HEAL Committee Meeting

37th PARLIAMENT, 1st SESSION

Standing Committee on Health

EVIDENCE

CONTENTS

Thursday, February 28, 2002

Á

1115

The Chair (Ms. Bonnie Brown (Oakville, Lib.))

Mr. Roy Romanow (Commissioner, Commission on the future of health care in Canada

Á

1120

Á

1125

Á

1130

Á

1135

The Chair

Mr. Merrifield (Canadian Alliance)

Mr. Roy Romanow

Á

1140

Mr. Merrifield

Mr. Roy Romanow

Mr. Merrifield

Mr. Roy Romanow

Mr. Merrifield

Á

1145

Mr. Roy Romanow

Mr. Merrifield

Mr. Roy Romanow

Mr. Merrifield

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1150

Mr. Roy Romanow

Mr. Rob Merrifield

Mr. Roy Romanow

The Chair

Mr. James Lunney (Nanaimo--Alberni, Canadian Alliance)

Mr. Roy Romanow

Mr. Lunney

Mr. Roy Romanow

The Chair

Á

1155

Mr. Réal Ménard (Hochelaga--Maisonneuve, BQ)

Mr. Roy Romanow

An hon. member

Mr. Réal Ménard

Mr. Roy Romanow

Mr. Réal Ménard

Mr. Roy Romanow

Â

1200

Mr. Réal Ménard

The Chair

Mr. Réal Ménard

Mr. Roy Romanow

Mr. Réal Ménard

The Chair

Mr. Roy Romanow

Mr. Réal Ménard

The Chair

Ms. Hélène Scherrer (Louis-Hébert, Lib.)

Â

1205

Mr. Roy Romanow

The Chair

Ms. Scherrer

The Chair

An hon. member

The Chair

Ms. Thibeault

Â

1210

Mr. Roy Romanow

The Chair

Ms. Judy Wasylycia-Leis (Winnipeg North Centre, NDP)

Mr. Roy Romanow

Â

1215

The Chair

Mr. Jeannot Castonguay (Madawaska--Restigouche, Lib.)

An hon. member

Mr. Jeannot Castonguay

Mr. Roy Romanow

The Chair

Mr. André Bachand (Richmond--Arthabaska, PC/RD)

Mr. Roy Romanow

Â

1220

The Chair

Ms. Fry

The Chair

Ms. Fry

Mr. Roy Romanow

Â

1225

The Chair

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CANADA

Standing Committee on Health

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NUMBER 060

l

1st SESSION

l

37th PARLIAMENT

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EVIDENCE

Thursday, February 28, 2002

[Recorded by Electronic Apparatus]

Á  (1115)  

[English]

    The Chair (Ms. Bonnie Brown (Oakville, Lib.)): Good morning, ladies and gentlemen. It's my pleasure to call this meeting to order and to extend, on behalf of you all, a very warm welcome to Mr. Roy Romanow, the commissioner of the Commission on the Future of Health Care in Canada, a subject that is engaging the minds of all Canadians these days. We are looking to him for his leadership—already proven on so many fronts—to be applied to this subject area, to lead us through this national debate, and to help us sift and sort through the choices that seem to be appearing before us.

    Mr. Romanow, with that very brief introduction and not mentioning all of your many credentials, I offer you the floor.

[Translation]

    Mr. Roy Romanow (Commissioner, Commission on the future of health care in Canada: Thank you very much, Madam Chair. I would also like to thank the committee for giving me the opportunity to be here today.

[English]

    Madam Chair, I'm very pleased that you haven't gone through the litany of past sins. It probably would have needlessly taken up all of the time.

    Madam Chair and ladies and gentlemen of the committee, if I may, I'll begin by saying what I strongly believe. In my judgment, this committee has demonstrated strong leadership on a whole host of issues affecting the health of Canadians. I am very pleased to be here to take part in what I would say is a joint effort by the elected people, the representatives of the people, the parliamentarians, and to add my small contribution to everybody's contribution to this very important discussion that we're having in Canada.

    As far as the committee's work is concerned, it's impressive when you consider that it ranges from assisted human reproduction to genetically modified foods to other issues. You have not backed down from tackling controversial and important issues. If I may say so, I applaud that approach. I can tell you, Madam Chair and members of the committee, that, in my judgment, it is one we will all need to adopt as Canadians if we are to successfully wrestle the issues to the ground and secure the future of our health care system in the days and months ahead.

    Let me just very briefly outline where our mission is and where we are headed. I'm mindful of the fact that you want to ask some questions. I'll try to be as brief as I can, but a little bit of background probably would be of some assistance. I hope it will be.

    As you know, a few weeks ago, Shape the Future of Health Care: Interim Report was presented in both French and English. It may not surprise you when I say that, personally speaking, I'm quite satisfied with the content of the interim report and with the largely—not totally, but largely—positive coverage that it has garnered. The report succeeds in its primary goal as I determined it, which was a goal of providing a framework for a national dialogue—some of my friends and advisers on the commission say to use the term “dialogue” and not “debate”, but I like to say “dialogue and/or debate”—with Canadians on the future of their health care system, or a framework for the national dialogue.

    According to a recent Pollara survey, 64% of Canadians feel the public has not had enough opportunity to participate in the debate on how to improve the health care system in Canada. That's why I'm satisfied with the report. I'm hoping this framework for the general dialogue will allow that 64%—more or less, but I think it's in that category, if not higher—a chance to be heard.

[Translation]

    Personally speaking, I'm quite satisfied with our Interim Report and the largely positive coverage that it has garnered. The report succeeds in its goal, namely, of providing a framework for a national dialogue with Canadians on the future of the health care system.

[English]

    The interim report did draw three broad conclusions. First, the health care house needs remodeling but does not need demolishing. Indeed, many parts work and work well, especially when they're compared to other systems in other countries. While we are necessarily focused on those aspects that are of concern to Canadians here at home, I would say respectfully that we should be careful not to condemn a program that has benefited so many Canadians, a program that has conferred important comparative advantages on the Canadian economy, and a program that is widely approved externally by other nations.

    Second, while health care spending is forecasted to grow, I would argue very strongly, Madam Chair, that we are not powerless as Canadians to alter the trajectory of these projections. Indeed, this notion that the health care system is somehow on autopilot and all we can do is strap ourselves in, hold on tightly, and see where it takes us, is both inaccurate and dangerous, in my judgment. It's inaccurate because we do have the power to take control and chart a different course. It's dangerous because the idea that the system is simply too vague or too entrenched to be changed invites inaction and—maybe even worse than that—skepticism, cynicism, and other such language associated with that approach. If one option is not on the table in terms of the spirit of taking it off autopilot, that option is the status quo.

    Third, as the interim report makes clear, I think Canadians of whatever political stripe or regional identification are in agreement on a few basics.

