.
Generally speaking, our data indicate that the volume of surgery in priority areas, that is, hip and knee replacement, cataract surgery, bypass surgery and cancer surgery, has increased by 13% in Canada, excluding data from Quebec, over the two years following the accord.
Overall, our numbers show that in the priority areas, the volume of surgeries in those areas named in the accord have increased by 13% across Canada over the two-year period following the accord, and that's excluding the volumes from Quebec.
In terms of reporting what those volume increases mean for wait times, what we know now is that most provinces are regularly reporting on wait times for priority areas. There have been improvements in that reporting, so there are more timely, comprehensive data available, but there are still variations in measurement in reporting, and that means interprovincial comparisons are difficult. And the trend data are not available across the board, but they are beginning to emerge for individual provinces.
There's an example from our February 2008 report for joint replacements--one of the priority areas. You can see there that all ten provinces are reporting in the area of hip and knee replacement. We can see the differences in some of the definitions in the provinces, and we note them there, in terms of what those differences in definitions are. You'll see that the reporting in terms of times is included for those two procedures.
The question that people often want answered is what does that mean in terms of wait times? We see that volumes are up. What does it mean for waiting times for individual Canadians? We've put forward the areas for a number of provinces where we feel the definitions have stayed stable enough over the last three years so that we can actually begin to look at trends. So in the area of joint replacement, those provinces would be Ontario, Alberta, and British Columbia. And for those provinces where we think the data are consistent enough, we can see that they report decreases in the median wait times for hip replacements of at least one month for hips and one month and a half for knees.
If you look at cataract surgeries, the story isn't as clear. We see in four provinces that we find the definitions to be consistent enough over that period where we can look at trends. For those provinces, some of them have reported decreases in wait times, but others have not seen decreases.
I will turn next to slide eight. This looks at diagnostic imaging. This is the next area, and another area that was named in the accord. What have the trends been there? Again, the data are stronger on volumes, so you'll see in this that we can look at the volumes of both diagnostic imaging equipment in the areas of MRI and CT scans and the number of exams that have occurred. So we can see between the two periods here, 2003-04 and 2006-07, that there are more scanners--27% more MRIs and 12% more CT scans--and the number of actual exams is up even greater. But what we don't know and aren't able to tell you is what that means for the wait for those procedures. We can see that there are increased volumes. What we don't know is what that impact has been on the waiting times for Canadians.
I will turn next to the access to health care professionals. This was another of the areas that was cited in the access portion of the accord. What we can see there is that there is no comparable indicator for access to health care professionals, so we cannot report on that. That hasn't been determined. But what we can see is CIHI does have data about numbers of practitioners. Here I show you the numbers of physicians and nurses. We can see those numbers are up modestly in the 2004 to 2006 period, but those increases are not particularly significant, given the increase in the population that has also occurred in that time. But we do have data there on the increase in the numbers of health professionals in those two professions.
Another question that has been posed to us about the accord from time to time is the question of whether the new federal money that was committed in the accord was in fact spent on health care, and I've included there the table that is appended to the actual 2004 accord. At CIHI we collect and analyze data on health spending at a national level, so that is a question at the broadest level that we can answer. Our data do show that in 2005 the provincial and territorial governments spent almost $91 billion on health care, which was an increase of about $6.1 billion over the 2004 level. And when you compare that to the accord, you would see that the accord put in $3.1 billion of new money in the 2005-06 period. So we can get some sense of that investment flowing to the health care sector, in terms of the expenditures of provinces and territories.
In conclusion, on the progress on wait times reporting--the task given to us in the accord--we do see increased activity in the priority areas. There are increased diagnostic imaging procedures and there are increases in the surgeries in the priority areas.
We do see improvements in the data. There is much more data than there was three years ago. In terms of the interprovincial comparisons, those are still a challenge, because the data is not collected in precisely the same way or using the same definitions across all the provinces. We do see pockets of trends that are beginning to emerge in individual provinces.
In conclusion, what we can say about progress in wait times is that while interprovincial comparisons remain a challenge, we are seeing increased activity in priority areas, improvements overall in wait times data being reported to the public and pockets of trends that are beginning to emerge.
Good morning, and thank you for inviting us here this morning.
My name is Jeanne Besner. I am the chair of the Health Council of Canada. In that role I'm pleased to report to the Standing Committee on Health regarding the progress made toward achieving the reforms set out in the 2003 accord on health care renewal and the 2004 ten-year plan to strengthen health care. I am reporting on that as we have observed it.
For those of you who may not be aware, the Health Council of Canada was created out of the 2003 accord to monitor and report on progress made in achieving health care reform based on the elements that were set out in the accords. In 2004 an additional role was given to us to report on health outcomes. I will take it from there.
