The Health of Canadians – The Federal Role
Interim Report
Volume Four – Issues and Options
Issues and Options for the Research and Evaluation Role
The role of the federal government in the field of research and evaluation is twofold: it encompasses both funding for health research and financial support for the evaluation of pilot projects.
The federal government has had a long tradition – over 40 years – in financing health research. In fact, up until 1994, the federal government was the main source of funding for health research in Canada. The Canadian Institutes of Health Research (CIHR) is currently the principal federal funding body for health research.
From time to time, the federal government also fulfils its role in health research by giving financial support for establishing and evaluating pilot projects that are designed to encourage innovation in health care delivery. Examples of such federal involvement include the Health Transition Fund (HTF, 1997 to 2001), which supports pilot projects undertaken jointly with provincial and territorial governments in the fields of Pharmacare, home care, primary care and integrated service delivery, as well as the Canada Health Infostructure Partnerships Program (CHIPP, 2000 to 2002), which supports provincial and territorial projects using new information technology in health care.
Throughout the Committee’s hearings on health research, there was unanimous consent among witnesses that funding innovative research and project evaluation should remain a major responsibility of the federal government. With respect to health research, the main concern raised by witnesses was that Canada’s funding level is low in comparison with other industrialized countries and that the federal government should devote more funding to health research. Other issues raised in the hearings related to the transfer of knowledge, regional disparities and ethics.
With regard to the evaluation of pilot projects designed to test new ways of delivering health care, all witnesses agreed that the federal government should maintain or increase its level of funding, while simultaneously addressing the issue of regional disparities. The latter issue arises because federal funding for pilot projects usually requires that a provincial government match the federal financial contribution. For Canada’s poorer provinces, this is often not financially possible. Thus, most of the pilot projects supported by the federal government are in the richer provinces, and the poorer provinces which most need the help receive very little.
9.1 Innovative Health Research
Canada has an international reputation for excellence in health research. Going back to the days of Banting and Best and the discovery of insulin more than 75 years ago, Canadian researchers have made discoveries that make a difference in the lives of people around the globe. For example:
- Canadian research pointed out that one dollar spent on early childhood intervention saves, on average, seven dollars in education, social services, justice system and health care costs;
- Canadian researchers discovered and developed 3TC, a drug that helps extent lives for many people living with HIV and AIDS.
Everybody agrees that health research will be one of the major drivers of change in Canada’s health care system in the coming years. The knowledge that is gained as a result of health research translates directly into better diagnosis, treatment, cure and prevention of many diseases. This, in turn, leads to reduced health care costs by:
- reducing both the social and economic cost of illness, through the development of new drugs, products, and technologies that shorten hospital stays, speed healing, and prolong good health;
- improving the efficiency and effectiveness of health care delivery; and,
- curing disease.
The federal government plays a major role in supporting health research carried out in universities, teaching hospitals and research institutes ("extramural" research), as well as in its own laboratories ("intramural" research). During Phase Two of its study, the Committee was told that strategic investment today by the federal government in programs and initiatives like the Canadian Institutes for Health Research (CIHR), the Canadian Foundation of Innovation (CFI), the Canadian Health Services Research Foundation (CHSRF), Genome Canada and the Canada Research Chairs (CRCs) will pay huge dividends for our health care system tomorrow.
Ongoing advances in genetics and genomics are of particular interest. For example, the ability to identify people whose genes make them susceptible to a given disease will enable a profound shift to take place in health care – moving the emphasis from disease treatment to disease prevention and health promotion. The better we understand the molecular mechanisms that underlie disease, the sooner we will be able to develop an entirely new generation of drugs that can combat the alterations made by disease to our molecular machinery. This knowledge, coupled with our growing appreciation of the complex interplay between genetic, social, and environmental factors that determine our susceptibility to disease, will transform our health care system over the next 10-20 years.
The creation of the CIHR by the federal government in April 2000 recognizes the critical link between a cost-effective and innovative health care system and a vibrant, internationally competitive health research industry. The CIHR brings together all four pillars of health research – biomedical, clinical, health services and systems, and population health research. It encourages Canadian researchers to take an integrated approach to the health issues that concern Canadians.
9.1.1 Increasing the Federal Share of Health Research Funding
The federal government plays an important role in funding health research in Canada. For example, in 1998, almost $370 million of federal funding was allocated to health research. This was prior to the establishment of the CIHR. However, the proportion of health research funding provided by the federal government declined steadily from a high of 28% in 1992 to 16% in 1998. Since 1994, the pharmaceutical industry has been the leading source of funds for health research in Canada.
The federal government believes that its position in terms of health research funding will greatly improve as a result of the establishment of the CIHR along with additional investment announced in both the February 2000 budget and the October 2000 Economic Statement and Budget Update. The federal government also provided an additional grant of $140 million in February 2001 to Genome Canada bringing its total budget to $300 million.
During its Phase Two hearings, the Committee was told that while the increase in federal funding represents significant support for health research, Canada still does not compare favourably with other countries in this regard. In fact, the role of the national government in financing health research, expressed in purchasing power parity (PPP) per capita, is far more important in the United States, the United Kingdom, France and Australia than in Canada. For example, the American government provides four times more funding per capita to health research than does the Canadian government.
Witnesses unanimously recommended that the federal government’s share of total spending on health research should be increased to 1% of total health care spending from its current level of approximately 0.5%. This would mean at least doubling CIHR’s current budget to $1 billion. In the view of several witnesses who testified before the Committee, this would bring the level of the federal contribution to health research more in line with that of national governments in other countries. More importantly, such federal investment would help maintain a vibrant, innovative and leading edge health research industry.
The Committee welcomes opinions on the option of raising the federal share of total spending on health research to 1% of total health care spending. We are particularly interested in obtaining views on how this greatly expanded federal funding for health research should be invested: should it be strategically targeted to the development of a number of areas (such as Aboriginal health, rural health, mental health, gender analysis, determinants of health, home care, etc.), or should it be distributed more evenly across the full range of health research areas?
9.1.2 Sustaining the Transfer of Knowledge
The Committee was told that the outcomes of health research must be made available, notably to policy-makers and health care providers, but also to the general public. There is a need to establish a public awareness campaign to inform Canadians about, among other things, genetic research, animal cloning, and embryo research. There is also a need to disseminate the results of health research to health care providers and policy makers. The timely transfer of knowledge generated by health research to policy makers and health care providers would greatly enhance evidence-based decision-making to the benefit of all Canadians.
One organization, the Canadian Health Services Research Foundation (CHSRF), is dedicated to knowledge transfer. The CHSRF is a not-for-profit organization established with federal funding whose mission is to sponsor and promote applied research on the health care system in order to enhance its quality, and to facilitate the use of research results in evidence-based decision-making by policy-makers and health care managers.
The CHSRF is devoted to health services research. What is needed, therefore, is an organization whose task would be to disseminate the results of biomedical and clinical research. One option could be to establish such an organization within the CIHR or within Health Canada. Another option could be to create a separate federal agency devoted to this task.