Á  (1120)  

[Translation]

Firstly, all Canadians must be able to access quality, prompt health care, regardless of income or where they live. Secondly, people who become ill should not have to run the risk of going bankrupt. Given the growing number of treatments and drugs that are not covered by the Canada Health Act, this is an increasingly important issue. Thirdly, any overhaul of the health system should not have a negative impact on poor and vulnerable groups in our society. Finally, governments have an important role to play in health care. This is a significant issue and is a solid basis that we can build on.

[English]

But first we need to know what Canadians want us to work towards, so that, as policy-makers, we can choose wisely from among the competing approaches.

    In regard to these choices, in my judgment, there appear to be four perspectives on how best to address the challenges confronting medicare. Each has its own compelling rationale and reflects values-based choices. Let me briefly describe these four perspectives—and this is a brief description, so if these perspectives suffer because of their brevity, please excuse me.

    The first perspective is more public investment. One perspective or school of thought says that's the answer. They argue that the system has clear needs that should be met through the tax system by reallocating spending from other government programs and/or by raising taxes.

    A second approach is what I describe as more user-pay. This school argues that the system needs money, but as taxes are high enough, this money should be raised through such things as user fees and co-payments, among other things, that have the added benefit of giving individuals an incentive to use the system prudently and wisely.

    A third school suggests an approach of increased private choice. It is argued by this school that, in order to relieve pressure on the public system, Canadians should be able to access health care services from a private-sector provider, with “private sector” to be defined as either “for profit” or “private” to be defined by “non-profit”. The obvious example is the Grey Nuns in Saskatchewan who provide or have provided hospital care. Theirs is a private, non-governmental form of provision of care, but not for profit. And this school argues that we should pay for these out of pocket or through private insurance.

    And there's a fourth approach. That approach is to reorganize or renew the current service delivery systems. Under this central thesis, it is argued that our health system is fragmented, poorly organized, and provides few incentives—in fact, it's argued that it provides many disincentives—to focus on health promotion and prevention. By restructuring how care is provided, members of this school argue, we can preserve, enhance, and protect the system into the future.

    These are not watertight compartments, and there may be a fifth or sixth versions, but after nine months of fact-finding, we think things fall into these four categories: more public investment; more user-pay; increased private choice; and reorganized service delivery. I think the elements of each of these approaches will clearly resonate, in some case or other, with some Canadians.

    You may find this somewhat strange, by the way, but we don't do any polling. However, the over two decades of public opinion research that we have analysed suggests that each one of these four perspectives enjoys the support of a substantial number of Canadians. The obvious irony is that the values base underpinning each approach is profoundly different and not easily reconcilable.

    Where do we go from here? How do we move from broad principles to specific proposals? How can we ensure that the voices of individual Canadians are heard?

    Madam Chair, members of the committee, the reason I am so pleased to be here today is that this forum provides one such important opportunity before the elected members and representatives of the public, in order to get these perspectives out and debated. I'm interested in learning your views. This is a key challenge, because, as I have said many times, Canadians themselves are the ultimate custodians of medicare. It's not politicians, not royal commissioners, but Canadians, pure and simple.

Á  (1125)  

[Translation]

    What we have to do is to develop a specific type of process, to allow an enlightened debate to take place and to involve Canadians in this discussion rather than relegating them to the sidelines and making decisions for them. To those who believe that we have already sufficiently discussed this issue or that Canadians have had their fill of discussion, I would like to make the following comments.

[English]

The numbers across the country are consistent: 53% of Atlantic Canada, 53% of Quebeckers, 52% of Ontarians, and 53% of Albertans.

    Second, if one can judge from the response to our call for submissions and abstracts, there is a very healthy appetite for getting the issues on the table. In each province or region, we're going to be forced to pick and choose from the many dozens of thoughtful and compelling abstracts and submissions that we've received to date. It's going to be a difficult task, and we haven't even started the public consultations yet.

    These are people and organizations wanting their voices to be heard, just to give you some examples: the Saskatchewan Palliative Care Association; les communautés francophones de la Saskatchewan; the BC Coalition of People with Disabilities; the Manitoba Chiropractors' Association; la Coalition Solidarité Santé; la Fédération des infirmières et infirmiers du Québec; and la Chambre de commerce. I can think of no more eloquent a response to cynics and critics who have dismissed or criticized our process of public hearings as being unnecessary and irrelevant, than to cite just how keen groups and individuals are to participate in the process—and that's in addition to that 64% Pollara figure I gave you at the beginning.

    If consultation and wanting to be heard is part of this, what is our consultation plan? Very briefly, I'll outline it for you. There are four phases. That sounds complicated, but there is a rationale to this, believe it or not.

[Translation]

    The first stage is undoubtedly to educate Canadians. Our Interim Report is just one part of this approach, which also includes a website where we post all the written submissions that we have received, as well as the 40 or so substantive and research papers that we have commissioned from Canadian and foreign experts.

[English]

    We've partnered with CPAC to promote informed discussion. Over the past six weeks, we've run a series of special, bilingual, open-line programs that expose interested Canadians to key issues in the health care debate and allow them to query experts on their points of view. In the coming days, very shortly, we're going to be releasing a commission workbook that will enable Canadians at home, in their church basement halls, around the kitchen table, or wherever, to better understand the pros and cons of the four perspectives I have outlined, to debate them, and to express their views on them.

    If I may say so, with respect, I would encourage each of you, as elected leaders, to use those workbooks as the basis for town hall meetings and public discussions in your own individual ridings, if you find the books useful. It would be of enormous benefit to hear back from your constituents, through you. I understand you'll be receiving householder and newsletter articles shortly in order to aid in this process.

    To further support informed debate, we will release nine discussion papers. Each will focus on a specific top-of-mind health issue, such as home care, pharmacare, globalization, and how to place the health system on a more sustainable footing, to name some. Each paper will enumerate three possible courses of action, as well as their pros and cons, and will seek the guidance of Canadians on which approach they favour. As these papers are released and posted on our website, we will use them as the basis for a series of public debates among health experts across the country. These debates will be public, and we're working with broadcasters to develop a format that ensures that as many Canadians as possible can view them before making up their minds.

    We've also organized a number of expert round table discussions on specific health issues. One, which took place in England, focused on the experiences of the OECD countries on public-private partnerships in the health care field. Another one in Paris, France, focused on the European Union countries and their various forms of co-payments and user fees.

    On Tuesday of this week, on February 26, I arrived back from Washington, D.C., where I met some American political leaders. There, in Washington, D.C., we had a round table hosted by Johns Hopkins University that focused on the so-called cost drivers for health care, and possible responses to them.

    So perhaps I've given you too much, but public education is the scenario of that first phase.