These accords have laudable, much needed and ambitious goals. But have they had the broad national impact that government leaders intended? In short, the answer is no.
Undoubtedly the accords have been a catalyst for change in many areas. In particular, the major purchases of medical equipment and various forms of information technology have helped to increase the number of services delivered. Many if not most jurisdictions have improved the way they manage waiting lists. I think Ms. Yeates made reference to that. Most jurisdictions provide wait time information for some procedures on their public websites. As a result, there's no question that many patients now know better than they did in the past when their cataract surgery or hip or knee replacement is likely to occur. In many cases they undergo their surgical procedures with less waiting than they might have five years ago.
Most Canadians have better access to health information and advice through telephone help lines. Some Canadians have better access to publicly insured prescription drugs, to primary health care teams, and to a range of health services at home or in their communities. Albeit slowly but surely, the health care system is adopting electronic health records, which will help to deliver safer, more efficient, and better-informed care.
In our forthcoming five-year report on health care renewal, which is due for release in June, the Health Council notes many other steps forward on the road to health care renewal.
But in other respects, progress on the accord commitments is not cause for celebration. The Health Council of Canada is particularly concerned about nine areas of health care renewal where action has been slower, less comprehensive and less collaborative than first ministers originally envisioned in the accords of 2003 and 2004.
First, in terms of drug coverage and appropriate prescribing, governments have not made substantial progress, to the best of our knowledge, in creating the national pharmaceutical strategy. Significant gaps in coverage are still evident across Canada, particularly in the Atlantic provinces. Too many Canadians remain vulnerable to personal hardship from needed drugs that cost more than they can afford. Also, Canadians are not always adequately protected from inappropriate prescribing because we don't have the necessary systems in place to keep health providers and consumers informed about drug safety and effectiveness.
With respect to home care, two weeks of publicly-funded home care coverage is not adequate for what many people need, and home care services continue to be poorly integrated with primary medical care in many parts of the country. There are clear disparities in the availability of publicly-funded home care across the country. No matter where people live, home care services that are seamlessly coordinated with other aspects of primary health care should be available.
In terms of aboriginal health, we note that the scope of preventable health problems in many aboriginal communities continues to be of concern across the country. Relatively little funding seems to have flowed from the promising intergovernmental agreements of 2005, the Kelowna communiqué and the blueprint on aboriginal health. Some provinces are working closely with aboriginal communities and the federal government to improve health care and living conditions on a regional basis, but developments are on a much smaller scale than we think were envisioned in those agreements.
Growth in the number of inter-professional teams to deliver primary health care is promising, and some parts of the country are on track to meet the target (set in the 2004 10-year plan) of having 50% of people served by teams by 2011. But nation-wide, progress is uneven and difficult to measure. More concerning, too many Canadians don't have timely access to their regular medical provider and too often primary health care services are not coordinated or comprehensive.
In terms of the health care workforce, ensuring that we have the right number of needed health care providers in the right place at the right time was a central component of both accords. There have been substantial increases in admissions to professional schools, more integration of foreign graduates, and some changes in how various kinds of professionals can practise. However, we still note that there are serious mismatches between need and supply in Canada's health care workforce. On the regional level, some provinces and territories are working together to plan and manage their health human resources more effectively, but the nationwide collaboration, the pan-Canadian framework envisioned in 2003 and 2004, doesn't seem yet to have resulted in coordinated planning.
The sixth area is electronic health records and information technology. Despite recent investments through Canada Health Infoway, Canadian governments have been slow to make progress in the information systems needed to support the delivery of high-quality care. We are not on track to meet Infoway's goal of 50% of Canadians having a secure electronic health record linked to other aspects of health care delivery by 2010—a goal that the Health Council has said was too modest from the start. Public support for these investments is strong, however, and governments must find ways to fund and accelerate this essential part of health care renewal.
In terms of reporting on progress, current and reliable data are fundamental tools to measure and understand what initiatives to improve health and health care are working and what are not. Today, despite the excellent work of a number of national and regional organizations devoted to health information and research, such as CIHI, Canada has a myriad of health databases, but not a comprehensive pan-Canadian health information system. Beginning in 2000, the governments had agreed to develop and use comparable indicators to report to Canadians their progress in health care renewal. A set of 18 indicators has been developed, but some are not as useful as we might like for reporting on the reform priorities of the accord, while those that are of value are not widely used for public reporting.
In 2003, the accord that created the Health Council of Canada also identified the federal/provincial/territorial advisory committee on governance and accountability as a key partner for the Health Council to do its work. However, this intergovernmental committee where governments shared information has been disbanded. Information about how governments spend targeted funds is not easily accessible or, in some cases, not available at all.