9.1.3 Reducing Regional Disparities
The Committee heard that there is great regional disparity in terms of health research capacity across the country. For example, some medical facilities and academic health centres, particularly in the Atlantic provinces and in the Prairies, are currently under-funded and unable to respond to the challenges of contributing to Canada’s success in developing a globally competitive health research industry.
Provinces that do not have a critical mass of expertise and proven excellence are at a severe advantage both in grant competitions and in the recruitment and retention of talented personnel. Provinces with larger budgets are able to offer salaries and resources that lure away well-trained and talented researchers from provinces with smaller budgets. Witnesses told the Committee that this internal competition for talented people is counter-productive and that this matter requires rapid attention from the federal government.
The Committee was glad to hear that the CIHR currently manages the Regional Partnerships Program (RPP) which provides health research funding dedicated to reduce regional disparities. Six provinces are eligible for funding under the RPP: Saskatchewan, Nova Scotia, Newfoundland, Manitoba, Prince Edward Island and New Brunswick. In addition to funding health research, the RPP supports local strategic planning processes to establish research priorities and partnerships, emphasizing the recruitment and retention of promising and/or excellent researchers, building on local strengths and priority interests of the research institutions.
The Committee would like to hear comments about the RPP programs as well as about other potential options on how the federal government can contribute to reducing provincial disparities in health research capacity.
9.1.4 A National Human Research Ethics Oversight Body
The Committee was told that health research must be undertaken in a way that ensures that the highest ethical standards are respected. Witnesses stressed that health research requires transparent and credible ethical procedures, primarily so that human subjects involved in research can be protected. Ethical principles must apply to all health research activities. It is also important to monitor, analyze and evaluate ethical issues pertaining to health research.
Recently, the CIHR, along with two other federal agencies funding research, the Social Sciences and Humanities Research Council (SSHRC) and the Natural Sciences and Engineering Research Council (NSERC), announced the creation of a new governance structure, the "Panel on Research Ethics," which will govern federal policy relating to the ethical conduct of research involving human subjects. This policy is entitled Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS). The Committee was told that while the current policy has high standards, effective oversight is required to ensure compliance with those standards. Moreover, the Panel on Research Ethics will review research funded by the CIHR, the SSHRC and NSERC, not all health research performed in Canada.
It was suggested that a national oversight body independent from the CIHR be established to provide ethics review functions for all publicly and privately funded health research, and in particular research using human embryo or foetal tissue, including embryonic stem cell research. We welcome your views on such a national oversight body.
9.2 Financing and Evaluation of Innovative Pilot Projects
In recent years, the federal government has been involved in the financing of pilot projects aimed at improving the delivery of health care. An important component of these pilot projects is the requirement to provide an evaluation of outcomes, including reporting on the impact of the project on health status and on health services utilization, its cost effectiveness, and improvements made in the provision of care.
For example, in 1997, the federal government announced the Health Transition Fund (HTF). This $150 million Fund supported 141 projects and numerous sub-studies across Canada in four priority areas: home care; Pharmacare/pharmaceutical issues; primary health care; and integrated service delivery. These projects were intended to generate evidence that governments, health authorities, hospitals and others could use in making informed decisions on how to provide better, more effective health services to Canadians. An overall evaluation of all these projects will be made public by Health Canada in March 2002.
Another example is the Canada Health Infostructure Partnerships Program (CHIPP), a two-year, $80 million, shared-cost incentive program, which was announced in June 2000. The objective of CHIPP is to support the implementation of innovative applications of information and communications technologies in the field of health care. The overall goal is to help improve accessibility and quality of care for all Canadians, while enhancing the efficiency and long-term sustainability of the health care system. CHIPP supports projects in the areas of telemedicine, tele-homecare and electronic health records. Like HTF, an evaluation plan is required for all CHIPP projects.
9.2.1 Federal
Investment in the Evaluation of Pilot Projects Aimed at
Improving Health Care Delivery
The Committee was told that pilot projects and evaluative research are expensive operations; however, there is no alternative to carrying them out if we are to obtain information on cost-effectiveness and health outcomes. The option here is therefore for the federal government to maintain, and even increase, the financial support it provides to the establishment and evaluation of pilot projects in the field of health care delivery.
9.2.2 Reducing Regional Disparities in the Funding of Pilot Projects
A major concern, however, was raised with respect to federal programs which involve federal/provincial cost-sharing. The Committee was told that federal investment in pilot projects sometimes widens regional disparities.
For example, under CHIPP, federal funding requires matching funds from the applicant. The relative needs of the different regions for service improvements, or health service deficiencies in particular regions, were not considered to be relevant in the project selection. According to witnesses, those provinces that already had money got more money, and those in great financial need were not able to apply because they could not afford the matching funds. Witnesses stressed that, while the opportunity to change the design of CHIPP has passed, the federal government should ensure that other federal programs supporting the evaluation of pilot projects should not replicate this aspect of the CHIPP program. Program conditions should place greater emphasis on projects in locations that have the greatest need, the willingness to act, and the commitment to implement system change, and less emphasis on provincial financial contribution.
Issues and Options for the Infrastructure Role: Technology and Information Systems
The Committee understands the concept of "health care infrastructure" to encompass the broad mix of resources – both physical and human – that sustain the delivery of health care. In this sense, infrastructure includes not only bricks and mortar and medical equipment and technology, but also human resources, the educational sector and the information and communication systems that support health care providers.
As stated previously, the federal government is not responsible for the administration, organization and delivery of health care, except to specific subgroups of the Canadian population. It is thus the responsibility of the provinces and territories to determine how many beds will be available in their jurisdictions, what categories of health care providers will be hired and how the system will serve the population. However, the federal government has a long tradition of assisting the provinces and territories to fulfil these responsibilities.
A prime example of this role is the Hospital Construction Grants Program of 1948. Under this program, the federal government paid the full cost of building hospitals in every province and territory. As a result, from 1948 to 1960 the number of hospital beds in Canada increased at a rate that was twice that of population growth. Similarly, in the 1960s, the federal government contributed capital funds towards the expansion of a number of medical schools. These federal funds made it possible for most of the health science centres in this country to be built, helping to ensure the provision of high quality education for health professionals, research and patient care.
More recently, the federal government has provided funding to the provinces and territories for the acquisition of health care technology, the development of health information systems and the establishment of a public reporting mechanism on the state of health of Canadians and on the performance of the health care system.
In addition to targeted programs, federal transfers provided under the CHST are also available for use by the provinces and territories for investment in the health care infrastructure to improve both health care delivery and the education of health care providers.
During the Committee’s study, all the witnesses who participated in the hearings on health-related information pointed to the critical role of the federal government in the health care infrastructure. They all agreed that this role must be maintained, and even expanded. Two options can be proposed: 1) that the federal government maintain its current level of funding for health care infrastructure or 2) that this level of funding be increased. These options necessarily involve trade-offs between the various components of the health care infrastructure (e.g. medical equipment versus human resources versus health information systems) as well as between the various components of the overall health care system (infrastructure versus hospital services versus home care.)