    The second phase is the public consultation phase proper, which starts next Monday—that's March 4, for some free advertising—in Regina, Saskatchewan. In this phase, we're going to hold eighteen public hearings across the country, at which we hope to hear from a wide range of invited public providers, organizations, and individual Canadians. In addition, in nine of these eighteen communities, we're holding a smaller decision-makers' focus group to try to synthesize and interpret what we heard the day before in the public hearings.

    The third phase involves five regional public sessions. Here, we're going to analyse the results of the public hearings and the decision-makers' forums from day two. The regional basis will try to identify areas of consensus and areas of cleavage.

    The fourth and final phase will be to organize a national, multi-stakeholder conference, in all likelihood here in Ottawa. We'll use this event, public again, to review the results of the previous three phases of our work and to move toward a consensus on a coherent set of recommendations for placing the health system on a more sustainable footing. Our final report will reflect the outcomes of all of these processes, and will reflect the best research and the most compelling evidence.

    I know some have suggested that this consultation process that I've outlined to you is too ambitious. I disagree, and I do so as one who has been in the public arena perhaps for too many years, as one who has gone through some of the previous experiences in this regard, when Canadians have felt shut out and excluded. I'm sure you're feeling those pressures yourselves as members of Parliament.

Á  (1130)  

    If I have learned anything from my own years in politics, it is that one should not attempt fundamental changes to fundamentally important national programs like medicare without first engaging and consulting those who pay for and own it. Surely no lesser standard should be maintained for this great, important Canadian achievement.

    The fact is that Canadians want to be part of the decision-making process. Some have suggested that our recommendations will come in too late; that's another suggestion I've heard. But some have said the time for change is now. Well, to be very frank about it, I find it somewhat strange that any reasonable person would find eighteen months to be excessive for a one-person commission to review a program in a sector that accounts for over $100 billion in expenditures and is arguably the number one issue for the country.

Á  (1135)  

[Translation]

    To conclude, I would like to stress that I am well aware of the issues which are currently undermining the confidence that Canadians have in the health care system. Canadians want answers and not more rhetoric. Canadians are concerned about waiting lists for emergency health care. They're also worried about treatment services and diagnostic services.

[English]

    I believe we are acutely aware of the top-of-mind issues that are worrying Canadians as well. They want answers, and we're going to hope to provide them. Those top-of-mind issues are emergency rooms, diagnostic services, waiting lists, and the like. They're worried about the supply of doctors and health care professionals, about appropriate care by the appropriate caregivers within the right communities. They're worried about quality of care. They're worried about delisting. They're worried about out-of-pocket expenses that they're being asked to pay. Moreover, they're worried about who is making the decisions about what is medically necessary and to what ends. A growing number of Canadians are concerned about the inability of our political leadership—and I point no fingers at anybody here, because I played more than my fair share in this game—the failure of our political leadership, to solve this problem, as opposed to retreating to our individual corners and finger-pointing and hollering at each other.

[Translation]

    I began my presentation by saying that the approach of this committee, whereby it is looking head-on at the reality of the situation, is bravely taking difficult decisions and is assessing evidence in a non-partisan way, is one that we will all have to replicate in the future.

[English]

    I firmly believe the goodwill, the collective will, the shared commitment, and the unwavering determination exist in this country in order to do what is required to build the kind of society we want to build in Canada, and to preserve for future generations the great public legacy we received from our forebears.

    I have with me our director of research, Dr. Pierre-Gerlier Forest, of the Université Laval. With the assistance of Dr. Pierre-Gerlier Forest, I would be happy to try to answer your questions.

    Thank you for listening to me. That may have been a little too long, but I don't get a chance to come before a distinguished body like this too often. I therefore thought I'd give you the whole load, as we say back home in western Canada.

    The Chair: Thank you very much, Mr. Romanow.

    We'll now proceed to the second phase of our meeting, which is questioning by members, and we'll begin with Mr. Merrifield.

    Mr. Rob Merrifield (Yellowhead, Canadian Alliance): Thank you very much for coming. We appreciated the full load. I enjoyed listening to it.

    I wish you well, because I think Canadians are of bated breath in waiting for something to come forward with regard to health care reform. Over the last decade, we've seen our health care system become increasingly and increasingly pressured, to the point at which, depending on who you want to listen to, it's in crisis or not in crisis. Nonetheless, we can argue that, but I think a lot depends on whether you're one of those lying in the waiting room or in the hallways of our hospitals while trying to get into service, or whether you're a healthy individual walking the streets.

    With regard to this, I know this was a debate over a number of the provincial initiatives on health care reform, as well as yours. Some are saying we're in crisis, and some are saying we're not. I don't know if I want to dwell on that issue that much, though, because I think that's subjective. Nonetheless, you have said the status quo is not an option. You're saying that obviously because you're suggesting that if we leave it the way it is, it will be in crisis in the future, and that would be non-disputable. Is that a fair statement?

    Mr. Roy Romanow: I think it is.

    On the status quo, I think the fundamental assumption is that money alone will solve the problems. I have always argued that money alone will not do so. Money is an important component, because we are facing a tidal wave—it may be hitting us now—of new technology, pharmaceuticals, aging demographics, expectations, and a variety of these kinds of cost drivers that probably will determine some increase in funding. But money is not the answer alone, and the status quo seems to imply that.

    To answer very briefly, I agree with you about crisis and stress, except to add the view that if you do poll Canadians and ask them if they or any of their immediate family have been in contact with the health care system, and how they rank the quality of care, then even during the tough times and the good times, consistently roughly in the neighbourhood of 87% say it has been excellent to good care.

    So I think it's under severe stress, but I do not think it is at crisis. But I think you're right in saying it may not be beneficial to debate that now.

Á  (1140)  

    Mr. Rob Merrifield: That's true, because leaving it status quo, the way it is, will likely cause it only to get worse. Obviously, you wouldn't say that the status quo is not an option if that was the case.

    Mr. Roy Romanow: That's why we have the royal commission, that's true

    Mr. Rob Merrifield: Fair enough.

    When we look at health care and at the federal jurisdictional role—and that's something we, as a committee, wrestle with from our perspective as federal members of Parliament—we look at the areas in which we have influence, which are the Canada Health Act and the funding of the system, which has now been eroded to 14% across Canada and is really the only lever to enforce the Canada Health Act.

    I guess what I'm struck by in your report is the fact that you make very little mention of the Canada Health Act. You suggest that it should perhaps open up, but we've heard comments from Monique Bégin, the founder of the Canada Health Act, who has suggested that it's time to open it up, that it's time to take a look at it. We've brought forward motions at this table to suggest that we're going to do that.

    My question, specifically with regard to the Canada Health Act, is whether or not the Canada Health Act, in its current form, embodies all the of values that need to be embodied to take our health care system into the 21st century and beyond. Or do we need to re-examine some of the values and perhaps add, identify, or define some of the Canada Health Act? Will your report in November bring forward recommendations in that regard?