In terms of wait times, I think that Ms. Yeates has provided information indicating that a lot of improvements have been made. We note, though, that wait-time benchmarks for diagnostic imaging, which were to have been produced by December 2007, have still not been released.
So why has progress on so many of the commitments not been achieved? The Health Council of Canada sees several reasons. First, we find that some of the key elements in the accords were not sufficiently well described at the outset to make them measurable. For example, while we talk about inter-professional teamwork, it's not clear what we mean by a multidisciplinary primary health care team. Is it a nurse working alongside a family doctor? Is it more professionals, and so on? Unless we are clear about what we are trying to accomplish, it's difficult to know whether or not we have achieved it.
Second, as a vehicle for financing change and coordinating reform, the accords have their strengths but also some critical weaknesses. All told, the cumulative new funding committed through the 2003 accord and the 2004 10-year plan will amount to well over $230 billion by 2014. While some of the funding is tied to general health care policy goals, much of it comes with no real strings attached, very few requirements for public reporting, and almost no measurable objectives and outcomes.
Third, it is the reality of health care in Canada that we don't have one health care system; we have at least 14, when we consider the care the federal government delivers or directly funds. Unquestionably, this reality presents challenges for coordinating reform on a large scale, but the accord envisioned that governments would collaborate to solve common problems for the benefit of all Canadians, wherever they live. While respecting the rights and responsibilities of the provinces and territories to deliver care, the Health Council believes that we need to revive the idea of a common or pan-Canadian vision of health and health care, and put mechanisms in place to make this vision a reality.
Finally, we are concerned that governments' commitment to the spirit of the accord may be weaning. Many of the commitments have not been honoured or at least not to the degree that Canadians expected. The practical marriage between money and the desire for health care renewal held considerable promise in 2003 and 2004. Governments should either explain what has changed in the interim or signal their recommitment to a clear set of reforms. We encourage governments to renew their vows—to each other and to the citizens.
As we look ahead to the next five years under the ten-year plan to strengthen health care, the Health Council of Canada urges governments to renew their national commitment to system-wide change. We know that Canadians care passionately about their health care system and are eager for reforms that will sustain and improve it. We remain very confident, however, that the public health system can and will deliver more accessible, more equitable, and higher-quality care. We call on governments to rekindle their commitments to health care renewal across Canada.
Thank you to the presenters. Your presentations in some way have made me want to yell “Help!” I'm sitting in for someone today, so I've not sat at this committee table for some time now, but the issues seem to be very similar to ones that were discussed when I was here.
My worry is that we have CIHI collecting the information that they're supposed to collect--fair enough--but indicating that there certainly are some differences in terms of availability of data, how people measure, and all of that across the country. From the Health Council of Canada we have some indicators of really the same sort of thing, either movement that is slower than it ought to be or indicators that we cannot find because they're not there.
None of this is anybody's fault. This isn't a finger-pointing exercise. But if we have two, probably three organizations, if not more, measuring or looking at similar things without the data to support how we do that, how do we fix this? I don't want to be here in six months' time and have the same kind of report: yes, we're moving forward slowly; yes, it's been a catalyst.
I would agree with one of the comments in here that the focus on the accord, at least in any kind of public way, is much, much decreased from what it was when it began, and so is the excitement around it--other than if you speak of wait times for hips, because then you can get people excited.
How do we go about integrating the information that people are gathering, for one thing? There's a lot of hunting and gathering going on out there. How do we integrate all of that information so that when we sit here, we hear something that has some match between the people who have gathered the information? And then, how do we more quickly ensure that there are compatible measurements so that when this information comes forward we know that it is at least empirically similar to what each organization is hearing?
I'm just worried about the lack of integration of the information, the inconsistency of the data that are being collected, the standards under which the data are being collected, and I guess the disappointment of people with the fact that this has not moved forward with more excitement.
Both people, please.
With regard to improving data, I appreciate the frustration, which I think all of us in the sector share. But if we take a longer view at CIHI.... We began 14 years ago with a few databases in acute care, and we're now up to 27 databases and building more. My sense is that there has been progress in terms of improving the data. It is slow work, as you point out.
In terms of branching out beyond acute care into new areas of home care, pharmaceuticals, and health professionals beyond doctors and nurses, and deepening our understanding of those health professions, we are continuing to build the data. It is never enough data to answer all the questions people have, but I think there is progress.
In terms of how to integrate it, we've concluded that there is a challenge in making sure we turn the data--because it is expensive to collect--into indicators and measures that people can actually use. We certainly work with our stakeholders to understand how to simplify and how to produce health indicators that can be used, whether it's in a small regional health authority, in a rural area, or elsewhere.
In terms of making the data comparable, that is, in a sense, a role that we take very seriously, and we do work to enhance the comparability of data. There has been convergence in wait-times data, but it is not yet at the point where we have comparable data, as we mentioned. As we point out the differences, that will help convergence to occur over time.