The options related to the federal role in the health care infrastructure are multi-faceted. For this reason, they will be dealt separately in the following sections. As well, given the broad range of issues pertaining to human resources in health care, the human resources options are covered in the next chapter.
It is generally agreed that health care technology constitutes an important component of health care delivery in industrialized countries. Health care technology can improve the speed and accuracy of diagnosis, cure disease, lengthen survival, alleviate pain, facilitate rehabilitation and maintain patient independence. However, many issues were raised before the Committee about the availability, assessment and cost of both new and existing health care technologies in Canada. Witnesses stressed that these issues need to be addressed if Canadians are to derive the maximum benefits health care technology can provide, while still maintaining an affordable health care system.
The Committee was told that although Canada ranks 5th among OECD countries in terms of total spending on health care (as a percentage of GDP), it is generally among the bottom third of OECD countries in the availability of health care technology. For example, Canada lags behind many other countries in terms of access to CT scanners, MRIs and lithotriptors.
Availability is not the only issue with respect to health care technology. The "aging" of that technology is also of concern. For example, information provided to the Committee indicates that between 30% to 63% of imaging technology currently used in Canada is outdated. The Committee was told that the shortage of new technology and the use of outdated equipment impede accurate diagnoses and limit the quality of treatment that can be provided. This situation, which can have a negative impact on the health of patients, also raises concerns about the legal liability of health care providers.
During the Committee’s Phase Two hearings, witnesses contended that the aging of the Canadian population as well as increased public expectations will greatly influence future needs for health care technology. Many experts told the Committee that the current deficit in health care technology requires a serious re-evaluation of the way in which equipment is supplied, funded and distributed in Canada.
Witnesses also argued that the restricted availability of health care technology has often been translated into limited access to care and lengthened waiting times. The Committee is concerned by the shortage of health care technology and the impact this might have on waiting times. In its view, timely access to diagnosis and treatment is a crucial objective that must be ensured in Canada’s health care system (see Section 7.4).
10.1.1 Funding the Acquisition and Upgrading of Health Care Technology
The federal government has recently responded to the deficit in health care technology. In September 2000, it announced that it would invest a total of $1 billion in 2000-01 and 2001-02, to assist the provinces and territories in the purchasing of new medical equipment. This funding was made available upon passage of legislation in October 2000, and it allows provinces and territories to start making immediate acquisitions of necessary diagnostic and clinical equipment.
Although the medical community has welcomed this injection of new federal funds, a number of concerns remain. First, some provinces have not applied for their share of this fund, possibly because the federal government requires matching grants. Second, the Committee heard that there are apparently no mechanisms for ensuring accountability on the part of the provinces as to exactly where money targeted towards purchasing new equipment is actually spent. Third, additional resources are required to operate the equipment. Estimates suggest that a $1 billion investment in new equipment necessitates an additional $700 million to cover operational costs. And fourth, this investment does not address the problem of the old equipment that needs to be upgraded. It was estimated that a further $1 billion investment would be required for the upgrading of existing equipment.
One option could therefore be to have the federal government commit to a longer term program of financing for health care technology. Such federal funding would encompass both the acquisition of new health care technology and the operation and upgrading of existing equipment. As part of this program, provincial and territorial governments could be required to report to Canadians on how they have invested these federal funds; otherwise, the federal government has no way of knowing if its money is spent on the things it is intended to be used for.
The decision to acquire new health care technology should also be based on the appropriate assessment of its efficacy and cost-effectiveness. This issue is discussed in more detail below.
10.1.2 Investing More in Health Care Technology Assessment
Health care technology assessment (HTA) provides information on safety, clinical effectiveness and economic efficiency. HTA can assist in deciding whether a new technology should be introduced and when an existing technology should be replaced. More importantly, HTA contributes in many ways to improving the quality of health care: it ensures that health care technologies are effective, that they are applied in the appropriate cases and conditions, and that the least costly technology is used to achieve the desired outcome.
Both federal and provincial/territorial governments support various HTA agencies. At the federal level, the Canadian Co-ordinating Office for Health Technology Assessment (CCOHTA) plays three major roles: it co-ordinates all HTA activities across the different jurisdictions; it attempts to minimize duplication by other national or provincial/territorial organizations; and it performs HTA activities on its own.
The Committee was told that not enough attention is devoted to HTA in Canada. For example, all levels of government invest less than $8 million in Canada, whereas the United Kingdom provides some $100 million to its national HTA body – the National Institute for Clinical Excellence (NICE). As a result, health care technologies are often introduced into the Canadian health care system with only superficial knowledge of their safety, effectiveness and cost.
Another important issue relates to the poor dissemination of the evidence generated by HTA activities to health care providers and managers. An improvement in this regard would certainly raise the quality of health care delivery and strengthen the formulation of public health care policy.
The main option therefore is for the federal government to invest more in health care technology assessment and to enhance the awareness and use of HTA findings. Raising the level of funding provided to the CCOHTA would help fulfil this option.
10.2 Health Information Systems
During Phase Two of the Committee’s study, witnesses stressed that a major weakness in our current health care system is that it still operates as a "cottage industry" (see the first part of Chapter 5), despite the fact that the health care sector is an extremely information intensive industry. Indeed, the most important single ingredient in any diagnosis or treatment is information. The health care sector in Canada is not making use of information and communications technology to the same extent as do other information intensive industries. Moreover, the health care system is not integrated: physicians and other health care providers, hospitals, laboratories and pharmacies all operate as independent entities with limited access to linkages that would enable a better sharing of information.
Greater use of information and communications technology along with better integration of health care providers and institutions would facilitate the determination of causal relationships between the various inputs typical of the health care system and the resulting outputs or outcomes. This would greatly improve evidence-based decision-making by health care providers, health care managers and health care policy makers. This would allow us to answer such questions as: Are we investing enough, too much, or too little in health care technology? Are there too many, too few, or just enough physicians, nurses, or other health care professionals? Are we getting our money’s worth? Currently, we simply do not know the answers to these questions.
Many witnesses pointed to the urgency of improving our capacity to manage health information, and suggested that this be done even if it means that in the short term waiting lists become somewhat longer, less health care technology is purchased, and other expenditures are postponed. In the view of many witnesses, enhancing our ability to manage health information is essential to the survival of Medicare.
The use of information and communications technology in the field of health care is often referred to as "telehealth". As discussed in the Committee’s Phase Two report, the telehealth applications that are envisioned in Canada for the purpose of sharing information and integrating health care delivery include a system of Electronic Health Records (EHR) and an Internet-based health information system:
- The EHR is an automated provider-based system within an electronic network that provides complete patients’ health records, including their visits to physicians, hospital stays, prescribed drugs, lab tests, and so on.
- An Internet-based health information network is a system that provides accurate, evidence-based health information to the general public on: health promotion and disease prevention; information on treatment options and drugs, as well as on illness management (e.g. blood pressure, diabetes or obesity); information on public health issues (e.g. quality of air, water and food); information on the effects of health determinants; and so on.