    Mr. Roy Romanow: Mr. Merrifield, on the latter question, I don't want to dodge it, but you'll understand that the final report will provide clear, concise recommendations for acceptance and rejection, however Parliament wants to deal with them and however the Canadian public wants to deal with them. That will be the basis of the final report, and those final recommendations will be made after I get the evidence from the Canadian public, as I've said in my main remarks.

    To address the question of the interim report, in talking about the Canada Health Act, I do say on page 18,

The Canada Health Act needs to be debated to ensure it still expresses thevalues Canadians share and provides a clear, coherent, and modern vision....

Secondly,

We need to consider establishing a new mechanism...forheading off disputes....

Thirdly,

Canadians need a greater say in determining what health services should orshould not be publicly covered.

    And on the next page, I list some fundamental questions—they're not comprehensive, but they are key questions—that I would ask Canadians to direct their minds to and to provide answers to. So with respect, I'm saying we do put the Canada Health Act right on the radar screen, up front.

    Mr. Rob Merrifield: I appreciate that, because when I look at your original mandate from the Privy Council, it suggests that your mandate is to work within the confines of the Canada Health Act and a publicly funded system. I applaud you for taking the initiative to bring it in as part of the dialogue, but I'm a little surprised that it isn't embodied in the four proposals you put forward. But let's change from that, because I think we've talked about it enough. We have your input on that.

    When it comes to those four, let's take a look at the four proposals on which you're asking for input. You're saying the first one is about more money. The federal government says it doesn't have any more, so that's likely not going to be the best option or the option that is going to be palatable. The second one is user-pay. I believe you have made a number of comments that this not a very favourable one. But one that is interesting is on private choices, your third one. A week ago Friday, the Minister of Health suggested in the House that it is certainly not a choice of this government, so that leaves it to renewal and reorganization of health care, which is your fourth option.

    Is that last option not primarily provincial jurisdiction? I'm just wondering how you're putting all that together and what kind of real debate we're going to have on that issue. Do you feel you've perhaps been somewhat undermined in the process by the federal government at the present time?

Á  (1145)  

    Mr. Roy Romanow: On the latter side, Mr. Merrifield, I do not feel undermined and “underminded” any more than I might by individual provincial commission reports that take a different tack. I don't. I welcome a variety of opinions from a variety of sources, because, quite clearly, if I had all the answers or if any one of us did, you could do it on the back of an envelope, end of issue, and we'd save ourselves a lot of money and time. I think this is a time when Canadians have to rally around and give us their best views, so I don't believe I've been undermined.

    By the way, on that point, I would just say that this royal commission was never intended to be a freeze-frame, saying to the Government of Canada and the provincial governments that they can't do anything until the commission reports. They have to govern on a day-to-day basis. I didn't leave the premier's chair so long ago that I don't remember that we used to open up the newspaper with fear every morning, waiting to see what health care crisis was facing us. They have these obligations, so I don't object, but I welcome these particular ideas.

    On the four perspectives, however, I would argue that they stem essentially from something as a condition precedent, Mr. Merrifield. As I tried to say in my opening remarks, I believe each of these four embodies different value judgments on which Canadians have to decide. I repeat again that they're not watertight compartments. In essence, they're questions of parallel systems. For example, I think option 3 articulates one choice quite objectively. There's a school of thought for that, and I want to hear from Canadians on it. It carries with it a set of values that is different from, say, option 1 or option 4.

    I'll wrap up my answer in this regard by saying that, to me, what is a condition of precedent about this debate is having a royal Canadian-to-Canadian debate about what the values of Canadians are. If we can get a consensus on that, the organizing principles surrounding the delivery of health care, the financing of health care, the measurement of its outcomes and quality, the collaborative mechanisms of the federal government, the provinces, and the territories, and amongst the caregivers, for that matter, will be made easier—not easy, but easier.

    Mr. Rob Merrifield: I appreciate that answer, but let's move on. There's one other point, but I know my time is running a little bit low. I do have time for another quick one, though.

    On the dispute mechanism panel, we have provinces right across this country—they met in Vancouver, as I'm sure you're aware—that basically pointed a gun to the federal government's head and said it had better come forward with a dispute mechanism panel so that we can deal with conflicts under the Canada Health Act. That has actually been promised since 1999, and now we have ninety days from January 1, so it's supposed to be there on April 1.

    I want your input on that. You do make mention of it a little bit, but you lay out some scenarios. I would like to know where you are on that. You don't have until November to come up with this one, so can you tell me what you think should happen with regard to that?

    Mr. Roy Romanow: I see no difficulty with the governments of Canada coming up, under SUFA, the Social Union Framework Agreement of 1999, with a dispute avoidance or dispute resolution mechanism. If newspaper reports are accurate, there seems to be some progress in this regard, because the three-year time of SUFA is now coming to an end, since we're in February.

    Mr. Rob Merrifield: February 4.

Á  (1150)  

    Mr. Roy Romanow: Yes, February 4, which has already passed.

    I was there on February 4, 1999, when we signed SUFA, which basically deals with the prospective social programs. Particularly in the area of health prospectives, we should have a dispute resolution mechanism. Under the Canada Health Act, we are talking about not only prospective but ongoing, continuing interpretations. I therefore think there very much needs to be a debate about avoidance and/or resolution. I took that position when I was premier, but I've been trying to be as objective as I can about it since becoming commissioner.

    Since the provinces primarily deliver the health care but the federal government has a role as well, there are differences that arise from time to time, so there needs to be a study of dispute avoidance or resolution. I think you could have a SUFA agreement that may be applicable to CHA, but we probably will require one for the CHA as well.

    Mr. Rob Merrifield: And that will be a recommendation?

    Mr. Roy Romanow: Well, we'll see. I certainly want it to be highly debated, but based on my previous statements when I was premier and based on the report, you will perhaps read between the lines to see where I'm headed.

    The Chair: Thank you, Mr. Merrifield.

    Mr. Lunney.

    Mr. James Lunney (Nanaimo--Alberni, Canadian Alliance): Thank you, Madam Chair.

    Mr. Romanow, let me be the third to welcome you to this Commons health committee meeting. We enjoy digging into debates and issues on this committee, and everyone is watching this debate with a lot of interest.

    Let me begin by quoting one of our senior Canadian health care economists. I heard him speak recently, and he made a remark to the effect that if we simply considered the problems that exist and the possible interventions, and if we then considered the evidence for what works and considered what can we afford, without regard for who delivers the service, health care planning should be relatively straightforward.

    Everyone seems to agree that one of the major issues in health care delivery is a manpower problem, including disproportionate distribution in some cases. For instance, there's the issue of nurse practitioners. We have areas in which there definitely seem to be shortages of physicians to deliver services, but we have nurse practitioners. The evidence is that they can do perhaps 75% or 80% of what a medical doctor can do. In a rural area, for instance—although maybe I shouldn't say it that way—

    Mr. Roy Romanow: Yes, and there are no rural charges allowed in my province, so it's very difficult.