That is a much broader base than the doctors and nurses.
I want to go back to something that was said earlier, which is about whether they will will get to the stage, and whether we should get to the stage that it simply is not possible to do comparable data; that, no matter how hard we try, we can't get it.
I don't want to find us waiting to do things, as I said earlier, for people who are literally, as aboriginal people are, dying while waiting for movement in the area, for instance, of aboriginal health or pharmacare. Is that a consideration or a discussion that the committee has had: that we might get to the stage where you say—I don't care who answers it—we tried; we looked, and it's not possible; let's move on and find a different way to get some of these improvements out to people, without forever chasing something that we've now decided is impossible to be caught, or will be simply a work of process for the sake of the process?
I would hope we would all agree that process is really about outcome, because those people who are dying for not having drugs or potable drinking water or health care in their communities at some stage will stop being very interested in our comparable data.
Somebody—anybody—have you had this discussion?
I'd like to thank the witnesses for being here today.
There has been talk about pan-Canadian initiatives, and I'd like to seek your views on the fact that the government has invested over $1 billion in public health across the country. We also had some mention about disseminating information on cancer--for example, the Canadian Partnership Against Cancer, which is a unique structure that has the buy-in and participation of all the cancer agencies in Canada, and the Canadian Cancer Society, the cancer care community in each province. They are tasked with doing exactly that. Part of their mandate is ensuring best practice and disseminating information. I wonder if you could comment on that.
We also have the cardiovascular steering committee, which is coming up with a plan that will likely be similar to the Canadian Partnership Against Cancer. They're meeting right now. So there is activity taking place in that realm.
Moreover, there is also the Mental Health Commission-- $100 million going into mental health. And though it's a taboo subject, it's something that affects one in four Canadians at least once in their life. It's very important. I'd be interested in your comments on that and perhaps the unintended positive consequences of these types of programs.
I also have a question for Ms. Besner. On page 2 of your report, you talk about the Kelowna communiqué. Could you explain the difference between a communiqué and an accord?
Certainly we know this is an area of critical interest in terms of the health sector, and we do look at a number of these questions. We do not have perfect information about all the questions, as we would like, but we do have a number of points I can respond to in terms of the points you raised.
We know the ratio of positions to population was increasing until about the early nineties, and then it fell a bit and has remained fairly stagnant. We do know that we have about the same number of physicians per population as we did ten years ago, but at the same time we know that medicine has changed: it's increasingly specialized, and we use physicians in a different way. We've seen the increased volumes of activity, so we can understand why, when you look at those ratios, you can feel the pressures we feel as a health system in terms of the numbers.
We also know that internationally Canada has fewer physicians in relation to its population than a number of the other similar countries in the OECD, for example.
We do have the breakdown in terms of those who are immigrating and registering as physicians in Canada, those who have come back to the country, and those who leave. For the last couple of years that we have been measuring this, the number of physicians who are returning to Canada from abroad is in excess of those Canadian physicians who are leaving Canada, so there is a good-news story there.
My understanding, in terms of the numbers of foreign physicians as a proportion of the foreign-trained physicians and as a proportion of the total number of physicians in the population, is that it is relatively stable; it's around the 18% mark, and that at the moment is relatively stable.
With regard to your question about retirement, we do know the physician workforce is aging, and we're tracking an increasing average age of physicians. While we don't know precisely when they will retire, we do know this is certainly an issue that planners need to take into account, as well as the increasing feminization of the workforce because the younger physicians do not work in the same way as the older physicians did.
These are all things we're documenting and trying to provide to health care planners for their benefit and for their purposes.
This is turning into a very interesting conversation with the witnesses. I'll just make a comment on some of the previous testimony.
I found it astounding that only one one-thousandth of the money that the former prime minister claimed did come out of that Kelowna communiqué. He's been going around the country stating there was a $5-billion agreement, but now we know, as we've always suspected, it was just a non-binding agreement with no impact. No money was set aside, and only one one-thousandth of the money ever flowed. That is very helpful, and I'd like to thank the Health Council of Canada for bringing that out today.
My question is to Ms. Yeates. I trust you've seen the Wait Time Alliance report card that came out a few weeks ago. There are a couple of tables in there, and I'm going to ask for your comments.
Table 2 talks about hip, knee, and a bunch of other procedures. There are areas for improvement, but it looks pretty good. Ontario gets five A's, Manitoba gets three A's and a couple of B's. On table 3, where it's talking about progress on the 10-year plan to strengthen health care--this accord we're talking about--the trends are up. It goes from a D to a C-plus, and from a C to a C-plus. So the trends are improving, it seems, according to the Wait Time Alliance report.
I'd like you to have an opportunity to comment on this report.