Telehealth is the foundation of what many people in Canada call the "health infostructure". Various components of a health infostructure are currently being implemented at all levels of government. However, these initiatives are all at different stages of development. In addition, they are isolated within organizations, institutions and provinces and currently constitute "a patchwork of unconnected projects, whose value would increase immensely if part of a coherent whole." The key issue is how to bring all these diverse infostructures together.
This is what the federal government is seeking to achieve through the development of a Canadian Health Infostructure. The proposed Canadian Health Infostructure will not be a single massive structure, but a network of networks, building on the initiatives that are already in place or under development at the federal, provincial and territorial levels.
It is a great challenge to integrate the information systems of 14 jurisdictions (10 provinces, 3 territories and the federal government). It is also an ambitious, costly and long-term undertaking which will take years to bring into being. It will require that careful attention be paid to ensuring the privacy and confidentiality of patient information which will form the basis of the information systems. Most experts believe, however, that it is essential to do so if we wish to acquire reliable information on the health of Canadians, the state of our health care system, and on the efficiency and effectiveness of health services delivery and distribution. Most importantly, it appears imperative to do so if we want to improve the quality of health care Canadians receive.
10.2.1 Deployment of a Pan-Canadian Health Infostructure
The federal government has been making financial contributions to the Canadian Health Infostructure since 1997. The provinces and territories have also expressed their desire to be involved in deploying a Canadian Health Infostructure. On September 11, 2000, the First Ministers agreed to work together to: 1) strengthen a Canada-wide health infostructure to improve quality, access and timeliness of health care for Canadians; 2) develop an electronic health record system and enhance technologies like telehealth over the next few years; 3) work collaboratively to develop common data standards to ensure compatibility of health information networks; 4) ensure stringent protection of privacy, confidentiality and security of personal health information; and 5) report regularly to Canadians on health status, health outcomes, and the performance of publicly funded health services."
In support of the agreement reached by First Ministers, the federal government committed $500 million in 2000-01 to accelerate the adoption of modern information technologies to provide better health care. The Committee was told that this money will be invested in a not-for-profit organization, known as Canada Health Infoway Inc., that will work with provinces and territories to create the necessary common components of an EHR over the next three to five years. This will represent a major step towards the full integration of the health infostructures.
Considerable agreement exists among the provinces and territories and other stakeholders that the federal government should foster collaboration in this area. The Committee welcomes this collaboration between the federal government and the provinces and territories.
Estimates suggest that between $6 and $10 billion would be needed to achieve full implementation of the Canadian Health-Infostructure. Nonetheless, there is a wide consensus that the benefits of a pan-Canadian Health Infostructure will be enormous.
The only real option, therefore, is for the federal government to continue its leadership role, pursue its collaborative approach and provide increased funding to assure the full deployment of the Canadian Health Infostructure. Once again, provincial and territorial governments and health care stakeholders receiving federal funding should be required to report to the federal government on their utilization of these federal funds.
In implementing this option, priority should be given to electronic patient records, since this kind of system is the cornerstone of an efficient and responsive health care delivery system that is able to improve quality and accountability. Without this kind of infostructure, the prospects for a truly patient-oriented health care system, and for enhancing efficiency in health care delivery, are dim. In fact, an EHR is essential if primary health care reform is to be realized.
10.2.2 Investing in Telehealth in Rural and Remote Communities
Not only can telehealth applications enhance the sharing of information among the various health care providers and health care settings, but they also offer the possibility of delivering care over large distances. Telemedicine is a form of telehealth applications that can greatly improve quality and timely access to care, particularly in rural and remote Canada.
Up to 30% of Canada’s population lives in rural, remote and northern areas of the country. Accessibility to health care is one of the four patient-oriented principles of the Canada Health Act. However, rural Canadians are increasingly voicing concern regarding disparities between services available in rural and remote areas and those in urban areas.
The federal government has responded to the concerns of rural Canadians in a number of ways. For example, the Office of Rural Health was established in September 1998 to ensure that the views and concerns of rural Canadians are better reflected in national health policy and health care system renewal strategies. In February 1999, the federal government announced funding of $50 million over three years (from 1999-00 to 2001-02) to support pilot projects under the "Innovations in Rural and Community Health Initiative".
In June 2000, the federal government announced a National Strategy on Rural Health that it sees as an important milestone on the road to ensuring that all Canadians have reliable access to quality health care. Then, in July 2001, the federal government announced the establishment of a Ministerial Advisory Committee on Rural Health to provide advice to the federal Minister of Health on how the federal government can improve the health of rural communities and individuals.
Tele-medicine is an important component of the overall rural health policy of the federal government. In the context of rural health, telemedicine offers the following advantages: it addresses the shortage of rural health care providers and medical training; it improves rural health infrastructure; it enables conformity with the accessibility principle of the Canada Health Act; and it ensures a more equitable development of health information systems across the country.
The option suggested here is for the federal government to sustain its efforts in rural health and tele-medicine.
10.2.3 Ensuring Confidentiality and Privacy of Personal Health Information
The issue of privacy, confidentiality and security related to personal health information in the context of the Health-Infostructure was perhaps the most sensitive one raised during the Committee’s hearings on this question. While these three terms are sometimes used interchangeably, they are, in fact, entirely separate issues:
- Privacy refers to the right of individuals to control their personal health information – including the collection, use, and disclosure of that information.
- Confidentiality deals with the obligation of health care providers to protect the personal health information of their patients, to maintain its secrecy and not misuse or wrongfully disclose it.
- Security refers to the set of standards in and around information systems that protect access to the system and the information it contains.
In other words, privacy drives the duty of confidentiality and the responsibility for security. Protection of privacy in Canada is a shared responsibility between the federal and provincial/territorial governments. Currently, the legal framework for protecting individual privacy is composed of a patchwork of various laws, policies, regulations and voluntary codes of practice. The Committee was told that the first step that needs to be made is to gain support for the harmonization of legislation and regulation across Canada so that the privacy of Canadians will be protected in matters of health. Witnesses stressed that Canadians need to be assured that governments are taking all the necessary steps to implement stringent rules in this regard.
The Committee was pleased to learn that a resolution for the harmonization of legislation is being examined by all jurisdictions and that an agreement is expected soon. At the technological level, it has already been demonstrated that a greater level of confidentiality and security of personal health data can be achieved electronically than is possible in a paper world. The problems that must still be overcome concern mostly the architecture of the systems that are to be put in place, and their governance from a pan-Canadian perspective.
However, the Committee is concerned by the noticeable lack of progress among stakeholders with respect to Bill C-6, the Personal Information Protection and Electronic Documents Act. In November and December 1999, the Committee held hearings on this Bill. The hearings focused largely on concerns regarding the application of Part 1 of the Bill to the collection, use and disclosure of personal information. The Committee was of the view that, while Part 1 is adequate in setting minimum legal standards for protecting the personal information of Canadians in the commercial arena, the appropriateness of these standards for the health care sector was open to question. Therefore, the Committee amended the Bill so that its application to personal health information would be delayed for one year following the coming into force of the legislation (January 1st, 2001). The purpose of this amendment was to provide health care stakeholders with an opportunity to formulate legislative measures appropriate to the special nature of personal health information and to put these changes in place by January 1st, 2002. The amendment was accepted by the House of Commons, and the Bill received Royal Assent on 13 April 2000.