    Mr. James Lunney: Exactly, so in an area where it's hard to get physicians to stay, there is evidence that one doctor and three nurse practitioners could perhaps competently provide the same level of service that three physicians could.

    On another issue, there is abundant scientific evidence—and it's very well documented—on the issue of mechanical, structural lower back pain. Other practitioners—those chiropractors you mentioned earlier—are capable of delivering a very good service that is in fact cost-effective, provides better value, and results in higher patient satisfaction than what is currently received under the funded medical system.

    So my first question to you would be about who decides what appropriate or medically necessary care is. In the interest of promoting cost-effectiveness, in order to make sure Canadians get value for their health care dollar, what is your commission doing to overcome professional fights over turf?

    Mr. Roy Romanow: On the latter issue, I want to report my perception—it's not a fact yet, but I strongly believe this—that amongst the health caregivers and the professionals themselves, there has been quite a noticeable change in their attitude toward cooperation. But let me tell you what I base that statement on.

    When I retired from politics provincially with the consent of the majority of the voters in my riding in Saskatchewan in 1982, I was asked by the Canadian Medical Association to serve on a task force for two years. The topic was aging and technology. That was twenty years ago, so the more things change, the less they change, because here we are on aging and technology.

    There was very much a silo, a tussle over turf back then—I may be overstating it a bit, but this is my impression as a lay person—but I don't find that now. In dealing with the CMA and the Canadian Nurses Association, I find that the cooperation with both these organizations is very high. There are many areas of agreement. They're trying to define the scopes of practice; how they can expand the role of the nurse practitioner; what the role of the GP is; and concepts of primary health care reform, which of course is the integrated model that I think you've articulated. These are all well underway.

    Among our many problems, one of our problems in achieving the straightforward organization model—to use your expert's quote—has been that we have not been able to elevate these from a pilot into some form of pan-Canadian, provincial, although not necessarily identical program. Quebec will have to have its own, and Newfoundland will obviously have to have its own, but we haven't been able to get it done on a pan-Canadian basis yet.

    What am I trying to do? I'm trying to encourage.... In part 4 of the interim report, you'll find that the key theme is collaborative mechanisms not only governmentally, but in an area that I think we've ignored, and that is those who are actually at the coal face: doctors and nurses who know where the areas of cooperation are.

    There's much dialogue here, and I'm thinking about ideas on which we can have common meeting ground to try to get to the straightforward scheme.

    The Chair: Thank you, Dr. Lunney.

    Mr. Ménard.

Á  (1155)  

[Translation]

    Mr. Réal Ménard (Hochelaga--Maisonneuve, BQ): I have been following your career for several years now. I was 19 years old in 1981, when you appeared on television to support a policy that Quebec has never recognized. However, that's a debate for another day.

[English]

    Mr. Roy Romanow: I was only 21 myself.

    An hon. member: Oh, oh!

[Translation]

    Mr. Réal Ménard: I want to ask you the following question. It seems to me that what you are doing creates a problem of legitimacy. I have to tell you that in some ways, I even think you are showing some gall here. We are faced with the federal government, which now only pays 14¢ of every dollar spent on health care in Canada. However, the same government committed, at the outset, to cover 50¢. This government, despite the fact that the seven provinces... As a matter of fact, I could even table the paper to prove it. Seven provinces, between 1996 and 2000, set up task forces on this issue and now the government, which contributes least to health care spending, which doesn't even live up to its own commitments that it set up in the 1960s, is now trying to put forward solutions to the problem. I think that you will understand that I think that that's quite a cheeky attitude and that, personally, I do not see much legitimacy in what you are doing. However, since you have got the ball rolling on health care, I would like to ask you three questions.

    Firstly, can we count on you to be more than just a servile entity in the hands of the federal government? Can we count on you to develop a critical perspective of the issues to fight the federal government's resolve to centralize, and finally, will you prevent the federal government from encroaching on services covered by the provinces, such as primary health care and home care?

    Secondly, can we count on you to be an ally of the provincial premiers, by maintaining a critical perspective on the situation? I would like to point out to you that many people have looked into this issue and that in 2000, all the provincial premiers, including those of Saskatchewan and New Brunswick, demanded that the federal government restore transfer payments—with indexation—to 1994 levels.

    You yourself gave us some hope in what you said on page 28 of your paper. Please tell me whether I have interpreted what you said correctly. In your paper you say the following:

Over the past few years, fluctuations in fund allocation have taken a toll on the health system. Consequently, this erratic procedure should be replaced by stable funding provisions...

    Consequently, are you going to be an ally to the provincial premiers or are you merely going to be a servile tool in the hands of the federal government to allow it to maintain its current course?

    Thirdly, Mr. Romanow, if we can indeed count on your support to avoid government centralization and to assist the provinces in obtaining more resources for health, do you share the belief of the provinces, and not only of the premiers, that health care spending in Canada, which currently stands at $56 billion, will rise within the next five years to $67 billion and, within the next ten years, to $85 billion? Consequently, any way you look at the issue, the federal government is going to have to restore transfer payments. If they do not, the health care system will no longer be viable.

    To sum up then, what I want to know is whether you intend to be a mere lackey to the federal government or an ally to the premiers.

[English]

    Mr. Roy Romanow: Well, Mr. Ménard, may I answer your very important question the following way? At the end of the day, which will bring the final recommendations, it will be for you, other members of Parliament, and the Canadian public to decide whether or not I am a tool, a slave, or however one wants to describe it. I can tell you that I'm not running for political office. I've had a very interesting—and some say too long—political career. I've been in political office for over thirty years, and this is my last go.

[Translation]

    Mr. Réal Ménard: [Editor's Note: Inaudible]

[English]

    Mr. Roy Romanow: I said it's been interesting, but I'll try to get a neutral word in there, Monsieur Ménard. Nonetheless, I'm not interested in running for political office.

    Secondly, as everybody here knows—and please forgive me, because I don't mean to be saying this in any sense except a quite legitimate one—as a royal commissioner appointed under part I of the Inquiries Act of Canada, I am not responsible to any government, federal or provincial. That's the whole purpose of a royal commission, so I'm going to call it the way I see it. As for whether I do or not, you'll have to make that judgment call at the end of the day.

    I would say two other things very briefly, because you raised three questions. On the funding issue, 14% is the figure many of the provincial governments have advocated. The federal government has advocated 31% to 33% factoring into tax points. Without getting into the debate about whether this is a legitimate factoring or not—I don't know—it requires careful determination of the actual accuracy and effectiveness of the numbers, so there is a debate there.

    Second, with respect to 50% funding, which was historically the case, I think it is clearly fair to say the 50% federal funding to the provinces was often accompanied by—how should I describe it, to be delicate?—some federal government thoughts on the nature and form of health care.