When the Committee met on the issue of health-related information in May 2001, witnesses indicated that no consensus had yet been reached on the changes that are required to Bill C-6 to ensure the flow of data between health care stakeholders involved in the health infostructure. The application of Bill C-6 to organizations involved in health information systems as well as in health research must be clarified in order that they may continue to provide information that is critical for the improvement of the health of all Canadians. It is the hope of the Committee that solutions will be found to this problem before the end of the one-year moratorium on December 31st, 2001.
10.3 Accountability and Quality
An important outcome of the Canadian Health Infostructure will be the generation of a massive amount of health information. In fact, the Canadian Health Infostructure will "enable the creation, analysis and dissemination of the best possible evidence as a basis for informed decisions by patients, informal caregivers, health care providers, health care managers and policymakers." It is the view of all levels of government, as well as of all health care stakeholders, that an evidence-based health care system can provide greater accountability and ensure continuous improvement to health status and health care delivery as well as a better understanding of the determinants of health.
The federal government, along with the provinces and territories, clearly made a commitment to move towards greater accountability in the area of health care with the signing of the First Ministers’ Agreement in September 2000. The Committee was told that a Performance Indicators Reporting Committee (PIRC), chaired by Alberta, with Newfoundland, Quebec, Ontario and Health Canada as members, is working to address issues and make recommendations on a list of indicators. Similarly, the report by the Canadian Institute for Health Information (CIHI), entitled Health Care in Canada, is a step towards a national accounting process for the health care system.
Recently, Minister Rock stated that the federal government is committed to creating a "Citizens’ Council on Quality Care. Decisions about how that council will be appointed and how it will function will be made in collaboration with provincial and territorial ministers of health.
The Committee strongly supports the ongoing development of performance indicators. Performance indicators should be developed according to a set of outcome-oriented goals, and will serve as useful tools in improving the quality of health care delivery. They will also provide the basis for enhancing accountability of government to the Canadian public as well as accountability between governments. The Committee also believes that a Citizens’ Council on Quality Care could provide useful guidance in the development of outcome-oriented goals.
10.3.1 An Annual Report on the Health Status of Canadians and on the State of the Health Care System
Currently, the Canadian Institute for Health Information (CIHI), which receives funding from the federal government and most provinces, is responsible for co-ordinating the development and maintenance of an integrated health information system. To this end, CIHI provides a series of indicators on the health status of Canadians and on the health care system. The option suggested here is to expand CIHI’s information analysis and its capacity to report publicly.
10.3.2 A National Health Care Quality Council
This option would be similar to the recommendation by the Fyke Commission in Saskatchewan, in that it suggests the creation of a National Health Care Quality Council that would be an independent, evidence-based organization, at arm’s length from government. Its purpose would be to provide the most objective assessment and evaluation possible of health service delivery and it would report to both government and the general public. The Council would undertake analysis of the performance of the health care system, develop benchmarks and standards, undertake cost and benefit analysis of programs and services, and assess trends in health status, etc.
The performance indicators developed by the National Health Care Quality Council would lay the foundation for quality improvement and serve as a guide to resource allocation. The Council would pinpoint areas in need of support and allow the public to make more informed judgements on individual sectors and services, as well as on the overall system. This would greatly improve the prospects for optimizing the use of available public resources.
10.3.3 Ensuring Greater Government Accountability
There are two directions to government accountability. The first involves the federal government reporting to Canadians on its policies and programs with respect to health care (public accountability). The second involves provincial/territorial reporting to the federal government on the use of federal transfer payments (government to government accountability).
The federal government could set a valuable example by establishing a permanent mechanism for reporting to the Canadian public on the impact of all its policies affecting health and health care. One possibility could be to create a Health Commissioner charged with this task. The initiative called "Healthy People" headed by the Surgeon General of the United States, with the collaboration of the US. Department of Health and Human Services, could be considered as a possible model. "Healthy People" establishes a set of health objectives to be achieved over a decade, and these then serve as the basis for developing activities and programs at the community level. Leading health indicators are tracked for the purpose of evaluating progress in public policies in 10 broad areas: physical activity; overweight and obesity; tobacco use; substance abuse; responsible sexual behaviour; mental health; injury and violence; environmental quality; immunization; and access to health care.
The second form of accountability – government to government – may appear problematic for some people who feel that there should be no role for the federal government with regard to establishing the accountability of provincially delivered programs. Many witnesses rejected this view. Given the substantial amount of money the federal government contributes to the provinces for health care delivery, accountability to federal taxpayers requires that the government understands how well, or how poorly, its contributions are being spent. The affirmation of a role for the federal government with respect to government to government accountability is not meant to tread on provincial prerogatives, but rather to allow all Canadians to judge how their tax dollars are being spent, including by the federal government in its role of provider of services to specific population groups. The Committee looks forward to receiving ideas on how this form of accountability can be most effectively carried out.
Issues and Options for
the Infrastructure Role:
Health Human Resources
Talk of a ‘crisis’ in health care has a good deal of plausibility in relation to human resource issues, particularly with regard to the situation facing registered nurses (RNs) in Canada. The Canadian Institute for Health Information (CIHI) reports a decline of 7.2% in the number of RNs employed in nursing since 1989, while the ratio of practising registered nurses to the Canadian population dropped from one nurse for every 120 Canadians in 1989 to one for every 133 Canadians in 1999. According to the Canadian Nurses’ Association, there is looming crisis in the supply of qualified nursing personnel. The Association forecasts that by 2011 there will be a shortfall of at least 59,000 nurses in Canada, but that this shortfall could be as high as 113,000 if all the needs of an aging population are taken into account.
There are also shortages of other health care professionals, in areas ranging from laboratory technologists to pharmacists. Assessing the situation with regard to physicians is more difficult. While the total number of physicians has increased, the physician-to-population ratio has, despite fluctuations, remained relatively constant over the years. Between 1986 and 1991, the physician-to-population ratio in fact improved somewhat, going from 1 physician for every 555 Canadians to 1 for every 516 people. It then declined to 1 in 524 in 1996. By 1999, this ratio had further deteriorated to 1 physician for every 546 people, a level that was, however, still lower than the 1986 ratio. Recent projections by the Canadian Medical Association (CMA) suggest that we have not yet seen the end of this trend. They anticipate that by 2021, if current trends remain stable, the ratio will drop to 1 physician for every 718 people.
Yet the aggregate numbers do not tell the whole story. Availability of physician services varies widely depending on what kind of doctor one is dealing with and where one lives. There is little doubt that there is a long-standing problem of geographical distribution of physicians, with all rural and remote areas having great difficulty recruiting and retaining both GPs and specialists. The gap between rural and urban Canada in this regard is growing. There are also certain specialities that are experiencing serious shortages, including radiology and geriatrics. Moreover, there is evidence that many younger doctors and female doctors are not prepared to work the long hours that were once considered normal, meaning that more physicians could be needed in the future.