  (1200)  

[Translation]

    Mr. Réal Ménard: You do not dispute the fact that the federal government has reneged on the investment commitment that it made when the funding procedure for these programs was set up in the 1960s. You do not dispute either that, apart from your personal merit, the legitimacy of your commission is debatable. This is especially true in light of the fact that seven of the ten provinces have already established working groups on this issue, and you are not going to reinvent the wheel.

    I'm not sure whether we know what tensions and pressures will exist over the coming years in Canada. A good number of people have looked into the issue of reorganizing the health care system.

    I would be very interested to know what you think of the National Health Forum which was held in 1984. I'm not sure that we have thought about that one. We are counting on you. You have a responsibility. If you are indeed not just a mere lackey to the government, as you claim—we are prepared to accept that claim —I hope that we will be able to count on you to recognize the fact that the federal government has a certain amount of gall in setting up a commission when it has not even kept its own promises.

    Can you give me an example of one premier who has not said that over the coming years they are going to face pressure in terms of rising costs and that they need more money for the health care system. Our hopes rest with you here too. We set great store by your ability to bring the federal government back into line. It's all too easy to set up commissions and to ask people to look into issues while the government fails to comply...

[English]

    The Chair: Mr. Ménard, your question please, very quickly. You're at six minutes already.

[Translation]

    Mr. Réal Ménard: Just let me ask my questions. You be chair of the committee, and I'll ask my questions. Please mind your own business, Madam Chair.

    My question is the following: Can we count on you to make recommendations, which will be consistent with the consensus developed by the provincial premiers at their two federal-provincial conferences?

[English]

    Mr. Roy Romanow: I can't answer except by saying what I said earlier. The answer I have to give you is that it will have to wait until the final recommendations are made. It has to be studied.

    In the interest of time, Monsieur Ménard, I'll take just one moment.

    We've commissioned Dr. Harvey Lazar and Queen's University to do an in-depth, independent, arm's-length study on fiscal federalism and the amount of shares that have been contributed on this particular topic. And I'm very interested, by the way, in what Monsieur Yves Séguin's commission is going to be reporting in Quebec, which is—

[Translation]

    Mr. Réal Ménard: The premiers and finance ministers have already done that.

[English]

    The Chair: Mr. Ménard, Mr. Romanow has the floor.

    Mr. Roy Romanow: If I may say so, with respect, I understand what the provincial premiers and territorial leaders have said. I was there, saying part of the same story. But there's another side to the story, and that is what the federal government says. What I have to do—to answer your question—is come up with an evidence-based, documented, factual argument one way or the other in this area.

[Translation]

    Mr. Réal Ménard: Are you preparing the ground for centralization? Are you going...

[English]

    The Chair: Mr. Ménard, thank you very much. You're all finished.

    Madame Scherrer.

[Translation]

    Ms. Hélène Scherrer (Louis-Hébert, Lib.): Thank you, Madam Chair. I would first of all like to extend a very special welcome to Dr. Pierre-Gerlier Forest of Laval University. It's a great pleasure for me to welcome you here today.

    Mr. Romanow, I would like to come back to one of the criteria used in your report. These criteria explain why health care now costs much more than it did in the past and why these costs are continually increasing. For example, you mentioned an aging population, the need to renew equipment and the lack of human resources. However, you also mentioned one area which worries me somewhat. You referred to the costs linked to research, to equipment and to pharmacology.

    This area worries me slightly because I think that the government, public bodies or health care stakeholders have some control over the other factors that you mentioned. For example, we can choose to renew or not to renew equipment or we can opt to update over a longer time period. There is some control over how many staff will be taken on. To a certain extent, it is possible to foresee the needs of an aging population.

    However, in terms of the cost of new computer technologies, equipment and new drugs, I tend to think that this is an area that is completely controlled by the private sector and that the private sector is getting richer at the same rate as we are getting poorer. I also tend to think that all health care stakeholders have absolutely no control over this area, which is going to become excessively expensive as time goes on.

    Only this week, there was a report about a new cancer drug, which costs users a fortune and which is not yet covered by the health care system. The pharmaceutical industry is making a packet out of this situation.

    Let's take new oncology, radiology, scanner or MRI equipment for example, where prices have doubled or even tripled each year. Lastly, I just wanted to say that this is enabling the private sector to get rich at the expense of Canadians. Indeed, the private sector is in a good position, because health care remains a priority at all levels of government. Consequently, it's very easy to get into that... Indeed, the need exists; it does not even need to be created.

    My question is the following: When, in assessment criteria for the Canadian health care system, reference is made to access to quality health care for all Canadians, what does that mean for you and for those who have looked into this issue? Does that mean that everybody needs these cutting-edge services and newfangled drugs? You did indeed touch on that point.

    As far as I can see, you have no control over the private sector. Indeed, this is one of the reasons why we will never succeed in keeping health care costs down over the coming years.

  (1205)  

[English]

    Mr. Roy Romanow: Well, you advance a very powerful argument about the risk in terms of being able to have a sustainable health care system.

    I hope I'm not misinterpreting your question, but I think a lot of it relates to expectations that the Canadian public has and that the public in America and western Europe has generally. They see and hear about all the new science and new technology, whether we're talking about drugs or procedures. Although it's against the law to have pharmaceuticals advertised on television in Canada, Canadians see it nonetheless. It comes across the border, and there it is: promotion. Perhaps the pharmaceutical companies will call it educating, but it's nonetheless whetting the appetite for some use of pharmacology, and I think all of it stems from and promotes a question of expectations.

    I think we have to be able to say quite frankly in Canada, to the Canadian public, that the health care system was never designed to be able to do all things for all people, at all times and almost immediately. It has always been a question of prioritization.

    On the specific question of the management of technology and drugs, of pharmacology and the new science, we have a very huge challenge before us. On drugs, there is the issue of the drug patent law and how it impacts on Canada vis-à-vis generics. Tied into this is the question of international trading arrangements that are now part of the factor since the changed generic laws, FTA, and NAFTA. No simple answers are to be found on any of these.

    There is also globalization, for good or for bad—although we are doing a paper on globalization, let's leave that argument aside for the moment—and its impact on all of this technology. The trick is going to be for us to decide, as Canadians, who decides what is medically necessary today and in the next ten, fifteen, and twenty years. This has to be done in such a way that Canadians have confidence that the decision-makers—or at least those who recommend to the decision-makers—can determine what is or isn't to be covered, so that there isn't profit but is care for the public, along with transparency, accountability and the mechanisms of cooperation. I think that's the only way to go. Thus, as I say, part 4 of the report highlights that side of it.

    The Chair: Thank you, Madame Scherrer.

    Ms. Hélène Scherrer: May I just ask one more?

    The Chair: No, you can't. We don't have enough time left for the number of people on the list.