However, many experts caution that there are complex and overlapping factors that influence the availability and deployment of human resources. Shortages are not necessarily due to an absolute lack of numbers of qualified personnel. Many nurses, for example, have left the profession because of frustration with lack of career opportunities or with working conditions. Moreover, nurses feel that their training would allow them to contribute more to patient care than the system currently allows.
Should we be concentrating on encouraging nurses to return to active practice, should we be training greater numbers of new nurses, or should we be doing both? Others have suggested that reforming the organisation of primary care services to make better use of the differentiated skills of all health care professionals could ease the real or perceived shortage of physicians, although it could also have the effect of increasing the demand for nurses, exacerbating the existing shortage.
It does appear certain, however, that there is unlikely to be a quick fix to human resource problems faced by the health care sector. On the one hand, even if the priorities for training were easily agreed to, it takes years to educate and train most health care professionals. But more importantly, it is not necessarily simply a matter of opening up new training places and hoping that they will be filled. Declines in the number of younger people studying to become nurses, for example, can be partly attributed to a greater range of career opportunities now available to young university-educated women and to the widespread perception that, because of fiscal constraint in the health care sector, nursing is not as attractive a career option as it might once have been.
In the past, Canada has been able to rely on recruitment from abroad to fill some of the gaps. For example, over 50% of doctors practising in Saskatchewan are international medical graduates (IMGs), that is, they have been trained elsewhere and moved to Saskatchewan later in their careers. However, other countries now face many of the same shortages that confront our system, and there does not seem to be much sense to countries endlessly poaching each other’s highly trained health care professionals.
11.2 The Need for a National Human Resources Strategy
All national organizations representing health care professionals that appeared before the Committee during its Phase Two hearings insisted that what is needed is a country-wide, long-term, made-in-Canada, human resources strategy co-ordinated by the federal government. Of course, not only do the provinces and territories have the responsibility for the delivery of health care services to their populations, they are also responsible for education and training. The challenge is therefore to find a way to develop such a strategy in a manner that is acceptable to the provinces and territories.
The federal government needs to be actively involved in helping to devise such a strategy for several reasons. In the first place, the federal government, as the government responsible for the delivery of health services to Canada’s aboriginal population and military personnel, must ensure that its needs are considered together with those of the provinces and territories in a national human resources plan.
Second, any plan must take into account the mobility of Canadians, particularly those with professional education and training. Its elaboration should therefore be the result of federal/provincial/territorial collaboration, so that the complex problems relating to the supply and geographical distribution of human health resources can be adequately addressed.
Provincial and territorial governments may resist the involvement of the federal government in the development of such a national human resources strategy. For example, when they met in August 2001, the provincial and territorial premiers and leaders agreed to develop ongoing inter-provincial co-operation to ensure that there is an adequate supply of health care providers, without the involvement of the federal government. However, the Committee believes that a national strategy (not a federal only strategy) involving all governments is needed.
The Committee welcomes comments on how best to co-ordinate the activities of the different levels of government in this area.
11.3 Towards a Spectrum Approach
There are two other human resource issues that clearly require the attention of all governments:
- How to make the best use of the full spectrum of differently qualified health professionals, so that the full range of abilities of each type of professional is productively employed;
- How to recruit, train and retain an adequate supply of health care professionals who can adapt to the changing health and health care needs of the Canadian population.
The overlap between these two issues is a further illustration of the complexity of the issues involved in human resource planning. The demand for different health care professionals will depend in part on how one conceives of the health and health care needs of the population, and it is the strength of the demand for each kind of professional that should determine priorities for education and training. Moreover, the attractiveness of embarking on different careers in the health and health care fields will also depend in part on how the different professions interact on the job.
Today there is a largely hierarchical structure to the ‘ranking’ of health care professionals and other caregivers. Specialist doctors are generally perceived to be at the top, followed by family physicians, various categories of nurses, from those with advanced training (nurse practitioners) through to auxiliaries (licensed practical nurses). Other professionals, from pharmacists to laboratory technologists, receive less attention but are no less important to the smooth running of the system. Then there are the practitioners of various kinds of complementary medicine who continually struggle for full recognition of their contribution to the health and well-being of Canadians. And finally there is an army of informal caregivers and volunteers whose essential work often goes completely unrecognized.
We need therefore to ask explicitly whether it is time to move away from this hierarchical way of thinking and attempt to adopt a ‘spectrum’ approach to health human resources. Such a ‘spectrum’ concept would challenge the idea that ‘specialist’ physicians are somehow ‘higher’ up the ladder by virtue of their more in-depth knowledge of a particular area than their family practitioner colleagues, or that doctors, in general, are necessarily more ‘highly’ qualified than nurses. Rather, it is based on the assumption that each profession has its particular strengths and these all need to be properly valued and deployed.
Consider the following facts from a 1999 report of the Ontario Health Services Restructuring Commission :
- One third of billings by specialists in Ontario in 1997 (at a total cost of $1.4 billion) was work that could have been done by family doctors;
- The five most frequently used billing codes by Ontario family doctors in 1997, which account for about 69% of the total amount billed by these doctors (at a cost of $1.2 billion), were for: intermediate assessments (well baby care), general assessments, minor assessments, individual psychotherapy, and counselling. The clinical consultants to the Ontario Health Services Restructuring Commission were of the opinion that most, if not all of the services these bills represent could well be provided by nurse practitioners, nurses and many well-trained health professionals.
Dr. Duncan Sinclair, the Chair of the Commission, went on to say:
"Throughout Canada we are not using our well and expensively trained, highly qualified health professionals – specialists, family doctors, nurses, pharmacists, rehabilitation therapists, the lot – to anything like the full extent of their capabilities.
Having a doctor do work that a nurse practitioner or nurse could do is like calling an electrician to change a light bulb or a licensed mechanic out of the garage to fill your tank and check the oil and tire pressure – would they do a good job? They would do an excellent job! But would it be a good use of their time, training and expertise? It would not! It would constitute an expensive and inefficient use of scarce resources, both of money and the expertise of very talented people."
11.4 Primary Care Reform and Human Resources
One of the major obstacles to the development of a plan that could help deal with these issues are the existing rules which define what the various health professions can, and cannot do (called the scope of practice rules). This points to the importance of considering the impact of primary care reform on our ability to rationalize the use of human health resources. Primary Health Care (PHC) is the first level of care, and usually the first point of contact that people have with the health care system. PHC supports individuals and families to make the best decisions for their health. PHC services need to be:
- co-ordinated
- accessible to all consumers
- provided by health care professionals who have the right skills to meet the needs of individuals and communities being served, and
- accountable to local citizens through community governance.
Multidisciplinary team work must therefore be a vital part of PHC. However, the goal of this team work should not be to displace one health care provider with another, but rather to look at the unique skills each one brings to the team and to co-ordinate the deployment of these skills. Clients need to see the health worker who is most appropriate to deal with their problem.
The way in which health care is now delivered in Canada does not normally reflect a PHC philosophy (although Community Health Centres are an example of organizations that do deliver health services using a PHC philosophy). Health services are often not co-ordinated, nor are they being provided by the most appropriate practitioner and the knowledge and skills of many practitioners are not being fully utilized.
Primary health care reform has become a high priority in all provinces and territories. In September 2000, provincial and territorial governments all agreed to accelerate primary health care renewal. They all agreed to promote the establishment of multidisciplinary primary health care teams that provide Canadians first contact with the health care system.
The federal government is actively supporting the efforts of provinces and territories in primary health care reform and renewal. More precisely, it has established a Primary Health Care Fund of $800 million over four years (2000-2004) to support the transitional costs of implementing systemic, large-scale, primary health care initiatives. Some 70% of the funds are to be devoted to major provincial and territorial reforms, while the remaining 30% is going to support national and multi-jurisdictional initiatives related to advancing primary health care reform.
The implementation of a PHC strategy, as noted earlier in this report, also entails rethinking the current reliance on fee-for-service payments as the main way of remunerating physicians. A fee-for-service actively discourages physicians from promoting teamwork, as their individual salaries depend on the number of patients they see. Moreover, it encourages family physicians to refer as a matter of course many of the more complex cases to specialists since they have no incentive to spend more time with ‘difficult’ cases. Finally, a fee-for-service reinforces the public’s perception of the current ‘hierarchy’ within the health care system, and can only serve to accentuate demand on the part of individual patients to always consult the most ‘highly’ qualified practitioner, regardless of whether or not they are the one best-suited to meeting the patient’s needs.
The main alternatives to a fee-for-service payment are salary and capitation based systems, where physician practices are remunerated based on the number of registered patients. Currently, some physicians with important teaching or administrative duties are on salary, while there have been a number of initiatives aimed at organising group practices in various provinces that utilise forms of capitation. It is also possible to combine these various forms of payment (as they do in Great Britain).
Finding alternative means of remuneration for physicians is not the only obstacle to be overcome in reforming the current system so that better use can be made of all types of human resources in the health care sector. Reform in this area necessarily challenges the current distribution of decision-making power, and is therefore likely to be resisted by those who are presently perceived to be in the most powerful position. Primary care reform would have the effect of expanding the number of people sharing the top of the pyramid, and means will have to be found to persuade those who are now in the dominant position to share some of their power.
In summary then, the options that would allow for a more efficient use to be made of the full range of human resources in the health care sector by operationalizing a ‘spectrum’ approach are intimately related to primary care reform that would ensure that patients have access to a continuum of care provided by differently skilled health care professionals. It should be noted that this is something that is of particular importance in the context of an aging population that will be making increasingly diversified demands on the health delivery system. As well, attention will need to be paid to ensuring that the training of health care professionals enables them to cope with the constant evolution of the system, and, in particular, fosters an ability to cooperage productively in multi-disciplinary teams.
11.5 Incentives for Individuals
Finally, it is important to consider various ways of encouraging individuals themselves to seek the most appropriate form of care. Canadians have been led to believe that they must see a doctor when consulting a nurse, or a nurse practitioner, may suffice, or that a specialist is needed when a general practitioner might easily provide care of comparable quality. The health care delivery system needs to be organized so that it is possible for patients to consult the most appropriate health care professional, and there need to be incentives that either reward patients for making the best choice or penalize them when they behave in a way that is unnecessarily costly to the system.
Among the options that could be considered to accomplish this goal are user fees that would kick in if (and only if) a patient insisted on seeing a particular health care professional when it was not considered necessary at the initial point of contact between the patient and the system. Referrals that were made on the advice of a health care professional (triage nurse, general practitioner) would be free of charge, but if patients requested a further consultation of their own volition, they would be required to pay a user fee that could vary according to the type of professional consulted. These fees could be made refundable if the consultation proved necessary, so as to avoid overly discouraging those who wish to obtain a second opinion on their case. It might also be possible to guarantee shorter waiting times for consulting some categories of professionals, and to use this as an additional incentive to promote cost-conscious behaviour on the part of health care consumers.
The Committee seeks the views of readers on what forms of rewards and penalties would be the most effective in encouraging behavioural change on the part of patients ─ change that would help patients to distinguish between real need and desired demand, and help make the health care system less costly while still retaining the same level of medical effectiveness.
11.6 Recruitment, Training, Retention
On most estimates, however, simply reforming the delivery of primary care will not solve all the foreseeable human resource problems. Moreover, implementing primary care reform will take time, if for no other reason than it will have to overcome many entrenched prejudices and behaviours among professionals and the public alike, as well as having slowly to break down the hierarchies that still characterise the structure of our health care system.
Some human resource issues cut across all the health care professions, while others are more specific to each discipline. For example, a whole range of decisions that were implemented in the course of the 1990s with the aim of controlling the growth in health care expenditures led to hospital closures, reductions in the availability of medical school places, the casualisation of many positions throughout the health care system, etc. Fewer people were increasingly being asked to do more with less. Doctors and nurses alike have complained that they are no longer able to provide the kind of care they would like, that they were trained to deliver, and that their patients request and require. Moreover, heavy workloads and the explosion of new research means that it is a serious challenge for all health care professionals to remain current in their fields.
Most of these broader human resource issues relate to the level of resources that are available to the health care system. That is, they are strongly influenced by the overall level of funding. If more resources are required, where are they to come from and how are they to be paid for? The options that relate to these kinds of questions were raised in Chapter 8, the financing chapter of this report.
But there are also some general issues that are directly related to human resources. The first of these concerns the availability of data to enable effective human resource planning. There continue to be large gaps in what is known about the state of the existing workforce and in our ability to forecast future needs. In this regard, the federal government must continue to play an important role in ensuring that accurate data is collected and made available to all governments and to all stakeholders in the health care system.
11.6.3 Dealing with the ‘Brain Drain’
Over the years there has been considerable media attention paid to the ‘brain drain’ in the health care sector. The extent and the causes of the migration of skilled professionals southward is a subject of controversy. But there does seem to be sufficient evidence to conclude that in this regard, as with most health human resource issues, simplistic analyses are not helpful.
It has sometimes been contended that it is a more onerous tax regime in Canada that drives high-earners to seek more favourable circumstances elsewhere. Surveys among doctors, however, indicate that income is usually not the prime motivator for leaving Canada, and that the conditions under which they are able to practice their profession ranks higher. Similarly, for nurses who move southward, it is often things such as the possibility for continuing education that attracts them rather than only higher salaries (although it has to be said that for nurses the possibility of obtaining full-time, rather than part-time or casual, employment is also a major attraction).
The point is that it is the overall set of working conditions that face health care professionals that need to be addressed if we are to retain as many of them as possible in this country, rather than just concentrating on any single factor, such as reducing the levels of taxation.
Moreover, it is this same comprehensive package of working conditions that might be able to persuade health care professionals who have left the country to return. A report written for the Provincial First Ministers recently suggested that the federal government take on the co-ordination of a ‘return-to-Canada’ campaign to lure health care professionals back from the United States. It is certain that a co-ordinated effort involving both levels of government would have a better chance of success, given the complex network of issues that have contributed to the departure of many health care professionals from Canada.