    I'm going to restrict each of you to about three and a half to four minutes for both the question and the answer, and this will be the order: Madame Thibeault, Ms. Wasylycia-Leis, Dr. Castonguay, Mr. Bachand, and Dr. Fry.

    Madame Thibeault, try to be succinct. You usually are.

    An hon. member: Will there be a second round?

    The Chair: Absolutely not.

[Translation]

    Ms. Yolande Thibeault (Saint-Lambert, Lib.): Thank you, Madam Chair. Yes, I'll try to be brief.

  (1210)  

     Welcome.

    Mr. Romanow, in your interim report, under the chapter on the role of values, you state, and I quote, “a debate [...] which has been confused by disagreements over the meaning of specific, currently used terminology in health care”.

    It appears that not all stakeholders have the same view of what the health care system requires, for example, in terms of portability and fairness. I find this somewhat disturbing, because, imagine when ministers of Health from throughout Canada meet with their officials, if they are not all speaking the same language, then how are they going to be able to reach an agreement.

    Can you see any solution which would allow us to address this problem?

[English]

    Mr. Roy Romanow: I think I can, and I think we can find the solution through the public dialogue, which is educative by its own nature; and by trying not to straitjacket, but by focusing the discussion along the values-based perspectives.

    There will always be differences when we're hearing from experts who help us to define. We will never find 100% agreement on what “need” means or what other particular terminology means, and I don't expect it. But I think we can certainly refine and improve the level of understanding and acceptance.

    The Chair: Thank you, Madame Thibeault.

    Mrs. Wasylycia-Leis—and I caution you about the length of your question.

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

    In three and a half minutes or less, let me try first to thank you, Mr. Romanow, for appearing before the committee, since it gives us at least one opportunity to get an overview of your important work and to try to see what we can do to play a role in the coming months. Let me also say that I think your interim report was significant in terms of helping to set the stage for allowing for a consensus report and for making decisions based on values.

    I want to ask you specifically about the question of money and the fact that you say all options are on the table. As a former premier of Saskatchewan, it seems to me that you know very well the difficulties of trying to grapple with significant changes in the transfer payments and with federal cuts and how to handle those. When you say all options are on the table, do you mean the very question of having the federal government as a partner in health care is in fact on the table?

    Related to that are my questions about the appropriate role for the federal government in terms of sustaining a national health care system; the debate about cash being on the table, versus tax points, in order to be the glue that holds the system together; and how we deal with current premiers' concerns about receiving a 14% share from the federal government while wanting to get back toward that 50-50 partnership. You've put all of those on the table, but I'm wondering if there is in fact a question here about the bottom line with respect to the federal role and federal spending power.

    Mr. Roy Romanow: In specifics, I hope that will be defined by the final recommendations. In general terms, perhaps with some controversy before this committee, there is a role for the federal government, but the primary role is a provincial role because that's what the Constitution says.

    I must repeat, though, that there is a role for the federal government. They are the fifth-largest provider of health care in Canada if you take the provinces into account. The federal government sets the provisions of the Canada Health Act and the CHST, whether these are good, bad, or otherwise. Should the sharing levels be higher or lower, as Monsieur Ménard wanted to know?

    So I think the answer is that there has to be something that is respectful of or mindful of constitutional responsibility and jurisdiction. I would just say very briefly that I'm very sensitive to this because, under our federal system, Saskatchewan was permitted the freedom to experiment with medicare way back in 1961-62. That's one of the strengths of our system. One of the weaknesses, of course, is that some differences abound.

    It is either going to be a ten-tier system in which we will have ten individual provinces having a basket of services—services that are one size in some provinces but another size in other provinces, with this method of delivery in one province and that method of payment in another—or there's going to be some element of nationality, of national approach to it—and by “national”, I mean federal-provincial, cooperative, and mindful of the Constitution; I stress that it does not mean Ottawa alone.

    Is there a role? There has to be a role. The exact definition and nature of the role will depend upon the reports, the studies, and the recommendations.

  (1215)  

    The Chair: Thank you, Mrs. Wasylycia-Leis.

    Dr. Castonguay.

[Translation]

    Mr. Jeannot Castonguay (Madawaska--Restigouche, Lib.): Thank you.

    I have two questions. Do you think that there is any room to improve cooperation between the various levels of government to achieve the common goal of ensuring the future of our health care system? If you do, how would you suggest we do that?

    Secondly, we are aware that the language of communication between health care professionals and health care users is a major factor in terms of the quality and efficacy of the delivery of health care. Do you intend to look at the language issue in your report?

[English]

    An hon. member: [Inaudible—Editor]

[Translation]

    Mr. Jeannot Castonguay: No, but I am however, a true Canadian. My vision is for all of Canada. Thank you.

[English]

    Mr. Roy Romanow: I'm trying to be as honest and forthcoming as I can be in answering all of the questions, which are very stimulating but very difficult sometimes.

    The key is that you have to provide timely, accessible, quality care to people. Clearly, language...I would extend this in a different context, perhaps even to culture and, in my province, first nations, aboriginal healing lodges, methods of delivery... I won't get into the complicated and controversial areas of governance with respect to aboriginals. Anything that isn't a barrier to the provision of proper care and an understanding of what the health caregiver recommends and what the receiver should be doing needs to be looked at.

    In addition to that, we have the laws of this country. We have the Charter of Rights and Freedoms, the Constitution, and the Official Languages Act, which all take a look at this. I'm receiving submissions from people from all parts of the country who say we need to focus more and sharpen up on this particular issue.

    Again, I have not decided what the recommendations are going to be, but you asked me if we are looking at and examining this. The answer is that we have to.

    The Chair: Thank you, Dr. Castonguay.

    We move to Mr. Bachand.

[Translation]

    Mr. André Bachand (Richmond--Arthabaska, PC/RD): Thank you, Madam Chair, for your generosity. Next time, I shall make sure that I have a card so that I'm sure to be recognized. In fact, I did do that at the beginning of the meeting, immediately following the presentation by our witness. As you know, I would do anything to get my rightful time allocation. Of course I'm being flippant here.

    Having said that, Mr. Romanow, welcome. You said at the outset that you were not running for public office, but I would just like to point out to you that we do not have an elected senate. That was just a bit of a joke.

    You used a Saskatchewan expression at the end of your presentation. We have a similar Quebec expression which goes something like this “what will be the results?” or as some would say “what's gonna happen?”.

    People are asking the following question. You talked about provincial jurisdiction at the end of your statement. What authority does a commission like yours have in terms of what happens in the provinces, when the majority of the provinces, as my Bloc colleague said earlier, have undertaken studies on this issue? That's my first question. What role can a commission like yours play, and what suggestion would you make to encourage communication between the various levels of government following your report? Do you think we should have a specific federal-provincial conference, or a special federal-provincial conference on health care? That's my first question.

    You said earlier that what we don't want is a ten-tier health care system. In your opinion, do you think we have a two, three, or even four-tier health care system currently in Canada?