We will now look briefly at some of the issues that relate to the particular professions and types of care.
As a result of attempts to contain growing costs, the number of places in medical schools was reduced over the course of the past decade. In particular, the Barer-Stoddart Report recommended in 1991 that enrolment in Canadian medical schools, along with positions in postgraduate training positions, be decreased by 10% in order to deal with a perceived unwarranted increase in physician supply.
Despite the report’s admonishments that this recommendation not be implemented in isolation from the others it proposed (53 in all), policymakers did precisely that. As a result, according to data from the Association of Canadian Medical Colleges, the size of first year classes in medical colleges has declined by 16% since 1991. Canada is now one of the most difficult countries for a student to gain entrance to medical school. The current first year enrolment of 1570, or 1 per 19,000 citizens, puts Canada well behind other industrialized countries such as the United Kingdom (1 per 12,200 citizens) or Australia (1 per 13,500).
A second dimension to the issue of enrolments has to do with rising tuition costs at medical schools across the country. There are concerns that it will soon only be possible for the most well-to-do to afford the costs of medical training.
Options that need to be considered include:
- Federal assistance via student loans
- Federal funding for medical school expansion
11.7.2 Geographic Maldistribution
As already noted, there is little disagreement that there is a worsening problem of geographic maldistribution of physicians that leads to reduced access to needed health care services in Canada’s remote and rural regions. There is evidence to suggest that physicians setting up their practices are more likely to choose rural or remote areas if they come from those backgrounds or if their training has exposed them to the positive challenges associated with locating in these areas.
As early as the Barer-Stoddart report in 1991, various measures were proposed to help alleviate the shortage of physicians in under-serviced areas. Many of these, including the following, remain worth considering today:
- Reserving undergraduate medical school places for qualified applicants willing to commit to rural area practice;
- Revising admissions criteria for medical school to favour qualified rural applicants;
- Enhance rural area exposure in both undergraduate and post-MD training;
- Developing new residency training programs designed explicitly to prepare specialists to serve as rural regional consultants;
- Introducing or increasing financial incentives to encourage choices of specialities in short rural supply.
While these kinds of measures do not fall directly under the purview of the federal government, it may nonetheless be possible for it to contribute financially to fostering these kinds of initiatives in the context of a comprehensive national health resources strategy that would be negotiated at the federal/provincial/territorial level. What is certainly clear is that a program of incentives, dealing both with issues of remuneration and other working conditions, is required in order to address the increasingly serious problem of physician shortages in rural and remote areas.
The factors contributing to the global discontent in the nursing profession in the 21st century are complex, multi-faceted, and interwoven with issues of gender, power and economics ─ not to mention broad employee and societal discontent that goes far beyond nursing. Ten years of downsizing the health care system have only exacerbated the situation by producing unhappy patients, horrific workloads for nurses across the system, destruction of organizational loyalty, and decaying morale among all healthcare workers. There is no easy fix, and no single strategy will turn the situation around. That being said, there are some short term strategies that likely would relieve some of the daily irritants lived by nurses, and in concert with longer term, system-wide workforce planning, would go a long way to improving working lives of nurses. Most important among these:
- the place where the work takes place must itself be healthy, safe and secure
- the tools required to do the job must be in place
- the work being done must be interesting and attractive enough to offer its own intrinsic rewards to those who carry it out ─ and at the same time must be adequately rewarded, recognized and respected externally
- working hours and the interplay of home life and work life must be addressed, particularly in a workforce largely staffed by women
The federal government is already collaborating with the provinces and territories in developing strategies to improve the working conditions for nurses across the country and in helping ensure an adequate supply of nurses in the future. These strategies need to specifically address the following issues:
- Workload. Patient care is a labour-intensive product that requires a full support team that includes environmental services, food services, clerical services, movement of materials, patients and equipment. Nurses are an expensive and shrinking resource and we cannot afford to be using them to carry out those non-nursing tasks. If nothing else is done, workload must be addressed in all settings across the system.
- Lifestyle Needs . Child care in or near the work setting, safe convenient parking, flexible scheduling systems (new scheduling software), creative scheduling, union contracts will need to look at innovative scheduling options (e.g. different lengths of shifts, permanent shifts, etc.), food should be accessible to workers in all settings on all shifts.
- Work Status . Create permanent full time work. Studies show that the least secure jobs produce the most anxiety, burnout, absenteeism, and poorer health
- Professional Practice & Leadership . Nursing suffers from poor morale and a systemic lack of work excitement. Nurses want to feel that they are regarded as true professionals who can make valuable contributions to decisions concerning patient care. Nurses want the space to provide quality care. They want freedom, innovation, as well as safe and secure environments. Qualified executive and head-nurse nursing leadership are essential. One nursing leader position in an agency is not nursing leadership. Capacity building needs to happen at all levels and must be supported nationally to improve the professional practice aspect of the nursing workplaces.
- Equipment & Supplies . We need immediately to conduct an inventory in every unit across the country, take note of absent, broken or dangerous equipment, and replace it immediately. This is a quick hit that could pay off significantly within weeks. We need to pay attention to the basics as equipment is funded; what nurses need to provide care is not MRI scanners - they need thermometers and wheelchairs, towels and scissors, patient lifts and IV poles, computers and books and even cars in community settings
- Education . Nursing culture is one of life long learning. We need to put the system supports in place to support that need (employer-based in-services as well as formal education, plus the need for replacement staff, tuition, nurse educators in the workplace)
11.9 Other Health Care Professionals
Many other health care professionals, from pharmacists to laboratory technologists to ultrasound technicians, have voiced similar complaints to the ones expressed by doctors and nurses over deteriorating working conditions throughout the health care delivery system. As well, these other professional groups often have a lower profile than either doctors or nurses which means their particular concerns are often less visible. For example during its hearings the Committee was told that because medical technology is a field that appeals to technically oriented people, many training programs are having difficulty filling their available places despite the existence of jobs for graduates. With regard to other health care professionals as well there is an ongoing problem with a lack of accurate data on the evolving situation.
There are four broad issues which are intertwined in the human resource planning problem:
- What role should the federal government play in the development of a national human resources plan for all health services sector personnel?
- What role should the federal government play in helping to implement such a plan (e.g. through infrastructure funding or financial contributions to training programs)?
- How can individual Canadians be "trained" or given incentives which will help them to differentiate and discriminate between their true needs for health services and their desired demand?; and
- How can those who are currently perceived to be at the top of the health care power structure be persuaded to relinquish some of their power and to change the scope of practice rules so that a more efficient use of health services personnel can be achieved (where efficient means that a patient is always seen by a health care worker who is qualified to address the patient’s needs, and who will refer the patient when necessary to a differently qualified service provider if that is what the patient genuinely requires)?
The difficulty in addressing these issues is that the first two depend critically on the assumptions one makes about the timing and the precise nature of the progress which can be made on the last two issues.