    I have one last question because my time is very limited and very precious to me. Would you be in favour of a specific cash transfer? There is a lot of argument over the amount of money transferred, especially through the Canadian health and social transfer program. Would you like to see this transfer divided? This would mean that the money transferred to the provinces for health would fall outside the overall transfer. Perhaps this would put an end to, or at least stem the arguing over the amount of money given by the federal government.

    Thank you.

[English]

    Mr. Roy Romanow: Monsieur Bachand, again, like all of the questions, this is a very important, serious question.

    On the latter point with respect to transfer funds, I can tell you we are considering this issue. For obvious reasons, I cannot and will not say today that this is a recommendation, but one body of opinion says that under the CHST, there should be a pulling out of funds for health, to be used for health, for education, for social services, and for other areas that we're trying to quantify and analyse. So I'm not ruling it out. Far from it.

    With respect to provinces, I have tried to recognize that primary responsibility constitutionally, and I've asked every province to nominate a liaison person, with whom we've worked very well. Quebec, however, takes the view that it's an exclusive jurisdiction. They have therefore not nominated a liaison person, but they have nominated a person to share information with us. On balance, that relationship with Quebec has not been too bad.

    Thirdly, in our public hearings, we've invited the provincial governments or their representatives to be the first presenters to outline their specific needs. On this point, let me make one point very quickly. This is not going to be a “one size fits all” royal commission set of findings. It can't be. The delivery of health care in the outports of Newfoundland is different from that in Sherbrooke, in downtown Toronto, in Sturgis, Saskatchewan, in the Northwest Territories, or in Nunavut. We need to recognize not only the Constitution, but just the pure practical reality that these systems need to be somewhat sensitive. Thus, I need the input of the provincial governments in that regard.

    So we're very much working closely with the provincial governments, even where publicly there may be apparent disagreement. Certainly, at the working level, I have found the relationship to be quite productive. My appointment is not a lifetime one, and I'm not expecting it to be.

  (1220)  

    The Chair: Thank you, Mr. Bachand.

    We now move to Dr. Fry.

    Ms. Hedy Fry (Vancouver Centre, Lib.): Thank you very much.

    I want to say that it's a pleasure to have you here, Mr. Romanow.

    I noticed in your report that you focused very much on Canadian values. If you recall when Emmett Hall came up with his decision or his recommendation for medicare, it was based on the concept of “medi-care“, which was what would happen to Canadians when they became ill, so that they would not have to go bankrupt or mortgage their homes in order to have access to care when ill.

    Perhaps one of the things I would like you to clarify is the difference between medicare and a health care system. Medicare is the delivery of services to people when they are ill, how you deal with people when they are chronically ill, and how you reach that time of life when they need palliative care. Health care is the over-arching component of prevention and promotion, the environment in which people will be able to achieve better health status. I think there is a tendency in the public mind to mix the two up, so I'd like to get your response to that.

    Secondly, you have talked about national principles. I believe very strongly that if we are to achieve portability and accessibility, we have to have clear national standards. I would like to hear your comment on that.

    Finally, the other question that I wanted to ask you is about the issue of evidence-based care. Do you believe the term “medically necessary” should be defined, and that the issue of who provides what care and when, has to be defined clearly by the evidence base and by outcomes, and not necessarily by emotionalism? I think that is something we need to discuss very clearly about the evidence base.

    On the issue of the evidence base, I think it's important that we define “medically necessary” so that can talk about what is involved within medicare per se. I would like to hear your comment on that and whether you believe the Canada Health Act, which only—

    The Chair: Dr. Fry, you're on your fifth question now.

    Ms. Hedy Fry: —defines “medically necessary”, ought to be expanded or opened up to discuss the concept of medically necessary care.

    Mr. Roy Romanow: Dr. Fry, thank you for those tough questions. They are important ones.

    First of all, if I may say so, with the greatest respect here, you're the expert in this area. I'm not, but I have learned very quickly that “medi-care”, in the context of doctors, hospitals, and the provision of acute care, is different from health care.

    From all the literature that I've read, the many people I've met—not all of whom are listed at the first appendix of this report—and all the visitations I've had, it's clear that health care and the social determinants of health care—education, housing, looking at prenatal and from zero to six—are going to affect quality of life, healthiness, lifestyles, and treatment down the road. It may cost something at the beginning, but it's going to save something at the end. At the end, given that life is the way it is, we get sick and we die. As a consequence of all this, at page 3 of the report, we talk about the social and physical environment, economic and social status, etc., being important components, and I visualize them as being important components in the final recommendations, without committing myself.

    On the question of so-called national standards, what I would prefer to have is a cooperative set of mechanisms that get the provinces to buy in because of their primary responsibility. It's not an imposed federal government set of standards, but an agreed to and manageable measurement of outcomes, goals, and statistics. You will know better than I do, Doctor, that we really suffer from a lack of evidence of what we do well and what we don't do well. I'm frustrated by that. Whether it amounts to whatever the terminology is, I don't know, but I think we should be looking at it.

    Evidence-based care is clearly something that is primary here. As a politician, Madam Chair, I can give you one example—and I know you're anxious for time. Under the current drug formularies, ten provinces set them. Some drugs are included in some provincial programs, some aren't. In the provinces where they aren't, political pressure will arise to include a drug even though our technical people say it's questionable. But now the political pressure enters into the picture, and the decision is made on that basis.

    By the way, I think this probably dictates...it's one example of getting two cultures to intermingle in a cooperative way. There's the culture of the medical people who take the attitude first to do no harm and to help the patient at all costs, and the political culture—and I mean this in the best sense of the word “political”—of the policy-makers who say to do the greatest good for the greatest number of people.

    In our organizational system—and I've been guilty of this—it is the latter that is structured for the former, and they don't mix and match. The hospital administrators and the doctors and nurses continually are reacting to changes based on their experiences and evidence, so we need some methodologies in this regard.

    I'll close very briefly on the CHA, which I talk about in the report. I think this is a seminal debate not only because of the act, but because the act personifies, in statutory form, the debate on values. I come back to the four perspectives. If we can get this issue sorted out, then we can answer Dr. Fry's question about whether to add on to it, or about what we do with the Canada Health Act.

  (1225)  

    The Chair: Thank you very much, Mr. Romanow. Certainly that ending there was a good summary of your thoughts.

    We're very grateful for your presence among us today. I'm sure everyone in the room had more questions than they were allowed to put forward, but we were limited for time. I did promise your staff that you would be walking out the door at 12:30 p.m., and I think we've managed to do that for you.

    So thank you again for your time today. You've given us some ideas as to how we might help you. In addition to that, though, I would like to offer you the opportunity to call on us if you think of some other way in which we can help you. Please do not hesitate to call.

    Ladies and gentlemen, this meeting is now adjourned.